1
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Romano A, Placidi L, Boldrini L, Chiloiro G, Dinapoli N, Galetto M, Mazzarella C, Meffe G, Nardini M, Panza G, Ceglie S, Chiusolo P, Rossi E, Indovina L, Gambacorta MA. Magnetic Resonance Imaging Guided Radiation Therapy for Splenomegaly: Clinical Experiences and Technical Tips. Adv Radiat Oncol 2024; 9:101616. [PMID: 39386317 PMCID: PMC11459635 DOI: 10.1016/j.adro.2024.101616] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2023] [Accepted: 08/12/2024] [Indexed: 10/12/2024] Open
Abstract
Purpose Splenomegaly is a common manifestation in chronic lymphoid and myeloid malignancies. Although splenectomy is the preferred treatment for symptomatic splenomegaly, it carries significant risks. Radiation therapy (RT) has traditionally been considered a palliative option. This study explores the use of magnetic resonance guided radiation therapy(MRgRT) for splenic irradiation (SI) in patients with myelofibrosis (MFI) and myelodysplastic/myeloproliferative neoplasms (MDS/MPN). Methods This single-center retrospective analysis includes patients with MFI and MDS/MPN who underwent MRgRT SI between 2018 and 2022. Ten 1 Gy fractions were delivered to the planning target volume (spleen + 3/5mm margin). An adaptive online/offline strategy has been used to reduce the dose to healthy organs. Dosimetric data and clinical outcomes, including pain relief, gastrointestinal symptoms, and hematological values, were assessed. Results Twelve patients completed SI without interruption, with supportive transfusions as needed for cytopenias. Pain and gastrointestinal symptom relief was observed in most cases. The mean percentage reduction in spleen volume was 53.61%, with an average craniocaudal extension reduction of 77.78%. Twenty-nine (24.2%) of 120 fractions were online adapted, and 14 (11.7%) were replanned offline. Nonhematological toxicities were not reported. At a median follow-up of 12.9 months, 6 patients died, whereas 9 patients underwent hematopoietic cell transplantation, with 6 of them surviving. Conclusion This study demonstrates MRgRT SI feasibility in MFI and MDS/MPN patients, offering symptom relief and significant spleen volume reduction. Real-time setup verification and adaptive planning allowed for tailored treatment with reduced margins, minimizing healthy tissue exposure. Larger prospective studies with longer follow-ups are needed to further validate its efficacy and safety.
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Affiliation(s)
- Angela Romano
- Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Lorenzo Placidi
- Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Luca Boldrini
- Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Giuditta Chiloiro
- Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Nicola Dinapoli
- Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Matteo Galetto
- Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Ciro Mazzarella
- Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Guenda Meffe
- Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Matteo Nardini
- Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Giulia Panza
- Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Sara Ceglie
- Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
- Catholic University of Sacred Heart, Hematology Service, Rome, Italy
| | - Patrizia Chiusolo
- Catholic University of Sacred Heart, Hematology Service, Rome, Italy
| | - Elena Rossi
- Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
- Catholic University of Sacred Heart, Hematology Service, Rome, Italy
| | - Luca Indovina
- Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
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2
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Dong HW, Hernandez L, Ghahremani JS, Chapek MA, Safran BA, Lau DL, Brewer MB. Venous Stasis Ulceration due to Massive Splenomegaly Causing Iliac Vein Compression From Secondary Myelofibrosis. Vasc Endovascular Surg 2024; 58:769-772. [PMID: 38770560 DOI: 10.1177/15385744241256318] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/22/2024]
Abstract
Venous stasis ulcers are nonhealing lesions due to venous hypertension secondary to valvular dysfunction or deep venous outflow obstruction. We describe a case of a 71-year-old male with a history of polycythemia vera, secondary myelofibrosis, and massive splenomegaly up to 38 cm who presented with chronic, perimalleolar venous stasis ulcers and pain on the left lower extremity. CT showed significant compression of the left common iliac vein due to mass effect from the spleen. He was managed medically while being evaluated for partial splenic artery embolization but expired due to other chronic conditions before any intervention could be performed. Partial splenic artery embolization may be considered as a treatment option for patients with symptomatic iliac vein compression due to massive splenomegaly secondary to myelofibrosis, as long as extramedullary hematopoiesis is not compromised.
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Affiliation(s)
- Henry W Dong
- Kaiser Permanente Bernard J. Tyson School of Medicine, Pasadena, CA, USA
| | - Lucille Hernandez
- Vascular and Endovascular Surgery, Department of Surgery, Kaiser Permanente Downey Medical Center, Downey, CA, USA
| | - Jacob S Ghahremani
- Kaiser Permanente Bernard J. Tyson School of Medicine, Pasadena, CA, USA
| | - Michael A Chapek
- Kaiser Permanente Bernard J. Tyson School of Medicine, Pasadena, CA, USA
| | - Brent A Safran
- Kaiser Permanente Bernard J. Tyson School of Medicine, Pasadena, CA, USA
- Vascular and Endovascular Surgery, Department of Surgery, Kaiser Permanente Downey Medical Center, Downey, CA, USA
| | - David L Lau
- Kaiser Permanente Bernard J. Tyson School of Medicine, Pasadena, CA, USA
- Vascular and Endovascular Surgery, Department of Surgery, Kaiser Permanente Downey Medical Center, Downey, CA, USA
| | - Michael B Brewer
- Kaiser Permanente Bernard J. Tyson School of Medicine, Pasadena, CA, USA
- Vascular and Endovascular Surgery, Department of Surgery, Kaiser Permanente Downey Medical Center, Downey, CA, USA
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3
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Furqan M, Oduoye MO. Momelotinib - a promising advancement in the management of myelofibrosis in adults with anemia. Front Oncol 2024; 14:1411972. [PMID: 38983933 PMCID: PMC11231182 DOI: 10.3389/fonc.2024.1411972] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2024] [Accepted: 06/12/2024] [Indexed: 07/11/2024] Open
Abstract
Myelofibrosis (MF) is a rare BCR-ABL negative myeloproliferative neoplasm characterized by clonal proliferation of stem cells, with mutations in JAK2, CALR, or MPL genes. MF presents in primary and secondary forms, with common symptoms including splenomegaly, anemia, and thrombocytopenia. Diagnostic criteria involve bone marrow examination and mutation studies. Current treatments are limited, with allogeneic stem cell transplant as the only curative option. Recent FDA approval of Momelotinib (MMB) offers new promise for MF patients with anemia. MMB, a JAK1/2 and ACVR1 inhibitor, effectively reduces spleen size, improves hemoglobin levels, and decreases transfusion dependency. The MOMENTUM trial compared MMB to danazol in JAK inhibitor-treated MF patients with anemia, showing MMB's superior symptom relief and transfusion independence rates. Additionally, the SIMPLIFY-1 and SIMPLIFY-2 trials evaluated MMB in JAK inhibitor-naïve and experienced patients, respectively, confirming MMB's non-inferiority to ruxolitinib in spleen volume reduction and highlighting its benefits in transfusion requirements. MMB's unique dual inhibition mechanism addresses anemia by suppressing hepcidin production, thus enhancing erythropoiesis. These trials collectively suggest MMB as an effective treatment for MF, improving quality of life and offering a survival advantage for patients with anemia. Despite challenges, such as trial design limitations and adverse events, MMB represents a significant advancement in MF management, providing a new therapeutic option for a previously underserved patient population.
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Affiliation(s)
- Muhammad Furqan
- Department of Medicine, King Edward Medical University, Lahore, Pakistan
| | - Malik O. Oduoye
- Department of Research and Education, Medical Research Circle, Goma, Democratic Republic of Congo
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4
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Ranalli P, Natale A, Guardalupi F, Santarone S, Cantò C, La Barba G, Di Ianni M. Myelofibrosis and allogeneic transplantation: critical points and challenges. Front Oncol 2024; 14:1396435. [PMID: 38966064 PMCID: PMC11222377 DOI: 10.3389/fonc.2024.1396435] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2024] [Accepted: 05/23/2024] [Indexed: 07/06/2024] Open
Abstract
New available drugs allow better control of systemic symptoms associated with myelofibrosis (MF) and splenomegaly but they do not modify the natural history of progressive and poor prognosis disease. Thus, hematopoietic stem cell transplantation (HSCT) is still considered the only available curative treatment for patients with MF. Despite the increasing number of procedures worldwide in recent years, HSCT for MF patients remains challenging. An increasingly complex network of the patient, disease, and transplant-related factors should be considered to understand the need for and the benefits of the procedure. Unfortunately, prospective trials are often lacking in this setting, making an evidence-based decision process particularly arduous. In the present review, we will analyze the main controversial points of allogeneic transplantation in MF, that is, the development of more sophisticated models for the identification of eligible patients; the need for tools offering a more precise definition of expected outcomes combining comorbidity assessment and factors related to the procedure; the decision-making process about the best transplantation time; the evaluation of the most appropriate platform for curative treatment; the impact of splenomegaly; and splenectomy on outcomes.
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Affiliation(s)
- Paola Ranalli
- Hematology Unit, Pescara Hospital, Pescara, Italy
- Department of Medicine and Aging Sciences, University of Chieti-Pescara, Chieti, Italy
| | | | - Francesco Guardalupi
- Department of Medicine and Aging Sciences, University of Chieti-Pescara, Chieti, Italy
| | | | - Chiara Cantò
- Hematology Unit, Pescara Hospital, Pescara, Italy
| | | | - Mauro Di Ianni
- Hematology Unit, Pescara Hospital, Pescara, Italy
- Department of Medicine and Aging Sciences, University of Chieti-Pescara, Chieti, Italy
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5
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Rienhoff HY, Gill H. Bomedemstat as an investigative treatment for myeloproliferative neoplasms. Expert Opin Investig Drugs 2023; 32:879-886. [PMID: 37804041 DOI: 10.1080/13543784.2023.2267980] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2023] [Accepted: 10/04/2023] [Indexed: 10/08/2023]
Abstract
INTRODUCTION Myeloproliferative neoplasm (MPN) is a heterogeneous group of hematopoietic stem cell disorders characterized by clonal proliferation of one of more of the hematopoietic stem cell lineages. Clinical manifestations result from uncontrolled myeloproliferation, extramedullary hematopoiesis with splenomegaly and excessive inflammatory cytokine production. Currently available therapy improves hematologic parameters and symptoms but does not adequately address the underlying neoplastic biology. Bomedemstat has thus far demonstrated clinical efficacy and tolerability in the treatment of MPNs with recent evidence of impacting the malignant stem cell population. AREAS COVERED This review summarizes the mechanisms of action, pharmacokinetics and pharmacodynamics, safety and efficacy of bomedemstat in MPN with specific emphasis on essential thrombocythemia (ET) and myelofibrosis (MF). EXPERT OPINION In patients with MPNs, bomedemstat appears effective and well tolerated. The signs and symptoms of these diseases are managed as a reduction in the frequency of mutant cells was demonstrated in patients with ET and MF. Ongoing and planned studies of bomedemstat in MPN will establish the position of bomedemstat in MPNs and may help to redefine treatment endpoints of MPNs in the future.
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Affiliation(s)
| | - Harinder Gill
- Department of Medicine, School of Clinical Medicine, LKS Faculty of Medicine, the University of Hong Kong, Hong Kong, China
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6
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Lee MW, Yeon SH, Ryu H, Song IC, Lee HJ, Yun HJ, Kim SY, Shin KS, Jo DY. Splenic Infarction in Patients with Philadelphia-negative Myeloproliferative Neoplasms. Intern Med 2022; 61:3483-3490. [PMID: 35527026 PMCID: PMC9790792 DOI: 10.2169/internalmedicine.9124-21] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
Objective We retrospectively analyzed the prevalence and clinical features of splenic infarctions in patients with Philadelphia chromosome-negative myeloproliferative neoplasms (Ph- MPNs). Patients Patients diagnosed with essential thrombocythemia (ET), polycythemia vera (PV), prefibrotic/early primary myelofibrosis (pre-PMF), or PMF from January 1996 to October 2020 in Chungnam National University Hospital, Daejeon, Korea, were reviewed. Results A total of 347 patients (143 ET, 129 PV, 44 pre-PMF, and 31 PMF patients; 201 men and 146 women) with a median age of 64 (range 15-91) years old were followed up for a median of 4.7 (range 0.1-26.5) years. Fifteen (4.3%) patients exhibited splenic infarctions at the diagnosis. These were most common in PMF patients (12.9%), followed by pre-PMF (9.1%) and PV (5.4%) patients. Multifocal infarcts (60.0%) were most common, followed by solitary (33.3%) and extensive infarcts (6.7%). The cumulative incidence of thrombosis in patients with splenic infarctions tended to be higher than in those lacking infarctions (10-year incidence 46.7% vs. 21.0% in PV; p=0.215; 33.3% vs. 17.9% in pre-PMF; p=0.473) patients, but statistical significance was lacking. Palpable splenomegaly (hazard ratio 14.89; 95% confidence interval 4.00-55.35; p<0.001) was the only independent risk factor for splenic infarction. During follow-up, 5 (1.4%) patients developed splenic infarctions. Conservative treatment adequately controlled the symptoms; no serious complications were noted in any patient. Conclusion Splenic infarctions occurred most frequently in patients with PMF; it was rare in patients with ET. The clinical courses were generally mild.
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Affiliation(s)
- Myung-Won Lee
- Division of Hematology/Oncology, Department of Internal Medicine, Chungnam National University College of Medicine, Korea
| | - Sang-Hoon Yeon
- Division of Hematology/Oncology, Department of Internal Medicine, Chungnam National University College of Medicine, Korea
| | - Hyewon Ryu
- Division of Hematology/Oncology, Department of Internal Medicine, Chungnam National University College of Medicine, Korea
| | - Ik-Chan Song
- Division of Hematology/Oncology, Department of Internal Medicine, Chungnam National University College of Medicine, Korea
| | - Hyo-Jin Lee
- Division of Hematology/Oncology, Department of Internal Medicine, Chungnam National University College of Medicine, Korea
| | - Hwan-Jung Yun
- Division of Hematology/Oncology, Department of Internal Medicine, Chungnam National University College of Medicine, Korea
| | - Seon Young Kim
- Department of Laboratory Medicine, Chungnam National University College of Medicine, Korea
| | - Kyung Sook Shin
- Department of Radiology, Chungnam National University College of Medicine, Korea
| | - Deog-Yeon Jo
- Division of Hematology/Oncology, Department of Internal Medicine, Chungnam National University College of Medicine, Korea
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7
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Low-dose Splenic Irradiation in Conjunction With Ruxolitinib to Provide Symptomatic Relief in Heavily Treated, Advanced Stage Myelofibrosis: A Case Series From a UK Tertiary Referral Center. Hemasphere 2021; 5:e611. [PMID: 34235403 PMCID: PMC8240780 DOI: 10.1097/hs9.0000000000000611] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2021] [Accepted: 05/27/2021] [Indexed: 12/03/2022] Open
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8
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Bacigalupo A, Innocenti I, Rossi E, Sora F, Galli E, Autore F, Metafuni E, Chiusolo P, Giammarco S, Laurenti L, Benintende G, Sica S, De Stefano V. Allogeneic Hemopoietic Stem Cell Transplantation for Myelofibrosis: 2021. Front Immunol 2021; 12:637512. [PMID: 34017327 PMCID: PMC8129535 DOI: 10.3389/fimmu.2021.637512] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2020] [Accepted: 04/13/2021] [Indexed: 11/13/2022] Open
Abstract
The aim of this review is to update the current status of allogeneic hemopoietic stem cell transplants (HSCT) for patients with myelofibrosis (MF). We have first summarized the issue of an indication for allogeneic HSCT, discussing several prognostic scoring systems, developed to predict the outcome of MF, and therefore to identify patients who will benefit of an allogeneic HSCT. Patients with low risk MF are usually not selected for a transplant, whereas patients with intermediate or high risk MF are eligible. A separate issue, is how to predict the outcome of HSCT: we will outline a clinical molecular myelofibrosis transplant scoring system (MTSS), which predicts overall survival, ranging from 90% for low risk patients, to 20% for very high risk patients. We will also discuss transfusion burden and spleen size, as predictors of transplant outcome. The choice of a transplant platform including the conditioning regimen, the stem cell source and GvHD prophylaxis, are crucial for a successful program in MF, and will be outlined. Complications such as poor graft function, graft failure, GvHD and relapse of the disease, will also be reviewed. Finally we discuss monitoring the disease after HSCT with donor chimerism, driver mutations and hematologic data. We have made an effort to make this review as comprehensive and up to date as possible, and we hope it will provide some useful data for the clinicians.
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Affiliation(s)
- Andrea Bacigalupo
- Dipartimento di Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, Fondazione Policlinico Universitario A. Gemelli IRCCS, Roma, Italy.,Sezione di Ematologia, Dipartimento di Scienze Radiologiche ed Ematologiche, Università Cattolica del Sacro Cuore, Roma, Italy
| | - Idanna Innocenti
- Dipartimento di Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, Fondazione Policlinico Universitario A. Gemelli IRCCS, Roma, Italy
| | - Elena Rossi
- Dipartimento di Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, Fondazione Policlinico Universitario A. Gemelli IRCCS, Roma, Italy.,Sezione di Ematologia, Dipartimento di Scienze Radiologiche ed Ematologiche, Università Cattolica del Sacro Cuore, Roma, Italy
| | - Federica Sora
- Dipartimento di Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, Fondazione Policlinico Universitario A. Gemelli IRCCS, Roma, Italy.,Sezione di Ematologia, Dipartimento di Scienze Radiologiche ed Ematologiche, Università Cattolica del Sacro Cuore, Roma, Italy
| | - Eugenio Galli
- Dipartimento di Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, Fondazione Policlinico Universitario A. Gemelli IRCCS, Roma, Italy
| | - Francesco Autore
- Dipartimento di Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, Fondazione Policlinico Universitario A. Gemelli IRCCS, Roma, Italy
| | - Elisabetta Metafuni
- Dipartimento di Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, Fondazione Policlinico Universitario A. Gemelli IRCCS, Roma, Italy
| | - Patrizia Chiusolo
- Dipartimento di Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, Fondazione Policlinico Universitario A. Gemelli IRCCS, Roma, Italy.,Sezione di Ematologia, Dipartimento di Scienze Radiologiche ed Ematologiche, Università Cattolica del Sacro Cuore, Roma, Italy
| | - Sabrina Giammarco
- Dipartimento di Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, Fondazione Policlinico Universitario A. Gemelli IRCCS, Roma, Italy
| | - Luca Laurenti
- Dipartimento di Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, Fondazione Policlinico Universitario A. Gemelli IRCCS, Roma, Italy.,Sezione di Ematologia, Dipartimento di Scienze Radiologiche ed Ematologiche, Università Cattolica del Sacro Cuore, Roma, Italy
| | - Giulia Benintende
- Sezione di Ematologia, Dipartimento di Scienze Radiologiche ed Ematologiche, Università Cattolica del Sacro Cuore, Roma, Italy
| | - Simona Sica
- Dipartimento di Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, Fondazione Policlinico Universitario A. Gemelli IRCCS, Roma, Italy.,Sezione di Ematologia, Dipartimento di Scienze Radiologiche ed Ematologiche, Università Cattolica del Sacro Cuore, Roma, Italy
| | - Valerio De Stefano
- Dipartimento di Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, Fondazione Policlinico Universitario A. Gemelli IRCCS, Roma, Italy.,Sezione di Ematologia, Dipartimento di Scienze Radiologiche ed Ematologiche, Università Cattolica del Sacro Cuore, Roma, Italy
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9
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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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10
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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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11
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Tremblay D, Schwartz M, Bakst R, Patel R, Schiano T, Kremyanskaya M, Hoffman R, Mascarenhas J. Modern management of splenomegaly in patients with myelofibrosis. Ann Hematol 2020; 99:1441-1451. [PMID: 32417942 DOI: 10.1007/s00277-020-04069-4] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2020] [Accepted: 04/28/2020] [Indexed: 12/17/2022]
Abstract
Myelofibrosis (MF) is a chronic myeloproliferative neoplasm which can lead to massive splenomegaly secondary to extramedullary hematopoiesis. Patients frequently exhibit debilitating symptoms including pain and early satiety, in addition to cellular sequestration causing severe cytopenias. JAK 1/2 inhibitors, such as ruxolitinib and fedratinib, are the mainstay of therapy and produce significant and durable reductions in spleen volume. However, many patients are not eligible for JAK 2 inhibitor therapy or become refractory to treatment over time. Novel therapies are in development that can reduce the degree of splenomegaly for some of these patients. However, splenectomy, splenic irradiation, and partial splenic artery embolization remain valuable therapeutic options in select patients. In this review, we will discuss currently available pharmacologic therapies and describe promising drugs currently in development. We will also delve into the efficacy and safety concerns of splenectomy, splenic irradiation, and partial splenic artery embolization. Finally, we will propose a treatment algorithm to help guide clinicians in the management of symptomatic splenomegaly in patients with MF.
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Affiliation(s)
- Douglas Tremblay
- Division of Hematology and Medical Oncology, Icahn School of Medicine at Mount Sinai, Tisch Cancer Institute, New York, NY, USA
| | - Myron Schwartz
- Recanati/Miller Transplantation Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Richard Bakst
- Department of Radiation of Oncology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Rahul Patel
- Division of Interventional Radiology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Thomas Schiano
- Recanati/Miller Transplantation Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Marina Kremyanskaya
- Division of Hematology and Medical Oncology, Icahn School of Medicine at Mount Sinai, Tisch Cancer Institute, New York, NY, USA
| | - Ronald Hoffman
- Division of Hematology and Medical Oncology, Icahn School of Medicine at Mount Sinai, Tisch Cancer Institute, New York, NY, USA
| | - John Mascarenhas
- Division of Hematology and Medical Oncology, Icahn School of Medicine at Mount Sinai, Tisch Cancer Institute, New York, NY, USA.
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12
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Malato A, Rossi E, Tiribelli M, Mendicino F, Pugliese N. Splenectomy in Myelofibrosis: Indications, Efficacy, and Complications. CLINICAL LYMPHOMA MYELOMA & LEUKEMIA 2020; 20:588-595. [PMID: 32482540 DOI: 10.1016/j.clml.2020.04.015] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/11/2020] [Revised: 04/20/2020] [Accepted: 04/22/2020] [Indexed: 10/24/2022]
Abstract
Splenomegaly, which may range from a few centimeters below the left costal border to massive dimensions, is one of the most characteristic features in patients with advanced myelofibrosis (MF). Splenectomy may offer an effective therapeutic option for treating massive splenomegaly in patients with MF, and especially in cases of disease refractory to conventional drugs, but it is associated with a number of complications as well as substantial morbidity and mortality. Whether splenectomy should be performed before allogeneic hematopoietic stem-cell transplantation is also controversial, and there is a lack of prospective randomized clinical trials that assess the role of splenectomy before hematopoietic stem-cell transplantation in patients with MF. Although splenectomy is not routinely performed before transplantation, it may be appropriate in patients with massive splenomegaly and related symptoms, so long as the higher risk of graft failure in such cases is taken into account. This review aims to describe the efficacy, indications, and complications of splenectomy in patients with MF; and to evaluate the long-term impact of splenectomy on patient survival and risk of disease transformation.
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Affiliation(s)
- Alessandra Malato
- UOC di Ematologia I ad Indirizzo Oncologico, Ospedali Riuniti Villa Sofia-Cervello, Palermo, Italy.
| | - Elena Rossi
- Istituto di Ematologia, Università Cattolica del Sacro Cuore, Rome, Italy; Department of Image, radiation therapy, oncology and hematology Diagnosis, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Mario Tiribelli
- Division of Hematology and Bone Marrow Transplantation, Department of Medical Area, University of Udine, Udine, Italy
| | - Francesco Mendicino
- Hematology Unit, Department of Hemato-oncology, Ospedale Annunziata, Cosenza, Italy
| | - Novella Pugliese
- Department of Clinical Medicine and Surgery, University of Naples Federico II, Naples, Italy
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13
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Oon SF, Singh D, Tan TH, Lee A, Noe G, Burbury K, Paiva J. Primary myelofibrosis: spectrum of imaging features and disease-related complications. Insights Imaging 2019; 10:71. [PMID: 31388788 PMCID: PMC6684717 DOI: 10.1186/s13244-019-0758-y] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2019] [Accepted: 05/28/2019] [Indexed: 02/08/2023] Open
Abstract
Primary myelofibrosis is a chronic clonal stem cell disorder that results in a build-up of marrow fibrosis and dysfunction, hypermetabolic states, and myeloid metaplasia. The clinical and radiological consequences can be quite diverse and range from the manifestations of osteosclerosis and extramedullary haematopoiesis to thrombohaemorrhagic complications from haemostatic dysfunction. In addition, there is the challenge of identifying less well-recognised sites of extramedullary haematopoiesis and their site-specific complications. The intent of this article is to illustrate the spectrum of primary myelofibrosis as declared though multimodality imaging, with examples of both common and rarer disease manifestations.
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Affiliation(s)
- Sheng Fei Oon
- Department of Radiology, Peter MacCallum Cancer Centre, Melbourne, Australia.
| | - Dalveer Singh
- Department of Radiology, Peter MacCallum Cancer Centre, Melbourne, Australia
| | - Teng Han Tan
- Department of Radiology, Peter MacCallum Cancer Centre, Melbourne, Australia
| | - Allan Lee
- Department of Radiology, Peter MacCallum Cancer Centre, Melbourne, Australia
| | - Geertje Noe
- Department of Haematology, Peter MacCallum Cancer Centre, Melbourne, Australia
| | - Kate Burbury
- Department of Haematology, Peter MacCallum Cancer Centre, Melbourne, Australia.,University of Melbourne, Melbourne, Australia
| | - Joseph Paiva
- Department of Radiology, Peter MacCallum Cancer Centre, Melbourne, Australia
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14
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Helbig G, Wieczorkiewicz-Kabut A, Markiewicz M, Krzemień H, Wójciak M, Białas K, Kopera M, Rzenno E, Woźniczka K, Kopińska A, Grygoruk-Wiśniowska I, Koclęga A. Splenic irradiation before allogeneic stem cell transplantation for myelofibrosis. Med Oncol 2019; 36:16. [PMID: 30617767 PMCID: PMC6326000 DOI: 10.1007/s12032-019-1245-5] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2018] [Accepted: 01/02/2019] [Indexed: 11/29/2022]
Abstract
Splenectomy before allogeneic stem cell transplantation (ASCT) for patients with myelofibrosis (MF) remains a matter of debate, and conflicting results have been reported to date. The procedure seems to fasten post-transplant hematological recovery, but it does not have an impact on survival. The role of pre-transplant splenic irradiation (SI) is much more difficult to evaluate. Forty-four patients (25 males and 19 females) with MF at median age of 49 years at diagnosis (range 14-67) underwent ASCT. The post-transplant outcome was compared between irradiated and non-irradiated patients. Eleven patients received irradiation before transplantation. Median dose of radiation was 1000 cGy (range 600-2400). There was no difference in median time to engraftment between patients with and without previous radiotherapy. Acute and chronic graft versus host disease (GVHD) occurred in 47% and 36% of patients, respectively. There was no difference in GVHD incidence between groups. Eight patients relapsed/progressed in irradiated group versus 17 in non-irradiated (70% vs. 51%; p = 0.3). Transformation to acute myeloid leukemia was observed in 3 patients: 2 in irradiated and 1 in non-irradiated group. In total, 22 patients died with no statistical difference in death rate between irradiated and non-irradiated subjects. The probability of overall survival after transplant for the entire cohort at 2 years was 54% (72% for irradiated and 48% for non-irradiated patients; p = 0.25). Splenic irradiation prior to ASCT for myelofibrosis has not beneficial effect on post-transplant outcome.
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Affiliation(s)
- Grzegorz Helbig
- Department of Hematology and Bone Marrow Transplantation, School of Medicine in Katowice, Medical University of Silesia, Dąbrowski Street 25, 40-032, Katowice, Poland.
| | - Agata Wieczorkiewicz-Kabut
- Department of Hematology and Bone Marrow Transplantation, School of Medicine in Katowice, Medical University of Silesia, Dąbrowski Street 25, 40-032, Katowice, Poland
| | - Mirosław Markiewicz
- Department of Hematology and Bone Marrow Transplantation, School of Medicine in Katowice, Medical University of Silesia, Dąbrowski Street 25, 40-032, Katowice, Poland
| | - Helena Krzemień
- Department of Hematology and Bone Marrow Transplantation, School of Medicine in Katowice, Medical University of Silesia, Dąbrowski Street 25, 40-032, Katowice, Poland
| | - Michał Wójciak
- Students' Research Group, Medical University of Warsaw, Warsaw, Poland
| | - Krzysztof Białas
- Department of Hematology and Bone Marrow Transplantation, School of Medicine in Katowice, Medical University of Silesia, Dąbrowski Street 25, 40-032, Katowice, Poland
| | - Małgorzata Kopera
- Department of Hematology and Bone Marrow Transplantation, School of Medicine in Katowice, Medical University of Silesia, Dąbrowski Street 25, 40-032, Katowice, Poland
| | - Ewa Rzenno
- Department of Hematology and Bone Marrow Transplantation, School of Medicine in Katowice, Medical University of Silesia, Dąbrowski Street 25, 40-032, Katowice, Poland
| | - Krzysztof Woźniczka
- Department of Hematology and Bone Marrow Transplantation, School of Medicine in Katowice, Medical University of Silesia, Dąbrowski Street 25, 40-032, Katowice, Poland
| | - Anna Kopińska
- Department of Hematology and Bone Marrow Transplantation, School of Medicine in Katowice, Medical University of Silesia, Dąbrowski Street 25, 40-032, Katowice, Poland
| | - Iwona Grygoruk-Wiśniowska
- Department of Hematology and Bone Marrow Transplantation, School of Medicine in Katowice, Medical University of Silesia, Dąbrowski Street 25, 40-032, Katowice, Poland
| | - Anna Koclęga
- Department of Hematology and Bone Marrow Transplantation, School of Medicine in Katowice, Medical University of Silesia, Dąbrowski Street 25, 40-032, Katowice, Poland
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15
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Fowlkes S, Murray C, Fulford A, De Gelder T, Siddiq N. Myeloproliferative neoplasms (MPNs) - Part 2: A nursing guide to managing the symptom burden of MPNs. Can Oncol Nurs J 2018; 28:276-281. [PMID: 31148831 DOI: 10.5737/23688076284276281] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Myeloproliferative neoplasms (MPNs) are rare, yet potentially life-threatening, disorders caused by overproliferation of bone marrow stem cells. The symptom burden experienced by patients with the BCR-ABL1-negative MPNs (also referred to as the classical MPNs, i.e., essential thrombocythemia [ET], polycythemia vera [PV] and myelofibrosis [MF]) can be significant and can negatively impact quality of life (QOL). Since patients with these MPNs can live for several years, thereby requiring long-term treatment and follow-up, nurses play an essential role in communicating with these patients, assessing their symptoms, and educating them on treatments and self-management strategies that can reduce their symptom burden. This article, which is the second of a twopart series, was developed to provide nurses and other healthcare professionals with practical guidance for managing the symptom burden associated with the classical MPNs in order to help enhance their patients' overall health and QOL.
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Affiliation(s)
- Sabrina Fowlkes
- Chronic Myelogenous Leukemia/Myeloproliferative Neoplasms, Jewish General Hospital, Montreal, Quebec
| | - Cindy Murray
- Malignant Hematology, UHN Princess Margaret Cancer Centre, Toronto, Ontario
| | - Adrienne Fulford
- Hematology Oncology, London Health Sciences Centre, London, Ontario
| | - Tammy De Gelder
- Hamilton Health Sciences, Juravinski Hospital and Cancer Centre, Hamilton, Ontario
| | - Nancy Siddiq
- Clinical Nurse Specialist for Myeloproliferative Neoplasms (MPN), Princess Margaret Cancer Centre, Toronto, Ontario
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16
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de la Pinta C, Fernández Lizarbe E, Montero Luis Á, Domínguez Rullán JA, Sancho García S. Treatment of symptomatic splenomegaly with low doses of radiotherapy: Retrospective analysis and review of the literature. Tech Innov Patient Support Radiat Oncol 2017; 3-4:23-29. [PMID: 32095563 PMCID: PMC7033798 DOI: 10.1016/j.tipsro.2017.08.002] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2017] [Revised: 07/09/2017] [Accepted: 08/09/2017] [Indexed: 01/28/2023] Open
Abstract
OBJECTIVES To evaluate the effectiveness of low doses of radiation therapy for symptomatic splenomegaly in malignant and benign diseases. PATIENTS AND METHODS 5 patients with symptomatic splenomegaly were treated with low doses of radiation in our centre (January 2008-December 2016). 4/5 patients had malignant neoplasia (acute myeloid leukemia, non Hogdkin lymphoma and prolymphocytic B cell leukemia) and splenomegaly was caused by extramedullary hematopoiesis. 1/5 patient had benign disease (HBV liver cirrhosis) and splenomegaly was caused by vascular ectasia. Median age was 73 years (range 61-86 years). There were 4 females and 1 male. These patients had exclusively splenic pain or abdominal discomfort in 20%, exclusively cytopenias 40% and both 40%. Patients needed radiation therapy for symptomatic control. Dose per fraction was 0.5 Gy every two days; total dose initially prescribed 10 Gy. IGRT were performed in all patients to ensure an appropriate position and to adapt the treatment volume to the changes in the spleen volume along the treatment. Median craneocaudal length size of the spleen was more than 26 cm (range 15.2-34.9 cm). RESULTS Median radiation doses were 4.85 Gy (range 2.5-10). Median craneocaudal spleen size reduction was 4.6 cm (0-8 cm). Splenic pain and abdominal disturbances improved in all patients. Median increase of haemoglobin and platelets levels was 1.6 mg/dl and 27.950 cells respectively in the first week after the end of radiotherapy.One patient had to interrupt her treatment due to grade II neutropenia. No other toxicities were described. With a median follow-up of 39 months (16-89 months), only one recurrence was described at 24 months and consisted of thrombocytopenia. The patient received a second course of radiotherapy with excellent response. CONCLUSION Low doses of radiation therapy for treatment of symptomatic splenomegaly were effective, with a low rate of side effects. Splenic pain and abdominal discomfort completely improved and cytopenias rised to secure levels.
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17
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Zaorsky NG, Williams GR, Barta SK, Esnaola NF, Kropf PL, Hayes SB, Meyer JE. Splenic irradiation for splenomegaly: A systematic review. Cancer Treat Rev 2017; 53:47-52. [PMID: 28063304 PMCID: PMC7537354 DOI: 10.1016/j.ctrv.2016.11.016] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2016] [Revised: 11/19/2016] [Accepted: 11/29/2016] [Indexed: 10/20/2022]
Abstract
Splenic irradiation (SI) is a palliative treatment option for symptomatic splenomegaly (i.e. for pain, early satiety, pancytopenia from sequestration) secondary to hematologic malignancies and disorders. The purpose of the current article is to review the literature on SI for hematologic malignancies and disorders, including: (1) patient selection and optimal technique; (2) efficacy of SI; and (3) toxicities of SI. PICOS/PRISMA methods are used to select 27 articles including 766 courses of SI for 486 patients from 1960 to 2016. The most common cancers treated included chronic lymphocytic leukemia and myeloproliferative disorders; the most common regimen was 10Gy in 1Gy fractions over two weeks, and 27% of patients received retreatment. A partial or complete response (for symptoms, lab abnormalities) was obtained in 85-90% of treated patients, and 30% were retreated within 6-12months. There was no correlation between biologically equivalent dose of radiation therapy and response duration, pain relief, spleen reduction, or cytopenia improvement (r2 all <0.4); therefore, lower doses (e.g. 5Gy in 5 fractions) may be as effective as higher doses. Grade 3-4 toxicity (typically leukopenia, infection) was noted in 22% of courses, with grade 5 toxicity in 0.7% of courses. All grade 5 toxicities were due to either thrombocytopenia with hemorrhage or leukopenia with sepsis (or a combination of both); they were sequelae of cancer and not directly caused by SI. In summary, SI is generally a safe and efficacious method for treating patients with symptomatic splenomegaly.
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Affiliation(s)
- Nicholas G Zaorsky
- Department of Radiation Oncology, Fox Chase Cancer Center, Philadelphia, PA, USA.
| | - Graeme R Williams
- Department of Radiation Oncology, Fox Chase Cancer Center, Philadelphia, PA, USA
| | - Stefan K Barta
- Department of Medical Oncology, Fox Chase Cancer Center, Philadelphia, PA, USA
| | - Nestor F Esnaola
- Department of Surgical Oncology, Fox Chase Cancer Center, Philadelphia, PA, USA
| | - Patricia L Kropf
- Department of Medical Oncology, Fox Chase Cancer Center, Philadelphia, PA, USA
| | - Shelly B Hayes
- Department of Radiation Oncology, Fox Chase Cancer Center, Philadelphia, PA, USA
| | - Joshua E Meyer
- Department of Radiation Oncology, Fox Chase Cancer Center, Philadelphia, PA, USA.
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18
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Al-Ali HK, Vannucchi AM. Managing patients with myelofibrosis and low platelet counts. Ann Hematol 2016; 96:537-548. [PMID: 27209535 DOI: 10.1007/s00277-016-2697-8] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2016] [Accepted: 05/10/2016] [Indexed: 12/18/2022]
Abstract
Myelofibrosis (MF) is a chronic myeloproliferative neoplasm characterized by bone marrow fibrosis, ineffective hematopoiesis, splenomegaly, constitutional symptoms, and shortened survival. Patients often experience multiple disease-associated, as well as treatment-emergent, cytopenias, including thrombocytopenia. However, patients with MF with thrombocytopenia have few therapeutic options, and there is little information on the management of these patients. Several Janus kinase (JAK) inhibitors have been developed for the treatment of MF, with one (ruxolitinib) having been approved. However, given their mechanism of action, JAK inhibitors are associated with high rates of thrombocytopenia. Patients can be successfully managed with dose modifications, but little is known about the safety and efficacy of these agents in patients with thrombocytopenia. Recent studies of JAK inhibitors in patients with MF who have low platelet counts have had mixed results. This review discusses the prevalence, prognostic implications, and management of thrombocytopenia in MF and the different therapeutic options available for this patient population, with an emphasis on current clinical experience with targeted therapies, as well as recent findings from several clinical studies currently underway.
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Affiliation(s)
| | - Alessandro M Vannucchi
- CRIMM, Center for Research and Innovation of Myeloproliferative Neoplasms, AOU Careggi, Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
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19
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Alimam S, Harrison C. Is there a role for pomalidomide in the treatment of myelofibrosis? Expert Opin Orphan Drugs 2016. [DOI: 10.1517/21678707.2016.1171139] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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20
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Adaptive splenic radiotherapy for symptomatic splenomegaly management in myeloproliferative disorders. TUMORI JOURNAL 2015; 101:84-90. [PMID: 25702680 DOI: 10.5301/tj.5000221] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/23/2014] [Indexed: 02/07/2023]
Abstract
AIMS AND BACKGROUND Symptomatic, massive splenomegaly is a debilitating complication of myeloproliferative disorders. In the study, we evaluated the use of a contemporary, individualized radiotherapeutic approach for splenic irradiation, including 3-dimensional computed tomography-based treatment planning, individualized treatment margins based on splenic motion assessment, online setup verification with volumetric image guidance at each fraction, and adaptive radiation treatment planning to account for changes in splenic size during the fractionated radiotherapy course. METHODS AND STUDY DESIGN Between December 2008 and January 2014, 18 patients (13 males, 5 females) with myeloproliferative disorders referred to Gulhane Military Medical Academy Radiation Oncology Department underwent 22 courses of splenic irradiation using 3-dimensional computed tomography-based treatment planning and volumetric image guidance for palliation of symptomatic splenomegaly. RESULTS Median age was 64 years (range 28-79). Significant pain relief was achieved in 20 of the 22 splenic irradiation courses (90.9%). Improvement in hematological parameters was achieved in 8 of the 11 splenic irradiation courses applied for cytopenia (72.7%). At least a 50% reduction in splenic size was achieved in 18 of the 22 splenic irradiation courses (81.8%). Toxicity was manageable with supportive treatment including antiemetics and platelet or red blood cell transfusions. CONCLUSIONS Splenic irradiation with a contemporary radiotherapeutic approach offers safe and effective palliation of symptomatic splenomegaly in myeloproliferative disorders.
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21
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Pardanani A, Tefferi A. Definition and management of ruxolitinib treatment failure in myelofibrosis. Blood Cancer J 2014; 4:e268. [PMID: 25501025 PMCID: PMC4315890 DOI: 10.1038/bcj.2014.84] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2014] [Accepted: 10/10/2014] [Indexed: 12/11/2022] Open
Abstract
Ruxolitinib, a Janus kinase (JAK)-1 and JAK-2 inhibitor, is the first-in-class drug to be licensed in the United States for the treatment of high- and intermediate-risk myelofibrosis (MF). Several other JAK inhibitors are in development with some currently undergoing phase-3 clinical trial testing. None of the currently available JAK inhibitors are specific to mutant JAK2; their mechanism of action involves attenuation of JAK-STAT signaling with downregulation of proinflammatory cytokines, rather than selective suppression of the disease clone. Accordingly, while ruxolitinib and other JAK inhibitors are effective in controlling splenomegaly and alleviating constitutional symptoms, their benefit in terms of reversing bone marrow fibrosis or inducing complete or partial remissions appears to be limited. The experience to date with ruxolitinib shows that despite its salutary effects on quality of life, over half of the patients discontinue treatment within 2-3 years. In the current perspective, we examine the incidence and causes of ruxolitinib 'treatment failure' in MF patients based on our personal experience as well as a review of the published literature. We also discuss the challenges in defining and classifying ruxolitinib failure, and within the context of several clinical scenarios, we provide recommendations for the post-ruxolitinib management of MF patients.
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Affiliation(s)
- A Pardanani
- Division of Hematology, Department of Medicine, Mayo Clinic, Rochester, MN, USA
| | - A Tefferi
- Division of Hematology, Department of Medicine, Mayo Clinic, Rochester, MN, USA
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22
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Cox JA, Sevak PR, Grumbles LL, Swanson TA, Hatch SS. Single-fraction radiotherapy for palliation of myelofibrosis-related extremity pain syndrome. J Pain Symptom Manage 2014; 48:299-304. [PMID: 24315514 DOI: 10.1016/j.jpainsymman.2013.09.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2013] [Revised: 09/04/2013] [Accepted: 09/10/2013] [Indexed: 12/12/2022]
Affiliation(s)
- John A Cox
- Department of Radiation Oncology, The University of Texas Medical Branch, Galveston, Texas, USA; Department of Radiation Oncology, Indiana University, Indianapolis, Indiana, USA.
| | - Parag R Sevak
- School of Medicine, The University of Texas Medical Branch, Galveston, Texas, USA
| | - Loretta L Grumbles
- Department of Internal Medicine, The University of Texas Medical Branch, Galveston, Texas, USA
| | - Todd A Swanson
- Department of Radiation Oncology, The University of Texas Medical Branch, Galveston, Texas, USA
| | - Sandra S Hatch
- Department of Radiation Oncology, The University of Texas Medical Branch, Galveston, Texas, USA
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23
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Manea PJ. Optimizing the management of patients with myelofibrosis. Clin J Oncol Nurs 2014; 18:330-7. [PMID: 24867113 DOI: 10.1188/14.cjon.330-337] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Myelofibrosis (MF) is a rare myeloproliferative neoplasm of the bone marrow associated with shortened survival. The disease is characterized by splenomegaly, cytopenias, and multiple disease-related symptoms that reduce quality of life. The clinical management of MF can be challenging because of its heterogeneous presentation and disease course. Therefore, knowledge of the underlying pathology and clinical manifestations of MF is needed. Ruxolitinib, a Janus kinase (JAK) 1 and 2 inhibitor, is the first therapy to be approved by the U.S. Food and Drug Administration for intermediate- or high-risk MF. Ruxolitinib therapy offers advantages over the previous palliative treatments and has shown durable reductions in splenomegaly and disease symptoms as well as improvements in quality of life. Two-year follow-up of the phase III trials also has shown that ruxolitinib treatment was associated with a survival advantage relative to control groups. Dose-dependent thrombocytopenia and anemia are expected but manageable adverse effects caused by the targeted JAK inhibition of ruxolitinib. This review provides an overview of MF and assessment of the primary clinical disease manifestations, with a focus on ruxolitinib from the oncology nurse perspective.
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Harrison C, Mesa R, Ross D, Mead A, Keohane C, Gotlib J, Verstovsek S. Practical management of patients with myelofibrosis receiving ruxolitinib. Expert Rev Hematol 2013; 6:511-23. [PMID: 24083419 PMCID: PMC8201600 DOI: 10.1586/17474086.2013.827413] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Myelofibrosis (MF) is characterized by bone marrow fibrosis, progressive anemia and extramedullary hematopoiesis, primarily manifested as splenomegaly. Patients also experience debilitating constitutional symptoms, including sequelae of splenomegaly, night sweats and fatigue. Ruxolitinib (INC424, INCB18424, Jakafi, Jakavi), a JAK1 and JAK2 inhibitor, was approved in November 2011 by the US FDA for the treatment of intermediate- or high-risk MF, and more recently in Europe and Canada for the treatment of MF-related splenomegaly or symptoms. These approvals were based on data from two randomized Phase III studies: COMFORT-I randomized against placebo, and COMFORT-II randomized against best available therapy. In these studies, ruxolitinib rapidly improved multiple disease manifestations of MF, reducing splenomegaly and improving quality of life of patients and potentially prolonging survival. However, as with other chemotherapies, ruxolitinib therapy is associated with some adverse events, such as anemia and thrombocytopenia. The aims of this article are to provide a brief overview of ruxolitinib therapy, to discuss some common adverse events associated with ruxolitinib therapy and to provide clinical management recommendations to maximize patients' benefit from ruxolitinib.
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Affiliation(s)
| | | | - David Ross
- SA Pathology, Flinders Medical Centre, Adelaide, Australia
| | | | | | | | - Srdan Verstovsek
- The University of Texas, MD Anderson Cancer Center, Houston, TX, USA
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