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Abstract
Myelodysplastic syndromes (MDS) are a family of myeloid cancers with diverse genotypes and phenotypes characterized by ineffective haematopoiesis and risk of transformation to acute myeloid leukaemia (AML). Some epidemiological data indicate that MDS incidence is increasing in resource-rich regions but this is controversial. Most MDS cases are caused by randomly acquired somatic mutations. In some patients, the phenotype and/or genotype of MDS overlaps with that of bone marrow failure disorders such as aplastic anaemia, paroxysmal nocturnal haemoglobinuria (PNH) and AML. Prognostic systems, such as the revised International Prognostic Scoring System (IPSS-R), provide reasonably accurate predictions of survival at the population level. Therapeutic goals in individuals with lower-risk MDS include improving quality of life and minimizing erythrocyte and platelet transfusions. Therapeutic goals in people with higher-risk MDS include decreasing the risk of AML transformation and prolonging survival. Haematopoietic cell transplantation (HCT) can cure MDS, yet fewer than 10% of affected individuals receive this treatment. However, how, when and in which patients with HCT for MDS should be performed remains controversial, with some studies suggesting HCT is preferred in some individuals with higher-risk MDS. Advances in the understanding of MDS biology offer the prospect of new therapeutic approaches.
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Baccarani M, Bonifazi F, Soverini S, Castagnetti F, Gugliotta G, Saber W, Estrada-Merly N, Rosti G, Gale RP. Questions concerning tyrosine kinase-inhibitor therapy and transplants in chronic phase chronic myeloid leukaemia. Leukemia 2022; 36:1227-1236. [PMID: 35338251 PMCID: PMC9061294 DOI: 10.1038/s41375-022-01522-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2022] [Revised: 01/25/2022] [Accepted: 02/02/2022] [Indexed: 01/07/2023]
Abstract
In this provocative commentary, we consider several questions posed by the late chronic myeloid leukaemia (CML) expert Prof. Michele Baccarani, which he challenged us to address after his death. He noted only a small proportion of people with chronic phase CML receiving tyrosine kinase-inhibitor (TKI)-therapy are likely to achieve sustained therapy-free remission (TFR) and even fewer are likely to be cured. Persons most likely to fail TKItherapy can be identified at diagnosis or soon after starting TKI-therapy. These persons are likely to need lifetime TKI-therapy with attendant risks of adverse events, cost and psychological consequences. Allogeneic transplants achieve much higher rates of leukaemia-free survival compared with TKI-therapy but are associated with transplant-related adverse events including an almost 20 percent risk of transplant-related deaths within 1 year post-transplant and a compromised quality-of-life because of complications such as chronic graft-versus-host disease. Subject-, disease- and transplant-related co-variates associated with transplant outcomes are known with reasonable accuracy. Not everyone likely to fail TKI-therapy is a transplant candidate. However, in those who candidates are physicians and patients need to weigh benefits and risks of TKI-therapy versus a transplant. We suggest transplants should be more often considered in the metric when counseling people with chronic phase CML unlikely to achieve TFR with TKI-therapy. We question whether we are discounting a possible important therapy intervention; we think so.
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Affiliation(s)
- Michele Baccarani
- IRCCS Azienda Ospedaliero -Universitaria di Bologna, Bologna, Italy
- Department of Experimental, Diagnostic and Specialty Medicine (DIMES), Hematology 'Lorenzo e Ariosto Seràgnoli', University of Bologna, Bologna, Italy
| | | | - Simona Soverini
- Department of Experimental, Diagnostic and Specialty Medicine (DIMES), Hematology 'Lorenzo e Ariosto Seràgnoli', University of Bologna, Bologna, Italy
| | - Fausto Castagnetti
- IRCCS Azienda Ospedaliero -Universitaria di Bologna, Bologna, Italy
- Department of Experimental, Diagnostic and Specialty Medicine (DIMES), Hematology 'Lorenzo e Ariosto Seràgnoli', University of Bologna, Bologna, Italy
| | | | - Wael Saber
- Center for International Blood and Marrow Transplant Research), Milwaukee, WI, USA
- Division of Hematology/Oncology, Department of Medicine, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Noel Estrada-Merly
- Center for International Blood and Marrow Transplant Research), Milwaukee, WI, USA
| | | | - Robert Peter Gale
- Haematology Research Centre, Department of Immunology and Inflammation, Imperial College London, London, UK
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Barosi G, Gale RP. Everyone is entitled to his or her own opinion but not to their own facts. Br J Haematol 2022; 196:1290-1292. [PMID: 35037244 DOI: 10.1111/bjh.18035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2021] [Accepted: 12/21/2021] [Indexed: 11/29/2022]
Affiliation(s)
- Giovanni Barosi
- Center for the Study of Myelofibrosis, IRCCS Policlinico S. Matteo Foundation, Pavia, Italy
| | - Robert Peter Gale
- Haematology Research Centre, Department of Immunology and Inflammation, Imperial College London, London, UK
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Gale RP, Lazarus HM. The impact of cult behavior on haematopoietic cell transplant practices: believers and non-believers. Bone Marrow Transplant 2022; 57:11-13. [PMID: 34580420 DOI: 10.1038/s41409-021-01473-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2021] [Revised: 09/07/2021] [Accepted: 09/15/2021] [Indexed: 02/08/2023]
Affiliation(s)
- Robert Peter Gale
- Centre for Haematology Research, Department of Immunology and Inflammation, Imperial College London, London, UK.
| | - Hillard M Lazarus
- Department of Medicine, Division of Hematology and Oncology, Case Western Reserve University, Cleveland, OH, USA
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Yang S, Huang X, Gale RP. Cell therapy of chronic lymphocytic leukaemia: Transplants and chimeric antigen receptor (CAR)-T cells. Blood Rev 2021; 51:100884. [PMID: 34489116 DOI: 10.1016/j.blre.2021.100884] [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: 03/31/2021] [Revised: 08/17/2021] [Accepted: 08/20/2021] [Indexed: 11/24/2022]
Abstract
There is substantial progress in the therapy of chronic lymphocytic leukaemia (CLL), much of it the result of new drug development. As such the definition of high-risk CLL is changing. Nevertheless, few persons with CLL are cured with current therapy. Two types of cell therapies of CLL are currently being evaluated or re-evaluated in the context of these advances: haematopoietic cell transplants and chimeric antigen receptor (CAR)-T-cells. We discuss the potential role of these cell therapies in the context of the evolving therapy topography of CLL including how these therapies work and who, if anyone, is an appropriate candidate for cell therapy.
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Affiliation(s)
- Shenmiao Yang
- Peking University Peoples Hospital, Peking University Institute of Hematology, National Clinical Research Center for Hematologic Disease, Beijing, China
| | - Xiaojun Huang
- Peking University Peoples Hospital, Peking University Institute of Hematology, National Clinical Research Center for Hematologic Disease, Beijing, China.
| | - Robert Peter Gale
- Centre for Haematology Research, Department of Immunology and Inflammation, Imperial College London, London, United Kingdom.
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Granulocyte transfusions in haematopoietic cell transplants and leukaemia: the phoenix or beating a dead horse? Bone Marrow Transplant 2021; 56:2046-2049. [PMID: 34218266 DOI: 10.1038/s41409-021-01399-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2021] [Revised: 06/16/2021] [Accepted: 06/24/2021] [Indexed: 02/05/2023]
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Will New Drugs Replace Transplants for Chronic Lymphocytic Leukaemia? J Clin Med 2021; 10:jcm10112516. [PMID: 34200119 PMCID: PMC8201027 DOI: 10.3390/jcm10112516] [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: 03/08/2021] [Revised: 05/15/2021] [Accepted: 06/03/2021] [Indexed: 11/16/2022] Open
Abstract
Transplants have been used to treat chronic lymphocytic leukemia (CLL) for more than 35 years. Use has been restricted to <1 percent of highly selected persons typically failing concurrent conventional therapies. As therapies of CLL have evolved, so have indications for transplantation and transplant techniques. The data that we review indicate that transplants can result in long-term leukemia-free survival in some persons but are associated with substantial transplant-related morbidity and mortality. We discuss the mechanisms underlying the anti-leukemia effects of transplants including drugs, ionizing radiations, immune-mediated mechanisms and/or a combination. We discuss prognostic and predicative covariates for transplant outcomes. Importantly, we consider whether there is presently a role of transplants in CLL and who, if anyone, is an appropriate candidate in the context of new drugs.
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Gale RP. Is there a role for haematopoietic cell transplants after radiation and nuclear accidents? JOURNAL OF RADIOLOGICAL PROTECTION : OFFICIAL JOURNAL OF THE SOCIETY FOR RADIOLOGICAL PROTECTION 2021; 41:R43-R49. [PMID: 33652427 DOI: 10.1088/1361-6498/abeb24] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/21/2020] [Accepted: 03/02/2021] [Indexed: 06/12/2023]
Abstract
My task is to consider whether haematopoietic cell transplants would be considered appropriate today in persons with features like victims of high-dose and dose-rate ionizing radiations after the Chernobyl nuclear power facility accident in 1986 given knowledge and experience gained over the past 35 years. First I consider the conceptual bases for considering an intervention appropriate and then the metric for deciding whether a transplant is appropriate in similar persons. Data needed to support this decision-making process include estimates of dose, dose-rate, dose uniformity, synchronous or metachronous injuries, donor availability and alternative interventions. Many of these co-variates have substantial uncertainties. Fundamental is a consideration of potential benefit-to-risk and risk-to-benefit ratios under conditions of substantial inaccuracy and imprecision. The bottom line is probably fewer transplants would be done and more victims would receive molecularly-cloned haematopoietic growth factors.
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Affiliation(s)
- Robert Peter Gale
- Centre of Haematology, Department of Immunology and Inflammation, Imperial College London, London, United Kingdom
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How I treat measurable (minimal) residual disease in acute leukemia after allogeneic hematopoietic cell transplantation. Blood 2020; 135:1639-1649. [PMID: 31961921 DOI: 10.1182/blood.2019003566] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2019] [Accepted: 01/18/2020] [Indexed: 12/12/2022] Open
Abstract
Although allogeneic hematopoietic cell transplantation (allo-HCT) is currently the standard curative treatment of acute leukemia, relapse remains unacceptably high. Measurable (minimal) residual disease (MRD) after allo-HCT may be used as a predictor of impending relapse and should be part of routine follow-up for transplanted patients. Patients with MRD may respond to therapies aiming to unleash or enhance the graft-versus-leukemia effect. However, evidence-based recommendations on how to best implement MRD testing and MRD-directed therapy after allo-HCT are lacking. Here, I describe our institutional approach to MRD monitoring for preemptive MRD-triggered intervention, using patient scenarios to illustrate the discussion.
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Pons-Estel BA, Bonfa E, Soriano ER, Cardiel MH, Izcovich A, Vázquez G, Alarcón GS. Response to: 'Clinical evidence guidelines in systemic lupus erythematosus: revaluation' by Scheinberg. Ann Rheum Dis 2018; 78:e120. [PMID: 30352890 DOI: 10.1136/annrheumdis-2018-214385] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2018] [Accepted: 10/06/2018] [Indexed: 11/04/2022]
Affiliation(s)
- Bernardo A Pons-Estel
- Departamento de Medicina Interna, Grupo Oroño-Centro Regional de Enfermedades Autoinmunes y Reumáticas (GO-CREAR), Rosario, Argentina
| | - Eloisa Bonfa
- Division of Rheumatology - Hospital das Clinicas HCFMUSP, Facultade de Medicina, Universidade de São Paulo, São Paulo, Brazil
| | - Enrique R Soriano
- Sección de Reumatología, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina.,Fundación Dr. Pedro M. Catoggio para el progreso de la Reumatología, Buenos Aires, Argentina
| | | | - Ariel Izcovich
- Hospital Alemán de Buenos Aires, Servicio de Clínica Médica, Buenos Aires, Argentina
| | - Gloria Vázquez
- Universidad de Antioquia, Hospital Universitario, Fundación San Vicente, Medellín, Colombia
| | - Graciela S Alarcón
- Division of Clinical Immunology and Rheumatology, Department of Medicine, School of Medicine, The University of Alabama at Birmingham, Birmingham, Alabama, United States.,Department of Medicine, Universidad Peruana Cayetano Heredia, Lima, Peru
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Barosi G, Passamonti F, Accorsi P, Pane F, Vannucchi AM, Velati C, Gale RP, Tura S, Barbui T. Response to "Questions arising on phlebotomy in polycythemia vera: prophylactic measures to reduce thromboembolic events require patient-focused decisions" by Heidel et al. Leukemia 2018; 32:2727-2728. [PMID: 30267006 DOI: 10.1038/s41375-018-0259-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2018] [Revised: 07/23/2018] [Accepted: 07/30/2018] [Indexed: 11/10/2022]
Affiliation(s)
- Giovanni Barosi
- Center for the Study of Myelofibrosis, IRCCS Policlinico S. Matteo Foundation, Pavia, Italy.
| | - Francesco Passamonti
- Department of Medicine and Surgery, University of Insubria, ASST Sette Laghi - Ospedale di Circolo, Varese, Italy
| | - Patrizia Accorsi
- Department of Hematology, Transfusion Medicine and Biotechnologies, Ospedale Civile, Pescara, Italy
| | - Fabrizio Pane
- Dipartimento di Medicina Clinica e Chirurgia, Università di Napoli Federico II, Napoli, Italy
| | - Alessandro M Vannucchi
- Center for Research and Innovation of Myeloproliferative Neoplasms, AOU Careggi, and Laboratorio Congiunto, University of Florence, Florence, Italy
| | - Claudio Velati
- Italian Society of Tranfusion Medicine and Immunohematology (SIMTI), Roma, Italy
| | - Robert Peter Gale
- Department of Medicine, Haematology Research Centre, Division of Experimental Medicine, Imperial College London, London, UK
| | | | - Tiziano Barbui
- Clinical Research Foundation (FROM), Ospedale Papa Giovanni XXIII, Bergamo, Italy
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Scheinberg M. Clinical evidence guidelines in systemic lupus erythematosus: revaluation. Ann Rheum Dis 2018; 78:e119. [PMID: 30254033 DOI: 10.1136/annrheumdis-2018-214357] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2018] [Accepted: 09/01/2018] [Indexed: 11/04/2022]
Affiliation(s)
- Morton Scheinberg
- Department of Rheumatology, Hospital Israelita Albert Einstein, Sao Paulo, Brazil
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The consensus on the monitoring, treatment, and prevention of leukemia relapse after allogeneic hematopoietic stem cell transplantation in China. Cancer Lett 2018; 438:63-75. [PMID: 30217562 DOI: 10.1016/j.canlet.2018.08.030] [Citation(s) in RCA: 101] [Impact Index Per Article: 16.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2018] [Revised: 07/29/2018] [Accepted: 08/28/2018] [Indexed: 02/05/2023]
Abstract
Allogeneic hematopoietic stem cell transplantation (allo-HSCT) is an important curative therapy for patients with leukemia. However, relapse remains the leading cause of death after transplantation. In recent years, substantial progress has been made by Chinese physicians in the field of establishment of novel transplant modality, patient selection, minimal residual disease (MRD) monitoring, and immunological therapies, such as modified donor lymphocyte infusion (DLI) and chimeric antigen receptor T (CART) cells, as well as MRD-directed intervention for relapse. Most of these unique systems are distinct from those in the Western world. In this consensus, we reviewed the efficacy of post-HSCT relapse management practice from available Chinese studies on behalf of the HSCT workgroup of the Chinese Society of Hematology, Chinese Medical Association, and compared these studies withthe consensus or guidelines outside China. We summarized the consensus on routine practices of post-HSCT relapse management in China and focused on the recommendations of MRD monitoring, risk stratification directed strategies, and modified DLI system. This consensus will likely contribute to the standardization of post-HSCT relapse management in China and become an inspiration for further international cooperation to refine global practices.
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Gale RP. Therapy for Immunoglobulin D Plasma Cell Myeloma. Acta Haematol 2018; 139:193-194. [PMID: 29642063 DOI: 10.1159/000487043] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2018] [Accepted: 01/19/2018] [Indexed: 11/19/2022]
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