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Battaglia MR, Cannova J, Madero-Marroquin R, Patel AA. Treatment of Anemia in Lower-Risk Myelodysplastic Syndrome. Curr Treat Options Oncol 2024; 25:752-768. [PMID: 38814537 DOI: 10.1007/s11864-024-01217-0] [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] [Accepted: 05/13/2024] [Indexed: 05/31/2024]
Abstract
OPINION STATEMENT A majority of patients with lower-risk myelodysplastic syndrome (MDS) will present with or develop anemia. Anemia in MDS is associated with decreased quality of life and may correlate with decreased progression-free survival and overall survival. In this state of the art review we summarize current risk stratification approaches to identify lower-risk MDS (LR-MDS), the natural history of the disease, and meaningful clinical endpoints. The treatment landscape of LR-MDS with anemia is also rapidly evolving; we review the role of supportive care, erythropoietin stimulating agents, lenalidomide, luspatercept, hypomethylating agents (HMAs), and immunosuppressive therapy (IST) in the management of LR-MDS with anemia. In patients with deletion 5q (del5q) syndrome lenalidomide has both efficacy and durability of response. For patients without del5q who need treatment, the management approach is impacted by serum erythropoietin (EPO) level, SF3B1 mutation status, and ring sideroblast status. Given the data from the Phase III COMMANDS trial, we utilize luspatercept in those with SF3B1 mutation or ring sideroblasts that have an EPO level < 500 U/L; in patients without an SF3B1 mutation or ring sideroblasts there is equipoise between luspatercept and use of an erythropoietin stimulating agent (ESA). For patients who have an EPO level ≥ 500 U/L or have been previously treated there is not a clear standard of care. For those without previous luspatercept exposure it can be considered particularly if there is an SF3B1 mutation or the presence of ring sideroblasts. Other options include HMAs or IST; the Phase III IMERGE trial supports the efficacy of the telomerase inhibitor imetelstat in this setting and this may become a standard option in the future as well.
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Affiliation(s)
| | - Joseph Cannova
- Section of Hematology-Oncology, Department of Medicine, University of Chicago, 5841 S Maryland Avenue MC 2115, Chicago, IL, 60637, USA
| | - Rafael Madero-Marroquin
- Section of Hematology-Oncology, Department of Medicine, University of Chicago, 5841 S Maryland Avenue MC 2115, Chicago, IL, 60637, USA
| | - Anand A Patel
- Section of Hematology-Oncology, Department of Medicine, University of Chicago, 5841 S Maryland Avenue MC 2115, Chicago, IL, 60637, USA.
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2
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Duarte TL, Lopes M, Oliveira M, Santos AG, Vasco C, Reis JP, Antunes AR, Gonçalves A, Chacim S, Oliveira C, Porto B, Teles MJ, Moreira AC, Silva AMN, Schwessinger R, Drakesmith H, Henrique R, Porto G, Duarte D. Iron overload induces dysplastic erythropoiesis and features of myelodysplasia in Nrf2-deficient mice. Leukemia 2024; 38:96-108. [PMID: 37857886 DOI: 10.1038/s41375-023-02067-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2023] [Revised: 10/04/2023] [Accepted: 10/09/2023] [Indexed: 10/21/2023]
Abstract
Iron overload (IOL) is hypothesized to contribute to dysplastic erythropoiesis. Several conditions, including myelodysplastic syndrome, thalassemia and sickle cell anemia, are characterized by ineffective erythropoiesis and IOL. Iron is pro-oxidant and may participate in the pathophysiology of these conditions by increasing genomic instability and altering the microenvironment. There is, however, lack of in vivo evidence demonstrating a role of IOL and oxidative damage in dysplastic erythropoiesis. NRF2 transcription factor is the master regulator of antioxidant defenses, playing a crucial role in the cellular response to IOL in the liver. Here, we crossed Nrf2-/- with hemochromatosis (Hfe-/-) or hepcidin-null (Hamp1-/-) mice. Double-knockout mice developed features of ineffective erythropoiesis and myelodysplasia including macrocytic anemia, splenomegaly, and accumulation of immature dysplastic bone marrow (BM) cells. BM cells from Nrf2/Hamp1-/- mice showed increased in vitro clonogenic potential and, upon serial transplantation, recipients disclosed cytopenias, despite normal engraftment, suggesting defective differentiation. Unstimulated karyotype analysis showed increased chromosome instability and aneuploidy in Nrf2/Hamp1-/- BM cells. In HFE-related hemochromatosis patients, NRF2 promoter SNP rs35652124 genotype TT (predicted to decrease NRF2 expression) associated with increased MCV, consistent with erythroid dysplasia. Our results suggest that IOL induces ineffective erythropoiesis and dysplastic hematologic features through oxidative damage in Nrf2-deficient cells.
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Affiliation(s)
- Tiago L Duarte
- i3S - Instituto de Investigação e Inovação em Saúde, Universidade do Porto, Porto, Portugal.
- IBMC - Instituto de Biologia Molecular e Celular, Universidade do Porto, Porto, Portugal.
| | - Marta Lopes
- i3S - Instituto de Investigação e Inovação em Saúde, Universidade do Porto, Porto, Portugal
- IBMC - Instituto de Biologia Molecular e Celular, Universidade do Porto, Porto, Portugal
| | - Mónica Oliveira
- i3S - Instituto de Investigação e Inovação em Saúde, Universidade do Porto, Porto, Portugal
- IBMC - Instituto de Biologia Molecular e Celular, Universidade do Porto, Porto, Portugal
| | - Ana G Santos
- i3S - Instituto de Investigação e Inovação em Saúde, Universidade do Porto, Porto, Portugal
- IBMC - Instituto de Biologia Molecular e Celular, Universidade do Porto, Porto, Portugal
| | - Catarina Vasco
- i3S - Instituto de Investigação e Inovação em Saúde, Universidade do Porto, Porto, Portugal
- IBMC - Instituto de Biologia Molecular e Celular, Universidade do Porto, Porto, Portugal
| | - Joana P Reis
- i3S - Instituto de Investigação e Inovação em Saúde, Universidade do Porto, Porto, Portugal
- IBMC - Instituto de Biologia Molecular e Celular, Universidade do Porto, Porto, Portugal
- Instituto de Ciências Biomédicas Abel Salazar (ICBAS), Universidade do Porto, Porto, Portugal
| | - Ana Rita Antunes
- i3S - Instituto de Investigação e Inovação em Saúde, Universidade do Porto, Porto, Portugal
- IBMC - Instituto de Biologia Molecular e Celular, Universidade do Porto, Porto, Portugal
| | - Andreia Gonçalves
- i3S - Instituto de Investigação e Inovação em Saúde, Universidade do Porto, Porto, Portugal
- IBMC - Instituto de Biologia Molecular e Celular, Universidade do Porto, Porto, Portugal
| | - Sérgio Chacim
- Serviço de Hematologia e Transplantação de Medula Óssea, Instituto Português de Oncologia do Porto Francisco Gentil, E.P.E. (IPO Porto), Porto, Portugal
| | - Cláudia Oliveira
- Laboratório de Citogenética, Instituto de Ciências Biomédicas Abel Salazar (ICBAS), Universidade do Porto, Porto, Portugal
| | - Beatriz Porto
- Laboratório de Citogenética, Instituto de Ciências Biomédicas Abel Salazar (ICBAS), Universidade do Porto, Porto, Portugal
| | - Maria José Teles
- Departmento de Patologia Clínica, Centro Hospitalar Universitário São João, Porto, Portugal
| | - Ana C Moreira
- i3S - Instituto de Investigação e Inovação em Saúde, Universidade do Porto, Porto, Portugal
- IBMC - Instituto de Biologia Molecular e Celular, Universidade do Porto, Porto, Portugal
- Instituto de Ciências Biomédicas Abel Salazar (ICBAS), Universidade do Porto, Porto, Portugal
| | - André M N Silva
- LAQV-REQUIMTE, Departamento de Química e Bioquímica, Faculdade de Ciências, Universidade do Porto, Porto, Portugal
- LAQV-REQUIMTE, Instituto de Ciências Biomédicas Abel Salazar (ICBAS), Universidade do Porto, Porto, Portugal
| | - Ron Schwessinger
- MRC Molecular Haematology Unit, MRC Weatherall Institute of Molecular Medicine, University of Oxford, Oxford, UK
- MRC WIMM Centre for Computational Biology, MRC Weatherall Institute of Molecular Medicine, University of Oxford, Oxford, UK
| | - Hal Drakesmith
- MRC Translational Immune Discovery Unit, MRC Weatherall Institute of Molecular Medicine, University of Oxford, John Radcliffe Hospital, Oxford, UK
| | - Rui Henrique
- Serviço de Anatomia Patológica, IPO Porto, Porto, Portugal
- Departamento de Patologia e Imunologia Molecular, Instituto de Ciências Biomédicas Abel Salazar (ICBAS), Universidade do Porto, Porto, Portugal
| | - Graça Porto
- i3S - Instituto de Investigação e Inovação em Saúde, Universidade do Porto, Porto, Portugal
- IBMC - Instituto de Biologia Molecular e Celular, Universidade do Porto, Porto, Portugal
- Departamento de Patologia e Imunologia Molecular, Instituto de Ciências Biomédicas Abel Salazar (ICBAS), Universidade do Porto, Porto, Portugal
- Serviço de Imuno-hemoterapia, Centro Hospitalar Universitário de Santo António (CHUdSA), Porto, Portugal
| | - Delfim Duarte
- i3S - Instituto de Investigação e Inovação em Saúde, Universidade do Porto, Porto, Portugal.
- Serviço de Hematologia e Transplantação de Medula Óssea, Instituto Português de Oncologia do Porto Francisco Gentil, E.P.E. (IPO Porto), Porto, Portugal.
- Departmento de Biomedicina, Faculdade de Medicina da Universidade do Porto (FMUP), Porto, Portugal.
- P.CCC - Porto Comprehensive Cancer Center Raquel Seruca, Porto, Portugal.
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3
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An W, Feola M, Levy M, Aluri S, Ruiz-Martinez M, Sridharan A, Fibach E, Zhu X, Verma A, Ginzburg Y. Iron chelation improves ineffective erythropoiesis and iron overload in myelodysplastic syndrome mice. eLife 2023; 12:e83103. [PMID: 38153418 PMCID: PMC10754500 DOI: 10.7554/elife.83103] [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: 08/31/2022] [Accepted: 11/27/2023] [Indexed: 12/29/2023] Open
Abstract
Myelodysplastic syndrome (MDS) is a heterogeneous group of bone marrow stem cell disorders characterized by ineffective hematopoiesis and cytopenias, most commonly anemia. Red cell transfusion therapy for anemia in MDS results in iron overload, correlating with reduced overall survival. Whether the treatment of iron overload benefits MDS patients remains controversial. We evaluate underlying iron-related pathophysiology and the effect of iron chelation using deferiprone on erythropoiesis in NUP98-HOXD13 transgenic mice, a highly penetrant well-established MDS mouse model. Our results characterize an iron overload phenotype with aberrant erythropoiesis in these mice which was reversed by deferiprone-treatment. Serum erythropoietin levels decreased while erythroblast erythropoietin receptor expression increased in deferiprone-treated MDS mice. We demonstrate, for the first time, normalized expression of the iron chaperones Pcbp1 and Ncoa4 and increased ferritin stores in late-stage erythroblasts from deferiprone-treated MDS mice, evidence of aberrant iron trafficking in MDS erythroblasts. Importantly, erythroblast ferritin is increased in response to deferiprone, correlating with decreased erythroblast ROS. Finally, we confirmed increased expression of genes involved in iron uptake, sensing, and trafficking in stem and progenitor cells from MDS patients. Taken together, our findings provide evidence that erythroblast-specific iron metabolism is a novel potential therapeutic target to reverse ineffective erythropoiesis in MDS.
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Affiliation(s)
- Wenbin An
- Division of Hematology and Medical Oncology, Tisch Cancer Institute, Icahn School of Medicine at Mount SinaiNew YorkUnited States
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Division of Pediatric Blood Diseases Center, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical CollegeTianjinChina
| | - Maria Feola
- Division of Hematology and Medical Oncology, Tisch Cancer Institute, Icahn School of Medicine at Mount SinaiNew YorkUnited States
| | - Maayan Levy
- Division of Hematology and Medical Oncology, Tisch Cancer Institute, Icahn School of Medicine at Mount SinaiNew YorkUnited States
| | - Srinivas Aluri
- Division of Hematology and Medical Oncology, Albert Einstein College of MedicineBronxUnited States
| | - Marc Ruiz-Martinez
- Division of Hematology and Medical Oncology, Tisch Cancer Institute, Icahn School of Medicine at Mount SinaiNew YorkUnited States
| | - Ashwin Sridharan
- Division of Hematology and Medical Oncology, Albert Einstein College of MedicineBronxUnited States
| | - Eitan Fibach
- Department of Hematology, Hadassah Medical Center, Hebrew UniversityJerusalemIsrael
| | - Xiaofan Zhu
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Division of Pediatric Blood Diseases Center, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical CollegeTianjinChina
| | - Amit Verma
- Division of Hematology and Medical Oncology, Albert Einstein College of MedicineBronxUnited States
| | - Yelena Ginzburg
- Division of Hematology and Medical Oncology, Tisch Cancer Institute, Icahn School of Medicine at Mount SinaiNew YorkUnited States
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4
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Meunier M, Park S. Lower-risk myelodysplastic syndromes: Current treatment options for anemia. EJHAEM 2022; 3:1091-1099. [PMID: 36467818 PMCID: PMC9713208 DOI: 10.1002/jha2.523] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 03/30/2022] [Revised: 06/11/2022] [Accepted: 06/16/2022] [Indexed: 06/17/2023]
Abstract
Myelodysplastic syndromes (MDS) are a heterogeneous group of clonal hematological disorders. Treatment options are classified and defined by prognostic risk based on the International Prognostic Scoring System (IPSS) and, more recently, the revised IPSS (IPSS-R). The treatment goal for lower-risk MDS is to correct cytopenias or their consequences, with the goal of maintaining or improving quality of life. Erythropoiesis-stimulating agents (ESAs) play an important role in treating anemia. Individuals with MDS who have a 5q deletion are particularly sensitive to treatment with lenalidomide; however, this comprises the minority of patients with MDS. Luspatercept was recently approved in the United States and the European Union for the treatment of ESA-refractory MDS with ring sideroblasts. Research into new treatment options, especially after ESA failure, is needed. In this review, we will focus on the current therapeutic options for MDS-related anemia.
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Affiliation(s)
- Mathieu Meunier
- Department of HaematologyCHU Grenoble AlpesGrenobleFrance
- Institute for Advanced BioscienceUniversité Grenoble AlpesGrenobleFrance
| | - Sophie Park
- Department of HaematologyCHU Grenoble AlpesGrenobleFrance
- Institute for Advanced BioscienceUniversité Grenoble AlpesGrenobleFrance
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5
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Leitch HA, Gattermann N. Hematologic improvement with iron chelation therapy in myelodysplastic syndromes: Clinical data, potential mechanisms, and outstanding questions. Crit Rev Oncol Hematol 2019; 141:54-72. [DOI: 10.1016/j.critrevonc.2019.06.002] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2018] [Revised: 11/25/2018] [Accepted: 06/03/2019] [Indexed: 12/25/2022] Open
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6
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Tataranni T, Mazzoccoli C, Agriesti F, De Luca L, Laurenzana I, Simeon V, Ruggieri V, Pacelli C, Della Sala G, Musto P, Capitanio N, Piccoli C. Deferasirox drives ROS-mediated differentiation and induces interferon-stimulated gene expression in human healthy haematopoietic stem/progenitor cells and in leukemia cells. Stem Cell Res Ther 2019; 10:171. [PMID: 31196186 PMCID: PMC6567456 DOI: 10.1186/s13287-019-1293-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2019] [Revised: 05/15/2019] [Accepted: 05/31/2019] [Indexed: 12/11/2022] Open
Abstract
Background Administration of the iron chelator deferasirox (DFX) in transfusion-dependent patients occasionally results in haematopoiesis recovery by a mechanism remaining elusive. This study aimed to investigate at a molecular level a general mechanism underlying DFX beneficial effects on haematopoiesis, both in healthy and pathological conditions. Methods Human healthy haematopoietic stem/progenitor cells (HS/PCs) and three leukemia cell lines were treated with DFX. N-Acetyl cysteine (NAC) and fludarabine were added as antioxidant and STAT1 inhibitor, respectively. In vitro colony-forming assays were assessed both in healthy and in leukemia cells. Intracellular and mitochondrial reactive oxygen species (ROS) as well as mitochondrial content were assessed by cytofluorimetric and confocal microscopy analysis; mtDNA was assessed by qRT-PCR. Differentiation markers were monitored by cytofluorimetric analysis. Gene expression analysis (GEA) was performed on healthy HS/PCs, and differently expressed genes were validated in healthy and leukemia cells by qRT-PCR. STAT1 expression and phosphorylation were assessed by Western blotting. Data were compared by an unpaired Student t test or one-way ANOVA. Results DFX, at clinically relevant concentrations, increased the clonogenic capacity of healthy human CD34+ HS/PCs to form erythroid colonies. Extension of this analysis to human-derived leukemia cell lines Kasumi-1, K562 and HL60 confirmed DFX capacity to upregulate the expression of specific markers of haematopoietic commitment. Notably, the abovementioned DFX-induced effects are all prevented by the antioxidant NAC and accompanied with overproduction of mitochondria-generated reactive oxygen species (ROS) and increase of mitochondrial content and mtDNA copy number. GEA unveiled upregulation of genes linked to interferon (IFN) signalling and tracked back to hyper-phosphorylation of STAT1. Treatment of leukemic cell lines with NAC prevented the DFX-mediated phosphorylation of STAT1 as well as the expression of the IFN-stimulated genes. However, STAT1 inhibition by fludarabine was not sufficient to affect differentiation processes in leukemic cell lines. Conclusions These findings suggest a significant involvement of redox signalling as a major regulator of multiple DFX-orchestrated events promoting differentiation in healthy and tumour cells. The understanding of molecular mechanisms underlying the haematological response by DFX would enable to predict patient’s ability to respond to the drug, to extend treatment to other patients or to anticipate the treatment, regardless of the iron overload. Electronic supplementary material The online version of this article (10.1186/s13287-019-1293-y) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Tiziana Tataranni
- Laboratory of Pre-Clinical and Translational Research, IRCCS-CROB, Referral Cancer Center of Basilicata, Rionero in Vulture, PZ, Italy
| | - Carmela Mazzoccoli
- Laboratory of Pre-Clinical and Translational Research, IRCCS-CROB, Referral Cancer Center of Basilicata, Rionero in Vulture, PZ, Italy
| | - Francesca Agriesti
- Laboratory of Pre-Clinical and Translational Research, IRCCS-CROB, Referral Cancer Center of Basilicata, Rionero in Vulture, PZ, Italy
| | - Luciana De Luca
- Laboratory of Pre-Clinical and Translational Research, IRCCS-CROB, Referral Cancer Center of Basilicata, Rionero in Vulture, PZ, Italy
| | - Ilaria Laurenzana
- Laboratory of Pre-Clinical and Translational Research, IRCCS-CROB, Referral Cancer Center of Basilicata, Rionero in Vulture, PZ, Italy
| | - Vittorio Simeon
- Department of Public, Clinical and Preventive Medicine, Medical Statistics Unit, University of Campania Luigi Vanvitelli, Caserta, Italy
| | - Vitalba Ruggieri
- Laboratory of Pre-Clinical and Translational Research, IRCCS-CROB, Referral Cancer Center of Basilicata, Rionero in Vulture, PZ, Italy
| | - Consiglia Pacelli
- Department of Clinical and Experimental Medicine, University of Foggia, Foggia, Italy
| | - Gerardo Della Sala
- Laboratory of Pre-Clinical and Translational Research, IRCCS-CROB, Referral Cancer Center of Basilicata, Rionero in Vulture, PZ, Italy
| | - Pellegrino Musto
- Hematology Department of Basilicata, IRCCS-CROB Referral Cancer Center of Basilicata, Rionero in Vulture, Italy
| | - Nazzareno Capitanio
- Department of Clinical and Experimental Medicine, University of Foggia, Foggia, Italy
| | - Claudia Piccoli
- Laboratory of Pre-Clinical and Translational Research, IRCCS-CROB, Referral Cancer Center of Basilicata, Rionero in Vulture, PZ, Italy. .,Department of Clinical and Experimental Medicine, University of Foggia, Foggia, Italy.
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7
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Management of anemia in low-risk myelodysplastic syndromes treated with erythropoiesis-stimulating agents newer and older agents. Med Oncol 2018; 35:76. [DOI: 10.1007/s12032-018-1135-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2018] [Accepted: 04/12/2018] [Indexed: 10/17/2022]
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8
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Zeidan AM, Griffiths EA. To chelate or not to chelate in MDS: That is the question! Blood Rev 2018; 32:368-377. [PMID: 29602612 DOI: 10.1016/j.blre.2018.03.002] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2017] [Revised: 02/16/2018] [Accepted: 03/06/2018] [Indexed: 01/19/2023]
Abstract
Myelodysplastic syndromes (MDS) are a heterogeneous group of hemopathies that exhibit physical manifestations with clinical consequences of bone marrow failure and inherent risk of progression to acute myeloid leukemia. Iron overload (IO) is common in MDS due to chronic transfusion support and disease-related alterations in iron metabolism. IO has been conclusively associated with inferior outcomes among MDS patients. Despite lack of randomized trials showing a survival impact of iron chelation therapy (ICT), ICT is recommended by experts and guidelines for select MDS patients with IO and is often used. The availability of effective oral ICT agents has reignited the controversy regarding ICT use in patients with MDS and IO. Here we summarize the studies evaluating the value of ICT in MDS and suggest a practical approach for use of these therapies. We also highlight controversies regarding use of ICT in MDS and discuss some ongoing efforts to answer these questions.
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Affiliation(s)
- Amer M Zeidan
- Section of Hematology, Department of Medicine, Yale University, Yale Cancer Center, New Haven, CT, USA.
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9
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Wong SA, Leitch HA. Iron chelation therapy in lower IPSS risk myelodysplastic syndromes; which subtypes benefit? Leuk Res 2017; 64:24-29. [PMID: 29149650 DOI: 10.1016/j.leukres.2017.11.005] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2017] [Revised: 09/29/2017] [Accepted: 11/09/2017] [Indexed: 11/19/2022]
Abstract
BACKGROUND Analyses suggest MDS patients with higher serum ferritin levels (SF) have inferior overall survival (OS), in one study across MDS subtypes. Multiple analyses suggest those with high SF receiving iron chelation therapy (ICT) have superior OS, but which MDS subtypes benefit from ICT remains undefined. METHODS We performed survival analyses of MDS subtypes by receipt of ICT. RESULTS 182 MDS were lower IPSS risk and received red blood cell (RBC) transfusions; 63 received ICT. For the entire cohort, receiving ICT independently predicted superior OS in a multivariate analysis (hazard ratio for death 0.3, p=0.01). Features differing for ICT and non-ICT patients, respectively, were: age; IPSS risk group; number of RBC units transfused; and SF, p≤0.03 for all. At a median follow up of 76.5 and 28.4 months, 65.1% and 63.0% were alive. Median OS (months) for ICT and non-ICT patients was: RA, 140.9 and 36.3, p=0.0008; RARS/RARS-t, 133.4 and 73.3, p=0.02. For RCMD/RCMD-RS, p=NS, however, 3 (20%) had significant erythroid improvement with ICT; other subtypes had small numbers. DISCUSSION In this retrospective analysis, RA and RARS/RARS-t patients receiving ICT had superior OS to non-ICT patients. These findings should be verified and other MDS subtypes examined in larger prospective analyses.
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Affiliation(s)
- Shannon A Wong
- Faculty of Medicine, Royal College of Surgeons, Dublin, Ireland
| | - Heather A Leitch
- Division of Hematology, St. Paul's Hospital, University of British Columbia, Vancouver, Canada.
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10
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Meunier M, Ancelet S, Lefebvre C, Arnaud J, Garrel C, Pezet M, Wang Y, Faure P, Szymanski G, Duployez N, Preudhomme C, Biard D, Polack B, Cahn JY, Moulis JM, Park S. Reactive oxygen species levels control NF-κB activation by low dose deferasirox in erythroid progenitors of low risk myelodysplastic syndromes. Oncotarget 2017; 8:105510-105524. [PMID: 29285268 PMCID: PMC5739655 DOI: 10.18632/oncotarget.22299] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2017] [Accepted: 08/26/2017] [Indexed: 11/25/2022] Open
Abstract
Anemia is a frequent cytopenia in myelodysplastic syndromes (MDS) and most patients require red blood cell transfusion resulting in iron overload (IO). Deferasirox (DFX) has become the standard treatment of IO in MDS and it displays positive effects on erythropoiesis. In low risk MDS samples, mechanisms improving erythropoiesis after DFX treatment remain unclear. Herein, we addressed this question by using liquid cultures with iron overload of erythroid precursors treated with low dose of DFX (3μM), which corresponds to DFX 5 mg/kg/day, an unusual dose used for iron chelation. We highlight a decreased apoptosis rate and an increased proportion of cycling cells, both leading to higher proliferation rates. The iron chelation properties of low dose DFX failed to activate the Iron Regulatory Proteins and to support iron depletion, but low dose DFX dampers intracellular reactive oxygen species. Furthermore low concentrations of DFX activate the NF-κB pathway in erythroid precursors triggering anti-apoptotic and anti-inflammatory signals. Establishing stable gene silencing of the Thioredoxin (TRX) 1 genes, a NF-κB modulator, showed that fine-tuning of reactive oxygen species (ROS) levels regulates NF-κB. These results justify a clinical trial proposing low dose DFX in MDS patients refractory to erythropoiesis stimulating agents.
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Affiliation(s)
- Mathieu Meunier
- CHU Grenoble Alpes, University Clinic of Hematology, Grenoble, France.,Université Grenoble Alpes, CNRS UMR 5525, Grenoble INP, CHU Grenoble Alpes, TIMC-IMAG ThEREx, Grenoble, France
| | - Sarah Ancelet
- Université Grenoble Alpes, CNRS UMR 5525, Grenoble INP, CHU Grenoble Alpes, TIMC-IMAG ThEREx, Grenoble, France
| | | | - Josiane Arnaud
- Unité de Biochimie Hormonale et Nutritionnelle, Département de Biologie - Toxicologie - Pharmacologie, CHU Grenoble Alpes, Grenoble, France
| | - Catherine Garrel
- Unité de Biochimie Hormonale et Nutritionnelle, Département de Biologie - Toxicologie - Pharmacologie, CHU Grenoble Alpes, Grenoble, France
| | - Mylène Pezet
- Plateforme de Microscopie Photonique - Cytométrie en Flux, Institut Albert Bonniot, La Tronche, France
| | - Yan Wang
- Université Grenoble Alpes, CNRS UMR 5525, Grenoble INP, CHU Grenoble Alpes, TIMC-IMAG ThEREx, Grenoble, France
| | - Patrice Faure
- Unité de Biochimie Hormonale et Nutritionnelle, Département de Biologie - Toxicologie - Pharmacologie, CHU Grenoble Alpes, Grenoble, France
| | | | - Nicolas Duployez
- Laboratory of Hematology and Tumor Bank, INSERM UMR-S 1172, Cancer Research Institute of Lille, CHRU of Lille, University Lille Nord de France, Lille, France
| | - Claude Preudhomme
- Laboratory of Hematology and Tumor Bank, INSERM UMR-S 1172, Cancer Research Institute of Lille, CHRU of Lille, University Lille Nord de France, Lille, France
| | - Denis Biard
- CEA, Institut de Biologie François Jacob, SEPIA, Team Cellular Engineering and Human Syndromes, Université Paris-Saclay, Fontenay-aux-Roses, France
| | - Benoit Polack
- Université Grenoble Alpes, CNRS UMR 5525, Grenoble INP, CHU Grenoble Alpes, TIMC-IMAG ThEREx, Grenoble, France.,Laboratory of Hematology, CHU Grenoble Alpes, Grenoble, France
| | - Jean-Yves Cahn
- CHU Grenoble Alpes, University Clinic of Hematology, Grenoble, France.,Université Grenoble Alpes, CNRS UMR 5525, Grenoble INP, CHU Grenoble Alpes, TIMC-IMAG ThEREx, Grenoble, France
| | - Jean Marc Moulis
- Université Grenoble Alpes, Laboratory of Fundamental and Applied Bioenergetics, and Environmental and Systems Biology, Grenoble, France.,INSERM U1055, Grenoble, France.,CEA-Grenoble, Bioscience and Biotechnology Institute, Grenoble, France
| | - Sophie Park
- CHU Grenoble Alpes, University Clinic of Hematology, Grenoble, France.,Université Grenoble Alpes, CNRS UMR 5525, Grenoble INP, CHU Grenoble Alpes, TIMC-IMAG ThEREx, Grenoble, France
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11
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Unraveling the mechanisms behind iron overload and ineffective hematopoiesis in myelodysplastic syndromes. Leuk Res 2017; 62:108-115. [DOI: 10.1016/j.leukres.2017.10.001] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2017] [Revised: 09/22/2017] [Accepted: 10/02/2017] [Indexed: 01/06/2023]
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12
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Pilo F, Angelucci E. A storm in the niche: Iron, oxidative stress and haemopoiesis. Blood Rev 2017; 32:29-35. [PMID: 28847531 DOI: 10.1016/j.blre.2017.08.005] [Citation(s) in RCA: 38] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2017] [Revised: 08/05/2017] [Accepted: 08/11/2017] [Indexed: 12/18/2022]
Abstract
Iron, although essential, is harmful in high amounts. Oxidative stress as a result of excess reactive oxygen species (ROS) and a prooxidative/antioxidative imbalance between ROS production and elimination, play a key role in cellular damage. There is evidence to support the role of ROS in the pathogenesis of a range of diseases including the myelodysplastic syndromes (MDS) and leukaemia. Oxidative stress seems to affect the self-renewal, proliferation and differentiation of haematopoietic stem cells and impair cell growth. Three aspects of these defective haemopoietic mechanisms may be associated with the activities of ROS: clonal evolution, haematological improvement and recovery of haemopoiesis after haematopoietic stem cell transplantation (HSCT). This review aims to provide haematologists with an overview of results from in vitro and murine models and preliminary clinical evidence on the diagnostic, prognostic and therapeutic implications of the complex interactions between the haemopoietic niche, iron, oxidative stress and inadequate haemopoiesis.
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Affiliation(s)
- Federica Pilo
- Hematology and Transplant Center, Ospedale Oncologico di Riferimento Regionale "Armando Businco", Azienda Ospedaliera Brotzu, Cagliari, Italy..
| | - Emanuele Angelucci
- Hematology and Transplant Center, Ospedale Policlinico San Martino, Genova, Italy.
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13
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Coates TD, Carson S, Wood JC, Berdoukas V. Management of iron overload in hemoglobinopathies: what is the appropriate target iron level? Ann N Y Acad Sci 2017; 1368:95-106. [PMID: 27186942 DOI: 10.1111/nyas.13060] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2015] [Revised: 03/04/2016] [Accepted: 03/09/2016] [Indexed: 01/19/2023]
Abstract
Patients with thalassemia become iron overloaded from increased absorption of iron, ineffective erythropoiesis, and chronic transfusion. Before effective iron chelation became available, thalassemia major patients died of iron-related cardiac failure in the second decade of life. Initial treatment goals for chelation therapy were aimed at levels of ferritin and liver iron concentrations associated with prevention of adverse cardiac outcomes and avoidance of chelator toxicity. Cardiac deaths were greatly reduced and survival was much longer. Epidemiological data from the general population draw clear associations between increased transferrin saturation (and, by inference, labile iron) and early death, diabetes, and malignant transformation. The rate of cancers now seems to be significantly higher in thalassemia than in the general population. Reduction in iron can reverse many of these complications and reduce the risk of malignancy. As toxicity can result from prolonged exposure to even low levels of excess iron, and survival in thalassemia patients is now many decades, it would seem prudent to refocus attention on prevention of long-term complications of iron overload and to maintain labile iron and total body iron levels within a normal range, if expertise and resources are available to avoid complications of overtreatment.
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Affiliation(s)
- Thomas D Coates
- Section of Hematology, Children's Center for Cancer, Blood Diseases and Bone Marrow Transplantation
| | - Susan Carson
- Section of Hematology, Children's Center for Cancer, Blood Diseases and Bone Marrow Transplantation
| | - John C Wood
- Division of Cardiology, Children's Hospital Los Angeles, University of Southern California, Keck School of Medicine, Los Angeles, California
| | - Vasilios Berdoukas
- Section of Hematology, Children's Center for Cancer, Blood Diseases and Bone Marrow Transplantation
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14
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Myelodysplastic Syndromes and Iron Chelation Therapy. Mediterr J Hematol Infect Dis 2017; 9:e2017021. [PMID: 28293409 PMCID: PMC5333736 DOI: 10.4084/mjhid.2017.021] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2016] [Accepted: 01/27/2017] [Indexed: 01/19/2023] Open
Abstract
Over recent decades we have been fortunate to witness the advent of new technologies and of an expanded knowledge and application of chelation therapies to the benefit of patients with iron overload. However, extrapolation of learnings from thalassemia to the myelodysplastic syndromes (MDS) has resulted in a fragmented and uncoordinated clinical evidence base. We’re therefore forced to change our understanding of MDS, looking with other eyes to observational studies that inform us about the relationship between iron and tissue damage in these subjects. The available evidence suggests that iron accumulation is prognostically significant in MDS, but levels of accumulation historically associated with organ damage (based on data generated in the thalassemias) are infrequent. Emerging experimental data have provided some insight into this paradox, as our understanding of iron-induced tissue damage has evolved from a process of progressive bulking of organs through high-volumes iron deposition, to one of ‘toxic’ damage inflicted through multiple cellular pathways. Damage from iron may, therefore, occur prior to reaching reference thresholds, and similarly, chelation may be of benefit before overt iron overload is seen. In this review, we revisit the scientific and clinical evidence for iron overload in MDS to better characterize the iron overload phenotype in these patients, which differs from the classical transfusional and non-transfusional iron overload syndrome. We hope this will provide a conceptual framework to better understand the complex associations between anemia, iron and clinical outcomes, to accelerate progress in this area.
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15
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Almeida A, Fenaux P, List AF, Raza A, Platzbecker U, Santini V. Recent advances in the treatment of lower-risk non-del(5q) myelodysplastic syndromes (MDS). Leuk Res 2017; 52:50-57. [DOI: 10.1016/j.leukres.2016.11.008] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2016] [Revised: 10/27/2016] [Accepted: 11/11/2016] [Indexed: 12/12/2022]
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16
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Iron overload enhances human mesenchymal stromal cell growth and hampers matrix calcification. Biochim Biophys Acta Gen Subj 2016; 1860:1211-23. [DOI: 10.1016/j.bbagen.2016.01.025] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2015] [Revised: 01/27/2016] [Accepted: 01/31/2016] [Indexed: 01/19/2023]
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17
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Groepper S, Schlue J, Haferlach C, Giagounidis A. Transfusion Independency and Histological Remission in a Patient with Advanced Primary Myelofibrosis Receiving Iron-Chelation Therapy with Deferasirox. Oncol Res Treat 2016; 39:384-7. [DOI: 10.1159/000446029] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2016] [Accepted: 03/29/2016] [Indexed: 11/19/2022]
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18
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Porter JB, de Witte T, Cappellini MD, Gattermann N. New insights into transfusion-related iron toxicity: Implications for the oncologist. Crit Rev Oncol Hematol 2015; 99:261-71. [PMID: 26806144 DOI: 10.1016/j.critrevonc.2015.11.017] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2015] [Revised: 09/28/2015] [Accepted: 11/24/2015] [Indexed: 01/19/2023] Open
Abstract
Iron overload is a potentially life-threatening consequence of multiple red-blood-cell transfusions. Here, we review factors affecting excess iron distribution and its damage to specific tissues, as well as mechanisms of oncogenesis by iron. Although consequences of transfusional iron overload are best described in thalassemia major and related inherited anemias, they are increasingly recognized in acquired conditions, such as myelodysplastic syndromes (MDS). Iron overload in MDS not only impacts on certain tissues, but may affect the clonal evolution of MDS through generation of reactive oxygen species. Iron overload may also influence hematopoietic-stem-cell-transplantation outcomes. Novel MRI methods for assessing body iron have impacted significantly on outcome in inherited anemias by allowing monitoring of iron burden and iron chelation therapy. This approach is increasingly being used in MDS and stem-cell-transplant procedures. Knowledge gained from managing transfusional iron overload in inherited anemias may be translated to general oncology, with potential for improved patient outcomes.
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Affiliation(s)
- John B Porter
- Department of Haematology, University College London, UCL Cancer Institute, Paul O'Gorman Building, 72 Huntley Street, London WC1E 6BT, UK.
| | - Theo de Witte
- Radboud University Nijmegen Medical Centre, Nijmegen, Netherlands
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19
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Sanford D, Hsia CC. A case of transfusion independence in a patient with myelodysplastic syndrome using deferasirox, sustained for two years after stopping therapy. ACTA ACUST UNITED AC 2015; 22:e128-32. [PMID: 25908918 DOI: 10.3747/co.22.2100] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Patients with myelodysplastic syndrome (mds) experience clinical complications related to progressive marrow failure and have an increased risk of developing acute myeloid leukemia. Frequent red blood cell transfusion can lead to clinical iron overload and is associated with decreased survival in mds patients. Iron chelation therapy reduces markers of iron overload and prevents end-organ damage. Here, we present the case of a patient with low-risk mds with transfusional iron overload. He was treated for 2 years with an oral iron chelator, deferasirox, and after 12 months of treatment, he experienced a hemoglobin increase of more than 50 g/L, becoming transfusion-independent. He has remained transfusion-independent, with a normal hemoglobin level, for more than 2 years since stopping chelation therapy. Hematologic and erythroid responses have previously been reported in mds patients treated with iron chelation. The durability of our patient's response suggests that iron chelation might alter the natural history of mds in some patients.
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Affiliation(s)
- D Sanford
- Department of Medicine, Division of Hematology, London Health Sciences Centre, University of Western Ontario, London, ON
| | - C C Hsia
- Department of Medicine, Division of Hematology, London Health Sciences Centre, University of Western Ontario, London, ON
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20
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Durable Red Blood Cell Transfusion Independence in a Patient with an MDS/MPN Overlap Syndrome Following Discontinuation of Iron Chelation Therapy. Case Rep Hematol 2015; 2015:253294. [PMID: 25918650 PMCID: PMC4396885 DOI: 10.1155/2015/253294] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2014] [Revised: 01/11/2015] [Accepted: 03/06/2015] [Indexed: 01/14/2023] Open
Abstract
Background. Hematologic improvement (HI) occurs in some patients with acquired anemias and transfusional iron overload receiving iron chelation therapy (ICT) but there is little information on transfusion status after stopping chelation. Case Report. A patient with low IPSS risk RARS-T evolved to myelofibrosis developed a regular red blood cell (RBC) transfusion requirement. There was no response to a six-month course of study medication or to erythropoietin for three months. At 27 months of transfusion dependence, she started deferasirox and within 6 weeks became RBC transfusion independent, with the hemoglobin normalizing by 10 weeks of chelation. After 12 months of chelation, deferasirox was stopped; she remains RBC transfusion independent with a normal hemoglobin 17 months later. We report the patient's course in detail and review the literature on HI with chelation. Discussion. There are reports of transfusion independence with ICT, but that transfusion independence may be sustained long term after stopping chelation deserves emphasis. This observation suggests that reduction of iron overload may have a lasting favorable effect on bone marrow failure in at least some patients with acquired anemias.
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21
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An increase in hemoglobin, platelets and white blood cells levels by iron chelation as single treatment in multitransfused patients with myelodysplastic syndromes: clinical evidences and possible biological mechanisms. Ann Hematol 2015; 94:771-7. [DOI: 10.1007/s00277-015-2341-z] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2014] [Accepted: 02/16/2015] [Indexed: 12/16/2022]
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22
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Abstract
Iron is essential for the growth and proliferation of cells, as well as for many biological processes that are important for the maintenance and survival of the human body. However, excess iron is associated with the development of cancer and other pathological conditions, due in part to the pro-oxidative nature of iron and its damaging effects on DNA. Current studies suggest that iron depletion may be beneficial for patients that have diseases associated with iron overload or other iron metabolism disorders that may increase the risk for cancer. On the other hand, studies suggest that cancer cells are more vulnerable to the effects of iron depletion and oxidative stress in comparison to normal cells. Therefore, cancer patients might benefit from treatments that alter both iron metabolism and oxidative stress. This review highlights the pro-oxidant effects of iron, the relationship between iron and cancer development, the vulnerabilities of the iron-dependent cancer phenotype, and how these characteristics may be exploited to prevent or treat cancer.
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Affiliation(s)
- Laura M Bystrom
- Department of Pediatrics-Hematology/Oncology, Weill Cornell Medical College, New York, NY 10021, USA.
| | - Stefano Rivella
- Department of Pediatrics-Hematology/Oncology, Weill Cornell Medical College, New York, NY 10021, USA; Department of Cell and Development Biology, Weill Cornell Medical College, New York, NY 10021, USA.
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23
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Puliyel M, Mainous AG, Berdoukas V, Coates TD. Iron toxicity and its possible association with treatment of Cancer: lessons from hemoglobinopathies and rare, transfusion-dependent anemias. Free Radic Biol Med 2015; 79:343-51. [PMID: 25463277 DOI: 10.1016/j.freeradbiomed.2014.10.861] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2014] [Revised: 10/22/2014] [Accepted: 10/30/2014] [Indexed: 01/19/2023]
Abstract
Exposure to elevated levels of iron causes tissue damage and organ failure, and increases the risk of cancer. The toxicity of iron is mediated through generation of oxidants. There is also solid evidence indicating that oxidant stress plays a significant role in a variety of human disease states, including malignant transformation. Iron toxicity is the main focus when managing thalassemia. However, the short- and long-term toxicities of iron have not been extensively considered in children and adults treated for malignancy, and only recently have begun to draw oncologists' attention. The treatment of malignancy can markedly increase exposure of patients to elevated toxic iron species without the need for excess iron input from transfusion. This under-recognized exposure likely enhances organ toxicity and may contribute to long-term development of secondary malignancy and organ failure. This review discusses the current understanding of iron metabolism, the mechanisms of production of toxic free iron species in humans, and the relation of the clinical marker, transferrin saturation (TS), to the presence of toxic free iron. We will present epidemiological data showing that high TS is associated with poor outcomes and development of cancer, and that lowering free iron may improve outcomes. Finally, we will discuss the possible relation between some late complications seen in survivors of cancer and those due to iron toxicity.
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Affiliation(s)
- Mammen Puliyel
- Section of Hematology, Childrens Center for Cancer, Blood Disease and Bone Marrow Transplantation, Children's Hospital Los Angeles, University of Southern California Keck School of Medicine, Los Angeles California, USA
| | - Arch G Mainous
- Department of Health Services Research, Management and Policy, University of Florida, Gainesville, Fla. USA
| | - Vasilios Berdoukas
- Section of Hematology, Childrens Center for Cancer, Blood Disease and Bone Marrow Transplantation, Children's Hospital Los Angeles, University of Southern California Keck School of Medicine, Los Angeles California, USA
| | - Thomas D Coates
- Section of Hematology, Childrens Center for Cancer, Blood Disease and Bone Marrow Transplantation, Children's Hospital Los Angeles, University of Southern California Keck School of Medicine, Los Angeles California, USA.
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24
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Meerpohl JJ, Schell LK, Rücker G, Fleeman N, Motschall E, Niemeyer CM, Bassler D. Deferasirox for managing iron overload in people with myelodysplastic syndrome. Cochrane Database Syst Rev 2014; 2014:CD007461. [PMID: 25348770 PMCID: PMC7202239 DOI: 10.1002/14651858.cd007461.pub3] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND The myelodysplastic syndrome (MDS) comprises a diverse group of haematopoietic stem cell disorders. Due to symptomatic anaemia, most people with MDS require supportive therapy including repeated red blood cell (RBC) transfusions. In combination with increased iron absorption, this contributes to the accumulation of iron resulting in secondary iron overload and the risk of organ dysfunction and reduced life expectancy. Since the human body has no natural means of removing excess iron, iron chelation therapy, i.e. the pharmacological treatment of iron overload, is usually recommended. However, it is unclear whether or not the newer oral chelator deferasirox leads to relevant benefit. OBJECTIVES To evaluate the effectiveness and safety of oral deferasirox for managing iron overload in people with myelodysplastic syndrome (MDS). SEARCH METHODS We searched the following databases up to 03 April 2014: MEDLINE, EMBASE, The Cochrane Library, Biosis Previews, Web of Science, Derwent Drug File and four trial registries: Current Controlled Trials (www.controlled-trials.com), ClinicalTrials.gov (www.clinicaltrials.gov), ICTRP (www.who.int./ictrp/en/), and German Clinical Trial Register (www.drks.de). SELECTION CRITERIA Randomised controlled trials (RCTs) comparing deferasirox with no therapy, placebo or with another iron-chelating treatment schedule. DATA COLLECTION AND ANALYSIS We did not identify any trials eligible for inclusion in this review. MAIN RESULTS No trials met our inclusion criteria. However, we identified three ongoing and one completed trial (published as an abstract only and in insufficient detail to permit us to decide on inclusion) comparing deferasirox with deferoxamine, placebo or no treatment. AUTHORS' CONCLUSIONS We planned to report evidence from RCTs that evaluated the effectiveness of deferasirox compared to either placebo, no treatment or other chelating regimens, such as deferoxamine, in people with MDS. However, we did not identify any completed RCTs addressing this question.We found three ongoing and one completed RCT (published as an abstract only and in insufficient detail) comparing deferasirox with deferoxamine, placebo or no treatment and data will hopefully be available soon. These results will be important to inform physicians and patients on the advantages and disadvantages of this treatment option.
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Affiliation(s)
- Joerg J Meerpohl
- Medical Center ‐ University of FreiburgGerman Cochrane CentreBerliner Allee 29FreiburgGermany79110
| | - Lisa K Schell
- Medical Center ‐ University of FreiburgGerman Cochrane CentreBerliner Allee 29FreiburgGermany79110
| | - Gerta Rücker
- Medical Center ‐ University of FreiburgCenter for Medical Biometry and Medical InformaticsStefan‐Meier‐Str. 26FreiburgGermany79104
| | - Nigel Fleeman
- University of LiverpoolLiverpool Reviews & Implementation Group2nd Floor, Sherrington BuildingsAshton StreetLiverpoolUKL69 3GE
| | - Edith Motschall
- Medical Center ‐ University of FreiburgCenter for Medical Biometry and Medical InformaticsStefan‐Meier‐Str. 26FreiburgGermany79104
| | - Charlotte M Niemeyer
- University Medical Center FreiburgPediatric Hematology & Oncology, Center for Pediatrics & Adolescent MedicineMathildenstrasse 1FreiburgGermany79106
| | - Dirk Bassler
- University Hospital ZurichDepartment of NeonatologyFrauenklinikstrasse 10ZurichSwitzerland
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25
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Coates TD. Physiology and pathophysiology of iron in hemoglobin-associated diseases. Free Radic Biol Med 2014; 72:23-40. [PMID: 24726864 PMCID: PMC4940047 DOI: 10.1016/j.freeradbiomed.2014.03.039] [Citation(s) in RCA: 101] [Impact Index Per Article: 10.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2014] [Revised: 03/26/2014] [Accepted: 03/27/2014] [Indexed: 01/19/2023]
Abstract
Iron overload and iron toxicity, whether because of increased absorption or iron loading from repeated transfusions, can be major causes of morbidity and mortality in a number of chronic anemias. Significant advances have been made in our understanding of iron homeostasis over the past decade. At the same time, advances in magnetic resonance imaging have allowed clinicians to monitor and quantify iron concentrations noninvasively in specific organs. Furthermore, effective iron chelators are now available, including preparations that can be taken orally. This has resulted in substantial improvement in mortality and morbidity for patients with severe chronic iron overload. This paper reviews the key points of iron homeostasis and attempts to place clinical observations in patients with transfusional iron overload in context with the current understanding of iron homeostasis in humans.
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Affiliation(s)
- Thomas D Coates
- Children׳s Center for Cancer and Blood Diseases, Children׳s Hospital Los Angeles, University of Southern California Keck School of Medicine, Los Angeles, CA 90027, USA.
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26
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Impact of iron overload and potential benefit from iron chelation in low-risk myelodysplastic syndrome. Blood 2014; 124:873-81. [PMID: 24923296 DOI: 10.1182/blood-2014-03-563221] [Citation(s) in RCA: 89] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Abstract
Myelodysplastic syndromes (MDSs) are a group of heterogeneous clonal bone marrow disorders characterized by ineffective hematopoiesis, peripheral blood cytopenias, and potential for malignant transformation. Lower/intermediate-risk MDSs are associated with longer survival and high red blood cell (RBC) transfusion requirements resulting in secondary iron overload. Recent data suggest that markers of iron overload portend a relatively poor prognosis, and retrospective analysis demonstrates that iron chelation therapy is associated with prolonged survival in transfusion-dependent MDS patients. New data provide concrete evidence of iron's adverse effects on erythroid precursors in vitro and in vivo. Renewed interest in the iron field was heralded by the discovery of hepcidin, the main serum peptide hormone negative regulator of body iron. Evidence from β-thalassemia suggests that regulation of hepcidin by erythropoiesis dominates regulation by iron. Because iron overload develops in some MDS patients who do not require RBC transfusions, the suppressive effect of ineffective erythropoiesis on hepcidin may also play a role in iron overload. We anticipate that additional novel tools for measuring iron overload and a molecular-mechanism-driven description of MDS subtypes will provide a deeper understanding of how iron metabolism and erythropoiesis intersect in MDSs and improve clinical management of this patient population.
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27
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Abstract
Sideroblastic anemias (SAs) may be acquired or congenital and share the features of disrupted utilization of iron in the erythroblast, ineffective erythropoiesis, and variable systemic iron overload. Congenital forms can have associated syndromic features or be nonsyndromic, and many of them have mutations in genes encoding proteins involved in heme biosynthesis, iron-sulfur cluster biogenesis, or mitochondrial protein synthesis. The mechanism(s) for the acquired clonal SA is undefined and is under intense study. Precise diagnosis of these disorders rests on careful clinical and laboratory evaluation, including molecular analysis. Supportive treatments usually provide for a favorable prognosis and often for normal survival.
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Affiliation(s)
- Sylvia S Bottomley
- Department of Medicine, University of Oklahoma College of Medicine, 755 Research Park, Suite 427, Oklahoma City, OK 73104, USA.
| | - Mark D Fleming
- Department of Pathology, Boston Children's Hospital, Harvard Medical School, 300 Longwood Avenue, Bader 124.1, Boston, MA 02115, USA
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28
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Finelli C, Clissa C, Stanzani M. Use of deferasirox in transfusion-dependent myelodysplastic syndromes with iron overload. Int J Hematol Oncol 2014. [DOI: 10.2217/ijh.14.19] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Abstract
SUMMARY In myelodysplastic syndromes (MDS), transfusion-dependent anemia has been established as an independent risk factor for decreased survival. Although evidence from prospective studies is still lacking, several guidelines recommend iron-chelating therapy in MDS patients with a longer life expectancy. With the recent introduction of deferasirox, an oral active iron-chelating drug, which has shown dose-dependent efficacy and acceptable tolerability, this therapeutic option has become feasible even in the elderly. Several retrospective and prospective studies showed that in MDS patients deferasirox is effective in reducing iron burden and in maintaining the circulating toxic iron fraction within the normal range. Moreover, in a substantial fraction of patients treated with deferasirox a significant improvement of peripheral cytopenias may occur.
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Affiliation(s)
- Carlo Finelli
- Institute of Hematology, “Seràgnoli”, Sant’Orsola-Malpighi University Hospital, Via Massarenti 9 – 40138 Bologna, Italy
| | - Cristina Clissa
- Institute of Hematology, “Seràgnoli”, Sant’Orsola-Malpighi University Hospital, Via Massarenti 9 – 40138 Bologna, Italy
| | - Marta Stanzani
- Institute of Hematology, “Seràgnoli”, Sant’Orsola-Malpighi University Hospital, Via Massarenti 9 – 40138 Bologna, Italy
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29
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Steensma DP, Gattermann N. When is iron overload deleterious, and when and how should iron chelation therapy be administered in myelodysplastic syndromes? Best Pract Res Clin Haematol 2013; 26:431-44. [DOI: 10.1016/j.beha.2013.09.009] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
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30
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Vigna E, Recchia AG, Cuzzola M, Morabito L, Gentile M, Morabito F. Erythroid but not cytogenetic response in a case with 5q- syndrome: a delayed effect of lenalidomide or a consequence of deferasirox treatment? Leuk Lymphoma 2013; 55:1408-9. [PMID: 23952245 DOI: 10.3109/10428194.2013.834053] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Affiliation(s)
- Ernesto Vigna
- Unità Operativa Complessa di Ematologia, Dipartimento Oncoematologico, Azienda Ospedaliera di Cosenza , Cosenza , Italy
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31
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Efficacy and safety of deferasirox in myelodysplastic syndromes. Ann Hematol 2013; 92:863-70. [PMID: 23417759 DOI: 10.1007/s00277-013-1703-7] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2012] [Accepted: 02/05/2013] [Indexed: 12/18/2022]
Abstract
Transfusion dependence in myelodysplastic syndrome (MDS) patients may lead to organ damage due to accumulation of non-transferrin-bound iron with consequent increased oxidative stress. Iron chelation has been reported in retrospective studies to improve overall survival in low-risk MDS patients, but this information needs to be validated in prospective trials. The oral iron chelator, deferasirox, has been shown to reduce serum ferritin levels in chelation naïve and pre-treated patients and to reduce labile plasma iron, independently from the efficacy on iron overload. Deferasirox is a potent NF-kB inhibitor, tested in vivo and on acute myeloid leukemia and MDS cell lines, and this effect may explain in part the phenomenon of hematological improvements reported in case reports and in different clinical trials. The drug has an acceptable safety profile, with the most common side effects reported being non-progressive change in serum creatinine level, gastrointestinal disturbances, and skin rash. In this review, we report the results of different studies testing safety and efficacy of deferasirox in MDS patients, side effects associated with the drug, and suggested management of iron overload.
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Tesch H, Ihling C. Loss of Transfusion Dependency Following Deferasirox Treatment of Iron Overload in a Woman with Myelofibrosis and Spherocytosis - a Case Report. ACTA ACUST UNITED AC 2013; 36:205-8. [DOI: 10.1159/000349939] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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Gattermann N, Finelli C, Della Porta M, Fenaux P, Stadler M, Guerci-Bresler A, Schmid M, Taylor K, Vassilieff D, Habr D, Marcellari A, Roubert B, Rose C. Hematologic responses to deferasirox therapy in transfusion-dependent patients with myelodysplastic syndromes. Haematologica 2012; 97:1364-71. [PMID: 22419577 DOI: 10.3324/haematol.2011.048546] [Citation(s) in RCA: 146] [Impact Index Per Article: 12.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
BACKGROUND Reductions in transfusion requirements/improvements in hematologic parameters have been associated with iron chelation therapy in transfusion-dependent patients, including those with myelodysplastic syndromes; data on there reductions/improvements have been limited to case reports and small studies. DESIGN AND METHODS To explore this observation in a large population of patients, we report a post-hoc analysis evaluating hematologic response to deferasirox in a cohort of iron-overloaded patients with myelodysplastic syndromes enrolled in the Evaluation of Patients' Iron Chelation with Exjade(®) (EPIC) study using International Working Group 2006 criteria. RESULTS Two-hundred and forty-seven, 100 and 50 patients without concomitant medication for myelodysplastic syndromes were eligible for analysis of erythroid, platelet and neutrophil responses, respectively. Erythroid, platelet and neutrophil responses were observed in 21.5% (53/247), 13.0% (13/100) and 22.0% (11/50) of the patients after a median of 109, 169 and 226 days, respectively. Median serum ferritin reductions were greater in hematologic responders compared with non-responders at end of study, although these differences were not statistically significant. A reduction in labile plasma iron to less than 0.4 μmol/L was observed from week 12 onwards; this change did not differ between hematologic responders and non-responders. CONCLUSIONS This analysis suggests that deferasirox treatment for up to 1 year could lead to improvement in hematologic parameters in some patients with myelodysplastic syndromes.
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Tazmini K, Bakken H, Schjesvold F. En kvinne i 70-årene med redusert allmenntilstand, dyspné og utbredte smerter. TIDSSKRIFT FOR DEN NORSKE LEGEFORENING 2012; 132:1969-72. [DOI: 10.4045/tidsskr.11.0608] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022] Open
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Leitch HA. Optimizing therapy for iron overload in the myelodysplastic syndromes: recent developments. Drugs 2011; 71:155-77. [PMID: 21275444 DOI: 10.2165/11585280-000000000-00000] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
The myelodysplastic syndromes (MDS) are characterized by cytopenias and risk of progression to acute myeloid leukaemia (AML). Most MDS patients eventually require transfusion of red blood cells for anaemia, placing them at risk of transfusional iron overload. In β-thalassaemia major, transfusional iron overload leads to organ dysfunction and death; however, with iron chelation therapy, organ function is improved, and survival improved to near normal and correlated with the degree of compliance with chelation. In lower-risk MDS, several nonrandomized studies suggest an adverse effect of iron overload on survival and that lowering iron with chelation may minimize this impact. Emerging data indicate that chelation may improve organ function, particularly hepatic function, and a minority of patients may have improvement in cell counts and decreased transfusion requirements. While guidelines for MDS generally recommend chelation in selected lower-risk patients, data from nonrandomized trials suggest iron overload may impact adversely on the outcome of higher-risk MDS and stem cell transplantation (SCT). This effect may be due to increased transplant-related mortality, infection and AML progression, and preliminary data suggest that lowering iron may be beneficial in this patient group. Other areas of active and future investigation include optimizing the monitoring of iron overload using imaging such as T2* MRI and measures of labile iron and oxidative stress; correlating new methods of measuring iron to clinical outcomes; clarifying the contribution of different cellular and extracellular iron pools to iron toxicity; optimizing chelation by using agents that access the appropriate iron pools to minimize the relevant clinical consequences in individual patients; and incorporating measures of quality of life and co-morbidities into clinical trials of chelation in MDS. It should be noted that chelation is costly and potentially toxic, and in MDS should be initiated after weighing potential risks and benefits for each patient until more definitive data are available. In this review, data on the impact of iron overload in MDS and SCT are discussed; for example, several noncontrolled studies show inferior survival in patients with iron overload in these clinical settings, including an increase in transplant-related mortality and infection risk. Possible mechanisms of iron toxicity include oxidative stress, which can damage cellular components, and the documented impact of lowering iron on organ function with measures such as iron chelation therapy includes an improvement in elevated liver transaminases. Lowering iron also appears to improve survival in both lower-risk MDS and SCT in nonrandomized studies. Selected aspects of iron metabolism, transport, storage and distribution that may be amenable to future intervention and improved removal of iron from important cellular sites are discussed, as are attempts to quantify quality of life and the importance of co-morbidities in measures to treat MDS, including chelation therapy.
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Affiliation(s)
- Heather A Leitch
- Division of Hematology, St Paul's Hospital and the University of British Columbia, 440–1144 Burrard Street, Vancouver, BC, Canada.
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Guariglia R, Martorelli MC, Villani O, Pietrantuono G, Mansueto G, D'Auria F, Grieco V, Bianchino G, Lerose R, Bochicchio GB, Musto P. Positive effects on hematopoiesis in patients with myelodysplastic syndrome receiving deferasirox as oral iron chelation therapy: a brief review. Leuk Res 2010; 35:566-70. [PMID: 21185078 DOI: 10.1016/j.leukres.2010.11.027] [Citation(s) in RCA: 55] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2010] [Revised: 11/27/2010] [Accepted: 11/29/2010] [Indexed: 01/10/2023]
Abstract
Iron overload is a frequent consequence in transfusion-dependent myelodysplastic syndromes (MDSs), which often requires iron chelation therapy (ICT). Interestingly, ICT may sometimes induce a hematologic improvement that leads to significant reduction or complete interruption of blood transfusions. This phenomenon has been recently described in MDS treated with the new oral chelator deferasirox. Here we briefly review the literature about this phenomenon and discuss the possible biological mechanisms underlying hematologic effects of deferasirox in MDS, starting from a new paradigmatic case in whom both hemoglobin level and platelet count improved, inducing transfusion-independence, soon after starting the treatment with deferasirox.
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Affiliation(s)
- Roberto Guariglia
- Department of Onco-Hematology, Centro di Riferimento Oncologico della Basilicata, IRCCS, Via San Pio 1, 85028 Rionero in Vulture, PZ, Italy
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Meerpohl JJ, Antes G, Rücker G, Fleeman N, Motschall E, Niemeyer CM, Bassler D. Deferasirox for managing iron overload in people with myelodysplastic syndrome. Cochrane Database Syst Rev 2010:CD007461. [PMID: 21069694 DOI: 10.1002/14651858.cd007461.pub2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
BACKGROUND The myelodysplastic syndrome (MDS) comprises a diverse group of haematopoietic stem cell disorders. Due to symptomatic anaemia most patients require supportive therapy including repeated red blood cell (RBC) transfusions. In combination with increased iron absorption, this contributes to the accumulation of iron resulting in secondary iron overload and the risk of organ dysfunction and reduced life expectancy. Since the human body has no natural means of getting rid of excess iron, iron chelation therapy is usually recommended. However, whether the new oral chelator deferasirox leads to relevant benefit is unclear. OBJECTIVES To assess the effectiveness and safety of oral deferasirox in people with myelodysplastic syndrome and iron overload. SEARCH STRATEGY We searched MEDLINE, EMBASE, The Cochrane Library, Biosis Previews, Web of Science, Derwent Drug File, XTOXLINE and three trial registries: Current Controlled Trials: www.controlled-trials.com, ClinicalTrials.gov: www.clinicaltrials.gov, ICTRP: www.who.int./ictrp/en/. Most recent searches of these databases: June 2010. SELECTION CRITERIA Randomised controlled trials comparing deferasirox with no therapy/placebo or with another iron chelating treatment schedule. DATA COLLECTION AND ANALYSIS No studies eligible for inclusion in this review were identified. MAIN RESULTS No studies were included in this review. However, we identified one ongoing study comparing deferasirox with deferoxamine. AUTHORS' CONCLUSIONS We planned to report evidence from randomised clinical trials evaluating the effectiveness of deferasirox compared to either placebo/no treatment or other chelating regimens such as deferoxamine in people with myelodysplastic syndrome. However, no completed randomised trials addressing this question could be identified.One ongoing randomised study comparing deferasirox with placebo was identified and preliminary data will hopefully be available soon. These results will be important to inform physicians and patients on the advantages and disadvantages of this treatment option.
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Affiliation(s)
- Joerg J Meerpohl
- German Cochrane Centre, Institute of Medical Biometry & Medical Informatics and Pediatric Hematology & Oncology, Center for Pediatrics & Adolescent Medicine, University Medical Center Freiburg, Berliner Allee 29, Freiburg, Germany, 79110
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Crosstalk between Erythropoiesis and Iron Metabolism. Adv Hematol 2010; 2010. [PMID: 20862206 PMCID: PMC2938435 DOI: 10.1155/2010/317095] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2010] [Accepted: 07/14/2010] [Indexed: 01/13/2023] Open
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Descamps V, Landry J, Francès C, Marinho E, Ratziu V, Chosidow O. Facial Cosmetic Filler Injections as Possible Target for Systemic Sarcoidosis in Patients Treated with Interferon for Chronic Hepatitis C: Two Cases. Dermatology 2008; 217:81-4. [PMID: 18446029 DOI: 10.1159/000128281] [Citation(s) in RCA: 47] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2007] [Accepted: 11/22/2007] [Indexed: 11/19/2022] Open
Affiliation(s)
- Vincent Descamps
- Department of Dermatology, Bichat Claude Bernard Hospital, Paris, France.
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