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Schulz F, Hauch U, Ketzler-Henkel S, von der Heyde E, Koenigsmann M, Lauseker M, Schulte N, Germing U. Iron Chelation in Patients with Myelodysplastic Syndromes and Myeloproliferative Neoplasms-Real-World Data from the German Noninterventional Study EXCALIBUR. J Clin Med 2023; 12:6569. [PMID: 37892707 PMCID: PMC10607194 DOI: 10.3390/jcm12206569] [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] [Revised: 09/29/2023] [Accepted: 10/13/2023] [Indexed: 10/29/2023] Open
Abstract
Myelodysplastic syndromes and myeloproliferative neoplasms both represent hematologic diseases associated with bone marrow failure often resulting in anemia. For those patients, transfusion of red blood cell (RBC) units is essential but results in iron overload (IOL) that may affect various organ functions. Therefore, iron chelation therapy plays a major role in anemic patients, not only because it reduces IOL, but also because it may improve hematopoietic function by increasing hemoglobin or diminishing the requirement for RBC transfusions. To assess the utility, efficacy, and safety of the different iron chelation medications approved in Germany, as well as to examine the effect of chelation on hematopoietic insufficiency, a prospective, multicenter, noninterventional study named EXCALIBUR was designed. In total, 502 patients from 106 German hospitals and medical practices were enrolled. A large proportion of patients switched from a deferasirox dispersible tablet to a deferasirox-film-coated tablet, mainly because of more convenient application, which was reflected in the treatment satisfaction questionnaire for medication scores. Iron chelation was effective in lowering serum ferritin levels, with the observed adverse drug reactions being in line with the known safety profile. Hematologic response occurred in a few patients, comparable to other studies that examined hematologic improvement in patients with MDS.
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Affiliation(s)
- Felicitas Schulz
- Department for Hematology, Oncology and Clinical Immunology, University Hospital Duesseldorf, 40225 Düsseldorf, Germany;
| | - Ulrich Hauch
- Practice for Hematology and Oncology, 99084 Erfurt, Germany
| | | | | | | | - Michael Lauseker
- Institut für Medizinische Informationsverarbeitung Biometrie und Epidemiologie (IBE), Fakultät für Medizin, Ludwig-Maximilians Universität München, 81377 Munich, Germany;
| | | | - Ulrich Germing
- Department for Hematology, Oncology and Clinical Immunology, University Hospital Duesseldorf, 40225 Düsseldorf, Germany;
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Management of patients with lower-risk myelodysplastic syndromes. Blood Cancer J 2022; 12:166. [PMID: 36517487 PMCID: PMC9751093 DOI: 10.1038/s41408-022-00765-8] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2022] [Revised: 11/30/2022] [Accepted: 12/01/2022] [Indexed: 12/15/2022] Open
Abstract
Myelodysplastic syndromes (MDS) are a heterogeneous group of hematopoietic stem cell disorders characterized by ineffective hematopoiesis with abnormal blood cell development (dysplasia) leading to cytopenias and an increased risk for progression to acute myeloid leukemia (AML). Patients with MDS can generally be classified as lower- (LR-MDS) or higher-risk (HR-MDS). As treatment goals for patients with LR-MDS and those with HR-MDS differ significantly, appropriate diagnosis, classification, and follow-up are critical for correct disease management. In this review, we focus on the diagnosis, prognosis, and treatment options, as well as the prediction of the disease course and monitoring of treatment response in patients with LR-MDS. We discuss how next-generation sequencing, increasing knowledge on mechanisms of MDS pathogenesis, and novel therapies may change the current treatment landscape in LR-MDS and why structured assessments of responses, toxicities, and patient-reported outcomes should be incorporated into routine clinical practice.
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Prognostic Role of Cell Blood Count in Chronic Myeloid Neoplasm and Acute Myeloid Leukemia and Its Possible Implications in Hematopoietic Stem Cell Transplantation. Diagnostics (Basel) 2022; 12:diagnostics12102493. [PMID: 36292182 PMCID: PMC9600993 DOI: 10.3390/diagnostics12102493] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2022] [Revised: 10/01/2022] [Accepted: 10/12/2022] [Indexed: 11/17/2022] Open
Abstract
Numerous prognostic indexes have been developed in hematological diseases based on patient characteristics and genetic or molecular assessment. However, less attention was paid to more accessible parameters, such as neutrophils, lymphocytes, monocytes, and platelet counts. Although many studies have defined the role of neutrophil-to-lymphocyte or platelet-to-lymphocyte in lymphoid malignancies, few applications exist for myeloid neoplasm or hematopoietic stem cell transplantation procedures. In this review, we synthesized literature data on the prognostic value of count blood cells in myeloid malignancies and hematopoietic stem cell transplantation in the context of classical prognostic factors and clinical outcomes.
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Ferric Carboxymaltose and Erythropoiesis-Stimulating Agent Treatment Reduces the Rate of Blood Transfusion in Refractory Anemia. J Clin Med 2022; 11:jcm11164744. [PMID: 36012983 PMCID: PMC9410338 DOI: 10.3390/jcm11164744] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2022] [Revised: 08/05/2022] [Accepted: 08/11/2022] [Indexed: 11/17/2022] Open
Abstract
Background: Erythropoiesis-stimulating agents (ESAs) are used to treat refractory anemia (RA). Guidelines suggest iron supplementation for unresponsive patients, regardless of iron deficiency. The primary aim of this study was to evaluate the effect of iron supplementation with ferric carboxymaltose (FCM) on the reduction of red blood cell transfusion (RBCT) rate in transfusion-dependent RA patients. Methods: This was a prospective quasi-randomized study, wherein patients were randomly assigned into three groups: (A) ESAs alone, (B) ferric gluconate (FG) and ESAs, and (C) FCM and ESAs. Hemoglobin and ferritin levels, as well as the number of RBCTs at 4 and 28 weeks were compared. Economic evaluation was also performed. Results: A total of 113 RA patients were enrolled. In total, 43 were treated with intravenous FG and ESAs, 38 with FCM and ESAs, and 32 with ESAs alone. At both follow-ups, erythropoietic response was increased in those receiving iron as compared with those with ESAs alone (p = 0.001), regardless of the type of iron. At one month, ferritin levels were higher in the FCM and ESA groups (p = 0.001). RBCTs were lower in both iron groups. The less costly treatment strategy was FCM, followed by FG, and lastly ESAs. Conclusions: Addition of iron to ESAs in RA reduced RBCT requirement and improved hemoglobin values.
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Litvin R, Dasgupta M, Saad Eldin M, Shah M, Fakhran S. Azacitidine-Induced Pneumonitis in a Patient With Acute Myeloid Leukemia and Hyperleukocytosis. Cureus 2022; 14:e26758. [PMID: 35967130 PMCID: PMC9365400 DOI: 10.7759/cureus.26758] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/11/2022] [Indexed: 11/18/2022] Open
Abstract
Chemotherapy-related toxicity is a complex aspect of oncologic care. Pulmonary toxicity, in particular, poses a significant challenge, as it can have diverse presentations and can closely mimic other common complications of cancer treatment, such as infections. Azacitidine is an agent widely employed in high-risk myelodysplastic syndrome and acute myeloid leukemia. We present a case of azacitidine-induced pneumonitis, a rare adverse effect, in a 70-year-old patient with acute myeloid leukemia (AML) and hyperleukocytosis. After discontinuation of the drug and introduction of steroids, the patient had complete resolution of symptoms, highlighting the importance of identifying and addressing chemotherapy-induced pneumonitis.
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Rozema J, Roon EV, Vogelzang L, Kibbelaar R, Veeger N, van de Loosdrecht A, Mels H. Management of infection prophylaxis in Dutch patients with myelodysplastic syndromes, a web-based case vignette questionnaire: the MINDSET study. Eur J Haematol Suppl 2022; 109:381-387. [PMID: 35753043 PMCID: PMC9544536 DOI: 10.1111/ejh.13820] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2022] [Revised: 06/21/2022] [Accepted: 06/22/2022] [Indexed: 11/30/2022]
Abstract
Objectives Infections are a major cause of morbidity and mortality in patients with myelodysplastic syndromes (MDS). The objective of the MINDSET study was to evaluate haematologists' management of infection prevention in MDS patients using a case vignette study and to assess the availability of guidelines. Methods We conducted a web‐based, nationwide survey amongst haematologists in the Netherlands between September and December 2021. The survey included a set of case vignettes. In addition, the availability of protocols was evaluated. Results Sixty responses were obtained (23.6%). These responses were well distributed across hospital types as well as level of experience. No protocols regarding infection prophylaxis specifically for MDS patients were received. In the case vignette of a 75‐year‐old MDS patient, respondents would primarily prescribe infection prophylaxis in case of recurrent infections (96.7%) and neutropenia (75.0% for absolute neutrophil count [ANC] < 0.2 × 109/L and 53.3% for ANC < 0.5 × 109/L), especially in combination with hypomethylating agents (80.0%), lenalidomide (66.7%) or chemotherapy (51.7%). Respondents would predominantly choose antibacterial agents (85.0%), followed by antifungal agents (71.7%). Conclusions This study showed diverse reasons and considerations of haematologists regarding whether to prescribe infection prophylaxis in MDS patients. Given the seriousness of infections in MDS patients, patient‐tailored recommendations might be valuable in clinical decision‐making.
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Affiliation(s)
- Johanne Rozema
- Unit of Pharmacotherapy, Epidemiology and Economics, Department of Pharmacy, University of Groningen, Groningen, the Netherlands.,Department of Clinical Pharmacy & Pharmacology, Medical Centre Leeuwarden, Leeuwarden, the Netherlands
| | - Eric van Roon
- Unit of Pharmacotherapy, Epidemiology and Economics, Department of Pharmacy, University of Groningen, Groningen, the Netherlands.,Department of Clinical Pharmacy & Pharmacology, Medical Centre Leeuwarden, Leeuwarden, the Netherlands
| | - Lars Vogelzang
- Unit of Pharmacotherapy, Epidemiology and Economics, Department of Pharmacy, University of Groningen, Groningen, the Netherlands
| | | | - Nic Veeger
- MCL Academy, Medical Centre Leeuwarden, Leeuwarden, the Netherlands.,Department of Epidemiology, University of Groningen, University Medical Centre Groningen, Groningen, the Netherlands
| | - Arjan van de Loosdrecht
- Department of Haematology, Amsterdam University Medical Centre, Location VUmc, Amsterdam, the Netherlands
| | - Hoogendoorn Mels
- Department of Internal Medicine, Medical Centre Leeuwarden, Leeuwarden, the Netherlands
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Finelli C, Parisi S, Paolini S. Exploring the rationale for red cell transfusion in myelodysplastic syndrome patients: emerging data and future insights. Expert Rev Hematol 2022; 15:411-421. [PMID: 35549626 DOI: 10.1080/17474086.2022.2077721] [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: 01/28/2023]
Abstract
INTRODUCTION Anemia is often present in mostly elderly patients with myelodysplastic syndromes (MDS), and is associated with a poorer outcome. Although Red blood cell (RBC) transfusions are the most immediate treatment, waiting for the response to disease-specific therapy, or in case of non-response, the choice of the optimal transfusion regimen is still controversial. AREAS COVERED The main objectives of RBC transfusion are the control of anemia-related symptoms and complications and the improvement of functional status and of health-related quality of life (HRQoL). However, RBC transfusions are associated with several negative clinical consequences, mainly adverse transfusion reactions and iron overload, which can be counteracted by iron chelation therapy. Recent few pilot prospective trials have shown a benefit, in terms of HRQoL, of more liberal transfusion regimens, with higher haemoglobin (Hb) targets, compared to conventional restrictive regimens, but these results need confirmation by larger studies. EXPERT OPINION : A patient-oriented RBC transfusion therapy in MDS patients must take into account several laboratory (Hb), clinical (age, comorbidities), psychological, family and social factors, and evaluation of HRQoL should become a fundamental parameter in assessing the clinical benefit of therapy. Many questions remain to be clarified, including why some patients report little benefit from transfusions.
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Affiliation(s)
- Carlo Finelli
- IRCCS Azienda Ospedaliero-Universitaria di Bologna, Istituto di Ematologia "Seràgnoli", Bologna, Italy
| | - Sarah Parisi
- IRCCS Azienda Ospedaliero-Universitaria di Bologna, Istituto di Ematologia "Seràgnoli", Bologna, Italy
| | - Stefania Paolini
- IRCCS Azienda Ospedaliero-Universitaria di Bologna, Istituto di Ematologia "Seràgnoli", Bologna, Italy
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Jain AG, Elmariah H. BMT for Myelodysplastic Syndrome: When and Where and How. Front Oncol 2022; 11:771614. [PMID: 35070975 PMCID: PMC8770277 DOI: 10.3389/fonc.2021.771614] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2021] [Accepted: 12/09/2021] [Indexed: 11/13/2022] Open
Abstract
Myelodysplastic syndromes (MDS) are a diverse group of hematological malignancies distinguished by a combination of dysplasia in the bone marrow, cytopenias and the risk of leukemic transformation. The hallmark of MDS is bone marrow failure which occurs due to selective growth of somatically mutated clonal hematopoietic stem cells. Multiple prognostic models have been developed to help predict survival and leukemic transformation, including the international prognostic scoring system (IPSS), revised international prognostic scoring system (IPSS-R), WHO prognostic scoring system (WPSS) and MD Anderson prognostic scoring system (MDAPSS). This risk stratification informs management as low risk (LR)-MDS treatment focuses on improving quality of life and cytopenias, while the treatment of high risk (HR)-MDS focuses on delaying disease progression and improving survival. While therapies such as erythropoiesis stimulating agents (ESAs), erythroid maturation agents (EMAs), immunomodulatory imide drugs (IMIDs), and hypomethylating agents (HMAs) may provide benefit, allogeneic blood or marrow transplant (alloBMT) is the only treatment that can offer cure for MDS. However, this therapy is marred, historically, by high rates of toxicity and transplant related mortality (TRM). Because of this, alloBMT is considered in a minority of MDS patients. With modern techniques, alloBMT has become a suitable option even for patients of advanced age or with significant comorbidities, many of whom who would not have been considered for transplant in prior years. Hence, a formal transplant evaluation to weigh the complex balance of patient and disease related factors and determine the potential benefit of transplant should be considered early in the disease course for most MDS patients. Once alloBMT is recommended, timing is a crucial consideration since delaying transplant can lead to disease progression and development of other comorbidities that may preclude transplant. Despite the success of alloBMT, relapse remains a major barrier to success and novel approaches are necessary to mitigate this risk and improve long term cure rates. This review describes various factors that should be considered when choosing patients with MDS who should pursue transplant, approaches and timing of transplant, and future directions of the field.
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Affiliation(s)
- Akriti G Jain
- Fellow, Hematology Oncology, H. Lee Moffitt Cancer and Research Institute, Tampa, FL, United States
| | - Hany Elmariah
- Department of Blood and Marrow Transplant and Cellular Immunotherapy, H. Lee Moffitt Cancer and Research Institute, Tampa, FL, United States
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Balaian E, Wobus M, Bornhäuser M, Chavakis T, Sockel K. Myelodysplastic Syndromes and Metabolism. Int J Mol Sci 2021; 22:ijms222011250. [PMID: 34681910 PMCID: PMC8541058 DOI: 10.3390/ijms222011250] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2021] [Revised: 10/06/2021] [Accepted: 10/14/2021] [Indexed: 12/01/2022] Open
Abstract
Myelodysplastic syndromes (MDS) are acquired clonal stem cell disorders exhibiting ineffective hematopoiesis, dysplastic cell morphology in the bone marrow, and peripheral cytopenia at early stages; while advanced stages carry a high risk for transformation into acute myeloid leukemia (AML). Genetic alterations are integral to the pathogenesis of MDS. However, it remains unclear how these genetic changes in hematopoietic stem and progenitor cells (HSPCs) occur, and how they confer an expansion advantage to the clones carrying them. Recently, inflammatory processes and changes in cellular metabolism of HSPCs and the surrounding bone marrow microenvironment have been associated with an age-related dysfunction of HSPCs and the emergence of genetic aberrations related to clonal hematopoiesis of indeterminate potential (CHIP). The present review highlights the involvement of metabolic and inflammatory pathways in the regulation of HSPC and niche cell function in MDS in comparison to healthy state and discusses how such pathways may be amenable to therapeutic interventions.
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Affiliation(s)
- Ekaterina Balaian
- Medical Department I, University Hospital Carl Gustav Carus, Technische Universität Dresden, 01307 Dresden, Germany; (M.W.); (M.B.)
- German Cancer Consortium (DKTK), Partner Site Dresden and German Cancer Research Center (DKFZ), 69120 Heidelberg, Germany
- Correspondence: (E.B.); (K.S.)
| | - Manja Wobus
- Medical Department I, University Hospital Carl Gustav Carus, Technische Universität Dresden, 01307 Dresden, Germany; (M.W.); (M.B.)
| | - Martin Bornhäuser
- Medical Department I, University Hospital Carl Gustav Carus, Technische Universität Dresden, 01307 Dresden, Germany; (M.W.); (M.B.)
- National Center for Tumor Diseases, Partner Site Dresden and German Cancer Research Center (DKFZ), 69120 Heidelberg, Germany;
| | - Triantafyllos Chavakis
- National Center for Tumor Diseases, Partner Site Dresden and German Cancer Research Center (DKFZ), 69120 Heidelberg, Germany;
- Institute for Clinical Chemistry and Laboratory Medicine, University Hospital Carl Gustav Carus Dresden, 01307 Dresden, Germany
| | - Katja Sockel
- Medical Department I, University Hospital Carl Gustav Carus, Technische Universität Dresden, 01307 Dresden, Germany; (M.W.); (M.B.)
- Correspondence: (E.B.); (K.S.)
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Ferrara F, Bernardi M. 2021 BSH guidelines for the management of adult myelodysplastic syndromes: a practical approach to a challenging disease. Br J Haematol 2021; 194:235-237. [PMID: 34180049 DOI: 10.1111/bjh.17640] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
| | - Massimo Bernardi
- Haematology and BMT Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy
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Mallo M, Solé F. Beyond morphology: to be or not to be an MDS. Br J Haematol 2021; 194:238-239. [PMID: 34180054 DOI: 10.1111/bjh.17649] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2021] [Accepted: 05/27/2021] [Indexed: 01/13/2023]
Affiliation(s)
- Mar Mallo
- MDS Group, Josep Carreras Leukaemia Research Institute (IJC), Barcelona, Spain.,Microarrays Unit, Josep Carreras Leukaemia Research Institute (IJC), Barcelona, Spain
| | - Francesc Solé
- MDS Group, Josep Carreras Leukaemia Research Institute (IJC), Barcelona, Spain.,Microarrays Unit, Josep Carreras Leukaemia Research Institute (IJC), Barcelona, Spain
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