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Battaglia MR, Cannova J, Madero-Marroquin R, Patel AA. Treatment of Anemia in Lower-Risk Myelodysplastic Syndrome. Curr Treat Options Oncol 2024; 25:752-768. [PMID: 38814537 DOI: 10.1007/s11864-024-01217-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/13/2024] [Indexed: 05/31/2024]
Abstract
OPINION STATEMENT A majority of patients with lower-risk myelodysplastic syndrome (MDS) will present with or develop anemia. Anemia in MDS is associated with decreased quality of life and may correlate with decreased progression-free survival and overall survival. In this state of the art review we summarize current risk stratification approaches to identify lower-risk MDS (LR-MDS), the natural history of the disease, and meaningful clinical endpoints. The treatment landscape of LR-MDS with anemia is also rapidly evolving; we review the role of supportive care, erythropoietin stimulating agents, lenalidomide, luspatercept, hypomethylating agents (HMAs), and immunosuppressive therapy (IST) in the management of LR-MDS with anemia. In patients with deletion 5q (del5q) syndrome lenalidomide has both efficacy and durability of response. For patients without del5q who need treatment, the management approach is impacted by serum erythropoietin (EPO) level, SF3B1 mutation status, and ring sideroblast status. Given the data from the Phase III COMMANDS trial, we utilize luspatercept in those with SF3B1 mutation or ring sideroblasts that have an EPO level < 500 U/L; in patients without an SF3B1 mutation or ring sideroblasts there is equipoise between luspatercept and use of an erythropoietin stimulating agent (ESA). For patients who have an EPO level ≥ 500 U/L or have been previously treated there is not a clear standard of care. For those without previous luspatercept exposure it can be considered particularly if there is an SF3B1 mutation or the presence of ring sideroblasts. Other options include HMAs or IST; the Phase III IMERGE trial supports the efficacy of the telomerase inhibitor imetelstat in this setting and this may become a standard option in the future as well.
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Affiliation(s)
| | - Joseph Cannova
- Section of Hematology-Oncology, Department of Medicine, University of Chicago, 5841 S Maryland Avenue MC 2115, Chicago, IL, 60637, USA
| | - Rafael Madero-Marroquin
- Section of Hematology-Oncology, Department of Medicine, University of Chicago, 5841 S Maryland Avenue MC 2115, Chicago, IL, 60637, USA
| | - Anand A Patel
- Section of Hematology-Oncology, Department of Medicine, University of Chicago, 5841 S Maryland Avenue MC 2115, Chicago, IL, 60637, USA.
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Niscola P, Gianfelici V, Giovannini M, Piccioni D, Mazzone C, de Fabritiis P. Latest Insights and Therapeutic Advances in Myelodysplastic Neoplasms. Cancers (Basel) 2024; 16:1563. [PMID: 38672645 PMCID: PMC11048617 DOI: 10.3390/cancers16081563] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2024] [Revised: 04/10/2024] [Accepted: 04/17/2024] [Indexed: 04/28/2024] Open
Abstract
Myelodysplastic syndromes/neoplasms (MDSs) encompass a range of hematopoietic malignancies, commonly affecting elderly individuals. Molecular alterations in the hematopoietic stem cell compartment drive disease pathogenesis. Recent advancements in genomic profiling have provided valuable insights into the biological underpinnings of MDSs and have expanded therapeutic options, particularly for specific molecularly defined subgroups. This review highlights the diagnostic principles, classification updates, prognostic stratification systems, and novel treatments, which could inform future clinical trials and enhance the management of adult MDS patients, particularly for specific molecularly defined subgroups.
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Affiliation(s)
- Pasquale Niscola
- Division of Haematology, Sant’ Eugenio Hospital, 00144 Rome, Italy; (V.G.); (M.G.); (D.P.); (C.M.); (P.d.F.)
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Butler C, Dunmire M, Choi J, Szalai G, Johnson A, Lei W, Chen X, Liu L, Li W, Walter MJ, Liu T. HSPA9/mortalin inhibition disrupts erythroid maturation through a TP53-dependent mechanism in human CD34+ hematopoietic progenitor cells. Cell Stress Chaperones 2024; 29:300-311. [PMID: 38508444 PMCID: PMC10998001 DOI: 10.1016/j.cstres.2024.03.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2023] [Revised: 03/16/2024] [Accepted: 03/16/2024] [Indexed: 03/22/2024] Open
Abstract
Myelodysplastic syndromes (MDS) are a heterogeneous group of clonal hematopoietic stem cell malignancies characterized by abnormal hematopoietic cell maturation, increased apoptosis of bone marrow cells, and anemia. They are the most common myeloid blood cancers in American adults. The full complement of gene mutations that contribute to the phenotypes or clinical symptoms in MDS is not fully understood. Around 10%-25% of MDS patients harbor an interstitial heterozygous deletion on the long arm of chromosome 5 [del(5q)], creating haploinsufficiency for a large set of genes, including HSPA9. The HSPA9 gene encodes for the protein mortalin, a highly conserved heat shock protein predominantly localized in mitochondria. Our prior study showed that knockdown of HSPA9 induces TP53-dependent apoptosis in human CD34+ hematopoietic progenitor cells. In this study, we explored the role of HSPA9 in regulating erythroid maturation using human CD34+ cells. We inhibited the expression of HSPA9 using gene knockdown and pharmacological inhibition and found that inhibition of HSPA9 disrupted erythroid maturation as well as increased expression of p53 in CD34+ cells. To test whether the molecular mechanism of HSPA9 regulating erythroid maturation is TP53-dependent, we knocked down HSPA9 and TP53 individually or in combination in human CD34+ cells. We found that the knockdown of TP53 partially rescued the erythroid maturation defect induced by HSPA9 knockdown, suggesting that the defect in cells with reduced HSPA9 expression is TP53-dependent. Collectively, these findings indicate that reduced levels of HSPA9 may contribute to the anemia observed in del(5q)-associated MDS patients due to the activation of TP53.
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Affiliation(s)
- Christopher Butler
- Department of Biomedical Sciences, West Virginia School of Osteopathic Medicine, Lewisburg, WV, USA
| | - Morgan Dunmire
- Department of Biomedical Sciences, West Virginia School of Osteopathic Medicine, Lewisburg, WV, USA
| | - Jaebok Choi
- Department of Medicine, Division of Oncology, Washington University School of Medicine, St. Louis, MO, USA
| | - Gabor Szalai
- Department of Biomedical Sciences, Burrell College of Osteopathic Medicine, Las Cruces, NM, USA
| | - Anissa Johnson
- Department of Biomedical Sciences, Burrell College of Osteopathic Medicine, Las Cruces, NM, USA
| | - Wei Lei
- Department of Pharmaceutical and Graduate Life Sciences, Manchester University College of Pharmacy, Natural and Health Sciences, Fort Wayne, IN, USA
| | - Xin Chen
- Department of Pharmaceutical and Clinical Sciences, College of Pharmacy and Health Sciences, Campbell University, Buies Creek, NC, USA
| | - Liang Liu
- Department of Cancer Biology, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Wei Li
- Department of Biomedical Sciences, Joan C. Edwards School of Medicine, Marshall University, Huntington, WV, USA
| | - Matthew J Walter
- Department of Medicine, Division of Oncology, Washington University School of Medicine, St. Louis, MO, USA
| | - Tuoen Liu
- Department of Biomedical Sciences, West Virginia School of Osteopathic Medicine, Lewisburg, WV, USA.
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Abdallah M, Reichard K, Gangat N, Tefferi A. Treatment-emergent mutations in myelodysplastic syndrome with del(5q) - lenalidomide related or disease-intrinsic clonal evolution? Blood Cancer J 2024; 14:49. [PMID: 38499527 PMCID: PMC10948768 DOI: 10.1038/s41408-024-01027-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2023] [Revised: 02/20/2024] [Accepted: 03/05/2024] [Indexed: 03/20/2024] Open
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Lovatel VL, da Silva BF, Rodrigues EF, da Rosa Borges MLR, de Cássia Barbosa Tavares R, Bueno APS, da Costa ES, de Jesus Marques Salles T, de Souza Fernandez T. Association between Leukemic Evolution and Uncommon Chromosomal Alterations in Pediatric Myelodysplastic Syndrome. Mediterr J Hematol Infect Dis 2024; 16:e2024003. [PMID: 38223485 PMCID: PMC10786138 DOI: 10.4084/mjhid.2024.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2023] [Accepted: 12/10/2023] [Indexed: 01/16/2024] Open
Abstract
Background Pediatric myelodysplastic syndrome (pMDS) is a group of rare clonal neoplasms with a difficult diagnosis and risk of progression to acute myeloid leukemia (AML). The early stratification in risk groups is essential to choose the treatment and indication for allogeneic hematopoietic stem cell transplantation (HSCT). According to the Revised International Prognostic Scoring System, cytogenetic analysis has demonstrated an essential role in diagnosis and prognosis. In pMDS, abnormal karyotypes are present in 30-50% of the cases. Monosomy 7 is the most common chromosomal alteration associated with poor prognosis. However, the rarity of specific cytogenetic alterations makes its prognosis uncertain. Thus, this study aimed to describe uncommon cytogenetic alterations in a cohort of 200 pMDS patients and their association with evolution to AML. Methods The cytogenetic analysis was performed in 200 pMDS patients by G-banding and fluorescence in situ hybridization between 2000 to 2022. Results Rare chromosome alterations were observed in 7.5% (15/200) of the cases. These chromosome alterations were divided into four cytogenetic groups: hyperdiploidy, biclonal chromosomal alterations, translocations, and uncommon deletions representing 33.3%, 33.3%, 20%, and 13.3%, respectively. Most of these patients (10/15) were classified with advanced MDS (MDS-EB and MDS/AML) and the initial subtype was present in five patients (RCC). The leukemic evolution was observed in 66.66% (10/15) of the patients. Most patients had poor clinical outcomes and they were indicated for HSCT. Conclusion The study of uncommon cytogenetic alterations in pMDS is important to improve the prognosis and guide early indication of HSCT.
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Affiliation(s)
- Viviane Lamim Lovatel
- Cytogenetic Laboratory, Cell and Gene Therapy Program, Instituto Nacional do Câncer (INCA), Rio de Janeiro, RJ, Brazil
| | - Beatriz Ferreira da Silva
- Cytogenetic Laboratory, Cell and Gene Therapy Program, Instituto Nacional do Câncer (INCA), Rio de Janeiro, RJ, Brazil
| | - Eliane Ferreira Rodrigues
- Cytogenetic Laboratory, Cell and Gene Therapy Program, Instituto Nacional do Câncer (INCA), Rio de Janeiro, RJ, Brazil
| | | | - Rita de Cássia Barbosa Tavares
- Outpatient Department, Bone Marrow Transplantation Center (CEMO), Instituto Nacional do Câncer (INCA), Rio de Janeiro, RJ, Brazil
| | - Ana Paula Silva Bueno
- Instituto de Puericultura e Pediatria Martagão Gesteira (IPPMG), Universidade Federal do Rio de Janeiro (UFRJ), Rio de Janeiro, RJ, Brazil
| | - Elaine Sobral da Costa
- Instituto de Puericultura e Pediatria Martagão Gesteira (IPPMG), Universidade Federal do Rio de Janeiro (UFRJ), Rio de Janeiro, RJ, Brazil
| | | | - Teresa de Souza Fernandez
- Cytogenetic Laboratory, Cell and Gene Therapy Program, Instituto Nacional do Câncer (INCA), Rio de Janeiro, RJ, Brazil
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Uliel N, Segal G, Perri A, Turpashvili N, Kassif Lerner R, Itelman E. Low ALT, a marker of sarcopenia and frailty, is associated with shortened survival amongst myelodysplastic syndrome patients: A retrospective study. Medicine (Baltimore) 2023; 102:e33659. [PMID: 37115069 PMCID: PMC10146076 DOI: 10.1097/md.0000000000033659] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2023] [Revised: 04/07/2023] [Accepted: 04/10/2023] [Indexed: 04/29/2023] Open
Abstract
Myelodysplastic Syndrome (MDS) is a common blood dyscrasia that mainly affects the elderly population. Several prognostic scores are available utilizing blood count variables and cytogenetic abnormalities, targeting the disease rather than the patient. Sarcopenia and frailty are associated with shortened survival rates in various disease states. Low Alanine Aminotransferase (ALT) levels are a marker of lowered muscle mass and frailty status. This study aimed to examine the correlation between low ALT levels and prognosis in MDS patients. This is a retrospective cohort study. We obtained the demographic, clinical, and laboratory data of patients in a tertiary hospital. Univariate and multivariate models were used to investigate the potential relationship between low ALT level and survival. The final study included 831 patients (median age 74.3 years, Interquartile range 65.6-81.8), and 62% were males. The median ALT level was 15 international units (IU)/L and 233 patients (28%) had low ALT levels (<12 IU/L). Univariate analysis showed that low ALT levels were associated with a 25% increase in mortality (95% confidence interval [CI]: 1.05-1.50, P = .014). A multivariate model controlling for age, sex, body mass index, hemoglobin and albumin concentrations, and low ALT levels was still significantly associated with increased mortality (hazard ratio [HR] = 1.25, 95% CI: 1.01-1.56, P = .041). Low ALT levels were associated with increased mortality among patients with MDS. Impact: Using ALT as a frailty metric may allow patient-centered, personalized care in this patient population. A low ALT level reflects the pre-morbid robustness of patients and is not intended to replace disease-centered characteristics.
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Affiliation(s)
- Noa Uliel
- HARVEY Faculty of medicine, Pavia University, Ramat Gan, Israel
| | - Gad Segal
- Education Authority, Sheba Medical Center. Affiliated to the Sackler Faculty of Medicine, Tel-Aviv University, Ramat Gan, Israel
| | - Avital Perri
- Department of Neurosurgery, Sheba Medical Center. Affiliated to the Sackler Faculty of Medicine, Tel-Aviv University, Ramat Gan, Israel
| | - Natia Turpashvili
- Institute of Hematology, Sheba Medical Center. Affiliated to the Sackler Faculty of Medicine, Tel-Aviv University, Ramat Gan, Israel
| | - Reut Kassif Lerner
- Department of Pediatric intensive care, The Edmond and Lily Safra Children’s hospital, Sheba Medical Center, Tel-Hashomer, Israel. Affiliate to Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Ramat Gan, Israel
| | - Edward Itelman
- Education Authority, Sheba Medical Center. Affiliated to the Sackler Faculty of Medicine, Tel-Aviv University, Ramat Gan, Israel
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Gurnari C, Xie Z, Zeidan AM. How I Manage Transplant Ineligible Patients with Myelodysplastic Neoplasms. Clin Hematol Int 2023; 5:8-20. [PMID: 36574201 PMCID: PMC10063738 DOI: 10.1007/s44228-022-00024-4] [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: 09/28/2022] [Accepted: 11/14/2022] [Indexed: 12/28/2022] Open
Abstract
Myelodysplastic neoplasms, formerly known as myelodysplastic syndromes (MDS), represent a group of clonal disorders characterized by a high degree of clinical and molecular heterogeneity, and an invariable tendency to progress to acute myeloid leukemia. MDS typically present in the elderly with cytopenias of different degrees and bone marrow dysplasia, the hallmarks of the disease. Allogeneic hematopoietic stem cell transplant is the sole curative approach to date. Nonetheless, given the disease's demographics, only a minority of patients can benefit from this procedure. Currently used prognostic schemes such as the Revised International Prognostic Scoring System (R-IPSS), and most recently the molecular IPSS (IPSS-M), guide clinical management by dividing MDS into two big categories: lower- and higher-risk cases, based on a cut-off score of 3.5. The main clinical problem of the lower-risk group is represented by the management of cytopenias, whereas the prevention of secondary leukemia progression is the goal for the latter. Herein, we discuss the non-transplant treatment of MDS, focusing on current practice and available therapeutic options, while also presenting new investigational agents potentially entering the MDS therapeutic arsenal in the near future.
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Affiliation(s)
- Carmelo Gurnari
- Translational Hematology and Oncology Research Department, Taussig Cancer Center, Cleveland Clinic, Cleveland, OH, USA
- Department of Biomedicine and Prevention, University of Rome Tor Vergata, Rome, Italy
| | - Zhuoer Xie
- Department of Hematology, H. Lee Moffitt Cancer Center, Tampa, FL, USA
| | - Amer M Zeidan
- Section of Hematology, Department of Medicine, Yale School of Medicine, and Yale Cancer Center, New Haven, CT, USA.
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Hoff FW, Madanat YF. Molecular Drivers of Myelodysplastic Neoplasms (MDS)-Classification and Prognostic Relevance. Cells 2023; 12:627. [PMID: 36831294 PMCID: PMC9954608 DOI: 10.3390/cells12040627] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2023] [Revised: 02/12/2023] [Accepted: 02/13/2023] [Indexed: 02/17/2023] Open
Abstract
Myelodysplastic neoplasms (MDS) form a broad spectrum of clonal myeloid malignancies arising from hematopoietic stem cells that are characterized by progressive and refractory cytopenia and morphological dysplasia. Recent advances in unraveling the underlying pathogenesis of MDS have led to the identification of molecular drivers and secondary genetic events. With the overall goal of classifying patients into relevant disease entities that can aid to predict clinical outcomes and make therapeutic decisions, several MDS classification models (e.g., French-American-British, World Health Organization, and International Consensus Classification) as well as prognostication models (e.g., International Prognostic Scoring system (IPSS), the revised IPSS (IPSS-R), and the molecular IPSS (IPSS-M)), have been developed. The IPSS-M is the first model that incorporates molecular data for individual genes and facilitates better prediction of clinical outcome parameters compared to older versions of this model (i.e., overall survival, disease progression, and leukemia-free survival). Comprehensive classification and accurate risk prediction largely depend on the integration of genetic mutations that drive the disease, which is crucial to improve the diagnostic work-up, guide treatment decision making, and direct novel therapeutic options. In this review, we summarize the most common cytogenetic and genomic drivers of MDS and how they impact MDS prognosis and treatment decisions.
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Affiliation(s)
- Fieke W. Hoff
- Department of Internal Medicine, UT Southwestern Medical Center, Dallas, TX 75390-8565, USA
- Harold C. Simmons Comprehensive Cancer Center, UT Southwestern Medical Center, Dallas, TX 75390-8565, USA
| | - Yazan F. Madanat
- Department of Internal Medicine, UT Southwestern Medical Center, Dallas, TX 75390-8565, USA
- Harold C. Simmons Comprehensive Cancer Center, UT Southwestern Medical Center, Dallas, TX 75390-8565, USA
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Brunner AM, Leitch HA, van de Loosdrecht AA, Bonadies N. Management of patients with lower-risk myelodysplastic syndromes. Blood Cancer J 2022; 12:166. [PMID: 36517487 PMCID: PMC9751093 DOI: 10.1038/s41408-022-00765-8] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2022] [Revised: 11/30/2022] [Accepted: 12/01/2022] [Indexed: 12/15/2022] Open
Abstract
Myelodysplastic syndromes (MDS) are a heterogeneous group of hematopoietic stem cell disorders characterized by ineffective hematopoiesis with abnormal blood cell development (dysplasia) leading to cytopenias and an increased risk for progression to acute myeloid leukemia (AML). Patients with MDS can generally be classified as lower- (LR-MDS) or higher-risk (HR-MDS). As treatment goals for patients with LR-MDS and those with HR-MDS differ significantly, appropriate diagnosis, classification, and follow-up are critical for correct disease management. In this review, we focus on the diagnosis, prognosis, and treatment options, as well as the prediction of the disease course and monitoring of treatment response in patients with LR-MDS. We discuss how next-generation sequencing, increasing knowledge on mechanisms of MDS pathogenesis, and novel therapies may change the current treatment landscape in LR-MDS and why structured assessments of responses, toxicities, and patient-reported outcomes should be incorporated into routine clinical practice.
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Affiliation(s)
| | - Heather A Leitch
- Hematology, St. Paul's Hospital, University of British Columbia, Vancouver, BC, Canada
| | - Arjan A van de Loosdrecht
- Department of Hematology, Cancer Center Amsterdam, Amsterdam University Medical Center, VU University Amsterdam, Amsterdam, Netherlands
| | - Nicolas Bonadies
- Department of Hematology and Central Hematology Laboratory, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
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