1
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Garcia-Manero G, Ribrag V, Zhang Y, Farooqui M, Marinello P, Smith BD. Pembrolizumab for myelodysplastic syndromes after failure of hypomethylating agents in the phase 1b KEYNOTE-013 study. Leuk Lymphoma 2022; 63:1660-1668. [PMID: 35244520 DOI: 10.1080/10428194.2022.2034155] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
The phase 1b multicohort KEYNOTE-013 study assessed the safety and antitumor activity of pembrolizumab given at 10 mg/kg/day every 2 weeks for up to 2 years in hematologic malignancies, including myelodysplastic syndromes (MDS) refractory to a hypomethylating agent (HMA). Primary outcomes were safety and objective response rate per International Working Group 2006 criteria. By June 26, 2020, 28 patients were enrolled; median duration of follow-up was 5.6 months (range, 1-78), and 25 patients (89%) had died. Treatment-related adverse events occurred in 10 patients (36%), including 2 (7%) treatment-related discontinuations. No patient achieved complete or partial response. Five patients (19%) had bone marrow complete response, 12 (44%) stable disease, 10 (37%) progressive disease, 6 (22%) cytogenetic response, and 5 (19%) hematologic improvement. Median overall survival (OS) was 6.0 months (95% CI, 4-12); the overall 2-year OS rate was 17%. Pembrolizumab had manageable safety and clinical activity in patients with HMA-refractory MDS.This trial was registered at www.clinicaltrials.gov as #NCT01953692.
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Affiliation(s)
| | - Vincent Ribrag
- Department of Hematology, Gustave Roussy, Villejuif, France
| | - Yayan Zhang
- Department of Medical Oncology, Merck & Co., Inc, Kenilworth, NJ, USA
| | - Mohammed Farooqui
- Department of Medical Oncology, Merck & Co., Inc, Kenilworth, NJ, USA
| | | | - B Douglas Smith
- Department of Oncology, Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins, Baltimore, MD, USA
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2
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Fan T, Feng X, Yokota A, Liu W, Tang Y, Yan X, Xiao H, Wang Y, Deng Z, Zhao P, Wang M, Wang H, Ma R, Hu X, Huang G. Arsenic Dispensing Powder Promotes Erythropoiesis in Myelodysplastic Syndromes via Downregulation of HIF1A and Upregulation of GATA Factors. THE AMERICAN JOURNAL OF CHINESE MEDICINE 2021; 49:461-485. [PMID: 33641653 DOI: 10.1142/s0192415x2150021x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Traditional Chinese Medicine (TCM) is a practical medicine based on thousands of years of medical practice in China. Arsenic dispensing powder (ADP) has been used as a treatment for MDS patients with a superior efficacy on anemia at Xiyuan Hospital of China Academy of Chinese Medical Sciences. In this study, we retrospectively analyzed MDS patients that received ADP treatment in the past 9 years and confirmed that ADP improves patients' anemia and prolongs overall survival in intermediate-risk MDS patients. Then, we used the MDS transgenic mice model and cell line to explore the drug mechanism. In normal and MDS cells, ADP does not show cellular toxicity but promotes differentiation. In mouse MDS models, we observed that ADP showed significant efficacy on promoting erythropoiesis. In the BFU-E and CFU-E assays, ADP could promote erythropoiesis not only in normal clones but also in MDS clones. Mechanistically, we found that ADP could downregulate HIF1A in MDS clones through upregulation of VHL, P53 and MDM2, which is involved in two parallel pathways to downregulate HIF1A. We also confirmed that ADP upregulates GATA factors in normal clones. Thus, our clinical and experimental studies indicate that ADP is a promising drug to promote erythropoiesis in both MDS and normal clones with a superior outcome than current regular therapies. ADP promotes erythropoiesis in myelodysplastic syndromes via downregulation of HIF1A and upregulation of GATA factors.
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Affiliation(s)
- Teng Fan
- Department of Hematology, Xiyuan Hospital, China Academy of Chinese Medical Sciences, Beijing, P. R. China.,Divisions of Pathology and Experimental Hematology and Cancer Biology, Cincinnati Children's Hospital Medical Center, OH, USA
| | - Xiaomin Feng
- Divisions of Pathology and Experimental Hematology and Cancer Biology, Cincinnati Children's Hospital Medical Center, OH, USA
| | - Asumi Yokota
- Divisions of Pathology and Experimental Hematology and Cancer Biology, Cincinnati Children's Hospital Medical Center, OH, USA
| | - Weiyi Liu
- Department of Hematology, Xiyuan Hospital, China Academy of Chinese Medical Sciences, Beijing, P. R. China
| | - Yuting Tang
- Divisions of Pathology and Experimental Hematology and Cancer Biology, Cincinnati Children's Hospital Medical Center, OH, USA
| | - Xiaomei Yan
- Divisions of Pathology and Experimental Hematology and Cancer Biology, Cincinnati Children's Hospital Medical Center, OH, USA
| | - Haiyan Xiao
- Department of Hematology, Xiyuan Hospital, China Academy of Chinese Medical Sciences, Beijing, P. R. China
| | - Yue Wang
- Department of Hematology, Xiyuan Hospital, China Academy of Chinese Medical Sciences, Beijing, P. R. China
| | - Zhongyang Deng
- Department of Hematology, Xiyuan Hospital, China Academy of Chinese Medical Sciences, Beijing, P. R. China
| | - Pan Zhao
- Department of Hematology, Xiyuan Hospital, China Academy of Chinese Medical Sciences, Beijing, P. R. China
| | - Mingjing Wang
- Department of Hematology, Xiyuan Hospital, China Academy of Chinese Medical Sciences, Beijing, P. R. China
| | - Hongzhi Wang
- Department of Hematology, Xiyuan Hospital, China Academy of Chinese Medical Sciences, Beijing, P. R. China
| | - Rou Ma
- Department of Hematology, Xiyuan Hospital, China Academy of Chinese Medical Sciences, Beijing, P. R. China
| | - Xiaomei Hu
- Department of Hematology, Xiyuan Hospital, China Academy of Chinese Medical Sciences, Beijing, P. R. China
| | - Gang Huang
- Divisions of Pathology and Experimental Hematology and Cancer Biology, Cincinnati Children's Hospital Medical Center, OH, USA
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3
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Zeidan AM, Hu X, Zhu W, Stahl M, Wang R, Huntington SF, Giri S, Bewersdorf JP, Podoltsev NA, Gore SD, Ma X, Davidoff AJ. Association of provider experience and clinical outcomes in patients with myelodysplastic syndromes receiving hypomethylating agents. Leuk Lymphoma 2019; 61:397-408. [PMID: 31570040 DOI: 10.1080/10428194.2019.1663423] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Population level survival of patients with myelodysplastic syndromes (MDS) treated with hypomethylating agents (HMA) is inferior to clinical trials. Using SEER-Medicare data, we identified 2086 MDS patients diagnosed in 2004-13, aged ≥66 years at diagnosis, and receiving ≥1 HMA cycle after 2005. We used multivariate logistic regression and Cox proportional hazards models to assess the impact of provider experience on persistent HMA therapy and overall survival (OS), respectively. Median number of HMA cycles was 4 and median OS was 10 months. Thirty-two percent of patients were treated by providers with ≥1 prior HMA initiation in the last 2 years and were more likely to receive ≥4 cycles of HMA therapy (OR = 1.29, 95% CI = 1.06-1.57; p = .01). No significant association was found between MDS or HMA initiation volume and survival. In conclusion, while HMA initiation volume was associated with persistent HMA treatment, neither MDS nor HMA initiation volumes were associated with OS in older MDS patients.
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Affiliation(s)
- Amer M Zeidan
- Department of Internal Medicine, School of Medicine, Yale University, New Haven, CT, USA.,Cancer Outcomes, Public Policy, and Effectiveness Research (COPPER) Center, Yale University, New Haven, CT, USA
| | - Xin Hu
- Cancer Outcomes, Public Policy, and Effectiveness Research (COPPER) Center, Yale University, New Haven, CT, USA
| | - Weiwei Zhu
- Cancer Outcomes, Public Policy, and Effectiveness Research (COPPER) Center, Yale University, New Haven, CT, USA
| | - Maximilian Stahl
- Department of Internal Medicine, School of Medicine, Yale University, New Haven, CT, USA
| | - Rong Wang
- Cancer Outcomes, Public Policy, and Effectiveness Research (COPPER) Center, Yale University, New Haven, CT, USA.,Department of Chronic Disease Epidemiology, School of Public Health, Yale University, New Haven, CT, USA
| | - Scott F Huntington
- Department of Internal Medicine, School of Medicine, Yale University, New Haven, CT, USA.,Cancer Outcomes, Public Policy, and Effectiveness Research (COPPER) Center, Yale University, New Haven, CT, USA
| | - Smith Giri
- Department of Internal Medicine, School of Medicine, Yale University, New Haven, CT, USA.,Cancer Outcomes, Public Policy, and Effectiveness Research (COPPER) Center, Yale University, New Haven, CT, USA
| | - Jan Philipp Bewersdorf
- Department of Internal Medicine, School of Medicine, Yale University, New Haven, CT, USA
| | - Nikolai A Podoltsev
- Department of Internal Medicine, School of Medicine, Yale University, New Haven, CT, USA.,Cancer Outcomes, Public Policy, and Effectiveness Research (COPPER) Center, Yale University, New Haven, CT, USA
| | - Steven D Gore
- Department of Internal Medicine, School of Medicine, Yale University, New Haven, CT, USA.,Cancer Outcomes, Public Policy, and Effectiveness Research (COPPER) Center, Yale University, New Haven, CT, USA
| | - Xiaomei Ma
- Cancer Outcomes, Public Policy, and Effectiveness Research (COPPER) Center, Yale University, New Haven, CT, USA.,Department of Chronic Disease Epidemiology, School of Public Health, Yale University, New Haven, CT, USA
| | - Amy J Davidoff
- Cancer Outcomes, Public Policy, and Effectiveness Research (COPPER) Center, Yale University, New Haven, CT, USA.,Department of Health Policy and Management, School of Public Health, Yale University, New Haven, CT, USA
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4
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Jacobse J, Sijpkens YWJ, van 't Wout JW, Peters EEM, Vlasveld LT. Vasculitis in Myelodysplastic Syndrome and Chronic Myelomonocytic Leukemia: A Report of Two Cases. J Hematol 2018; 7:158-162. [PMID: 32300432 PMCID: PMC7155851 DOI: 10.14740/jh461w] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2018] [Accepted: 10/18/2018] [Indexed: 11/30/2022] Open
Abstract
There is a clear association between myelodysplastic syndrome (MDS)/chronic myelomonocytic leukemia (CMML) and autoimmune manifestations such as vasculitis. It is not clear if autoimmune manifestations in myelodysplastic syndrome are a cause or consequence. We describe two patients with polyarteritis nodosa and large vessel vasculitis, as presenting symptom of a myelodysplastic syndrome with excess blasts type 2 and chronic myelomonocytic leukemia respectively. Immunosuppressive treatment resulted in amelioration of the vasculitis with improvement of the myelodysplastic features in the first patient and rapid evolution to acute myeloid leukemia in the other patient. The association between MDS/CMML and autoimmune manifestations, such as vasculitis, emphasizes the role of autoimmunity in the clinical features and even pathogenesis of MDS/CMML.
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Affiliation(s)
- Justin Jacobse
- Department of Internal Medicine, HMC Bronovo, The Hague, Netherlands
| | - Yvo W J Sijpkens
- Department of Internal Medicine, HMC Bronovo, The Hague, Netherlands
| | - Jan W van 't Wout
- Department of Internal Medicine, HMC Bronovo, The Hague, Netherlands
| | - Elke E M Peters
- Department of Pathology, HMC Bronovo, The Hague, Netherlands
| | - L Tom Vlasveld
- Department of Internal Medicine, HMC Bronovo, The Hague, Netherlands
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5
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Zeidan AM, Giri S, DeVeaux M, Ballas SK, Duong VH. Systematic review and meta-analysis of the effect of iron chelation therapy on overall survival and disease progression in patients with lower-risk myelodysplastic syndromes. Ann Hematol 2018; 98:339-350. [PMID: 30413901 DOI: 10.1007/s00277-018-3539-7] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2018] [Accepted: 10/29/2018] [Indexed: 01/17/2023]
Abstract
The impact of iron chelation therapy (ICT) on overall survival (OS) and progression to acute myeloid leukemia (AML) in patients with iron overload and International Prognostic Scoring System low- or intermediate-risk myelodysplastic syndromes (MDS) is not well understood. We conducted a systematic review and meta-analysis of published studies of ICT in patients with MDS to better elucidate these relationships. We searched PubMed, EMBASE, Cochrane databases, and the World Health Organization Clinical Trial Registry for studies reporting the impact of ICT on OS in patients with low- or intermediate-risk MDS. Studies were examined for demographics, effect measures, and potential bias risk. Fixed and random-effects models were used to calculate adjusted OS and adjusted hazards ratio (aHR) estimates, respectively, among the different studies. Nine observational studies (four prospective and five retrospective) were identified. For patients with MDS, ICT was associated with an overall lower risk of mortality compared with no ICT (aHR 0.42; 95% confidence interval (CI) 0.28-0.62; P < 0.01); however, there was significant heterogeneity across the studies. In studies reporting progression to AML, ICT was not associated with decreased risk of progression (odds ratio 0.68; 95% CI 0.31-1.43; P < 0.030). This systematic review and meta-analysis of nine nonrandomized trials demonstrated significant reduction in risk of mortality in patients with iron overload and low- or intermediate-risk MDS treated with ICT; however, a causal relationship cannot be established. Randomized, controlled trials are needed to more definitively evaluate the relationship between ICT and survival in patients with iron overload and low- or intermediate-risk MDS.
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Affiliation(s)
- Amer M Zeidan
- Yale University School of Medicine and Yale Cancer Center, Smilow Cancer Hospital at Yale New Haven, New Haven, CT, USA.
| | - Smith Giri
- Yale University School of Medicine and Yale Cancer Center, Smilow Cancer Hospital at Yale New Haven, New Haven, CT, USA
| | | | - Samir K Ballas
- Cardeza Foundation for Hematologic Research, Thomas Jefferson University, Philadelphia, PA, USA
| | - Vu H Duong
- University of Maryland School of Medicine, Baltimore, MD, USA
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6
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Shallis RM, Ahmad R, Zeidan AM. The genetic and molecular pathogenesis of myelodysplastic syndromes. Eur J Haematol 2018; 101:260-271. [PMID: 29742289 DOI: 10.1111/ejh.13092] [Citation(s) in RCA: 47] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/30/2018] [Indexed: 12/14/2022]
Abstract
Myelodysplastic syndromes (MDS) comprise a diverse group of clonal and malignant myeloid disorders characterized by ineffective hematopoiesis, resultant peripheral cytopenias, and a meaningful increased risk of progression to acute myeloid leukemia. A wide array of recurring genetic mutations involved in RNA splicing, histone manipulation, DNA methylation, transcription factors, kinase signaling, DNA repair, cohesin proteins, and other signal transduction elements has been identified as important substrates for the development of MDS. Cytogenetic abnormalities, namely those characterized by loss of genetic material (including 5q- and 7q-), have also been strongly implicated and may influence the clonal architecture which predicts such mutations and may provoke an inflammatory bone marrow microenvironment as the substrate for clonal expansion. Other aspects of the molecular pathogenesis of MDS continue to be further elucidated, predicated upon advances in gene expression profiling and the development of new, and improved high-throughput techniques. More accurate understanding of the genetic and molecular basis for the development of MDS directly provides additional opportunity for treatment, which to date remains limited. In this comprehensive review, we examine the current understanding of the molecular pathogenesis and pathophysiology of MDS, as well as review future prospects which may enhance this understanding, treatment strategies, and hopefully outcomes.
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Affiliation(s)
- Rory M Shallis
- Division of Hematology/Medical Oncology, Department of Medicine, Yale University School of Medicine, New Haven, CT, USA
| | - Rami Ahmad
- Division of Hematology/Medical Oncology, Department of Medicine, Yale University School of Medicine, New Haven, CT, USA
| | - Amer M Zeidan
- Division of Hematology/Medical Oncology, Department of Medicine, Yale University School of Medicine, New Haven, CT, USA.,Cancer Outcomes, Public Policy, and Effectiveness Research (COPPER) Center, Yale University, New Haven, CT, USA
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7
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Abstract
Acute myeloid leukemia (AML) is one of the best studied malignancies, and significant progress has been made in understanding the clinical implications of its disease biology. Unfortunately, drug development has not kept pace, as the '7+3' induction regimen remains the standard of care for patients fit for intensive therapy 40 years after its first use. Temporal improvements in overall survival were mostly confined to younger patients and driven by improvements in supportive care and use of hematopoietic stem cell transplantation. Multiple forms of novel therapy are currently in clinical trials and are attempting to bring bench discoveries to the bedside to benefit patients. These novel therapies include improved chemotherapeutic agents, targeted molecular inhibitors, cell cycle regulators, pro-apoptotic agents, epigenetic modifiers, and metabolic therapies. Immunotherapies in the form of vaccines; naked, conjugated and bispecific monoclonal antibodies; cell-based therapy; and immune checkpoint inhibitors are also being evaluated in an effort to replicate the success seen in other malignancies. Herein, we review the scientific basis of these novel therapeutic approaches, summarize the currently available evidence, and look into the future of AML therapy by highlighting key clinical studies and the challenges the field continues to face.
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8
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Shallis RM, Zeidan AM. Lenalidomide in non-deletion 5q lower-risk myelodysplastic syndromes: a glass quarter full or three quarters empty? Leuk Lymphoma 2018; 59:2015-2017. [PMID: 29411698 DOI: 10.1080/10428194.2018.1430797] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Affiliation(s)
- Rory M Shallis
- a Department of Internal Medicine School of Medicine , Yale University , New Haven , USA
| | - Amer M Zeidan
- a Department of Internal Medicine School of Medicine , Yale University , New Haven , USA.,b Cancer Outcomes, Public Policy, and Effectiveness Research (COPPER) Center, Yale University , New Haven , USA
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9
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Parisi S, Ratti S, Mongiorgi S, Suh PG, Manzoli L, McCubrey JA, Cocco L, Follo MY, Finelli C. Current therapy and new drugs: a road to personalized treatment of myelodysplastic syndromes. EXPERT REVIEW OF PRECISION MEDICINE AND DRUG DEVELOPMENT 2018. [DOI: 10.1080/23808993.2018.1419820] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Affiliation(s)
- Sarah Parisi
- Department of Experimental, Diagnostic and Specialty Medicine, Institute of Hematology “L. e A. Seràgnoli”, S. Orsola-Malpighi Hospital, Bologna, Italy
| | - Stefano Ratti
- Cellular Signalling Laboratory, Institute of Human Anatomy DIBINEM, University of Bologna, Bologna, Italy
| | - Sara Mongiorgi
- Cellular Signalling Laboratory, Institute of Human Anatomy DIBINEM, University of Bologna, Bologna, Italy
| | - Pann-Ghill Suh
- School of Life Sciences, UNIST, Ulsan, Republic of Korea
| | - Lucia Manzoli
- Cellular Signalling Laboratory, Institute of Human Anatomy DIBINEM, University of Bologna, Bologna, Italy
| | - James A. McCubrey
- Department of Microbiology and Immunology, Brody School of Medicine, East Carolina University, Greenville, NC, USA
| | - Lucio Cocco
- Cellular Signalling Laboratory, Institute of Human Anatomy DIBINEM, University of Bologna, Bologna, Italy
| | - Matilde Y. Follo
- Cellular Signalling Laboratory, Institute of Human Anatomy DIBINEM, University of Bologna, Bologna, Italy
| | - Carlo Finelli
- Department of Experimental, Diagnostic and Specialty Medicine, Institute of Hematology “L. e A. Seràgnoli”, S. Orsola-Malpighi Hospital, Bologna, Italy
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10
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Zeidan AM, Stahl M, Sekeres MA, Steensma DP, Komrokji RS, Gore SD. A call for action: Increasing enrollment of untreated patients with higher-risk myelodysplastic syndromes in first-line clinical trials. Cancer 2017; 123:3662-3672. [DOI: 10.1002/cncr.30903] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2017] [Revised: 05/22/2017] [Accepted: 06/12/2017] [Indexed: 11/11/2022]
Affiliation(s)
- Amer M. Zeidan
- Department of Hematology, Department of Internal Medicine, Yale Comprehensive Cancer Center; Yale University School of Medicine; New Haven Connecticut
| | - Maximilian Stahl
- Department of Hematology, Department of Internal Medicine, Yale Comprehensive Cancer Center; Yale University School of Medicine; New Haven Connecticut
| | | | - David P. Steensma
- Dana-Farber Cancer Institute; Harvard Medical School; Boston Massachusetts
| | - Rami S. Komrokji
- H. Lee Moffitt Cancer Center and Research Institute; Tampa Florida
| | - Steven D. Gore
- Department of Hematology, Department of Internal Medicine, Yale Comprehensive Cancer Center; Yale University School of Medicine; New Haven Connecticut
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11
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Gbolahan OB, Zeidan AM, Stahl M, Abu Zaid M, Farag S, Paczesny S, Konig H. Immunotherapeutic Concepts to Target Acute Myeloid Leukemia: Focusing on the Role of Monoclonal Antibodies, Hypomethylating Agents and the Leukemic Microenvironment. Int J Mol Sci 2017; 18:E1660. [PMID: 28758974 PMCID: PMC5578050 DOI: 10.3390/ijms18081660] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2017] [Revised: 07/22/2017] [Accepted: 07/24/2017] [Indexed: 12/20/2022] Open
Abstract
Intensive chemotherapeutic protocols and allogeneic stem cell transplantation continue to represent the mainstay of acute myeloid leukemia (AML) treatment. Although this approach leads to remissions in the majority of patients, long-term disease control remains unsatisfactory as mirrored by overall survival rates of approximately 30%. The reason for this poor outcome is, in part, due to various toxicities associated with traditional AML therapy and the limited ability of most patients to tolerate such treatment. More effective and less toxic therapies therefore represent an unmet need in the management of AML, a disease for which therapeutic progress has been traditionally slow when compared to other cancers. Several studies have shown that leukemic blasts elicit immune responses that could be exploited for the development of novel treatment concepts. To this end, early phase studies of immune-based therapies in AML have delivered encouraging results and demonstrated safety and feasibility. In this review, we discuss opportunities for immunotherapeutic interventions to enhance the potential to achieve a cure in AML, thereby focusing on the role of monoclonal antibodies, hypomethylating agents and the leukemic microenvironment.
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Affiliation(s)
- Olumide Babajide Gbolahan
- Department of Medicine, Division of Hematology/Oncology, Indiana University School of Medicine, Indianapolis, IN 46202, USA.
| | - Amer M Zeidan
- Department of Medicine, Section of Hematology, Yale University School of Medicine, New Haven, CT 06510, USA.
| | - Maximilian Stahl
- Department of Medicine, Section of Hematology, Yale University School of Medicine, New Haven, CT 06510, USA.
| | - Mohammad Abu Zaid
- Department of Medicine, Bone Marrow and Stem Cell Transplantation, Indiana University School of Medicine, Indianapolis, IN 46202, USA.
| | - Sherif Farag
- Department of Medicine, Bone Marrow and Stem Cell Transplantation, Indiana University School of Medicine, Indianapolis, IN 46202, USA.
| | - Sophie Paczesny
- Wells Center for Pediatric Research, Riley Hospital for Children, Indiana University School of Medicine, Indianapolis, IN 46202, USA.
| | - Heiko Konig
- Department of Medicine, Division of Hematology/Oncology, Indiana University School of Medicine, Indianapolis, IN 46202, USA.
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12
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Stahl M, Zeidan AM. Management of lower-risk myelodysplastic syndromes without del5q: current approach and future trends. Expert Rev Hematol 2017; 10:345-364. [PMID: 28277851 DOI: 10.1080/17474086.2017.1297704] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
INTRODUCTION Myelodysplastic syndromes (MDS) are characterized by progressive bone marrow failure manifesting as blood cytopenia and a variable risk of progression into acute myeloid leukemia. MDS is heterogeneous in biology and clinical behavior. MDS are generally divided into lower-risk (LR) and higher-risk (HR) MDS. Goals of care in HR-MDS focus on changing the natural history of the disease, whereas in LR-MDS symptom control and quality of life are the main goals. Areas covered: We review the epidemiology, tools of risk assessment, and the available therapeutic modalities for LR-MDS. We discuss the use of erythropoiesis stimulating agents (ESAs), immunosuppressive therapy (IST), lenalidomide and the hypomethylating agents (HMAs). We also discuss the predictors of response, combination treatment modalities, and management of iron overload. Lastly, we overview the most promising investigational agents for LR-MDS. Expert commentary: It remains unclear how to best incorporate a wealth of new genetic and epigenetic prognostic markers into risk assessment tools especially for LR-MDS patients. Only a subset of patients respond to current treatment modalities and most responders eventually lose their response. Once standard therapeutic options fail, management becomes more challenging. Combination-based approaches have been largely unsuccessful. Among the most promising investigational are the TPO agonists, TGF- β pathway inhibitors, telomerase inhibitors, and the splicing modifiers.
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Affiliation(s)
- Maximilian Stahl
- a Section of Hematology, Department of Internal Medicine, Section of Hematology, Yale University and the Yale Comprehensive Cancer Center , Yale University School of Medicine , New Haven , CT , USA
| | - Amer M Zeidan
- a Section of Hematology, Department of Internal Medicine, Section of Hematology, Yale University and the Yale Comprehensive Cancer Center , Yale University School of Medicine , New Haven , CT , USA
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13
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Weed J, Ko C, Stahl M, Much M, Witt D, Zeidan AM, Leventhal J. Reactive granulomatous dermatitis presenting as subcutaneous nodules and cords in a patient with advanced myelodysplastic syndrome. Ann Hematol 2017; 96:1037-1039. [PMID: 28220192 DOI: 10.1007/s00277-017-2954-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2017] [Accepted: 02/13/2017] [Indexed: 12/24/2022]
Affiliation(s)
- Jason Weed
- Department of Dermatology, Yale School of Medicine, 333 Cedar St, LCI 501, PO Box 208059, New Haven, CT, USA
| | - Christine Ko
- Department of Dermatology, Yale School of Medicine, 333 Cedar St, LCI 501, PO Box 208059, New Haven, CT, USA
| | - Maximilian Stahl
- Department of Hematology, Yale School of Medicine, 333 Cedar Street WWW-403, P.O. Box 208021, New Haven, CT, 06520-8021, USA
| | - Melissa Much
- Department of Hematology, Yale School of Medicine, 333 Cedar Street WWW-403, P.O. Box 208021, New Haven, CT, 06520-8021, USA
| | - David Witt
- Department of Hematology, Yale School of Medicine, 333 Cedar Street WWW-403, P.O. Box 208021, New Haven, CT, 06520-8021, USA
| | - Amer M Zeidan
- Department of Hematology, Yale School of Medicine, 333 Cedar Street WWW-403, P.O. Box 208021, New Haven, CT, 06520-8021, USA
| | - Jonathan Leventhal
- Department of Dermatology, Yale School of Medicine, 333 Cedar St, LCI 501, PO Box 208059, New Haven, CT, USA.
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14
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Stahl M, Zeidan AM. Lenalidomide use in myelodysplastic syndromes: Insights into the biologic mechanisms and clinical applications. Cancer 2017; 123:1703-1713. [PMID: 28192601 DOI: 10.1002/cncr.30585] [Citation(s) in RCA: 36] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2016] [Revised: 12/30/2016] [Accepted: 01/01/2017] [Indexed: 12/13/2022]
Abstract
Myelosysplastic syndromes (MDS) include a heterogeneous group of clonal myeloid neoplasms characterized by ineffective hematopoiesis leading to blood cytopenias and a variable risk of progression into acute myeloid leukemia (AML). Although the hypomethylating agent azacitidine prolongs survival among patients with higher risk (HR)-MDS compared with conventional care, no drug has been shown conclusively to prolong survival or delay progression to AML among patients with lower-risk MDS (LR-MDS). Lenalidomide is the drug with the most impressive clinical activity in the subset of anemic LR-MDS patients who harbor a deletion of the long arm of chromosome 5 (5q-), where it leads to high rates of transfusion independence and cytogenetic responses. Furthermore, lenalidomide delays progression to AML and prolongs survival among responders. In this article, we review the recently recognized mechanisms of action of lenalidomide and discuss the most recent clinical data regarding its use in patients with both 5q- MDS as well as non-5q- MDS. Finally, we forecast the future directions to improve the efficacy of lenalidomide in MDS with and without 5q-. Cancer 2017;123:1703-1713. © 2017 American Cancer Society.
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Affiliation(s)
- Maximilian Stahl
- Yale Cancer Center, New Haven, Connecticut.,Section of Hematology, Department of Internal Medicine Yale University, New Haven, Connecticut
| | - Amer M Zeidan
- Section of Hematology, Department of Internal Medicine Yale University, New Haven, Connecticut
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Zeidan AM, Al Ali N, Barnard J, Padron E, Lancet JE, Sekeres MA, Steensma DP, DeZern A, Roboz G, Jabbour E, Garcia-Manero G, List A, Komrokji R. Comparison of clinical outcomes and prognostic utility of risk stratification tools in patients with therapy-related vs de novo myelodysplastic syndromes: a report on behalf of the MDS Clinical Research Consortium. Leukemia 2017; 31:1391-1397. [PMID: 28111463 DOI: 10.1038/leu.2017.33] [Citation(s) in RCA: 38] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2016] [Revised: 12/30/2016] [Accepted: 01/09/2017] [Indexed: 01/01/2023]
Abstract
While therapy-related (t)-myelodysplastic syndromes (MDS) have worse outcomes than de novo MDS (d-MDS), some t-MDS patients have an indolent course. Most MDS prognostic models excluded t-MDS patients during development. The performances of the International Prognostic Scoring System (IPSS), revised IPSS (IPSS-R), MD Anderson Global Prognostic System (MPSS), WHO Prognostic Scoring System (WPSS) and t-MDS Prognostic System (TPSS) were compared among patients with t-MDS. Akaike information criteria (AIC) assessed the relative goodness of fit of the models. We identified 370 t-MDS patients (19%) among 1950 MDS patients. Prior therapy included chemotherapy alone (48%), chemoradiation (31%), and radiation alone in 21%. Median survival for t-MDS patients was significantly shorter than for d-MDS (19 vs 46 months, P<0.005). All models discriminated survival in t-MDS (P<0.005 for each model). Patients with t-MDS had a significantly higher hazard of death relative to d-MDS in every risk model, and had inferior survival compared to patients with d-MDS within all risk group categories. AIC Scores (lower is better) were 2316 (MPSS), 2343 (TPSS), 2343 (IPSS-R), 2361 (WPSS) and 2364 (IPSS). In conclusion, subsets of t-MDS patients with varying clinical outcomes can be identified using conventional risk stratification models. The MPSS, TPSS and IPSS-R provide the best predictive power.
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Affiliation(s)
- A M Zeidan
- Section of Hematology, Department of Internal Medicine, Yale University, and Yale Comprehensive Cancer Center, New Haven, CT, USA
| | - N Al Ali
- Department of Malignant Hematology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA
| | - J Barnard
- Department of Hematology and Medical Oncology, Leukemia Program, Cleveland Clinic, Cleveland, OH, USA
| | - E Padron
- Department of Malignant Hematology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA
| | - J E Lancet
- Department of Malignant Hematology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA
| | - M A Sekeres
- Department of Hematology and Medical Oncology, Leukemia Program, Cleveland Clinic, Cleveland, OH, USA
| | - D P Steensma
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA
| | - A DeZern
- Department of Medicine, Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins University, Baltimore, MD, USA
| | - G Roboz
- Department of Medicine, Division of Hematology and Oncology, Weill Medical College of Cornell University, New York, NY, USA
| | - E Jabbour
- Department of Leukemia, MD Anderson Cancer Center, Houston, TX, USA
| | - G Garcia-Manero
- Department of Leukemia, MD Anderson Cancer Center, Houston, TX, USA
| | - A List
- Department of Malignant Hematology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA
| | - R Komrokji
- Department of Malignant Hematology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA
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