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Panghal A, Sahu C, Singla S, Jena G. Juvenile exposure and adult risk assessment with single versus repeated exposure of melphalan in the germ cells of male SD rat: Deciphering the molecular mechanisms. Reprod Toxicol 2022; 113:71-84. [PMID: 35961530 DOI: 10.1016/j.reprotox.2022.08.006] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2022] [Revised: 08/04/2022] [Accepted: 08/08/2022] [Indexed: 10/15/2022]
Abstract
Melphalan significantly contributes to the increase in childhood cancer survival rate. It acts as a gonadotoxic agent and leads to testes damage, dysbalance in gonadal hormones, and impairment in the germ cell proliferation. Therefore, it might be a potent threat to male fertility in individuals who have undergone melphalan treatment during childhood cancer. However, the molecular mechanisms of melphalan-induced gonadal damage are not yet fully explored and they need to be investigated to determine the benefit-risk profile. In the present study, juvenile male SD rats were subjected to single and intermittent cycles of melphalan exposure in a dose-dependent (0.375, 0.75 and 1.5 mg/kg) manner. Methods of end-points evaluations were quantification of micronuclei formation in peripheral blood, sperm count, sperm motility and head morphology, sperm and testicular DNA damage, histological studies in testes, oxidative/nitrosative stress parameters. A single cycle of exposure at high dose (1.5 mg/kg) produced significant effect on micronuclei formation only after the first week of exposure, whereas failed to produce significant effect at the end of the sixth week. Intermittent cycles of exposure at the dose of 1.5 mg/kg produced significant alterations in all the parameters (micronuclei in peripheral blood, testes and epididymides weight and length, MDA, GSH and nitrite levels, sperm count and motility, sperm head morphology, testicular and sperm DNA damage, protein expression in testes and histological parameters). So, time of exposure as well as the amount of exposure (total dosage administered) is critical in determining the magnitude of the damage in germ cell risk assessment.
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Affiliation(s)
- Archna Panghal
- Facility for Risk Assessment and Intervention Studies, Department of Pharmacology and Toxicology, National Institute of Pharmaceutical Education and Research, S.A.S Nagar, Punjab 160062, India.
| | - Chittaranjan Sahu
- Facility for Risk Assessment and Intervention Studies, Department of Pharmacology and Toxicology, National Institute of Pharmaceutical Education and Research, S.A.S Nagar, Punjab 160062, India.
| | - Shivani Singla
- Facility for Risk Assessment and Intervention Studies, Department of Pharmacology and Toxicology, National Institute of Pharmaceutical Education and Research, S.A.S Nagar, Punjab 160062, India.
| | - Gopabandhu Jena
- Facility for Risk Assessment and Intervention Studies, Department of Pharmacology and Toxicology, National Institute of Pharmaceutical Education and Research, S.A.S Nagar, Punjab 160062, India.
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Mayerhofer C, Niemeyer CM, Flotho C. Current Treatment of Juvenile Myelomonocytic Leukemia. J Clin Med 2021; 10:3084. [PMID: 34300250 PMCID: PMC8305558 DOI: 10.3390/jcm10143084] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2021] [Revised: 07/09/2021] [Accepted: 07/10/2021] [Indexed: 02/06/2023] Open
Abstract
Juvenile myelomonocytic leukemia (JMML) is a rare pediatric leukemia characterized by mutations in five canonical RAS pathway genes. The diagnosis is made by typical clinical and hematological findings associated with a compatible mutation. Although this is sufficient for clinical decision-making in most JMML cases, more in-depth analysis can include DNA methylation class and panel sequencing analysis for secondary mutations. NRAS-initiated JMML is heterogeneous and adequate management ranges from watchful waiting to allogeneic hematopoietic stem cell transplantation (HSCT). Upfront azacitidine in KRAS patients can achieve long-term remissions without HSCT; if HSCT is required, a less toxic preparative regimen is recommended. Germline CBL patients often experience spontaneous resolution of the leukemia or exhibit stable mixed chimerism after HSCT. JMML driven by PTPN11 or NF1 is often rapidly progressive, requires swift HSCT and may benefit from pretransplant therapy with azacitidine. Because graft-versus-leukemia alloimmunity is central to cure high risk patients, the immunosuppressive regimen should be discontinued early after HSCT.
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Affiliation(s)
- Christina Mayerhofer
- Division of Pediatric Hematology and Oncology, Department of Pediatrics and Adolescent Medicine, Medical Center, Faculty of Medicine, University of Freiburg, 79106 Freiburg, Germany; (C.M.); (C.M.N.)
| | - Charlotte M. Niemeyer
- Division of Pediatric Hematology and Oncology, Department of Pediatrics and Adolescent Medicine, Medical Center, Faculty of Medicine, University of Freiburg, 79106 Freiburg, Germany; (C.M.); (C.M.N.)
- German Cancer Consortium (DKTK), 79106 Freiburg, Germany
| | - Christian Flotho
- Division of Pediatric Hematology and Oncology, Department of Pediatrics and Adolescent Medicine, Medical Center, Faculty of Medicine, University of Freiburg, 79106 Freiburg, Germany; (C.M.); (C.M.N.)
- German Cancer Consortium (DKTK), 79106 Freiburg, Germany
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Edahiro T, Kawase T, Nagoshi H, Fujino K, Toishigawa K, Miyama T, Mino T, Yoshida T, Morioka T, Hirata Y, Noma M, Fujii T, Nishizawa M, Fukushima N, Ichinohe T. Allogeneic hematopoietic cell transplantation using fludarabine plus myeloablative busulfan and melphalan confers promising survival in high-risk hematopoietic neoplasms: a single-center retrospective analysis. ACTA ACUST UNITED AC 2021; 26:186-198. [PMID: 33594942 DOI: 10.1080/16078454.2021.1881228] [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: 10/22/2022]
Abstract
OBJECTIVES Optimal selection of pretransplant conditioning is crucially vital for improving survival and quality-of-life of patients who receive allogeneic hematopoietic cell transplantation (allo-HCT), particularly in those with high-risk diseases. In this study, we evaluated the efficacy and safety of recently-developed reduced-toxicity myeloablative regimen that combines fludarabine, intravenous busulfan, and melphalan (FBM). METHODS We conducted a single-center retrospective analysis of 39 patients (23 with myeloid neoplasms and 16 with lymphoid neoplasms), with a median age of 50 (range, 17-68) years, who underwent their first allo-HCT using the FBM regimen. Graft types were bone marrow in 11, peripheral blood in 11, and cord blood in 17 patients. Cyclosporine- or tacrolimus-based graft-versus-host disease (GVHD) prophylaxis was administered. The primary end point of the study was the overall survival rate at 2-year after transplantation. RESULTS After a median follow-up of 910 days for the surviving patients, 2-year overall survival was 62% for the entire cohort; 73% in the low-to-intermediate-risk group and 44% in the high-to-very high-risk group classified by the refined CIBMTR Disease Risk Index. Cumulative incidences of engraftment, grade II-IV acute GVHD, chronic GVHD, relapse, and non-relapse mortality were 95%, 56%, 56%, 31%, and 17%, respectively. CONCLUSION These results suggest that our FBM regimen can be applied to allo-HCT using various graft types and yields acceptable outcomes with relatively low non-relapse mortality in both myeloid and lymphoid neoplasms. Also, we observed a promising survival in the group of patients with high-risk diseases, warranting more accumulation of patients and longer follow-up.
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Affiliation(s)
- Taro Edahiro
- Department of Hematology and Oncology, Research Institute for Radiation Biology and Medicine (RIRBM), Hiroshima University, Hiroshima, Japan
| | - Takakazu Kawase
- Department of Hematology and Oncology, Research Institute for Radiation Biology and Medicine (RIRBM), Hiroshima University, Hiroshima, Japan
| | - Hisao Nagoshi
- Department of Hematology and Oncology, Research Institute for Radiation Biology and Medicine (RIRBM), Hiroshima University, Hiroshima, Japan
| | - Keita Fujino
- Department of Hematology and Oncology, Research Institute for Radiation Biology and Medicine (RIRBM), Hiroshima University, Hiroshima, Japan
| | - Kayo Toishigawa
- Department of Hematology and Oncology, Research Institute for Radiation Biology and Medicine (RIRBM), Hiroshima University, Hiroshima, Japan
| | - Takahiko Miyama
- Department of Hematology and Oncology, Research Institute for Radiation Biology and Medicine (RIRBM), Hiroshima University, Hiroshima, Japan
| | - Tatsuji Mino
- Department of Hematology and Oncology, Research Institute for Radiation Biology and Medicine (RIRBM), Hiroshima University, Hiroshima, Japan
| | - Tetsumi Yoshida
- Department of Hematology and Oncology, Research Institute for Radiation Biology and Medicine (RIRBM), Hiroshima University, Hiroshima, Japan
| | - Takehiko Morioka
- Department of Hematology and Oncology, Research Institute for Radiation Biology and Medicine (RIRBM), Hiroshima University, Hiroshima, Japan
| | - Yuji Hirata
- Department of Hematology and Oncology, Research Institute for Radiation Biology and Medicine (RIRBM), Hiroshima University, Hiroshima, Japan
| | - Mitsunori Noma
- Division of Transfusion Medicine, Hiroshima University Hospital, Hiroshima, Japan
| | - Teruhisa Fujii
- Division of Transfusion Medicine, Hiroshima University Hospital, Hiroshima, Japan
| | - Masatoshi Nishizawa
- Next Generation Development of Genome and Cellular Therapy Program, Research Institute for Radiation Biology and Medicine (RIRBM), Hiroshima University, Hiroshima, Japan
| | - Noriyasu Fukushima
- Department of Hematology and Oncology, Research Institute for Radiation Biology and Medicine (RIRBM), Hiroshima University, Hiroshima, Japan
| | - Tatsuo Ichinohe
- Department of Hematology and Oncology, Research Institute for Radiation Biology and Medicine (RIRBM), Hiroshima University, Hiroshima, Japan.,Next Generation Development of Genome and Cellular Therapy Program, Research Institute for Radiation Biology and Medicine (RIRBM), Hiroshima University, Hiroshima, Japan
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Greenmyer JR, Kohorst M. Pediatric Neoplasms Presenting with Monocytosis. Curr Hematol Malig Rep 2021; 16:235-246. [PMID: 33630234 DOI: 10.1007/s11899-021-00611-x] [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] [Accepted: 02/01/2021] [Indexed: 11/24/2022]
Abstract
PURPOSE OF REVIEW Juvenile myelomonocytic leukemia (JMML) is a rare but severe pediatric neoplasm with hematopoietic stem cell transplant as its only established curative option. The development of targeted therapeutics for JMML is being guided by an understanding of the pathobiology of this condition. Here, we review JMML with an emphasis on genetics in order to (i) demonstrate the relationship between JMML genotype and clinical phenotype and (ii) explore potential genetic targets of novel JMML therapies. RECENT FINDINGS DNA hypermethylation studies have demonstrated consistently that methylation is related to disease severity. Increasing understanding of methylation in JMML may open the door to novel therapies, such as DNA methyltransferase inhibitors. The PI3K/AKT/MTOR, JAK/STAT, and RAF/MEK/ERK pathways are being investigated as therapeutic targets for JMML. Future therapy for JMML will be driven by an increased understanding of pathobiology. Targeted therapeutic approaches hold potential for improving outcomes in patients with JMML.
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Affiliation(s)
| | - Mira Kohorst
- Pediatric Hematology and Oncology, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA.
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Ai Y, Lu X, Zhu T, Zhu Y, Liu H, Sun S. Combination of DNA-hypomethylating agent and hematopoietic stem cell transplantation in treatment of juvenile myelomonocytic leukemia: A case report. Medicine (Baltimore) 2020; 99:e23606. [PMID: 33327329 PMCID: PMC7738035 DOI: 10.1097/md.0000000000023606] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
Abstract
INTRODUCTION Juvenile myelomonocytic leukemia (JMML) is a rare myeloproliferative neoplasm of early childhood characterized by excessive proliferation of myelomonocytic cells and an aggressive clinical course. Allogenic hematopoietic stem cell transplantation (HSCT) is a firmly established treatment, but patients without fully matched donors have poor prognoses. Disease recurrence is the main cause of treatment failure. Meanwhile, most cases with splenomegaly present with platelet transfusion refractoriness, but splenectomy remains controversial. DNA hypermethylation correlates with poor prognosis in JMML; however, hypomethylating therapy alone does not eradicate leukemic clones. Thus, a suitable treatment with a good success rate remains elusive. PATIENT CONCERNS Here, we report our experience with a patient who suffered from recurrent fever, pallor, abdominal distention, leukocytosis, and thrombocytopenia with a silent past history and family history of somatic KRAS mutation. The patient was treated with decitabine as a bridging therapy before haploidentical HSCT. Decitabine was also used prophylactically after transplantation. DIAGNOSIS We arrived at a JMML diagnosis after observing leukocytosis, less than 20% blast cells in the peripheral blood and bone marrow, increased monocyte counts, negativity for the BCR-ABL fusion gene, positivity for somatic KRAS mutation, and massive splenomegaly. INTERVENTIONS The patient accepted splenectomy before HSCT, and haploidentical HSCT was applied after treatment with a DNA-hypomethylating agent. The hypomethylating agent was administered for 1 year after HSCT to prevent disease recurrence. OUTCOMES The patient presented with complete remission of the disease and mild graft versus host disease for 26 months after treatment with decitabine and HSCT. LESSONS Combining haploidentical HSCT and DNA-hypomethylating agents may improve the prognosis of JMML. Meanwhile, splenectomy could be an effective option in cases with massive splenomegaly and platelet transfusion refractoriness.
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Affiliation(s)
- Yuan Ai
- Department of Pediatrics, West China Second University Hospital, Sichuan University
- Key Laboratory of Obstetric & Gynecologic and Pediatric Diseases and Birth Defects of Ministry of Education, Sichuan University, Chengdu, Sichuan, China
| | - Xiaoxi Lu
- Department of Pediatrics, West China Second University Hospital, Sichuan University
- Key Laboratory of Obstetric & Gynecologic and Pediatric Diseases and Birth Defects of Ministry of Education, Sichuan University, Chengdu, Sichuan, China
| | - Tingting Zhu
- Department of Pediatrics, West China Second University Hospital, Sichuan University
- Key Laboratory of Obstetric & Gynecologic and Pediatric Diseases and Birth Defects of Ministry of Education, Sichuan University, Chengdu, Sichuan, China
| | - Yiping Zhu
- Department of Pediatrics, West China Second University Hospital, Sichuan University
- Key Laboratory of Obstetric & Gynecologic and Pediatric Diseases and Birth Defects of Ministry of Education, Sichuan University, Chengdu, Sichuan, China
| | - Hanmin Liu
- Department of Pediatrics, West China Second University Hospital, Sichuan University
- Key Laboratory of Obstetric & Gynecologic and Pediatric Diseases and Birth Defects of Ministry of Education, Sichuan University, Chengdu, Sichuan, China
| | - Shuwen Sun
- Department of Pediatrics, West China Second University Hospital, Sichuan University
- Key Laboratory of Obstetric & Gynecologic and Pediatric Diseases and Birth Defects of Ministry of Education, Sichuan University, Chengdu, Sichuan, China
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Helgadóttir H, Ólafsson Í, Andersen K, Gizurarson S. Stability of thromboxane in blood samples. Vasc Health Risk Manag 2019; 15:143-147. [PMID: 31239692 PMCID: PMC6556106 DOI: 10.2147/vhrm.s204925] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2019] [Accepted: 05/01/2019] [Indexed: 11/23/2022] Open
Abstract
Introduction: Conventional venous blood collection requires a puncture with a needle through the endothelium of a vessel. The endothelial injury causes activation of circulating platelets and the release of thromboxane A2. The aim of the study was to investigate if platelets continue to form thromboxane A2 in the blood tube after sample collection, but such synthesis would give false information about the actual circulating thromboxane A2 value. Methods: Thromboxane B2 is a biologically inactive but stable metabolite of thromboxane A2 and can be measured in blood samples by a standard enzyme immunoassay. Thromboxane B2 measurements reflect thromboxane A2 concentration. Blood samples were collected in 3.2% sodium citrate vials and EDTA vials from ten individuals and centrifuged and frozen at different time points (0, 30, and 120 minutes). Plasma aliquots were transferred to and frozen in 1.8 mL polypropylene tubes and the citrate samples were also transferred to and frozen in propylene tubes containing indomethacin. Results: Concentrations of thromboxane B2 in plasma samples collected in citrate vials and stored in propylene tubes increased very rapidly as the samples were left for longer after sampling and allowed to stand at room temperature. After 120 minutes, the amount of thromboxane B2 was 400% higher than in the reference sample at time zero. In comparison, thromboxane B2 concentration was about 200% higher in the 120-minute samples compared to the reference in samples collected in citrate vials but stored in indomethacin tubes. In samples collected in EDTA vials, a 10% reduction in thromboxane B2 concentration in the 120-minute samples was observed. Conclusion: Storage conditions, type of sampling vial and time from sampling until sample processing (centrifuging) has a major impact on thromboxane B2 stability.
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Affiliation(s)
- Helga Helgadóttir
- Faculty of Pharmaceutical Sciences, University of Iceland, Reykjavik, Iceland.,Department of Clinical Biochemistry, Landspitali University Hospital, Reykjavik, Iceland
| | - Ísleifur Ólafsson
- Department of Clinical Biochemistry, Landspitali University Hospital, Reykjavik, Iceland
| | - Karl Andersen
- Faculty of Medicine, University of Iceland, Reykjavik, Iceland
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Locatelli F, Algeri M, Merli P, Strocchio L. Novel approaches to diagnosis and treatment of Juvenile Myelomonocytic Leukemia. Expert Rev Hematol 2018; 11:129-143. [DOI: 10.1080/17474086.2018.1421937] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Affiliation(s)
- Franco Locatelli
- Department of Pediatric Hematology/Oncology, IRCCS Bambino Gesù Children’s Hospital, Rome, Italy
- Department of Pediatric Science, University of Pavia, Pavia, Italy
| | - Mattia Algeri
- Department of Pediatric Hematology/Oncology, IRCCS Bambino Gesù Children’s Hospital, Rome, Italy
| | - Pietro Merli
- Department of Pediatric Hematology/Oncology, IRCCS Bambino Gesù Children’s Hospital, Rome, Italy
| | - Luisa Strocchio
- Department of Pediatric Hematology/Oncology, IRCCS Bambino Gesù Children’s Hospital, Rome, Italy
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Abstract
Despite significant recent progress in precision medicine and immunotherapy, conventional chemotherapy remains the cornerstone of the treatment of most cancers. Chemotherapy-induced lung toxicity represents a serious diagnostic challenge for health care providers and requires careful consideration because it is a diagnosis of exclusion with significant impact on therapeutic decisions. This review aims to provide clinicians with a valuable guide in assessing their patients with possible chemotherapy-induced lung toxicity.
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Affiliation(s)
- Paul Leger
- Division of Internal Medicine, Vanderbilt University Medical Center, T1218 Medical Center North, Nashville, TN 37232-2650, USA
| | - Andrew H Limper
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA
| | - Fabien Maldonado
- Division of Allergy, Pulmonary and Critical Care Medicine, Vanderbilt University Medical Center, T1218 Medical Center North, Nashville, TN 37232-2650, USA.
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9
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Paulus S, Koronowska S, Fölster-Holst R. Association Between Juvenile Myelomonocytic Leukemia, Juvenile Xanthogranulomas and Neurofibromatosis Type 1: Case Report and Review of the Literature. Pediatr Dermatol 2017; 34:114-118. [PMID: 28111791 DOI: 10.1111/pde.13064] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
The occurrence of juvenile myelomonocytic leukemia (JMML), juvenile xanthogranuloma (JXG), and neurofibromatosis type 1 (NF1) together is relatively rare. Approximately only 20 cases have been reported in the literature. It is debated whether children with NF1 and JXG are at higher risk of developing JMML than children with NF1 alone. We present the case of a boy primarily diagnosed with NF1 with coexisting JXG who developed JMML at the age of 22 months. The clinical course from initial presentation to final diagnosis is detailed and the genetic features and hematologic characteristics are discussed. We report this case to underscore the importance of close monitoring of blood count and strict clinical follow-up in children presenting with concurrent NF1 and JXG and provide a possible explanation for this association.
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Affiliation(s)
- Samuel Paulus
- Department of Dermatology, University of Kiel, Kiel, Germany
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10
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Alternative Donor Hematopoietic Cell Transplantation Conditioned With Myeloablative Busulfan, Fludarabine, and Melphalan is Well Tolerated and Effective Against High-risk Myeloid Malignancies. J Pediatr Hematol Oncol 2016; 38:e315-e318. [PMID: 27467368 DOI: 10.1097/mph.0000000000000621] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
Busulfan, fludarabine, and melphalan as hematopoietic cell transplant conditioning, was used in 6 patients aged 1 to 19 years with very high-risk myeloid malignancies. This dose regimen had an acceptable toxicity profile resulting in complete donor engraftment even following transplantation of small 2/6 antigen disparate umbilical cord blood grafts. It provided excellent disease control as all patients had high-risk features in terms of cytogenetics, therapy-related leukemia, and/or significant measurable disease before transplant. All patients remain in remission, without acute or chronic graft-versus-host disease with a median follow-up of 24 months. A larger study is indicated to confirm the efficacy and safety of this regimen.
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11
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Niemeyer CM, Loh ML, Cseh A, Cooper T, Dvorak CC, Chan R, Xicoy B, Germing U, Kojima S, Manabe A, Dworzak M, De Moerloose B, Starý J, Smith OP, Masetti R, Catala A, Bergstraesser E, Ussowicz M, Fabri O, Baruchel A, Cavé H, Zwaan M, Locatelli F, Hasle H, van den Heuvel-Eibrink MM, Flotho C, Yoshimi A. Criteria for evaluating response and outcome in clinical trials for children with juvenile myelomonocytic leukemia. Haematologica 2015; 100:17-22. [PMID: 25552679 DOI: 10.3324/haematol.2014.109892] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
Juvenile myelomonocytic leukemia is a rare myeloproliferative disease in young children. While hematopoietic stem cell transplantation remains the only curative therapeutic option for most patients, children with juvenile myelomonocytic leukemia increasingly receive novel agents in phase I-II clinical trials as pre-transplant therapy or therapy for relapse after transplantation. However, response criteria or definitions of outcome for standardized evaluation of treatment effect in patients with juvenile myelomonocytic leukemia are currently lacking. Here we propose criteria to evaluate the response to the non-transplant therapy and definitions of remission status after hematopoietic stem cell transplantation. For the evaluation of non-transplant therapy, we defined 6 clinical variables (white blood cell count, platelet count, hematopoietic precursors and blasts in peripheral blood, bone marrow blast percentage, spleen size and extramedullary disease) and 3 genetic variables (cytogenetic, molecular and chimerism response) which serve to describe the heterogeneous picture of response to therapy in each individual case. It is hoped that these criteria will facilitate the comparison of results between clinical trials in juvenile myelomonocytic leukemia.
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Affiliation(s)
- Charlotte M Niemeyer
- Department of Pediatrics and Adolescent Medicine, Division of Pediatric Hematology and Oncology University of Freiburg, Germany
| | - Mignon L Loh
- Department of Pediatrics and the Helen Diller Comprehensive Cancer Center, University of California, San Francisco, CA, USA
| | - Annamaria Cseh
- Department of Pediatrics and Adolescent Medicine, Division of Pediatric Hematology and Oncology University of Freiburg, Germany
| | - Todd Cooper
- Aflac Cancer and Blood Disorders Center/Children's Healthcare of Atlanta/Emory University, Atlanta, GA, USA
| | - Christopher C Dvorak
- Division of Pediatric Allergy, Immunology, and Bone Marrow Transplant, Benioff Children's Hospital, University of California, San Francisco, CA, USA
| | - Rebecca Chan
- Department of Pediatrics, The Herman B Wells Center for Pediatric Research, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Blanca Xicoy
- Department of Hematology, Hospital Germans Trias i Pujol and Institut Català d'Oncologia-José Carreras Leukemia Research Institute, Badalona, Spain
| | - Ulrich Germing
- Department of Hematology, Oncology and Clinical Immunology, Heinrich-Heine-University, Düsseldorf, Germany
| | - Seiji Kojima
- Department of Pediatrics, Nagoya University Graduate School of Medicine, Japan
| | - Atsushi Manabe
- Department of Pediatrics, St. Luke's International Hospital, Tokyo, Japan
| | - Michael Dworzak
- St. Anna Children's Hospital and Children's Cancer Research Institute, Department of Pediatrics, Medical University of Vienna, Austria
| | | | - Jan Starý
- Department of Pediatric Hematology and Oncology, Charles University and University Hospital Motol, Czech Pediatric Hematology Working Group, Prague, Czech Republic
| | - Owen P Smith
- Pediatric Oncology and Hematology, Our Lady's Children's Hospital, Crumlin, Dublin, Ireland
| | - Riccardo Masetti
- Department of Pediatric Oncology and Hematology, University of Bologna, Italy
| | - Albert Catala
- Department of Hematology, Hospital Sant Joan de Déu, Barcelona, Spain
| | - Eva Bergstraesser
- Department of Hematology and Oncology, University Children's Hospital, Zurich, Switzerland
| | - Marek Ussowicz
- Department of Pediatric Oncology, Hematology and BMT, Wroclaw Medical University, Poland
| | - Oskana Fabri
- Department of Hematology and Transfusiology, Comenius University, Bratislava, Slovakia
| | - André Baruchel
- Department of Pediatric Hematology of Robert Debré Hospital and Paris Diderot University, Paris, France
| | - Hélène Cavé
- Department of Genetics, Hôpital Robert Debré, and Paris Diderot University, Paris, France
| | - Michel Zwaan
- ErasmusMC-Sophia Children's Hospital, Erasmus Medical Center, Rotterdam, and the Netherlands and ITCC
| | - Franco Locatelli
- Department of Pediatric Hematology and Oncology, Bambino Gesù Children's Hospital, Rome, University of Pavia, Italy
| | - Henrik Hasle
- Department of Pediatrics, Aarhus University Hospital Skejby, Aarhus, Denmark
| | - Marry M van den Heuvel-Eibrink
- ErasmusMC-Sophia Children's Hospital, Erasmus Medical Center, Rotterdam, and Dutch Childhood Oncology Group, The Hague, The Netherlands
| | - Christian Flotho
- Department of Pediatrics and Adolescent Medicine, Division of Pediatric Hematology and Oncology University of Freiburg, Germany
| | - Ayami Yoshimi
- Department of Pediatrics and Adolescent Medicine, Division of Pediatric Hematology and Oncology University of Freiburg, Germany
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12
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Abstract
RAS genes encode a family of 21 kDa proteins that are an essential hub for a number of survival, proliferation, differentiation and senescence pathways. Signaling of the RAS-GTPases through the RAF-MEK-ERK pathway, the first identified mitogen-associated protein kinase (MAPK) cascade is essential in development. A group of genetic syndromes, named "RASopathies", had been identified which are caused by heterozygosity for germline mutations in genes that encode protein components of the RAS/MAPK pathway. Several of these clinically overlapping disorders, including Noonan syndrome, Noonan-like CBL syndrome, Costello syndrome, cardio-facio-cutaneous (CFC) syndrome, neurofibromatosis type I, and Legius syndrome, predispose to cancer and abnormal myelopoiesis in infancy. This review focuses on juvenile myelomonocytic leukemia (JMML), a malignancy of early childhood characterized by initiating germline and/or somatic mutations in five genes of the RAS/MAPK pathway: PTPN11, CBL, NF-1, KRAS and NRAS. Natural courses of these five subtypes differ, although hematopoietic stem cell transplantation remains the only curative therapy option for most children with JMML. With whole-exome sequencing studies revealing few secondary lesions it will be crucial to better understand the RAS/MAPK signaling network with its crosstalks and feed-back loops to carefully design early clinical trials with novel pharmacological agents in this still puzzling leukemia.
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Affiliation(s)
- Charlotte M Niemeyer
- Department of Pediatric Hematology and Oncology, Universitätsklinikum Freiburg, Germany
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13
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Abstract
Abstract
Juvenile myelomonocytic leukemia (JMML) is a unique, aggressive hematopoietic disorder of infancy/early childhood caused by excessive proliferation of cells of monocytic and granulocytic lineages. Approximately 90% of patients carry either somatic or germline mutations of PTPN-11, K-RAS, N-RAS, CBL, or NF1 in their leukemic cells. These genetic aberrations are largely mutually exclusive and activate the Ras/mitogen-activated protein kinase pathway. Allogeneic hematopoietic stem cell transplantation (HSCT) remains the therapy of choice for most patients with JMML, curing more than 50% of affected children. We recommend that this option be promptly offered to any child with PTPN-11-, K-RAS-, or NF1-mutated JMML and to the majority of those with N-RAS mutations. Because children with CBL mutations and few of those with N-RAS mutations may have spontaneous resolution of hematologic abnormalities, the decision to proceed to transplantation in these patients must be weighed carefully. Disease recurrence remains the main cause of treatment failure after HSCT. A second allograft is recommended if overt JMML relapse occurs after transplantation. Recently, azacytidine, a hypomethylating agent, was reported to induce hematologic/molecular remissions in some children with JMML, and its role in both reducing leukemia burden before HSCT and in nontransplant settings requires further studies.
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Yabe M, Ohtsuka Y, Watanabe K, Inagaki J, Yoshida N, Sakashita K, Kakuda H, Yabe H, Kurosawa H, Kudo K, Manabe A. Transplantation for juvenile myelomonocytic leukemia: a retrospective study of 30 children treated with a regimen of busulfan, fludarabine, and melphalan. Int J Hematol 2014; 101:184-90. [PMID: 25504334 DOI: 10.1007/s12185-014-1715-7] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2014] [Revised: 11/21/2014] [Accepted: 11/27/2014] [Indexed: 11/26/2022]
Abstract
We report the outcomes of 30 patients with juvenile myelomonocytic leukemia (JMML) who received unmanipulated hematopoietic stem cell transplantation (HSCT) with oral or intravenous busulfan, fludarabine, and melphalan between 2001 and 2011. Mutations in PTPN11 were detected in 15 patients. Six patients received human leukocyte antigen (HLA)-matched HSCT from related donors, and 24 patients received HSCT from alternative donors, including 13 HLA-mismatched donors. Primary engraftment failed in five patients, all of whom had received allografts from HLA-mismatched donors. HLA-mismatched HSCT resulted in poorer event-free survival than HLA-matched HSCT (28.8 vs. 70.6 %). Three patients died of transplantation-related causes, and eight patients experienced hematological relapse (including five patients who died due to disease progression). Eight patients received a second HSCT, and four of these patients have survived. The 5-year estimated overall survival for all patients was 72.4: 88.9 % for the patients without a mutation in PTPN11 (n = 10) and 58.3 % for the patients with a mutation in PTPN11 (n = 15) (P = 0.092). The conditioning regimen reported in the present study achieved hematological and clinical remission in >50 % of patients with JMML who received HSCT from alternative donors, and may also be effective for JMML patients with PTPN11 mutation.
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Affiliation(s)
- Miharu Yabe
- Department of Cell Transplantation and Regenerative Medicine, Tokai University Hospital, 143 Shimokasuya, Isehara, Kanagawa, 259-1193, Japan,
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15
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Myeloablative BU, fludarabine, antithymocyte globulin and low-dose TBI in the treatment of juvenile myelomonocytic leukaemia with allogeneic haematopoietic cell transplantation. Bone Marrow Transplant 2014; 50:455-6. [PMID: 25486583 DOI: 10.1038/bmt.2014.272] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
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16
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Ueda S, Sakata N, Muramatsu H, Sakaguchi H, Wang X, Xu Y, Kojima S, Yamaguchi T, Higa T, Takemura T. Clinical course of juvenile myelomonocytic leukemia in the blast crisis phase treated by acute myeloid leukemia-oriented chemotherapy and allogeneic hematopoietic stem cell transplantation. Int J Hematol 2014; 100:502-6. [DOI: 10.1007/s12185-014-1638-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2013] [Revised: 07/07/2014] [Accepted: 07/08/2014] [Indexed: 01/10/2023]
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Honda Y, Tsuchida M, Zaike Y, Masunaga A, Yoshimi A, Kojima S, Ito M, Kikuchi A, Nakahata T, Manabe A. Clinical characteristics of 15 children with juvenile myelomonocytic leukaemia who developed blast crisis: MDS Committee of Japanese Society of Paediatric Haematology/Oncology. Br J Haematol 2014; 165:682-7. [DOI: 10.1111/bjh.12796] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2013] [Accepted: 01/08/2014] [Indexed: 02/03/2023]
Affiliation(s)
- Yuko Honda
- Department of Paediatrics; University of Occupational and Environmental Health; Kitakyusyu Japan
| | | | - Yuji Zaike
- Clinical Laboratory; Research Hospital; The Institution of Medical Science; The University of Tokyo; Tokyo Japan
| | - Atsuko Masunaga
- Department of Diagnostic Pathology; Showa University Fujigaoka Hospital; Yokohama Japan
| | - Ayami Yoshimi
- Department of Paediatrics and Adolescent Medicine; University of Freiburg; Freiburg Germany
| | - Seiji Kojima
- Department of Paediatrics; Graduate School of Medicine; Nagoya University; Nagoya Japan
| | - Masafumi Ito
- Department of Pathology; Nagoya Daiichi Red Cross Hospital; Nagoya Japan
| | - Akira Kikuchi
- Department of Paediatrics; School of Medicine; Teikyo University; Tokyo Japan
| | - Tatsutoshi Nakahata
- Department of Clinical Application; Center for iPS Cell Research and Application; Kyoto University; Kyoto Japan
| | - Atsushi Manabe
- Department of Paediatrics; St. Luke's International Hospital; Tokyo Japan
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18
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19
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Dvorak CC, Loh ML. Juvenile myelomonocytic leukemia: molecular pathogenesis informs current approaches to therapy and hematopoietic cell transplantation. Front Pediatr 2014; 2:25. [PMID: 24734223 PMCID: PMC3975112 DOI: 10.3389/fped.2014.00025] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2014] [Accepted: 03/15/2014] [Indexed: 01/20/2023] Open
Abstract
Juvenile myelomonocytic leukemia (JMML) is a rare childhood leukemia that has historically been very difficult to confidently diagnose and treat. The majority of patients ultimately require allogeneic hematopoietic cell transplantation (HCT) for cure. Recent advances in the understanding of the pathogenesis of the disease now permit over 90% of patients to be molecularly characterized. Pre-HCT management of patients with JMML is currently symptom-driven. However, evaluation of potential high-risk clinical and molecular features will determine which patients could benefit from pre-HCT chemotherapy and/or local control of splenic disease. Furthermore, new techniques to quantify minimal residual disease burden will determine whether pre-HCT response to chemotherapy is beneficial for long-term disease-free survival. The optimal approach to HCT for JMML is unclear, with high relapse rates regardless of conditioning intensity. An ongoing clinical trial in the Children's Oncology Group will test if less toxic approaches can be equally effective, thereby shifting the focus to post-HCT immunomanipulation strategies to achieve long-term disease control. Finally, our unraveling of the molecular basis of JMML is beginning to identify possible targets for selective therapeutic interventions, either pre- or post-HCT, an approach which may ultimately provide the best opportunity to improve outcomes for this aggressive disease.
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Affiliation(s)
- Christopher C Dvorak
- Department of Pediatrics, University of California San Francisco , San Francisco, CA , USA
| | - Mignon L Loh
- Department of Pediatrics, University of California San Francisco , San Francisco, CA , USA
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Huang L, Lizak P, Aweeka F, Long-Boyle J. Determination of intracellular fludarabine triphosphate in human peripheral blood mononuclear cells by LC-MS/MS. J Pharm Biomed Anal 2013; 86:198-203. [PMID: 24013121 DOI: 10.1016/j.jpba.2013.08.007] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2013] [Revised: 07/15/2013] [Accepted: 08/05/2013] [Indexed: 12/01/2022]
Abstract
Fludarabine is a nucleoside analog routinely used in conditioning regimens of pediatric allogeneic stem cell transplantation to promote stem cell engraftment. In children, it remains a challenge to accurately and precisely quantify the active intracellular triphosphate species of fludarabine in vivo, primarily due to limitations on blood volume and inadequate assay sensitivity. Here we report a liquid chromatography tandem mass spectrometry (LC-MS/MS) method for determination of fludarabine triphosphate in human peripheral blood mononuclear cells (PBMC). PBMC (∼5 million cells) were collected and lysed in 1mL 70% methanol containing 1.2mM tris buffer (pH 7.4). The lysate (80μL) was mixed with internal standard (2-chloro-adenosine triphosphate, 150ng/mL, 20μL) and injected onto an API5000 LC-MS/MS system. Separation was achieved on a hypercarb column (100mm×2.1mm, 3μm) eluted with 100mM ammonium acetate (pH 9.8) and acetonitrile in a gradient mode at a flow rate of 0.4mL/min. Multiple reactions monitoring (MRM) and electrospray ionization in negative mode (ESI(-)) were used for detection. The ion pairs 524.0/158.6 for the drug and 540.0/158.8 for the IS were selected for quantification and 524.0/425.7 used for confirmation. Retention time was 3.0 and 3.4min for fludarabine triphosphate and the IS, respectively. The concentration range for the calibration curve was 1.52-76nM. Our method is simple, fast, and has been successfully applied in a clinical dose-concentration study in children to quantify intracellular fludarabine in low volume clinical samples. The median concentration was 1.03 and 3.19pmole/million PBMC at trough and peak time points, respectively. Fludarabine triphosphate is degraded in water within hours but relatively stable in 70% methanol-tris (1.2mM, pH 7.4). One limitation is that the hypercarb column takes a longer time to equilibrate than conventional reverse phase columns, and peaks become broad and distorted if the column is not washed and stored properly.
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Affiliation(s)
- Liusheng Huang
- Drug Research Unit, Department of Clinical Pharmacy, University of California at San Francisco, San Francisco, CA 94143, USA.
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21
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Flotho C, Vraetz T, Lang P, Niemeyer CM, Strahm B. Successful double umbilical cord blood transplantation for relapsed juvenile myelomonocytic leukemia. Leukemia 2012; 27:988-9. [PMID: 23000834 DOI: 10.1038/leu.2012.273] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
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Yoshida N, Doisaki S, Kojima S. Current management of juvenile myelomonocytic leukemia and the impact of RAS mutations. Paediatr Drugs 2012; 14:157-63. [PMID: 22480363 DOI: 10.2165/11631360-000000000-00000] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
Abstract
Juvenile myelomonocytic leukemia (JMML) is a rare clonal myelodysplastic/myeloproliferative disorder that affects young children. It is characterized by hypersensitivity of JMML cells to granulocyte-macrophage colony-stimulating factor (GM-CSF) in vitro. The pathogenesis of JMML seems to arise from constitutional activation of the GM-CSF/RAS (a GTPase) signaling pathway, a result of mutations in RAS, NF1, PTPN11, and CBL that interfere with downstream components of the pathway. Most patients with JMML usually experience an aggressive clinical course, and hematopoietic stem cell transplantation (HSCT) is currently the only curative treatment, although the high rates of relapses and graft failures are of great concern. In contrast, a certain proportion of patients experience a stable clinical course for a considerable period of time, and sometimes the disease even spontaneously resolves without any treatment. Recent studies have provided us with increased knowledge of genotype-phenotype correlations in JMML, and suggested that differences in clinical courses may reflect genetic status. Thus, genotype-based management is of current international interest, especially for JMML with RAS mutations. Cumulative evidence suggests that RAS mutations can be related to favorable clinical outcomes, and HSCT may not have to be a mandatory therapeutic option for a portion of patients with this mutation, although a consensus regarding genotype-based management has not yet been achieved. Further efforts toward identifying which patients who will do well without HSCT are required.
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Affiliation(s)
- Nao Yoshida
- Department of Hematology and Oncology, Childrens Medical Center, Japanese Red Cross Nagoya First Hospital, Nagoya, Japan
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Fukushima H, Fukushima T, Hiraki A, Suzuki R, Mahmoud SSA, Yoshimi A, Nakao T, Kato K, Kobayashi C, Koike K, Fukasawa M, Morishita Y, Doisaki S, Muramatsu H, Sumazaki R. Central nervous system lesions due to juvenile myelomonocytic leukemia progressed in a boy undergoing first line chemotherapy. Int J Hematol 2012; 95:581-4. [PMID: 22461033 DOI: 10.1007/s12185-012-1046-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2011] [Revised: 02/27/2012] [Accepted: 02/28/2012] [Indexed: 11/24/2022]
Abstract
Juvenile myelomonocytic leukemia is a rare malignancy that occurs in pediatric patients. Previous reports, have described leukemic cells may infiltrate many organs, such as the lungs, skin, liver, spleen, and intestines, but not the central nervous system, although central nervous system infiltration remains a point of concern in every patient with acute leukemia. Here, we present one case of a boy with juvenile myelomonocytic leukemia who developed multiple lesions in the brain while undergoing chemotherapy with 6-mercaptopurine and cytarabine. We diagnosed the central nervous system involvement by magnetic resonance imaging, cerebrospinal fluid cytology, and the patient's clinical course. He was treated with a high dose of cytarabine and intrathecal chemotherapy, then with unrelated cord blood stem cell transplantation. He has been in a first complete remission for more than 18 months after cord blood stem cell transplantation without any neurological sequelae. In conclusion, we encountered a boy with juvenile myelomonocytic leukemia who developed central nervous system lesions under standard chemotherapy. We subsequently switched treatment to central nervous system-oriented chemotherapy, which resulted in a good clinical condition and successful cord blood stem cell transplantation.
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Affiliation(s)
- Hiroko Fukushima
- Department of Pediatrics, Tsukuba University Hospital, Tsukuba, Japan.
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Yoshimi A, Kojima S, Hirano N. Juvenile myelomonocytic leukemia: epidemiology, etiopathogenesis, diagnosis, and management considerations. Paediatr Drugs 2010; 12:11-21. [PMID: 20034338 DOI: 10.2165/11316200-000000000-00000] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
Juvenile myelomonocytic leukemia (JMML) is a rare hematopoietic malignancy of early childhood with features characteristic of both myelodysplastic and myeloproliferative disorders. Recent studies clearly show that the deregulated activation of the RAS signaling pathway plays a central role in the pathogenesis of JMML. Somatic defects in either RAS, PTPN11 or NF1 genes involved in this pathway are detected in 70-80% of JMML patients, allowing a molecular diagnosis to be made in the majority of cases. Patients with JMML respond poorly to chemotherapy, and the probability of survival without allogeneic hematopoietic stem cell transplantation (HSCT) is less than 10%. Recent studies show that the event-free survival after HSCT is between 24 and 54%, with no difference between transplants using matched family donors and those using unrelated donors. The use of therapies such as intensive chemotherapy and splenectomy prior to HSCT does not improve the outcome. The relapse rate following HSCT is over 30%, which is unacceptably high. Cumulative evidence suggests that a graft-versus-leukemia effect occurs in JMML. Donor leukocyte infusion is not usually successful in JMML, but the outcome of second HSCT is generally favorable. Based on recent advances in the understanding of the pathogenesis of JMML, the development of novel targeted therapies, which might improve the outcome of patients, is keenly awaited.
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Affiliation(s)
- Ayami Yoshimi
- Department of HSCT Data Management, Nagoya University, Japan.
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