1
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Steinmetz T, Totzke U, Kasprzak A, Schmitz S, Gattermann N, Germing U. MDS patient registries - achievements and challenges. Ann Hematol 2024:10.1007/s00277-024-05925-3. [PMID: 39174754 DOI: 10.1007/s00277-024-05925-3] [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: 05/30/2024] [Accepted: 07/30/2024] [Indexed: 08/24/2024]
Abstract
Since the late 1980s, patient registries have played a pivotal role in the elucidation of rare diseases. For myelodysplastic syndromes (MDS), they revealed the disease actually to be diverse rather than rare. Registry data enabled the definition of various MDS subtypes and prognostic scores tailoring therapy. These classifications have been revised and refined several times, and the differential diagnosis of MDS has become increasingly complex. At the same time, the diagnosis has been made more commonly and no longer by specialized centers of expertise only. Consequently, several registries have collected data with different focuses and from different patient subpopulations. The current review presents three MDS registries and their rationale, scope, design, and achievements. All three complement each other and will remain a mainstay to advance the knowledge on MDS as well as to validate the outcomes of clinical trials. However, delineation of subtypes after the most recent WHO and IPC revisions, as well as the determination of the newest risk score M of the International Prognostic Scoring System (IPSS-M), no longer just shift cut-offs but are based on multivariate compilations of highly specific genetic information. This paradigm shift involves challenging registries with respect to the assignment of all patients for whom this information has not yet been available.
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Affiliation(s)
- Tilman Steinmetz
- Outpatient Clinics for Hematology and Oncology, Sachsenring 69, 50677, Cologne, Germany.
| | - Uwe Totzke
- Totzke & Dreher Scientific (TDS), Basel, Switzerland
| | - Annika Kasprzak
- Clinic for Hematology, Oncology and Clinical Immunology, Heinrich-Heine University, Dusseldorf, Germany
| | - Stephan Schmitz
- Outpatient Clinics for Hematology and Oncology, Sachsenring 69, 50677, Cologne, Germany
| | - Norbert Gattermann
- Clinic for Hematology, Oncology and Clinical Immunology, Heinrich-Heine University, Dusseldorf, Germany
| | - Ulrich Germing
- Clinic for Hematology, Oncology and Clinical Immunology, Heinrich-Heine University, Dusseldorf, Germany
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2
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Diez-Campelo M, Yucel A, Goyal RK, Parikh RC, Esterberg E, Jimenez M, Sluga-O'Callaghan M, Miteva D, Xiao H, Germing U. Treatment characteristics and outcomes in lower-risk, non-del(5q) myelodysplastic syndromes: findings from a medical record review in the USA, Canada and Europe. Future Oncol 2024:1-12. [PMID: 39140298 DOI: 10.1080/14796694.2024.2379228] [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: 09/15/2023] [Accepted: 07/09/2024] [Indexed: 08/15/2024] Open
Abstract
Aim: To assess treatment patterns and outcomes in patients with non-del(5q) lower-risk myelodysplastic syndromes. Methods: Patient medical records were reviewed in the USA, Canada (CAN), UK and the EU. Results: Analysis included 119 patients in the USA/CAN (median age, 61.5 years) and 245 patients in the UK/EU (median age, 67.3 years). Most patients received erythropoiesis-stimulating agents (ESAs) as first-line (1L) therapy (USA/CAN: 89.0%; UK/EU: 90.2%). A substantial proportion of 1L erythropoiesis-stimulating agent-treated patients were transfusion dependent before 1L (USA/CAN: 37.1%; UK/EU: 51.2%); a small percentage of these patients achieved transfusion independence during 1L therapy (USA/CAN: 2.8%; UK/EU: 14.4%). Conclusion: These findings highlight an unmet need for more effective treatments among patients with non-del(5q) lower-risk myelodysplastic syndromes.
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Affiliation(s)
- Maria Diez-Campelo
- Hematology Department, Institute of Biomedical Research of Salamanca, University Hospital of Salamanca, 37007 Salamanca, Spain
| | - Aylin Yucel
- Bristol Myers Squibb, Princeton,NJ 08540, USA
| | - Ravi K Goyal
- RTI Health Solutions, Research Triangle Park, NC 27709, USA
| | - Rohan C Parikh
- RTI Health Solutions, Research Triangle Park, NC 27709, USA
| | | | - Maria Jimenez
- RTI Health Solutions, Research Triangle Park, NC 27709, USA
| | | | - Dimana Miteva
- Celgene International Sàrl, a Bristol-Myers Squibb Company, 2017 Boudry, Switzerland
| | - Hong Xiao
- Bristol Myers Squibb, Princeton,NJ 08540, USA
| | - Ulrich Germing
- Department of Haematology, Oncology, and Clinical Immunology, University Hospital of Dusseldorf, 40225 Dusseldorf, Germany
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3
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Topping J, Taylor A, Nadat F, Crouch S, Ibbotson A, Čermák J, Symeonidis A, Tatic A, Langemeijer S, Hellström-Lindberg E, Culligan D, Garelius HG, Ashcroft J, Nga E, Parker J, Kolade S, McDermott MF, De Witte T, Bowen D, Smith A, Cargo C, Savic S. Inflammatory profile of lower risk myelodysplastic syndromes. Br J Haematol 2024. [PMID: 38772913 DOI: 10.1111/bjh.19530] [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: 12/22/2023] [Accepted: 05/06/2024] [Indexed: 05/23/2024]
Abstract
The precise link between inflammation and pathogenesis of myelodysplastic syndrome (MDS) is yet to be fully established. We developed a novel method to measure ASC/NLRP3 protein specks which are specific for the NLRP3 inflammasome only. We combined this with cytokine profiling to characterise various inflammatory markers in a large cohort of patients with lower risk MDS in comparison to healthy controls and patients with defined autoinflammatory disorders (AIDs). The ASC/NLRP3 specks were significantly elevated in MDS patients compared to healthy controls (p < 0.001) and these levels were comparable to those found in patients with AIDs. The distribution of protein specks positive only for ASC was different to ASC/NLRP3 ones suggesting that other ASC-containing inflammasome complexes might be important in the pathogenesis of MDS. Patients with MDS-SLD had the lowest levels of interleukin (IL)-1β, tumour necrosis factor (TNF), IL-23, IL-33, interferon (IFN) γ and IFN-α2, compared to other diagnostic categories. We also found that inflammatory cytokine TNF was positively associated with MDS progression to a more aggressive form of disease and IL-6 and IL-1β with time to first red blood cell transfusion. Our study shows that there is value in analysing inflammatory biomarkers in MDS, but their diagnostic and prognostic utility is yet to be fully validated.
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Affiliation(s)
- Joanne Topping
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Leeds, UK
| | - Adele Taylor
- Epidemiology and Cancer Statistics Group, University of York, York, UK
| | - Fatima Nadat
- Department of Clinical Immunology and Allergy, St James's University Hospital, Leeds, UK
| | - Simon Crouch
- Epidemiology and Cancer Statistics Group, University of York, York, UK
| | - Alice Ibbotson
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Leeds, UK
| | - Jaroslav Čermák
- Department of Clinical Hematology, Institute of Hematology and Blood Transfusion, Praha, Czech Republic
| | - Argiris Symeonidis
- Division of Hematology, Department of Internal Medicine, University of Patras Medical School, Patras, Greece
| | - Aurelia Tatic
- Center of Hematology and Bone Marrow Transplantation, Fundeni Clinical Institute, Bucharest, Romania
| | - Saskia Langemeijer
- Department of Hematology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Eva Hellström-Lindberg
- Division of Hematology, Department of Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Dominic Culligan
- Department of Haematology, Aberdeen Royal Infirmary, Aberdeen, UK
| | | | - John Ashcroft
- Department of Hematology, Mid Yorkshire Hospitals, Wakefield, UK
| | - Emma Nga
- Department of Haematology, Royal Blackburn Teaching Hospital, Blackburn, Lancashire, UK
| | - Jane Parker
- Northampton General Hospital, Northampton, UK
| | - Seye Kolade
- Department of Haematology, Blackpool Victoria Hospital, Blackpool, Lancashire, UK
| | - Michael F McDermott
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Leeds, UK
| | - Theo De Witte
- Department of Tumor Immunology, Nijmegen Center for Molecular Life Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
| | - David Bowen
- Epidemiology and Cancer Statistics Group, University of York, York, UK
| | - Alexandra Smith
- Epidemiology and Cancer Statistics Group, University of York, York, UK
| | - Catherine Cargo
- Haematological Malignancy Diagnostic Service, St James's University Hospital, Leeds, UK
| | - Sinisa Savic
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Leeds, UK
- National Institute for Health Research-Leeds Biomedical Research Centre, Leeds, UK
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4
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Binder AF, Hossain A, Doshi R, Vivero A, Gonzalez KM, Gentsch A, Wilde L, Rising KL. Patient and caregiver perceptions of the possibility of home blood transfusions. Transfusion 2024; 64:483-492. [PMID: 38263774 DOI: 10.1111/trf.17728] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2023] [Revised: 12/09/2023] [Accepted: 12/13/2023] [Indexed: 01/25/2024]
Abstract
BACKGROUND Patients with hematologic malignancies (HM) often develop transfusion dependence. The patient and caregiver burdens associated with the need for frequent transfusions are high. Home blood transfusions has the potential to reduce these burdens, but is not widely practiced in the United States. We designed a qualitative study to evaluate the patient and caregiver perceptions of the potential for a home blood transfusion program. STUDY DESIGN AND METHODS Eligible patients included Adult (≥18 years) patients who were English speaking and met the definition for transfusion dependence within 3 months of study enrollment. We identified and interviewed eligible participants (patients and caregivers), using a semi-structured interview guide to elicit patient perceptions of the acceptability, barriers, and benefits related to home blood product transfusions. Interviews were audio recorded and transcribed. Results were imported into NVivo 12 (version 12; QSR International, Burlington, VT) for coding and analysis. RESULTS We recruited participants until we reached thematic saturation, which occurred at 29 participants (20 patients, 9 caregivers). Among the 20 patient participants, nine had MDS (45%) and 11 had acute leukemia (55%). Most of the patients (60%) reported getting one transfusion per week. Four themes emerged when the participants discussed their perception regarding the potential of a home blood transfusion program: (1) current in-person experience, (2) caregiver burden, (3) perceptions of home blood transfusions, and (4) interest in participating in a home blood transfusion program. CONCLUSION The concept of home blood transfusions was well received and further research to study its implementation is warranted.
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Affiliation(s)
- Adam F Binder
- Department of Medical Oncology, Sidney Kimmel Cancer Center, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Alavi Hossain
- Sidney Kimmel Medical College, Philadelphia, Pennsylvania, USA
| | - Riyana Doshi
- Sidney Kimmel Medical College, Philadelphia, Pennsylvania, USA
| | - Angelica Vivero
- Department of Pathology and Genomic Medicine, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Karla Martin Gonzalez
- Department of Emergency Medicine, Center for Connected Care, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Alexzandra Gentsch
- Department of Emergency Medicine, Center for Connected Care, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Lindsay Wilde
- Department of Medical Oncology, Sidney Kimmel Cancer Center, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Kristin L Rising
- Department of Emergency Medicine, Center for Connected Care, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
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5
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Buckstein R, Callum J, Prica A, Bowen D, Wells RA, Leber B, Heddle N, Chodirker L, Cheung M, Mozessohn L, Yee K, Gallagher J, Parmentier A, Jamula E, Zhang L, Mamedov A, Stanworth SJ, Lin Y. Red cell transfusion thresholds in outpatients with myelodysplastic syndromes: Results of a pilot randomized trial RBC-ENHANCE. Transfusion 2024; 64:223-235. [PMID: 38323704 DOI: 10.1111/trf.17721] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2023] [Revised: 11/16/2023] [Accepted: 11/18/2023] [Indexed: 02/08/2024]
Abstract
BACKGROUND The optimal hemoglobin (Hb) threshold for red blood cell transfusions in adult patients with myelodysplastic syndromes (MDS) has not been defined. STUDY DESIGN AND METHODS We conducted a pilot randomized multi-center study of two transfusion algorithms (liberal, to maintain Hb 110-120 g/L, transfuse 2 units if Hb < 105 g/L and 1 unit if Hb 105-110 g/L vs. restrictive, 85-105 g/L, transfuse 2 units when Hgb < 85 g/L). Primary objectives were 70% compliance in maintaining the q2 week hemoglobin within the targeted range and the achievement of a 15 g/L difference in pre-transfusion Hb. Secondary outcomes included measures of quality of life (QOL), iron studies and safety. RESULTS Twenty-eight patients were randomized between February 2015-2020, 13 to the restrictive arm and 15 to the liberal arm in three tertiary care centers. The compliance was 66% and 45% and the mean pre-transfusion Hb thresholds were 86 (standard deviation [SD] 8) and 98 g/L (SD 10) in the restrictive and liberal arms, (mean difference 11.8 g/L, p < .0001), respectively. Patients in the liberal arm experienced a mean of 3.4 (SD 2.6) more transfusion visits and received a mean of 5.3 (SD 5.5) more units of blood during the 12-week study. Ferritin increased by 1043 (SD 1516) IU/L and 148 (SD 1319) IU/L in the liberal and restrictive arms, respectively. Selected QOL scores were superior pre-transfusion and more patients achieved clinically important improvements in the liberal arm compared with the restrictive arm for selected symptoms and function domains. CONCLUSION The results establish that policies for transfusion support can be delivered in practice at multiple hospitals, but further research is required to understand the full clinical effects and safety of liberal transfusion policies in MDS outpatients.
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Affiliation(s)
- Rena Buckstein
- Department of Medicine, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Jeannie Callum
- Department of Pathology and Molecular Medicine, Kingston Health Sciences Centre and Queen's University, Kingston, Ontario, Canada
| | - Anca Prica
- Department of Medicine, Princess Margaret Hospital, United Health Network, Toronto, Ontario, Canada
| | - David Bowen
- Department of Medicine, University of York, York, UK
| | - Richard A Wells
- Department of Medicine, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Brian Leber
- Department of Medicine, Mcmaster University, Hamilton, Ontario, Canada
| | - Nancy Heddle
- Mcmaster Centre for Transfusion Research, Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Lisa Chodirker
- Department of Medicine, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Matthew Cheung
- Department of Medicine, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Lee Mozessohn
- Department of Medicine, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Karen Yee
- Department of Medicine, Princess Margaret Hospital, United Health Network, Toronto, Ontario, Canada
| | - Jennifer Gallagher
- Department of Medicine, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Anne Parmentier
- Department of Medicine, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Erin Jamula
- Department of Medicine, Mcmaster University, Hamilton, Ontario, Canada
| | | | - Alex Mamedov
- Department of Medicine, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Simon J Stanworth
- NHS Blood and Transplant, Oxford, UK
- Oxford University NHS Trust, The John Radcliffe Hospital, Oxford, UK
- Radcliffe Department of Medicine, University of Oxford, Oxford, UK
| | - Yulia Lin
- Precision Diagnostics and Therapeutics Program, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
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6
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Mukherjee S, Brown‐Bickerstaff C, Falkenstein A, Makinde AY, Bland E, Laney J, Garretson M, Huggar D, McBride A. Treatment patterns and outcomes with luspatercept in patients with lower-risk myelodysplastic syndromes: A retrospective US cohort analysis. Hemasphere 2024; 8:e38. [PMID: 38434524 PMCID: PMC10878180 DOI: 10.1002/hem3.38] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2023] [Accepted: 12/08/2023] [Indexed: 03/05/2024] Open
Affiliation(s)
- Sudipto Mukherjee
- Department of Hematology and Medical OncologyTaussig Cancer Institute, Cleveland ClinicClevelandOhioUSA
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7
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DeZern AE, Greenberg PL. The trajectory of prognostication and risk stratification for patients with myelodysplastic syndromes. Blood 2023; 142:2258-2267. [PMID: 37562001 DOI: 10.1182/blood.2023020081] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2023] [Revised: 07/20/2023] [Accepted: 08/04/2023] [Indexed: 08/12/2023] Open
Abstract
ABSTRACT Risk stratification and prognostication are crucial for the appropriate management of patients with myelodysplastic syndromes (MDSs) or myelodysplastic neoplasms, for whom the expected survival can vary from a few months to >10 years. For the past 5 decades, patients with MDS have been classified into higher-risk vs lower-risk disease phenotypes using sequentially developed clinical prognostic scoring systems. Factors such as morphologic dysplasia, clinical hematologic parameters, cytogenetics, and, more recently, mutational information have been captured in prognostic scoring systems that refine risk stratification and guide therapeutic management in patients with MDS. This review describes the progressive evolution and improvement of these systems which has led to the current Molecular International Prognostic Scoring System.
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Affiliation(s)
- Amy E DeZern
- Department of Oncology, Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins, Baltimore, MD
| | - Peter L Greenberg
- Hematology Division, Department of Medicine, Stanford University School of Medicine, Stanford, CA
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8
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Kewan T, Bewersdorf JP, Gurnari C, Xie Z, Stahl M, Zeidan AM. When to use which molecular prognostic scoring system in the management of patients with MDS? Best Pract Res Clin Haematol 2023; 36:101517. [PMID: 38092484 DOI: 10.1016/j.beha.2023.101517] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2023]
Abstract
Myelodysplastic syndromes/neoplasms (MDS) are a heterogeneous group of hematopoietic cancers characterized by recurrent molecular alterations driving the disease pathogenesis with a variable propensity for progression to acute myeloid leukemia (AML). Clinical decision making for MDS relies on appropriate risk stratification at diagnosis, with higher-risk patients requiring more intensive therapy. The conventional clinical prognostic systems including the International Prognostic Scoring System (IPSS) and its revised version (IPSS-R) have dominated the risk stratification of MDS from 1997 until 2022. Concurrently, the use of next-generation sequencing has revolutionized the field by revealing multiple recurrent genetic mutations, which correlate with phenotype and prognosis. Significant efforts have been made to formally incorporate molecular data into prognostic tools to improve proper risk identification and personalize treatment strategies. In this review, we will critically compare the available molecular scoring systems for MDS focusing on areas of progress and potential limitations that can be improved in subsequent revisions of these tools.
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Affiliation(s)
- Tariq Kewan
- Department of Hematology and Oncology, Yale University, New Haven, CT, USA
| | - Jan Philipp Bewersdorf
- Memorial Sloan Kettering Cancer Center, Leukemia Service, Department of Medicine, New York, NY, USA
| | - Carmelo Gurnari
- Department of Translational Hematology and Oncology Research, Taussig Cancer Institute, Cleveland Clinic, Cleveland, USA; Department of Biomedicine and Prevention, University of Rome Tor Vergata, Rome, Italy
| | - Zhuoer Xie
- Department of Malignant Hematology, H. Lee Moffitt Cancer Center, Tampa, FL, USA
| | - Maximilian Stahl
- Department of Medical Oncology, Dana-Farber Cancer Institute and Harvard Medical School, Boston, MA, USA
| | - Amer M Zeidan
- Department of Hematology and Oncology, Yale University, New Haven, CT, USA.
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9
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Rydén J, Clements M, Wikman A, Hellström-Lindberg E, Edgren G, Höglund P. Red blood cell alloimmunization in myelodysplastic syndromes: Associations with sex, DAT-positivity, and increased transfusion needs. Transfusion 2023; 63:2040-2051. [PMID: 37818926 DOI: 10.1111/trf.17562] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2023] [Revised: 08/10/2023] [Accepted: 08/15/2023] [Indexed: 10/13/2023]
Abstract
BACKGROUND Many patients with myelodysplastic syndromes (MDS) need repeated red blood cell transfusions which entails a risk of immunization and antibody formation. Associations between alloantibodies, autoantibodies and increased transfusion requirements have been reported, but their relationship remains unclear. In this study, we analyzed factors potentially associated with red blood cell alloimmunization, as well as changes in transfusion intensity and post-transfusion hemoglobin increments. METHODS In a retrospective cohort study, we linked Swedish MDS patients diagnosed between 2003 and 2017 to transfusion and immunohematology data. Potentially associated factors were analyzed using Cox proportional hazards regression. The transfusion rate after detected alloimmunization was analyzed using a fixed effects Poisson regression. Post-transfusion hemoglobin increments before and after alloimmunization were compared using a mixed effects regression. RESULTS Alloantibodies following MDS diagnosis were detected in 50 out of 429 patients (11.7%). Female sex and a positive direct antiglobulin test (DAT) were independently associated with alloimmunization, with hazard ratios of 2.02 (95% confidence interval [CI] 1.08-3.78) and 9.72 (95% CI, 5.31-17.74), respectively. The transfusion rate following alloimmunization was increased with an incidence rate ratio of 1.33 (95% CI, 0.98-1.80) and the post-transfusion hemoglobin increment after alloimmunization was 1.40 g/L (95% CI, 0.52-2.28) lower per red blood cell unit (p = .002) compared to before alloimmunization, in multivariable analyses. DISCUSSION Alloimmunization against blood group antigens was associated with sex, DAT-positivity, increased transfusion needs, and lower post-transfusion hemoglobin increments. These findings warrant further investigation to evaluate the clinical significance of up-front typing and prophylactic antigen matching in patients with MDS.
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Affiliation(s)
- Jenny Rydén
- Center for Hematology and Regenerative Medicine, Department of Medicine, Karolinska Institutet, Stockholm, Sweden
- Department of Hematology, Karolinska University Hospital, Stockholm, Sweden
| | - Mark Clements
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
| | - Agneta Wikman
- Department of Clinical Immunology and Transfusion Medicine, Karolinska University Hospital, Stockholm, Sweden
- Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Stockholm, Sweden
| | - Eva Hellström-Lindberg
- Center for Hematology and Regenerative Medicine, Department of Medicine, Karolinska Institutet, Stockholm, Sweden
- Department of Hematology, Karolinska University Hospital, Stockholm, Sweden
| | - Gustaf Edgren
- Department of Cardiology, Södersjukhuset, Stockholm, Sweden
- Department of Medicine, Solna, Division of Clinical Epidemiology, Karolinska Institutet, Stockholm, Sweden
| | - Petter Höglund
- Center for Hematology and Regenerative Medicine, Department of Medicine, Karolinska Institutet, Stockholm, Sweden
- Department of Clinical Immunology and Transfusion Medicine, Karolinska University Hospital, Stockholm, Sweden
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10
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Mosquera Orgueira A, Perez Encinas MM, Diaz Varela NA, Mora E, Díaz-Beyá M, Montoro MJ, Pomares H, Ramos F, Tormo M, Jerez A, Nomdedeu JF, De Miguel Sanchez C, Leonor A, Cárcel P, Cedena Romero MT, Xicoy B, Rivero E, del Orbe Barreto RA, Diez-Campelo M, Benlloch LE, Crucitti D, Valcárcel D. Machine Learning Improves Risk Stratification in Myelodysplastic Neoplasms: An Analysis of the Spanish Group of Myelodysplastic Syndromes. Hemasphere 2023; 7:e961. [PMID: 37841754 PMCID: PMC10569758 DOI: 10.1097/hs9.0000000000000961] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2023] [Accepted: 08/23/2023] [Indexed: 10/17/2023] Open
Abstract
Myelodysplastic neoplasms (MDS) are a heterogeneous group of hematological stem cell disorders characterized by dysplasia, cytopenias, and increased risk of acute leukemia. As prognosis differs widely between patients, and treatment options vary from observation to allogeneic stem cell transplantation, accurate and precise disease risk prognostication is critical for decision making. With this aim, we retrieved registry data from MDS patients from 90 Spanish institutions. A total of 7202 patients were included, which were divided into a training (80%) and a test (20%) set. A machine learning technique (random survival forests) was used to model overall survival (OS) and leukemia-free survival (LFS). The optimal model was based on 8 variables (age, gender, hemoglobin, leukocyte count, platelet count, neutrophil percentage, bone marrow blast, and cytogenetic risk group). This model achieved high accuracy in predicting OS (c-indexes; 0.759 and 0.776) and LFS (c-indexes; 0.812 and 0.845). Importantly, the model was superior to the revised International Prognostic Scoring System (IPSS-R) and the age-adjusted IPSS-R. This difference persisted in different age ranges and in all evaluated disease subgroups. Finally, we validated our results in an external cohort, confirming the superiority of the Artificial Intelligence Prognostic Scoring System for MDS (AIPSS-MDS) over the IPSS-R, and achieving a similar performance as the molecular IPSS. In conclusion, the AIPSS-MDS score is a new prognostic model based exclusively on traditional clinical, hematological, and cytogenetic variables. AIPSS-MDS has a high prognostic accuracy in predicting survival in MDS patients, outperforming other well-established risk-scoring systems.
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Affiliation(s)
- Adrian Mosquera Orgueira
- Complexo Hospitalario Universitario de Santiago de Compostela, Department of Hematology, Instituto de Investigacións Sanitarias de Santiago, Santiago de Compostela, Spain
| | - Manuel Mateo Perez Encinas
- Complexo Hospitalario Universitario de Santiago de Compostela, Department of Hematology, Instituto de Investigacións Sanitarias de Santiago, Santiago de Compostela, Spain
| | | | - Elvira Mora
- Hematology Department, Hospital Universitario y Politécnico La Fe, Valencia, Spain
| | | | - María Julia Montoro
- Department of Hematology, Vall d’Hebron Institute of Oncology (VHIO), Hospital Universitari Vall d’Hebron, Barcelona, Spain
| | - Helena Pomares
- Hematology Department., Hospital Duran i Reynals. Institut Català d’Oncologia, Hospital Duran i Reynals. Institut Català d’Oncologia, Hospitalet, Barcelona, Spain
| | - Fernando Ramos
- Department of Hematology, Hospital Universitario de León, Spain
| | - Mar Tormo
- Servicio de Hematología. Hospital Clínico Universitario de Valencia, Spain
| | - Andres Jerez
- Hematology and Medical Oncology Department, Hospital Morales Meseguer, IMIB, Murcia, Spain
| | - Josep F Nomdedeu
- Hematology Department, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
| | | | - Arenillas Leonor
- Laboratoris de Citologia Hematològica i Citogenètica, servei de Patologia, Hospital del Mar. GRETNHE- Institut Hospital del Mar d’Investigacions Mèdiques (IMIM), Barcelona, Spain
| | - Paula Cárcel
- Department of Hematology, Hospital Público Universitario de la Ribera, Alzira, Valencia, Spain
| | | | - Blanca Xicoy
- HU German Trias i Pujol - Institut Català d’ Oncologia, Josep Carreras Leukemia Research Institute, Universitat Autònoma de Barcelona, Badalona, Spain
| | - Eugenia Rivero
- Department of Hematology, University Hospital Arnau de Vilanova, Lleida, Spain
| | - Rafael Andres del Orbe Barreto
- Edif. Laboratorios, planta baja., Hospital Universitario Cruces Servicio de Hematología. Sección Eritropatología – Hem. Molecular, Barakaldo, Spain
| | - Maria Diez-Campelo
- Hematology Department, Institute of Biomedical Research of Salamanca, University Hospital of Salamanca, Spain
| | - Luis E. Benlloch
- Grupo Español de Síndromes Mielodisplásicos (GESMD), Valencia, Spain
| | - Davide Crucitti
- Instituto de Investigacions Sanitarias de Santiago de Compostela (IDIS-CHUS), Santiago de Compostela, Spain
| | - David Valcárcel
- Department of Hematology, Vall d’Hebron Institute of Oncology (VHIO), Hospital Universitari Vall d’Hebron, Barcelona, Spain
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11
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Haring Y, Goldschmidt N, Taha S, Stemer G, Filanovsky K, Hellman I, Okasha D, Krayem B, Levi I, Rosenbaum H, Koren-Michowitz M, Yagna S, Nemets A, Gino-Moor S, Saban R, Cohen J, Halperin E, Wolach O, Dally N, Merkel D, Oster HS, Mittelman M. MDS-Related Anemia Is Associated with Impaired Quality of Life but Improvement Is Not Always Achieved by Increased Hemoglobin Level. J Clin Med 2023; 12:5865. [PMID: 37762806 PMCID: PMC10532166 DOI: 10.3390/jcm12185865] [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: 08/04/2023] [Revised: 08/29/2023] [Accepted: 09/06/2023] [Indexed: 09/29/2023] Open
Abstract
Quality of life is impaired in MDS, but the role of hemoglobin level is unclear. To study the Hb-QoL correlation at diagnosis and 1 year later, patients filled out the EQ-5D questionnaire, assessing their mobility, self care, daily activities, pain/discomfort, and anxiety/depression, using scores of 0 (normal), 1 (mild/moderate), or 2 (poor). They also evaluated their health using a visual analogue scale, scoring from 0 (poor) to 100 (excellent). The anemia subgroups were: none/normal (Hb ≥ 12.5 g/dL), mild (10 ≤ Hb < 12.5), moderate (9 ≤ Hb < 10), severe (8 ≤ Hb < 9), or very severe (Hb < 8). LR-MDS patients (n = 127) and inpatient controls (n = 141) participated. The anemic patients had a poor QoL and the MDS patients had a lower QoL with a lower Hb. The controls had no QoL difference among the various anemia subgroups. In addition, the MDS QoL sharply decreased with an Hb of < 9. The MDS patients showed a wide QoL variability, i.e., different QoL scores in the same Hb subgroup, suggesting that other factors affect QoL (e.g., age and comorbidities). After 1 year (n = 61), the QoL was still poor for most MDS patients (including 27 patients with an increased Hb). In summary: (1) a poor QoL in MDS-anemia is non-linear, suggesting other influencing factors on QoL. (2) The sharp QoL drop with Hb < 9 g/dL challenges the transfusion Hb threshold. (3) The QoL in anemic MDS patients might differ from that in non-MDS patients. (4) Raising Hb, while recommended, does not guarantee an improved QoL.
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Affiliation(s)
- Yael Haring
- Department of Hematology, Tel Aviv Sourasky Medical Center, Tel Aviv 6423906, Israel; (Y.H.); (N.G.)
- MDS Center, Tel Aviv Sourasky Medical Center, Tel Aviv 6423906, Israel
- Faculty of Medicine, Tel Aviv University, Tel Aviv 6997801, Israel; (S.T.); (D.M.)
| | - Noa Goldschmidt
- Department of Hematology, Tel Aviv Sourasky Medical Center, Tel Aviv 6423906, Israel; (Y.H.); (N.G.)
- MDS Center, Tel Aviv Sourasky Medical Center, Tel Aviv 6423906, Israel
| | - Shaimaa Taha
- Faculty of Medicine, Tel Aviv University, Tel Aviv 6997801, Israel; (S.T.); (D.M.)
- Department of Internal Medicine, Tel Aviv Sourasky Medical Center, Tel Aviv 6423906, Israel
| | - Galia Stemer
- Galillee Medical Center, Bar-Ilan University, Nahariya 5290002, Israel;
| | | | | | - Doaa Okasha
- Haemek Medical Center, Afula 1834111, Israel;
| | - Baher Krayem
- Rambam Health Care Campus, Haifa 3109601, Israel;
| | - Itai Levi
- Soroka Medical Center, Be’er Sheva 84101, Israel;
| | | | | | - Shai Yagna
- Baruch Pade-Poriya Medical Center, Tiberias 1528001, Israel
| | | | | | | | - Joseph Cohen
- Laniado Medical Center, Netanya 4290200, Israel;
| | - Erez Halperin
- Davidoff Cancer Center, Rabin Medical Center, Petah Tikva 4941492, Israel; (E.H.); (O.W.)
| | - Ofir Wolach
- Davidoff Cancer Center, Rabin Medical Center, Petah Tikva 4941492, Israel; (E.H.); (O.W.)
| | - Najib Dally
- Ziv Medical Center, Bar-Ilan University, Zefad 5290002, Israel;
| | - Drorit Merkel
- Faculty of Medicine, Tel Aviv University, Tel Aviv 6997801, Israel; (S.T.); (D.M.)
- MDS Center, Sheba Medical Center, Ramat Gan 5262000, Israel
| | - Howard S. Oster
- MDS Center, Tel Aviv Sourasky Medical Center, Tel Aviv 6423906, Israel
- Faculty of Medicine, Tel Aviv University, Tel Aviv 6997801, Israel; (S.T.); (D.M.)
| | - Moshe Mittelman
- Department of Hematology, Tel Aviv Sourasky Medical Center, Tel Aviv 6423906, Israel; (Y.H.); (N.G.)
- MDS Center, Tel Aviv Sourasky Medical Center, Tel Aviv 6423906, Israel
- Faculty of Medicine, Tel Aviv University, Tel Aviv 6997801, Israel; (S.T.); (D.M.)
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12
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Badar T, Madanat YF, Zeidan AM. Updates on risk stratification and management of lower-risk myelodysplastic syndromes/neoplasms. Future Oncol 2023; 19:1877-1889. [PMID: 37750305 DOI: 10.2217/fon-2023-0454] [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: 09/27/2023] Open
Abstract
The majority of lower-risk myelodysplastic syndromes/neoplasms patients present with anemia. Historically, these patients were treated with erythropoiesis-stimulating agents (ESA), with modest responses. A subset of these patients with del(5q) may do better with lenalidomide. Recently, in randomized trials, luspatercept has shown better responses compared with ESAs in treatment-naive patients and imetelstat in patients refractory to ESAs. Other evaluated novel compounds (fostamatinib, H3B-880, roxadustat, pyruvate kinase receptor activator) have not yet shown meaningful efficacy. More needs to be done to improve outcomes; in pursuance of this, participation in clinical trials evaluating novel therapies should be encouraged. While lower-risk myelodysplastic syndromes/neoplasms tend to have an indolent course, a subset of them has a dismal prognosis. Improving prognostication and serial monitoring will help in identifying high-risk patients for appropriate management.
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Affiliation(s)
- Talha Badar
- Division of Hematology & Oncology, Department of Medicine, Mayo Clinic, Jacksonville, FL 32224, USA
| | - Yazan F Madanat
- Division of Hematology & Medical Oncology, Department of Internal Medicine, UT Southwestern Medical Center, Dallas, TX 75390, USA
- Leukemia Program, Harold C. Simmons Comprehensive Cancer Center, UT Southwestern Medical Center, Dallas, TX 75390, USA
| | - Amer M Zeidan
- Section of Hematology, Department of Internal Medicine, Yale School of Medicine & Yale Cancer Center, New Haven, CT 06510, USA
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13
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Yun JP, Ding PQ, Dolley A, Cheung WY. Decitabine/Cedazuridine in the Management of Myelodysplastic Syndrome and Chronic Myelomonocytic Leukemia in Canada. Curr Oncol 2023; 30:8005-8018. [PMID: 37754496 PMCID: PMC10528038 DOI: 10.3390/curroncol30090581] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2023] [Revised: 08/22/2023] [Accepted: 08/29/2023] [Indexed: 09/28/2023] Open
Abstract
The management of myelodysplastic syndrome (MDS) and chronic myelomonocytic leukemia (CMML) is limited and remains an unmet need. Decitabine/cedazuridine (DEC-C, ASTX727) is Canada's first and only approved oral hypomethylating agent for MDS and CMML. We characterized the real-world use of DEC-C through a Canadian compassionate use program. Demographic and clinical data from 769 patients enrolled in Taiho Pharma Canada's Patient Support Program were collected and analyzed. These patients represent a collection period from 10 November 2020 to 31 August 2022 with a median age of 76 years. Among 651 patients who started DEC-C, the median treatment duration was 4.2 cycles. The median overall and progression-free survival were 21.6 and 10.7 months, respectively. Among 427 patients who discontinued treatment, the majority (69.5%) stopped due to death (n = 164) or disease progression (n = 133). Multivariable cox regression showed that age, province of residence, blast counts, antibiotic prophylaxis, and number of dose reductions and delays were not significantly associated with overall and progression-free survival. DEC-C is a promising alternative to parenteral hypomethylating agent therapy, and it likely addresses an important unmet need for effective and convenient therapies in this setting.
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Affiliation(s)
- John Paul Yun
- Oncology Outcomes Program, Department of Oncology, University of Calgary, Calgary, AB T2N 1N4, Canada; (J.P.Y.); (P.Q.D.)
- Galway University Hospital, H91 YR71 Galway, Ireland
| | - Philip Q. Ding
- Oncology Outcomes Program, Department of Oncology, University of Calgary, Calgary, AB T2N 1N4, Canada; (J.P.Y.); (P.Q.D.)
- Faculty of Medicine & Dentistry, University of Alberta, Edmonton, AB T6G 2R3, Canada
| | - Aastha Dolley
- Taiho Pharma Canada, Inc., Oakville, ON L6H 5R7, Canada;
| | - Winson Y. Cheung
- Oncology Outcomes Program, Department of Oncology, University of Calgary, Calgary, AB T2N 1N4, Canada; (J.P.Y.); (P.Q.D.)
- Department of Oncology, Cumming School of Medicine, University of Calgary, Calgary, AB T2N 1N4, Canada
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14
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Stojkov I, Conrads-Frank A, Rochau U, Arvandi M, Koinig KA, Schomaker M, Mittelman M, Fenaux P, Bowen D, Sanz GF, Malcovati L, Langemeijer S, Germing U, Madry K, Guerci-Bresler A, Culligan DJ, Kotsianidis I, Sanhes L, Mills J, Puntscher S, Schmid D, van Marrewijk C, Smith A, Efficace F, de Witte T, Stauder R, Siebert U. Determinants of low health-related quality of life in patients with myelodysplastic syndromes: EUMDS Registry study. Blood Adv 2023; 7:2772-2783. [PMID: 36607832 PMCID: PMC10275700 DOI: 10.1182/bloodadvances.2022008360] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2022] [Revised: 12/02/2022] [Accepted: 12/15/2022] [Indexed: 01/07/2023] Open
Abstract
Patients with myelodysplastic syndromes (MDS) frequently experience a significant symptom burden, which reduces health-related quality of life (HRQoL). We aimed to identify determinants of low HRQoL in patients recently diagnosed with MDS, for guiding early intervention strategies. We evaluated longitudinal data in 2205 patients with MDS during their first year after diagnosis. Median values of EQ-5D 3-level (EQ-5D-3L) index (0.78) and visual analog scale (VAS) score (0.70) were used as thresholds for low HRQoL. In addition, the 5 dimensions of EQ-5D-3L were analyzed for impairments (any level vs "no problem" category). After multiple imputation of missing values, we used generalized estimating equations (GEE) to estimate odds ratios (OR) for univariable determinant screening (P < .15), and to subsequently derive multivariable models for low HRQoL with 95% confidence intervals (CI). Multivariable GEE analysis showed the following independent determinants (OR, 95% CI) for low EQ-5D index: increased age (60-75 years: 1.33, 1.01-1.75; >75: 1.84, 1.39-2.45), female sex (1.70, 1.43-2.03), high serum ferritin level (≥1000 vs ≤300 μg/L: 1.41, 1.06-1.87), comorbidity burden (per unit: 1.11, 1.02-1.20), and reduced Karnofsky performance status (KPS, per 10 units: 0.62, 0.58-0.67). For low VAS score, additional determinants were transfusion dependence (1.53, 1.03-2.29), low hemoglobin <10 g/dL (1.34, 1.12-1.61), and high body mass index (≥30 vs 23-29.9 kg/m2: 1.26, 1.02-1.57). Sex, KPS, comorbidity burden, hemoglobin count, and transfusion burden were determinants for all EQ-5D dimensions. Low HRQoL is determined by multiple factors, which should be considered in the management and shared decision making of patients with MDS. This trial was registered at www.clinicaltrials.gov as #NCT00600860.
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Affiliation(s)
- Igor Stojkov
- Institute of Public Health, Medical Decision Making and Health Technology Assessment, Department of Public Health, Health Services Research and Health Technology Assessment, UMIT - University for Health Sciences, Medical Informatics and Technology, Hall in Tirol, Austria
| | - Annette Conrads-Frank
- Institute of Public Health, Medical Decision Making and Health Technology Assessment, Department of Public Health, Health Services Research and Health Technology Assessment, UMIT - University for Health Sciences, Medical Informatics and Technology, Hall in Tirol, Austria
| | - Ursula Rochau
- Institute of Public Health, Medical Decision Making and Health Technology Assessment, Department of Public Health, Health Services Research and Health Technology Assessment, UMIT - University for Health Sciences, Medical Informatics and Technology, Hall in Tirol, Austria
| | - Marjan Arvandi
- Institute of Public Health, Medical Decision Making and Health Technology Assessment, Department of Public Health, Health Services Research and Health Technology Assessment, UMIT - University for Health Sciences, Medical Informatics and Technology, Hall in Tirol, Austria
| | - Karin A. Koinig
- Department of Internal Medicine V (Hematology and Oncology), Innsbruck Medical University, Innsbruck, Austria
| | - Michael Schomaker
- Institute of Public Health, Medical Decision Making and Health Technology Assessment, Department of Public Health, Health Services Research and Health Technology Assessment, UMIT - University for Health Sciences, Medical Informatics and Technology, Hall in Tirol, Austria
- Centre for Infectious Disease Epidemiology and Research, University of Cape Town, Cape Town, South Africa
| | - Moshe Mittelman
- Department of Medicine A, Tel Aviv Sourasky (Ichilov) Medical Center and Sackler Medical Faculty, Tel Aviv University, Tel Aviv, Israel
| | - Pierre Fenaux
- Service d’Hématologie Séniors, Hôpital Saint-Louis, Assistance Publique des Hôpitaux de Paris and Université Paris 7, Paris, France
| | - David Bowen
- St. James’s Institute of Oncology, Leeds Teaching Hospitals, Leeds, United Kingdom
| | - Guillermo F. Sanz
- Department of Haematology, Hospital Universitario y Politécnico La Fe, Valencia, Spain
- Centro de Investigación Biomédica en Red de Cáncer, CIBERONC, Instituto de Salud Carlos III, Madrid, Spain
| | - Luca Malcovati
- Department of Hematology Oncology, Fondazione IRCCS Policlinico San Matteo, University of Pavia, Pavia, Italy
| | - Saskia Langemeijer
- Department of Hematology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Ulrich Germing
- Department of Haematology, Oncology and Clinical Immunology, Universitätsklinik Düsseldorf, Düsseldorf, Germany
| | - Krzysztof Madry
- Department of Haematology, Oncology and Internal Medicine, Warszawa Medical University, Warsaw, Poland
| | - Agnès Guerci-Bresler
- Service d'Hématologie Clinique, Centre Hospitalier Universitaire Brabois, Nancy, France
| | - Dominic J. Culligan
- Department of Haematology, Aberdeen Royal Infirmary, Aberdeen, United Kingdom
| | - Ioannis Kotsianidis
- Department of Hematology, Democritus University of Thrace, University Hospital of Alexandroupolis, Alexandroupolis, Greece
| | - Laurence Sanhes
- Haematology Department of Perpignan, Saint Jean Hospital, Perpignan, France
| | - Juliet Mills
- Worcestershire Acute Hospitals NHS Trust and University Hospitals Birmingham NHS Foundation Trust, Worcester, United Kingdom
| | - Sibylle Puntscher
- Institute of Public Health, Medical Decision Making and Health Technology Assessment, Department of Public Health, Health Services Research and Health Technology Assessment, UMIT - University for Health Sciences, Medical Informatics and Technology, Hall in Tirol, Austria
| | - Daniela Schmid
- Division for Quantitative Methods in Public Health and Health Services Research, Department of Public Health, Health Services Research and Health Technology Assessment, UMIT - University for Health Sciences, Medical Informatics and Technology, Hall in Tirol, Austria
| | - Corine van Marrewijk
- Department of Hematology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Alexandra Smith
- Epidemiology and Cancer Statistics Group, Department of Health Sciences, University of York, York, United Kingdom
| | - Fabio Efficace
- Health Outcomes Research Unit, Gruppo Italiano Malattie Ematologiche dell’Adulto (GIMEMA), Rome, Italy
| | - Theo de Witte
- Department of Tumor Immunology - Nijmegen Center for Molecular Life Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Reinhard Stauder
- Department of Internal Medicine V (Hematology and Oncology), Innsbruck Medical University, Innsbruck, Austria
| | - Uwe Siebert
- Institute of Public Health, Medical Decision Making and Health Technology Assessment, Department of Public Health, Health Services Research and Health Technology Assessment, UMIT - University for Health Sciences, Medical Informatics and Technology, Hall in Tirol, Austria
- Division of Health Technology Assessment, ONCOTYROL - Center for Personalized Cancer Medicine, Innsbruck, Austria
- Center for Health Decision Science, Departments of Epidemiology and Health Policy & Management, Harvard Chan School of Public Health, Boston, MA
- Institute for Technology Assessment and Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, MA
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15
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Zamanillo I, Poza M, Ayala R, Rapado I, Martinez-Lopez J, Cedena MT. Impact of IPSS-M implementation in real-life clinical practice. Front Oncol 2023; 13:1199023. [PMID: 37274292 PMCID: PMC10233005 DOI: 10.3389/fonc.2023.1199023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2023] [Accepted: 05/02/2023] [Indexed: 06/06/2023] Open
Abstract
Objectives The IPSS-M is a recently published score for risk stratification in myelodysplastic syndromes (MDS), based on clinical and molecular data. We aimed to evaluate its relevance on treatment choice in a real-life setting. Methods We retrospectively collected clinical, cytogenetic and molecular data from 166 MDS patients. We calculated IPSS-R and IPSS-M scores and compared Overall Survival (OS) and Leukemia Free Survival (LFS). We also analyzed which patients would have been affected by the re-stratification in terms of clinical management. Results We found that 86.1% of the patients had at least one genetic alteration. The most frequent mutated genes were SF3B1 (25.9%), DNMT3A (16.8%) and ASXL1 (14.4%). IPSS-M re-stratified 48.2% of the patients, of which 16.9% were downgraded and 31.3% were upgraded. IPSS-M improved outcome prediction, with a Harrell's c-index of 0.680 vs 0.626 for OS and 0.801 vs 0.757 for LFS. In 22.2% of the cohort, the reclassification of the IPSS-M could potentially affect clinical management; 17.4% of the patients would be eligible for treatment intensification and 4.8% for treatment reduction. Conclusions IPSS-M implementation in clinical practice could imply different treatment approaches in a significant number of patients. Our work validates IPSS-M in an external cohort and confirms its applicability in a real-life setting.
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Affiliation(s)
- Irene Zamanillo
- Hematology Department and Research Institute (imas12), University Hospital 12 Octubre, Madrid, Spain
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16
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Randall MP, DeZern AE. The Management of Low-Risk Myelodysplastic Syndromes-Current Standards and Recent Advances. Cancer J 2023; 29:152-159. [PMID: 37195771 DOI: 10.1097/ppo.0000000000000655] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/18/2023]
Abstract
ABSTRACT The myelodysplastic syndromes (MDSs) are a heterogeneous group of hematologic neoplasms with varied natural histories and prognoses. Specific to this review, treatment of low-risk MDS most often focuses on improving quality of life by correcting cytopenias, as opposed to urgent disease modification to avoid acute myeloid leukemia. These treatments include transfusion support with iron chelation when necessary, growth factors including novel maturation agents such as luspatercept, lenalidomide for del(5q) disease, and, increasingly, low-dose hypomethylating agents. Recent advances in the understanding of the genetic lesions that drive MDS have prompted a reassessment of how low-risk disease is defined and helped to identify a subset of low-risk MDS patients who may benefit from a more aggressive treatment paradigm, including hematopoietic stem cell transplantation.
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Affiliation(s)
- Michael P Randall
- From the Division of Hematology and Oncology, Department of Medicine, University of California San Francisco, San Francisco, CA
| | - Amy E DeZern
- Division of Hematologic Malignancies, The Johns Hopkins University School of Medicine, Baltimore, MD
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17
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Pophali P, Desai SR, Shastri A. Therapeutic Targets in Myelodysplastic Neoplasms: Beyond Hypomethylating Agents. Curr Hematol Malig Rep 2023; 18:56-67. [PMID: 37052811 DOI: 10.1007/s11899-023-00693-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/13/2023] [Indexed: 04/14/2023]
Abstract
PURPOSE OF REVIEW To discuss novel targeted therapies under investigation for treatment of myelodysplastic neoplasms (MDS). RECENT FINDINGS Over the last few years, results of phase 3 trials assessing novel therapies for high-risk MDS have been largely disappointing. Pevonedistat (NEDD-8 inhibitor) and APR-246 (TP53 reactivator) both did not meet trial endpoints. However, early phase trials of BCL-2, TIM3, and CD47 inhibitors have shown exciting data and are currently under phase 3 investigation. Moreover, combination of hypomethylating agents (HMA) with novel therapies targeting the mutational (IDH, FLT3, spliceosome complex) or immune (PD-1/PDL-1, TIM-3, IRAK-4) pathways are being investigated in early phase clinical trials and have shown adequate safety and promising efficacy. Myelodysplastic neoplasms (MDS) are a group of hematopoietic neoplasms defined by cytopenias and morphological dysplasia. They are characterized by clonal proliferation of aberrant hematopoietic stem cells caused by recurrent genetic abnormalities. This leads to ineffective erythropoiesis, peripheral blood cytopenias, abnormal cell maturation, and a high risk of transformation into acute myeloid leukemia (AML). Allogeneic hematopoietic stem cell transplantation is the only curative therapy; however, it is not a suitable option for majority patients due to their age, comorbidities, and the high rate of treatment-related complications. HMAs remain the only FDA-approved treatment option for high-risk MDS. Due to intolerance, primary, and secondary resistance to HMA, there is a large unmet need to develop new safe and effective therapies for patients with MDS. In this review, we focus on the current management strategies and novel therapies in development for treatment of high-risk MDS.
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Affiliation(s)
- Prateek Pophali
- Division of Hematology and Oncology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Sudhamsh Reddy Desai
- Department of Medicine, Jacobi Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Aditi Shastri
- Department of Oncology, Department of Developmental & Molecular Biology, Montefiore Medical Center & Albert Einstein College of Medicine, Chanin 302A, 1300 Morris Park Avenue, Bronx, NY, 10461, USA.
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18
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Mądry K, Lis K, Fenaux P, Bowen D, Symeonidis A, Mittelman M, Stauder R, Čermák J, Sanz G, Hellström-Lindberg E, Langemeijer S, Malcovati L, Germing U, Holm MS, Guerci-Bresler A, Culligan D, Sanhes L, Kotsianidis I, van Marrewijk C, Crouch S, de Witte T, Smith A. Cause of death and excess mortality in patients with lower-risk myelodysplastic syndromes (MDS): A report from the European MDS registry. Br J Haematol 2023; 200:451-461. [PMID: 36335984 DOI: 10.1111/bjh.18542] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2022] [Revised: 10/16/2022] [Accepted: 10/19/2022] [Indexed: 11/09/2022]
Abstract
Information on causes of death (CoDs) and the impact of myelodysplastic syndromes (MDS) on survival in patients with lower-risk MDS (LR-MDS) is limited. A better understanding of the relationship between disease characteristics, clinical interventions and CoDs may improve outcomes of patients with LR-MDS. We prospectively collected data on patients with LR-MDS in the European MDS registry from 2008 to 2019. Clinical, laboratory and CoDs data were obtained. To examine MDS-specific survival, relative survival (RS) was estimated using national life tables. Of 2396 evaluated subjects, 900 died (median overall survival [OS]: 4.7 years; median follow-up: 3.5 years). The most common CoDs were acute myeloid leukaemia/MDS (20.1%), infection (17.8%) and cardiovascular disease (CVD; 9.8%). Patients with isolated del(5q) and with red cell transfusion needed during the disease course, had a higher risk of fatal CVD. The 5-year OS was 47.3% and the 5-year RS was 59.6%, indicating that most patients died due to their underlying MDS. Older patients (aged >80 years) and the lowest-risk patients were more likely to die from competing causes. This study shows that MDS and its related complications play crucial role in the outcome of patients with LR-MDS.
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Affiliation(s)
- Krzysztof Mądry
- Department of Haematology, Transplantation and Internal Medicine, Warszawa Medical University, Warsaw, Poland
| | - Karol Lis
- Department of Haematology, Transplantation and Internal Medicine, Warszawa Medical University, Warsaw, Poland
| | - Pierre Fenaux
- Service d'Hématologie, Hôpital Saint-Louis, Assistance Publique des Hôpitaux de Paris (AP-HP) and Université Paris 7, Paris, France
| | - David Bowen
- St. James's Institute of Oncology, Leeds Teaching Hospitals, Leeds, UK
| | - Argiris Symeonidis
- Department of Medicine, Division of Hematology, University of Patras Medical School, Patras, Greece
| | - Moshe Mittelman
- Department of Medicine A, Tel Aviv Sourasky (Ichilov) Medical Center and Sackler Medical Faculty, Tel Aviv University, Tel Aviv, Israel
| | - Reinhard Stauder
- Department of Internal Medicine V (Haematology and Oncology), Innsbruck Medical University, Innsbruck, Austria
| | - Jaroslav Čermák
- Department of Clinical Hematology, Institute of Hematology & Blood Transfusion, Praha, Czech Republic
| | - Guillermo Sanz
- Department of Haematology, Hospital Universitario y Politécnico La Fe & Scientific Director IIS La Fe, Madrid, Spain
| | - Eva Hellström-Lindberg
- Department of Medicine, Division of Hematology, Karolinska Institutet, Stockholm, Sweden
| | - Saskia Langemeijer
- Department of Hematology, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Luca Malcovati
- Department of Hematology Oncology, Fondazione IRCCS Policlinico San Matteo, University of Pavia, Pavia, Italy
| | - Ulrich Germing
- Department of Haematology, Oncology and Clinical Immunology, Universitätsklinik Düsseldorf, Düsseldorf, Germany
| | - Mette Skov Holm
- Department of Haematology, Aarhus University Hospital, Aarhus, Denmark
| | - Agnes Guerci-Bresler
- Service d'Hématologie, Centre Hospitalier Universtaire Brabois Vandoeuvre, Nancy, France
| | - Dominic Culligan
- Department of Haematology, Aberdeen Royal Infirmary, Aberdeen, UK
| | - Laurence Sanhes
- Service d'Hématologie, Centre Hospitalier de Perpignan, Perpignan, France
| | - Ioannis Kotsianidis
- Department of Hematology, Democritus University of Thrace Medical School, University Hospital of Alexandroupolis, Alexandroupolis, Greece
| | - Corine van Marrewijk
- Department of Hematology, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Simon Crouch
- Epidemiology and Cancer Statistics Group, Department of Health Sciences, University of York, York, UK
| | - Theo de Witte
- Department of Tumor Immunology - Nijmegen Center for Molecular Life Sciences, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Alex Smith
- Epidemiology and Cancer Statistics Group, Department of Health Sciences, University of York, York, UK
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19
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Zeidan AM, Platzbecker U, Garcia-Manero G, Sekeres MA, Fenaux P, DeZern AE, Greenberg PL, Savona MR, Jurcic JG, Verma AK, Mufti GJ, Buckstein R, Santini V, Shetty JK, Ito R, Zhang J, Zhang G, Ha X, Backstrom JT, Komrokji RS. Longer-term benefit of luspatercept in transfusion-dependent lower-risk myelodysplastic syndromes with ring sideroblasts. Blood 2022; 140:2170-2174. [PMID: 35797468 PMCID: PMC10653038 DOI: 10.1182/blood.2022016171] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2022] [Accepted: 06/22/2022] [Indexed: 11/20/2022] Open
Abstract
Luspatercept is an approved therapy for selected patients with lower risk myelodysplasia requiring transfusion despite erythropoiesis-stimulating agents, based on the early results of a randomized trial against placebo. Zeidan and colleagues report that after a median of 26 months follow-up, 27% of patients commencing luspatercept were continuing therapy. Their updated analyses confirm that a significant minority (45%) of eligible patients can achieve transfusion independence, with a median durability of 30 weeks. These longer follow-up data better quantify the incremental benefit of luspatercept over placebo.
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Affiliation(s)
- Amer M. Zeidan
- Department of Internal Medicine, Yale School of Medicine and Yale Cancer Center, Yale University, New Haven, CT
| | - Uwe Platzbecker
- Department of Hematology, Cellular Therapy and Hemostaseology, Leipzig University Hospital, Leipzig, Germany
| | | | - Mikkael A. Sekeres
- Division of Hematology, Sylvester Comprehensive Cancer Center, University of Miami, Miami, FL
| | - Pierre Fenaux
- Service d’Hématologie Séniors, Hôpital Saint-Louis, Université de Paris 7, Paris, France
| | - Amy E. DeZern
- The Sidney Kimmel Comprehensive Cancer Center, The Johns Hopkins Hospital, Baltimore, MD
| | | | - Michael R. Savona
- Vanderbilt-Ingram Cancer Center, Vanderbilt University Medical Center, Nashville, TN
| | - Joseph G. Jurcic
- Division of Hematology/Oncology, Herbert Irving Comprehensive Cancer Center, Columbia University Irving Medical Center, New York, NY
| | - Amit K. Verma
- Department of Oncology, Albert Einstein College of Medicine, Montefiore Medical Center, New York, NY
| | - Ghulam J. Mufti
- Department of Haemato-Oncology, King’s College Hospital, London, United Kingdom
| | - Rena Buckstein
- Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Valeria Santini
- MDS Unit, Azienda Ospedaliero Universitaria Careggi, University of Florence, Florence, Italy
| | - Jeevan K. Shetty
- Celgene International Sàrl, a Bristol-Myers Squibb Company, Boudry, Switzerland
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20
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The Proliferation Index of Erythroid Cells Predicts the Development of Transfusion-dependence in Myelodysplastic Syndrome Patients With Mildly Reduced Hemoglobin Levels at Initial Diagnosis. Hemasphere 2022; 6:e804. [PMID: 36382052 PMCID: PMC9649276 DOI: 10.1097/hs9.0000000000000804] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2022] [Accepted: 10/12/2022] [Indexed: 01/24/2023] Open
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21
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Okoye-Okafor UC, Javarappa KK, Tsallos D, Saad J, Yang D, Zhang C, Benard L, Thiruthuvanathan VJ, Cole S, Ruiz S, Tatiparthy M, Choudhary G, DeFronzo S, Bartholdy BA, Pallaud C, Ramos PM, Shastri A, Verma A, Heckman CA, Will B. Megakaryopoiesis impairment through acute innate immune signaling activation by azacitidine. J Exp Med 2022; 219:e20212228. [PMID: 36053753 PMCID: PMC9441716 DOI: 10.1084/jem.20212228] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2021] [Revised: 04/02/2022] [Accepted: 07/22/2022] [Indexed: 11/04/2022] Open
Abstract
Thrombocytopenia, prevalent in the majority of patients with myeloid malignancies, such as myelodysplastic syndrome (MDS) or acute myeloid leukemia (AML), is an independent adverse prognostic factor. Azacitidine (AZA), a mainstay therapeutic agent for stem cell transplant-ineligible patients with MDS/AML, often transiently induces or further aggravates disease-associated thrombocytopenia by an unknown mechanism. Here, we uncover the critical role of an acute type-I interferon (IFN-I) signaling activation in suppressing megakaryopoiesis in AZA-mediated thrombocytopenia. We demonstrate that megakaryocytic lineage-primed progenitors present IFN-I receptors and, upon AZA exposure, engage STAT1/SOCS1-dependent downstream signaling prematurely attenuating thrombopoietin receptor (TPO-R) signaling and constraining megakaryocytic progenitor cell growth and differentiation following TPO-R stimulation. Our findings directly implicate RNA demethylation and IFN-I signal activation as a root cause for AZA-mediated thrombocytopenia and suggest mitigation of TPO-R inhibitory innate immune signaling as a suitable therapeutic strategy to support platelet production, particularly during the early phases of AZA therapy.
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Affiliation(s)
- Ujunwa Cynthia Okoye-Okafor
- Albert Einstein College of Medicine/Montefiore Medical Center, Department of Cell Biology, Bronx, NY
- Albert Einstein College of Medicine/Montefiore Medical Center, Cancer Stem Cell Pharmacodynamics Unit, Bronx, NY
| | - Komal K. Javarappa
- Institute for Molecular Medicine Finland (FIMM), Helsinki Institute of Life Science, University of Helsinki, Helsinki, Finland
| | - Dimitrios Tsallos
- Institute for Molecular Medicine Finland (FIMM), Helsinki Institute of Life Science, University of Helsinki, Helsinki, Finland
| | - Joseph Saad
- Institute for Molecular Medicine Finland (FIMM), Helsinki Institute of Life Science, University of Helsinki, Helsinki, Finland
| | - Daozheng Yang
- Albert Einstein College of Medicine/Montefiore Medical Center, Department of Cell Biology, Bronx, NY
| | - Chi Zhang
- Albert Einstein College of Medicine/Montefiore Medical Center, Department of Cell Biology, Bronx, NY
| | - Lumie Benard
- Albert Einstein College of Medicine/Montefiore Medical Center, Department of Cell Biology, Bronx, NY
- Albert Einstein College of Medicine/Montefiore Medical Center, Cancer Stem Cell Pharmacodynamics Unit, Bronx, NY
| | - Victor J. Thiruthuvanathan
- Albert Einstein College of Medicine/Montefiore Medical Center, Department of Cell Biology, Bronx, NY
- Albert Einstein College of Medicine/Montefiore Medical Center, Cancer Stem Cell Pharmacodynamics Unit, Bronx, NY
| | - Sally Cole
- Albert Einstein College of Medicine/Montefiore Medical Center, Department of Cell Biology, Bronx, NY
- Albert Einstein College of Medicine/Montefiore Medical Center, Cancer Stem Cell Pharmacodynamics Unit, Bronx, NY
| | - Stephen Ruiz
- Albert Einstein College of Medicine/Montefiore Medical Center, Department of Cell Biology, Bronx, NY
- Albert Einstein College of Medicine/Montefiore Medical Center, Cancer Stem Cell Pharmacodynamics Unit, Bronx, NY
| | - Madhuri Tatiparthy
- Albert Einstein College of Medicine/Montefiore Medical Center, Department of Cell Biology, Bronx, NY
- Albert Einstein College of Medicine/Montefiore Medical Center, Cancer Stem Cell Pharmacodynamics Unit, Bronx, NY
| | - Gaurav Choudhary
- Albert Einstein College of Medicine/Montefiore Medical Center, Department of Medicine (Oncology), Bronx, NY
| | - Stefanie DeFronzo
- Albert Einstein College of Medicine/Montefiore Medical Center, Department of Cell Biology, Bronx, NY
| | - Boris A. Bartholdy
- Albert Einstein College of Medicine/Montefiore Medical Center, Department of Cell Biology, Bronx, NY
| | | | | | - Aditi Shastri
- Albert Einstein College of Medicine/Montefiore Medical Center, Department of Medicine (Oncology), Bronx, NY
| | - Amit Verma
- Albert Einstein College of Medicine/Montefiore Medical Center, Department of Medicine (Oncology), Bronx, NY
| | - Caroline A. Heckman
- Institute for Molecular Medicine Finland (FIMM), Helsinki Institute of Life Science, University of Helsinki, Helsinki, Finland
| | - Britta Will
- Albert Einstein College of Medicine/Montefiore Medical Center, Department of Cell Biology, Bronx, NY
- Albert Einstein College of Medicine/Montefiore Medical Center, Cancer Stem Cell Pharmacodynamics Unit, Bronx, NY
- Albert Einstein College of Medicine/Montefiore Medical Center, Department of Medicine (Oncology), Bronx, NY
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22
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Fattizzo B, Michel M, Giannotta JA, Hansen DL, Arguello M, Sutto E, Bianchetti N, Patriarca A, Cantoni S, Mingot-Castellano ME, McDonald V, Capecchi M, Zaninoni A, Consonni D, Vos JM, Vianelli N, Chen F, Glenthøj A, Frederiksen H, González-López TJ, Barcellini W. Evans syndrome in adults: an observational multicenter study. Blood Adv 2021; 5:5468-5478. [PMID: 34592758 PMCID: PMC8714709 DOI: 10.1182/bloodadvances.2021005610] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2021] [Accepted: 08/10/2021] [Indexed: 11/20/2022] Open
Abstract
Evans syndrome (ES) is a rare condition, defined as the presence of 2 autoimmune cytopenias, most frequently autoimmune hemolytic anemia and immune thrombocytopenia (ITP) and rarely autoimmune neutropenia. ES can be classified as primary or secondary to various conditions, including lymphoproliferative disorders, other systemic autoimmune diseases, and primary immunodeficiencies, particularly in children. In adult ES, little is known about clinical features, disease associations, and outcomes. In this retrospective international study, we analyzed 116 adult patients followed at 13 European tertiary centers, focusing on treatment requirements, occurrence of complications, and death. ES was secondary to or associated with underlying conditions in 24 cases (21%), mainly other autoimmune diseases and hematologic neoplasms. Bleeding occurred in 42% of patients, mainly low grade and at ITP onset. Almost all patients received first-line treatment (steroids with or without intravenous immunoglobulin), and 23% needed early additional therapy for primary refractoriness. Additional therapy lines included rituximab, splenectomy, immunosuppressants, thrombopoietin receptor agonists, and others, with response rates >80%. However, a remarkable number of relapses occurred, requiring ≥3 therapy lines in 54% of cases. Infections and thrombotic complications occurred in 33% and 21% of patients, respectively, mainly grade ≥3, and correlated with the number of therapy lines. In addition to age, other factors negatively affecting survival were severe anemia at onset and occurrence of relapse, infection, and thrombosis. These data show that adult ES is often severe and marked by a relapsing clinical course and potentially fatal complications, pinpointing the need for high clinical awareness, prompt therapy, and anti-infectious/anti-thrombotic prophylaxis.
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Affiliation(s)
- Bruno Fattizzo
- Hematology Unit, Fondazione Istituto di Ricovero e Cura a Carattere Scientifico Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy
- Department of Oncology and Hemato-Oncology, University of Milan, Milan, Italy
| | - Marc Michel
- Centre de Référence Maladies Rares sur les Cytopénies Auto-Immunes de l’Adulte, Centre Hospitalier Universitaire Henri Mondor, Assistance Publique–Hôpitaux de Paris, Créteil Université Paris-Est Créteil, Paris, France
| | - Juri Alessandro Giannotta
- Hematology Unit, Fondazione Istituto di Ricovero e Cura a Carattere Scientifico Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy
| | | | - Maria Arguello
- Hospital Universitario Principe de Asturias (Alcala de Henares), Madrid, Spain
| | - Emanuele Sutto
- Institute of Hematology “L. e A. Seragnoli”, University of Bologna, Bologna, Italy
| | | | - Andrea Patriarca
- Department of Translational Medicine, Azienda Ospedaliera-Universitaria “Maggiore della Carità”, University of Eastern Piedmont, Novara, Italy
| | - Silvia Cantoni
- Dipartimento di Ematologia e Oncologia, Niguarda Cancer Center, Azienda Socio Sanitaria Territoriale Ospedale Niguarda, Milan, Italy
| | | | - Vickie McDonald
- Clinical Haematology, Barts Health National Health Service Trust, Queen Mary University, London, United Kingdom
| | - Marco Capecchi
- Hematology Unit, Fondazione Istituto di Ricovero e Cura a Carattere Scientifico Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Anna Zaninoni
- Hematology Unit, Fondazione Istituto di Ricovero e Cura a Carattere Scientifico Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Dario Consonni
- Epidemiology Unit, Fondazione Istituto di Ricovero e Cura a Carattere Scientifico Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Josephine Mathilde Vos
- Amsterdam University Medical Center, University of Amsterdam–Sanquin Landsteiner Laboratory, Amsterdam, The Netherlands
| | - Nicola Vianelli
- Institute of Hematology “L. e A. Seragnoli”, University of Bologna, Bologna, Italy
| | - Frederick Chen
- Clinical Haematology, Barts Health National Health Service Trust, Queen Mary University, London, United Kingdom
| | - Andreas Glenthøj
- Department of Hematology, Rigshospitalet, Copenhagen, Denmark; and
| | | | | | - Wilma Barcellini
- Hematology Unit, Fondazione Istituto di Ricovero e Cura a Carattere Scientifico Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy
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23
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Ball S, Komrokji RS, Sallman DA. Prognostic scoring systems and risk stratification in myelodysplastic syndrome: focus on integration of molecular profile. Leuk Lymphoma 2021; 63:1281-1291. [PMID: 34933652 DOI: 10.1080/10428194.2021.2018579] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Myelodysplastic syndromes (MDS) form a clinically and molecularly heterogeneous disease group. Precise risk stratification remains crucial for choosing optimal management strategies. Several conventional prognostic scoring systems have been developed and validated in the MDS population. These risk models divide patients into prognostic subgroups based on clinical and cytogenetic characteristics. Lack of dynamicity, variable risk estimate across models, and heterogeneity within intermediate-risk group are the limitations of traditional models like IPSS-R, with questionable relevance of these scoring systems in treated MDS patients. Recent progress in next-generation sequencing techniques has improved understanding of the distribution and prognostic importance of recurrent genetic mutations in MDS. Early studies have suggested that incorporating mutations in risk stratification could supplement IPSS-R in further refining the model's performance in predicting overall survival and risk of transformation to acute myeloid leukemia and should translate into a molecularly driven prognostication approach in the near future.
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Affiliation(s)
- Somedeb Ball
- Department of Malignant Hematology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA
| | - Rami S Komrokji
- Department of Malignant Hematology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA
| | - David A Sallman
- Department of Malignant Hematology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA
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24
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Abstract
PURPOSE OF REVIEW To review available data on the relationship of MDS and aging and to address the question if biological changes of (premature) aging are a prerequisite for the development of MDS. RECENT FINDINGS Whereas the association of MDS with advanced age and some common biologic features of aging and MDS are well established, additional evidence for both, especially on the role of stem cells, the stem cell niche, and inflammation, has been recently described. Biologically, many but not all drivers of aging also play a role in the development and propagation of MDS and vice versa. As a consequence, aging contributes to the development of MDS which can be seen as an interplay of clonal disease and normal and premature aging. The impact of aging may be different in specific MDS subtypes and risk groups.
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Affiliation(s)
- Sonja Heibl
- Department of Internal Medicine IV, Klinikum Wels-Grieskirchen, Wels, Austria
- Paracelsus Medical University, Salzburg, Austria
| | - Reinhard Stauder
- Department of Internal Medicine V, Hematology and Oncology, Comprehensive Cancer Center Innsbruck (CCCI), Medical University of Innsbruck, Innsbruck, Austria
| | - Michael Pfeilstöcker
- 3rd Medical Department, Hanusch Hospital, H.Collinstr 30, 1140, Vienna, Austria.
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25
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Core Set of Patient-Reported Outcomes for Myelodysplastic Syndromes - EUMDS Delphi Study in Patients and Hematologists. Blood Adv 2021; 6:1-12. [PMID: 34492684 PMCID: PMC8753222 DOI: 10.1182/bloodadvances.2021004568] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2021] [Accepted: 06/03/2021] [Indexed: 12/04/2022] Open
Abstract
Systematically developed set of core PROs in MDS, involving patients and hematologists in a 2-round Delphi survey. Core PROs will support unified outcome measurement and facilitate inclusion of reliable patient information in MDS disease care.
Patient-reported outcomes (PROs) are relevant and valuable end points in the care of patients with myelodysplastic syndromes (MDS). However, a consensus-based selection of PROs for MDS, derived by both patients and hematologists, is lacking. We aimed to develop a core set of PROs for patients with MDS as part of the prospective European LeukemiaNet MDS (EUMDS) Registry. According to international guidelines, candidate PROs were identified from a comprehensive literature search of MDS studies. Overall, 40 PROs were selected and evaluated in a two-round Delphi survey by 40 patients with MDS and 38 hematologists in the first round and 38 patients and 32 hematologists in the second round. Based on an agreement scale and predefined inclusion criteria, both patients and hematologists selected “general quality of life” as a core PRO. Hematologists also selected “transfusion-dependency burden” and “ability to work/activities of daily living” as core PROs. The second Delphi round increased PRO rating agreements. Statistically significant rating differences between patients and hematologists were observed for 28 PROs (Mann-Whitney U test; P < .05) in the first round and for 19 PROs in the second round, with “disease knowledge” and “confidence in health care services” rated notably higher by patients. The overall mean PRO ratings correlation between the 2 groups was moderate (Spearman’s rank correlation coefficient = 0.5; P < .05). This first consensus on a core set of PROs jointly developed by patients and hematologists forms the basis for patient-centered care in daily practice and clinical research.
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26
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Wouters HJCM, Conrads-Frank A, Koinig KA, Smith A, Yu G, de Witte T, Wolffenbuttel BHR, Huls G, Siebert U, Stauder R, van der Klauw MM. The anemia-independent impact of myelodysplastic syndromes on health-related quality of life. Ann Hematol 2021; 100:2921-2932. [PMID: 34476573 PMCID: PMC8592948 DOI: 10.1007/s00277-021-04654-1] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2021] [Accepted: 08/24/2021] [Indexed: 01/12/2023]
Abstract
Myelodysplastic syndromes (MDS) are in the majority of cases characterized by anemia. Both anemia and MDS per se may directly contribute to impairments in health-related quality of life (HRQoL). In this study, we aimed to investigate the anemia-independent impact of MDS on HRQoL. We evaluated participants (≥ 50 years) from the large population-based Lifelines cohort (N = 44,694, mean age 59.0 ± 7.4 years, 43.6% male) and the European MDS Registry (EUMDS) (N = 1538, mean age 73.4 ± 9.0 years, 63.0% male), which comprises a cohort of lower-risk MDS patients. To enable comparison concerning HRQoL, SF-36 scores measured in Lifelines were converted to EQ-5D-3L index (range 0–1) and dimension scores. Lower-risk MDS patients had significantly lower HRQoL than those from the Lifelines cohort, as illustrated in both the index score and in the five different dimensions. Multivariable linear regression analysis demonstrated that MDS had an adjusted total impact on the EQ-5D index score (B = − 0.12, p < 0.001) and an anemia-independent “direct” impact (B = − 0.10, p < 0.001). Multivariable logistic regression analysis revealed an anemia-independent impact of MDS in the dimension mobility, self-care, usual activities, and anxiety/depression (all except pain/discomfort). This study demonstrates that the major part of the negative impact of lower-risk MDS on HRQoL is not mediated via anemia. Thus, the therapeutic focus should include treatment strategies directed at underlying pathogenic mechanisms to improve HRQoL, rather than aiming predominantly at increasing hemoglobin levels.
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Affiliation(s)
- Hanneke J C M Wouters
- Department of Hematology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands.
- Department of Endocrinology, University of Groningen, University Medical Center Groningen, 9700 RB, Groningen, The Netherlands.
| | - Annette Conrads-Frank
- Institute of Public Health, Medical Decision Making and Health Technology Assessment, Department of Public Health, Health Services Research and Health Technology Assessment, UMIT - University for Health Sciences, Medical Informatics and Technology, Hall in Tirol, Austria
| | - Karin A Koinig
- Department of Internal Medicine V (Hematology and Oncology), Medical University Innsbruck, Innsbruck, Austria
| | - Alex Smith
- Epidemiology and Cancer Statistics Group, Department of Health Sciences, University of York, York, UK
| | - Ge Yu
- Epidemiology and Cancer Statistics Group, Department of Health Sciences, University of York, York, UK
- Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Theo de Witte
- Department of Tumor Immunology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Bruce H R Wolffenbuttel
- Department of Endocrinology, University of Groningen, University Medical Center Groningen, 9700 RB, Groningen, The Netherlands
| | - Gerwin Huls
- Department of Hematology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Uwe Siebert
- Institute of Public Health, Medical Decision Making and Health Technology Assessment, Department of Public Health, Health Services Research and Health Technology Assessment, UMIT - University for Health Sciences, Medical Informatics and Technology, Hall in Tirol, Austria
- Division of Health Technology Assessment, ONCOTYROL - Center for Personalized Cancer Medicine, Innsbruck, Austria
- Center for Health Decision Science, Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, MA, USA
- Institute for Technology Assessment and Department of Radiology and Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Reinhard Stauder
- Department of Internal Medicine V (Hematology and Oncology), Medical University Innsbruck, Innsbruck, Austria
| | - Melanie M van der Klauw
- Department of Endocrinology, University of Groningen, University Medical Center Groningen, 9700 RB, Groningen, The Netherlands
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27
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A predictive algorithm using clinical and laboratory parameters may assist in ruling out and in diagnosing MDS. Blood Adv 2021; 5:3066-3075. [PMID: 34387647 DOI: 10.1182/bloodadvances.2020004055] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2020] [Accepted: 04/08/2021] [Indexed: 02/08/2023] Open
Abstract
We present a noninvasive Web-based app to help exclude or diagnose myelodysplastic syndrome (MDS), a bone marrow (BM) disorder with cytopenias and leukemic risk, diagnosed by BM examination. A sample of 502 MDS patients from the European MDS (EUMDS) registry (n > 2600) was combined with 502 controls (all BM proven). Gradient-boosted models (GBMs) were used to predict/exclude MDS using demographic, clinical, and laboratory variables. Area under the receiver operating characteristic curve (AUC), sensitivity, and specificity were used to evaluate the models, and performance was validated using 100 times fivefold cross-validation. Model stability was assessed by repeating its fit using different randomly chosen groups of 502 EUMDS cases. AUC was 0.96 (95% confidence interval, 0.95-0.97). MDS is predicted/excluded accurately in 86% of patients with unexplained anemia. A GBM score (range, 0-1) of less than 0.68 (GBM < 0.68) resulted in a negative predictive value of 0.94, that is, MDS was excluded. GBM ≥ 0.82 provided a positive predictive value of 0.88, that is, MDS. The diagnosis of the remaining patients (0.68 ≤ GBM < 0.82) is indeterminate. The discriminating variables: age, sex, hemoglobin, white blood cells, platelets, mean corpuscular volume, neutrophils, monocytes, glucose, and creatinine. A Web-based app was developed; physicians could use it to exclude or predict MDS noninvasively in most patients without a BM examination. Future work will add peripheral blood cytogenetics/genetics, EUMDS-based prospective validation, and prognostication.
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28
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Oliva EN, Platzbecker U, Fenaux P, Garcia-Manero G, LeBlanc TW, Patel BJ, Kubasch AS, Sekeres MA. Targeting health-related quality of life in patients with myelodysplastic syndromes - Current knowledge and lessons to be learned. Blood Rev 2021; 50:100851. [PMID: 34088518 DOI: 10.1016/j.blre.2021.100851] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2020] [Revised: 05/10/2021] [Accepted: 05/13/2021] [Indexed: 12/12/2022]
Abstract
Using a range of health-related quality of life (HRQoL) instruments, most - but not all - studies of myelodysplastic syndromes (MDS) have reported that lower hemoglobin levels and red blood cell transfusion dependency are associated with worse HRQoL. In addition, some MDS treatments may significantly improve HRQoL, particularly among those patients who respond to therapy; however, the majority of these studies were underpowered for this secondary endpoint. Furthermore, decreased HRQoL has been associated with worse survival outcomes, and HRQoL scores can be used to refine classical prognostic systems. Despite the subjective nature of HRQoL, the importance and validity of measuring it in trials and clinical practice are increasingly being recognized, but properly validated MDS-specific instruments are required. We describe what is currently known about HRQoL in patients with MDS, and the limitations of measuring HRQoL, and we provide some recommendations to improve the measurement of this outcome in future trials.
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Affiliation(s)
- Esther N Oliva
- Grande Ospedale Metropolitano Bianchi Melacrino Morelli, Reggio Calabria, Italy.
| | - Uwe Platzbecker
- Department of Hematology, Cellular Therapy and Hemostaseology, Leipzig University Hospital, Leipzig, Germany.
| | - Pierre Fenaux
- Service d'Hématologie Séniors, Hôpital Saint-Louis, Université Paris 7, Paris, France.
| | | | | | | | - Anne Sophie Kubasch
- Department of Hematology, Cellular Therapy and Hemostaseology, Leipzig University Hospital, Leipzig, Germany.
| | - Mikkael A Sekeres
- Sylvester Cancer Center, University of Miami Miller School of Medicine, Miami, FL, USA.
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29
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EnvIRONmental Aspects in Myelodysplastic Syndrome. Int J Mol Sci 2021; 22:ijms22105202. [PMID: 34068996 PMCID: PMC8156755 DOI: 10.3390/ijms22105202] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2021] [Revised: 05/06/2021] [Accepted: 05/11/2021] [Indexed: 11/24/2022] Open
Abstract
Systemic iron overload is multifactorial in patients suffering from myelodysplastic syndrome (MDS). Disease-immanent ineffective erythropoiesis together with chronic red blood cell transfusion represent the main underlying reasons. However, like the genetic heterogeneity of MDS, iron homeostasis is also diverse in different MDS subtypes and can no longer be generalized. While a certain amount of iron and reactive oxygen species (ROS) are indispensable for proper hematological output, both are harmful if present in excess. Consequently, iron overload has been increasingly recognized as an important player in MDS, which is worth paying attention to. This review focuses on iron- and ROS-mediated effects in the bone marrow niche, their implications for hematopoiesis and their yet unclear involvement in clonal evolution. Moreover, we provide recent insights into hepcidin regulation in MDS and its interaction between erythropoiesis and inflammation. Based on Tet methylcytosine dioxygenase 2 (TET2), representing one of the most frequently mutated genes in MDS, leading to disturbances in both iron homeostasis and hematopoiesis, we highlight that different genetic alteration may have different implications and that a comprehensive workup is needed for a complete understanding and development of future therapies.
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30
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Liu Q, Dong J, Li J, Duan Y, Wang K, Kong Q, Zhang H. LINC01255 combined with BMI1 to regulate human mesenchymal stromal senescence and acute myeloid leukemia cell proliferation through repressing transcription of MCP-1. Clin Transl Oncol 2021; 23:1105-1116. [PMID: 33405050 DOI: 10.1007/s12094-020-02505-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2020] [Accepted: 09/05/2020] [Indexed: 12/19/2022]
Abstract
BACKGROUND Long non-coding RNAs (lncRNAs) govern fundamental biochemical and cellular biology processes, for example, participate in chromatin remodeling, imprinting, splicing, transcriptional regulation and translation. Dysregulation of lncRNA expression is act as a feature of various diseases and cancers, including hematopoietic malignancies. However, the clinical relevance of myelodysplastic syndrome (MDS) and acute myeloid leukemia preceded by MDS (MDS-AML) requires further research. Recently, lncRNAs have been demonstrated, which play an important role in hematopoiesis, thus, to further finding more functional lncRNA seemed particularly important. METHODS Western blotting, real-time PCR, RNA-pulldown, RIP (RNA immunoprecipitation), Chromatin immunoprecipitation (ChIP), cellular compartments extraction assays, SA-β-gal staining, lentivirus transfection, cell viability assay and cell proliferation assays were used to examine the relationship between lncRNA LINC01255 and its regulation of p53-p21 pathway in human mesenchymal stromal and acute myeloid leukemia cells. RESULTS LncRNA LINC01255 is highly expressed in bone marrow cells of AML patients, CD34+ cells of MDS-AML patients and AML cell lines and the higher expression of LINC01255 is associated with poor survival rate of AML patients. LINC01255 can interact with BMI1 and repress the transcription of MCP-1 to active p53-p21 pathway, thus inhibiting the senescence of human mesenchymal stromal and proliferation of acute myeloid leukemia cell. CONCLUSIONS We discovered a novel functional lncRNA LINC01255, which can regulate the senescence of human mesenchymal stromal and the proliferation of acute myeloid leukemia cell through inhibiting the transcription of MCP-1.
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Affiliation(s)
- Q Liu
- Clinical Laboratory, The Second Affiliated Hospital of Shandong First Medical University, Taian, Shandong, China
| | - J Dong
- Department of Hematology, The Second Affiliated Hospital of Shandong First Medical University, No. 706, Taishan Street, Taian, 271000, Shandong, China
| | - J Li
- Department of Hematology, The Second Affiliated Hospital of Shandong First Medical University, No. 706, Taishan Street, Taian, 271000, Shandong, China
| | - Y Duan
- Department of Hematology, The Second Affiliated Hospital of Shandong First Medical University, No. 706, Taishan Street, Taian, 271000, Shandong, China
| | - K Wang
- Research Service Office, The Second Affiliated Hospital of Shandong First Medical University, Taian, Shandong, China
| | - Q Kong
- Department of Hematology, The Second Affiliated Hospital of Shandong First Medical University, No. 706, Taishan Street, Taian, 271000, Shandong, China
| | - H Zhang
- Department of Hematology, The Second Affiliated Hospital of Shandong First Medical University, No. 706, Taishan Street, Taian, 271000, Shandong, China.
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Wood EM, McQuilten ZK. Outpatient transfusions for myelodysplastic syndromes. HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2020; 2020:167-174. [PMID: 33275745 PMCID: PMC7727529 DOI: 10.1182/hematology.2020000103] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/07/2023]
Abstract
Patients with myelodysplastic syndromes (MDS) often need extended periods of red blood cell or platelet transfusion support, with the goal to manage symptoms of anemia and thrombocytopenia, respectively, and improve quality of life. Many questions about the optimal approach to transfusion management in MDS, especially in the outpatient setting, remain unanswered, including hemoglobin and platelet thresholds for transfusion. Restrictive transfusion approaches are often practised, but whether these are appropriate for outpatients with MDS, who are often older and may be frail, is not known. Current schedules for transfusion-dependent patients are burdensome, necessitating frequent visits to hospitals for sample collection and blood administration. Questions of optimal schedule and dosage are being explored in clinical trials, including the recently completed REDDS study. Patient-reported outcomes and functional assessments are increasingly being incorporated into research in this area so that we can better understand and improve transfusion support for patients with MDS.
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De Witte T, Malcovati L, Fenaux P, Bowen D, Symeonidis A, Mittelman M, Stauder R, Sanz G, Čermák J, Langemeijer S, Hellström-Lindberg E, Germing U, Skov Holm M, Mądry K, Tatic A, Medina Almeida A, Savic A, Mandac Rogulj I, Itzykson R, Hoeks M, Gravdahl Garelius H, Culligan D, Kotsianidis I, Ades L, Van de Loosdrecht AA, Van Marrewijk C, Yu G, Crouch S, Smith A. Novel dynamic outcome indicators and clinical endpoints in myelodysplastic syndrome; the European LeukemiaNet MDS Registry and MDS-RIGHT project perspective. Haematologica 2020; 105:2516-2523. [PMID: 33054132 PMCID: PMC7604570 DOI: 10.3324/haematol.2020.266817] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Affiliation(s)
- Theo De Witte
- Department of Tumor Immunology - Nijmegen Center for Molecular Life Sciences, Radboud University Medical Center, Nijmegen; TdW and LM both contributed equally as co-first authors.
| | - Luca Malcovati
- Department of Hematology Oncology, Fondazione IRCCS Policlinico San Matteo, University of Pavia, Pavia; TdW and LM both contributed equally as co-first authors.
| | - Pierre Fenaux
- Service d'Hématologie, Hôpital Saint-Louis, Assistance Publique des Hôpitaux de Paris (AP-HP) and Université Paris 7, Paris.
| | - David Bowen
- St. James's Institute of Oncology, Leeds Teaching Hospitals, Leeds.
| | - Argiris Symeonidis
- Department of Medicine, Division of Hematology, University of Patras Medical School, Patras.
| | - Moshe Mittelman
- Department of Medicine A, Tel Aviv Sourasky (Ichilov) Medical Center and Sackler Medical Faculty, Tel Aviv University, Tel Aviv.
| | - Reinhard Stauder
- Department of Internal Medicine V (Haematology and Oncology), Innsbruck Medical University, Innsbruck.
| | - Guillermo Sanz
- Department of Haematology, Hospital Universitario y Politécnico La Fe, Valencia, and CIBERONC, Madrid.
| | - Jaroslav Čermák
- Department of Clinical Hematology, Inst. of Hematology and Blood Transfusion, Praha.
| | | | | | - Ulrich Germing
- Department of Haematology, Oncology and Clinical Immunology, Universitätsklinik Düsseldorf, Düsseldorf.
| | - Mette Skov Holm
- Department of Haematology, Aarhus University Hospital, Aarhus.
| | - Krzysztof Mądry
- Department of Haematology, Oncology and Internal Medicine, Warszawa Medical University, Warszawa.
| | - Aurelia Tatic
- Center of Hematology and Bone Marrow Transplantation, Fundeni Clinical Institute, Bucharest.
| | | | - Aleksandar Savic
- Clinic of Hematology - Clinical Center of Vojvodina, Faculty of Medicine, University of Novi Sad, Novi Sad.
| | - Inga Mandac Rogulj
- Department of Internal Medicine, Division of Hematology, Merkur University Hospital, Zagreb.
| | - Raphael Itzykson
- Service d'Hématologie, Hôpital Saint-Louis, Assistance Publique des Hôpitaux de Paris (AP-HP) and Université Paris 7, Paris.
| | - Marlijn Hoeks
- Department of Hematology, Radboud University Medical Center, Nijmegen.
| | | | | | - Ioannis Kotsianidis
- Department of Hematology, Democritus University of Thrace Medical School, University Hospital of Alexandroupolis, Alexandroupolis.
| | - Lionel Ades
- Service d'Hématologie, Hôpital Saint-Louis, Assistance Publique des Hôpitaux de Paris (AP-HP) and Université Paris 7, Paris.
| | - Arjan A Van de Loosdrecht
- Department of Hematology - Cancer Center Amsterdam, Amsterdam UMC, Location VU University Medical Center, Amsterdam.
| | | | - Ge Yu
- Epidemiology and Cancer Statistics Group, Department of Health Sciences, University of York, York.
| | - Simon Crouch
- Epidemiology and Cancer Statistics Group, Department of Health Sciences, University of York, York.
| | - Alex Smith
- Epidemiology and Cancer Statistics Group, Department of Health Sciences, University of York, York.
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Trudeau JJ, He J, Rose E, Panter C, Randhawa S, Gater A. Content validity of patient-reported outcomes for use in lower-risk myelodysplastic syndromes. J Patient Rep Outcomes 2020; 4:69. [PMID: 32851569 PMCID: PMC7450032 DOI: 10.1186/s41687-020-00235-4] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2019] [Accepted: 08/13/2020] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND The lower-risk (low and intermediate-1 risk based on IPSS) myelodysplastic syndrome (MDS) has a negative impact on patients' health-related quality of life (HRQoL). Patient Reported Outcomes (PROs) instruments, which are used to collect patients' HRQoL data, should have established content validity in the target population to ensure that the instrument is comprehensive and comprehensible. The present study was conducted to evaluate the content validity of the Quality of Life in Myelodysplasia Scale (QUALMS) and the Functional Assessment of Cancer Therapy-Anemia (FACT-An) PRO instruments in patients with lower-risk MDS. METHODS In this cross-sectional, qualitative study, 16 patients aged ≥18 years with lower-risk MDS, who were RBC transfusion dependent, literate and fluent in US-English were interviewed. Interviews were semi-structured comprising of two parts: concept elicitation (CE) explored symptoms and impacts important to patients, and cognitive debriefing (CD) assessed understanding and relevance of the QUALMS and FACT-An. A conceptual model was developed, which was used to map the concepts that emerged during CE onto the QUALMS and FACT-An to assess concept coverage and suitability of the instruments. RESULTS The median age of participants was 67.5 years (range: 51-91), with half being female (n = 8). Nine (56.2%) participants had intermediate-1-risk MDS and 10 (62.5%) were relapsed or refractory to erythropoiesis-stimulating agent treatment. Fatigue/tiredness (100.0%), shortness of breath (87.5%), weakness (81.2%), and low energy (75.0%) were reported most commonly and were the most bothersome symptoms as well. Of seven high-level HRQoL domains identified, activities of daily living (n = 16, 100.0%), physical functioning (n = 15, 93.8%), emotional wellbeing (n = 13, 81.3%), social functioning (n = 12, 75.0%), sleep disturbance (n = 9, 56.3%), and impact on work (n = 9, 56.3%) were the most commonly reported. For CD, the QUALMS and FACT-An were found to be mostly relevant and very well understood; response options were easy to use, and recall period was appropriate. CONCLUSION Both QUALMS and FACT-An demonstrated a strong face and content validity in patients with lower-risk MDS, suggesting that these instruments are appropriate for assessing HRQoL in this population.
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Affiliation(s)
| | - Jianming He
- Janssen Global Services LLC, 700 US 202 South, Raritan, NJ, 08869, USA
| | - Esther Rose
- Janssen Pharmaceuticals LLC, Raritan, NJ, 08869, USA
| | | | | | - Adam Gater
- Adelphi Values, Bollington, Cheshire, UK
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34
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Brownstein CG, Daguenet E, Guyotat D, Millet GY. Chronic fatigue in myelodysplastic syndromes: Looking beyond anemia. Crit Rev Oncol Hematol 2020; 154:103067. [PMID: 32739782 DOI: 10.1016/j.critrevonc.2020.103067] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2020] [Revised: 07/10/2020] [Accepted: 07/23/2020] [Indexed: 12/11/2022] Open
Abstract
Chronic fatigue is the most common and severe symptom in myelodysplastic syndromes (MDS) and has a strong negative association with health-related quality of life (HRQoL). Despite anemia being the most common objective manifestation of MDS, and the associated link between anemia and fatigue, evidence on treatments which temporarily mitigate anemia is equivocal regarding the effects on fatigue. Furthermore, previous work has found weak associations between anemia and chronic fatigue in MDS. As such, given that improving HRQoL is one of the primary treatment aims in MDS, further work is required to identify other potential contributors to chronic fatigue in these patients. In addition to anemia, MDS is associated with numerous other deviations in physiological homeostasis and has negative psychological consequences with links to chronic fatigue. Accordingly, the present review provides several potential aetiologic agents relevant to chronic fatigue in MDS which can be used to guide future research in this field.
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Affiliation(s)
- Callum G Brownstein
- Univ Lyon, UJM-Saint-Etienne, Inter-University Laboratory of Human Movement Biology, EA 7424, F-42023, Saint-Etienne, France.
| | - Elisabeth Daguenet
- Lucien Neuwirth Cancer Institute, Hematology and Cell Therapy, F-42271 Saint-Priest-en-Jarez, France; Lucien Neuwirth Cancer Institute, Research and Teaching Department, F-42271 Saint-Priest-en-Jarez, France
| | - Denis Guyotat
- Lucien Neuwirth Cancer Institute, Hematology and Cell Therapy, F-42271 Saint-Priest-en-Jarez, France; UMR 5239 Laboratoire de Biologie et Modélisation de la Cellule, Ecole Normale Supérieure, Lyon, France
| | - Guillaume Y Millet
- Univ Lyon, UJM-Saint-Etienne, Inter-University Laboratory of Human Movement Biology, EA 7424, F-42023, Saint-Etienne, France; Institut Universitaire de France (IUF), France
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35
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Mittelman M. Balanced translocations in myelodysplastic syndromes (MDS) – an unrecognised MDS patient subgroup? Br J Haematol 2020; 190:141-142. [DOI: 10.1111/bjh.16641] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2020] [Accepted: 03/12/2020] [Indexed: 12/16/2022]
Affiliation(s)
- Moshe Mittelman
- Department of Hematology Sackler Faculty of Medicine Tel Aviv Sourasky Medical Center Tel Aviv University Tel Aviv Israel
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36
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Golicki D, Jaśkowiak K, Wójcik A, Młyńczak K, Dobrowolska I, Gawrońska A, Basak G, Snarski E, Hołownia-Voloskova M, Jakubczyk M, Niewada M. EQ-5D-Derived Health State Utility Values in Hematologic Malignancies: A Catalog of 796 Utilities Based on a Systematic Review. VALUE IN HEALTH : THE JOURNAL OF THE INTERNATIONAL SOCIETY FOR PHARMACOECONOMICS AND OUTCOMES RESEARCH 2020; 23:953-968. [PMID: 32762998 DOI: 10.1016/j.jval.2020.04.1825] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/27/2019] [Revised: 03/14/2020] [Accepted: 04/06/2020] [Indexed: 06/11/2023]
Abstract
OBJECTIVES We performed a systematic review of health state utility values (HSUVs) obtained using the EQ-5D questionnaire for patients with hematologic malignancies. METHODS The following databases were searched up to September 2018: MEDLINE, EMBASE, The Cochrane Library, and the EQ-5D publications database on the EuroQol website. Additional references were extracted from reviewed articles. Only studies presenting EQ-Index results were incorporated. In view of the heterogeneity across the included publications, we limited ourselves to a narrative synthesis of original HSUVs found. RESULTS Fifty-nine studies (described in 63 articles) met the inclusion criteria. Data from 21 635 respondents provided 796 HSUV estimates for hematologic malignancy patients. EQ-Index scores ranged from -0.025 to 0.980. The most represented area was multiple myeloma (4 studies, 11 112 patients, and 249 HSUVs). In clinical areas such as chronic myeloid leukemia, acute myeloid leukemia, chronic lymphocytic leukemia, non-Hodgkin lymphoma, and mantle cell lymphoma, we described over 50 health utilities in each. In contrast, we identified only 13 HSUVs (based on 4 studies and the data of 166 patients) for Hodgkin lymphoma. Areas without EQ-5D-based health utilities comprised: polycythemia vera, primary myelofibrosis, essential thrombocythemia, mastocytosis, myeloid sarcoma, chronic myelomonocytic, eosinophilic leukemia, and neutrophilic leukemia. CONCLUSIONS There is a wide range of HSUVs available for hematologic cancer patients with different indications. The review provides a catalog of utility values for use in cost-effectiveness models for hematologic malignancies.
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Affiliation(s)
- Dominik Golicki
- Department of Experimental and Clinical Pharmacology, Medical University of Warsaw, Poland; HealthQuest Spółka z ograniczoną odpowiedzialnością Sp. k., Warsaw, Poland.
| | | | - Alicja Wójcik
- HealthQuest Spółka z ograniczoną odpowiedzialnością Sp. k., Warsaw, Poland
| | - Katarzyna Młyńczak
- Department of Experimental and Clinical Pharmacology, Medical University of Warsaw, Poland; HealthQuest Spółka z ograniczoną odpowiedzialnością Sp. k., Warsaw, Poland
| | - Iwona Dobrowolska
- HealthQuest Spółka z ograniczoną odpowiedzialnością Sp. k., Warsaw, Poland
| | | | - Grzegorz Basak
- Department of Hematology, Oncology and Internal Medicine, Medical University of Warsaw, Warsaw, Poland
| | - Emilian Snarski
- Department of Hematology, Oncology and Internal Medicine, Medical University of Warsaw, Warsaw, Poland
| | - Malwina Hołownia-Voloskova
- Department of Experimental and Clinical Pharmacology, Medical University of Warsaw, Poland; Scientific and Practical Center for Clinical Research and Health Technology Assessment, Moscow Department of Healthcare, Moscow, Russia
| | - Michał Jakubczyk
- HealthQuest Spółka z ograniczoną odpowiedzialnością Sp. k., Warsaw, Poland; Decision Analysis and Support Unit, SGH Warsaw School of Economics, Warsaw, Poland
| | - Maciej Niewada
- Department of Experimental and Clinical Pharmacology, Medical University of Warsaw, Poland; HealthQuest Spółka z ograniczoną odpowiedzialnością Sp. k., Warsaw, Poland
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Feld J, Belasen A, Navada SC. Myelodysplastic syndromes: a review of therapeutic progress over the past 10 years. Expert Rev Anticancer Ther 2020; 20:465-482. [PMID: 32479130 DOI: 10.1080/14737140.2020.1770088] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
INTRODUCTION Myelodysplastic syndromes (MDS) represent a range of bone marrow disorders, with patients affected by cytopenias and risk of progression to AML. There are limited therapeutic options available for patients, including hypomethylating agents (azacitidine/decitabine), growth factor support, lenalidomide, and allogeneic stem cell transplant. AREAS COVERED This review provides an overview of the progress made over the past decade for emerging therapies for lower- and higher-risk MDS (MDS-HR). We also cover advances in prognostication, supportive care, and use of allogeneic SCT in MDS. EXPERT OPINION While there have been no FDA-approved therapies for MDS in the past decade, we anticipate the approval of luspatercept based on results from the MEDALIST trial for patients with lower-risk MDS (MDS-LR) and ringed sideroblasts who have failed or are ineligible for erythropoiesis stimulating agents (ESAs). With growing knowledge of the biologic and molecular mechanisms underlying MDS, it is anticipated that new therapies will be approved in the coming years.
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Affiliation(s)
- Jonathan Feld
- Tisch Cancer Institute, Division of Hematology/Oncology, Icahn School of Medicine , New York, USA
| | - Abigail Belasen
- Department of Medicine, Icahn School of Medicine , New York, USA
| | - Shyamala C Navada
- Tisch Cancer Institute, Division of Hematology/Oncology, Icahn School of Medicine , New York, USA
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38
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Rochau U, Stojkov I, Conrads-Frank A, Borba HH, Koinig KA, Arvandi M, van Marrewijk C, Garelius H, Germing U, Symeonidis A, Sanz GF, Fenaux P, de Witte T, Efficace F, Siebert U, Stauder R. Development of a core outcome set for myelodysplastic syndromes - a Delphi study from the EUMDS Registry Group. Br J Haematol 2020; 191:405-417. [PMID: 32410281 PMCID: PMC8221029 DOI: 10.1111/bjh.16654] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2019] [Accepted: 03/18/2020] [Indexed: 12/11/2022]
Abstract
Treatment options for myelodysplastic syndromes (MDS) vary widely, depending on the natural disease course and patient‐related factors. Comparison of treatment effectiveness is challenging as different endpoints have been included in clinical trials and outcome reporting. Our goal was to develop the first MDS core outcome set (MDS‐COS) defining a minimum set of outcomes that should be reported in future clinical studies. We performed a comprehensive systematic literature review among MDS studies to extract patient‐ and/or clinically relevant outcomes. Clinical experts from the European LeukemiaNet MDS (EUMDS) identified 26 potential MDS core outcomes and participated in a three‐round Delphi survey. After the first survey (56 experts), 15 outcomes met the inclusion criteria and one additional outcome was included. The second round (38 experts) resulted in six included outcomes. In the third round, a final check on plausibility and practicality of the six included outcomes and their definitions was performed. The final MDS‐COS includes: health‐related quality of life, treatment‐related mortality, overall survival, performance status, safety, and haematological improvement. This newly developed MDS‐COS represents the first minimum set of outcomes aiming to enhance comparability across future MDS studies and facilitate a better understanding of treatment effectiveness.
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Affiliation(s)
- Ursula Rochau
- Department of Public Health, Health Services Research and Health Technology Assessment, Institute of Public Health, Medical Decision Making and Health Technology Assessment, UMIT - University for Health Sciences, Medical Informatics and Technology, Hall i.T., Austria
| | - Igor Stojkov
- Department of Public Health, Health Services Research and Health Technology Assessment, Institute of Public Health, Medical Decision Making and Health Technology Assessment, UMIT - University for Health Sciences, Medical Informatics and Technology, Hall i.T., Austria
| | - Annette Conrads-Frank
- Department of Public Health, Health Services Research and Health Technology Assessment, Institute of Public Health, Medical Decision Making and Health Technology Assessment, UMIT - University for Health Sciences, Medical Informatics and Technology, Hall i.T., Austria
| | - Helena H Borba
- Department of Pharmacy, Pharmaceutical Sciences Postgraduate Research Program, Federal University of Paraná, Curitiba, Brazil
| | - Karin A Koinig
- Department of Internal Medicine V (Hematology and Oncology), Innsbruck Medical University, Innsbruck, Austria
| | - Marjan Arvandi
- Department of Public Health, Health Services Research and Health Technology Assessment, Institute of Public Health, Medical Decision Making and Health Technology Assessment, UMIT - University for Health Sciences, Medical Informatics and Technology, Hall i.T., Austria
| | - Corine van Marrewijk
- Department of Hematology, Radboud university medical center, Nijmegen, the Netherlands
| | - Hege Garelius
- Department of Medicine, Section of Hematology and Coagulation, Sahlgrenska University Hospital, Göteborg, Sweden
| | - Ulrich Germing
- Department of Hematology, Oncology and Clinical Immunology, Universitätsklinik Düsseldorf, Düsseldorf, Germany
| | - Argiris Symeonidis
- Department of Internal Medicine, Division of Hematology, University of Patras Medical School, Patras, Greece
| | - Guillermo F Sanz
- Department of Hematology, Hospital Universitario y Politécnico La Fe, Valencia, Spain.,Centro de Investigación Biomédica en Red de Cáncer, CIBERONC, Instituto de Salud Carlos III, Madrid, Spain
| | - Pierre Fenaux
- Service d'Hématologie, Hôpital Saint-Louis, Assistance Publique des Hôpitaux de Paris (AP-HP) and Université Paris 7, Paris, France
| | - Theo de Witte
- Department of Tumor Immunology - Nijmegen Center for Molecular Life Sciences, Radboud university medical center, Nijmegen, the Netherlands
| | - Fabio Efficace
- Health Outcomes Research Unit, Gruppo Italiano Malattie Ematologiche dell'Adulto (GIMEMA), Rome, Italy
| | - Uwe Siebert
- Department of Public Health, Health Services Research and Health Technology Assessment, Institute of Public Health, Medical Decision Making and Health Technology Assessment, UMIT - University for Health Sciences, Medical Informatics and Technology, Hall i.T., Austria.,Center for Health Decision Science, Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, MA, USA.,Institute for Technology Assessment and Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Reinhard Stauder
- Department of Internal Medicine V (Hematology and Oncology), Innsbruck Medical University, Innsbruck, Austria
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Du MY, Xu M, Deng J, Liu L, Guo T, Xia LH, Hu Y, Mei H. Evaluation of different scoring systems and gene mutations for the prognosis of myelodysplastic syndrome (MDS) in Chinese population. J Cancer 2020; 11:508-519. [PMID: 31897246 PMCID: PMC6930433 DOI: 10.7150/jca.30363] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2018] [Accepted: 09/14/2019] [Indexed: 11/25/2022] Open
Abstract
MDS is a heterogeneous disease with diverse clinical manifestations, and an effective prognostic evaluation tool for MDS patients is needed. To achieve more accurate prognosis assessment for Chinese MDS patients, here we examined several scoring systems and explored the implications of gene mutations. The prognostic conditions were stratified against three different score systems (International Prognostic Scoring System (IPSS), WHO Prognostic Scoring System (WPSS), and Revised International Prognostic Scoring System (IPSS-R)) were retrospectively applied to 110 de novo MDS patients in study cohort in our hospital and the prognostic conditions were stratified respectively. IPSS-R out-performed the others, since it had less overlaps in survival curve, especially in the relatively low-risk group. Furthermore, genetic mutations were identified in 84 out of 110 patients and their association with overall survival (OS) were determined. Among them, sixty-three percent patients had at least one-point mutation, including thirty-five patients with normal karyotypes. The presence of TP53 mutations, but not TET2, DNMT3A or ASXL1 mutations was significantly correlated with shorter OS. A new model incorporating IPSS-R and TP53 mutations into survival analysis was proposed, and the prognostic value of this model was validated to be predominant in a 190-primary MDS patient independent cohort. Our data suggested that IPSS-R was more suitable for Chinese population. Attentions should be paid to the unfavourable mutations that might exert impact on the survival, especially in patients with relatively low risk.
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Affiliation(s)
- Meng-Yi Du
- Institute of Hematology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China
| | - Min Xu
- Institute of Hematology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China
| | - Jun Deng
- Institute of Hematology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China
| | - Lin Liu
- Institute of Hematology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China
| | - Tao Guo
- Institute of Hematology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China
| | - Ling-Hui Xia
- Institute of Hematology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China
| | - Yu Hu
- Institute of Hematology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China.,Collaborative Innovation Center of Hematology, Huazhong University of Science and Technology, Wuhan, Hubei 430022, PR China
| | - Heng Mei
- Institute of Hematology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China.,Collaborative Innovation Center of Hematology, Huazhong University of Science and Technology, Wuhan, Hubei 430022, PR China
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40
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Buckstein RJ. Integrating patient-centered factors in the risk assessment of MDS. HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2019; 2019:373-380. [PMID: 31808887 PMCID: PMC6913474 DOI: 10.1182/hematology.2019000041] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/13/2023]
Abstract
Myelodysplastic syndromes are clonal myeloid neoplasms that primarily present in older adults. Although leukemia develops in approximately 25% to 30% of individuals, the significantly shortened survival in this population is attributed more commonly to nonleukemic causes. The current prognostic scoring systems for leukemia and overall survival based on disease characteristics are becoming increasingly sophisticated and accurate with the incorporation of molecular data. The addition of patient-related factors such as comorbidity, disability, frailty, and fatigue to these new models may improve their predictive power for overall survival, treatment toxicity, and health care costs. To improve the generalizability of clinical trial results to the real world, geriatric assessment testing should become a standard of care in MDS clinical trials.
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Affiliation(s)
- Rena J Buckstein
- Odette Cancer Center, Sunnybrook Health Sciences Center, Toronto, ON, Canada
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41
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Germing U, Oliva EN, Hiwase D, Almeida A. Treatment of Anemia in Transfusion-Dependent and Non-Transfusion-Dependent Lower-Risk MDS: Current and Emerging Strategies. Hemasphere 2019; 3:e314. [PMID: 31976486 PMCID: PMC6924547 DOI: 10.1097/hs9.0000000000000314] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2019] [Revised: 10/10/2019] [Accepted: 10/21/2019] [Indexed: 12/17/2022] Open
Abstract
Myelodysplastic syndromes (MDS) are a heterogeneous group of bone marrow disorders with a highly diverse clinical course. For lower-risk MDS patients, therapeutic objectives aim to correct chronic anemia and improve/maintain health-related quality of life (HRQoL). However, disease burden is often insufficiently recognized, and although some patients do not respond/lose response to standard treatment, many are treated late. This is the case for non-transfusion-dependent patients with symptomatic anemia, in whom delayed treatment initiation may lead to unnecessary morbidity. Current active treatment options for lower-risk MDS are limited. Standard care for lower-risk 5q deletion [del(5q)] MDS patients with anemia remains supportive, consisting of red blood cell (RBC) transfusions, iron chelation therapy, and treatment with erythropoiesis-stimulating agents (ESAs) in the case of low serum erythropoietin levels. Response rates to ESAs range from 15% to 63%, whereas 56% to 67% of patients with del(5q) MDS achieve RBC transfusion independence with lenalidomide. Treatment options for patients’ refractory to ESAs and/or lenalidomide, however, are limited. Frequent transfusions are associated with profound clinical, HRQoL, and economic consequences for transfusion-dependent patients. This review focuses on the multiple unmet clinical needs that exist in the treatment of anemia associated with lower-risk MDS and the current and future treatment options that may improve disease management and patient outcomes.
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Affiliation(s)
- Ulrich Germing
- Department of Hematology, Oncology and Clinical Immunology, Universitätsklinikum Düsseldorf, Düsseldorf, Germany
| | - Ester N Oliva
- Department of Hematology, Grande Ospedale Metropolitano Bianchi Melacrino Morelli, Reggio Calabria, Italy
| | - Devendra Hiwase
- Hematology, Royal Adelaide Hospital, Adelaide, SA, Australia
| | - Antonio Almeida
- Clinical Hematology, Hospital da Luz Lisboa, Lisbon, Portugal
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42
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Leitch HA, Gattermann N. Hematologic improvement with iron chelation therapy in myelodysplastic syndromes: Clinical data, potential mechanisms, and outstanding questions. Crit Rev Oncol Hematol 2019; 141:54-72. [DOI: 10.1016/j.critrevonc.2019.06.002] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2018] [Revised: 11/25/2018] [Accepted: 06/03/2019] [Indexed: 12/25/2022] Open
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de Swart L, Crouch S, Hoeks M, Smith A, Langemeijer S, Fenaux P, Symeonidis A, Cermâk J, Hellström-Lindberg E, Stauder R, Sanz G, Mittelman M, Holm MS, Malcovati L, Mądry K, Germing U, Tatic A, Savic A, Almeida AM, Gredelj-Simec N, Guerci-Bresler A, Beyne-Rauzy O, Culligan D, Kotsianidis I, Itzykson R, van Marrewijk C, Blijlevens N, Bowen D, de Witte T. Impact of red blood cell transfusion dose density on progression-free survival in patients with lower-risk myelodysplastic syndromes. Haematologica 2019; 105:632-639. [PMID: 31171638 PMCID: PMC7049377 DOI: 10.3324/haematol.2018.212217] [Citation(s) in RCA: 33] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2018] [Accepted: 06/05/2019] [Indexed: 01/01/2023] Open
Abstract
Progression-free survival (PFS) of patients with lower-risk myelodysplastic syndromes (MDS) treated with red blood cell transfusions is usually reduced, but it is unclear whether transfusion dose density is an independent prognostic factor. The European MDS Registry collects prospective data at 6-monthly intervals from newly diagnosed lower-risk myelodysplastic syndromes patients in 16 European countries and Israel. Data on the transfusion dose density - the cumulative dose received at the end of each interval divided by the time since the beginning of the interval in which the first transfusion was received - were analyzed using proportional hazards regression with time-varying co-variates, with death and progression to higher-risk MDS/acute myeloid leukemia as events. Of the 1,267 patients included in the analyses, 317 died without progression; in 162 patients the disease had progressed. PFS was significantly associated with age, EQ-5D index, baseline World Health Organization classification, bone marrow blast count, cytogenetic risk category, number of cytopenias, and country. Transfusion dose density was inversely associated with PFS (P<1×10−4): dose density had an increasing effect on hazard until a dose density of 3 units/16 weeks. The transfusion dose density effect continued to increase beyond 8 units/16 weeks after correction for the impact of treatment with erythropoiesis-stimulating agents, lenalidomide and/or iron chelators. In conclusion, the negative effect of transfusion treatment on PFS already occurs at transfusion densities below 3 units/16 weeks. This indicates that transfusion dependency, even at relatively low dose densities, may be considered as an indicator of inferior PFS. This trial was registered at www.clinicaltrials.gov as #NCT00600860.
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Affiliation(s)
- Louise de Swart
- Department of Hematology, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Simon Crouch
- Epidemiology and Cancer Statistics Group, Department of Health Sciences, University of York, York, UK
| | - Marlijn Hoeks
- Department of Hematology, Radboud University Medical Center, Nijmegen, the Netherlands.,Center for Clinical Transfusion Research, Sanquin Research, Leiden, the Netherlands
| | - Alex Smith
- Epidemiology and Cancer Statistics Group, Department of Health Sciences, University of York, York, UK
| | - Saskia Langemeijer
- Department of Hematology, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Pierre Fenaux
- Service d'Hématologie, Hôpital Saint-Louis, Assistance Publique des Hôpitaux de Paris and Université Paris 7, Paris, France
| | - Argiris Symeonidis
- Department of Medicine, Division of Hematology, University of Patras Medical School, Patras, Greece
| | - Jaroslav Cermâk
- Department of Clinical Hematology, Institute of Hematology & Blood Transfusion, Praha, Czech Republic
| | - Eva Hellström-Lindberg
- Department of Medicine, Division of Hematology, Karolinska Institutet, Stockholm, Sweden
| | - Reinhard Stauder
- Department of Internal Medicine V (Hematology and Oncology), Innsbruck Medical University, Innsbruck, Austria
| | - Guillermo Sanz
- Department of Hematology, Hospital Universitario y Politécnico La Fe, Valencia, Spain
| | - Moshe Mittelman
- Department of Medicine A, Tel Aviv Sourasky (Ichilov) Medical Center and Sackler Medical Faculty, Tel Aviv University, Tel Aviv, Israel
| | - Mette Skov Holm
- Department of Hematology, Aarhus University Hospital, Aarhus, Denmark
| | - Luca Malcovati
- Department of Hematology Oncology, Fondazione IRCCS Policlinico San Matteo, University of Pavia, Pavia, Italy
| | - Krzysztof Mądry
- Department of Hematology, Oncology and Internal Medicine, Warsaw Medical University, Warsaw, Poland
| | - Ulrich Germing
- Department of Hematology, Oncology and Clinical Immunology, Universitatsklinik Düsseldorf, Düsseldorf, Germany
| | - Aurelia Tatic
- Center of Hematology and Bone Marrow Transplantation, Fundeni Clinical Institute, Bucharest, Romania
| | - Aleksandar Savic
- Clinic of Hematology - Clinical Center of Vojvodina, Faculty of Medicine, University of Novi Sad, Novi Sad, Serbia
| | | | - Njetocka Gredelj-Simec
- Department of Internal Medicine, Division of Hematology, Merkur University Hospital, Zagreb, Croatia
| | - Agnes Guerci-Bresler
- Service d'Hématologie, Centre Hospitalier Universitaire (CHU) Brabois Vandoeuvre, Nancy, France
| | - Odile Beyne-Rauzy
- Service de Médecine Interne, IUCT-Oncopole, CHU Toulouse, Toulouse, France
| | - Dominic Culligan
- Department of Haematology, Aberdeen Royal Infirmary, Aberdeen, UK
| | - Ioannis Kotsianidis
- Department of Hematology, Democritus University of Thrace Medical School, University Hospital of Alexandroupolis, Alexandroupolis, Greece
| | - Raphael Itzykson
- Service d'Hématologie, Hôpital Saint-Louis, Assistance Publique des Hôpitaux de Paris and Université Paris 7, Paris, France
| | - Corine van Marrewijk
- Department of Hematology, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Nicole Blijlevens
- Department of Hematology, Radboud University Medical Center, Nijmegen, the Netherlands
| | - David Bowen
- St. James's Institute of Oncology, Leeds Teaching Hospitals, Leeds, UK
| | - Theo de Witte
- Department of Tumor Immunology - Nijmegen Center for Molecular Life Sciences, Radboud University Medical Center, Nijmegen, the Netherlands
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44
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Early platelet count kinetics has prognostic value in lower-risk myelodysplastic syndromes. Blood Adv 2019; 2:2079-2089. [PMID: 30126931 DOI: 10.1182/bloodadvances.2018020495] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2018] [Accepted: 07/06/2018] [Indexed: 01/03/2023] Open
Abstract
Prognosis of lower-risk (International Prognostic Scoring System [IPSS] low/intermediate-1) myelodysplastic syndrome (MDS) is heterogeneous and relies on steady-state assessment of cytopenias. We analyzed relative drops in neutrophil and platelet counts during the first 6 months of follow-up of lower-risk MDS patients. We performed a landmark analysis of overall survival (OS) of lower-risk MDS patients prospectively included in the European LeukaemiaNet MDS registry having a visit at 6 ± 1 month from inclusion to assess the prognostic relevance of relative drops in neutrophils and platelets, defined as (count at landmark - count at inclusion)/count at inclusion. Of 2102 patients, 807 were eligible for the stringent 6-month landmark analysis. Median age was 73 years. Revised IPSS was very low, low, and intermediate/higher in 26%, 43%, and 31% of patients, respectively. A relative drop in platelets >25% at landmark predicted shorter OS (5-year OS, 21.9% vs 48.6% with platelet drop ≤25%, P < 10-4), regardless of baseline IPSS-revised or absolute platelet counts. Relative neutrophil drop >25% had no significant impact on OS. We built a classifier based on red blood cell transfusion dependence (RBC-TD) and relative platelet drop >25% at landmark. Patients with none (62%), either (27%), or both criteria (11%) had 5-year OS of 53.3%, 32.7%, and 9.0%, respectively (P < 10-4). This classifier was validated in an independent cohort of 335 patients. Combining relative platelet drop >25% and RBC-TD at 6 months from diagnosis provides an inexpensive and noninvasive way to predict outcome in lower-risk MDS. This study was registered at www.clinicaltrials.gov as #NCT00600860.
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Bakhtiari T, Ghaderi A, Safaee Nodehi SR, Aghazadeh Z, Tofighi Zavareh F, Jafarnezhad‐Ansariha F, Barati A, Mirshafiey A. An in vitro assessment for evaluating the efficiency of β‐
d
‐mannuronic acid (M2000) in myelodysplastic syndrome. J Cell Physiol 2018; 234:12971-12977. [DOI: 10.1002/jcp.27966] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2018] [Accepted: 11/19/2018] [Indexed: 01/02/2023]
Affiliation(s)
- Tahereh Bakhtiari
- Department of Immunology School of Public Health, Tehran University of Medical Sciences Tehran Iran
| | - Afshin Ghaderi
- Department of Internal Medicine Hematology and Medical Oncology Ward, Cancer Research Centre. Cancer Institute, Imam Khomeini Hospital Complex, Tehran University of Medical Science Tehran Iran
| | - Sayyed Reza Safaee Nodehi
- Department of Internal Medicine Hematology and Medical Oncology Ward, Cancer Research Centre. Cancer Institute, Imam Khomeini Hospital Complex, Tehran University of Medical Science Tehran Iran
| | - Zahra Aghazadeh
- Department of Immunology School of Public Health, Tehran University of Medical Sciences Tehran Iran
| | - Farzaneh Tofighi Zavareh
- Department of Immunology School of Public Health, Tehran University of Medical Sciences Tehran Iran
- Research Centre for Immunodeficiencies, Children's Medical Centre, Tehran University of Medical Sciences Tehran Iran
| | | | - Anis Barati
- Department of Biology College of Sciences, Shiraz University Shiraz Iran
| | - Abbas Mirshafiey
- Department of Immunology School of Public Health, Tehran University of Medical Sciences Tehran Iran
- Research Centre for Immunodeficiencies, Children's Medical Centre, Tehran University of Medical Sciences Tehran Iran
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46
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Aapro M, Beguin Y, Bokemeyer C, Dicato M, Gascón P, Glaspy J, Hofmann A, Link H, Littlewood T, Ludwig H, Österborg A, Pronzato P, Santini V, Schrijvers D, Stauder R, Jordan K, Herrstedt J. Management of anaemia and iron deficiency in patients with cancer: ESMO Clinical Practice Guidelines. Ann Oncol 2018; 29:iv96-iv110. [PMID: 29471514 DOI: 10.1093/annonc/mdx758] [Citation(s) in RCA: 121] [Impact Index Per Article: 20.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/08/2023] Open
Affiliation(s)
- M Aapro
- Genolier Cancer Centre, Clinique de Genolier, Genolier, Switzerland
| | - Y Beguin
- University of Liège, Liège
- CHU of Liège, Liège, Belgium
| | - C Bokemeyer
- Department of Oncology, Hematology and BMT with Section Pneumology, University of Hamburg, Hamburg, Germany
| | - M Dicato
- Hématologie-Oncologie, Centre Hospitalier de Luxembourg, Luxembourg, Luxembourg
| | - P Gascón
- Department of Haematology-Oncology, Hospital Clínic de Barcelona, University of Barcelona, Barcelona, Spain
| | - J Glaspy
- Division of Hematology and Oncology, Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, USA
| | - A Hofmann
- Medical Society for Blood Management, Laxenburg, Austria
| | - H Link
- Klinik für Innere Medizin I, Westpfalz-Klinikum, Kaiserslautern, Germany
| | - T Littlewood
- Department of Haematology, John Radcliffe Hospital, Oxford, UK
| | - H Ludwig
- Wilhelminen Cancer Research Institute, Wilhelminenspital, Vienna, Austria
| | - A Österborg
- Karolinska Institute and Karolinska Hospital, Stockholm, Sweden
| | - P Pronzato
- Medica Oncology, IRCCS Asiana Pedaliter Universitaria San Martino - IST, Institutor Nazionale per la Ricercars sol Chancre, Genova
| | - V Santini
- Department of Experimental and Clinical Medicine, Haematology, University of Florence, Florence, Italy
| | - D Schrijvers
- Department of Medical Oncology, Ziekenhuisnetwerk Antwerpen, Antwerp, Belgium
| | - R Stauder
- Department of Internal Medicine V (Haematology and Oncology), Innsbruck Medical University, Innsbruck, Austria
| | - K Jordan
- Department of Medicine V, University of Heidelberg, Heidelberg, Germany
| | - J Herrstedt
- Department of Oncology, Zealand University Hospital Roskilde, Roskilde
- University of Copenhagen, Copenhagen, Denmark
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47
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Rydén J, Edgren G, Karimi M, Walldin G, Tobiasson M, Wikman A, Hellström-Lindberg E, Höglund P. Male sex and the pattern of recurrent myeloid mutations are strong independent predictors of blood transfusion intensity in patients with myelodysplastic syndromes. Leukemia 2018; 33:522-527. [PMID: 30267009 DOI: 10.1038/s41375-018-0256-0] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2018] [Revised: 07/23/2018] [Accepted: 08/07/2018] [Indexed: 01/29/2023]
Affiliation(s)
- Jenny Rydén
- Center for Hematology and Regenerative Medicine, Department of Medicine, Karolinska Institutet, Stockholm, Sweden.,Hematology Center, Karolinska University Hospital, Stockholm, Sweden
| | - Gustaf Edgren
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden.,Department of Cardiology, Södersjukhuset, Stockholm, Sweden
| | - Mohsen Karimi
- Center for Hematology and Regenerative Medicine, Department of Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Gunilla Walldin
- Center for Hematology and Regenerative Medicine, Department of Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Magnus Tobiasson
- Center for Hematology and Regenerative Medicine, Department of Medicine, Karolinska Institutet, Stockholm, Sweden.,Hematology Center, Karolinska University Hospital, Stockholm, Sweden
| | - Agneta Wikman
- Department of Clinical Immunology and Transfusion Medicine, Karolinska University Hospital, Stockholm, Sweden.,Department of Laboratory Medicine, Karolinska University Hospital, Stockholm, Sweden
| | - Eva Hellström-Lindberg
- Center for Hematology and Regenerative Medicine, Department of Medicine, Karolinska Institutet, Stockholm, Sweden.,Hematology Center, Karolinska University Hospital, Stockholm, Sweden
| | - Petter Höglund
- Center for Hematology and Regenerative Medicine, Department of Medicine, Karolinska Institutet, Stockholm, Sweden. .,Department of Clinical Immunology and Transfusion Medicine, Karolinska University Hospital, Stockholm, Sweden.
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48
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Basood M, Oster HS, Mittelman M. Thrombocytopenia in Patients with Myelodysplastic Syndromes: Still an Unsolved Problem. Mediterr J Hematol Infect Dis 2018; 10:e2018046. [PMID: 30002802 PMCID: PMC6039085 DOI: 10.4084/mjhid.2018.046] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2018] [Accepted: 06/24/2018] [Indexed: 12/12/2022] Open
Abstract
The myelodysplastic syndromes (MDS) are a group of clonal bone marrow (BM) stem cell disorders, characterized by ineffective hematopoiesis, peripheral cytopenias, and hematologic cellular dysfunction, as well as potential transformation to acute leukemia. Thrombocytopenia is common in MDS and is associated with bleeding complications, occasionally life-threatening. Low platelet count (PLT), as well declining PLT also serves as a prognostic marker. Understanding thrombopoiesis led to the cloning of thrombopoietin, resulting in the development of platelet stimulating agents, thrombomimetics, romiplostim and eltrombopag. Both agents have been shown to increase PLT, decrease the need for platelet transfusions and reduce the number of bleeding episodes, with a reasonable tolerance. They are already approved for immune thrombocytopenia and thrombocytopenia related to liver disease. Romiplostim and eltrombopag have proven efficacy in lower- and higher-risk MDS with thrombocytopenia, as monotherapy, as well as a part of a combination, either with lenalidomide, and mainly combined with hypomethylating agents. However, safety concerns have been raised: while several trials have been completed with no evidence of disease progression, others have been early terminated due to an increased number of BM blasts and possible leukemic transformation in treated-patients. The jury is still out regarding this safety concern, although recent publications are more encouraging.
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Affiliation(s)
- May Basood
- Department of Medicine A, Tel Aviv Sourasky Medical Center, Sackler School of Medicine, Tel Aviv University, Tel Aviv, ISRAEL
| | - Howard S Oster
- Department of Medicine A, Tel Aviv Sourasky Medical Center, Sackler School of Medicine, Tel Aviv University, Tel Aviv, ISRAEL
| | - Moshe Mittelman
- Department of Medicine A, Tel Aviv Sourasky Medical Center, Sackler School of Medicine, Tel Aviv University, Tel Aviv, ISRAEL
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49
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Moreno Berggren D, Folkvaljon Y, Engvall M, Sundberg J, Lambe M, Antunovic P, Garelius H, Lorenz F, Nilsson L, Rasmussen B, Lehmann S, Hellström-Lindberg E, Jädersten M, Ejerblad E. Prognostic scoring systems for myelodysplastic syndromes (MDS) in a population-based setting: a report from the Swedish MDS register. Br J Haematol 2018; 181:614-627. [PMID: 29707769 DOI: 10.1111/bjh.15243] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2017] [Accepted: 02/16/2018] [Indexed: 01/22/2023]
Abstract
The myelodysplastic syndromes (MDS) have highly variable outcomes and prognostic scoring systems are important tools for risk assessment and to guide therapeutic decisions. However, few population-based studies have compared the value of the different scoring systems. With data from the nationwide Swedish population-based MDS register we validated the International Prognostic Scoring System (IPSS), revised IPSS (IPSS-R) and the World Health Organization (WHO) Classification-based Prognostic Scoring System (WPSS). We also present population-based data on incidence, clinical characteristics including detailed cytogenetics and outcome from the register. The study encompassed 1329 patients reported to the register between 2009 and 2013, 14% of these had therapy-related MDS (t-MDS). Based on the MDS register, the yearly crude incidence of MDS in Sweden was 2·9 per 100 000 inhabitants. IPSS-R had a significantly better prognostic power than IPSS (P < 0·001). There was a trend for better prognostic power of IPSS-R compared to WPSS (P = 0·05) and for WPSS compared to IPSS (P = 0·07). IPSS-R was superior to both IPSS and WPSS for patients aged ≤70 years. Patients with t-MDS had a worse outcome compared to de novo MDS (d-MDS), however, the validity of the prognostic scoring systems was comparable for d-MDS and t-MDS. In conclusion, population-based studies are important to validate prognostic scores in a 'real-world' setting. In our nationwide cohort, the IPSS-R showed the best predictive power.
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Affiliation(s)
- Daniel Moreno Berggren
- Department of Medical Science, Section of Haematology, Uppsala University, Uppsala, Sweden
| | - Yasin Folkvaljon
- Department of Surgical Sciences, Uppsala University Hospital, Uppsala, Sweden
| | - Marie Engvall
- Department of Immunology, Genetics and Pathology, Uppsala University, Uppsala, Sweden
| | - Johan Sundberg
- Department of Medical Science, Section of Haematology, Uppsala University, Uppsala, Sweden
| | - Mats Lambe
- Department of Surgical Sciences, Uppsala University Hospital, Uppsala, Sweden.,Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
| | - Petar Antunovic
- Department of Haematology, Linköping University Hospital, Linköping, Sweden
| | - Hege Garelius
- Section for Haematology and Coagulation, Department of Medicine, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Fryderyk Lorenz
- Department of Medical Biosciences, Umeå University, Umeå, Sweden
| | - Lars Nilsson
- Department of Haematology, Oncology and Radiation Physics, Skåne University Hospital, Lund, Sweden
| | - Bengt Rasmussen
- School of Medical Sciences, Örebro University Hospital, Örebro, Sweden
| | - Sören Lehmann
- Department of Medical Science, Section of Haematology, Uppsala University, Uppsala, Sweden
| | - Eva Hellström-Lindberg
- Centre for Haematology and Regenerative Medicine, Department of Medicine Huddinge, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | - Martin Jädersten
- Centre for Haematology and Regenerative Medicine, Department of Medicine Huddinge, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | - Elisabeth Ejerblad
- Department of Medical Science, Section of Haematology, Uppsala University, Uppsala, Sweden
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50
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Management of anemia in low-risk myelodysplastic syndromes treated with erythropoiesis-stimulating agents newer and older agents. Med Oncol 2018; 35:76. [DOI: 10.1007/s12032-018-1135-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2018] [Accepted: 04/12/2018] [Indexed: 10/17/2022]
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