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Tang ASO, Leong TS, Wong QY, Tan XY, Ko CT, Ngew KY, Teh EKJ, Chew LP. The Sarawak Myelofibrosis (SaMy) experience: Demographics and outcome of myelofibrosis patients in Sarawak, Malaysia. SAGE Open Med 2023; 11:20503121231194433. [PMID: 37705719 PMCID: PMC10496467 DOI: 10.1177/20503121231194433] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2023] [Accepted: 07/27/2023] [Indexed: 09/15/2023] Open
Abstract
Introduction: Myelofibrosis is a rare disease. There is currently no published data reporting the demographics and outcome of myelofibrosis patients in Malaysia. We aimed to study the demographics, clinical characteristics, and outcome of our patients in Sarawak. Materials and methods: This non-interventional, retrospective, and multi-center study was conducted on secondary data of medical records collected at four Sarawak Public Hospitals. All adult myelofibrosis patients diagnosed between January 2001 and December 2021 were included. Results: A total of 63 patients (male 31) with myelofibrosis were included-47 (74.6%) primary and 16 (25.4%) secondary myelofibrosis. Eleven had antecedent polycythaemia vera, whereas five transformed from essential thrombocythaemia. The combined annual incidence rate was 0.182 per 100,000 population. The period prevalence per 100,000 population over the entire study duration was 2.502. The median age was 59.0 years (33.0-93.0). Majority had high-risk (34/63(54.0%)) and intermediate-2 risk disease (19/63(30.2%)). JAK2V617F mutation was identified in 52 patients (82.5%), followed by CALR mutation in 6 (9.5%) and negative for both mutations in 5 (7.9%). Hydroxyurea was used as first-line therapy in 41/63 (65.1%), followed by interferon (8/63(12.7%)) and ruxolitinib (4/63(6.3%)). Out of 46 patients who received second-line therapy, 18 (39.1%) were switched to ruxolitinib and 9 (19.6%) to interferon. The median age of survival for overall patients was 6.8 years. The use of ruxolitinib in myelofibrosis patients showed a better overall 5-year survival compared to the no ruxolitinib arm, despite no statistical significance (p = 0.34). Patients who had good performance status had lower hazard of death than patients who had poor performance status (high-risk (95% confidence intervals): 0.06(0.013-0.239), p < 0.001). Patients with intermediate risk disease had better overall survival compared to those in high-risk group (95% confidence intervals): 0.24(0.082-0.695), p = 0.009). Conclusion: This registry provides a real-world overview of myelofibrosis patients in our state and highlights the key insight into the unmet clinical need.
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Affiliation(s)
- Andy Sing Ong Tang
- Department of Medicine, Haematology Unit, Sarawak General Hospital, Ministry of Health Malaysia, Kuching, Malaysia
| | - Tze Shin Leong
- Department of Medicine, Haematology Unit, Sarawak General Hospital, Ministry of Health Malaysia, Kuching, Malaysia
| | - Qi Ying Wong
- Department of Medicine, Miri Hospital, Ministry of Health Malaysia, Miri, Sarawak, Malaysia
| | - Xin Yee Tan
- Department of Medicine, Sibu Hospital, Ministry of Health Malaysia, Sibu, Sarawak, Malaysia
| | - Ching Tiong Ko
- Department of Medicine, Haematology Unit, Sarawak General Hospital, Ministry of Health Malaysia, Kuching, Malaysia
| | - Kok Yew Ngew
- RWE, CONEXTS, Novartis Corporation (Malaysia) Sdn Bhd, Petaling Jaya, Malaysia
| | - Erik Kah Jin Teh
- Medical Affairs, Novartis Corporation (Malaysia) Sdn Bhd, Petaling Jaya, Malaysia
| | - Lee Ping Chew
- Department of Medicine, Haematology Unit, Sarawak General Hospital, Ministry of Health Malaysia, Kuching, Malaysia
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2
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Freyer CW, Babushok DV, Frey NV, Gill SI, Loren AW, Luger SM, Maity A, Martin ME, Plastaras JP, Porter DL, Hexner EO. Low-Dose Total Body Irradiation Added to Fludarabine and Busulfan Reduced-Intensity Conditioning Reduces Graft Failure in Patients with Myelofibrosis. Transplant Cell Ther 2022; 28:590-596. [DOI: 10.1016/j.jtct.2022.06.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2022] [Revised: 06/16/2022] [Accepted: 06/20/2022] [Indexed: 10/17/2022]
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3
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CD34+ -selected hematopoietic stem cell transplant conditioned with a myeloablative regimen in patients with advanced myelofibrosis. Bone Marrow Transplant 2022; 57:1101-1107. [PMID: 35484207 PMCID: PMC10015419 DOI: 10.1038/s41409-022-01684-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2021] [Revised: 03/23/2022] [Accepted: 04/06/2022] [Indexed: 11/09/2022]
Abstract
Allogeneic hematopoietic stem cell transplantation (Allo-HCT) remains the only curative treatment for myelofibrosis (MF). Transplantation in patients with MF is mostly done using a reduced intensity conditioning regimen with calcineurin inhibitors for graft versus host disease (GVHD) prophylaxis. Here we sought to evaluate outcomes of patients who underwent an ex vivo CD34+ -selected allo-HCT using myeloablative conditioning (MAC). Twenty-seven patients were included in this retrospective analysis. All patients were conditioned with busulfan, melphalan and fludarabine and antithymocyte globulin to prevent graft rejection. G-CSF mobilized peripheral blood stem cell grafts were depleted of T-cells using immunomagnetic CD34+ selection by CliniMACS device. Median follow-up among survivors was 50.6 months. The estimated 3-year overall survival, relapse free survival and the combined endpoint of GVHD/relapse free survival were 88% (95% CI, 75-100%), 80% (95% CI, 66-98%) and 74% (95% CI, 59-93%), respectively. The cumulative incidence of grade II-IV acute GVHD at day 100 was 33.3% (95% CI 16.4-51.3%), and two patients suffered chronic GVHD. There were no cases of primary graft failure. However, delayed graft failure occurred in two patients. We conclude that CD34+ selected allo-HCT with a MAC resulted in high survival rates in this cohort of patients with MF.
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Bewersdorf JP, Sheth AH, Vetsa S, Grimshaw A, Giri S, Podoltsev NA, Gowda L, Tamari R, Tallman MS, Rampal RK, Zeidan AM, Stahl M. Outcomes of Allogeneic Hematopoietic Cell Transplantation in Patients With Myelofibrosis-A Systematic Review and Meta-Analysis. Transplant Cell Ther 2021; 27:873.e1-873.e13. [PMID: 34052505 PMCID: PMC8478722 DOI: 10.1016/j.jtct.2021.05.016] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2021] [Revised: 05/18/2021] [Accepted: 05/20/2021] [Indexed: 01/14/2023]
Abstract
Allogeneic hematopoietic cell transplant (allo-HCT) remains the only potentially curative therapeutic modality for patients with primary or secondary myelofibrosis (MF). However, many patients are considered ineligible for allo-HCT, and transplant-related mortality can be substantial. Data on the efficacy and safety of allo-HCT are mixed and largely derived from retrospective studies. We aimed to synthesize the available evidence on the safety and efficacy of allo-HCT in MF and to identify patient, disease, and transplant characteristics with prognostic impact on outcomes of patients with MF undergoing allo-HCT. For this systematic review and meta-analysis, Cochrane Library, Google Scholar, Ovid Medline, Ovid Embase, PubMed, Scopus, and Web of Science Core Collection were searched from inception to October 11, 2020, for studies on allo-HCT in MF. Random-effects models were used to pool response rates for the co-primary outcomes of 1-year, 2-year, and 5-year overall survival (OS). Rates of non-relapse mortality and acute and chronic graft-versus-host-disease (GVHD) were studied as secondary endpoints. Subgroup analyses on the effect of conditioning regimen intensity, baseline dynamic international prognostic scoring system (DIPSS) score, and patient age were performed. The study protocol has been registered on PROSPERO (CRD42020188706). Forty-three studies with 8739 patients were identified and included in this meta-analysis. Rates of 1-year, 2-year, and 5-year OS were 66.7% (95% confidence interval [CI], 63.5%-69.8%), 64.4% (95% CI, 57.6%-70.6%), and 55.0% (95% CI, 51.8%-58.3%), respectively. Rates of 1-year, 2-year, and 5-year nonrelapse mortality were 25.9% (95% CI, 23.3%-28.7%), 29.7% (95% CI, 24.5%-35.4%), and 30.5% (95% CI, 25.9%-35.5%), respectively. The combined rate of graft failure was 10.6% (95% CI, 8.9%-12.5%) with primary and secondary graft failure occurring in 7.3% (95% CI, 5.7%-9.4%) and 5.9% (95% CI, 4.3%-8.0%) of patients, respectively. Rates of acute and chronic graft-versus-host disease were 44.0% (95% CI, 39.6%-48.4%; grade III/IV: 15.2%) and 46.5% (95% CI, 42.2%-50.8%; extensive or moderate/severe: 26.1%), respectively. Subgroup analyses did not show any significant difference between conditioning regimen intensity (myeloablative versus reduced-intensity), median patient age, and proportion of DIPSS-intermediate-2/high patients. The quality of the evidence is limited by the absence of randomized clinical trials in the field and the heterogeneity of patient and transplant characteristics across included studies. Given the poor prognosis of patients not receiving transplants and in the absence of curative nontransplantation therapies, our results support consideration of allo-HCT for eligible patients with MF.
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Affiliation(s)
- Jan Philipp Bewersdorf
- Department of Internal Medicine, Section of Hematology, Yale School of Medicine, New Haven, Connecticut
| | | | - Shaurey Vetsa
- Yale School of Medicine, Department of Neurosurgery, New Haven, Connecticut
| | - Alyssa Grimshaw
- Harvey Cushing/John Hay Whitney Medical Library, Yale University, New Haven, Connecticut
| | - Smith Giri
- Division of Hematology and Oncology, University of Alabama School of Medicine
| | - Nikolai A Podoltsev
- Department of Internal Medicine, Section of Hematology, Yale School of Medicine, New Haven, Connecticut; Cancer Outcomes, Public Policy, and Effectiveness Research (COPPER) Center, Yale University, New Haven, Connecticut
| | - Lohith Gowda
- Department of Internal Medicine, Section of Hematology, Yale School of Medicine, New Haven, Connecticut
| | - Roni Tamari
- Bone Marrow Transplant Service, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Martin S Tallman
- Leukemia Service, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Raajit K Rampal
- Leukemia Service, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Amer M Zeidan
- Department of Internal Medicine, Section of Hematology, Yale School of Medicine, New Haven, Connecticut; Cancer Outcomes, Public Policy, and Effectiveness Research (COPPER) Center, Yale University, New Haven, Connecticut
| | - Maximilian Stahl
- Department of Medical Oncology, Adult Leukemia Program, Dana-Farber Cancer Institute, Boston, Massachusetts.
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5
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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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6
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Abstract
Myelofibrosis (MF) belongs to a group of clonal stem cell disorders known as the BCR-ABL-negative myeloproliferative neoplasms. Allogeneic hematopoietic stem cell transplantation (HCT) is currently the only curative treatment option for MF. Because HCT can be associated with significant morbidity and mortality, patients need to be carefully selected based on disease-risk, fitness, and transplant factors. Furthermore, in the era of JAK inhibitors, the timing of transplantation has become a challenging question. Here the authors review recent developments in HCT for MF, focusing on risk stratification and optimal timing.
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Affiliation(s)
- Marta B Davidson
- Division of Medical Oncology and Hematology, University Health Network, Princess Margaret Cancer Centre, 700 University 6W091, Toronto, Ontario M5G 1Z5, Canada
| | - Vikas Gupta
- Department of Medicine, Princess Margaret Cancer Centre, Suite 5-303C, 610-University Avenue, University of Toronto, Toronto, Ontario M5G 2M9, Canada.
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7
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Kim SY, Bae SH, Bang SM, Eom KS, Hong J, Jang S, Jung CW, Kim HJ, Kim HY, Kim MK, Kim SJ, Mun YC, Nam SH, Park J, Won JH, Choi CW. The 2020 revision of the guidelines for the management of myeloproliferative neoplasms. Korean J Intern Med 2021; 36:45-62. [PMID: 33147902 PMCID: PMC7820646 DOI: 10.3904/kjim.2020.319] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2020] [Accepted: 11/07/2020] [Indexed: 02/07/2023] Open
Abstract
In 2016, the World Health Organization revised the diagnostic criteria for myeloproliferative neoplasms (MPNs) based on the discovery of disease-driving genetic aberrations and extensive analysis of the clinical characteristics of patients with MPNs. Recent studies have suggested that additional somatic mutations have a clinical impact on the prognosis of patients harboring these genetic abnormalities. Treatment strategies have also advanced with the introduction of JAK inhibitors, one of which has been approved for the treatment of patients with myelofibrosis and those with hydroxyurea-resistant or intolerant polycythemia vera. Recently developed drugs aim to elicit hematologic responses, as well as symptomatic and molecular responses, and the response criteria were refined accordingly. Based on these changes, we have revised the guidelines and present the diagnosis, treatment, and risk stratification of MPNs encountered in Korea.
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Affiliation(s)
- Sung-Yong Kim
- Division of Hematology, Department of Internal Medicine, Konkuk University Medical Center, Seoul,
Korea
| | - Sung Hwa Bae
- Department of Internal Medicine, Daegu Catholic University School of Medicine, Daegu,
Korea
| | - Soo-Mee Bang
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam,
Korea
| | - Ki-Seong Eom
- Department of Hematology, Seoul St. Mary’s Hematology Hospital, College of Medicine, The Catholic University of Korea, Seoul,
Korea
| | - Junshik Hong
- Division of Hematology and Medical Oncology, Department of Internal Medicine, Seoul National University Hospital, Seoul,
Korea
| | - Seongsoo Jang
- Department of Laboratory Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul,
Korea
| | - Chul Won Jung
- Division of Hematology/Oncology, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul,
Korea
| | - Hee-Jin Kim
- Department of Laboratory Medicine & Genetics, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul,
Korea
| | - Ho Young Kim
- Department of Internal Medicine, Hallym University Medical Center, Anyang,
Korea
| | - Min Kyoung Kim
- Department of Internal Medicine, Yeungnam University College of Medicine, Daegu,
Korea
| | - Soo-Jeong Kim
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul,
Korea
| | - Yeung-Chul Mun
- Department of Internal Medicine, Ewha Womans University School of Medicine, Seoul,
Korea
| | - Seung-Hyun Nam
- Department of Internal Medicine, Veterans Health Service Medical Center, Seoul,
Korea
| | - Jinny Park
- Division of Hematology, Department of Internal Medicine, Gachon University Gil Medical Center, Incheon,
Korea
| | - Jong-Ho Won
- Division of Hematology-Oncology, Department of Internal Medicine, Soonchunhyang University College of Medicine, Seoul,
Korea
| | - Chul Won Choi
- Division of Hematology-Oncology, Department of Internal Medicine, Korea University Guro Hospital, Seoul,
Korea
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8
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Yoon JH, Min GJ, Park SS, Park S, Lee SE, Cho BS, Kim YJ, Lee S, Kim HJ, Min CK, Cho SG, Lee JW, Eom KS. HLA-mismatched donor and high ferritin level showed poor clinical outcomes after allogeneic hematopoietic cell transplantation in patients with advanced myelofibrosis. Ther Adv Hematol 2020; 11:2040620720936935. [PMID: 32994911 PMCID: PMC7502801 DOI: 10.1177/2040620720936935] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2020] [Accepted: 05/19/2020] [Indexed: 11/16/2022] Open
Abstract
Background: Preconditioning intensity, donor choice and graft-versus-host disease (GVHD) prophylaxis of allogeneic hematopoietic cell transplantation (allo-HCT) for advanced myelofibrosis (MF) have not been fully elucidated. Methods: Thirty-five patients with advanced MF were treated with reduced-intensity conditioning (RIC) allo-HCT. We searched for matched sibling donors first, followed by matched or mismatched unrelated donors and familial mismatched donors. Preconditioning regimen consisted of fludarabine (total 150 mg/m2) and busulfan (total 6.4 mg/kg) with total body irradiation ⩽400cGy. Results: All showed engraftments, but four showed either leukemic relapse or delayed graft failure. Two-year overall survival (OS) and non-relapse mortality (NRM) was 60.0% and 29.9%, respectively. Acute GVHD was observed in 19 patients, and grade III–IV acute GVHD (eight grade III and four grade IV) was higher in human leukocyte antigen (HLA)-mismatched donor HCT compared with HLA-matched HCT (70% versus 20%). Chronic GVHD was observed in 16 patients, and a cumulative incidence of severe chronic GVHD was 33% in HLA-mismatched donor HCT and 7.7% in HLA-matched HCT. Significant hepatic GVHD was observed in nine patients (five acute, four chronic) and six of them died. Multivariate analysis revealed inferior OS in HLA-mismatched donor HCT (hazard ratio (HR) = 6.40, 95% confidence interval (CI) 1.6–25.7, p = 0.009) and in patients with high ferritin level at the time of pre-conditioning period (HR = 7.22, 95% CI 1.9–27.5, p = 0.004), which were related to higher incidence of hepatic GVHD with high NRM rate. Conclusion: RIC allo-HCT can be a valid choice providing graft-versus-fibrosis effect for advanced MF patients. However, HLA-mismatched donor and high pre-HCT ferritin level related to fatal hepatic GVHD should be regarded as poor-risk parameters.
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Affiliation(s)
- Jae-Ho Yoon
- Department of Hematology, Catholic Hematology Hospital and Leukemia Research Institute, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Gi June Min
- Department of Hematology, Catholic Hematology Hospital and Leukemia Research Institute, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Sung-Soo Park
- Department of Hematology, Catholic Hematology Hospital and Leukemia Research Institute, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Silvia Park
- Department of Hematology, Catholic Hematology Hospital and Leukemia Research Institute, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Sung-Eun Lee
- Department of Hematology, Catholic Hematology Hospital and Leukemia Research Institute, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Byung-Sik Cho
- Department of Hematology, Catholic Hematology Hospital and Leukemia Research Institute, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Yoo-Jin Kim
- Department of Hematology, Catholic Hematology Hospital and Leukemia Research Institute, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Seok Lee
- Department of Hematology, Catholic Hematology Hospital and Leukemia Research Institute, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Hee-Je Kim
- Department of Hematology, Catholic Hematology Hospital and Leukemia Research Institute, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Chang-Ki Min
- Department of Hematology, Catholic Hematology Hospital and Leukemia Research Institute, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Seok-Goo Cho
- Department of Hematology, Catholic Hematology Hospital and Leukemia Research Institute, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Jong Wook Lee
- Department of Hematology, Catholic Hematology Hospital and Leukemia Research Institute, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Ki-Seong Eom
- Department of Hematology, Catholic Hematology Hospital and Leukemia Research Institute, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, 222, Banpo-daero, Seocho-gu, Seoul 06591, Republic of Korea
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9
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Popat U, Mehta RS, Bassett R, Kongtim P, Chen J, Alousi AM, Anderlini P, Ciurea S, Hosing C, Jones R, Kebriaei P, Khouri I, Lindsay R, Nieto Y, Olson A, Oran B, Qazilbash MH, Rondon G, Shpall EJ, Verstovsek S, Andersson BS, Champlin RE. Optimizing the Conditioning Regimen for Hematopoietic Cell Transplant in Myelofibrosis: Long-Term Results of a Prospective Phase II Clinical Trial. Biol Blood Marrow Transplant 2020; 26:1439-1445. [PMID: 32438043 DOI: 10.1016/j.bbmt.2020.03.020] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2020] [Revised: 03/05/2020] [Accepted: 03/23/2020] [Indexed: 12/16/2022]
Abstract
Optimal conditioning regimens for older patients with myelofibrosis undergoing allogeneic hematopoietic cell transplant are not known. Likewise, the role of dose intensity is not clear. We conducted a nonrandomized, prospective, phase II trial using low-dose, later escalated to high-dose (myeloablative conditioning), busulfan with fludarabine (Bu-Flu) in myelofibrosis patients up to age 74 years. The first 15 patients received i.v. busulfan 130 mg/m2/day on days -3 and -2 ("low dose"); 31 patients received high-dose conditioning, either 100 mg/m2/day (days -5 to -2; n = 4) or pharmacokinetic-guided area under the curve of 4000 μmol/min (days -5 to -2; n = 27). The primary endpoint was day 100 nonrelapse mortality (NRM). Median age was 58 years (interquartile range [IQR], 53-63). Dynamic international prognostic scoring system-plus was intermediate (n = 28) or high (n = 18). Donors were related (n = 19) or unrelated (n = 27). Cumulative incidence of NRM was 9.7% (95% confidence interval [CI], 0-20.3) at day 100 and at 3 years in the high-dose group and 0% in the low-dose group at day 100, which increased to 20% (95% CI, 0-41.9) at 3 years. With a median follow-up of 5.1 years (IQR, 3.8-6), 3-year relapse was 32.3% (95% CI, 15.4-49.1) in high dose versus 53.3% (95% CI, 26.6-80.1) in low dose. Event-free survival was 58% (95% CI, 43-78) versus 27% (95% CI, 12-62), and overall survival was 74% (95% CI, 60-91) versus 60% (95% CI, 40-91). In multivariate analysis, high-dose busulfan had a trend toward lower relapse (hazard ratio, .44; 95% CI, .18-1.07; P = .07), with no impact on NRM. Intensifying the Bu-Flu regimen using pharmacokinetic-monitoring appears to be promising in reducing relapse without increasing NRM.
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Affiliation(s)
- Uday Popat
- Department of Stem Cell Transplantation and Cellular Therapy, University of Texas M.D. Anderson Cancer Center, Houston, Texas.
| | - Rohtesh S Mehta
- Department of Stem Cell Transplantation and Cellular Therapy, University of Texas M.D. Anderson Cancer Center, Houston, Texas
| | - Roland Bassett
- Department of Biostatistics, University of Texas M.D. Anderson Cancer Center, Houston, Texas
| | - Piyanuch Kongtim
- Department of Stem Cell Transplantation and Cellular Therapy, University of Texas M.D. Anderson Cancer Center, Houston, Texas; Division of Hematology, Department of Internal Medicine, Faculty of Medicine, Thammasat University, Bangkok, Thailand
| | - Julianne Chen
- Department of Stem Cell Transplantation and Cellular Therapy, University of Texas M.D. Anderson Cancer Center, Houston, Texas
| | - Amin M Alousi
- Department of Stem Cell Transplantation and Cellular Therapy, University of Texas M.D. Anderson Cancer Center, Houston, Texas
| | - Paolo Anderlini
- Department of Stem Cell Transplantation and Cellular Therapy, University of Texas M.D. Anderson Cancer Center, Houston, Texas
| | - Stefan Ciurea
- Department of Stem Cell Transplantation and Cellular Therapy, University of Texas M.D. Anderson Cancer Center, Houston, Texas
| | - Chitra Hosing
- Department of Stem Cell Transplantation and Cellular Therapy, University of Texas M.D. Anderson Cancer Center, Houston, Texas
| | - Roy Jones
- Department of Stem Cell Transplantation and Cellular Therapy, University of Texas M.D. Anderson Cancer Center, Houston, Texas
| | - Partow Kebriaei
- Department of Stem Cell Transplantation and Cellular Therapy, University of Texas M.D. Anderson Cancer Center, Houston, Texas
| | - Issa Khouri
- Department of Stem Cell Transplantation and Cellular Therapy, University of Texas M.D. Anderson Cancer Center, Houston, Texas
| | - Richard Lindsay
- Department of Stem Cell Transplantation and Cellular Therapy, University of Texas M.D. Anderson Cancer Center, Houston, Texas
| | - Yago Nieto
- Department of Stem Cell Transplantation and Cellular Therapy, University of Texas M.D. Anderson Cancer Center, Houston, Texas
| | - Amanda Olson
- Department of Stem Cell Transplantation and Cellular Therapy, University of Texas M.D. Anderson Cancer Center, Houston, Texas
| | - Betul Oran
- Department of Stem Cell Transplantation and Cellular Therapy, University of Texas M.D. Anderson Cancer Center, Houston, Texas
| | - Muzaffar H Qazilbash
- Department of Stem Cell Transplantation and Cellular Therapy, University of Texas M.D. Anderson Cancer Center, Houston, Texas
| | - Gabriela Rondon
- Department of Stem Cell Transplantation and Cellular Therapy, University of Texas M.D. Anderson Cancer Center, Houston, Texas
| | - Elizabeth J Shpall
- Department of Stem Cell Transplantation and Cellular Therapy, University of Texas M.D. Anderson Cancer Center, Houston, Texas
| | - Srdan Verstovsek
- Department of Stem Cell Transplantation and Cellular Therapy, University of Texas M.D. Anderson Cancer Center, Houston, Texas
| | - Borje S Andersson
- Department of Stem Cell Transplantation and Cellular Therapy, University of Texas M.D. Anderson Cancer Center, Houston, Texas
| | - Richard E Champlin
- Department of Stem Cell Transplantation and Cellular Therapy, University of Texas M.D. Anderson Cancer Center, Houston, Texas
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10
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Mannelli L, Guglielmelli P, Vannucchi AM. Stem cell transplant for the treatment of myelofibrosis. Expert Rev Hematol 2020; 13:363-374. [DOI: 10.1080/17474086.2020.1733406] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Affiliation(s)
- Lara Mannelli
- CRIMM, Centro di Ricerca e Innovazione per le Malattie Mieloproliferative, Azienda Ospedaliera Universitaria Careggi, Dipartimento di Medicina Sperimentale e Clinica, Università Degli Studi, Firenze, Italy
- Department of Medical Biotechnologies, University of Siena, Siena, Italy
| | - Paola Guglielmelli
- CRIMM, Centro di Ricerca e Innovazione per le Malattie Mieloproliferative, Azienda Ospedaliera Universitaria Careggi, Dipartimento di Medicina Sperimentale e Clinica, Università Degli Studi, Firenze, Italy
| | - Alessandro M. Vannucchi
- CRIMM, Centro di Ricerca e Innovazione per le Malattie Mieloproliferative, Azienda Ospedaliera Universitaria Careggi, Dipartimento di Medicina Sperimentale e Clinica, Università Degli Studi, Firenze, Italy
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11
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Zhang L, Yang F, Feng S. Allogeneic hematopoietic stem-cell transplantation for myelofibrosis. Ther Adv Hematol 2020; 11:2040620720906002. [PMID: 32110286 PMCID: PMC7019406 DOI: 10.1177/2040620720906002] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2019] [Accepted: 01/09/2020] [Indexed: 12/22/2022] Open
Abstract
Myelofibrosis is one of the Philadelphia chromosome (Ph)-negative
myeloproliferative neoplasms with heterogeneous clinical course. Though many
treatment options, including Janus kinase (JAK) inhibitors, have provided
clinical benefits and improved survival, allogeneic hematopoietic stem-cell
transplantation (AHSCT) remains the only potentially curative therapy.
Considering the significant transplant-related morbidity and mortality, it is
crucial to decide who to proceed to AHSCT, and when. In this review, we discuss
recent updates in patient selection, prior splenectomy, conditioning regimen,
donor type, molecular mutation, and other factors affecting AHSCT outcomes.
Relapse is a major cause of treatment failure; we also describe recent data on
minimal residual disease monitoring and management of relapse. In addition,
emerging studies have reported pretransplant therapy with ruxolitinib for
myelofibrosis showing favorable results, and further research is needed to
explore its use in the post-transplant setting.
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Affiliation(s)
- Lining Zhang
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Institute of Hematology and Blood Diseases Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Tianjin, China
| | - Fan Yang
- Aerospace Center Hospital, Beijing, China
| | - Sizhou Feng
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Institute of Hematology and Blood Diseases Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, 288 Nanjing Road, Heping District, Tianjin, 300020, China
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12
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Cruz NM, Gergis U, Silver RT. Myelofibrosis: best practices, controversies and 2019 update. Expert Rev Hematol 2019; 13:71-84. [PMID: 31709843 DOI: 10.1080/17474086.2020.1691519] [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: 10/25/2022]
Abstract
Introduction: Recent advances in the prognostic scheme and treatment of primary and secondary myelofibrosis (MF) have resulted in an overwhelming amount of clinical information to assimilate. The authors believe a comprehensive review that summarizes the most recent published literature, could serve as guidelines for the practicing hematologist.Areas covered: The authors provide a summary of landmark articles regarding epidemiology, symptoms, and pathogenesis of disease. The authors conducted a systematic literature review to answer questions regarding differences between primary myelofibrosis (PMF) and secondary myelofibrosis (SMF), appropriate use and selection of the current risk-stratification models, early versus late treatment of MF and current practices in allogeneic hematopoietic stem cell transplantation (allo-HCT) for MF. The authors conclude the article with their clinical opinion based on their experience and literature review. The purpose of this article is to identify current practices, address any variation, identify and investigate conflicting results and produce statements to guide decision-making.Expert opinion: In this section, the authors advocate for and provide examples of a standardized way of incorporating future discoveries in the pathogenesis and risk-stratification models of MF. They also discuss the importance of using only one risk-stratification model for PMF and one for SMF and their reasoning for early instead of late treatment of MF.
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Affiliation(s)
- Nicole M Cruz
- Division of Hematology & Medical Oncology, Weill Cornell Medicine, New York, NY, USA
| | - Usama Gergis
- Division of Hematology & Medical Oncology, Weill Cornell Medicine, New York, NY, USA
| | - Richard T Silver
- Division of Hematology & Medical Oncology, Weill Cornell Medicine, New York, NY, USA.,Richard T. Silver, M.D. Myeloproliferative Neoplasms (MPN) Center, Weill Cornell Medical College, New York, NY, USA
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13
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Palmer J, Kosiorek HE, Wolschke C, Fauble VDS, Butterfield R, Geyer H, Scherber RM, Dueck AC, Gathany A, Mesa RA, Kroger N. Assessment of Quality of Life following Allogeneic Stem Cell Transplant for Myelofibrosis. Biol Blood Marrow Transplant 2019; 25:2267-2273. [PMID: 31288096 PMCID: PMC8114229 DOI: 10.1016/j.bbmt.2019.07.001] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2019] [Revised: 06/08/2019] [Accepted: 07/01/2019] [Indexed: 01/27/2023]
Abstract
Patient-reported outcomes (PROs) for patients with myelofibrosis (MF) have been well characterized, but little is known about quality of life (QoL) following allogeneic stem cell transplantation (allo-SCT). Medical data and PRO measures were collected before transplant and at day 30, day 100, and 1 year after allo-SCT. PRO measures include Myeloproliferative Neoplasm Symptom Assessment Form (MPN-SAF), Brief Fatigue Inventory, Global Assessment of Change, and Functional Assessment of Cancer Therapy-Bone Marrow Transplant. Forty-four patients who had baseline QoL and at least 1 post-transplant assessment were included. The median age of the patients was 62.5 years (range, 35 to 74 years). At baseline, the mean MPN Total Symptom Score was 28.0, and at day 30, day 100, and 1 year, it was 25.4, 32.3, and 24.3, respectively. However, in myeloproliferative neoplasm-specific symptoms, such as itching, night sweats, bone pain, and fever, a statistically significant improvement was observed for at least 1 time point following transplant. At day 30, 10 (26.3%) patients reported a little/moderately/very much better overall QoL since their transplant, and 26 (68.45%) had a little/moderately/very much worse QoL. At day 100, 10 (30.3%) reported better QoL and 19 (57.6%) reported worsening since transplant. By 1 year, 16 (61.5%) reported feeling better. Our study shows that there is very little change in symptom burden at 1 year following transplant in general, but MF-specific symptoms showed improvement. By 1 year, 61% felt that their QoL was better than it was before transplant.
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Affiliation(s)
- Jeanne Palmer
- Division of Hematology and Medical Oncology, Department of Medicine, Mayo Clinic, Phoenix, Arizona.
| | | | - Christine Wolschke
- Department of Stem Cell Transplantation, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | | | | | - Holly Geyer
- Department of Medicine, Mayo Clinic, Phoenix, Arizona
| | | | - Amylou C Dueck
- Department of Biostatistics, Mayo Clinic Arizona, Scottsdale, Arizona
| | - Allison Gathany
- Division of Hematology/Oncology, Dartmouth-Hitchcock Medical Center, Hanover, New Hampshire
| | - Ruben A Mesa
- UT Health San Antonio Cancer Center, San Antonio, Texas
| | - Nicolaus Kroger
- Department of Stem Cell Transplantation, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
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14
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McLornan D, Szydlo R, Koster L, Chalandon Y, Robin M, Wolschke C, Beelen D, Socié G, Bornhäuser M, Angelucci E, Niederwieser D, Gerbitz A, Finke J, Vitek A, Itälä-Remes M, Radujkovic A, Kanz L, Potter V, Chevallier P, Stelljes M, Petersen E, Robinson S, Poiré X, Klyuchnikov E, Hernández-Boluda JC, Czerw T, Hayden P, Kröger N, Yakoub-Agha I. Myeloablative and Reduced-Intensity Conditioned Allogeneic Hematopoietic Stem Cell Transplantation in Myelofibrosis: A Retrospective Study by the Chronic Malignancies Working Party of the European Society for Blood and Marrow Transplantation. Biol Blood Marrow Transplant 2019; 25:2167-2171. [PMID: 31284069 DOI: 10.1016/j.bbmt.2019.06.034] [Citation(s) in RCA: 60] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2019] [Revised: 06/18/2019] [Accepted: 06/28/2019] [Indexed: 11/25/2022]
Abstract
This retrospective study by the European Society for Blood and Marrow Transplantation analyzed the outcome of 2224 patients with myelofibrosis (MF) who underwent allogeneic stem cell transplantation (allo-SCT) between 2000 and 2014; 781 (35%) underwent myeloablative conditioning (MAC) and 1443 (65%) reduced-intensity conditioning (RIC). Median patient age was 52.9 years (range, 18 to 74 years) and 57.5 years (range, 21 to 76 years) in the MAC and RIC cohorts, respectively. Donor type was similar: matched sibling donors (MAC, 317 [41%]; RIC, 552 [38%]) and unrelated donors (MAC, 464 [59%]; RIC, 891 [62%]). Median time to both neutrophil and platelet (>20 × 109/L) engraftment did not differ between cohorts. Rates of grade II to IV acute GVHD were 28% (MAC) and 31% (RIC; P = NS). Cumulative chronic GVHD rates (limited/extensive) were 22%/27% (MAC) and 19%/31% (RIC; P = .10). Cumulative incidences of nonrelapse mortality (NRM) at 1, 3, and 5 years were 25.5%, 32.2%, and 34.6% (MAC) and 26.3%, 32.8%, and 34.4% (RIC), respectively. There was a trend toward a higher relapse rate with RIC regimens compared with MAC (P = .08); rates at 1, 3, and 5 years were 10.9%, 17.2%, and 20.1% (MAC) and 14%, 19.7%, and 23.2% (RIC), respectively. No significant difference in 5-year probabilities of overall survival (OS) was noted: MAC (53.0%; 95% confidence interval [CI], 49.1% to 56.9%) and RIC (51.0%; 95% CI, 48.3% to 53.7%); P = .78. Regarding the composite end point of GVHD-free/relapse-free survival (GRFS), the unadjusted Kaplan-Meier estimate of 5-year GRFS was 32.4% (95% CI, 29.0% to 36.1%) in the MAC group and 26.1% (95% CI, 23.9% to 28.2%) in the RIC group (P = .001). In the MAC cohort, multivariable analysis confirmed worse OS and NRM with older age (>50 years), using an unrelated donor and a Karnofsky Performance Status of 80 or less. For the RIC cohort, worse OS and NRM were associated with age 60 to 70 years compared with younger recipients, use of a mismatched donor, and poor performance status. In conclusion, although similar OS rates existed for both cohorts overall, this study suggests that MAC should still be used for younger individuals suitable for such an approach due to a trend toward less relapse and an overall suggested advantage of improved GRFS, albeit this should be examined in a more homogeneous cohort. RIC allo-SCT still offers significant survival advantage in the older, fitter MF allograft patient, and optimization to reduce significant relapse and NRM rates is required.
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Affiliation(s)
- Donal McLornan
- Department of Haematology, Guy's and St. Thomas' NHS Foundation Trust, London, United Kingdom.
| | - Richard Szydlo
- Department of Clinical Sciences, Imperial College, London, United Kingdom
| | - Linda Koster
- Department of Haematology, EBMT Data Office, Leiden, The Netherlands
| | - Yves Chalandon
- Division of Hematology, Geneva University Hospitals, Geneva, Switzerland
| | - Marie Robin
- Department of Haematology, Service d'Hématologie-Greffe, Assistance Publique Hôpitaux de Paris, Hôpital Saint-Louis, Paris, France
| | - Christine Wolschke
- Division of Stem Cell Transplantation, University Hospital Eppendorf, Hamburg, Germany
| | | | - Gerard Socié
- Department of Haematology, Service d'Hématologie-Greffe, Assistance Publique Hôpitaux de Paris, Hôpital Saint-Louis, Paris, France
| | - Martin Bornhäuser
- Department of Haematology, Universitaetsklinikum Dresden, Dresden, Germany
| | | | | | - Arnim Gerbitz
- Department of Haematology, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Jürgen Finke
- Department of Haematology, University of Freiburg, Freiburg, Germany
| | - Antonin Vitek
- Department of Haematology, Institute of Hematology and Blood Transfusion, Prague, Czech Republic
| | - Maija Itälä-Remes
- Department of Haematology, HUCH Comprehensive Cancer Center, Helsinki, Finland
| | | | - Lothar Kanz
- Department of Haematology, Universität Tübingen, Tübingen, Germany
| | - Victoria Potter
- Department of Haematology, King's College Hospital, London, United Kingdom
| | | | | | - Eefke Petersen
- Department of Haematology, University Medical Centre, Utrecht, The Netherlands
| | - Stephen Robinson
- Department of Stem Cell Transplantation, University Hospitals, Bristol, United Kingdom
| | - Xavier Poiré
- Department of Haematology, Cliniques Universitaires St. Luc, Brussels, Belgium
| | - Evgeny Klyuchnikov
- Division of Stem Cell Transplantation, University Hospital Eppendorf, Hamburg, Germany
| | | | - Tomasz Czerw
- Department of Haematology, Maria Sklodowska-Curie Memorial Cancer Center and Institute of Oncology, Gliwice Branch, Gliwice, Poland
| | - Patrick Hayden
- Department of Haematology, St. James Hospital, Dublin, Ireland
| | - Nicolaus Kröger
- Division of Stem Cell Transplantation, University Hospital Eppendorf, Hamburg, Germany
| | - Ibrahim Yakoub-Agha
- Department of Haematology, CHU de Lille, LIRIC, INSERM U995, Universite de Lille, Lille, France
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15
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Tavares RS, Nonino A, Pagnano KBB, Nascimento ACKVD, Conchon M, Fogliatto LM, Funke VAM, Bendit I, Clementino NCD, Chauffaille MDLLF, Bernardo WM, Santos FPDS. Guideline on myeloproliferative neoplasms: Associacão Brasileira de Hematologia, Hemoterapia e Terapia Cellular: Project guidelines: Associação Médica Brasileira - 2019. Hematol Transfus Cell Ther 2019; 41 Suppl 1:1-73. [PMID: 31248788 PMCID: PMC6630088 DOI: 10.1016/j.htct.2019.03.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2019] [Accepted: 03/20/2019] [Indexed: 12/22/2022] Open
Affiliation(s)
| | - Alexandre Nonino
- Instituto Hospital de Base do Distrito Federal (IHBDF), Brasília, DF, Brazil
| | | | | | | | | | | | - Israel Bendit
- Hospital Das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), São Paulo, SP, Brazil
| | | | | | - Wanderley Marques Bernardo
- Hospital Das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), São Paulo, SP, Brazil; Associação Médica Brasileira (AMB), São Paulo, SP, Brazil
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16
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McLornan DP, Yakoub-Agha I, Robin M, Chalandon Y, Harrison CN, Kroger N. State-of-the-art review: allogeneic stem cell transplantation for myelofibrosis in 2019. Haematologica 2019; 104:659-668. [PMID: 30872371 PMCID: PMC6442950 DOI: 10.3324/haematol.2018.206151] [Citation(s) in RCA: 45] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2018] [Accepted: 11/16/2018] [Indexed: 12/14/2022] Open
Abstract
Advances in understanding the pathogenesis and molecular landscape of myelofibrosis have occurred over the last decade. Treating physicians now have access to an ever-evolving armamentarium of novel agents to treat patients, although allogeneic hematopoietic stem cell transplantation remains the only curative approach. Improvements in donor selection, conditioning regimens, disease monitoring and supportive care have led to augmented survival after transplantation. Nowadays, there are comprehensive guidelines concerning allogeneic hematopoietic stem cell transplantation for patients with myelofibrosis. However, it commonly remains difficult for both physicians and patients alike to weigh up the risk-benefit ratio of transplantation given the inherent heterogeneity regarding both clinical course and therapeutic response. In this timely review, we provide an up-to-date synopsis of current transplantation recommendations, discuss usage of JAK inhibitors before and after transplantation, examine donor selection and compare conditioning platforms. Moreover, we discuss emerging data concerning the impact of the myelofibrosis mutational landscape on transplantation outcome, peritransplant management of splenomegaly, poor graft function and prevention/management of relapse.
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Affiliation(s)
- Donal P McLornan
- Guy's and St. Thomas' NHS Foundation Trust, Department of Haematology, Guy's Tower, Great Maze Pond, London, UK
- Comprehensive Cancer Centre, King's College, London, UK
| | | | - Marie Robin
- Hôpital Saint-Louis, Service d'Hématologie-Greffe, Assistance Publique Hôpitaux de Paris, University Paris 7, INSERM 1131, France
| | - Yves Chalandon
- Geneva University Hospitals, Division of Hematology, Rue Gabrielle-Perret-Gentil 4 and Faculty of Medicine, University of Geneva, Switzerland
| | - Claire N Harrison
- Guy's and St. Thomas' NHS Foundation Trust, Department of Haematology, Guy's Tower, Great Maze Pond, London, UK
- Comprehensive Cancer Centre, King's College, London, UK
| | - Nicolaus Kroger
- University Hospital Eppendorf, Hematology Department, Hamburg, Germany
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17
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Tamari R, Rapaport F, Zhang N, McNamara C, Kuykendall A, Sallman DA, Komrokji R, Arruda A, Najfeld V, Sandy L, Medina J, Litvin R, Famulare CA, Patel MA, Maloy M, Castro-Malaspina H, Giralt SA, Weinberg RS, Mascarenhas JO, Mesa R, Rondelli D, Dueck AC, Levine RL, Gupta V, Hoffman R, Rampal RK. Impact of High-Molecular-Risk Mutations on Transplantation Outcomes in Patients with Myelofibrosis. Biol Blood Marrow Transplant 2019; 25:1142-1151. [PMID: 30625392 DOI: 10.1016/j.bbmt.2019.01.002] [Citation(s) in RCA: 42] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2018] [Accepted: 01/01/2019] [Indexed: 12/22/2022]
Abstract
Mutational profiling has demonstrated utility in predicting the likelihood of disease progression in patients with myelofibrosis (MF). However, there is limited data regarding the prognostic utility of genetic profiling in MF patients undergoing allogeneic hematopoietic stem cell transplantation (allo-HCT). We performed high-throughput sequencing of 585 genes on pre-transplant samples from 101 patients with MF who underwent allo-HCT and evaluated the association of mutations and clinical variables with transplantation outcomes. Overall survival (OS) at 5 years post-transplantation was 52%, and relapse-free survival (RFS) was 51.1 % for this cohort. Nonrelapse mortality (NRM) accounted for most deaths. Patient's age, donor's age, donor type, and Dynamic International Prognostic Scoring System score at diagnosis did not predict for outcomes. Mutations known to be associated with increased risk of disease progression, such as ASXL1, SRSF2, IDH1/2, EZH2, and TP53, did not impact OS or RFS. The presence of U2AF1 (P = .007) or DNMT3A (P = .034) mutations was associated with worse OS. A Mutation-Enhanced International Prognostic Scoring System 70 score was available for 80 patients (79%), and there were no differences in outcomes between patients with high risk scores and those with intermediate and low risk scores. Collectively, these data identify mutational predictors of outcome in MF patients undergoing allo-HCT. These genetic biomarkers in conjunction with clinical variables may have important utility in guiding transplantation decision making.
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Affiliation(s)
- Roni Tamari
- Memorial Sloan Kettering Cancer Center, New York, New York
| | - Franck Rapaport
- Center for Clinical and Translational Science, Rockefeller University, New York, New York
| | | | | | | | | | | | - Andrea Arruda
- Princess Margaret Hospital Cancer Center, Toronto, Ontario, Canada
| | | | | | - Juan Medina
- Memorial Sloan Kettering Cancer Center, New York, New York
| | - Rivka Litvin
- Memorial Sloan Kettering Cancer Center, New York, New York
| | | | - Minal A Patel
- Memorial Sloan Kettering Cancer Center, New York, New York
| | - Molly Maloy
- Memorial Sloan Kettering Cancer Center, New York, New York
| | | | | | | | | | | | - Damiano Rondelli
- University of Illinois Hospital & Health Sciences System and University of Illinois Cancer Center, Chicago, Illinois
| | | | - Ross L Levine
- Memorial Sloan Kettering Cancer Center, New York, New York
| | - Vikas Gupta
- Princess Margaret Hospital Cancer Center, Toronto, Ontario, Canada
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18
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Palmer J, Scherber R, Girardo M, Geyer H, Kosiorek H, Dueck A, Jain T, Mesa R. Patient Perspectives Regarding Allogeneic Bone Marrow Transplantation in Myelofibrosis. Biol Blood Marrow Transplant 2018; 25:398-402. [PMID: 30292010 DOI: 10.1016/j.bbmt.2018.09.033] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2018] [Accepted: 09/27/2018] [Indexed: 11/29/2022]
Abstract
Hematopoietic stem cell transplantation (HCT) is a curative treatment for patients with myelofibrosis (MF); however, many HCT-eligible patients decline this potentially life-saving procedure. The reasons behind this decision are not clear. We sought to survey patients with MF to understand their perspective on HCT. A 63-question survey was posted on myeloproliferative neoplasm patient advocacy websites. A total of 129 patients with MF responded to the survey. Among these patients, 49 (41%) were referred for HCT, and 41(32%) attended the transplantation consult. Of the patients who attended the transplantation consult, 24 (59%) did not plan on going on to HCT, and 16 (41%) intended to proceed with HCT. Reasons for the decision to not undergo transplantation included the desire to not be ill, desire to not spend time in the hospital, and concerns about overall quality of life. Specifically, concerns related to financial impact and the risk of graft-versus-host disease (GVHD) were expressed. Patients who decided to proceed with HCT felt that this would extend their survival and allow them to be around family for longer. This is the first survey to investigate patient perceptions regarding HCT for MF. Less than one-half of the patients were referred for HCT, and of those, less than one-half planned on proceeding with the transplantation, suggesting that many patients do not receive this life-saving procedure. Further exploration of the basis of patients' reluctance to proceed with HCT is warranted.
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Affiliation(s)
- Jeanne Palmer
- Division of Hematology and Medical Oncology, Department of Medicine, Mayo Clinic, Phoenix Arizona.
| | - Robyn Scherber
- Department of Hematology/Oncology, Oregon Health Sciences University, Portland, Oregon; Department of Hematology/Oncology, University of Texas Health Science Center at San Antonio, San Antonio, Texas
| | - Marlene Girardo
- Division of Biostatistics, Department of Health Sciences Research, Mayo Clinic, Scottsdale, Arizona
| | - Holly Geyer
- Department of Internal Medicine, Mayo Clinic, Phoenix, Arizona
| | - Heidi Kosiorek
- Division of Biostatistics, Department of Health Sciences Research, Mayo Clinic, Scottsdale, Arizona
| | - Amylou Dueck
- Division of Biostatistics, Department of Health Sciences Research, Mayo Clinic, Scottsdale, Arizona
| | - Tania Jain
- Division of Hematology and Medical Oncology, Department of Medicine, Mayo Clinic, Phoenix Arizona
| | - Ruben Mesa
- Department of Hematology/Oncology, University of Texas Health Science Center at San Antonio, San Antonio, Texas
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19
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Takenaka K, Shimoda K, Akashi K. Recent advances in the diagnosis and management of primary myelofibrosis. Korean J Intern Med 2018; 33:679-690. [PMID: 29665657 PMCID: PMC6030412 DOI: 10.3904/kjim.2018.033] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2018] [Accepted: 03/07/2018] [Indexed: 12/13/2022] Open
Abstract
Primary myelofibrosis (PMF) is a myeloproliferative neoplasm (MPN) in which dysregulation of the Janus kinase/signal transducers and activators of transcription (JAK/STAT) signaling pathways is the major pathogenic mechanism. Most patients with PMF carry a driver mutation in the JAK2, MPL (myeloproliferative leukemia), or CALR (calreticulin) genes. Mutations in epigenetic regulators and RNA splicing genes may also occur, and play critical roles in PMF disease progression. Based on revised World Health Organization diagnostic criteria for MPNs, both screening for driver mutations and bone marrow biopsy are required for a specific diagnosis. Clinical trials of JAK2 inhibitors for PMF have revealed significant efficacy for improving splenomegaly and constitutional symptoms. However, the currently available drug therapies for PMF do not improve survival. Although allogeneic stem cell transplantation is potentially curative, it is associated with substantial treatment-related morbidity and mortality. PMF is a heterogeneous disorder and decisions regarding treatments are often complicated, necessitating the use of prognostic models to determine the management of treatments for individual patients. This review focuses on the clinical aspects and outcomes of a cohort of Japanese patients with PMF, including discussion of recent advances in the management of PMF.
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Affiliation(s)
- Katsuto Takenaka
- Department of Medicine and Biosystemic Science, Kyushu University Graduate School of Medical Sciences, Fukuoka, Japan
- Correspondence to Katsuto Takenaka, M.D. Division of Hematology, Oncology & Cardiovascular Medicine, Kyushu University Hospital, 3-1-1 Maidashi, Higashi-ku, Fukuoka 812-8582, Japan Tel: +81-92-642-5230 Fax: +81-92-642-5247 E-mail:
| | - Kazuya Shimoda
- Department of Gastroenterology and Hematology, University of Miyazaki Faculty of Medicine, Miyazaki, Japan
| | - Koichi Akashi
- Department of Medicine and Biosystemic Science, Kyushu University Graduate School of Medical Sciences, Fukuoka, Japan
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Transplant Decisions in Patients with Myelofibrosis: Should Mutations Be the Judge? Biol Blood Marrow Transplant 2018; 24:649-658. [DOI: 10.1016/j.bbmt.2017.10.037] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2017] [Accepted: 10/26/2017] [Indexed: 02/06/2023]
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Malhotra H, Agarwal M, Chakarborti P, Varma N, Mathews V, Bhattacharyya J, Seth T, Gyathri K, Menon H, Subramanian PG, Sharma A, Bhattacharyya M, Mehta J, Shah S, Gogoi PK, Nair R, Agarwal U, Varma S, Prasad SVVS, Mishra D. Revised myeloproliferative neoplasms working group consensus recommendations for diagnosis and management of primary myelofibrosis, polycythemia vera, and essential thrombocythemia. Indian J Med Paediatr Oncol 2018. [DOI: 10.4103/ijmpo.ijmpo_88_17] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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Lestang E, Peterlin P, Le Bris Y, Dubruille V, Delaunay J, Godon C, Theisen O, Blin N, Mahe B, Gastinne T, Garnier A, Touzeau C, Voldoire M, Bene MC, Le Gouill S, Milpied N, Mohty M, Moreau P, Guillaume T, Chevallier P. Is allogeneic stem cell transplantation for myelofibrosis still indicated at the time of molecular markers and JAK inhibitors era? Eur J Haematol 2017; 99:60-69. [DOI: 10.1111/ejh.12891] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/27/2017] [Indexed: 12/26/2022]
Affiliation(s)
- Elsa Lestang
- Hematology Department; CHU Hotel-Dieu; Nantes France
| | | | - Yannick Le Bris
- Hematology/Biology Department; CHU Hotel-Dieu; Nantes France
| | | | | | - Catherine Godon
- Hematology/Biology Department; CHU Hotel-Dieu; Nantes France
| | - Olivier Theisen
- Hematology/Biology Department; CHU Hotel-Dieu; Nantes France
| | - Nicolas Blin
- Hematology Department; CHU Hotel-Dieu; Nantes France
| | - Beatrice Mahe
- Hematology Department; CHU Hotel-Dieu; Nantes France
| | | | - Alice Garnier
- Hematology Department; CHU Hotel-Dieu; Nantes France
| | | | - Maud Voldoire
- Hematology Department; CHU Hotel-Dieu; Nantes France
| | - Marie C. Bene
- Hematology/Biology Department; CHU Hotel-Dieu; Nantes France
| | | | - Noel Milpied
- Hematology Department; CHU Hotel-Dieu; Nantes France
| | - Mohamad Mohty
- Hematology Department; CHU Hotel-Dieu; Nantes France
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Bělohlávková P, Maisnar V, Voglová J, Buchler T, Žák P. Improvement of Anaemia in Patients with Primary Myelofibrosis by Low-Dose Thalidomide and Prednisone. ACTA MEDICA (HRADEC KRÁLOVÉ) 2017; 59:50-3. [PMID: 27526305 DOI: 10.14712/18059694.2016.89] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
BACKGROUND A combination of low-dose thalidomide and corticosteroids is a treatment option for anaemic patients with primary myelofibrosis (PMF) who are not eligible for allogeneic hematopoietic stem cell transplantation. METHODS We describe the outcomes of 13 patients with PMF treated with thalidomide 50 mg daily in combination with prednisone 0.5 mg/kg daily. Treatment responses were seen in 10/13 (77%) patients with a median onset of therapeutic effect at 4 weeks (range 3-7 weeks) after treatment initiation. Improvements of anaemia and thrombocytopenia and reduction in splenomegaly were observed in 70%, 38%, and 30% of patients, respectively. Four of six initially transfusion-dependent patients became transfusion independent following the therapy. The median duration of treatment response was 18 months (range 3-35 months). The treatment was well tolerated, with only one patient discontinuing therapy due to toxicity. Responders included both patients with and without JAK2 V617F, and included patients with both newly diagnosed and longstanding PMF. CONCLUSIONS Our retrospective analysis confirmed that the therapy with low-doses thalidomide with prednisone in patients with PMF achieves significant response rate in anaemia with low treatment toxicity.
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Affiliation(s)
- Petra Bělohlávková
- 4th Department of Internal Medicine - Hematology, Charles University, Faculty Hospital and Faculty of Medicine in Hradec Králové, Hradec Králové, Czech Republic.
| | - Vladimír Maisnar
- 4th Department of Internal Medicine - Hematology, Charles University, Faculty Hospital and Faculty of Medicine in Hradec Králové, Hradec Králové, Czech Republic
| | - Jaroslava Voglová
- 4th Department of Internal Medicine - Hematology, Charles University, Faculty Hospital and Faculty of Medicine in Hradec Králové, Hradec Králové, Czech Republic
| | - Tomáš Buchler
- Department of Oncology, First Faculty of Medicine and Thomayer Hospital, Prague, Czech Republic
| | - Pavel Žák
- 4th Department of Internal Medicine - Hematology, Charles University, Faculty Hospital and Faculty of Medicine in Hradec Králové, Hradec Králové, Czech Republic
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Devlin R, Gupta V. Myelofibrosis: to transplant or not to transplant? HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2016; 2016:543-551. [PMID: 27913527 PMCID: PMC6142493 DOI: 10.1182/asheducation-2016.1.543] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/13/2023]
Abstract
Hematopoietic cell transplantation (HCT) is the only curative therapeutic modality for myelofibrosis (MF) at present. The optimal timing of HCT is not known in the presence of wider availability of less risky nontransplant therapies such as JAK 1/2 inhibitors. Careful review of patient, disease, and transplant-related factors is required in the appropriate selection of HCT vs the best available nontransplant therapies. We highlight some of the relevant issues and positioning of HCT in light of evolving data on JAK 1/2 inhibitors. The goal of this study is to provide the reader with updated evidence of HCT for MF, recognizing that knowledge in this area is limited by the absence of comparative studies between HCT and nontransplant therapies. Prospective studies are needed for better information on: the determination of optimal timing and conditioning regimens, the best way to integrate JAK inhibitors in the HCT protocols, and the impact of JAK inhibitors on graft-versus-host disease.
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Affiliation(s)
- Rebecca Devlin
- The Elizabeth and Tony Comper Myeloproliferative Neoplasm Program, Princess Margaret Cancer Center, Toronto, Ontario, Canada
| | - Vikas Gupta
- The Elizabeth and Tony Comper Myeloproliferative Neoplasm Program, Princess Margaret Cancer Center, Toronto, Ontario, Canada
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Farhadfar N, Cerquozzi S, Patnaik M, Tefferi A. Allogeneic Hematopoietic Stem-Cell Transplantation for Myelofibrosis: A Practical Review. J Oncol Pract 2016; 12:611-21. [DOI: 10.1200/jop.2016.013268] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Myelofibrosis is a myeloproliferative neoplasm with cardinal features of extramedullary hematopoiesis, hepatosplenomegaly, cytopenias, and constitutional symptoms that result in shortened survival and leukemic transformation. It is a disease predominantly of the elderly, and currently available therapies only offer symptom control without curative benefit or ability to alter disease progression. Allogeneic hematopoietic stem-cell transplant (HSCT) is the only potentially curative intervention; however, this is only feasible in younger and medically fit patients and selectively offered to those with high-risk disease. Despite ongoing advancements, HSCT is associated with substantial morbidity and mortality, and the determination of which patients with myelofibrosis are ideal candidates and the selection of the opportune moment to proceed with transplantation remains challenging. This review summarizes our current recommendations for the role of and indications for HSCT in myelofibrosis.
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Allogeneic Transplantation for Patients With Advanced Myelofibrosis: Splenomegaly and High Serum LDH are Adverse Risk Factors for Successful Engraftment. CLINICAL LYMPHOMA MYELOMA & LEUKEMIA 2016; 16:297-303. [DOI: 10.1016/j.clml.2016.02.004] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/28/2015] [Accepted: 02/09/2016] [Indexed: 11/18/2022]
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27
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Sultan S, Irfan SM. Primary Idiopathic Myelofibrosis: Clinico-Epidemiological Profile and Risk Stratification in Pakistani Patients. Asian Pac J Cancer Prev 2016; 16:8629-31. [DOI: 10.7314/apjcp.2015.16.18.8629] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
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Choi CW, Bang SM, Jang S, Jung CW, Kim HJ, Kim HY, Kim SJ, Kim YK, Park J, Won JH. Guidelines for the management of myeloproliferative neoplasms. Korean J Intern Med 2015; 30:771-88. [PMID: 26552452 PMCID: PMC4642006 DOI: 10.3904/kjim.2015.30.6.771] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2015] [Accepted: 03/30/2015] [Indexed: 01/04/2023] Open
Abstract
Polycythemia vera, essential thrombocythemia, and primary myelofibrosis are collectively known as 'Philadelphia-negative classical myeloproliferative neoplasms (MPNs).' The discovery of new genetic aberrations such as Janus kinase 2 (JAK2) have enhanced our understanding of the pathophysiology of MPNs. Currently, the JAK2 mutation is not only a standard criterion for diagnosis but is also a new target for drug development. The JAK1/2 inhibitor, ruxolitinib, was the first JAK inhibitor approved for patients with intermediate- to high-risk myelofibrosis and its effects in improving symptoms and survival benefits were demonstrated by randomized controlled trials. In 2011, the Korean Society of Hematology MPN Working Party devised diagnostic and therapeutic guidelines for Korean MPN patients. Subsequently, other genetic mutations have been discovered and many kinds of new drugs are now under clinical investigation. In view of recent developments, we have revised the guidelines for the diagnosis and management of MPN based on published evidence and the experiences of the expert panel. Here we describe the epidemiology, new genetic mutations, and novel therapeutic options as well as diagnostic criteria and standard treatment strategies for MPN patients in Korea.
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Affiliation(s)
- Chul Won Choi
- Division of Oncology-Hematology, Department of Internal Medicine, Korea University Guro Hospital, Seoul, Korea
| | - Soo-Mee Bang
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Seongsoo Jang
- Department of Laboratory Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Chul Won Jung
- Division of Hematology/Oncology, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Hee-Jin Kim
- Department of Laboratory Medicine & Genetics, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Ho Young Kim
- Department of Internal Medicine, Hallym University Sacred Heart Hospital, Anyang, Korea
| | - Soo-Jeong Kim
- Department of Internal Medicine, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Yeo-Kyeoung Kim
- Division of Hematology-Oncology, Department of Internal Medicine, Chonnam National University Hwasun Hospital, Hwasun, Korea
| | - Jinny Park
- Division of Hematology-Oncology, Department of Internal Medicine, Gachon University Gil Medical Center, Incheon, Korea
| | - Jong-Ho Won
- Division of Hematology-Oncology, Department of Internal Medicine, Soonchunhyang University College of Medicine, Seoul, Korea
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Shanavas M, Popat U, Michaelis LC, Fauble V, McLornan D, Klisovic R, Mascarenhas J, Tamari R, Arcasoy MO, Davies J, Gergis U, Ukaegbu OC, Kamble RT, Storring JM, Majhail NS, Romee R, Verstovsek S, Pagliuca A, Vasu S, Ernst B, Atenafu EG, Hanif A, Champlin R, Hari P, Gupta V. Outcomes of Allogeneic Hematopoietic Cell Transplantation in Patients with Myelofibrosis with Prior Exposure to Janus Kinase 1/2 Inhibitors. Biol Blood Marrow Transplant 2015; 22:432-40. [PMID: 26493563 DOI: 10.1016/j.bbmt.2015.10.005] [Citation(s) in RCA: 105] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2015] [Accepted: 10/06/2015] [Indexed: 12/31/2022]
Abstract
The impact of Janus kinase (JAK) 1/2 inhibitor therapy before allogeneic hematopoietic cell transplantation (HCT) has not been studied in a large cohort in myelofibrosis (MF). In this retrospective multicenter study, we analyzed outcomes of patients who underwent HCT for MF with prior exposure to JAK1/2 inhibitors. One hundred consecutive patients from participating centers were analyzed, and based on clinical status and response to JAK1/2 inhibitors at the time of HCT, patients were stratified into 5 groups: (1) clinical improvement (n = 23), (2) stable disease (n = 31), (3) new cytopenia/increasing blasts/intolerance (n = 15), (4) progressive disease: splenomegaly (n = 18), and (5) progressive disease: leukemic transformation (LT) (n = 13). Overall survival (OS) at 2 years was 61% (95% confidence interval [CI], 49% to 71%). OS was 91% (95% CI, 69% to 98%) for those who experienced clinical improvement and 32% (95% CI, 8% to 59%) for those who developed LT on JAK1/2 inhibitors. In multivariable analysis, response to JAK1/2 inhibitors (P = .03), dynamic international prognostic scoring system score (P = .003), and donor type (P = .006) were independent predictors of survival. Among the 66 patients who remained on JAK1/2 inhibitors until stopped for HCT, 2 patients developed serious adverse events necessitating delay of HCT and another 8 patients had symptoms with lesser severity. Adverse events were more common in patients who started tapering or abruptly stopped their regular dose ≥6 days before conditioning therapy. We conclude that prior exposure to JAK1/2 inhibitors did not adversely affect post-transplantation outcomes. Our data suggest that JAK1/2 inhibitors should be continued near to the start of conditioning therapy. The favorable outcomes of patients who experienced clinical improvement with JAK1/2 inhibitor therapy before HCT were particularly encouraging, and need further prospective validation.
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Affiliation(s)
- Mohamed Shanavas
- MPN Program, Princess Margaret Cancer Centre, Toronto, Ontario, Canada
| | - Uday Popat
- Department of Stem Cell Transplantation and Cellular Therapy, University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Laura C Michaelis
- Department of Medicine, Division of Hematology/Oncology, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Veena Fauble
- Department of Hematology and Oncology, Mayo Clinic Cancer Center, Scottsdale, Arizona
| | - Donal McLornan
- Department of Haematological Medicine, King's College Hospital NHS Foundation Trust, London, United Kingdom
| | - Rebecca Klisovic
- Department of Internal Medicine, Ohio State University Wexner Medical Center, Columbus, Ohio
| | - John Mascarenhas
- Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Roni Tamari
- Department of Medicine, Adult Bone Marrow Transplant Service, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Murat O Arcasoy
- Division of Cellular Therapy and Hematologic Malignancies, Duke Cancer Institute, Duke University School of Medicine, Durham, North Carolina
| | - James Davies
- Oxford University Hospitals NHS trust, Oxford, UK
| | - Usama Gergis
- Department of Medicine, Weill Cornell Medical College, New York, New York
| | - Oluchi C Ukaegbu
- Department of Internal Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Rammurti T Kamble
- Center for Cell and Gene Therapy, Baylor College of Medicine and Houston Methodist Hospital, Houston, Texas
| | - John M Storring
- Department of Medicine, McGill University Health Centre, Montreal, Quebec, Canada
| | - Navneet S Majhail
- Blood and Marrow Transplant Program, Cleveland Clinic, Cleveland, Ohio
| | - Rizwan Romee
- Division of Oncology, Department of Medicine, Washington University School of Medicine, St. Louis, Missouri
| | - Srdan Verstovsek
- Hanns A. Pielenz Clinical Research Center for Myeloproliferative Neoplasms, Department of Leukemia, MD Anderson Cancer Center, Houston, TX, US
| | - Antonio Pagliuca
- Department of Haematological Medicine, King's College Hospital NHS Foundation Trust, London, United Kingdom
| | - Sumithira Vasu
- Department of Internal Medicine, Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Brenda Ernst
- Department of Hematology and Oncology, Mayo Clinic Cancer Center, Scottsdale, Arizona
| | - Eshetu G Atenafu
- Department of Biostatistics, Princess Margaret Cancer Centre, Toronto, ON, Canada
| | - Ahmad Hanif
- Department of Medicine, Division of Hematology/Oncology, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Richard Champlin
- Department of Stem Cell Transplantation and Cellular Therapy, University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Paremeswaran Hari
- Department of Medicine, Division of Hematology/Oncology, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Vikas Gupta
- MPN Program, Princess Margaret Cancer Centre, Toronto, Ontario, Canada.
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Indication and management of allogeneic stem cell transplantation in primary myelofibrosis: a consensus process by an EBMT/ELN international working group. Leukemia 2015; 29:2126-33. [PMID: 26293647 DOI: 10.1038/leu.2015.233] [Citation(s) in RCA: 205] [Impact Index Per Article: 22.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2015] [Accepted: 08/10/2015] [Indexed: 12/15/2022]
Abstract
The aim of this work is to produce recommendations on the management of allogeneic stem cell transplantation (allo-SCT) in primary myelofibrosis (PMF). A comprehensive systematic review of articles released from 1999 to 2015 (January) was used as a source of scientific evidence. Recommendations were produced using a Delphi process involving a panel of 23 experts appointed by the European LeukemiaNet and European Blood and Marrow Transplantation Group. Key questions included patient selection, donor selection, pre-transplant management, conditioning regimen, post-transplant management, prevention and management of relapse after transplant. Patients with intermediate-2- or high-risk disease and age <70 years should be considered as candidates for allo-SCT. Patients with intermediate-1-risk disease and age <65 years should be considered as candidates if they present with either refractory, transfusion-dependent anemia, or a percentage of blasts in peripheral blood (PB) >2%, or adverse cytogenetics. Pre-transplant splenectomy should be decided on a case by case basis. Patients with intermediate-2- or high-risk disease lacking an human leukocyte antigen (HLA)-matched sibling or unrelated donor, should be enrolled in a protocol using HLA non-identical donors. PB was considered the most appropriate source of hematopoietic stem cells for HLA-matched sibling and unrelated donor transplants. The optimal intensity of the conditioning regimen still needs to be defined. Strategies such as discontinuation of immune-suppressive drugs, donor lymphocyte infusion or both were deemed appropriate to avoid clinical relapse. In conclusion, we provided consensus-based recommendations aimed to optimize allo-SCT in PMF. Unmet clinical needs were highlighted.
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Alchalby H, Kröger N. Allogeneic stem cell transplant vs.Janus kinase inhibition in the treatment of primary myelofibrosis or myelofibrosis after essential thrombocythemia or polycythemia vera. CLINICAL LYMPHOMA MYELOMA & LEUKEMIA 2015; 14 Suppl:S36-41. [PMID: 25486953 DOI: 10.1016/j.clml.2014.06.012] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/21/2014] [Revised: 04/04/2014] [Accepted: 06/04/2014] [Indexed: 11/26/2022]
Abstract
Primary myelofibrosis is one of the Philadelphia chromosome-negative myeloproliferative neoplasms and is the member of that group with the worst survival and the most significant limitations in quality of life. Hepatosplenomegaly due to extramedullary hematopoiesis, constitutional symptoms, and cytopenias are the main manifestations. The natural history is highly variable, and up to 30% of patients can experience acceleration to acute myelogenous leukemia. Conventional therapy is only palliative and not always effective. However, huge advances have been achieved in the past 2 decades toward a better understanding of the pathogenesis of this disease, as well as improved management. Powerful risk stratification systems are now available and can reliably separate the patients into different prognostic categories to aid clinical management. Allogeneic stem cell transplant can offer cure but is still not universally applicable owing to the treatment-related mortality and toxicity. Nevertheless, outcomes of transplant are improving, owing to the introduction of reduced-intensity conditioning regimens and the optimization of remission monitoring techniques and relapse prevention strategies. The discovery of the V617F mutation of JAK2 (Janus kinase 2) and some other molecular aberrations has shed more light on the molecular pathogenesis of the disease and has led to the introduction of novel therapies such as JAK2 inhibitors. In fact, JAK inhibitors have shown promising symptomatic efficacy, and the JAK inhibitor ruxolitinib has also shown a potential survival benefit. Future effort should be made to combine allogeneic stem cell transplant with JAK inhibition.
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Affiliation(s)
- Haefaa Alchalby
- University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Nicolaus Kröger
- University Medical Center Hamburg-Eppendorf, Hamburg, Germany.
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Effect of conditioning regimens on graft failure in myelofibrosis: a retrospective analysis. Bone Marrow Transplant 2015; 50:1424-31. [PMID: 26237165 DOI: 10.1038/bmt.2015.172] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2014] [Revised: 05/04/2015] [Accepted: 06/02/2015] [Indexed: 12/31/2022]
Abstract
In myelofibrosis, the introduction of reduced-intensity conditioning (RIC) preceding allogeneic stem cell transplantation (SCT) resulted in lower transplant-related mortality rates compared with myeloablative conditioning. However, lowering the intensity of conditioning may increase the risk of graft failure in myelofibrosis, although hitherto this has not been indisputably proven. We here report the outcome of 53 patients who underwent allogeneic SCT with different conditioning regimens (RIC and non-myeloablative (NMA)) in three transplantation centers in the Netherlands. The cumulative incidence of graft failure within 60 days after SCT was high (28%), and this was primarily associated with the intensity of the conditioning regimen. Cumulative neutrophil engraftment at 60 days was lower in patients who received NMA conditioning compared with those who received RIC (56% vs 84%, P=0.03). Furthermore, of six patients who received a second transplantation after graft failure, the three patients with RIC regimens subsequently engrafted, whereas the three patients who received a second NMA regimen did not. This study indicates that in myelofibrosis, NMA regimens result in high engraftment failure rates. We propose the use of more intensive conditioning regimens, incorporating busulfan or melphalan.
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Tamari R, Mughal TI, Rondelli D, Hasserjian R, Gupta V, Odenike O, Fauble V, Finazzi G, Pane F, Mascarenhas J, Prchal J, Giralt S, Hoffman R. Allo-SCT for myelofibrosis: reversing the chronic phase in the JAK inhibitor era? Bone Marrow Transplant 2015; 50:628-36. [PMID: 25665047 PMCID: PMC6394215 DOI: 10.1038/bmt.2014.323] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2014] [Revised: 11/16/2014] [Accepted: 11/17/2014] [Indexed: 01/30/2023]
Abstract
At present, allo-SCT is the only curative treatment for patients with myelofibrosis (MF). Unfortunately, a significant proportion of candidate patients are considered transplant ineligible due to their poor general condition and advanced age at the time of diagnosis. The approval of the first JAK inhibitor, ruxolitinib, for patients with advanced MF in 2011 has had a qualified impact on the treatment algorithm. The drug affords substantial improvement in MF-associated symptoms and splenomegaly but no major effect on the natural history. There has, therefore, been considerable support for assessing the drug's candidacy in the peritransplant period. The drug's precise impact on clinical outcome following allo-SCT is currently not known; nor are the drug's long-term efficacy and safety known. Considering the rarity of MF and the small proportion of patients who undergo allo-SCT, well designed collaborative efforts are required. In order to address some of the principal challenges, an expert panel of laboratory and clinical experts in this field was established, and an independent workshop held during the 54th American Society of Hematology Annual Meeting in New Orleans, USA on 6 December 2013, and the European Hematology Association's Annual Meeting in Milan, Italy on 13 June 2014. This document summarizes the results of these efforts.
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Affiliation(s)
- R Tamari
- Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - T I Mughal
- Division of Hematology and Oncology, Tufts Medical Center, Boston, MA, USA
| | - D Rondelli
- University of Illinois, Chicago, IL, USA
| | | | - V Gupta
- Princess Margaret Cancer Center, Toronto, Canada
| | - O Odenike
- University of Chicago, Chicago, IL, USA
| | - V Fauble
- Mayo Clinic Cancer Center, Scottsdale, AZ, USA
| | - G Finazzi
- Papa Giovani XXIII Hospital and Research Center, Bergamo, Italy
| | - F Pane
- Federico II University, Naples, Italy
| | - J Mascarenhas
- Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - J Prchal
- Huntsman Cancer Center, Salt Lake City, UT, USA
| | - S Giralt
- Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - R Hoffman
- Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
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Agarwal MB, Malhotra H, Chakrabarti P, Varma N, Mathews V, Bhattacharyya J, Seth T, Gayathri K, Menon H, Subramanian PG, Sharma A, Bhattacharyya M, Mehta J, Vaid AK, Shah S, Aggarwal S, Gogoi PK, Nair R, Agarwal U, Varma S, Prasad SVSS, Manipadam MT. Myeloproliferative neoplasms working group consensus recommendations for diagnosis and management of primary myelofibrosis, polycythemia vera, and essential thrombocythemia. Indian J Med Paediatr Oncol 2015; 36:3-16. [PMID: 25810569 PMCID: PMC4363847 DOI: 10.4103/0971-5851.151770] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023] Open
Abstract
According to the 2008 revision of the World Health Organization (WHO) classification of myeloid malignancies, philadelphia chromosome (Ph)-negative myeloproliferative neoplasms (MPNs) include clonal, hematologic disorders such as polycythemia vera, primary myelofibrosis, and essential thrombocythemia. Recent years have witnessed major advances in the understanding of the molecular pathophysiology of these rare subgroups of chronic, myeloproliferative disorders. Identification of somatic mutations in genes associated with pathogenesis and evolution of these myeloproliferative conditions (Janus Kinase 2; myeloproliferative leukemia virus gene; calreticulin) led to substantial changes in the international guidelines for diagnosis and treatment of Ph-negative MPN during the last few years. The MPN-Working Group (MPN-WG), a panel of hematologists with expertise in MPN diagnosis and treatment from various parts of India, examined applicability of this latest clinical and scientific evidence in the context of hematology practice in India. This manuscript summarizes the consensus recommendations formulated by the MPN-WG that can be followed as a guideline for management of patients with Ph-negative MPN in the context of clinical practice in India.
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Affiliation(s)
- M B Agarwal
- Department of Hematology, Bombay Hospital Institute of Medical Sciences, Mumbai, Maharashtra, India
| | - Hemant Malhotra
- Division of Medical Oncology, RK Birla Cancer Center, SMS Medical College Hospital, Jaipur, Rajasthan, India
| | | | - Neelam Varma
- Department of Hematology and Pathology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Vikram Mathews
- Department of Hematology, Christian Medical College, Vellore, Tamil Nadu, India
| | - Jina Bhattacharyya
- Department of Clinical Hematology, Guwahati Medical College and Hospital, Assam, India
| | - Tulika Seth
- Department of Hematology, All India Institute of Medical Sciences, Delhi Cantonment, India
| | - K Gayathri
- Department of Hematopathology, Lifeline Tapadia Diagnostic Centre, Hyderabad, Telangana, India
| | - Hari Menon
- Department of Medical Oncology, Tata Memorial Hospital, Mumbai, Maharashtra, India
| | - P G Subramanian
- Department of Hematopathology Laboratory, Tata Memorial Hospital, Mumbai, Maharashtra, India
| | - Ajay Sharma
- Hematology and Center for Stem Cell Transplantation and Research, Army Research and Referral Hospital, Delhi Cantonment, India
| | - Maitreyee Bhattacharyya
- Institute of Hematology and Transfusion Medicine, Medical College, Kolkata, West Bengal, India
| | - Jay Mehta
- Centre of Excellence in Histopathology, SRL Diagnostics, Mumbai, Maharashtra, India
| | - A K Vaid
- Cancer Institute-Division of Medical Oncology and Haemotology, Medanta-The Medicity, New Delhi, India
| | - Sandeep Shah
- Department of Medical Oncology, Gujarat Cancer and Research Institute, Ahmedabad, Gujarat, India
| | - Shyam Aggarwal
- Department of Medical Oncology, Sir Ganga Ram Hospital, New Delhi, India
| | - P K Gogoi
- East India Hematological Centre, Rajgarh Road, Guwahati, Assam, India
| | - Reena Nair
- Department of Clinical Hematology, Tata Medical Centre, Kolkata, West Bengal, India
| | - Usha Agarwal
- Ashirwad Hematology Centre, Dadar, Mumbai, Maharashtra, India
| | - Subhash Varma
- Department of Pathology, Christian Medical College, Vellore, Tamil Nadu, India
| | - S V S S Prasad
- Division of Medical Oncology, Apollo Cancer Hospitals, Hyderabad, Telangana, India
| | - Marie Therese Manipadam
- Department of Internal Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India
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Olsson RF, Logan BR, Chaudhury S, Zhu X, Akpek G, Bolwell BJ, Bredeson CN, Dvorak CC, Gupta V, Ho VT, Lazarus HM, Marks DI, Ringdén OTH, Pasquini MC, Schriber JR, Cooke KR. Primary graft failure after myeloablative allogeneic hematopoietic cell transplantation for hematologic malignancies. Leukemia 2015; 29:1754-62. [PMID: 25772027 PMCID: PMC4527886 DOI: 10.1038/leu.2015.75] [Citation(s) in RCA: 87] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2014] [Revised: 02/09/2015] [Accepted: 03/09/2015] [Indexed: 11/18/2022]
Abstract
Clinical outcomes after primary graft failure (PGF) remain poor. Here we present a large retrospective analysis (n=23,272) which investigates means to prevent PGF and early detection of patients at high risk. In patients with hematologic malignancies, who underwent their first myeloablative allogeneic hematopoietic cell transplantation, PGF was reported in 1,278 (5.5%), and there was a marked difference in PGFs using peripheral blood stem cell compared to bone marrow grafts (2.5 vs. 7.3%; P<0.001). A 4-fold increase of PGF was observed in myeloproliferative disorders compared to acute leukemia (P<0.001). Other risk factors for PGF included recipient age below 30, HLA-mismatch, male recipients of female donor grafts, ABO-incompatibility, busulfan/cyclophosphamide conditioning, and cryopreservation. In bone marrow transplants, total nucleated cell doses ≤2.4 × 108/kg were associated with PGF (OR 1.39; P<0.001). The use of tacrolimus-based immunosuppression and granulocyte colony-stimulating factor were associated with decreased PGF risk. These data, allow clinicians to do more informed choices with respect to graft source, donor selection, conditioning and immunosuppressive regimens to reduce the risk of PGF. Moreover, a novel risk score determined on day 21 post-transplant may provide the rationale for an early request for additional hematopoietic stem cells.
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Affiliation(s)
- R F Olsson
- 1] Division of Therapeutic Immunology, Department of Laboratory Medicine, Karolinska Institutet, Stockholm, Sweden [2] Centre for Clinical Research Sörmland, Uppsala University, Uppsala, Sweden
| | - B R Logan
- 1] CIBMTR (Center for International Blood and Marrow Transplant Research), Department of Medicine, Medical College of Wisconsin, Milwaukee, WI, USA [2] Division of Biostatistics, Institute for Health and Society, Medical College of Wisconsin, Milwaukee, WI, USA
| | - S Chaudhury
- Division of Pediatric Hematology, Oncology and Stem Cell Transplant, Department of Pediatrics, Ann & Robert H Lurie Children's Hospital of Chicago, Chicago, IL, USA
| | - X Zhu
- CIBMTR (Center for International Blood and Marrow Transplant Research), Department of Medicine, Medical College of Wisconsin, Milwaukee, WI, USA
| | - G Akpek
- Section of Hematology/Oncology, Banner MD Anderson Cancer Center, Gilbert, AZ, USA
| | - B J Bolwell
- Department of Hematology and Oncology, Cleveland Clinic, Cleveland, OH, USA
| | - C N Bredeson
- The Ottawa Hospital Blood and Marrow Transplant Program and the Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - C C Dvorak
- Department of Pediatrics, University of California San Francisco Medical Center, San Francisco, CA, USA
| | - V Gupta
- Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada
| | - V T Ho
- Center for Hematologic Oncology, Dana-Farber Cancer Institute, Boston, MA, USA
| | - H M Lazarus
- Seidman Cancer Center, University Hospitals Case Medical Center, Cleveland, OH, USA
| | - D I Marks
- Pediatric Bone Marrow Transplant, University Hospitals Bristol NHS Trust, Bristol, UK
| | - O T H Ringdén
- 1] Division of Therapeutic Immunology, Department of Laboratory Medicine, Karolinska Institutet, Stockholm, Sweden [2] Centre for Allogeneic Stem Cell Transplantation, Stockholm, Sweden
| | - M C Pasquini
- CIBMTR (Center for International Blood and Marrow Transplant Research), Department of Medicine, Medical College of Wisconsin, Milwaukee, WI, USA
| | - J R Schriber
- 1] Cancer Transplant Institute, Virginia G Piper Cancer Center, Scottsdale, AZ, USA [2] Arizona Oncology, Scottsdale, AZ, USA
| | - K R Cooke
- Pediatric Blood and Marrow Transplantation Program, The Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins, Baltimore, MD, USA
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Allogeneic haematopoietic stem cell transplantation for primary myelofibrosis and myelofibrosis evolved from other myeloproliferative neoplasms. Curr Opin Hematol 2015; 22:184-90. [DOI: 10.1097/moh.0000000000000121] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
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Salit RB, Deeg HJ. Role of hematopoietic stem cell transplantation in patients with myeloproliferative disease. Hematol Oncol Clin North Am 2014; 28:1023-35. [PMID: 25459177 DOI: 10.1016/j.hoc.2014.08.003] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Myeloproliferative neoplasms (MPN) are clonal hematopoietic stem cell disorders. While some MPN patients have an indolent course, all are at risk of progressing to severe marrow failure or transforming into acute leukemia. Allogeneic hematopoietic cell transplantation (allo-HCT) is the only potential curative therapy. Major pre-transplant risk factors are disease stage of the MPN, the presence of comorbid conditions and the use of HLA non-identical donors. The development of reduced-intensity conditioning regimens has allowed for successful allo-HCT even for older patients and patients with comorbid conditions. The pre-transplant use of JAK2 inhibitors, which may be effective in down staging a patient's disease, may improve the outcomes following allo-HCT.
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Affiliation(s)
- Rachel B Salit
- Clinical Research Division, Cord Blood Transplant Research Program, Fred Hutchinson Cancer Research Center, Seattle, WA 98109, USA; University of Washington Medical Center, Seattle, WA 98195, USA
| | - H Joachim Deeg
- Clinical Research Division, Cord Blood Transplant Research Program, Fred Hutchinson Cancer Research Center, Seattle, WA 98109, USA; University of Washington Medical Center, Seattle, WA 98195, USA.
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Shanavas M, Gupta V. Controversies and dilemmas in allogeneic transplantation for myelofibrosis. Best Pract Res Clin Haematol 2014; 27:165-74. [PMID: 25189727 DOI: 10.1016/j.beha.2014.07.007] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2014] [Accepted: 07/11/2014] [Indexed: 01/10/2023]
Abstract
JAK1/2 inhibitors have broadened the therapeutic options in myelofibrosis. Though not curative, they result in a meaningful clinical benefit with relatively fewer side effects. In contrast, allogeneic hematopoietic cell transplantation (HCT) is a potentially curative option, but is associated with significant morbidity and mortality. Hence, an important question is the optimal timing of HCT in the era of JAK inhibitors. Timing of HCT is a crucial decision, and need to be individualized based on the personal preferences and goals of therapy; in addition to patient, disease, and transplant related factors. Risk stratification by the currently established prognostic scoring systems need to be further refined by incorporation of prognostically significant mutations to guide the treatment choices better. Data on use of JAK inhibitors prior to HCT have just started to emerge. We discuss some of the current controversies and dilemmas in transplantation for myelofibrosis based on a few real life scenarios.
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Affiliation(s)
- Mohamed Shanavas
- Allogeneic Blood and Marrow Transplant Program, Princess Margaret Cancer Center and University of Toronto, 610 University Avenue, Toronto, Ontario, M5G 2M9, Canada
| | - Vikas Gupta
- Allogeneic Blood and Marrow Transplant Program, Princess Margaret Cancer Center and University of Toronto, 610 University Avenue, Toronto, Ontario, M5G 2M9, Canada.
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Allogeneic hematopoietic cell transplantation for myelofibrosis using fludarabine-, intravenous busulfan- and low-dose TBI-based conditioning. Bone Marrow Transplant 2014; 49:1162-9. [PMID: 24978138 DOI: 10.1038/bmt.2014.131] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2014] [Revised: 05/08/2014] [Accepted: 05/12/2014] [Indexed: 12/31/2022]
Abstract
Graft failure is one of the major barriers to the success of allogeneic hematopoietic cell transplantation (HCT) in myelofibrosis (MF). We report our institutional experience with 27 MF patients who underwent HCT using fludarabine-, intravenous BU- and low-dose total body irradiation (FBT)-based reduced-intensity (n=20) or full-intensity (n=7) conditioning regimens. Eight patients had prior exposure to JAK1/2 inhibitor therapy; six patients received JAK1/2 inhibitors leading on to HCT and two patients received transplant at the failure of JAK1/2 inhibitor therapy. No adverse impact of JAK1/2 inhibitor therapy was observed on early post-transplant outcomes. All evaluable patients had neutrophil recovery, and no primary graft failure was observed. Cumulative incidence of grades II-IV acute GVHD at day 100 was 48% (95% confidence interval (CI), 29-67%) and chronic GVHD at 2 years was 66% (95% CI, 49-84%). Cumulative incidences of nonrelapse mortality (NRM), relapse and probability of OS at 2 years were: 43% (95% CI, 12-74%), 10% (95% CI, 0-39%) and 56% (95% CI, 28-77%), respectively. FBT-based conditioning regimen has a favorable impact on engraftment; however, further efforts are required to reduce NRM.
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MPD-RC 101 prospective study of reduced-intensity allogeneic hematopoietic stem cell transplantation in patients with myelofibrosis. Blood 2014; 124:1183-91. [PMID: 24963042 DOI: 10.1182/blood-2014-04-572545] [Citation(s) in RCA: 107] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
From 2007 to 2011, 66 patients with primary myelofibrosis or myelofibrosis (MF) preceded by essential thrombocythemia or polycythemia vera were enrolled into a prospective phase 2 clinical trial of reduced-intensity allogeneic hematopoietic stem cell transplantation (AHSCT), Myeloproliferative Disorder Research Consortium 101 trial. The study included patients with sibling donors (n = 32) receiving fludarabine/melphalan (FluMel) as a preparative regimen and patients with unrelated donors (n = 34) receiving conditioning with FluMel plus anti-thymocyte globulin (ATG). Patient characteristics in the 2 cohorts were similar. Engraftment occurred in 97% of siblings and 76% of unrelated transplants, whereas secondary graft failure occurred in 3% and 12%, respectively. With a median follow-up of 25 months for patients alive, the overall survival (OS) was 75% in the sibling group (median not reached) and 32% in the unrelated group (median OS: 6 months, 95% confidence interval [CI]: 3, 25) (hazard ratio 3.9, 95% CI: 1.8,8.9) (P < .001). Nonrelapse mortality was 22% in sibling and 59% in unrelated AHSCT. Survival correlated with type of donor, but not with the degree of histocompatibility match, age, or JAK2(V617F) status. In patients with MF with sibling donors, AHSCT is an effective therapy, whereas AHSCT from unrelated donors with FluMel/ATG conditioning led to a high rate of graft failure and limited survival. This trial was registered at www.clinicaltrials.gov as #NCT00572897.
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Babushok D, Hexner E. Allogeneic transplantation for myelofibrosis: for whom, when, and what are the true benefits? Curr Opin Hematol 2014; 21:114-22. [PMID: 24378706 PMCID: PMC4104209 DOI: 10.1097/moh.0000000000000015] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
PURPOSE OF REVIEW Allogeneic hematopoietic stem cell transplantation (HSCT) is the only potentially curative therapy for myelofibrosis. Despite improved outcomes, morbidity and mortality of HSCT remain high. Here we examine recent data on patient selection, timing, and outcomes of HSCT in myelofibrosis. RECENT FINDINGS While there is a general effort to restrict HSCT to transplant-eligible intermediate-2 and high-risk patients, this group has comparatively worse HSCT outcomes, largely driven by their high transplant-related mortality (TRM). When adjusted for age, reduced intensity conditioning (RIC) has shown superior outcomes compared with myeloablative conditioning (MAC), making RIC-HSCT a viable option for older patients. Emerging concepts include the use of ruxolitinib pretransplant, optimizing MAC to decrease toxicity, and use of posttransplant JAK2-mutant allele burden to guide prophylactic immunotherapy to prevent relapse. The recognition of prognostic significance of somatic mutations in the ASXL1, EZH2, SRSF2, and IDH1/2 genes, and the improved assessment of risk of leukemic transformation have added a new dimension to risk stratification. SUMMARY Improving our understanding of molecular genetics and leukemic transformation holds promise for more precise patient selection for HSCT. Although RIC-HSCT may reduce TRM, further studies are needed to optimize conditioning regimens and to define the optimal timing of HSCT.
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Affiliation(s)
- Daria Babushok
- Division of Hematology and Oncology and Abramson Cancer Center, University of Pennsylvania, Philadelphia, Pennsylvania, USA
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Abstract
PURPOSE OF REVIEW A succinct yet comprehensive review of the biology of myeloproliferative neoplasms and therapeutic options with a focus on rational decision making for hematopoietic stem cell transplantation. RECENT FINDINGS The introduction of Janus kinase inhibitors for myelofibrosis have ushered in a new era for treatment of constitutional symptoms and splenomegaly in myelofibrosis, but the effect of these agents on the natural history of the disease has yet to be clearly defined. Reduced intensity transplants have emerged as the preferred option with recent evidence suggesting fludarabine and melphalan as the optimal conditioning regimen. SUMMARY Myelofibrosis is a rare hematologic malignancy with limited curative therapeutic options. Significant advances in our understanding of disease pathogenesis have led to new targets and new therapeutic options are forthcoming. Hematopoietic stem cell transplantation is at present the only treatment with curative intent; however, the selection of patients who are likely to be best served by this procedure is difficult. As myelofibrosis is an extremely rare disease, randomized clinical trials specifically investigating the role of transplantation in myelofibrosis are unlikely to occur, thus current decision making processes are best guided by retrospective analyses from registry databases and single institution experiences.
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Hultcrantz M, Kristinsson SY, Andersson TML, Landgren O, Eloranta S, Derolf AR, Dickman PW, Björkholm M. Patterns of survival among patients with myeloproliferative neoplasms diagnosed in Sweden from 1973 to 2008: a population-based study. J Clin Oncol 2012; 30:2995-3001. [PMID: 22802311 DOI: 10.1200/jco.2012.42.1925] [Citation(s) in RCA: 168] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023] Open
Abstract
PURPOSE Reported survival in patients with myeloproliferative neoplasms (MPNs) shows great variation. Patients with primary myelofibrosis (PMF) have substantially reduced life expectancy, whereas patients with polycythemia vera (PV) and essential thrombocythemia (ET) have moderately reduced survival in most, but not all, studies. We conducted a large population-based study to establish patterns of survival in more than 9,000 patients with MPNs. PATIENTS AND METHODS We identified 9,384 patients with MPNs (from the Swedish Cancer Register) diagnosed from 1973 to 2008 (divided into four calendar periods) with follow-up to 2009. Relative survival ratios (RSRs) and excess mortality rate ratios were computed as measures of survival. RESULTS Patient survival was considerably lower in all MPN subtypes compared with expected survival in the general population, reflected in 10-year RSRs of 0.64 (95% CI, 0.62 to 0.67) in patients with PV, 0.68 (95% CI, 0.64 to 0.71) in those with ET, and 0.21 (95% CI, 0.18 to 0.25) in those with PMF. Excess mortality was observed in patients with any MPN subtype during all four calendar periods (P < .001). Survival improved significantly over time (P < .001); however, the improvement was less pronounced after the year 2000 and was confined to patients with PV and ET. CONCLUSION We found patients with any MPN subtype to have significantly reduced life expectancy compared with the general population. The improvement over time is most likely explained by better overall clinical management of patients with MPN. The decreased life expectancy even in the most recent calendar period emphasizes the need for new treatment options for these patients.
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Allogeneic hematopoietic cell transplantation for myelofibrosis in the era of JAK inhibitors. Blood 2012; 120:1367-79. [PMID: 22700718 DOI: 10.1182/blood-2012-05-399048] [Citation(s) in RCA: 87] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023] Open
Abstract
The discovery of JAK2617F mutation paved the way for the development of small molecule inhibitors of JAK1/2 resulting in first approved JAK1/2 inhibitor, ruxolitinib, for the treatment of patients with myelofibrosis (MF). Although JAK1/2 inhibitor therapy is effective in decreasing the burden of symptoms associated with splenomegaly and MF-related constitutional symptoms, it is neither curative nor effective in reducing the risk of leukemic transformation. Presently, allogeneic hematopoietic cell transplantation (HCT) is the only curative therapy for MF. A significant risk of regimen-related toxicities, graft failure, and GVHD are major barriers to the success of HCT in MF. Because of significant HCT-associated morbidity and mortality, divergent opinions regarding its appropriate role in this clinical situation have emerged. In this review, the risk-benefit ratios of modern drug therapy compared with HCT in MF patients are analyzed. A risk-adapted approach individualized to each patient's biologic characteristics and comorbidities is described, which is currently warranted in determining optimal treatment strategies for patients with MF. Inclusion of JAK1/2 inhibitor therapy in future transplant conditioning regimens may provide an opportunity to overcome some of these barriers, resulting in greater success with HCT for MF patients.
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Ditschkowski M, Elmaagacli AH, Trenschel R, Gromke T, Steckel NK, Koldehoff M, Beelen DW. Dynamic International Prognostic Scoring System scores, pre-transplant therapy and chronic graft-versus-host disease determine outcome after allogeneic hematopoietic stem cell transplantation for myelofibrosis. Haematologica 2012; 97:1574-81. [PMID: 22491742 DOI: 10.3324/haematol.2011.061168] [Citation(s) in RCA: 53] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
BACKGROUND Myelofibrosis is a myeloproliferative stem cell disorder curable exclusively by allogeneic hematopoietic stem cell transplantation and is associated with substantial mortality and morbidity. The aim of this study was to assess disease-specific and transplant-related risk factors that influence post-transplant outcome in patients with myelofibrosis. DESIGN AND METHODS We retrospectively assessed 76 consecutive patients with primary (n=47) or secondary (n=29) myelofibrosis who underwent bone marrow (n=6) or peripheral blood stem cell (n=70) transplantation from sibling (n=30) or unrelated (n=46) donors between January 1994 and December 2010. The median follow-up of surviving patients was 55 ± 7.5 months. RESULTS Primary graft failure occurred in 5% and the non-relapse mortality rate at 1 year was 28%. The relapse-free survival rate was 50% with a relapse rate of 19% at 5 years. The use of pharmacological pre-treatment and the post-transplant occurrence of chronic graft-versus-host disease were significant independent unfavourable risk factors for post-transplant survival in multivariate analysis. Using the Dynamic International Prognostic Scoring System for risk stratification, low-risk patients had significantly better overall survival (P=0.014, hazard ratio 1.4) and relapse-free survival (P=0.02, hazard ratio 1.3) compared to the other risk groups of patients. The additional inclusion of thrombocytopenia, abnormal karyotype and transfusion need (Dynamic International Prognostic Scoring System Plus) resulted in a predicted 5-year overall survival of 100%, 51%, 54% and 30% for low, intermediate-1, intermediate-2 and high-risk groups, respectively. The relapse incidence was significantly higher in the absence of chronic graft-versus-host disease (P=0.006), and pharmacological pre-treatment (n=43) was associated with reduced relapse-free survival (P=0.001). CONCLUSIONS The data corroborate a strong correlation between alloreactivity and long-term post-transplant disease control and confirm an inverse relationship between disease stage, pharmacotherapy and outcome after allogeneic hematopoietic stem cell transplantation for myelofibrosis. The Dynamic International Prognostic Scoring System was demonstrated to be useful for risk stratification of patients with myelofibrosis who are to undergo hematopoietic stem cell transplantation.
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Affiliation(s)
- Markus Ditschkowski
- Department of Bone Marrow Transplantation, WTZ, University Hospital of Essen, Essen, Germany.
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47
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McLornan DP, Mead AJ, Jackson G, Harrison CN. Allogeneic stem cell transplantation for myelofibrosis in 2012. Br J Haematol 2012; 157:413-25. [PMID: 22463701 DOI: 10.1111/j.1365-2141.2012.09107.x] [Citation(s) in RCA: 47] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Myelofibrosis (MF) is a heterogeneous disease for which long-term, effective medical therapeutic options are currently limited. The role of allogeneic haematopoietic stem cell transplant (AHSCT) in this population, many of whom are elderly, often provides a challenge with regard to the identification of suitable candidates, timing of transplantation in the disease course and choice of conditioning regimen. This review summarizes key findings from published data concerning AHSCT in MF and attempts to provide a state of the art approach to MF-AHSCT in 2012. In addition, we postulate on how the era of JAK inhibition might impact on transplantation for MF.
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Affiliation(s)
- Donal P McLornan
- Department of Haematological Medicine, King's College Hospital NHS Foundation Trust, London, UK.
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