1
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Tripodi J, Hoffman R, Tremblay D, Ahire D, Mascarenhas J, Kremyanskaya M, Najfeld V. Conventional Cytogenetic Analysis and Array CGH + SNP Identify Essential Thrombocythemia and Prefibrotic Primary Myelofibrosis Patients Who Are at Risk for Disease Progression. Int J Mol Sci 2024; 25:4061. [PMID: 38612873 PMCID: PMC11012420 DOI: 10.3390/ijms25074061] [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] [Received: 02/26/2024] [Revised: 03/26/2024] [Accepted: 03/29/2024] [Indexed: 04/14/2024] Open
Abstract
The Philadelphia chromosome-negative myeloproliferative neoplasms (Ph-MPNs) are a heterogeneous group of clonal hematopoietic malignancies that include polycythemia vera (PV), essential thrombocythemia (ET), and the prefibrotic form of primary myelofibrosis (prePMF). In this study, we retrospectively reviewed the karyotypes from conventional cytogenetics (CC) and array Comparative Genomic Hybridization + Single Nucleotide Polymorphism (aCGH + SNP) in patients with ET or prePMF to determine whether the combined analysis of both methodologies can identify patients who may be at a higher risk of disease progression. We performed a comprehensive genomic review on 169 patients with a clinical diagnosis of ET (154 patients) or prePMF (15 patients). Genomic alterations detected by CC or array-CGH + SNP were detected in 36% of patients. In patients who progressed, 68% had an abnormal genomic finding by either technology. There was a shorter progression-free survival (PFS) among patients who were cytogenetically abnormal or who were cytogenetically normal but had an abnormal aCGH + SNP result. Leveraging the ability to detect submicroscopic copy number alterations and regions of copy neutral-loss of heterozygosity, we identified a higher number of patients harboring genomic abnormalities than previously reported. These results underscore the importance of genomic analysis in prognostication and provide valuable information for clinical management and treatment decisions.
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Affiliation(s)
- Joseph Tripodi
- Tumor CytoGenomics Laboratory, Department of Pathology, Molecular and Cell-Based Medicine, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA
| | - Ronald Hoffman
- Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA
| | - Douglas Tremblay
- Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA
| | - Daiva Ahire
- Tumor CytoGenomics Laboratory, Department of Pathology, Molecular and Cell-Based Medicine, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA
| | - John Mascarenhas
- Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA
| | - Marina Kremyanskaya
- Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA
| | - Vesna Najfeld
- Tumor CytoGenomics Laboratory, Department of Pathology, Molecular and Cell-Based Medicine, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA
- Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA
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2
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Holl K, Chatain N, Krapp S, Baumeister J, Maié T, Schmitz S, Scheufen A, Brock N, Koschmieder S, Moreno-Andrés D. Calreticulin and JAK2V617F driver mutations induce distinct mitotic defects in myeloproliferative neoplasms. Sci Rep 2024; 14:2810. [PMID: 38308077 PMCID: PMC10837458 DOI: 10.1038/s41598-024-53240-8] [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: 10/23/2023] [Accepted: 01/30/2024] [Indexed: 02/04/2024] Open
Abstract
Myeloproliferative neoplasms (MPNs) encompass a diverse group of hematologic disorders driven by mutations in JAK2, CALR, or MPL. The prevailing working model explaining how these driver mutations induce different disease phenotypes is based on the decisive influence of the cellular microenvironment and the acquisition of additional mutations. Here, we report increased levels of chromatin segregation errors in hematopoietic cells stably expressing CALRdel52 or JAK2V617F mutations. Our investigations employing murine 32DMPL and human erythroleukemic TF-1MPL cells demonstrate a link between CALRdel52 or JAK2V617F expression and a compromised spindle assembly checkpoint (SAC), a phenomenon contributing to error-prone mitosis. This defective SAC is associated with imbalances in the recruitment of SAC factors to mitotic kinetochores upon CALRdel52 or JAK2V617F expression. We show that JAK2 mutant CD34 + MPN patient-derived cells exhibit reduced expression of the master mitotic regulators PLK1, aurora kinase B, and PP2A catalytic subunit. Furthermore, the expression profile of mitotic regulators in CD34 + patient-derived cells allows to faithfully distinguish patients from healthy controls, as well as to differentiate primary and secondary myelofibrosis from essential thrombocythemia and polycythemia vera. Altogether, our data suggest alterations in mitotic regulation as a potential driver in the pathogenesis in MPN.
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Affiliation(s)
- Kristin Holl
- Institute of Biochemistry and Molecular Cell Biology, Faculty of Medicine, RWTH Aachen University, Aachen, Germany
| | - Nicolas Chatain
- Department of Hematology, Oncology, Hemostaseology, and Stem Cell Transplantation, Faculty of Medicine, RWTH Aachen University, Aachen, Germany
- Center of Integrated Oncology Aachen Bonn Cologne Düsseldorf (CIO ABCD), Aachen, Germany
| | - Susanne Krapp
- Institute of Biochemistry and Molecular Cell Biology, Faculty of Medicine, RWTH Aachen University, Aachen, Germany
| | - Julian Baumeister
- Department of Hematology, Oncology, Hemostaseology, and Stem Cell Transplantation, Faculty of Medicine, RWTH Aachen University, Aachen, Germany
- Center of Integrated Oncology Aachen Bonn Cologne Düsseldorf (CIO ABCD), Aachen, Germany
| | - Tiago Maié
- Institute for Computational Genomics, Joint Research Center for Computational Biomedicine, Faculty of Medicine, RWTH Aachen University, Aachen, Germany
| | - Sarah Schmitz
- Institute of Biochemistry and Molecular Cell Biology, Faculty of Medicine, RWTH Aachen University, Aachen, Germany
| | - Anja Scheufen
- Institute of Biochemistry and Molecular Cell Biology, Faculty of Medicine, RWTH Aachen University, Aachen, Germany
| | - Nathalie Brock
- Institute of Biochemistry and Molecular Cell Biology, Faculty of Medicine, RWTH Aachen University, Aachen, Germany
| | - Steffen Koschmieder
- Department of Hematology, Oncology, Hemostaseology, and Stem Cell Transplantation, Faculty of Medicine, RWTH Aachen University, Aachen, Germany
- Center of Integrated Oncology Aachen Bonn Cologne Düsseldorf (CIO ABCD), Aachen, Germany
| | - Daniel Moreno-Andrés
- Institute of Biochemistry and Molecular Cell Biology, Faculty of Medicine, RWTH Aachen University, Aachen, Germany.
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3
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Puglianini OC, Peker D, Zhang L, Papadantonakis N. Essential Thrombocythemia and Post-Essential Thrombocythemia Myelofibrosis: Updates on Diagnosis, Clinical Aspects, and Management. Lab Med 2023; 54:13-22. [PMID: 35960786 DOI: 10.1093/labmed/lmac074] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023] Open
Abstract
Although several decades have passed since the description of myeloproliferative neoplasms (MPN), many aspects of their pathophysiology have not been elucidated. In this review, we discuss the mutational landscape of patients with essential thrombocythemia (ET), prognostic scores and salient pathology, and clinical points. We discuss also the diagnostic challenges of differentiating ET from prefibrotic MF. We then focus on post-essential thrombocythemia myelofibrosis (post-ET MF), a rare subset of MPN that is usually studied in conjunction with post-polycythemia vera MF. The transition of ET to post-ET MF is not well studied on a molecular level, and we present available data. Patients with secondary MF could benefit from allogenic hematopoietic stem cell transplantation, and we present available data focusing on post-ET MF.
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Affiliation(s)
- Omar Castaneda Puglianini
- H. Lee Moffitt Cancer Center & Research Institute, Department of Blood & Marrow Transplant & Cellular Immunotherapy, Tampa, FL, USA
- Department of Oncologic Sciences, University of South Florida Morsani College of Medicine, Tampa, FL, USA
| | - Deniz Peker
- Department of Pathology and Laboratory Medicine, Emory University School of Medicine, Atlanta, GA, USA
| | - Linsheng Zhang
- Department of Pathology and Laboratory Medicine, Emory University School of Medicine, Atlanta, GA, USA
| | - Nikolaos Papadantonakis
- Winship Cancer Institute of Emory University, Department of Hematology and Medical Oncology, Atlanta, GA, USA
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4
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Thiele J, Kvasnicka HM, Orazi A, Gianelli U, Gangat N, Vannucchi AM, Barbui T, Arber DA, Tefferi A. The international consensus classification of myeloid neoplasms and acute Leukemias: myeloproliferative neoplasms. Am J Hematol 2023; 98:166-179. [PMID: 36200127 DOI: 10.1002/ajh.26751] [Citation(s) in RCA: 27] [Impact Index Per Article: 27.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2022] [Revised: 09/30/2022] [Accepted: 10/02/2022] [Indexed: 02/04/2023]
Abstract
A group of international experts, including hematopathologists, oncologists, and geneticists were recently summoned (September 2021, Chicago, IL, USA) to update the 2016/17 World Health Organization classification system for hematopoietic tumors. After careful deliberation, the group introduced the new International Consensus Classification (ICC) for Myeloid Neoplasms and Acute Leukemias. This current in-depth review focuses on the ICC-2022 category of JAK2 mutation-prevalent myeloproliferative neoplasms (MPNs): essential thrombocythemia, polycythemia vera, primary myelofibrosis, and MPN, unclassifiable. The ICC MPN subcommittee chose to preserve the primary role of bone marrow morphology in disease classification and diagnostics, while also acknowledging the complementary role of genetic markers for establishing clonality, facilitating MPN subtype designation, and disease prognostication.
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Affiliation(s)
- Jürgen Thiele
- Institute of Pathology, University of Cologne, Cologne, Germany
| | | | - Attilio Orazi
- Department of Pathology, Texas Tech University Health Sciences Center, El Paso, Texas, USA
| | - Umberto Gianelli
- Department of Health Sciences and S.C. Anatomia Patologica, ASST Santi Paolo e Carlo, University of Milan, Milan, Italy
| | - Naseema Gangat
- Division of Hematology, Department of Internal Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Alessandro M Vannucchi
- CRIMM-Centro Ricerca e Innovazione delle Malattie Mieloproliferative, Azienda Ospedaliera-Universitaria Careggi, Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
| | - Tiziano Barbui
- FROM Research Foundation, Papa Giovanni XXIII Hospital, Bergamo, Italy
| | - Daniel A Arber
- Department of Pathology, University of Chicago, Chicago, Illinois, USA
| | - Ayalew Tefferi
- Division of Hematology, Department of Internal Medicine, Mayo Clinic, Rochester, Minnesota, USA
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5
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Rolles B, Mullally A. Molecular Pathogenesis of Myeloproliferative Neoplasms. Curr Hematol Malig Rep 2022; 17:319-329. [PMID: 36336766 DOI: 10.1007/s11899-022-00685-1] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/10/2022] [Indexed: 11/09/2022]
Abstract
PURPOSE OF REVIEW Myeloproliferative neoplasms (MPNs) are chronic hematological malignancies characterized by increased proliferation of MPN stem and myeloid progenitor cells with or without bone marrow fibrosis that typically lead to increased peripheral blood cell counts. The genetic and cytogenetic alterations that initiate and drive the development of MPNs have largely been defined, and we summarize these here. RECENT FINDINGS In recent years, advances in understanding the pathogenesis of MPNs have defined a long-preclinical phase in JAK2-mutant MPN, identified genetic loci associated with MPN predisposition and uncovered mechanistic insights in CALR-mutant MPN. The integration of molecular genetics into prognostic risk models is well-established in myelofibrosis and ongoing studies are interrogating the prognostic implications of concomitant mutations in ET and PV. Despite all these advances, the field is deficient in clonally selective therapies to effectively target the MPN clone at any stage of disease, from pre-clinical to advanced. Although the biological understanding of the pathogenesis of MPNs has progressed quickly, substantial knowledge gaps remain, including in the molecular mechanisms underlying MPN progression and myelofibrotic transformation. An ongoing goal for the MPN field is to translate advances in biological understanding to improved treatments for patients.
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Affiliation(s)
- Benjamin Rolles
- Division of Hematology, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Harvard Institutes of Medicine Building, Room 738, 77 Avenue Louis Pasteur, Boston, MA, 02115, USA
| | - Ann Mullally
- Division of Hematology, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Harvard Institutes of Medicine Building, Room 738, 77 Avenue Louis Pasteur, Boston, MA, 02115, USA. .,Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA. .,Broad Institute, Cambridge, MA, USA.
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6
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Gangat N, Jadoon Y, Szuber N, Hanson CA, Wolanskyj-Spinner AP, Ketterling RP, Pardanani A, Tefferi A. Cytogenetic abnormalities in essential thrombocythemia: Clinical and molecular correlates and prognostic relevance in 809 informative cases. Blood Cancer J 2022; 12:44. [PMID: 35301278 PMCID: PMC8931050 DOI: 10.1038/s41408-022-00639-z] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2022] [Revised: 01/14/2022] [Accepted: 01/19/2022] [Indexed: 11/12/2022] Open
Abstract
Cytogenetic studies among 809 consecutive patients with essential thrombocythemia (ET; median age 59 years; 65% females) revealed normal karyotype in 754 (93%), loss of chromosome Y only (-Y) in 16 (2%), and abnormalities other than -Y in 39 (4.8%), the most frequent being sole 20q- (n = 8). At presentation, abnormal karyotype, excluding -Y, was associated with older age (p = 0.04), higher leukocyte count (p = 0.03) and arterial thrombosis history (p = 0.02); no associations were apparent for JAK2/CALR/MPL mutations whereas ASXL1 mutations clustered with normal karyotype/-Y and TP53 with abnormal karyotype. Survival was significantly shorter in patients with abnormal karyotype or -Y, compared to those with normal karyotype (median 12, 10, and 21 years, respectively; p < 0.0001). During multivariable analysis that included IPSET (international prognostic score for ET) variables, abnormal karyotype (p < 0.01, HR 2.0), age >60 years (p < 0.01, HR 4.5), leukocytosis >11 × 109/L (p < 0.01, HR 1.5), and male gender (p < 0.01, HR 1.4) were independently associated with inferior survival; abnormal karyotype and age >60 years remained significant, along with SF3B1/SRSF2/U2AF1/TP53 mutations (p = 0.04; HR 2.9), when the latter was included in the multivariable model. The current study suggests prognostic relevance for karyotype in ET.
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Affiliation(s)
- Naseema Gangat
- Division of Hematology, Mayo Clinic, Rochester, MN, USA.
| | - Yamna Jadoon
- Division of Hematology, Mayo Clinic, Rochester, MN, USA
| | - Natasha Szuber
- Department of Hematology, Université de Montréal, Montréal, QC, Canada
| | - Curtis A Hanson
- Division of Hematopathology, Mayo Clinic, Rochester, MN, USA
| | | | - Rhett P Ketterling
- Division of Laboratory Medicine and Cytogenetics, Mayo Clinic, Rochester, MN, USA
| | | | - Ayalew Tefferi
- Division of Hematology, Mayo Clinic, Rochester, MN, USA.
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7
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Hashimoto Y, Ito T, Gotoh A, Nakamae M, Kimura F, Koike M, Kirito K, Wada H, Usuki K, Tanaka T, Mori T, Wakita S, Saito TI, Kada A, Saito AM, Shimoda K, Sugimoto Y, Kurokawa T, Tomita A, Edahiro Y, Akashi K, Matsumura I, Takenaka K, Komatsu N. Clinical characteristics, prognostic factors, and outcomes of patients with essential thrombocythemia in Japan: the JSH-MPN-R18 study. Int J Hematol 2021; 115:208-221. [PMID: 34727329 DOI: 10.1007/s12185-021-03253-0] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2021] [Revised: 10/23/2021] [Accepted: 10/24/2021] [Indexed: 11/25/2022]
Abstract
We conducted a large-scale, nationwide retrospective study of Japanese patients who were diagnosed with essential thrombocythemia based on the diagnostic criteria in the World Health Organization classification. We investigated clinical characteristics, survival rates, and the incidence of thrombohemorrhagic events as well as risk factors for these events. A total of 1152 patients were analyzed in the present study. Median age at diagnosis was 65 years, the median platelet count was 832 × 109/L, and the positive mutation rates of JAK2V617F, CALR, and MPL were 62.8, 25.1, and 4.1%, respectively. Compared with European and American patients, Japanese patients were more likely to have cardiovascular risk factors and less likely to have systemic symptoms including palpable splenomegaly. Thrombocytosis was identified as a risk factor for hemorrhagic events and prognosis, but not for thrombotic events. The prognostic factors and risk classifications reported in Europe and the United States were generally applicable to Japanese patients. Regarding transformations, secondary myelofibrosis progressed in a time-dependent manner, but progression to acute leukemia was low in "true" ET patients. Skin cancers were less common and gastrointestinal cancers more common as secondary malignancies in Japanese patients, suggesting ethnic differences.
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Affiliation(s)
- Yoshinori Hashimoto
- Department of Hematology, Juntendo University Graduate School of Medicine, 2-1-1 Hongo, Bunkyo-ku, Tokyo, 113-8421, Japan
- Laboratory for the Development of Therapies Against MPN, Juntendo University Graduate School of Medicine, Tokyo, Japan
- Department of Advanced Hematology, Juntendo University Graduate School of Medicine, Tokyo, Japan
| | - Tomoki Ito
- First Department of Internal Medicine, Kansai Medical University, Osaka, Japan
| | - Akihiko Gotoh
- Department of Hematology, Tokyo Medical University, Tokyo, Japan
| | - Mika Nakamae
- Hematology, Graduate School of Medicine, Osaka City University, Osaka, Japan
| | - Fumihiko Kimura
- Division of Hematology, Department of Internal Medicine, National Defense Medical College, Saitama, Japan
| | - Michiaki Koike
- Department of Hematology, Juntendo University Shizuoka Hospital, Shizuoka, Japan
| | - Keita Kirito
- Department of Hematology and Oncology, University of Yamanashi, Yamanashi, Japan
| | - Hideho Wada
- Department of Hematology, Kawasaki Medical School, Okayama, Japan
| | - Kensuke Usuki
- Department of Hematology, NTT Medical Center Tokyo, Tokyo, Japan
| | - Takayuki Tanaka
- Department of Hematology, Tottori Prefectural Central Hospital, Tottori, Japan
| | - Takehiko Mori
- Division of Hematology, Department of Medicine, Keio University School of Medicine, Tokyo, Japan
- Department of Hematology, Tokyo Medical and Dental University, Tokyo, Japan
| | - Satoshi Wakita
- Division of Hematology, Department of Internal Medicine, Nippon Medical School, Tokyo, Japan
| | - Toshiki I Saito
- Clinical Research Center, National Hospital Organization Nagoya Medical Center, Aichi, Japan
| | - Akiko Kada
- Clinical Research Center, National Hospital Organization Nagoya Medical Center, Aichi, Japan
| | - Akiko M Saito
- Clinical Research Center, National Hospital Organization Nagoya Medical Center, Aichi, Japan
| | - Kazuya Shimoda
- Division of Hematology, Diabetes, and Endocrinology, Department of Internal Medicine, Faculty of Medicine, University of Miyazaki, Miyazaki, Japan
| | - Yuka Sugimoto
- Department of Community Hematology, Mie University, Mie, Japan
| | - Toshiro Kurokawa
- Department of Hematology, Toyama Red Cross Hospital, Toyama, Japan
| | - Akihiro Tomita
- Department of Hematology, Fujita Health University School of Medicine, Aichi, Japan
| | - Yoko Edahiro
- Department of Hematology, Juntendo University Graduate School of Medicine, 2-1-1 Hongo, Bunkyo-ku, Tokyo, 113-8421, Japan
- Laboratory for the Development of Therapies Against MPN, Juntendo University Graduate School of Medicine, Tokyo, Japan
- Department of Advanced Hematology, Juntendo University Graduate School of Medicine, Tokyo, Japan
| | - Koichi Akashi
- Department of Medicine and Biosystemic Science, Kyushu University Graduate School of Medical Sciences, Fukuoka, Japan
| | - Itaru Matsumura
- Division of Hematology and Rheumatology, Kindai University Faculty of Medicine, Osaka, Japan
| | - Katsuto Takenaka
- Department of Hematology, Clinical Immunology and Infectious Diseases, Ehime University Graduate School of Medicine, Ehime, Japan
| | - Norio Komatsu
- Department of Hematology, Juntendo University Graduate School of Medicine, 2-1-1 Hongo, Bunkyo-ku, Tokyo, 113-8421, Japan.
- Laboratory for the Development of Therapies Against MPN, Juntendo University Graduate School of Medicine, Tokyo, Japan.
- Department of Advanced Hematology, Juntendo University Graduate School of Medicine, Tokyo, Japan.
- PharmaEssentia Japan KK, Tokyo, Japan.
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8
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The Prognostic Role of Cytogenetics Analysis in Philadelphia Negative Myeloproliferative Neoplasms. ACTA ACUST UNITED AC 2021; 57:medicina57080813. [PMID: 34441019 PMCID: PMC8398709 DOI: 10.3390/medicina57080813] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2021] [Revised: 08/03/2021] [Accepted: 08/06/2021] [Indexed: 11/16/2022]
Abstract
Myeloproliferative neoplasms (MPNs) are clonal stem cell disorders characterized collectively by clonal proliferation of myeloid cells with variable morphologic maturity and hematopoietic efficiency. Although the natural history of these neoplasms can be measured sometimes in decades more than years, the cytogenetics analysis can offer useful information regarding the prognosis. Cytogenetics has a well-established prognostic role in acute leukemias and in myelodysplastic syndromes, where it drives the clinical decisions. NGS techniques can find adverse mutations with clear prognostic value and are currently included in the prognostic evaluation of MPNs in scores such as MIPSS, GIPSS, MIPSS-PV, and MIPSS-ET. We suggest that cytogenetics (considering its availability and relative cost) has a role regarding prognostic and therapeutic decisions.
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9
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Batanian JR, Malherbe JAJ, Erber WN. A novel translocation t(10;17)(p13;q11.2) harboring two cryptic deletions identified by array-CGH and characterized by SUZ12 overexpression in a patient with chronic thrombocytosis. Genes Chromosomes Cancer 2020; 59:661-666. [PMID: 32557935 DOI: 10.1002/gcc.22881] [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: 05/05/2020] [Revised: 06/15/2020] [Accepted: 06/15/2020] [Indexed: 11/11/2022] Open
Abstract
No specific translocation is associated with myeloproliferative neoplasms (MPNs). However, an interstitial deletion involving subband 17q11.2 which includes the NF1 gene, although rare, is a recurrent aberration in several myeloid disorders including MPNs. For the first time, we report an acquired novel translocation involving 10p13 and 17q11.2 in a 62-year-old Caucasian female which was referred for investigation of chronic and persistent unexplained thrombocytosis. The patient had no history of hematological sequelae and genomic testing for JAK2, CALR, and MPL mutations were negative. She was subsequently diagnosed with a triple negative essential thrombocythemia. Array-CGH analysis noted that the translocation harbored two cryptic deletions, one of which involved 17q11.2 encompassing the NF1 gene. One of the junction breakpoints involved the SUZ12 gene. Immunohistochemical assessment of the marrow trephine showed increased megakaryocytic expression of the SUZ12 protein, as well as EZH2 and Ki67; biochemical abnormalities suggestive of excess megakaryocytic hyperplasia. This novel translocation may affect the expression of SUZ12 and its downstream targets, and may represent a unique pathogenomic etiology which drives chronic thrombocytosis in essential thrombocythemia.
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Affiliation(s)
- Jacqueline R Batanian
- Department of Pediatrics, SSM Cardinal Glennon Children's Hospital, St. Louis, MO, USA.,Department of Pathology, St. Louis University School of Medicine, SSM Cardinal Glennon Children's Hospital, St. Louis, MO, USA
| | - Jacques A J Malherbe
- School of Biomedical Sciences, The University of Western Australia, Crawley, WA, Australia
| | - Wendy N Erber
- School of Biomedical Sciences, The University of Western Australia, Crawley, WA, Australia
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10
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Dunbar AJ, Rampal RK, Levine R. Leukemia secondary to myeloproliferative neoplasms. Blood 2020; 136:61-70. [PMID: 32430500 PMCID: PMC7332899 DOI: 10.1182/blood.2019000943] [Citation(s) in RCA: 79] [Impact Index Per Article: 19.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2019] [Accepted: 01/23/2020] [Indexed: 12/11/2022] Open
Abstract
Secondary acute myeloid leukemias (AMLs) evolving from an antecedent myeloproliferative neoplasm (MPN) are characterized by a unique set of cytogenetic and molecular features distinct from de novo AML. Given the high frequency of poor-risk cytogenetic and molecular features, malignant clones are frequently insensitive to traditional AML chemotherapeutic agents. Allogeneic stem cell transplant, the only treatment modality shown to have any beneficial long-term outcome, is often not possible given the advanced age of patients at time of diagnosis and frequent presence of competing comorbidities. Even in this setting, relapse rates remain high. As a result, outcomes are generally poor and there remains a significant unmet need for novel therapeutic strategies. Although advances in cancer genomics have dramatically enhanced our understanding of the molecular events governing clonal evolution in MPNs, the cell-intrinsic and -extrinsic mechanisms driving leukemic transformation at this level remain poorly understood. Here, we review known risk factors for the development of leukemic transformation in MPNs, recent progress made in our understanding of the molecular features associated with leukemic transformation, current treatment strategies, and emerging therapeutic options for this high-risk myeloid malignancy.
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MESH Headings
- Abnormal Karyotype
- Allografts
- Antineoplastic Agents/therapeutic use
- Cell Transformation, Neoplastic
- Chromosome Aberrations
- Clonal Evolution
- Combined Modality Therapy
- Comorbidity
- Disease Progression
- Drug Resistance, Neoplasm
- Drugs, Investigational/therapeutic use
- Genes, Neoplasm
- Hematopoietic Stem Cell Transplantation
- Humans
- Leukemia, Myeloid, Acute/etiology
- Leukemia, Myeloid, Acute/genetics
- Leukemia, Myeloid, Acute/pathology
- Leukemia, Myeloid, Acute/therapy
- Models, Biological
- Mutation
- Myeloproliferative Disorders/genetics
- Myeloproliferative Disorders/pathology
- Neoplasm Proteins/genetics
- Recurrence
- Risk Factors
- Single-Cell Analysis
- Therapies, Investigational
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Affiliation(s)
- Andrew J Dunbar
- Leukemia Service, Department of Medicine
- Center for Hematologic Malignancies
| | - Raajit K Rampal
- Leukemia Service, Department of Medicine
- Center for Hematologic Malignancies
| | - Ross Levine
- Leukemia Service, Department of Medicine
- Center for Hematologic Malignancies
- Human Oncology and Pathogenesis Program, and
- Center for Epigenetics Research, Memorial Sloan Kettering Cancer Center, New York, NY
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11
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Tefferi A, Guglielmelli P, Lasho TL, Coltro G, Finke CM, Loscocco GG, Sordi B, Szuber N, Rotunno G, Pacilli A, Hanson CA, Ketterling RP, Pardanani A, Gangat N, Vannucchi AM. Mutation-enhanced international prognostic systems for essential thrombocythaemia and polycythaemia vera. Br J Haematol 2020; 189:291-302. [PMID: 31945802 DOI: 10.1111/bjh.16380] [Citation(s) in RCA: 125] [Impact Index Per Article: 31.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2019] [Accepted: 10/15/2019] [Indexed: 01/08/2023]
Abstract
Survival prediction in essential thrombocythaemia (ET) and polycythaemia vera (PV) is currently based on clinically-derived variables; we examined the possibility of integrating genetic information for predicting survival. To this end, 906 molecularly-annotated patients (416 Mayo Clinic; 490 University of Florence, Italy), including 502 ET and 404 PV, were recruited. Multivariable analysis identified spliceosome mutations to adversely affect overall (SF3B1, SRSF2 in ET and SRSF2 in PV) and myelofibrosis-free (U2AF1, SF3B1 in ET) survival; TP53 mutations predicted leukaemic transformation in ET; "adverse" mutations occurred in 51 (10%) ET and 8 (2%) PV patients. We confirmed the independent survival effect of adverse mutations [hazard ratio (HR) 2·4, 95% CI 1·6-3·5], age >60 years (6·6, 4·6-9·7), male sex (1·8, 1·3-2·4) and leukocytosis ≥11 × 109 /l (1·6, 1·1-2·2), in ET, and adverse mutations (7·8, 3·1-17·0), age >67 years (5·4, 3·6-8·1), leukocytosis ≥15 × 109 /l (2·8, 1·8-4·2) and thrombosis history (2·0, 1·4-2·9), in PV. HR-based risk point allocation allowed development of three-tiered mutation-enhanced international prognostic systems (MIPSS) which were validated in both cohorts and performance was shown to be superior to conventional scoring systems. Spliceosome mutations enhance survival prediction in ET and PV and identify patients at risk for fibrotic progression. TP53 mutations predict leukaemic transformation in ET.
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Affiliation(s)
- Ayalew Tefferi
- Division of Hematology, Departments of Internal Medicine and Laboratory Medicine, Mayo Clinic, Rochester, MN, USA
| | - Paola Guglielmelli
- Department of Experimental and Clinical Medicine, CRIMM, Center of Research and Innovation of Myeloproliferative Neoplasms, Azienda Ospedaliera Universitaria Careggi, University of Florence, and Denothe Excellence Center, Florence, Italy
| | - Terra L Lasho
- Division of Hematology, Departments of Internal Medicine and Laboratory Medicine, Mayo Clinic, Rochester, MN, USA
| | - Giacomo Coltro
- Department of Experimental and Clinical Medicine, CRIMM, Center of Research and Innovation of Myeloproliferative Neoplasms, Azienda Ospedaliera Universitaria Careggi, University of Florence, and Denothe Excellence Center, Florence, Italy
| | - Christy M Finke
- Division of Hematology, Departments of Internal Medicine and Laboratory Medicine, Mayo Clinic, Rochester, MN, USA
| | - Giuseppe G Loscocco
- Department of Experimental and Clinical Medicine, CRIMM, Center of Research and Innovation of Myeloproliferative Neoplasms, Azienda Ospedaliera Universitaria Careggi, University of Florence, and Denothe Excellence Center, Florence, Italy
| | - Benedetta Sordi
- Department of Experimental and Clinical Medicine, CRIMM, Center of Research and Innovation of Myeloproliferative Neoplasms, Azienda Ospedaliera Universitaria Careggi, University of Florence, and Denothe Excellence Center, Florence, Italy
| | - Natasha Szuber
- Division of Hematology, Departments of Internal Medicine and Laboratory Medicine, Mayo Clinic, Rochester, MN, USA
| | - Giada Rotunno
- Department of Experimental and Clinical Medicine, CRIMM, Center of Research and Innovation of Myeloproliferative Neoplasms, Azienda Ospedaliera Universitaria Careggi, University of Florence, and Denothe Excellence Center, Florence, Italy
| | - Annalisa Pacilli
- Department of Experimental and Clinical Medicine, CRIMM, Center of Research and Innovation of Myeloproliferative Neoplasms, Azienda Ospedaliera Universitaria Careggi, University of Florence, and Denothe Excellence Center, Florence, Italy
| | - Curtis A Hanson
- Division of Hematopathology, Departments of Internal Medicine and Laboratory Medicine, Mayo Clinic, Rochester, MN, USA
| | - Rhett P Ketterling
- Division of Laboratory Genetics and Genomics, Departments of Internal Medicine and Laboratory Medicine, Mayo Clinic, Rochester, MN, USA
| | - Animesh Pardanani
- Division of Hematology, Departments of Internal Medicine and Laboratory Medicine, Mayo Clinic, Rochester, MN, USA
| | - Naseema Gangat
- Division of Hematology, Departments of Internal Medicine and Laboratory Medicine, Mayo Clinic, Rochester, MN, USA
| | - Alessandro M Vannucchi
- Department of Experimental and Clinical Medicine, CRIMM, Center of Research and Innovation of Myeloproliferative Neoplasms, Azienda Ospedaliera Universitaria Careggi, University of Florence, and Denothe Excellence Center, Florence, Italy
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12
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Transcriptional alteration of DNA repair genes in Philadelphia chromosome negative myeloproliferative neoplasms. Ann Hematol 2019; 98:2703-2709. [DOI: 10.1007/s00277-019-03836-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2019] [Accepted: 10/28/2019] [Indexed: 12/21/2022]
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13
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Tavares RS, Nonino A, Pagnano KBB, Nascimento ACKVD, Conchon M, Fogliatto LM, Funke VAM, Bendit I, Clementino NCD, Chauffaille MDLLF, Bernardo WM, Santos FPDS. Guideline on myeloproliferative neoplasms: Associacão Brasileira de Hematologia, Hemoterapia e Terapia Cellular: Project guidelines: Associação Médica Brasileira - 2019. Hematol Transfus Cell Ther 2019; 41 Suppl 1:1-73. [PMID: 31248788 PMCID: PMC6630088 DOI: 10.1016/j.htct.2019.03.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2019] [Accepted: 03/20/2019] [Indexed: 12/22/2022] Open
Affiliation(s)
| | - Alexandre Nonino
- Instituto Hospital de Base do Distrito Federal (IHBDF), Brasília, DF, Brazil
| | | | | | | | | | | | - Israel Bendit
- Hospital Das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), São Paulo, SP, Brazil
| | | | | | - Wanderley Marques Bernardo
- Hospital Das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), São Paulo, SP, Brazil; Associação Médica Brasileira (AMB), São Paulo, SP, Brazil
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14
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Cytogenetic evolution in myeloproliferative neoplasms with different molecular abnormalities. Blood Cells Mol Dis 2019; 77:120-128. [PMID: 31059941 DOI: 10.1016/j.bcmd.2019.04.007] [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: 02/08/2019] [Revised: 04/12/2019] [Accepted: 04/12/2019] [Indexed: 11/20/2022]
Abstract
We investigated the changes in chromosomal abnormalities in myeloproliferative neoplasm (MPN) patients during long-term follow-up. In total, 28 MPN patients (22 with primary myelofibrosis and 6 with polycythemia vera) were included. Among them, 25 patients underwent serial bone marrow (BM) biopsies during disease progression, and 3 patients had cytogenetic abnormalities at initial diagnosis but lacked follow-up BM biopsies. JAK2, CALR, and MPL mutation analyses were performed. Targeted sequencing analysis was conducted in 11 patients. Among the 28 patients, 21 (75.0%) had cytogenetic abnormalities either at diagnosis (8/26) or during follow-up. The median time from the initial analysis to the appearance of additional cytogenetic abnormalities was 8.4 years. Among the chromosomal abnormalities at initial diagnosis, trisomy 8 (3/26, 11.5%) was the most frequent, followed by gain of 1q, del(20q), and del(9q) (each in 2/26). Among all chromosomal abnormalities, including those that occurred during follow-up, the most frequent was del(20q) and +1q (8/28, 28.6%), followed by del(6p) (14.3%) and trisomy 8 (10.7%). Del(20q) was more frequent in CALR-mutated patients (4/6, 66.7%) than in JAK2-mutated patients (3/19, 15.8%, P = 0.016). The presence of cytogenetic abnormalities at initial diagnosis was associated with poor prognosis. Cytogenetic evolution may provide interesting insights into the disease course.
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15
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Cytogenetic clonal evolution in myeloproliferative neoplasms: contexts and prognostic impact among 648 patients with serial bone marrow biopsies. Leukemia 2019; 33:2522-2553. [PMID: 31040370 DOI: 10.1038/s41375-019-0453-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2018] [Revised: 11/28/2018] [Accepted: 12/07/2018] [Indexed: 11/08/2022]
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Mora B, Passamonti F. Developments in diagnosis and treatment of essential thrombocythemia. Expert Rev Hematol 2019; 12:159-171. [PMID: 30793984 DOI: 10.1080/17474086.2019.1585239] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
INTRODUCTION Essential thrombocythemia (ET) is a chronic myeloproliferative neoplasm characterized by thrombocytosis, increased risk of thrombotic/hemorrhagic events and clonal evolution into blast phase or myelofibrosis. Areas covered: The authors will discuss biology, diagnosis, prognosis, therapy, and outcome of ET. An accurate molecular-morphologic assessment is necessary in order to properly establish diagnosis and prognosis of ET. Stratification for thrombosis prediction is essential, and IPSET-t model is widely applied. The current treatment strategy is directed to lower the rate of vascular events using cytoreduction in patients at high risk. Prophylactic low dose aspirin indication is more uncertain. To date, therapies for patients who are resistant or intolerant to first-line treatments are scarce. Overall, life expectancy indicates an indolent disease, but IPSET model helps in predicting survival at the time of diagnosis. Expert opinion: Challenging for the future will be to share criteria for ET diagnosis with the community. New insights into the molecular pathogenesis of the disease will improve the prediction of clonal evolution and outcome, and lead to the use of disease-modifying treatments.
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Affiliation(s)
- Barbara Mora
- a Ospedale di Circolo , ASST Sette Laghi, Hematology , Varese , Italy
| | - Francesco Passamonti
- a Ospedale di Circolo , ASST Sette Laghi, Hematology , Varese , Italy.,b Department of Medicine and Surgery , Universita degli Studi dell'Insubria , Varese , Italy
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17
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Caponetti GC, Bagg A. Genetic studies in the evaluation of myeloproliferative neoplasms. Semin Hematol 2019; 56:7-14. [DOI: 10.1053/j.seminhematol.2018.05.004] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2018] [Accepted: 05/07/2018] [Indexed: 12/23/2022]
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18
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Post-ET and Post-PV Myelofibrosis: Updates on a Distinct Prognosis from Primary Myelofibrosis. Curr Hematol Malig Rep 2018; 13:173-182. [DOI: 10.1007/s11899-018-0453-y] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
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19
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Mora B, Giorgino T, Guglielmelli P, Rumi E, Maffioli M, Rambaldi A, Caramella M, Komrokji R, Gotlib J, Kiladjian JJ, Cervantes F, Devos T, Palandri F, De Stefano V, Ruggeri M, Silver RT, Benevolo G, Albano F, Cavalloni C, Barraco D, Merli M, Pietra D, Casalone R, Barbui T, Rotunno G, Cazzola M, Vannucchi AM, Passamonti F. Value of cytogenetic abnormalities in post-polycythemia vera and post-essential thrombocythemia myelofibrosis: a study of the MYSEC project. Haematologica 2018; 103:e392-e394. [PMID: 29622658 DOI: 10.3324/haematol.2017.185751] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Affiliation(s)
- Barbara Mora
- Hematology, Department of Medicine and Surgery, University of Insubria, Ospedale di Circolo, ASST Sette Laghi, Varese, Italy
| | - Toni Giorgino
- Biophysics Institute, National Research Council of Italy, Milano, Italy
| | - Paola Guglielmelli
- CRIMM-Centro Ricerca e Innovazione delle Malattie Mieloproliferative, Department of Experimental and Clinical Medicine, Azienda ospedaliera-Universitaria Careggi, University of Florence, Italy
| | - Elisa Rumi
- Department of Hematology Oncology, Fondazione IRCCS Policlinico San Matteo, Università di Pavia, Italy
| | - Margherita Maffioli
- Hematology, Department of Medicine and Surgery, University of Insubria, Ospedale di Circolo, ASST Sette Laghi, Varese, Italy
| | - Alessandro Rambaldi
- University of Milan, Hematology and BMT Unit, ASST Papa Giovanni XXIII, Bergamo, Italy
| | | | | | | | | | | | - Timothy Devos
- Department of Hematology, University Hospitals Leuven and Laboratory of Experimental Transplantation, Department of Microbiology and Immunology, KU Leuven, Belgium
| | | | | | | | | | - Giulia Benevolo
- Centro Oncologico Ematologico Subalpino (COES), Torino, Italy
| | | | - Chiara Cavalloni
- Department of Hematology Oncology, Fondazione IRCCS Policlinico San Matteo, Università di Pavia, Italy
| | - Daniela Barraco
- Hematology, Department of Medicine and Surgery, University of Insubria, Ospedale di Circolo, ASST Sette Laghi, Varese, Italy
| | - Michele Merli
- Hematology, Department of Medicine and Surgery, University of Insubria, Ospedale di Circolo, ASST Sette Laghi, Varese, Italy
| | - Daniela Pietra
- Department of Hematology Oncology, Fondazione IRCCS Policlinico San Matteo, Università di Pavia, Italy
| | - Rosario Casalone
- Cytogenetics and Medical Genetics Laboratory, Ospedale di Circolo, ASST Sette Laghi, Varese, Italy
| | - Tiziano Barbui
- FROM Research Foundation, ASST Papa Giovanni XXIII, Bergamo, Italy
| | - Giada Rotunno
- CRIMM-Centro Ricerca e Innovazione delle Malattie Mieloproliferative, Department of Experimental and Clinical Medicine, Azienda ospedaliera-Universitaria Careggi, University of Florence, Italy
| | - Mario Cazzola
- Department of Hematology Oncology, Fondazione IRCCS Policlinico San Matteo, Università di Pavia, Italy
| | - Alessandro Maria Vannucchi
- CRIMM-Centro Ricerca e Innovazione delle Malattie Mieloproliferative, Department of Experimental and Clinical Medicine, Azienda ospedaliera-Universitaria Careggi, University of Florence, Italy
| | - Francesco Passamonti
- Hematology, Department of Medicine and Surgery, University of Insubria, Ospedale di Circolo, ASST Sette Laghi, Varese, Italy
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20
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Ayres-Silva JP, Bonamino MH, Gouveia ME, Monte-Mor BCR, Coutinho DF, Daumas AH, Solza C, Braggio E, Zalcberg IR. Genetic Alterations in Essential Thrombocythemia Progression to Acute Myeloid Leukemia: A Case Series and Review of the Literature. Front Oncol 2018. [PMID: 29515972 PMCID: PMC5826070 DOI: 10.3389/fonc.2018.00032] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
The genetic events associated with transformation of myeloproliferative neoplasms (MPNs) to secondary acute myeloid leukemia (sAML), particularly in the subgroup of essential thrombocythemia (ET) patients, remain incompletely understood. Deep studies using high-throughput methods might lead to a better understanding of genetic landscape of ET patients who transformed to sAML. We performed array-based comparative genomic hybridization (aCGH) and whole exome sequencing (WES) to analyze paired samples from ET and sAML phases. We investigated five patients with previous history of MPN, which four had initial diagnosis of ET (one case harboring JAK2 p.Val617Phe and the remaining three CALR type II p.Lys385fs*47), and one was diagnosed with MPN/myelodysplastic syndrome with thrombocytosis (SF3B1 p.Lys700Glu). All were homogeneously treated with hydroxyurea, but subsequently transformed to sAML (mean time of 6 years/median of 4 years to transformation). Two of them have chromosomal abnormalities, and both acquire 2p gain and 5q deletion at sAML stage. The molecular mechanisms associated with leukemic progression in MPN patients are not clear. Our WES data showed TP53 alterations recurrently observed as mutations (missense and frameshift) and monoallelic loss. On the other hand, aCGH showed novel chromosome abnormalities (+2p and del5q) potentially associated with disease progression. The results reported here add valuable information to the still fragmented molecular basis of ET to sAML evolution. Further studies are necessary to identify minimal deleted/amplified region and genes relevant to sAML transformation.
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Affiliation(s)
- Jackline P Ayres-Silva
- Bone Marrow Transplantation Unit, Specialized Laboratories, Laboratory of Molecular Biology, National Cancer Institute (INCa), Rio de Janeiro, Brazil
| | - Martin H Bonamino
- Programa de Carcinogênese Molecular, National Cancer Institute (INCa), Rio de Janeiro, Brazil.,Vice-presidência de Pesquisa e Coleções Biológicas, Oswaldo Cruz Foundation, Rio de Janeiro, Brazil
| | - Maria E Gouveia
- Hematology Department, Chemotherapy Unit, Hospital Universitario Antonio Pedro - HUAP, Rio de Janeiro, Brazil
| | - Barbara C R Monte-Mor
- Bone Marrow Transplantation Unit, Specialized Laboratories, Laboratory of Molecular Biology, National Cancer Institute (INCa), Rio de Janeiro, Brazil
| | - Diego F Coutinho
- Bone Marrow Transplantation Unit, Specialized Laboratories, Laboratory of Molecular Biology, National Cancer Institute (INCa), Rio de Janeiro, Brazil
| | - Adelmo H Daumas
- Hematology Department, Chemotherapy Unit, Hospital Universitario Antonio Pedro - HUAP, Rio de Janeiro, Brazil
| | - Cristiana Solza
- Hematology Unit, Hospital Universitario Pedro Ernesto - HUPE, Rio de Janeiro, Brazil
| | - Esteban Braggio
- Department of Hematology and Oncology, Mayo Clinic, Scottsdale, AZ, United States
| | - Ilana Renault Zalcberg
- Bone Marrow Transplantation Unit, Specialized Laboratories, Laboratory of Molecular Biology, National Cancer Institute (INCa), Rio de Janeiro, Brazil
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21
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Abstract
Current drug therapy for myeloproliferative neoplasms, including essential thrombocythemia (ET) and polycythemia vera (PV), is neither curative nor has it been shown to prolong survival. Fortunately, prognosis in ET and PV is relatively good, with median survivals in younger patients estimated at 33 and 24 years, respectively. Therefore, when it comes to treatment in ET or PV, less is more and one should avoid exposing patients to new drugs that have not been shown to be disease-modifying, and whose long-term consequences are suspect (e.g., ruxolitinib). Furthermore, the main indication for treatment in ET and PV is to prevent thrombosis and, in that regard, none of the newer drugs have been shown to be superior to the time-tested older drugs (e.g., hydroxyurea). We currently consider three major risk factors for thrombosis (history of thrombosis, JAK2/MPL mutations, and advanced age), in order to group ET patients into four risk categories: "very low risk" (absence of all three risk factors); "low risk" (presence of JAK2/MPL mutations); "intermediate-risk" (presence of advanced age); and "high-risk" (presence of thrombosis history or presence of both JAK2/MPL mutations and advanced age). Herein, we provide a point-of-care treatment algorithm that is risk-adapted and based on evidence and decades of experience.
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22
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Tefferi A, Betti S, Barraco D, Mudireddy M, Shah S, Hanson CA, Ketterling RP, Pardanani A, Gangat N, Coltro G, Guglielmelli P, Vannucchi AM. Gender and survival in essential thrombocythemia: A two-center study of 1,494 patients. Am J Hematol 2017; 92:1193-1197. [PMID: 28795425 DOI: 10.1002/ajh.24882] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2017] [Revised: 08/07/2017] [Accepted: 08/07/2017] [Indexed: 12/30/2022]
Abstract
Based on suggestive information from recent epidemiologic data and earlier retrospective studies, we revisited the effect of gender on survival in 1,494 patients with essential thrombocythemia (ET). The primary study population included 904 patients from the Mayo Clinic (median age 58 years; 65% females); risk distribution, according to the international prognostic score for ET (IPSET), was 23% high, 42% intermediate and 35% low. Multivariable analysis that included IPSET-relevant risk factors identified male sex (HR 1.6, 95% CI 1.3-2.0), age ≥60 years (HR 4.3, 95% CI 3.4-5.4) and leukocyte count ≥11 × 10(9)/L (HR 1.5, 95% CI 1.3-1.9) as independent predictors of shortened survival. These findings were confirmed by analysis of a separate cohort of 590 ET patients (65% females) from the University of Florence, Italy, with corresponding HRs (95% CI) of 1.6 (1.1-2.5), 4.6 (2.2-9.5) and 1.8 (1.1-2.8). The independent prognostic effect of gender was further corroborated by a separate multivariable analysis against IPSET risk categories; HR (95% CI) for the Mayo Clinic/Florence cohorts were 1.5/1.6 (1.2/1.1-1.8/2.5) for male sex, 6.8/7.5 (5.0/3.1-9.3/18.3) for IPSET high risk and 2.8/4.1 (2.1/1.8-3.8/9.5) for IPSET intermediate risk. Furthermore, the survival disadvantage in men was most apparent in IPSET high risk category and in patients older than 60 years. In both patient cohorts, thrombosis history garnered significance in univariate, but not in multivariable analysis. The observations from the current study suggest that women with ET live longer than their male counterparts and that gender might supersede thrombosis history as a risk variable for overall survival.
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Affiliation(s)
- Ayalew Tefferi
- Divisions of Hematology; Mayo Clinic; Rochester Minnesota
| | - Silvia Betti
- Divisions of Hematology; Mayo Clinic; Rochester Minnesota
| | | | | | - Sahrish Shah
- Divisions of Hematology; Mayo Clinic; Rochester Minnesota
| | | | - Rhett P. Ketterling
- Cytogenetics, Departments of Medicine and Laboratory Medicine; Mayo Clinic; Rochester Minnesota
| | | | - Naseema Gangat
- Divisions of Hematology; Mayo Clinic; Rochester Minnesota
| | - Giacomo Coltro
- Department of Experimental and Clinical Medicine; CRIMM, Center Research and Innovation of Myeloproliferative Neoplasms, Azienda Ospedaliera Universitaria Careggi, University of Florence; Florence Italy
| | - Paola Guglielmelli
- Department of Experimental and Clinical Medicine; CRIMM, Center Research and Innovation of Myeloproliferative Neoplasms, Azienda Ospedaliera Universitaria Careggi, University of Florence; Florence Italy
| | - Alessandro M. Vannucchi
- Department of Experimental and Clinical Medicine; CRIMM, Center Research and Innovation of Myeloproliferative Neoplasms, Azienda Ospedaliera Universitaria Careggi, University of Florence; Florence Italy
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Tefferi A, Vannucchi AM. Genetic Risk Assessment in Myeloproliferative Neoplasms. Mayo Clin Proc 2017; 92:1283-1290. [PMID: 28778261 DOI: 10.1016/j.mayocp.2017.06.002] [Citation(s) in RCA: 46] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2017] [Revised: 06/05/2017] [Accepted: 06/06/2017] [Indexed: 12/31/2022]
Abstract
The World Health Organization classification system recognizes 4 variants of JAK2 mutation-enriched myeloproliferative neoplasms (for expansion of gene symbols, use search tool at www.genenames.org): essential thrombocythemia (ET), polycythemia vera (PV), primary myelofibrosis (PMF), and prefibrotic PMF. All 4 disorders are characterized by stem cell-derived clonal myeloproliferation with mutually exclusive driver mutations, including JAK2, CALR, and MPL. The median survival is approximately 20 years for ET, 14 years for PV, and 6 years for PMF; age is the most important determinant of survival with the corresponding median of 33, 24, and 15 years in patients younger than 60 years. Genetic information is the second most important prognostic tool and includes karyotype, driver mutational status, and presence of specific other mutations. Karyotype has been shown to carry prognostic relevance in PV (abnormal vs normal) and PMF (unfavorable vs favorable abnormalities). Driver mutational status is prognostically most relevant in PMF; type 1/type 1-like CALR vs other driver mutational status has been associated with superior survival. In ET, arterial thrombosis risk is higher in patients with JAK2 or MPL mutations whereas MPL-mutated patients might be at risk for accelerated fibrotic progression. ASXL1 and SRSF2 mutations have been associated with inferior overall, leukemia-free, or fibrosis-free survival in both PV and PMF, and a recent targeted sequencing study has identified additional other adverse mutations in both these disorders, as well as in ET. Further enhancement of genetic risk stratification in myeloproliferative neoplasms is possible by combining cytogenetic and mutation information and developing a prognostic model that is adjusted for age.
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Affiliation(s)
- Ayalew Tefferi
- Division of Hematology, Department of Medicine, Mayo Clinic, Rochester, MN.
| | - Alessandro Maria Vannucchi
- Department of Experimental and Clinical Medicine, CRIMM, Center Research and Innovation of Myeloproliferative Neoplasms, Azienda Ospedaliera Universitaria Careggi, University of Florence, Florence, Italy
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24
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Chuzi S, Stein BL. Essential thrombocythemia: a review of the clinical features, diagnostic challenges, and treatment modalities in the era of molecular discovery. Leuk Lymphoma 2017; 58:2786-2798. [DOI: 10.1080/10428194.2017.1312371] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Affiliation(s)
- Sarah Chuzi
- Department of Medicine, Northwestern Feinberg University School of Medicine, Chicago, IL, USA
| | - Brady L. Stein
- Department of Medicine, Northwestern Feinberg University School of Medicine, Chicago, IL, USA
- Robert H. Lurie Comprehensive Cancer Center, Northwestern Feinberg University School of Medicine, Chicago, IL, USA
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25
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Zaidi U, Shahid S, Fatima N, Ahmed S, Sufaida G, Nadeem M, Shamsi T. Genomic profile of a patient with triple negative essential thrombocythemia, unresponsive to therapy: A case report and literature review. J Adv Res 2017; 8:375-378. [PMID: 28560052 PMCID: PMC5435578 DOI: 10.1016/j.jare.2017.04.001] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2017] [Revised: 04/12/2017] [Accepted: 04/14/2017] [Indexed: 11/15/2022] Open
Abstract
Clonal analysis of patients with triple negative myeloproliferative neoplasm (MPN) has provided evidence of additional aberrations, including epigenetic alterations. To discover such novel genetic aberrations, patients were screened through next-generation sequencing using a myeloid sequencing panel of 54 genes using a genetic analyser. Genetic variants in 28 genes, including TET2, BCOR, BCR, and ABL1 were identified in a triple negative essential thrombocythemia (ET) patient. The individual role of some of these variants in disease pathogenesis has yet to be studied. Somatic mutations in the same genes have been reported with variable frequencies in myeloid malignancies. However, no pathogenic impact of these variants could be found; therefore, long-term follow up of patients with genetic analysis of a large cohort and the use of whole genome sequencing is required to assess the effects of these variants.
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Affiliation(s)
- Uzma Zaidi
- Department of Clinical Haematology, National Institute of Blood Diseases and Bone Marrow Transplantation, P.O. Box 75300, Pakistan
| | - Saba Shahid
- Department of Genomics, National Institute of Blood Diseases and Bone Marrow Transplantation, P.O. Box 75300, Pakistan
- Corresponding author.
| | - Naveen Fatima
- Department of Research & Molecular Medicine, National Institute of Blood Diseases and Bone Marrow Transplantation, P.O. Box 75300, Pakistan
| | - Shariq Ahmed
- Department of Genomics, National Institute of Blood Diseases and Bone Marrow Transplantation, P.O. Box 75300, Pakistan
| | - Gul Sufaida
- Department of Genomics, National Institute of Blood Diseases and Bone Marrow Transplantation, P.O. Box 75300, Pakistan
| | - Muhammad Nadeem
- Department of Genomics, National Institute of Blood Diseases and Bone Marrow Transplantation, P.O. Box 75300, Pakistan
| | - Tahir Shamsi
- Department of Clinical Haematology, National Institute of Blood Diseases and Bone Marrow Transplantation, P.O. Box 75300, Pakistan
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Kim JR, Cho YU, Bae MH, Kim B, Jang S, Seo EJ, Chi HS, Park CJ. Myelodysplasia-Related Features of Acute Myeloid Leukemia Evolving From Philadelphia-Negative Myeloproliferative Neoplasms. Ann Lab Med 2016; 36:377-9. [PMID: 27139614 PMCID: PMC4855061 DOI: 10.3343/alm.2016.36.4.377] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2015] [Revised: 12/29/2015] [Accepted: 03/18/2016] [Indexed: 11/19/2022] Open
Affiliation(s)
- Jae Ryuk Kim
- Department of Laboratory Medicine, University of Ulsan, College of Medicine and Asan Medical Center, Seoul, Korea
| | - Young Uk Cho
- Department of Laboratory Medicine, University of Ulsan, College of Medicine and Asan Medical Center, Seoul, Korea.
| | - Mi Hyun Bae
- Department of Laboratory Medicine, University of Ulsan, College of Medicine and Asan Medical Center, Seoul, Korea
| | - Bohyun Kim
- Department of Laboratory Medicine, University of Ulsan, College of Medicine and Asan Medical Center, Seoul, Korea
| | - Seongsoo Jang
- Department of Laboratory Medicine, University of Ulsan, College of Medicine and Asan Medical Center, Seoul, Korea
| | - Eul Ju Seo
- Department of Laboratory Medicine, University of Ulsan, College of Medicine and Asan Medical Center, Seoul, Korea
| | - Hyun Sook Chi
- Department of Laboratory Medicine, University of Ulsan, College of Medicine and Asan Medical Center, Seoul, Korea
| | - Chan Jeoung Park
- Department of Laboratory Medicine, University of Ulsan, College of Medicine and Asan Medical Center, Seoul, Korea
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Suleiman Y, Dalia S, Liu JJ, Bowers JW, Padron E, Lancet JE, Fulp W, Moscinski LC, Komrokji RS, Zuckerman KS, Zhang L. Clinical prognostic factors and outcomes of essential thrombocythemia when transformed to myelodysplastic syndromes and acute myeloid leukemia. Leuk Res 2016; 42:52-8. [PMID: 26894965 DOI: 10.1016/j.leukres.2016.01.015] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2015] [Revised: 01/14/2016] [Accepted: 01/31/2016] [Indexed: 01/31/2023]
Abstract
Transformation of essential thrombocythemia (ET) to myelodysplastic syndromes or acute myeloid leukemia is infrequent, comprising 1-5% of cases with dismal clinical outcome. Studies on prognosis in ET patients with leukemic transformation are limited. The large cohort included 40 patients (1990-2014) with ET transformation (median age of 59 years, M:F of 1:1). Median time from ET diagnosis to transformation was 76 months (26-481) with median follow-up time of 15 years. Advanced age, myelofibrosis (grade 2-3), and leukocytosis at the time of transformation were associated with inferior OS from transformation (p<0.05). Given rarity of the clinical scenario, multicenter efforts are encouraged.
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Affiliation(s)
- Yaman Suleiman
- Department of Malignant Hematology, H. Lee Moffitt Cancer Center & Research Institute, Tampa, FL, United States
| | - Samir Dalia
- Mercy Clinic Oncology and Hematology Joplin, Joplin, MO, United States
| | - Jane Jijun Liu
- Department of Malignant Hematology, H. Lee Moffitt Cancer Center & Research Institute, Tampa, FL, United States
| | - Jeremy W Bowers
- Department of Hematopathology and Laboratory Medicine, H. Lee Moffitt Cancer Center & Research Institute, Tampa, FL, United States
| | - Eric Padron
- Department of Malignant Hematology, H. Lee Moffitt Cancer Center & Research Institute, Tampa, FL, United States
| | - Jeffrey E Lancet
- Department of Malignant Hematology, H. Lee Moffitt Cancer Center & Research Institute, Tampa, FL, United States
| | - William Fulp
- Department of Biostatistics, H. Lee Moffitt Cancer Center & Research Institute, Tampa, FL, United States
| | - Lynn C Moscinski
- Department of Hematopathology and Laboratory Medicine, H. Lee Moffitt Cancer Center & Research Institute, Tampa, FL, United States
| | - Rami S Komrokji
- Department of Malignant Hematology, H. Lee Moffitt Cancer Center & Research Institute, Tampa, FL, United States
| | - Kenneth S Zuckerman
- Department of Malignant Hematology, H. Lee Moffitt Cancer Center & Research Institute, Tampa, FL, United States
| | - Ling Zhang
- Department of Hematopathology and Laboratory Medicine, H. Lee Moffitt Cancer Center & Research Institute, Tampa, FL, United States.
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Cerquozzi S, Tefferi A. Blast transformation and fibrotic progression in polycythemia vera and essential thrombocythemia: a literature review of incidence and risk factors. Blood Cancer J 2015; 5:e366. [PMID: 26565403 PMCID: PMC4670948 DOI: 10.1038/bcj.2015.95] [Citation(s) in RCA: 176] [Impact Index Per Article: 19.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2015] [Accepted: 09/18/2015] [Indexed: 12/12/2022] Open
Abstract
Polycythemia vera (PV) and essential thrombocythemia (ET) constitute two of the three BCR-ABL1-negative myeloproliferative neoplasms and are characterized by relatively long median survivals (approximately 14 and 20 years, respectively). Potentially fatal disease complications in PV and ET include disease transformation into myelofibrosis (MF) or acute myeloid leukemia (AML). The range of reported frequencies for post-PV MF were 4.9–6% at 10 years and 6–14% at 15 years and for post-ET MF were 0.8–4.9% at 10 years and 4–11% at 15 years. The corresponding figures for post-PV AML were 2.3–14.4% at 10 years and 5.5–18.7% at 15 years and for post-ET AML were 0.7–3% at 10 years and 2.1–5.3% at 15 years. Risk factors cited for post-PV MF include advanced age, leukocytosis, reticulin fibrosis, splenomegaly and JAK2V617F allele burden and for post-ET MF include advanced age, leukocytosis, anemia, reticulin fibrosis, absence of JAK2V617F, use of anagrelide and presence of ASXL1 mutation. Risk factors for post-PV AML include advanced age, leukocytosis, reticulin fibrosis, splenomegaly, abnormal karyotype, TP53 or RUNX1 mutations as well as use of pipobroman, radiophosphorus (P32) and busulfan and for post-ET AML include advanced age, leukocytosis, anemia, extreme thrombocytosis, thrombosis, reticulin fibrosis, TP53 or RUNX1 mutations. It is important to note that some of the aforementioned incidence figures and risk factor determinations are probably inaccurate and at times conflicting because of the retrospective nature of studies and the inadvertent labeling, in some studies, of patients with prefibrotic primary MF or ‘masked' PV, as ET. Ultimately, transformation of MPN leads to poor outcomes and management remains challenging. Further understanding of the molecular events leading to disease transformation is being investigated.
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Affiliation(s)
- S Cerquozzi
- Division of Hematology, Department of Medicine, Mayo Clinic, Rochester, MN, USA
| | - A Tefferi
- Division of Hematology, Department of Medicine, Mayo Clinic, Rochester, MN, USA
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Abstract
Essential thrombocythemia patients develop acute myeloid leukemia (AML) at a rate of 1-4% during a median follow-up of 7-10 years. The risk increases with advanced age, anemia, platelet count ≥ 1000 × 10(9)/l, the presence of ≥ 2 somatic mutations and after the first decade of diagnosis. The use of alkylating agents and (32)radiophosphorus, particularly in higher doses, but not hydroxyurea and anagrelide, increases the risk. AML in essential thrombocythemia patients is frequently associated with unfavorable cytogenetics and poor prognosis. In young and fit patients, AML-type induction chemotherapy followed by allogeneic stem cell transplantation may offer the best chance of long-term disease control. In select elderly patients with poor performance status, hypomethylating agent such as azacytidine may prolong survival.
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Hahm C, Huh HJ, Mun YC, Seong CM, Chung WS, Huh J. Genomic aberrations of myeloproliferative and myelodysplastic/myeloproliferative neoplasms in chronic phase and during disease progression. Int J Lab Hematol 2014; 37:181-9. [DOI: 10.1111/ijlh.12257] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2014] [Accepted: 04/14/2014] [Indexed: 01/22/2023]
Affiliation(s)
- C Hahm
- Department of Laboratory Medicine, Ewha Womans University School of Medicine, Seoul, South Korea; Department of Laboratory Medicine, Eone Laboratories, Incheon, South Korea
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Tiziana Storlazzi C, Pieri L, Paoli C, Daniele G, Lasho T, Tefferi A, Vannucchi AM. Complex karyotype in a polycythemia vera patient with a novel SETD1B/GTF2H3 fusion gene. Am J Hematol 2014; 89:438-42. [PMID: 24382738 DOI: 10.1002/ajh.23659] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2013] [Revised: 12/24/2013] [Accepted: 12/28/2013] [Indexed: 11/07/2022]
Abstract
The patient had been diagnosed with polycythemia vera (PV) in 1999, at the age of 61, according to the criteria of the Polycythemia Vera Study Group (PVSG) on the basis of the increased red cell mass by isotope determination, normal oxygen saturation, low plasma erythropoietin level, presence of endogenous erythroid colonies (EEC), and splenomegaly. Histopathology of bone marrow biopsy was also consistent with polycythemia vera with no evidence of increased reticulin fibrosis. A karyotype analysis was not performed at that time. He had been treated initially with phlebotomies and then with hydroxyurea with the aim to obtain a better control of hematocrit; he was under low-dose aspirin. In 2009, 10 years after the diagnosis, while the patient was still being treated with hydroxyurea and phlebotomies, he noticed worsening of general conditions and fatigue, and the appearance of night sweats; he also reported that his spleen volume had increased rapidly in the past few months. He complained of severe pruritus especially after (but not limited to) a shower. He was referred to our center for further evaluation. At presentation, his blood counts were as follows: hemoglobin 157 g/L, hematocrit 54.7%, leukocytes 13.1 × 10⁹ /L, platelets 238 × 10⁹ /L, LDH 856 U/L (normal upper limit, 250 U/L). Blood film examination showed neutrophilia (8.9 × 10⁹ /L) but immature myeloid cells and nucleated erythroblasts were absent. The spleen was 14 cm below the left costal margin, the liver was at 4 cm below the right costal margin. He was found to harbor the JAK2V617F mutation with an allele burden of 85% and the circulating CD34⁺ cell count was 14 × 10⁶ /L. A bone marrow biopsy showed the presence of hyperplasia of myeloid and erythroid lineages, increased number of scattered megakarocytes without overt morphologic abnormalities; reticulin fibrosis was grade 1 according to the European classification. On these basis, we considered the patient as presenting the features of PV according to the 2008 WHO classification of myeloid neoplasms associated with grade 1 reticulin fibrosis.
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Affiliation(s)
- Clelia Tiziana Storlazzi
- Department of Experimental and Clinical Medicine; University of Florence; Largo Brambilla 3 50134 Florence Italy
| | - Lisa Pieri
- Department of Experimental and Clinical Medicine; University of Florence; Largo Brambilla 3 50134 Florence Italy
| | - Chiara Paoli
- Department of Experimental and Clinical Medicine; University of Florence; Largo Brambilla 3 50134 Florence Italy
| | - Giulia Daniele
- Department of Experimental and Clinical Medicine; University of Florence; Largo Brambilla 3 50134 Florence Italy
| | - Terra Lasho
- Department of Experimental and Clinical Medicine; University of Florence; Largo Brambilla 3 50134 Florence Italy
| | - Ayalew Tefferi
- Department of Experimental and Clinical Medicine; University of Florence; Largo Brambilla 3 50134 Florence Italy
| | - Alessandro M. Vannucchi
- Department of Experimental and Clinical Medicine; University of Florence; Largo Brambilla 3 50134 Florence Italy
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Dos Santos LC, Ribeiro JCDC, Silva NP, Cerutti J, da Silva MRR, Chauffaille MDLLF. Cytogenetics, JAK2 and MPL mutations in polycythemia vera, primary myelofibrosis and essential thrombocythemia. Rev Bras Hematol Hemoter 2013; 33:417-24. [PMID: 23049357 PMCID: PMC3459377 DOI: 10.5581/1516-8484.20110116] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2011] [Accepted: 08/29/2011] [Indexed: 11/27/2022] Open
Abstract
Background The detection of molecular and cytogenetic alterations is important for the diagnosis, prognosis and classification of myeloproliferative neoplasms. Objectives The aim of this study was to detect the following mutations: JAK2 V617F, JAK2 exon 12 and MPL W515K/L, besides chromosomal abnormalities. Furthermore, molecular and cytogenetic alterations were correlated with the leukocyte and platelet counts, hemoglobin levels and age in all patients and with the degree of fibrosis in primary myelofibrosis cases. Methods Twenty cases of polycythemia vera, 17 of essential thrombocythemia and 21 of primary myelofibrosis were selected in the Hematology Department of the Universidade Federal de São Paulo (UNIFESP) between February 2008 and December 2009. The JAK2 V617F, JAK2 exon 12 mutations, MPL W515K and MPL W515L mutations were investigated by real-time PCR and direct sequencing. G-band karyotyping and fluorescence in situ hybridization were used to detect chromosomal abnormalities. Results Chromosomal abnormalities were observed only in polycythemia vera (11.8%) and primary myelofibrosis cases (17.6%), without correlation to clinical data. Chromosomal abnormalities were not detected by fluorescence in situ hybridization. The JAK2 V617F mutation was observed in polycythemia vera (90%), primary myelofibrosis (42.8%) and essential thrombocythemia (47%). Patients with JAK2 V617F-negative polycythemia vera had lower platelet and leukocyte counts compared to V617F-positive polycythemia vera (p-value = 0.0001 and p-value = 0.023, respectively). JAK2 V617F-positive and MPL W515L-positive primary myelofibrosis cases had a higher degree of fibrosis than V617F-negative cases (p-value = 0.022). JAK2 exon 12 mutations were not detected in polycythemia vera patients. The MPL W515L mutation was observed in one case of primary myelofibrosis and in one of essential thrombocythemia. The MPL W515K mutation was not found in patients with essential thrombocythemia or primary myelofibrosis. The MPL W515L-positive patient with primary myelofibrosis had more severe anemia than other patients with primary myelofibrosis. Conclusions This study demonstrates that karyotyping for JAK2 and MPL mutations is useful in the diagnosis of myeloproliferative neoplasms. The precise pathogenetic contribution of these alterations is still unclear. However, this study adds more information about the pathophysiology of polycythemia vera, essential thrombocythemia and primary myelofibrosis.
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Palandri F, Polverelli N, Catani L, Cavo M, Vianelli N. Update on the treatment of Ph-negative myeloproliferative neoplasms. Int J Hematol Oncol 2013. [DOI: 10.2217/ijh.13.24] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023] Open
Abstract
SUMMARY Myeloproliferative neoplasms (MPNs) that do not harbor the BCR–ABL rearrangement include polycythemia vera (PV), essential thrombocythemia (ET) and primary myelofibrosis. All of these diseases are characterized by an increased risk of vascular complications and by the propensity to evolve into acute leukemia. The JAK2V617F mutation determines a gain of function in the gene encoding JAK2 and is the most frequent molecular abnormality in MPNs, with an estimated prevalence of more than 95% in PV and 50% in ET and primary myelofibrosis. Molecular markers, together with marrow histology and cytogenetic data, are increasingly relevant for MPN diagnosis, and their prognostic value is under evaluation. In PV and ET, the use of aspirin, hydroxyurea and phlebotomy remain the mainstay of treatment. In myelofibrosis, conventional therapy (androgens, steroids, chemotherapy and splenectomy) has still only palliative effects. The only potentially curative approach is allogeneic stem cell transplantation, but treatment-related mortality remains high. In the last 2 years, the JAK–STAT pathway has become the target of selective tyrosine kinase inhibitors, which might represent a promising therapeutic option. Their role in future therapy, as single agents and/or in combinatorial approaches, is yet to be determined.
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Affiliation(s)
- Francesca Palandri
- Department of Hematology & Oncology “L. & A. Seràgnoli”, University of Bologna, Italy.
| | - Nicola Polverelli
- Department of Hematology & Oncology “L. & A. Seràgnoli”, University of Bologna, Italy
| | - Lucia Catani
- Department of Hematology & Oncology “L. & A. Seràgnoli”, University of Bologna, Italy
| | - Michele Cavo
- Department of Hematology & Oncology “L. & A. Seràgnoli”, University of Bologna, Italy
| | - Nicola Vianelli
- Department of Hematology & Oncology “L. & A. Seràgnoli”, University of Bologna, Italy
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Myelofibrosis in Philadelphia chromosome-negative myeloproliferative neoplasms is associated with aberrant karyotypes. Cancer Genet 2013; 206:116-23. [PMID: 23571153 DOI: 10.1016/j.cancergen.2013.02.002] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2012] [Revised: 02/25/2013] [Accepted: 02/25/2013] [Indexed: 12/15/2022]
Abstract
In Philadelphia chromosome-negative myeloproliferative neoplasms (Ph¯ MPN), non-specific chromosomal defects are detectable and essential thrombocythemia (ET) has the lowest rate of aberrations, whereas primary myelofibrosis (PMF) and post-polycythemia vera (PV) myelofibrosis have the highest rates of aberrations. The frequency of cytogenetic defects in pre-fibrotic stage PMF has not been characterized thus far and the underlying molecular defects of chromosomal instability are unknown. In this study, histopathological findings were correlated with cytogenetic data (n = 249). The expression of DNA repair factors ERCC1 and LIG4 were determined in Ph¯ MPN with and without cytogenetic aberrations. Pre-fibrotic PMF and ET have similarly low frequencies of karyotype anomalies. The expression of ERCC1, but not LIG4, is increased in fibrotic stage PMF but is not associated with accumulation of cytogenetic defects. In conclusion, aberrant karyotypes in Ph¯ MPN reflect the chromosomal instability in these diseases and, in comparison with pre-fibrotic stages, Ph¯ MPN with fibrosis has the highest frequency of cytogenetic aberrations.
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Myeloproliferative neoplasms 2012: The John M. Bennett 80th birthday anniversary lecture. Leuk Res 2012; 36:1481-9. [DOI: 10.1016/j.leukres.2012.08.011] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2012] [Revised: 07/30/2012] [Accepted: 08/06/2012] [Indexed: 01/12/2023]
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36
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Two cases of pediatric essential thrombocythemia managed effectively with hydroxyurea. Int J Hematol 2012; 96:810-3. [PMID: 23054653 DOI: 10.1007/s12185-012-1193-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2012] [Revised: 09/21/2012] [Accepted: 09/24/2012] [Indexed: 10/27/2022]
Abstract
Thrombocytosis is common in infancy and childhood. Essential thrombocythemia (ET), a myeloproliferative disorder, is a much less common cause of thrombocytosis in childhood. We report two cases of essential thrombocythemia in 5- and 10-year-old children, who presented with platelet counts of more than 1,000,000/mm(3). Treatment is not recommended for ET in an asymptomatic patient in the absence of bleeding or thrombosis and a platelet count <1,500,000/mm(3). Our first case had platelets >1,500,000/mm(3), and a second child was symptomatic with recurrent headache. Both responded well to therapy with hydroxyurea (dose 15-30 mg/kg/day) and tolerated it well.
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Bittencourt RI, Vassallo J, Chauffaille MDLLF, Xavier SG, Pagnano KB, Nascimento ACK, De Souza CA, Chiattone CS. Philadelphia-negative chronic myeloproliferative neoplasms. Rev Bras Hematol Hemoter 2012; 34:140-9. [PMID: 23049404 PMCID: PMC3459391 DOI: 10.5581/1516-8484.20120034] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2011] [Accepted: 02/10/2011] [Indexed: 11/27/2022] Open
Abstract
Chronic myeloproliferative diseases without the Philadelphia chromosome marker (Ph-), although first described 60 years ago, only became the subject of interest after the turn of the millennium. In 2001, the World Health Organization (WHO) defined the classification of this group of diseases and in 2008 they were renamed myeloproliferative neoplasms based on morphological, cytogenetic and molecular features. In 2005, the identification of a recurrent molecular abnormality characterized by a gain of function with a mutation in the gene encoding Janus kinase 2 (JAK2) paved the way for greater knowledge of the pathophysiology of myeloproliferative neoplasms. The JAK2 mutation is found in 90-98% of polycythemia vera and in about 50% essential thrombocytosis and primary myelofibrosis. In addition to the JAK2 mutation, other mutations involving TET2 (ten-eleven translocation), LNK (a membrane-bound adaptor protein); IDH1/2 (isocitrate dehydrogenase 1/2 enzyme); ASXL1 (additional sex combs-like 1) genes were found in myeloproliferative neoplasms thus showing the importance of identifying molecular genetic alterations to confirm diagnosis, guide treatment and improve our understanding of the biology of these diseases. Currently, polycythemia vera, essential thrombocytosis, myelofibrosis, chronic neutrophilic leukemia, chronic eosinophilic leukemia and mastocytosis are included in this group of myeloproliferative neoplasms, but are considered different situations with individualized diagnostic methods and treatment. This review updates pathogenic aspects, molecular genetic alterations, the fundamental criteria for diagnosis and the best approach for each of these entities.
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Affiliation(s)
- Rosane Isabel Bittencourt
- Hematology Department, Hospital das Clinicas da Universidade Federal do Rio Grande do Sul - UFRGS, Porto Alegre, RS, Brazil
| | - Jose Vassallo
- Laboratory of Experimental Pathology, CIPED, Universidade Estadual de Campinas - UNICAMP, Campinas, SP, Brazil
| | | | - Sandra Guerra Xavier
- Hematology Department, Universidade Federal de Minas Gerais - UFMG, Belo Horizonte, MG, Brazil
| | - Katia Borgia Pagnano
- Hematology Department, Universidade Estadual de Campinas - UNICAMP, Campinas, SP, Brazil
| | - Ana Clara Kneese Nascimento
- Hematology Department, Faculdade de Ciências Médicas da Santa Casa de São Paulo - FCMSCSP, São Paulo, SP, Brazil
| | | | - Carlos Sergio Chiattone
- Hematology Department, Faculdade de Ciências Médicas da Santa Casa de São Paulo - FCMSCSP, São Paulo, SP, Brazil
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Translocation t(1;9) is a recurrent cytogenetic abnormality associated with progression of essential thrombocythemia patients displaying the JAK2 V617F mutation. Leuk Res 2011; 35:1188-92. [DOI: 10.1016/j.leukres.2011.02.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2010] [Revised: 01/12/2011] [Accepted: 02/02/2011] [Indexed: 11/21/2022]
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Genome integrity of myeloproliferative neoplasms in chronic phase and during disease progression. Blood 2011; 118:167-76. [DOI: 10.1182/blood-2011-01-331678] [Citation(s) in RCA: 133] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Abstract
Philadelphia chromosome–negative myeloproliferative neoplasms (MPNs) are clonal myeloid disorders with increased production of terminally differentiated cells. The disease course is generally chronic, but some patients show disease progression (secondary myelofibrosis or accelerated phase) and/or leukemic transformation. We investigated chromosomal aberrations in 408 MPN samples using high-resolution single-nucleotide polymorphism microarrays to identify disease-associated somatic lesions. Of 408 samples, 37.5% had a wild-type karyotype and 62.5% harbored at least 1 chromosomal aberration. We identified 25 recurrent aberrations that were found in 3 or more samples. An increased number of chromosomal lesions was significantly associated with patient age, as well as with disease progression and leukemic transformation, but no association was observed with MPN subtypes, Janus kinase 2 (JAK2) mutational status, or disease duration. Aberrations of chromosomes 1q and 9p were positively associated with disease progression to secondary myelofibrosis or accelerated phase. Changes of chromosomes 1q, 7q, 5q, 6p, 7p, 19q, 22q, and 3q were positively associated with post-MPN acute myeloid leukemia. We mapped commonly affected regions to single target genes on chromosomes 3p (forkhead box P1 [FOXP1]), 4q (tet oncogene family member 2 [TET2]), 7p (IKAROS family zinc finger 1 [IKZF1]), 7q (cut-like homeobox 1 [CUX1]), 12p (ets variant 6 [ETV6]), and 21q (runt-related transcription factor 1 [RUNX1]). Our data provide insight into the genetic complexity of MPNs and implicate new genes involved in disease progression.
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BCR-ABL1--negative myeloproliferative neoplasms: a review of molecular biology, diagnosis, and treatment. CLINICAL LYMPHOMA MYELOMA & LEUKEMIA 2011; 11 Suppl 1:S37-45. [PMID: 22035746 DOI: 10.1016/j.clml.2011.04.002] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/19/2011] [Revised: 04/07/2011] [Accepted: 04/07/2011] [Indexed: 01/12/2023]
Abstract
In 2008, the World Health Organization expanded the classification of myeloproliferative disorders based on increasing amounts of molecular and cytogenetic data. Myeloproliferative neoplasms (MPN) that do not contain the BCR-ABL1 mutation include polycythemia vera (PV), essential thrombocythemia (ET), and primary myelofibrosis (PMF). JAK2V617F is the best characterized mutation in BCR-ABL1-negative neoplasms, with an estimated prevalence of more than 95% in PV, 50% in ET, and 50% in PMF. Current diagnostic strategies are increasingly reliant on molecular markers, and their prognostic value continues to be investigated. The use of aspirin, hydroxyurea, and phlebotomy for PV and ET, and the use of androgens, steroids, chemotherapy, and radiation therapy for PMF continues to be the mainstay of therapy. The only potentially curative therapy is allogeneic hematopoietic stem cell transplantation, but treatment-related mortality remains high. There have been promising results from clinical trials that involve the JAK tyrosine kinase inhibitors TG101384 and INCB018424, but their role in future therapy is yet to be established. Despite the optimism, it is increasingly apparent that pathogenicity in BCR-ABL1-negative MPN is more complex than for chronic myeloid leukemia, and a pathognomonic mutation may not be forthcoming.
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Dunlap J, Kelemen K, Leeborg N, Braziel R, Olson S, Press R, Huang J, Gatter K, Loriaux M, Fan G. Association of JAK2 mutation status and cytogenetic abnormalities in myeloproliferative neoplasms and myelodysplastic/myeloproliferative neoplasms. Am J Clin Pathol 2011; 135:709-19. [PMID: 21502425 DOI: 10.1309/ajcps6c8evycqnrm] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Myeloproliferative neoplasms and myelodysplastic/myeloproliferative neoplasms are heterogeneous disorders. JAK2 mutation testing and karyotyping are routinely used for diagnosis but have not been incorporated into risk stratification in Philadelphia chromosome-negative myeloproliferative neoplasms. This study correlated cytogenetic abnormalities with disease stage and JAK2 status. A total of 179 cases were analyzed for the JAK2 mutation. Among them, cytogenetic data were available for 97 cases-45 of 106 JAK2+ and 52 of 73 JAK2-. The JAK2+ group showed a higher frequency of cytogenetic anomalies than the JAK2- group (23/45 [51%] vs 14/52 [27%]). Chromosome 9, chromosome 7, and 20q- were recurrent abnormalities in the JAK2+ group, whereas 13q- and trisomy 21 were common in the JAK2- group. In the JAK2+ group, chromosome 7 and complex cytogenetic abnormalities were associated with excess blasts/blastic transformation (P < .05), whereas no cases with 20q- underwent blastic transformation. Our results suggest that incorporation of JAK2 mutation testing and karyotyping allows for monitoring of disease progression with prognostic and therapeutic implications.
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Wong GC. Should Chemotherapy Be Administered for Essential Thrombocythemia (ET) Patients with Leukemic Transformation? PROCEEDINGS OF SINGAPORE HEALTHCARE 2011. [DOI: 10.1177/201010581102000107] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Introduction: Essential Thrombocythemia (ET) is a clonal myeloproliferative disease presenting predominantly with thrombocytosis. One of its rare complications is leukemic transformation (LT). Once leukemic transformation occurs, prognosis is dismal. We aim to determine the disease profile of LT in our ET patients and evaluate if chemotherapy can alter prognosis. Methods: Clinical data of all patients diagnosed and treated with ET from 1999 to 2008 in the Department of Hematology, Singapore General Hospital, were captured in the Myeloproliferative Disease(MPD) Registry. ET patients with LT were selected. Patient characteristics, disease profile, including ET treatment, duration from ET diagnosis to LT, prior myelofibrosis (MF) history, type of chemotherapy, response and eventual survival were recorded. Results: Two hundred and thirty ET patients were diagnosed and treated from 1999 to 2008. Six patients had LT (2.6%). All were Chinese. Four were females. Age range was 47–70 years (mean 61.2 years). Transformation to acute myeloid leukemia (AML) was seen in 5 patients, after a latency period of 3–28 years. Acute biphenotypic leukemia was diagnosed in 1 patient 4 years after ET diagnosis. All patients had received hydroxyurea. There was no prior evolution to MF. Complex cytogenetics were seen in all cases. Three patients treated conservatively died within 1 month. The other 3 patients did not go into durable complete remission despite chemotherapy and succumbed within 9 months. Conclusions: Leukemic transformation in ET, though rare, is associated with grave prognosis. Outcome with chemotherapy is dismal. More studies are needed to evaluate if alternative treatment can improve survival.
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Campbell LJ. Cytogenetics of myeloproliferative neoplasms. Methods Mol Biol 2011; 730:89-98. [PMID: 21431636 DOI: 10.1007/978-1-61779-074-4_7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/30/2023]
Abstract
The introduction of JAK2 mutation testing has changed dramatically the diagnostic algorithms for myeloproliferative neoplasms (MPNs) but there is still a place for conventional cytogenetic analysis in the initial work-up of MPN cases, particularly as this group of myeloid disorders has been expanded to include chronic eosinophilic leukaemia and myeloid neoplasms with abnormalities of the PDGFRA, PDGFRB, and FGFR1 genes. Mastocytosis is also included under the umbrella of MPN but the cytogenetic abnormalities observed usually reflect any associated clonal haematological non-mast cell lineage disease.
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Affiliation(s)
- Lynda J Campbell
- Victorian Cancer Cytogenetics Service, St. Vincent's Hospital Melbourne, Fitzroy, VIC, Australia.
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Wong KF, Yu PH, Wong WS. Essential thrombocythemia with deleted 5q – a genetic and morphologic hybrid? ACTA ACUST UNITED AC 2010; 201:39-41. [DOI: 10.1016/j.cancergencyto.2010.04.019] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2010] [Revised: 04/13/2010] [Accepted: 04/21/2010] [Indexed: 11/28/2022]
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Caramazza D, Hussein K, Siragusa S, Pardanani A, Knudson RA, Ketterling RP, Tefferi A. Chromosome 1 abnormalities in myeloid malignancies: a literature survey and karyotype-phenotype associations. Eur J Haematol 2010; 84:191-200. [DOI: 10.1111/j.1600-0609.2009.01392.x] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
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Myeloproliferative neoplasms: contemporary diagnosis using histology and genetics. Nat Rev Clin Oncol 2009; 6:627-37. [DOI: 10.1038/nrclinonc.2009.149] [Citation(s) in RCA: 104] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
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Sever M, Kantarjian H, Pierce S, Jain N, Estrov Z, Cortes J, Verstovsek S. Cytogenetic abnormalities in essential thrombocythemia at presentation and transformation. Int J Hematol 2009; 90:522-525. [PMID: 19728024 DOI: 10.1007/s12185-009-0411-5] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2009] [Revised: 07/28/2009] [Accepted: 08/06/2009] [Indexed: 02/02/2023]
Abstract
Cytogenetic abnormalities in patients with essential thrombocythemia (ET) are infrequent. Their role in survival of patients and disease transformation is not extensively studied. We describe cytogenetic abnormalities in 172 patients with ET at a single institution. At presentation nine (5.2%) patients had cytogenetic abnormality and three (1.7%) additional patients acquired them during follow-up. Survival of patients with cytogenetic changes at presentation did not differ when compared to the patients with normal karyotype. The more common were abnormalities of chromosome 9 (n = 4), 20 (n = 2), 5 (n = 2), and complex abnormalities (n = 2). Forty-one patients (23.8%) had additional cytogenetic tests performed for monitoring purposes during follow-up. Five patients (2.9%) with normal karyotype transformed to myelofibrosis (MF) without developing new cytogenetic changes at transformation. Two patients (1.2%) with normal karyotypes at presentation transformed to myelodysplastic syndrome and acute myeloid leukemia, respectively. Both acquired complex cytogenetic changes at the time of transformation. There is no rationale for repeating cytogenetic tests in ET patients on follow up, unless blood cell count changes suggest possible transformation.
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Affiliation(s)
- Matjaz Sever
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Unit 428, 1515 Holcombe Blvd., Houston, TX, 77030, USA
| | - Hagop Kantarjian
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Unit 428, 1515 Holcombe Blvd., Houston, TX, 77030, USA
| | - Sherry Pierce
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Unit 428, 1515 Holcombe Blvd., Houston, TX, 77030, USA
| | - Nitin Jain
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Unit 428, 1515 Holcombe Blvd., Houston, TX, 77030, USA
| | - Zeev Estrov
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Unit 428, 1515 Holcombe Blvd., Houston, TX, 77030, USA
| | - Jorge Cortes
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Unit 428, 1515 Holcombe Blvd., Houston, TX, 77030, USA
| | - Srdan Verstovsek
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Unit 428, 1515 Holcombe Blvd., Houston, TX, 77030, USA.
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