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Spampinato M, Giallongo C, Romano A, Longhitano L, La Spina E, Avola R, Scandura G, Dulcamare I, Bramanti V, Di Rosa M, Vicario N, Parenti R, Li Volti G, Tibullo D, Palumbo GA. Focus on Osteosclerotic Progression in Primary Myelofibrosis. Biomolecules 2021. [PMID: 33477816 DOI: 10.3390/biom11010122.pmid:33477816;pmcid:pmc7832894] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/09/2023] Open
Abstract
Primary myelofibrosis (PMF) is a myeloproliferative neoplasm characterized by hematopoietic stem-cell-derived clonal proliferation, leading to bone marrow (BM) fibrosis. Hematopoiesis alterations are closely associated with modifications of the BM microenvironment, characterized by defective interactions between vascular and endosteal niches. As such, neoangiogenesis, megakaryocytes hyperplasia and extensive bone marrow fibrosis, followed by osteosclerosis and bone damage, are the most relevant consequences of PMF. Moreover, bone tissue deposition, together with progressive fibrosis, represents crucial mechanisms of disabilities in patients. Although the underlying mechanisms of bone damage observed in PMF are still unclear, the involvement of cytokines, growth factors and bone marrow microenvironment resident cells have been linked to disease progression. Herein, we focused on the role of megakaryocytes and their alterations, associated with cytokines and chemokines release, in modulating functions of most of the bone marrow cell populations and in creating a complex network where impaired signaling strongly contributes to progression and disabilities.
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Affiliation(s)
- Mariarita Spampinato
- Section of Biochemistry, Department of Biomedical and Biotechnological Sciences, University of Catania, 95123 Catania, Italy
| | - Cesarina Giallongo
- Department of Medical and Surgical Sciences and Advanced Technologies "G.F. Ingrassia", University of Catania, 95123 Catania, Italy
| | - Alessandra Romano
- Department of General Surgery and Medical-Surgical Specialties, Division of Hematology, A.O.U. "Policlinico-Vittorio Emanuele", University of Catania, 95123 Catania, Italy
| | - Lucia Longhitano
- Section of Biochemistry, Department of Biomedical and Biotechnological Sciences, University of Catania, 95123 Catania, Italy
| | - Enrico La Spina
- Department of General Surgery and Medical-Surgical Specialties, Division of Hematology, A.O.U. "Policlinico-Vittorio Emanuele", University of Catania, 95123 Catania, Italy
| | - Roberto Avola
- Section of Biochemistry, Department of Biomedical and Biotechnological Sciences, University of Catania, 95123 Catania, Italy
| | - Grazia Scandura
- Department of General Surgery and Medical-Surgical Specialties, Division of Hematology, A.O.U. "Policlinico-Vittorio Emanuele", University of Catania, 95123 Catania, Italy
| | - Ilaria Dulcamare
- Department of General Surgery and Medical-Surgical Specialties, Division of Hematology, A.O.U. "Policlinico-Vittorio Emanuele", University of Catania, 95123 Catania, Italy
| | - Vincenzo Bramanti
- Division of Clinical Pathology, "Giovanni Paolo II" Hospital-A.S.P. Ragusa, 97100 Ragusa, Italy
| | - Michelino Di Rosa
- Section of Human Anatomy and Histology, Department of Biomedical and Biotechnological Sciences, University of Catania, 95123 Catania, Italy
| | - Nunzio Vicario
- Section of Physiology, Department of Biomedical and Biotechnological Sciences, University of Catania, 95123 Catania, Italy
| | - Rosalba Parenti
- Section of Physiology, Department of Biomedical and Biotechnological Sciences, University of Catania, 95123 Catania, Italy
| | - Giovanni Li Volti
- Section of Biochemistry, Department of Biomedical and Biotechnological Sciences, University of Catania, 95123 Catania, Italy
| | - Daniele Tibullo
- Section of Biochemistry, Department of Biomedical and Biotechnological Sciences, University of Catania, 95123 Catania, Italy
| | - Giuseppe A Palumbo
- Department of Medical and Surgical Sciences and Advanced Technologies "G.F. Ingrassia", University of Catania, 95123 Catania, Italy
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Spampinato M, Giallongo C, Romano A, Longhitano L, La Spina E, Avola R, Scandura G, Dulcamare I, Bramanti V, Di Rosa M, Vicario N, Parenti R, Li Volti G, Tibullo D, Palumbo GA. Focus on Osteosclerotic Progression in Primary Myelofibrosis. Biomolecules 2021; 11:biom11010122. [PMID: 33477816 PMCID: PMC7832894 DOI: 10.3390/biom11010122] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2020] [Revised: 01/09/2021] [Accepted: 01/16/2021] [Indexed: 12/22/2022] Open
Abstract
Primary myelofibrosis (PMF) is a myeloproliferative neoplasm characterized by hematopoietic stem-cell-derived clonal proliferation, leading to bone marrow (BM) fibrosis. Hematopoiesis alterations are closely associated with modifications of the BM microenvironment, characterized by defective interactions between vascular and endosteal niches. As such, neoangiogenesis, megakaryocytes hyperplasia and extensive bone marrow fibrosis, followed by osteosclerosis and bone damage, are the most relevant consequences of PMF. Moreover, bone tissue deposition, together with progressive fibrosis, represents crucial mechanisms of disabilities in patients. Although the underlying mechanisms of bone damage observed in PMF are still unclear, the involvement of cytokines, growth factors and bone marrow microenvironment resident cells have been linked to disease progression. Herein, we focused on the role of megakaryocytes and their alterations, associated with cytokines and chemokines release, in modulating functions of most of the bone marrow cell populations and in creating a complex network where impaired signaling strongly contributes to progression and disabilities.
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Affiliation(s)
- Mariarita Spampinato
- Section of Biochemistry, Department of Biomedical and Biotechnological Sciences, University of Catania, 95123 Catania, Italy; (M.S.); (L.L.); (R.A.); (D.T.)
| | - Cesarina Giallongo
- Department of Medical and Surgical Sciences and Advanced Technologies “G.F. Ingrassia”, University of Catania, 95123 Catania, Italy;
| | - Alessandra Romano
- Department of General Surgery and Medical-Surgical Specialties, Division of Hematology, A.O.U. “Policlinico-Vittorio Emanuele”, University of Catania, 95123 Catania, Italy; (A.R.); (E.L.S.); (G.S.); (I.D.)
| | - Lucia Longhitano
- Section of Biochemistry, Department of Biomedical and Biotechnological Sciences, University of Catania, 95123 Catania, Italy; (M.S.); (L.L.); (R.A.); (D.T.)
| | - Enrico La Spina
- Department of General Surgery and Medical-Surgical Specialties, Division of Hematology, A.O.U. “Policlinico-Vittorio Emanuele”, University of Catania, 95123 Catania, Italy; (A.R.); (E.L.S.); (G.S.); (I.D.)
| | - Roberto Avola
- Section of Biochemistry, Department of Biomedical and Biotechnological Sciences, University of Catania, 95123 Catania, Italy; (M.S.); (L.L.); (R.A.); (D.T.)
| | - Grazia Scandura
- Department of General Surgery and Medical-Surgical Specialties, Division of Hematology, A.O.U. “Policlinico-Vittorio Emanuele”, University of Catania, 95123 Catania, Italy; (A.R.); (E.L.S.); (G.S.); (I.D.)
| | - Ilaria Dulcamare
- Department of General Surgery and Medical-Surgical Specialties, Division of Hematology, A.O.U. “Policlinico-Vittorio Emanuele”, University of Catania, 95123 Catania, Italy; (A.R.); (E.L.S.); (G.S.); (I.D.)
| | - Vincenzo Bramanti
- Division of Clinical Pathology, “Giovanni Paolo II” Hospital–A.S.P. Ragusa, 97100 Ragusa, Italy;
| | - Michelino Di Rosa
- Section of Human Anatomy and Histology, Department of Biomedical and Biotechnological Sciences, University of Catania, 95123 Catania, Italy;
| | - Nunzio Vicario
- Section of Physiology, Department of Biomedical and Biotechnological Sciences, University of Catania, 95123 Catania, Italy; (N.V.); (R.P.)
| | - Rosalba Parenti
- Section of Physiology, Department of Biomedical and Biotechnological Sciences, University of Catania, 95123 Catania, Italy; (N.V.); (R.P.)
| | - Giovanni Li Volti
- Section of Biochemistry, Department of Biomedical and Biotechnological Sciences, University of Catania, 95123 Catania, Italy; (M.S.); (L.L.); (R.A.); (D.T.)
- Correspondence: (G.L.V.); (G.A.P.)
| | - Daniele Tibullo
- Section of Biochemistry, Department of Biomedical and Biotechnological Sciences, University of Catania, 95123 Catania, Italy; (M.S.); (L.L.); (R.A.); (D.T.)
| | - Giuseppe A. Palumbo
- Department of Medical and Surgical Sciences and Advanced Technologies “G.F. Ingrassia”, University of Catania, 95123 Catania, Italy;
- Correspondence: (G.L.V.); (G.A.P.)
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The Relationship between Platelet Count and Host Gut Microbiota: A Population-Based Retrospective Cross-Sectional Study. J Clin Med 2019; 8:jcm8020230. [PMID: 30744195 PMCID: PMC6406547 DOI: 10.3390/jcm8020230] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2018] [Revised: 02/07/2019] [Accepted: 02/07/2019] [Indexed: 01/19/2023] Open
Abstract
Platelet count reflects the severity and prognosis of multiple diseases. Additionally, alterations in gut microbiota have been linked to several chronic diseases. The purpose of this study was to investigate the association between gut microbiota and platelet count. We selected 1268 subjects with fecal 16S RNA gene sequencing data from a Healthcare Screening Center cohort. Based on the third quartile of platelets (277 × 109/L), we compared the gut microbiota between the upper quartile (n = 321) and lower three quartiles groups (n = 947). The upper quartile group had lower alpha diversity based on observed amplicon sequence variants (q = 0.004) and phylogenetic index (q < 0.001) than the lower three quartiles group. Significant differences were also found in the weighted UniFrac distance (q = 0.001) and Jaccard dissimilarity (q = 0.047) beta diversity measures between the two groups. Compared with the lower three quartiles group, the upper quartile group exhibited decreased relative abundances of the genus Faecalibacterium, which was also inversely correlated with the platelet count. Increased platelet count was associated with reduced diversity in gut microbiota and lower abundances of Faecalibacterium with beneficial gut bacteria spices F. prausnitzii, suggesting that an increased platelet count, even within normal range, may adversely affect gut microbial diversity and composition.
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Affiliation(s)
- John T. Reilly
- Royal Hallamshire Hospital, Glossop Road, Sheffield, S10 2JF
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Song MK, Chung JS, Lim SN, Lee GW, Lee SM, Lee NK, Choi JC, Oh SY. Usefulness of spleen volume measured by computed tomography for predicting clinical outcome in primary myelofibrosis. Int J Hematol 2016; 104:476-84. [PMID: 27349913 DOI: 10.1007/s12185-016-2050-y] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2016] [Revised: 06/20/2016] [Accepted: 06/21/2016] [Indexed: 11/28/2022]
Abstract
Although splenomegaly is major characteristic of primary myelofibrosis (PMF), splenomegaly has been devalued due to a less reliable method based on physical examination (PEx). We evaluated whether spleen volume (SV) on CT would accurately predict clinical outcomes in PMF. A total of 188 patients were enrolled. SV was quantitated by the automatic volume software. In ROC curve, the SV predicted prognosis more accurately than spleen length by PEx (p < 0.001). The ideal cut-off value was 378.1 cm(3) for SV, which was divided into high- and low-volume status. Patients with low SV status had superior leukemia-free survival and overall survival compared to high SV status (p < 0.001, p < 0.001) In the Cox analysis, old age ≥65 years (p = 0.004, p = 0.001), low Hemoglobin <10.0 g/dL (p = 0.023, p = 0.021), high WBC counts ≥25 × 10(9)/L (p = 0.003, p = 0.006), peripheral blasts ≥1 % (p = 0.029, p = 0.020), unfavorable cytogenetic abnormalities (p = 0.025, p = 0.028), and high SV status (p = 0.004, p = 0.003) were independently associated with survivals. SV measured by CT was important for predicting survival in patients with PMF.
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Affiliation(s)
- Moo-Kon Song
- Department of Hematology-Oncology, Hanyang University Hanmaeum Changwon Hospital, WoniDae-Ro 682 road, 21 Changwon, 51497, Republic of Korea.
| | - Joo-Seop Chung
- Department of Hematology-Oncology, Pusan National University Hospital, Busan, Korea
| | - Sung-Nam Lim
- Department of Hematology, Haeundae Paik Hospital, Busan, Korea
| | - Gyeong-Won Lee
- Department of Hematology, Gyeong-Sang National University Hospital, School of Medicine, Gyeong-Sang National University, Jinju, Korea
| | - Sang-Min Lee
- Department of Hematology, Busan Paik Hospital, Busan, Korea
| | - Nam-Kyung Lee
- Department of Radiology, Pusan National University Hospital, Busan, Korea
| | - Jae-Cheol Choi
- Department of Laboratory Medicine, Hanyang University Hanmaeum Changwon Hospital, Changwon, Korea
| | - So-Yeon Oh
- Department of Hematology-Oncology, Pusan National University Yangsan Hospital, Yangsan, Korea
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Malik M, Segars J, Catherino WH. Integrin β1 regulates leiomyoma cytoskeletal integrity and growth. Matrix Biol 2012; 31:389-97. [PMID: 23023061 DOI: 10.1016/j.matbio.2012.09.005] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2012] [Revised: 09/14/2012] [Accepted: 09/18/2012] [Indexed: 11/17/2022]
Abstract
Uterine leiomyomas are characterized by an excessive extracellular matrix, increased mechanical stress, and increased active RhoA. Previously, we observed that mechanical signaling was attenuated in leiomyoma, but the mechanisms responsible remain unclear. Integrins, especially integrin β1, are transmembrane adhesion receptors that couple extracellular matrix stresses to the intracellular cytoskeleton to influence cell proliferation and differentiation. Here we characterized integrin and laminin to signaling in leiomyoma cells. We observed a 2.25±0.32 fold increased expression of integrin β1 in leiomyoma cells, compared to myometrial cells. Antibody-mediated inhibition of integrin β1 led to significant growth inhibition in leiomyoma cells and a loss of cytoskeletal integrity. Specifically, polymerization of actin filaments and formation of focal adhesions were reduced by inhibition of integrin β1. Inhibition of integrin β1 in leiomyoma cells led to 0.81±0.02 fold decrease in active RhoA, and resembled levels found in serum-starved cells. Likewise, inhibition of integrin β1 was accompanied by a decrease in phospho-ERK. Compared to myometrial cells, leiomyoma cells demonstrated increased expression of integrin α6 subunit to laminin receptor (1.91±0.11 fold), and increased expression of laminin 5α (1.52±0.02), laminin 5β (3.06±0.92), and laminin 5γ (1.66±0.06). Of note, leiomyoma cells grown on laminin matrix appear to realign themselves. Taken together, the findings reveal that the attenuated mechanical signaling in leiomyoma cells is accompanied by an increased expression and a dependence on integrin β1 signaling in leiomyoma cells, compared to myometrial cells.
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Affiliation(s)
- Minnie Malik
- Department of Obstetrics and Gynecology, Uniformed Services University of the Health Sciences, Bethesda, MD 20814, United States
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Skov V, Larsen TS, Thomassen M, Riley CH, Jensen MK, Bjerrum OW, Kruse TA, Hasselbalch HC. Increased gene expression of histone deacetylases in patients with Philadelphia-negative chronic myeloproliferative neoplasms. Leuk Lymphoma 2011; 53:123-9. [PMID: 21806350 DOI: 10.3109/10428194.2011.597905] [Citation(s) in RCA: 49] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
Myeloproliferation, myeloaccumulation (decreased apoptosis), inflammation, bone marrow fibrosis and angiogenesis are cardinal features of the Philadelphia-negative chronic myeloproliferative neoplasms: essential thrombocythemia (ET), polycythemia vera (PV) and primary myelofibrosis (PMF). Histone deacetylases (HDACs) have a critical role in modulating gene expression and, accordingly, in the control of cell pathobiology and cancer development. HDAC inhibition has been shown to inhibit tumor growth (impaired myeloproliferation), to modulate the balance between pro- and antiapoptotic proteins in favor of apoptosis (enhanced apoptosis) and also to inhibit angiogenesis. Recently, enhanced HDAC enzyme activity has been found in CD34+cells from patients with PMF, enzyme activity levels highly exceeding those recorded in other chronic myeloproliferative neoplasms (CMPNs). The raised levels correlated to the degree of splenomegaly, suggesting that HDAC might be recruited as ET or PV progresses into myelofibrosis or PMF progresses into a more advanced stage. Accordingly, HDAC inhibition is an obvious novel therapeutic approach in these neoplasms. Using global gene expression profiling of whole blood from patients with CMPNs, we have found a pronounced deregulation of HDAC genes, involving significant up-regulation of the HDAC genes 9 and 11, with the highest expression levels being found in patients with ET (HDAC9 and 11), PMF (HDAC9) and CMPNs (both HDAC9 and HDAC11). Furthermore, we have identified that the HDAC6 gene is progressively expressed in patients with ET, PV and PMF, reflecting a steady accumulation of abnormally expressed HDAC6 during disease evolution. Our results lend further support to HDACs as important epigenetic targets in the future treatment of patients with CMPNs. Since the highest expression levels of HDAC genes were recorded in ET, in PMF and in the entire CMPN group, their down-regulation by HDAC inhibitors might be associated with decreased disease activity, including reduction of splenomegaly.
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Affiliation(s)
- Vibe Skov
- Department of Clinical Genetics, Odense University Hospital, Denmark
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Abstract
Managing patients with myelofibrosis (MF)-either those with primary MF or those whose MF has evolved from antecedent polycythemia vera or essential thrombocythemia-presents many challenges to the hematologist. Cure is potentially achievable through allogeneic stem cell transplantation, but this therapy is either inappropriate or not feasible for most patients. MF patients suffer from a range of debilitating disease manifestations (eg, massive splenomegaly, cytopenias, constitutional symptoms, and transformation to a treatment-refractory blast phase). Currently available therapies are palliative but can be of significant value to some MF patients for anemia, splenomegaly, or sometimes both manifestations. New medical therapies for MF revolve around three main themes: immunomodulation (to assist anemia), hypomethylation strategies, and (the most robust pipeline) the use of targeted JAK2 inhibitors. These latter agents have shown the ability to improve MF-associated splenomegaly and MF-associated symptoms but do not improve (and may exacerbate) anemia or thrombocytopenia. Future targeted agents, and perhaps combinations of agents that currently show complementary benefits, are anticipated to further enhance the efficacy of medical therapy for MF.
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Abstract
Chronic hyperparathyroidism (HPT) is a common cause of metabolic bone disease. These studies investigated the underlying cellular and molecular mechanisms responsible for the detrimental actions of elevated parathyroid hormone (PTH) on the skeleton. Bone biopsies from hyperparathyroid patients revealed an association between parathyroid bone disease and increased numbers of bone marrow mast cells. We therefore evaluated the role of mast cells in the etiology of parathyroid bone disease in a rat model for chronic HPT. In rats, mature mast cells were preferentially located at sites undergoing bone turnover, and the number of mast cells at the bone-bone marrow interface was greatly increased following treatment with PTH. Time-course studies and studies employing parathyroid hormone-related peptide (PTHrP), as well as inhibitors of platelet-derived growth factor-A (PDGF-A, trapidil), kit (gleevec), and PI3K (wortmannin) signaling revealed that mature mast cell redistribution from bone marrow to bone surfaces precedes and is associated with osteitis fibrosa, a hallmark of parathyroid bone disease. Importantly, mature mast cells were not observed in the bone marrow of mice. Mice, in turn, were resistant to the development of PTH-induced bone marrow fibrosis. These findings suggest that the mast cell may be a novel target for treatment of metabolic bone disease.
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Affiliation(s)
- Russell T Turner
- Department of Nutrition and Exercise Sciences, Oregon State University, Corvallis, OR 97331, USA.
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Ye JY, Chan GCF, Qiao L, Lian Q, Meng FY, Luo XQ, Khachigian LM, Ma M, Deng R, Chen JL, Chong BH, Yang M. Platelet-derived growth factor enhances platelet recovery in a murine model of radiation-induced thrombocytopenia and reduces apoptosis in megakaryocytes via its receptors and the PI3-k/Akt pathway. Haematologica 2010; 95:1745-53. [PMID: 20562316 DOI: 10.3324/haematol.2009.020958] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023] Open
Abstract
BACKGROUND Platelet-derived growth factor is involved in the regulation of hematopoiesis. Imatinib mesylate, a platelet-derived growth factor receptor inhibitor, induces thrombocytopenia in a significant proportion of patients with chronic myeloid leukemia. Although our previous studies showed that platelet-derived growth factor enhances megakaryocytopoiesis in vitro, the in vivo effect of platelet-derived growth factor in a model of radiation-induced thrombocytopenia has not been reported. DESIGN AND METHODS In this study, we investigated the effect of platelet-derived growth factor on hematopoietic stem/progenitor cells and platelet production using an irradiated-mouse model. We also explored the potential molecular mechanisms of platelet-derived growth factor on thrombopoiesis in M-07e cells. RESULTS Platelet-derived growth factor, like thrombopoietin, significantly promoted the recovery of platelets and the formation of bone marrow colony-forming unit-megakaryocyte in irradiated mice. Histology confirmed the protective effect of platelet-derived growth factor, as shown by an increased number of hematopoietic stem/progenitor cells and a reduction of apoptosis. In a megakaryocytic apoptotic model, platelet-derived growth factor had a similar anti-apoptotic effect as thrombopoietin on megakaryocytes. We also demonstrated that platelet-derived growth factor activated the PI3-k/Akt signaling pathway, while addition of imatinib mesylate reduced p-Akt expression. CONCLUSIONS Our findings show that platelet-derived growth factor enhances platelet recovery in mice with radiation-induced thrombocytopenia. This radioprotective effect is likely to be mediated via platelet-derived growth factor receptors with subsequent activation of the PI3-k/Akt pathway. We also provide a possible explanation that blockage of platelet-derived growth factor receptors may reduce thrombopoiesis and play a role in imatinib mesylate-induced thrombocytopenia.
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Affiliation(s)
- Jie Yu Ye
- Department of Paediatrics and Adolescent Medicine, LKS Faculty of Medicine, The University of Hong Kong, Hong Kong
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Kvasnicka HM, Thiele J. Prodromal myeloproliferative neoplasms: the 2008 WHO classification. Am J Hematol 2010; 85:62-9. [PMID: 19844986 DOI: 10.1002/ajh.21543] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
The concept of prodromal chronic myeloproliferative neoplasms has been endorsed by the WHO classification implicating a stepwise evolution of disease. Histology of the bone marrow (BM) and borderline to mildly expressed clinical features play a pivotal role for diagnosing prefibrotic-early primary myelofibrosis. By lowering the platelet count for essential thrombocythemia and regarding BM morphology, early manifestations are tackled. Pre-polycythemic stages of polycythemia vera with a low hemoglobin level at onset are diagnosed by positive JAK2V617F mutation status, a low erythropoietin value, and characteristic BM features. The revised WHO classification incorporates hematological, morphological, and molecular-genetic parameters to generate a consensus-based working diagnosis.
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12
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Bone marrow hyaluronan and reticulin in patients with malignant disorders. Med Oncol 2009; 27:618-23. [DOI: 10.1007/s12032-009-9257-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2009] [Accepted: 06/08/2009] [Indexed: 11/25/2022]
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Abstract
Managing patients with myelofibrosis (MF), either those with primary MF or those whose MF has evolved from antecedent polycythemia vera or essential thrombocythemia, presents many challenges to the hematologist. MF patients have a range of debilitating disease manifestations (eg, massive splenomegaly, cytopenias, constitutional symptoms, and transformation to a treatment-refractory blast phase). Cure is potentially achievable through allogeneic stem cell transplantation; however, this therapy is either inappropriate or not feasible for the majority of patients. Therefore, remaining therapies are palliative but can be of significant value to some MF patients. In particular, management of symptomatic splenomegaly remains one of the most perplexing aspects of MF clinical care. Using medications is the simplest approach for reducing splenomegaly, yet achieving symptomatic response without undue myelosuppression is challenging. Splenectomy or radiotherapy offers benefit, but careful patient selection and close monitoring are required because both have the potential for dangerous adverse effects. Experimental medical therapies, such as JAK2 inhibitors, show promise and may soon play an important role in the management of symptomatic splenomegaly in MF patients. Future care of MF patients, including splenomegaly management, will continue to require the hematologist to select therapeutic options carefully in the context of realistic, achievable goals.
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Abdulkarim K, Girodon F, Johansson P, Maynadié M, Kutti J, Carli PM, Bovet E, Andréasson B. AML transformation in 56 patients with Ph- MPD in two well defined populations. Eur J Haematol 2009; 82:106-11. [PMID: 19134023 DOI: 10.1111/j.1600-0609.2008.01163.x] [Citation(s) in RCA: 55] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
The Philadelphia chromosome-negative (Ph-) chronic myeloproliferative disorders (MPD) have an inherent tendency for transformation into acute myelogenous leukaemia (AML). The long-term rate of leukaemic transformation in unselected MPD patients was studied in well-defined MPD populations in Gothenburg, Sweden and the Côte d'Or area, Burgundy, France, respectively. Over a median observation time of 15 yr, 56 subjects (7%) out of a total of 795 patients with Ph- MPD transformed to AML. The yearly incidence of AML transformation was 0.38% in polycythaemia vera (PV), 0.37% in essential thrombocythaemia (ET) and 1.09% in idiopathic myelofibrosis (IMF). The incidence of AML development was significantly higher in IMF as compared with both PV and ET (P = 0.002 and P = 0.02, respectively). Six of the patients who developed AML had never been treated with cytoreductive agents and two had only been exposed to interferon. In IMF, the average time from diagnosis to AML transformation was 42 +/- 33 months, which was significantly shorter than for both PV and ET (88 +/- 56 and 76 +/- 57 months; P = 0.0075 and P = 0.027, respectively). The time from diagnosis to AML transformation appears to be a continuous event as regards all three MPD entities. It was shown that 17 out of the 18 patients with PV who developed AML were females; this was true despite the fact that the male/female ratio for the whole PV group was 146/171 (0.85). As regards ET and IMF patients who transformed to AML, the gender ratio showed slight male predominance (1.33 and 1.13, respectively). The average survival time for the 56 MPD patients who developed AML was 4.6 +/- 5.5 (range 0-28) months and did not differ with respect to the three subtypes of pre-AML MPD.
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Affiliation(s)
- Khadija Abdulkarim
- Hematology and Coagulation Section, Department of Medicine, Sahlgrenska University Hospital, Gothenburg, Sweden
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Hasselbalch HC. Myelofibrosis with myeloid metaplasia: The advanced phase of an untreated disseminated hematological cancer. Leuk Res 2009; 33:11-8. [DOI: 10.1016/j.leukres.2008.06.002] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2008] [Revised: 05/31/2008] [Accepted: 06/03/2008] [Indexed: 12/31/2022]
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Does primary myelofibrosis involve a defective stem cell niche? From concept to evidence. Blood 2008; 112:3026-35. [PMID: 18669872 DOI: 10.1182/blood-2008-06-158386] [Citation(s) in RCA: 106] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023] Open
Abstract
Primary myelofibrosis (PMF) is the rarest and the most severe Philadelphia-negative chronic myeloproliferative syndrome. By associating a clonal proliferation and a mobilization of hematopoietic stem cells from bone marrow to spleen with profound alterations of the stroma, PMF is a remarkable model in which deregulation of the stem cell niche is of utmost importance for the disease development. This paper reviews key data suggesting that an imbalance between endosteal and vascular niches participates in the development of clonal stem cell proliferation. Mechanisms by which bone marrow niches are altered with ensuing mobilization and homing of neoplastic hematopoietic stem cells in new or reinitialized niches in the spleen and liver are examined. Differences between signals delivered by both endosteal and vascular niches in the bone marrow and spleen of patients as well as the responsiveness of PMF stem cells to their specific signals are discussed. A proposal for integrating a potential role for the JAK2 mutation in their altered sensitivity is made. A better understanding of the cross talk between stem cells and their niche should imply new therapeutic strategies targeting not only intrinsic defects in stem cell signaling but also regulatory hematopoietic niche-derived signals and, consequently, stem cell proliferation.
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Hultdin M, Sundström G, Wahlin A, Lundström B, Samuelsson J, Birgegård G, Engström-Laurent A. Progression of bone marrow fibrosis in patients with essential thrombocythemia and polycythemia vera during anagrelide treatment. Med Oncol 2007; 24:63-70. [PMID: 17673813 DOI: 10.1007/bf02685904] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2006] [Revised: 11/30/1999] [Accepted: 09/18/2006] [Indexed: 10/23/2022]
Abstract
Anagrelide is a second-line option for reduction of thrombocythemia in patients with chronic myeloproliferative disorders (CMPDs). A multicenter, open, phase II study of anagrelide treatment in 60 patients during 2 yr was performed by the Swedish Myeloproliferative Disorder Study Group. Adequate bone marrow biopsies were obtained from 53 of the CMPD patients [36 essential thrombocythemia (ET), 16 polycythemia vera (PV), 1 chronic idiopathic myelofibrosis (CIMF)] before treatment and compared with biopsies from 30 healthy volunteers and 34 patients with acute myeloid leukemia (AML). Higher reticulin and hyaluronan (HYA) scores were found before anagrelide therapy in the CMPD patients than in the normal controls (p < 0.001 and p < 0.001, respectively) and AML patients (p < 0.001 and p = 0.011, respectively). At the end of the study 30 CMPD patients were still on anagrelide treatment and in 19 of these patients, all diagnosed as ET (n = 16) or PV (n = 3), pretreatment bone marrow biopsies were compared with follow-up samples. After 2 yr of anagrelide therapy the reticulin and HYA scores were significantly higher than before treatment (p = 0.02 and p = 0.002, respectively). The cellularity was significantly higher (p = 0.014), although the number of megakaryocytes did not change significantly. The increase of reticulin and HYA in the bone marrow after 2 yr of treatment with anagrelide indicated progression of fibrosis. Although anagrelide is a valuable drug for reduction of platelet levels, it seems unable to stop progression of bone marrow fibrosis and hypercellularity in ET and PV.
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Affiliation(s)
- Magnus Hultdin
- Department of Medical Biosciences, Pathology, Umeå University, SE-901 85 Umeå, Sweden.
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18
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Hogan WJ, Litzow MR, Tefferi A. Allogeneic hematopoietic cell transplantation in myelofibrosis with myeloid metaplasia. Curr Hematol Malig Rep 2007; 2:34-42. [DOI: 10.1007/s11899-007-0005-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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19
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Elliott MA, Verstovsek S, Dingli D, Schwager SM, Mesa RA, Li CY, Tefferi A. Monocytosis is an adverse prognostic factor for survival in younger patients with primary myelofibrosis. Leuk Res 2007; 31:1503-9. [PMID: 17397921 DOI: 10.1016/j.leukres.2006.12.025] [Citation(s) in RCA: 76] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2006] [Revised: 12/28/2006] [Accepted: 12/31/2006] [Indexed: 11/24/2022]
Abstract
We recently developed a modified Dupriez prognostic scoring system (PSS) that effectively discriminated between high-, intermediate-, and low-risk young patients (age < or =60 years) with primary myelofibrosis (PMF) based on the respective presence of none, one, or two or more of the following parameters: hemoglobin <10 g/dL, leukocyte count <4 or >30 x 10(9)L(-1), and platelet count <100 x 10(9)L(-1). The current study (n=129; median age, 52 years; 69 males) reveals, on multivariable analysis, that an absolute monocyte count of > or =1 x 10(9)L(-1) carries an independent predictive value (p=0.02), for an inferior survival, in addition to that provided by hemoglobin level (p=0.002), platelet count (0.02), and leukocyte count (p=0.16). The inclusion of the monocyte count as a fourth risk factor enabled the construction of a new and improved Mayo PSS; median survival was 173, 61, and 26 months in the absence of all four (low-risk), three (intermediate-risk), or two or less (high-risk) adverse features, respectively (p<0.0001). The independent prognostic value of monocytosis was validated in a separate database of 97 patients with PMF from another institution.
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Affiliation(s)
- M A Elliott
- Department of Internal Medicine, Division of Hematology, Mayo Clinic College of Medicine, Rochester, MN 55905, USA
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20
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Rühli FJ, Kuhn G, Evison R, Müller R, Schultz M. Diagnostic value of micro-CT in comparison with histology in the qualitative assessment of historical human skull bone pathologies. AMERICAN JOURNAL OF PHYSICAL ANTHROPOLOGY 2007; 133:1099-111. [PMID: 17530700 DOI: 10.1002/ajpa.20611] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
Cases of pathologically changed bone might constitute a diagnostic pitfall and frequently need histological methods to be etiologically properly evaluated. With micro-computed tomography (microCT), a new epoch of 2D and 3D imaging has been launched. We evaluated the diagnostic investigation of this analytical method versus well established histological investigations of historical human bone. Pathological changes due to various etiologies (infectious, traumatic, endocrinological, neoplasia) observed in autopsy-based macerated human skulls (Galler Collection, Natural History Museum Basel, Switzerland) were investigated by microCT and compared with histological thin ground sections using polarized light. Micro-CT images visualize the architecture of the bone with high spatial resolution without preparation or destruction of the sample in the area to be sectioned. Changes in the bone surfaces as well as alterations of the diploë can be assessed. However, morphological patterns caused by reactive response, such as typical arrangements of collagen fibers, can only be visualized by the microscopic investigation of thin ground sections using polarized light. A great advantage of microCT is the high number of slices obtained so that spatial differences within the areas of the specimen become visible. Micro-CT is a valuable tool for the diagnosis of vestiges of skull bone diseases. Its advantages over histology are the fast, automated image acquisition and the fact that the specimen is not completely destroyed. Only excision of the area to be scanned is necessary, if the specimen is too large to be scanned as a whole. Further, the 3D visualization of the micro-architecture allows an easy orientation within the sample, for example, for the choice of the location of the histological slices. However, the need to differentiate woven from lamellar bone still makes histology an indispensable method.
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Affiliation(s)
- F J Rühli
- Institute of Anatomy, University of Zurich, CH-8057 Zurich, Switzerland
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21
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Hasselbalch HC, Riley CH. Statins in the treatment of polycythaemia vera and allied disorders: An antithrombotic and cytoreductive potential? Leuk Res 2006; 30:1217-25. [PMID: 16483650 DOI: 10.1016/j.leukres.2005.12.018] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2005] [Revised: 12/02/2005] [Accepted: 12/22/2005] [Indexed: 12/01/2022]
Abstract
Thrombohaemorrhagic complications are major clinical problems in the classical chronic Ph-negative myeloproliferative disorders (CMPDs), polycytaemia vera (PV), essential thrombocythaemia (ET) and idiopathic myelofibrosis (IMF), contributing significantly to morbidity and mortality. Pathophysiologically these disorders are characterized by clonal myeloproliferation, myeloaccumulation and a propensity to develop myelofibrosis and neoangiogenesis in both the bone marrow and spleen. Based upon in vitro and in vivo studies of the effects of statins (antithrombotic, antiproliferative, proapoptotic and antiangiogenic), this review focuses on the translation of these effects into potential clinical benefits of statin therapy in patients with CMPDs.
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Affiliation(s)
- Hans Carl Hasselbalch
- Department of Haematology, Odense University Hospital, University of Southern Denmark, Odense, Denmark.
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22
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Thiele J, Kvasnicka HM, Vardiman J. Bone marrow histopathology in the diagnosis of chronic myeloproliferative disorders: A forgotten pearl. Best Pract Res Clin Haematol 2006; 19:413-37. [PMID: 16781481 DOI: 10.1016/j.beha.2005.07.015] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Histopathology of bone marrow (BM) biopsies plays a crucial role in the interdisciplinary approach to diagnosis and classification of chronic myeloproliferative disorders (CMPDs). Based on careful clinicopathologic studies, BM features are critical determinants that help to predict overall prognosis, to detect complications such as progression to myelofibrosis and blast crisis, and to assess therapy-related changes. A systematic evaluation of BM histopathology allows an objective identification of cases of (true) essential thrombocythemia (ET) and their separation from (false) ET, which often is the prodromal stage of chronic idiopathic myelofibrosis (CIMF). By follow-up examinations that include BM biopsies, the progression of the disease process is unveiled, which is especially important for patients with initial (early) polycythemia vera and prefibrotic CIMF that may require a different therapeutic approach than the full-blown stages. In conclusion, BM biopsy should be considered as major diagnostic tool for evaluation and follow-up of patients enrolled in prospective studies.
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Affiliation(s)
- J Thiele
- Institute of Pathology, University of Cologne, Joseph-Stelzmann-Str.9, D-50924 Cologne, Germany.
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23
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Michiels JJ, Bernema Z, Van Bockstaele D, De Raeve H, Schroyens W. Current diagnostic criteria for the chronic myeloproliferative disorders (MPD) essential thrombocythemia (ET), polycythemia vera (PV) and chronic idiopathic myelofibrosis (CIMF). ACTA ACUST UNITED AC 2006; 55:92-104. [PMID: 16919893 DOI: 10.1016/j.patbio.2006.06.002] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
The clinical criteria for the diagnosis of essential thrombocythemia (ET) according to the polycythemia vera study group (PVSG) do not distinguish between ET and thrombocythemia associated with early stage PV and prefibrotic chronic idiopathic myelofibrosis (CIMF). The clinical criteria of the PVSG for the diagnosis of polycythemia vera (PV) only detects advanced stage of PV with increased red cell mass. The bone marrow criteria of the World Health Organization (WHO) are defined by pathologists to explicitly define the pathological criteria for the diagnostic differentiation of ET, PV, and prefibrotic and fibrotic CIMF. As the clinical PVSG and the pathological WHO criteria show significant shortcomings, an updated set of European Clinical and Pathological (ECP) criteria combined with currently available biological and molecular markers are proposed to much better distinct true ET from early PV mimicking ET, to distinguish ET from thrombocythemia associated with prefibrotic CIMF, and to define the various clinical and pathological stages of PV and CIMF that has important therapeutic and prognostic implications. Comparing the finding of clustered giant abnormal megakaryocytes in a representative bone marrow as a diagnostic clue to MPD, the sensitivity for the diagnosis of MPD associated with splanchnic vein thrombosis was 63% for increased red cell mass, 52% for low serum EPO level, 72% for EEC, and 74% for splenomegaly indicating the superiority of bone marrow histopathology to detect masked early and overt MPD in this setting. The majority of PV and about half of the ET patients have spontaneous EEC, low serum EPO levels and PRV-1 over-expression and are JAK2 V617F positive. The positive predictive value for the diagnosis of PV of spontaneous growth of endogenous erythroid colonies (EEC) of peripheral blood (PB) and bone marrow (BM) cells is about 80-85% when either PB or BM EEC assays, and up to 94% when BM and PB EEC assays were performed. The diagnostic impact of low serum EPO levels (ELISA assay) in a large study of 186 patients below the normal range (<3.3 IU/l) had a sensitivity specificity and positive predictive value of 87%, 97% and 97.8%, respectively, for the diagnosis of PV. There is a significant overlap of serum EPO levels in PV versus control and controls versus SE. The specificity of a JAK2 V617F PCR test for the diagnosis of MPD is high (near 100%), but only half of ET and MF (50%) and the majority of PV (up to 97%) are JAK2 V617F positive. The use of biological markers including JAK2 V617 PCR test, serum EPO, PRV-1, EEC, leukocyte alkaline phosphatase score and peripheral blood parameters combined with bone marrow histopathology has a high sensitivity and specificity (almost 100%) to diagnose the early and overt stages of ET, PV and CIMF in JAK2 V617F positive and negative MPDs.
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Affiliation(s)
- J J Michiels
- Department of Hematology, University Hospital Antwerp Wilrijkstraat 10, 2650 Edegem/Antwerp, Belgium.
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Thiele J, Kvasnicka HM. A critical reappraisal of the WHO classification of the chronic myeloproliferative disorders. Leuk Lymphoma 2006; 47:381-96. [PMID: 16396760 DOI: 10.1080/10428190500331329] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Following the introduction of the WHO classification of chronic myeloproliferative disorders (MPDs), after approximately 5 years, a critical reappraisal appears to be warranted. Retrospective clinico-pathological evaluations conducted in the meantime, as well as the detection of new biomarkers, may aid in testing the validity of these new criteria. Based on a large series of patients with chronic myeloid leukemia (CML), an analysis of bone marrow (BM) features and risk classifications revealed that the fiber content exerted a most important and independent impact on prognosis. This finding was also supported in a prospective randomized study and therefore myelofibrosis should be included in any staging system in CML related to survival. Moreover, it is important to emphasize the dynamics of the disease process in MPDs, especially in polycythemia vera (PV) and chronic idiopathic myelofibrosis (CIMF). Latent-stage PV is difficult to recognize when adhering to the proposed limits for hemoglobin (or red cell mass) without regarding the erythropoietin (EPO) level, endogenous erythroid colonies (EECs) or BM histopathology. Initial PV may firstly present with complications and, when accompanied by a high platelet count, mimics essential thrombocythemia (ET). Consequently, BM morphology and EPO level should be entered as major diagnostic criteria for PV. To document more accurately the progress of disease, a simplified scoring system concerning myelofibrosis has to be included in the histological description of CIMF. The diagnostic guidelines of BM features in ET should be improved because, usually, there is neither a significant proliferation nor left-shifting of the granulo- and erythropoiesis detectable and no relevant increase in reticulin. A comparison of clinical data and BM morphology reveals that biomarkers (EPO, EECs, PRV-1, JAK2) show an overlapping pattern of positivity between the different subtypes of MPDs.
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MESH Headings
- Chronic Disease
- Disease Progression
- Humans
- Leukemia, Myelogenous, Chronic, BCR-ABL Positive/classification
- Leukemia, Myelogenous, Chronic, BCR-ABL Positive/diagnosis
- Leukemia, Myelogenous, Chronic, BCR-ABL Positive/pathology
- Myeloproliferative Disorders/classification
- Myeloproliferative Disorders/diagnosis
- Myeloproliferative Disorders/pathology
- Primary Myelofibrosis/classification
- Primary Myelofibrosis/diagnosis
- Primary Myelofibrosis/pathology
- Retrospective Studies
- Thrombocythemia, Essential/classification
- Thrombocythemia, Essential/diagnosis
- Thrombocythemia, Essential/pathology
- World Health Organization
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Affiliation(s)
- Juergen Thiele
- Institute of Pathology, University Cologne, Cologne, Germany.
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Mesa RA, Nagorney DS, Schwager S, Allred J, Tefferi A. Palliative goals, patient selection, and perioperative platelet management: outcomes and lessons from 3 decades of splenectomy for myelofibrosis with myeloid metaplasia at the Mayo Clinic. Cancer 2006; 107:361-70. [PMID: 16770787 DOI: 10.1002/cncr.22021] [Citation(s) in RCA: 137] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND Although splenectomy may palliate massive splenomegaly in patients with myelofibrosis with myeloid metaplasia, this procedure carries significant risks. The authors retrospectively analyzed their experience with splenectomy over the course of 30 years to analyze the impact of improved techniques, antimicrobials, and aggressive postoperative control of platelet counts on outcome. METHODS A total of 314 patients underwent splenectomy between 1976 and 2004 for mechanical symptoms (= 156 patients [49%]), anemia (= 78 patients [25%]), portal hypertension (= 47 patients [15%]), or thrombocytopenia (= 33 patients [11%]). Of a total of 91 patients studied during the last decade, 69 patients (76%) experienced a palliative benefit for their primary surgical indication for a median of 12 months (range, 1-91 months). RESULTS Perioperative complications occurred in 87 patients (27.7%) including infection (= 31 patients [9.9%]), thrombosis (= 31 patients [9.9%]), or bleeding (= 44 patients [14%]), 21 of which (6.7% of all patients) were fatal. Perioperative thrombohemorrhagic complications decreased in the last decade through the use of platelet apheresis and the prompt use of cytoreductive agents to counteract postsplenectomy thrombocytosis. Survival after splenectomy was found to be decreased in patients with preoperative thrombocytopenia (<100 x 10(9)/L [P = 0.006]) but not by indication, myelofibrosis with myeloid metaplasia (MMM) prognostic score, or the decade in which splenectomy was performed. CONCLUSIONS The lack of improvement in overall postsplenectomy survival over time may be a reflection on the failure of medical therapy to improve survival in patients with MMM.
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Affiliation(s)
- Ruben A Mesa
- Division of Hematology and Internal Medicine, Mayo Clinic, Rochester, Minnesota 55905, USA.
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Wagner-Ballon O, Chagraoui H, Prina E, Tulliez M, Milon G, Raslova H, Villeval JL, Vainchenker W, Giraudier S. Monocyte/macrophage dysfunctions do not impair the promotion of myelofibrosis by high levels of thrombopoietin. THE JOURNAL OF IMMUNOLOGY 2006; 176:6425-33. [PMID: 16709799 DOI: 10.4049/jimmunol.176.11.6425] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Several lines of evidence indicate that the megakaryocyte/platelet lineage is crucial in myelofibrosis induction. The demonstration that NOD/SCID mice with functionally deficient monocytes do not develop fibrotic changes when exposed to thrombopoietin (TPO) also suggests an important role for monocyte/macrophages. However, in this animal model, the development of myelofibrosis is dependent on the level of TPO. This study was conducted to investigate whether NOD/SCID mice exposed to high TPO levels mediated by a retroviral vector would be refractory to the development of bone marrow fibrosis. We show that TPO and TGF-beta1 in plasma from NOD/SCID and SCID mice engrafted with TPO-overexpressing hemopoietic cells reach levels similar to the ones reached in immunocompetent mice, and all animals develop a myeloproliferative disease associated with a dense myelofibrosis at 8 wk posttransplantation. Monocytes in NOD/SCID mice are functionally deficient to secrete cytokines such as IL-1alpha in response to stimuli, even under TPO expression. Surprisingly, the plasma of these mice displays high levels of IL-alpha, which was demonstrated to originate from platelets. Together, these data suggest that completely functional monocytes are not required to develop myelofibrosis and that platelets are able, under TPO stimulation, to synthesize inflammatory cytokines, which may be involved in the pathogenesis of myelofibrosis and osteosclerosis.
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Affiliation(s)
- Orianne Wagner-Ballon
- Institut National de la Sante et de la Recherche Medicale (INSERM) U790, Pavillon de Recherche 1, Institut Gustave Roussy, Villejuif, France
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Dingli D, Schwager SM, Mesa RA, Li CY, Tefferi A. Prognosis in transplant-eligible patients with agnogenic myeloid metaplasia. Cancer 2006; 106:623-30. [PMID: 16369987 DOI: 10.1002/cncr.21644] [Citation(s) in RCA: 46] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Allogeneic hematopoietic stem cell transplantation is potentially curative in agnogenic myeloid metaplasia (AMM) but is associated with substantial mortality and morbidity that necessitates accurate identification of patients in whom benefit outweighs risk. The current study describes the natural history of AMM in transplant-eligible patients and proposes a new prognostic scoring system that favorably compares with other established models. METHODS Patients diagnosed with AMM before the age of 60 years and seen at Mayo Clinic were identified and the diagnosis confirmed. Relevant demographic, clinical, and laboratory characteristics were abstracted, and the impact of various parameters on overall survival (OS) was evaluated with univariate and multivariate analyses. RESULTS A cohort of 160 patients with AMM is described. OS was 78 months. Multivariate analysis identified a hemoglobin level of <10 g/dL, white blood cell count of either <4 or >30x10(9)/L, platelet count of <100x10(9)/L, presence of constitutional symptoms, and hepatomegaly as independent predictors of inferior survival. The first 3 complete blood count-based parameters were combined into a new scoring system that resulted in median survivals of 155, 69, and 24 months in the presence of 0, 1, or >or=2 adverse features. The chi-square value for the new model was 80.6 compared with 51.4, 48.4, and 43.7 for the models by Dupriez, Cervantes, and Visani, respectively. CONCLUSIONS A new scoring system based on blood count at the time of diagnosis can adequately stratify by risk transplant-eligible patients with AMM and can accurately identify high-risk as well as intermediate-risk disease. The new system displayed a stronger discriminative value, between risk categories, compared with currently existing prognostic models.
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Affiliation(s)
- David Dingli
- Division of Hematology, Mayo Clinic College of Medicine, Rochester, Minnesota 55905, USA
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28
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Wang JC. Importance of plasma matrix metalloproteinases (MMP) and tissue inhibitors of metalloproteinase (TIMP) in development of fibrosis in agnogenic myeloid metaplasia. Leuk Lymphoma 2005; 46:1261-8. [PMID: 16109602 DOI: 10.1080/10428190500126463] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Tissue inhibitors of metalloproteinase (TIMP) and matrix metalloproteinases (MMP) are key elements in the formation, remodeling and degradation of matrix protein. Bone marrow fibrosis in AMM, with deposition, not only of interstitial and basement membrane collagen but also of fibronectin, vitronectin, laminin and proteoglycans, results from a disturbed balance between synthesis and proteolytic degradation of matrix protein. Although TIMP and MMP play important roles in the development of fibrosing diseases of skin, liver and lung, only a few studies of TIMP and MMP in the formation of bone marrow fibrosis in AMM have been published. The literature shows that TIMP-1 (both the total, complex and the free form) is significantly increased in AMM and other myeloproliferative syndromes (including polycythemia vera (PV) and essential thrombocytosis (ET)), while MMP-3 is significantly decreased, and levels of MMP-2 and MMP-9 are not different from control values. Variance from control values for both TIMP-1 and MMP-3 is more evident in AMM than in PV and ET, thus further suggesting bone marrow fibrosis in AMM results from enhanced TIMP and decreased MMP activities.
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Affiliation(s)
- Jen Chin Wang
- Division of Hematology/Oncology, Maimonides Hospital Medical Center, Brooklyn, NY-11219, USA.
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29
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Abstract
The conventional treatment of myelofibrosis involves a wait-and-see approach for asymptomatic patients, oral chemotherapy for the hyperproliferative forms of the disease, androgens or erythropoietin for the anaemia, and splenectomy in selected patients. Low-dose thalidomide plus prednisone is a well-tolerated therapy for the anaemia and the thrombocytopenia of myelofibrosis, whereas imatinib has shown little efficacy. Allogeneic stem cell transplantation (allo-SCT) is the only curative therapy for myelofibrosis. Its standard modality has an associated mortality of about 30% and can be applied to younger patients with high-risk disease or resistant to conventional treatment. Reduced-intensity conditioning allo-SCT involves a low mortality and is a promising therapy for patients aged 45-70 years old with the above characteristics. Autologous SCT is a palliative therapy for patients resistant to conventional treatment who lack a suitable donor. The next candidates for the treatment of myelofibrosis are the thalidomide derivatives, the proteasome inhibitors, and vascular endothelial growth factor neutralizing antibodies.
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Affiliation(s)
- Francisco Cervantes
- Haematology Department, Hospital Clínic, IDIBAPS, University of Barcelona, Barcelona, Spain.
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30
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Al-Assar O, Ul-Hassan A, Brown R, Wilson GA, Hammond DW, Reilly JT. Gains on 9p are common genomic aberrations in idiopathic myelofibrosis: a comparative genomic hybridization study. Br J Haematol 2005; 129:66-71. [PMID: 15801957 DOI: 10.1111/j.1365-2141.2005.05413.x] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Ideopathic myelofibrosis (IMF) is a chronic myeloproliferative disorder resulting in bone marrow fibrosis as a consequence of growth factor release from clonal haematopoiesis. Conventional cytogenetic analysis identifies abnormalities in approximately a third of cases at diagnosis, although rarely uncovers unique, primary genetic events. We have used comparative genomic hybridization (CGH) to study 25 IMF cases and have compared the results with conventional cytogenetics. Metaphase cells were available for analysis in 13 cases, of which seven showed an abnormal karyotype. CGH chromosomal profiles showed imbalances in 21 of 25 cases. The most frequent aberrations were gains of 9p (12 cases), 2q (seven cases), 3p (seven cases), chromosome 4 (seven cases), 12q (seven cases), 13q (eight cases). The main losses were at 17q and occurred in six cases. The results for CGH and cytogenetics were matched for one case only. Investigation of IMF by CGH suggests that genomic aberrations are much more common than has been previously indicated by conventional cytogenetic analysis and occur in the majority of cases. Gains of 9p were the most frequent finding, occurring in 50% of patients and suggests that genes on 9p may play a crucial role in the pathogenesis of IMF.
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Affiliation(s)
- O Al-Assar
- Institute for Cancer Studies, Division of Genomic Medicine, Medical School, University of Sheffield, Sheffield, UK
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31
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Ho CL, Arora B, Hoyer JD, Wellik LE, Mesa RA, Tefferi A. Bone marrow expression of vascular endothelial growth factor in myelofibrosis with myeloid metaplasia. Eur J Haematol 2005; 74:35-9. [PMID: 15613104 DOI: 10.1111/j.1600-0609.2004.00355.x] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
The biologic relevance and prognostic impact of angiogenesis is being increasingly recognized in many solid tumors and hematologic malignancies including myelofibrosis with myeloid metaplasia (MMM). Many cytokines including vascular endothelial growth factor (VEGF) have been implicated for neoangiogenesis in MMM. However, the exact humoral basis remains to be elucidated. We examined the expression of VEGF by immunohistochemistry in a prospective cohort of 66 MMM patients, including six with cellular phase disease, and five normal controls. Contrary to most other hematologic malignancies, the distribution and intensity of staining for VEGF in bone marrow was similar between the MMM patients and controls. Interestingly, all six cellular phase patients displayed significantly increased VEGF expression. Thus, upregulation of angiogenic cytokines other than VEGF such as TGF-beta or loss of activity of an anti-angiogenic cytokine might be the dominant pathway of endothelial activation in MMM. However, VEGF might contribute to the process in the early stages of the disease.
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Affiliation(s)
- Ching-Liang Ho
- Division of Hematology and Oncology, Department of Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
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32
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Cervantes F, Alvarez-Larrán A, Hernández-Boluda JC, Sureda A, Torrebadell M, Montserrat E. Erythropoietin treatment of the anaemia of myelofibrosis with myeloid metaplasia: results in 20 patients and review of the literature. Br J Haematol 2004; 127:399-403. [PMID: 15521916 DOI: 10.1111/j.1365-2141.2004.05229.x] [Citation(s) in RCA: 114] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
Recombinant human erythropoietin (rHuEPO) is an effective treatment for the anaemia that occurs secondary to various conditions, but its role in myelofibrosis with myeloid metaplasia (MMM) is not well established. rHuEPO, at an initial dose of 10 000 U thrice a week, was given to 20 patients with MMM and anaemia. Complete response (CR) was defined as transfusion cessation with normal haemoglobin (Hb) levels and partial response (PR) as a transfusion decrease > or =50% and Hb > 10 g/dl maintained for at least 8 weeks. Nine patients (45%) showed a favourable response to treatment, including four CR and five PR, four of whom have maintained their response at a median follow-up of 12.5 months (range: 4-21 months) from the start of treatment. The pretreatment factors associated with a favourable response were lack of transfusion requirement (P = 0.002) and higher Hb at start treatment of (P = 0.01). An analysis of the present series (n = 20) and 31 patients from the literature identified 28 (55%) favourable responses to rHuEPO, including 16 CR and 12 PR. In the multivariate analysis, serum erythropoietin level <125 U/l was found to be associated with a favourable response to rHuEPO, whereas lack of transfusional support had borderline significance.
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Affiliation(s)
- Francisco Cervantes
- Haematology Department, Hospital Clínic, IDIBAPS, University of Barcelona, Barcelona, Spain.
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MESH Headings
- Anemia, Refractory/genetics
- Anemia, Refractory/pathology
- Anemia, Refractory/therapy
- Antineoplastic Agents/therapeutic use
- Benzamides
- Hematopoietic Stem Cell Transplantation
- Humans
- Imatinib Mesylate
- Leukemia, Myelomonocytic, Chronic/genetics
- Leukemia, Myelomonocytic, Chronic/pathology
- Leukemia, Myelomonocytic, Chronic/therapy
- Models, Biological
- Myelodysplastic Syndromes/genetics
- Myelodysplastic Syndromes/pathology
- Myelodysplastic Syndromes/therapy
- Myeloproliferative Disorders/genetics
- Myeloproliferative Disorders/pathology
- Myeloproliferative Disorders/therapy
- Piperazines/therapeutic use
- Pyrimidines/therapeutic use
- Signal Transduction/genetics
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Affiliation(s)
- Richard A Van Etten
- Molecular Oncology Research Institute, Tufts-New England Medical Center, Boston, MA 02111, USA.
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34
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Sayinalp N, Cinar H, Uner A, Haznedaroğlu IC, Büyükaşik Y, Göker H, Aksu S, Ozcebe OI, Karakuş S, Kirazli S, Dündar SV. Plasma basic fibroblast growth factor and bone marrow fibrosis in clonal myeloproliferative disorders. ACTA ACUST UNITED AC 2004; 26:265-8. [PMID: 15279663 DOI: 10.1111/j.1365-2257.2004.00616.x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Basic fibroblast growth factor (bFGF) is an important growth factor involved in clonal hematopoietic expansion, neoangiogenesis, and bone marrow fibrosis, all of which are important pathobiologic features of clonal chronic myeloproliferative disorders (CMPD) and myelodysplastic syndromes (MDS). The aim of this study was to assess circulating bFGF concentrations in patients with CMPD and MDS with respect to the presence of bone marrow fibrosis in histopathologic examination. The study group comprised 18 patients with CMPD (six female, 12 male; median age 50 years), seven patients with MDS (one female, six male; median age 66 years) and 10 healthy adults as controls (four female, six male; median age 29 years). CMPD group included six chronic myelogenous leukemia (CML), seven essential thrombocythemia (ET), three polycythemia vera (PV), two agnogenic myeloid metaplasia (AMM). All seven MDS patients were the FAB subtype of refractory anemia (RA). Bone marrow biopsy sections stained with hematoxylin and eosin (H & E) and for reticulin were examined for the presence of fibrosis. The median plasma bFGF level was 18.2 pg/ml (interquartile range, IQR: 15.2-26.7) in patients with CMPD, 18.0 pg/ml (IQR: 15.8-26.4) in patients with MDS, 13.6 pg/ml (IQR: 9.9-20.0) in the control group. The bFGF levels were significantly higher in patients with CMPD in comparison with the healthy control group (P = 0.031). Circulating bFGF tended to be significantly lower in relation to the development of marrow fibrosis (P = 0.028). The complicated interactions of bFGF and fibrosis in the context of CMPD may be either 'cause' or 'effect'. The bFGF might represent an important link between angiogenesis, fibrosis, and clonal neoplastic hematopoiesis during the development of CMPD.
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Affiliation(s)
- N Sayinalp
- Department of Hematology, Hacettepe University Medical School, Ankara, Turkey.
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35
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Panteli K, Zagorianakou N, Bai M, Katsaraki A, Agnantis NJ, Bourantas K. Angiogenesis in chronic myeloproliferative diseases detected by CD34 expression. Eur J Haematol 2004; 72:410-5. [PMID: 15128419 DOI: 10.1111/j.1600-0609.2004.00235.x] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
Increased bone marrow angiogenesis estimated as bone marrow microvessel density (MVD), or as serum angiogenic factor levels and/or immunohistochemical expression of these factors in bone marrow biopsy has been demonstrated in a variety of hematological disorders including chronic myeloproliferative diseases (MPDs). The aim of this study was to investigate the MVD in 25 cases of myelofibrosis with myeloid metaplasia (MMM). MVD was estimated by CD34 immunohistochemical expression in bone marrow biopsies. A control group of 27 patients without bone marrow disease, eight cases of polycythemia vera (PV), 41 cases of essential thrombocythemia (ET) and nine cases of chronic myeloid leukemia (CML) were also studied. Moreover, in cases with MMM, MVD was correlated with clinical, laboratory, histological parameters and the outcome of the patients. Our study confirmed a significantly higher degree of angiogenesis in MMM, PV, ET and CML compared with controls (P < 0.001, P = 0.0007, P < 0.001 and P = 0.0008, respectively). Angiogenesis was higher in MMM than PV, ET and CML cases (P < 0.001, P < 0.001 and P = 0.008). Increased angiogenesis was correlated with hypercatabolic symptoms in MMM patients (P = 0.009). No correlation with other clinicopathological parameters or clinical outcome was found. However, definitive conclusions regarding the prognostic value of increased angiogenesis may require additional follow-up and a larger group of patients.
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Affiliation(s)
- K Panteli
- Department of Hematology, University Hospital of Ioannina, Ioannina, Greece.
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36
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Abstract
Idiopathic myelofibrosis (IMF) is a clonal stem cell disorder and is one of the four major myeloproliferative disorders, which include essential thrombocythemia (ET), polycythemia vera (PV), and chronic myelogenous leukemia (CML). Patients may be asymptomatic at the early stages, but later progress to marrow fibrosis, splenomegaly with pancytopenia leading to anemia, and other constitutional symptoms. Most of the care available is supportive and only palliates the constitutional symptoms. Prognosis for these patients is dependent on karyotype, hemoglobin count, and age. Stem cell transplantation is the only curative therapy, which results in eradication of the stem cell clone, with the cessation of extramedullary hematopoiesis and resolution of marrow fibrosis and its sequelae. Stem cell replacement therapy using either autologous or allogeneic stem cells has been attempted in small populations of patients with variable benefit. A nonmyeloablative approach has shown promise in a very small number of patients, but additional investigation is required for the ideal management of these patients.
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Affiliation(s)
- John M McCarty
- Bone Marrow Transplantation Program, Division of Hematology/Oncology, VCU Health System/MCV Hospitals and Physicians, Virginia Commonwealth University, Richmond, 23298-0157, USA
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37
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Moore AS, Caldwell E, Coleman J. Pathologic quiz case: ascites associated with a coagulation abnormality in a 52-Year-old woman. Portal vein thrombosis associated with a chronic myeloproliferative disorder. Arch Pathol Lab Med 2003; 127:e385-6. [PMID: 12951987 DOI: 10.5858/2003-127-e385-pqcaaw] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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38
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Aziz KA, Till KJ, Chen H, Slupsky JR, Campbell F, Cawley JC, Zuzel M. The role of autocrine FGF-2 in the distinctive bone marrow fibrosis of hairy-cell leukemia (HCL). Blood 2003; 102:1051-6. [PMID: 12689941 DOI: 10.1182/blood-2002-12-3737] [Citation(s) in RCA: 36] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Bone marrow (BM) fibrosis is a central diagnostic and pathogenetic feature of hairy-cell leukemia (HCL). It is known that fibronectin (FN) produced and assembled by the malignant hairy cells (HCs) themselves is a major component of this fibrosis. It is also known that FN production is greatly enhanced by adhesion of HCs to hyaluronan (HA) via CD44. The aim of the present study was to establish the roles of fibrogenic autocrine cytokines (fibroblast growth factor-2 [FGF-2] and transforming growth factor beta [TGFbeta]) and of different isoforms of CD44 in this FN production. We show that HC adhesion to HA stimulates FGF-2, but not TGFbeta, production and that HCs possess FGF-2 receptor. In a range of experiments, FN production was greatly reduced by blocking FGF-2 but not TGFbeta. Moreover FN, but not FGF-2, secretion was blocked by down-regulation of the v3 isoform of CD44 and by addition of heparitinase. These results show that autocrine FGF-2 secreted by HCs is the principal cytokine responsible for FN production by these cells when cultured on HA. The central role of FGF-2 in the pathogenesis of the BM fibrosis of HCL was supported by our immunohistochemical demonstration of large amounts of this cytokine in fibrotic BM but not in HCL spleen where there is no fibrosis. As regards CD44 isoforms, the present work demonstrates that CD44v3 is essential for providing the heparan sulfate necessary for HC stimulation by FGF-2, whereas the signal for production of the cytokine was provided by HA binding to CD44H, the standard hematopoietic form of the molecule.
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Affiliation(s)
- Khalil A Aziz
- Department of Haematology, University of Liverpool, Liverpool, United Kingdom
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Visani G, Mele A, Malagola M, Isidori A, Finelli C, Piccaluga PP. Sequential combination of thalidomide and erythropoietin determines transfusion independence and disease control in idiopathic myelofibrosis previously insensitive to both drugs used as single agents. Leukemia 2003; 17:1669-70. [PMID: 12886259 DOI: 10.1038/sj.leu.2403017] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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40
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Chou JM, Li CY, Tefferi A. Bone marrow immunohistochemical studies of angiogenic cytokines and their receptors in myelofibrosis with myeloid metaplasia. Leuk Res 2003; 27:499-504. [PMID: 12648509 DOI: 10.1016/s0145-2126(02)00268-0] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
Bone marrow specimens from 11 patients with myelofibrosis with myeloid metaplasia (MMM) and seven normal controls were studied immunohistochemically to determine expression of transforming growth factor beta (TGF-beta), platelet-derived growth factor (PDGF), vascular endothelial growth factor (VEGF), basic fibroblast growth factor (bFGF) and corresponding receptors. Staining distribution and intensity for TGF-beta, PDGF, VEGF, TGF-beta type II receptor, a receptor for PDGF, and receptors for VEGF and bFGF were similar in patients and controls. Bone marrow from 10 MMM patients showed increased TGF-beta type I receptor (TGF-betaRI) expression in small vessel endothelial cells. Eight patient specimens had bFGF overexpression in megakaryocytes. Increased microvessel density and decreased concentration of bFGF-staining stromal cells accompanied these changes. Microvascular TGF-betaRI upregulation and bFGF overexpression by megakaryocytes may cause bone marrow microenvironmental changes in MMM patients.
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Affiliation(s)
- Jung M Chou
- Department of Pathology, Tri-Service General Hospital, National Defense Medical Center, ROC, Taipei, Taiwan
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41
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Mesa RA, Steensma DP, Pardanani A, Li CY, Elliott M, Kaufmann SH, Wiseman G, Gray LA, Schroeder G, Reeder T, Zeldis JB, Tefferi A. A phase 2 trial of combination low-dose thalidomide and prednisone for the treatment of myelofibrosis with myeloid metaplasia. Blood 2003; 101:2534-41. [PMID: 12517815 DOI: 10.1182/blood-2002-09-2928] [Citation(s) in RCA: 226] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Single-agent thalidomide (THAL) at "conventional" doses (> 100 mg/d) has been evaluated in myelofibrosis with myeloid metaplasia (MMM) based on its antiangiogenic properties and the prominent neoangiogenesis that occurs in MMM. THAL monotherapy at such doses produces approximately a 20% response rate in anemia but is poorly tolerated (an adverse dropout rate of > 50% in 3 months). To improve efficacy and tolerability, we prospectively treated 21 symptomatic patients (hemoglobin level < 10 g/dL or symptomatic splenomegaly) with MMM with low-dose THAL (50 mg/d) along with a 3-month oral prednisone (PRED) taper (beginning at 0.5 mg/kg/d). THAL-PRED was well tolerated in all enrolled patients, with 20 patients (95%) able to complete 3 months of treatment. An objective clinical response was demonstrated in 13 (62%) patients, all improvements in anemia. Among 10 patients who were dependent on erythrocyte transfusions, 7 (70%) improved and 4 (40%) became transfusion independent. Among 8 patients with thrombocytopenia (platelet count < 100 x 10(9)/L), 6 (75%) experienced a 50% or higher increase in their platelet count. In 4 of 21 patients (19%), spleen size decreased by more than 50%. Responses observed were mostly durable after discontinuation of the PRED. The dose of THAL in this study (50 mg/d) was better tolerated than the higher doses used in previous studies. Adverse events associated with corticosteroid therapy were mild and transient. Clinical responses did not correlate with improvements in either intramedullary fibrosis or angiogenesis. THAL-PRED is well tolerated and preliminarily appears to be a promising drug regimen for treating cytopenias in patients with MMM.
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Affiliation(s)
- Ruben A Mesa
- Division of Hematology and Internal Medicine, Mayo Clinic, Rochester, MN 55905, USA
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42
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Abstract
Myelofibrosis with myeloid metaplasia, also known as idiopathic myelofibrosis (IF) or agnogenic myeloid metaplasia, is one of the characteristic manifestations of polycythemia vera (PV) in the spent phase, and has a particularly adverse prognosis. IF may also present de novo. To date, treatment strategies for both spent-phase PV and IF have frustrated both clinicians and patients, with little clear progress made over the past 50 years. Treatment modalities with some benefit in chronic myeloid leukemia (CML), such as interferon (IFN), have been used to shrink the massive organomegaly seen in these patients and to improve their marrow function, but are not curative, and not all patients respond or can tolerate the agent. A curative approach is allogeneic peripheral hematopoietic stem cell transplantation. The preparative regimens used in fully ablative techniques rule out older patients for consideration, and many younger patients with good prognostic criteria may do sufficiently well on medical treatment or observation to avoid transplantation. Older patients may have the option to undergo a human leukocyte antigen (HLA)-identical sibling transplant using a reduced intensity preparative regimen in order to minimize peritransplant mortality. Thus a prerequisite to the broad use of transplantation is objective determination of candidacy. Several evaluation methods agree that anemia, age, and cytogenetic abnormalities all predict poor survival in IF, suggesting that patients with anemia and an abnormal karyotype are the prime candidates for allogeneic transplantation. Experimental peripheral blood models that may reflect the degree of marrow fibrosis, such as the serum procollagen 3 peptide assay, have been used to determine if they are more informative of patient status than a single, random bone marrow sampling. Marrow fibrosis may be patchy, and thus a marrow biopsy alone without other data about marrow function may be misleading. Considerable long-term success in eradicating fibrosis and restoring normal cytogenetics, normal bone marrow morphology, and normal complete blood cell counts through transplantation has been reported. Many questions remain to be answered, however, before the appropriate role of hematopoietic stem cell transplantation in the setting of both spent-phase PV and IF can be determined.
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Affiliation(s)
- Steven M Fruchtman
- Division of Hematology, Mount Sinai School of Medicine, One Gustave L. Levy Place, Box 1410, New York, NY 10029, USA
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43
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Cervantes F, Alvarez-Larrán A, Talarn C, Gómez M, Montserrat E. Myelofibrosis with myeloid metaplasia following essential thrombocythaemia: actuarial probability, presenting characteristics and evolution in a series of 195 patients. Br J Haematol 2002; 118:786-90. [PMID: 12181046 DOI: 10.1046/j.1365-2141.2002.03688.x] [Citation(s) in RCA: 120] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Myelofibrotic transformation is a known complication of essential thrombocythaemia (ET), but information on its incidence, presenting features and evolution is scarce. In a series of 195 patients with ET followed for a median of 7.2 years (range: 1.9-24), evolution into myelofibrosis with myeloid metaplasia (MMM) occurred in 13 cases, a median of 8 years (range: 3.6-20.2) from diagnosis. The actuarial probability of this complication was 2.7% (95% CI: 2.4-2.9) at 5 years, 8.3% (95% CI: 7.8-8.9) at 10 years, and 15.3% (95% CI: 6.1-24.5) at 15 years. Four patients had not been treated before developing MMM. The main features indicating this condition were the appearance of immature myeloid precursors in the peripheral blood, a decrease in the Hb value not related to treatment and increased serum lactate dehydrogenase levels, followed by a progressive decrease in the platelet count, increasing leucocytosis and progressive splenomegaly. No patient had constitutional symptoms, and none of five evaluable cases showed chromosome abnormalities in bone marrow or unstimulated blood. After a median the myelofibrotic transformation, three patients have died and four have not required treatment for MMM as yet.
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Affiliation(s)
- Francisco Cervantes
- Haematology Department, Institute of Haematology and Oncology, Hospital Clinic, IDIBAPS, University of Barcelona, Spain.
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44
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Hasselbalch HC, Clausen NT, Jensen BA. Successful treatment of anemia in idiopathic myelofibrosis with recombinant human erythropoietin. Am J Hematol 2002; 70:92-9. [PMID: 12111781 DOI: 10.1002/ajh.10076] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
Thirteen patients with idiopathic myelofibrosis (5 osteomyelosclerosis) were treated with recombinant human erythropoietin (rHuEpo) for transfusion-dependent anemia. All but 7 patients were concomitantly treated with alpha interferon, and 5 patients also received a interferon before the start of erythropoietin (EPO) treatment. All but two patients became transfusion independent. The highly positive results of the present study of transfusion-dependent patients with idiopathic myelofibrosis calls for further studies to delineate more precisely in larger series those patients who are likely to respond to rHuEpo.
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45
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Cochran-Black DL, Burnside LK. Agnogenic Myeloid Metaplasia Terminating in Acute Megakaryoblastic Leukemia. Lab Med 2002. [DOI: 10.1309/t5gr-ul10-c337-dkle] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022] Open
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46
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Elliott MA, Mesa RA, Li CY, Hook CC, Ansell SM, Levitt RM, Geyer SM, Tefferi A. Thalidomide treatment in myelofibrosis with myeloid metaplasia. Br J Haematol 2002; 117:288-96. [PMID: 11972510 DOI: 10.1046/j.1365-2141.2002.03443.x] [Citation(s) in RCA: 98] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Myelofibrosis with myeloid metaplasia (MMM) is uniquely characterized by macroscopic bone marrow stromal changes that are believed to be both reactive and cytokine mediated. Furthermore, a prognostically detrimental increase in bone marrow angiogenesis has recently been demonstrated. These observations suggest a potential therapeutic role for agents that are inhibitory to angiogenesis as well as cytokines that are pathogenetically implicated in MMM. In a prospective study of 15 patients with MMM, thalidomide treatment, starting at a dose of 200 mg/d, resulted in increased platelet counts (12 of 15 patients), increased haemoglobin level (3 of 15), a modest decrease in spleen size (3 of 12), increased bone marrow megakaryopoiesis (5 of 9) and decreased bone marrow angiogenesis (2 of 9). Undesirable haematological effects included pericardial extramedullary haematopoiesis in one patient, marked leucocytosis in two patients and extreme thrombocytosis in three patients. The thrombocytosis occurred in both patients with post-thrombocythaemic myeloid metaplasia (PTMM) and was also associated with higher baseline levels of circulating CD34+ cells. Previously described toxicities of thalidomide were seen in the majority of patients and dose escalation to 400 mg/d was permitted in only two patients. In contrast, toxicity-related dose reductions to 50 mg/d did not appear to lessen drug efficacy. We conclude that thalidomide has both beneficial and potentially adverse biological activity in MMM. A lower dose of the drug might be more tolerable without compromising therapeutic value. Patients with PTMM and/or markedly increased circulating CD34+ cell counts might be susceptible to thalidomide-induced thrombocytosis.
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Affiliation(s)
- Michelle A Elliott
- Division of Hematology and Internal Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA.
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47
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Schmitt A, Drouin A, Massé JM, Guichard J, Shagraoui H, Cramer EM. Polymorphonuclear neutrophil and megakaryocyte mutual involvement in myelofibrosis pathogenesis. Leuk Lymphoma 2002; 43:719-24. [PMID: 12153156 DOI: 10.1080/10428190290016809] [Citation(s) in RCA: 41] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
The study presented here, performed on the bone marrow from patients with idiopathic myelofibrosis (MF) and on a murine model of MF, demonstrates a pathological interaction between PMN leukocytes and megakaryocyte (Mk), correlated with MF development. The data obtained revealed abnormal subcellular P-selectin distribution, which appeared to correlate with excessive and pathological emperipolesis of PMN leukocytes within Mk, leading to the destruction of Mk storage organelles and leakage of alpha-granular contents into the bone marrow microenvironment. The prominent role of growth factors, PDGF and TGFbeta, stored in the Mk alpha-granular compartment in the generation of MF has been previously largely documented. Both growth factors are essential for the Mk-dependent fibroblast proliferation. The destructive mutual cellular interaction of Mk and PMN leading to the pathological release of PDGF and TGFbeta within the bone marrow microenvironment may participate, through fibroblast activation, to the generation of MF. Therefore, this study provides insight into the possible pathophysiological mechanisms for the genesis of MF.
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Affiliation(s)
- Alain Schmitt
- INSERM U.474, Intitut Cochin de Génétique Moléculaire, Paris, France
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48
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Affiliation(s)
- D P Steensma
- Department of Internal Medicine, Division of Hematology, West 10, Mayo Clinic Rochester, 200 First Street SW, Rochester, MN 55905, USA.
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49
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Abstract
Myelofibrosis with myeloid metaplasia (MMM) is a chronic myeloproliferative disorder in which the accumulation and growth of circulating myeloid progenitors in the spleen lead to pathologic enlargement of the organ with resulting mechanical discomfort, hypercatabolic symptoms, anemia, thrombocytopenia, and portal hypertension. Medical therapy and splenic irradiation may be of benefit in certain patients, yet many may still require splenectomy to palliate their symptoms. Although there is no clear survival advantage to splenectomy in MMM, the procedure can result in substantial palliation of symptoms. However, the surgical procedure is associated with an approximately 9% mortality rate, and the postsplenectomy occurrence of extreme thrombocytosis, hepatomegaly, and leukemic transformation is of major concern. The management of splenomegaly and the role of splenectomy in MMM are discussed in this review.
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Affiliation(s)
- R A Mesa
- Division of Hematology and Internal Medicine, Mayo Clinic, Rochester, MN 55905, USA
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50
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Rosendaal M, Krenács T T. Regulatory pathways in blood-forming tissue with particular reference to gap junctional communication. Pathol Oncol Res 2001; 6:243-9. [PMID: 11173655 DOI: 10.1007/bf03187326] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Blood formation by pluripotent stem cells and their progeny is thought to be regulated by receptor-ligand interactions between cell-substrate, cell-cell and cell-matrix in the bone marrow. Primitive stem cells form progenitors and, in their turn, these give rise to haemopoietic progeny which are more specifically committed in that they can form progressively fewer types of blood cells. Recently we have established that direct cell-cell communication via gap junctions may be part of this regulatory system. Connexin43 gap junctions metabolically couple the three dimensional meshwork of bone marrow stromal cells to form a functional syncytium in which some blood-forming cells are also coupled. The expression of gap junctions in the bone marrow is markedly upregulated when there is an urgent and substantial demand for blood-formation; for example, following cytotoxic injury after 5-fluorouracil or irradiation; or during neonatal blood-formation and in the epiphysis of growing bones. Chemical blockade of gap junctions blocks blood-formation in long-term cultures but is reversible after the blockade has been relieved. This short review highlights briefly the known regulatory mechanisms of blood-formation with especial attention to gap junctional communication.
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Affiliation(s)
- M Rosendaal
- Department of Anatomy and Developmental Biology, University College London, Gower Street, London, WC1E 6BT, England.
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