1
|
Wei Y, Qian K, Le N, Wang L, Li F, Luan S, Wang L, Jin X, Peng B, Wang N, Dou L, Liu D. Addition of ruxolitinib and decitabine to modified busulfan/cyclophosphamide conditioning regimen for prophylaxis relapse in high-risk acute myeloid leukemia: the phase 2 prospective study. Ann Hematol 2024:10.1007/s00277-024-05972-w. [PMID: 39243311 DOI: 10.1007/s00277-024-05972-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2024] [Accepted: 08/23/2024] [Indexed: 09/09/2024]
Abstract
The prognosis of patients with high-risk acute myeloid leukemia (AML) is dismal even after allogeneic stem cell transplantation (allo-HSCT), with relapse remaining the leading cause of treatment failure. Here, we investigated whether ruxolitinib and decitabine plus modified busulfan-cyclophosphamide (mBu/Cy) conditioning could reduce relapse in high-risk AML after allo-HSCT. This prospective, single-arm, phase II trial enrolled 37 patients who received allo-HSCT between September 2020 and March 2022 at the First Medical Center of Chinese People's Liberation Army (PLA) General Hospital. Eligible patients (10-62 years) had relapsed/refractory, positive measurable residual disease (MRD) prior to conditioning or adverse genetic abnormalities. Ruxolitinib (35 mg twice daily, days - 15 to - 10) and decitabine (20 mg/m2/day, days - 15 to - 10) were administered followed by mBu/Cy conditioning. All patients achieved engraftment. The cumulative incidences (CIs) of acute graft-versus-host disease (GVHD) grades II-IV and III-IV were 35.0% and 10.5%, respectively. The 1-year cumulative incidence of chronic GVHD was 8.1%. The 1-year CI of relapse was 29.7% among all patients, 0% in patients who achieved the first complete remission (CR1) prior to conditioning, and 0% in those with MRD-negative prior to conditioning. The 1-year non-relapse mortality was 5.4%. The 1-year probabilities of overall survival, disease-free survival, and GVHD-free relapse-free survival were 70.3%, 62.2%, and 54.1%, respectively. In conclusion, the novel conditioning showed primary efficacy in terms of a reduction in relapse in high-risk patients with AML after allo-HSCT, especially in those who achieved CR1 and MRD-negative prior to conditioning. Also, the new conditioning regimen may help reduce the incidence of chronic GVHD. ClinicalTrials.gov identifier: NCT04582604.
Collapse
Affiliation(s)
- Yujun Wei
- School of Medicine, Nankai University, Tianjin, 300071, China
- Chief Department of Hematology, The Fifth Medical Center of Chinese PLA General Hospital, Beijing, 100071, China
| | - Kun Qian
- School of Medicine, Nankai University, Tianjin, 300071, China
- Chief Department of Hematology, The Fifth Medical Center of Chinese PLA General Hospital, Beijing, 100071, China
| | - Ning Le
- Chief Department of Hematology, The Fifth Medical Center of Chinese PLA General Hospital, Beijing, 100071, China
| | - Lili Wang
- Chief Department of Hematology, The Fifth Medical Center of Chinese PLA General Hospital, Beijing, 100071, China
| | - Fei Li
- Chief Department of Hematology, The Fifth Medical Center of Chinese PLA General Hospital, Beijing, 100071, China
| | - Songhua Luan
- Department of Hematology, The First Medical Center of Chinese PLA General Hospital, Beijing, 100853, China
| | - Lu Wang
- Chief Department of Hematology, The Fifth Medical Center of Chinese PLA General Hospital, Beijing, 100071, China
| | - Xiangshu Jin
- Chief Department of Hematology, The Fifth Medical Center of Chinese PLA General Hospital, Beijing, 100071, China
| | - Bo Peng
- Chief Department of Hematology, The Fifth Medical Center of Chinese PLA General Hospital, Beijing, 100071, China
| | - Nan Wang
- Chief Department of Hematology, The Fifth Medical Center of Chinese PLA General Hospital, Beijing, 100071, China
| | - Liping Dou
- Chief Department of Hematology, The Fifth Medical Center of Chinese PLA General Hospital, Beijing, 100071, China.
| | - Daihong Liu
- School of Medicine, Nankai University, Tianjin, 300071, China.
- Chief Department of Hematology, The Fifth Medical Center of Chinese PLA General Hospital, Beijing, 100071, China.
| |
Collapse
|
2
|
Chen D, Geyer J, Bagg A, Hasserjian R, Weinberg OK. A comparative analysis of the clinical and genetic profiles of blast phase BCR::ABL1-negative myeloproliferative neoplasm and acute myeloid leukemia, myelodysplasia-related. Int J Lab Hematol 2024; 46:687-694. [PMID: 38665121 DOI: 10.1111/ijlh.14280] [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: 11/08/2023] [Accepted: 03/22/2024] [Indexed: 07/04/2024]
Abstract
INTRODUCTION The classic Philadelphia chromosome-negative myeloproliferative neoplasms (Ph (-) MPNs), have variable potential for progression to the blast phase (MPN-BP) of the disease. Except initiated by distinct driver mutations, MPN-BP frequently carry similar genetic abnormalities defining acute myeloid leukemia myelodysplasia-related (AML-MR). Because of dissimilar initial pathogenesis, MPN-BP and AML-MR are retained under different disease categories. To determine if separately classifying these entities is justified, we compare MPN-BP with AML-MR patients based on mutational landscape and clinical parameters. METHODS 104 MPN-BP patients and 145 AML-MR patients were identified with available clinical, cytogenetic, and genetic data. RESULTS AML-MR patients presented with a higher blast count (median, 51% vs. 30%) while MPN-BP patients had higher WBC counts, platelet counts and bone marrow cellularity (all p<0.0001). Patients with MPN-BP showed similar genetic mutations with similar mutation pattern (functional domain, hotspot and locus involved by the mutations) but a different mutation rate from AML-MR, with more frequent JAK2, CALR, MPL, ASXL1, IDH2, SETBP1 and SRSF2 mutations and less frequent TP53 and DNMT3A mutations. The overall survival (OS) of MPN-BP (OS post-BP-progression) is comparable to that of AML-MR (median OS, 9.5 months vs. 13.1 months, p=0.20). In addition, the subgroups of MPN-BP show similar OS as AML-MR. When harboring certain mutation such as TP53, ASXL1, DNMT3A, TET2, RUNX1, IDH1, IDH2, EZH2, U2AF1, BCOR and SRSF2, MPN-BP and AML-MR patients carrying the same somatic mutation show no difference in OS. CONCLUSION MPN-BP and AML-MR harbor similar somatic mutations and clinical outcomes, suggesting a unified clinical disease entity.
Collapse
Affiliation(s)
- Dong Chen
- Department of Pathology and Laboratory Medicine, University of Connecticut, Farmington, Connecticut, USA
| | - Julia Geyer
- Department of Pathology and Laboratory Medicine, Weill Cornell Medical College, Cornell University, New York, New York, USA
| | - Adam Bagg
- Department of Pathology and Laboratory Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Robert Hasserjian
- Department of Pathology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Olga K Weinberg
- Department of Pathology, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| |
Collapse
|
3
|
Patel AA, Yoon JJ, Johnston H, Davidson MB, Shallis RM, Chen EC, Burkart M, Oh TS, Iyer SG, Madarang E, Muthiah C, Gross I, Dean R, Kassner J, Viswabandya A, Madero-Marroquin R, Rampal RK, Guru Murthy GS, Bradley T, Abaza Y, Garcia JS, Gupta V, Pettit KM, Cursio JF, Odenike O. Treatment approach and outcomes of patients with accelerated/blast-phase myeloproliferative neoplasms in the current era. Blood Adv 2024; 8:3468-3477. [PMID: 38739724 PMCID: PMC11260843 DOI: 10.1182/bloodadvances.2024012880] [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: 02/06/2024] [Revised: 03/28/2024] [Accepted: 04/27/2024] [Indexed: 05/16/2024] Open
Abstract
ABSTRACT Progression of myeloproliferative neoplasms (MPNs) to accelerated or blast phase is associated with poor survival outcomes. Since 2017 there have been several therapies approved for use in acute myeloid leukemia (AML); these therapies have been incorporated into the management of accelerated/blast-phase MPNs (MPN-AP/BP). We performed a multicenter analysis to investigate outcomes of patients diagnosed with MPN-AP/BP in 2017 or later. In total, 202 patients were identified; median overall survival (OS) was 0.86 years. We also analyzed patients based on first-line treatment; the 3 most common approaches were intensive chemotherapy (n = 65), DNA methyltransferase inhibitor (DNMTi)-based regimens (n = 65), and DNMTi + venetoclax-based regimens (n = 54). Median OS was not significantly different by treatment type. In addition, we evaluated response by 2017 European LeukemiaNet AML criteria and 2012 MPN-BP criteria in an effort to understand the association of response with survival outcomes. We also analyzed outcomes in 65 patients that received allogeneic hematopoietic stem cell transplant (allo-HSCT); median OS was 2.30 years from time of allo-HSCT. Our study demonstrates that survival among patients with MPN-AP/BP is limited in the absence of allo-HSCT even in the current era of therapeutics and underscores the urgent need for new agents and approaches.
Collapse
Affiliation(s)
- Anand A. Patel
- Department of Medicine, Section of Hematology-Oncology, University of Chicago, Chicago, IL
| | - James J. Yoon
- Division of Hematologic Malignancies, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA
| | - Hannah Johnston
- Department of Medicine, Internal Medicine Residency, University of Chicago, Chicago, IL
| | - Marta B. Davidson
- Medical Oncology and Hematology, Princess Margaret Cancer Centre, Toronto, ON, Canada
| | - Rory M. Shallis
- Department of Internal Medicine, Section of Hematology, Yale School of Medicine and Yale Cancer Center, New Haven, CT
| | - Evan C. Chen
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA
| | - Madelyn Burkart
- Atrium Health Wake Forest Baptist Comprehensive Cancer Center, Winston-Salem, NC
| | - Timothy S. Oh
- Division of Hematology and Oncology, Robert H. Lurie Comprehensive Cancer Center, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Sunil G. Iyer
- Division of Hematology and Oncology, Herbert Irving Comprehensive Cancer Center, Columbia University Irving Medical Center, New York, NY
| | - Ellen Madarang
- University of Miami Sylvester Comprehensive Cancer Center, Miami, FL
| | | | - Iyana Gross
- University of Chicago Comprehensive Cancer Center, Chicago, IL
| | - Raven Dean
- University of Chicago Comprehensive Cancer Center, Chicago, IL
| | | | - Auro Viswabandya
- Medical Oncology and Hematology, Princess Margaret Cancer Centre, Toronto, ON, Canada
| | | | - Raajit K. Rampal
- Department of Medicine, Leukemia Service, Memorial Sloan Kettering Cancer Center, New York, NY
| | | | - Terrence Bradley
- University of Miami Sylvester Comprehensive Cancer Center, Miami, FL
| | - Yasmin Abaza
- Division of Hematology and Oncology, Robert H. Lurie Comprehensive Cancer Center, Northwestern University Feinberg School of Medicine, Chicago, IL
| | | | - Vikas Gupta
- Medical Oncology and Hematology, Princess Margaret Cancer Centre, Toronto, ON, Canada
| | - Kristen M. Pettit
- Division of Hematology and Medical Oncology, Department of Internal Medicine, University of Michigan Medical School, Michigan Medicine, Ann Arbor, MI
| | - John F. Cursio
- Department of Public Health Sciences, University of Chicago, Chicago, IL
| | - Olatoyosi Odenike
- Department of Medicine, Section of Hematology-Oncology, University of Chicago, Chicago, IL
| |
Collapse
|
4
|
Ortí G, Gras L, Zinger N, Finazzi MC, Sockel K, Robin M, Forcade E, Avenoso D, Kröger N, Finke J, Radujkovic A, Hunault-Berger M, Schroyens W, Zuckerman T, Bourhis JH, Chalandon Y, Bloor A, Schots R, de Wreede LC, Drozd-Sokolowska J, Raj K, Polverelli N, Czerw T, Hernández-Boluda JC, McLornan D, Yakoub-Agha I. Outcomes after allogeneic hematopoietic cell transplant in patients diagnosed with blast phase of myeloproliferative neoplasms: A retrospective study from the Chronic Malignancies Working Party of the European Society for Blood and Marrow Transplantation. Am J Hematol 2023; 98:628-638. [PMID: 36606718 DOI: 10.1002/ajh.26833] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2022] [Revised: 12/27/2022] [Accepted: 01/01/2023] [Indexed: 01/07/2023]
Abstract
Allogeneic hematopoietic cell transplant (allo-HCT) provides the only potential route to long-term remission in patients diagnosed with blast phase transformation of myeloproliferative neoplasm (BP-MPN). We report on a large, retrospective European Society for Blood and Marrow Transplantation registry-based study of BP-MPN patients undergoing allo-HCT. BP-MPN patients undergoing first allo-HCT between 2005 and 2019 were included. A total of 663 patients were included. With a median follow-up of 62 months, the estimated 3-year overall survival (OS) was 36% (95% confidence interval [CI], 32-36). Factors associated with lower OS were Karnofsky Performance Score (KPS) <90 (hazard ratio [HR] 1.65, p < .001) and active disease at allo-HCT (HR 1.45, p < .001), whereas patients undergoing allo-HCT more recently associated with a higher OS (HR 0.96, p = .008). In a selected patient's population, the 3-year OS of patients undergoing allo-HCT in complete response (CR) and with a KPS ≥90 was 60%. KPS < 90 (HR 1.4, p = .001) and active disease (HR 1.44, p = .0004) were associated with a lower progression-free survival (PFS). Conversely, most recent allo-HCT associated with a higher PFS (HR 0.96, p = .008). Active disease at allo-HCT (HR 1.34, p = .03) was associated with a higher cumulative incidence of relapse (RI) and allo-HCT in earlier calendar years (HR 0.96, p = .02) associated with a lower RI. Last, KPS < 90 (HR 1.91, p < .001), active disease (HR 1.74, p = .003) and allo-HCT from mismatched related donors were associated with a higher non-relapse mortality (HR 2.66, p = .003). In this large series of BP-MPN patients, about one third were alive at 3 years after transplantation. Patients undergoing allo-HCT in the more recent era, with a KPS ≥90 and in CR at transplant had a better prognosis.
Collapse
Affiliation(s)
- Guillermo Ortí
- Department of Hematology, Vall d'Hebron University Hospital, Vall d'Hebron Institute of Oncology (VHIO), Barcelona, Spain
| | - Luuk Gras
- EBMT Statistical Unit, Leiden, The Netherlands
| | | | - Maria Chiara Finazzi
- Department of Oncology and Hematology, University of Milan and Papa Giovanni XXIII, Bergamo, Italy
| | - Katja Sockel
- Medical Clinic I, University Hospital Dresden, TU Dresden, Germany
| | - Marie Robin
- Hopital Saint Louis, APHP, Université de Paris Cité, Paris, France
| | - Edouard Forcade
- Service d'Hématologie Clinique et Thérapie Cellulaire, Bordeaux, France
| | | | | | | | | | | | | | | | | | - Yves Chalandon
- Hôpitaux Universitaire Genève, Département d'Oncologie, Service d'Hématologie, Faculty of Medicine, University of Geneva, Geneva, Switzerland
| | | | - Rik Schots
- Universitair Ziekenhuis Brussel, Brussels, Belgium
| | | | | | - Kavita Raj
- University College London Hospital, London, UK
| | | | - Tomasz Czerw
- Maria Skłodowska-Curie National Research Institute of Oncology, Gliwice, Poland
| | | | - Donal McLornan
- Department of Stem Cell Transplantation, University College London Hospital, London, UK
| | | |
Collapse
|
5
|
Patel AA, Odenike O. SOHO State of the Art Updates and Next Questions | Accelerated Phase of MPN: What It Is and What to Do About It. CLINICAL LYMPHOMA, MYELOMA & LEUKEMIA 2023; 23:303-309. [PMID: 36907766 DOI: 10.1016/j.clml.2023.01.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/05/2022] [Revised: 01/20/2023] [Accepted: 01/20/2023] [Indexed: 01/26/2023]
Abstract
Progression of Philadelphia-chromosome negative myeloproliferative neoplasms (MPNs) to the accelerated phase (AP) or blast phase (BP) is associated with poor outcomes. As our understanding of the molecular drivers of MPN progression has grown, there has been increasing investigation into the use of novel targeted approaches in the treatment of these diseases. In this review we summarize the clinical and molecular risk factors for progression to MPN-AP/BP followed by discussion of treatment approach. We also highlight outcomes using conventional approaches such as intensive chemotherapy and hypomethylating agents along with considerations around allogeneic hematopoietic stem cell transplant. We then focus on novel targeted approaches in MPN-AP/BP including venetoclax-based regimens, IDH inhibition, and ongoing prospective clinical trials.
Collapse
Affiliation(s)
- Anand A Patel
- Section of Hematology/Oncology, Department of Medicine, University of Chicago, Chicago, IL
| | - Olatoyosi Odenike
- Section of Hematology/Oncology, Department of Medicine, University of Chicago, Chicago, IL.
| |
Collapse
|
6
|
Hitting the brakes on accelerated and blast-phase myeloproliferative neoplasms: current and emerging concepts. HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2022; 2022:218-224. [PMID: 36485103 PMCID: PMC9820986 DOI: 10.1182/hematology.2022000341] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
The BCR-ABL-negative myeloproliferative neoplasms (MPNs) have a variable risk of progressing to accelerated- or blast-phase MPN (MPN-AP/MPN-BP), defined by the presence of 10% to 19% and more than or equal to 20% myeloid blasts in the peripheral blood or bone marrow, respectively. The molecular processes underlying the progression to MPN-AP/MPN-BP are becoming increasingly understood with the acquisition of additional mutations in epigenetic modifiers (eg, ASXL1, EZH2, TET2), TP53, the Ras pathway, or splicing factors (eg, SRSF2, U2AF1), having been described as important steps in this evolutionary process. At least partially driven by the enrichment of these high-risk molecular features, the prognosis of patients with MPN-BP remains inferior to other patients with acute myeloid leukemia, with a median overall survival of 3 to 6 months. Allogeneic hematopoietic cell transplantation remains the only potentially curative therapeutic modality, but only a minority of patients are eligible. In the absence of curative intent, therapeutic strategies or palliative treatment with hypomethylating agents as monotherapy or in combination with ruxolitinib or venetoclax can be considered. Several novel agents are in various stages of clinical development but are not available for routine use at this point, highlighting the need for ongoing research and the prioritization of clinical trial enrollment when feasible.
Collapse
|
7
|
Hernández-Boluda JC, Czerw T. Transplantation algorithm for myelofibrosis in 2022 and beyond. Best Pract Res Clin Haematol 2022; 35:101369. [DOI: 10.1016/j.beha.2022.101369] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2022] [Accepted: 07/27/2022] [Indexed: 11/16/2022]
|
8
|
Castillo Tokumori F, Al Ali N, Chan O, Sallman D, Yun S, Sweet K, Padron E, Lancet J, Komrokji R, Kuykendall AT. Comparison of Different Treatment Strategies for Blast-Phase Myeloproliferative Neoplasms. CLINICAL LYMPHOMA, MYELOMA & LEUKEMIA 2022; 22:e521-e525. [PMID: 35241387 PMCID: PMC10766145 DOI: 10.1016/j.clml.2022.01.015] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/04/2022] [Revised: 01/26/2022] [Accepted: 01/28/2022] [Indexed: 01/08/2023]
Abstract
INTRODUCTION Up to 20% of patients with myeloproliferative neoplasms (MPN) will progress to blast phase (MPN-BP). Outcomes are dismal, with intensive chemotherapy providing little benefit. Low-intensity therapy is preferred due to better tolerability, but the prognosis remains poor. Allogeneic stem cell transplant (AHSCT) is still the only potential for long term survival. PATIENTS AND METHODS To better evaluate the initial treatment approach in MPN-BP, we performed a single-institution retrospective analysis of 75 patients with MPN-BP treated at Moffitt Cancer Center between 2001 and 2021. Patients were stratified by initial treatment: best supportive care (BSC), hypomethylating agent (HMA)-based therapy or intensive chemotherapy (IC). RESULTS Median overall survival (mOS) for the entire cohort was 4.8 months (BSC 0.8 months, HMA 4.7 months, and IC 11.4 months). Among IC patients, improved survival was evident in those that received AHSCT (mOS 40.8 months vs. 4.9 months, p < .01). Most patients that underwent AHSCT were initially treated with IC (p < .01). All patients that underwent AHSCT had achieved complete response (CR) or CR with incomplete hematological recovery (CRi). On multivariate analysis, factors associated with improved survival were receipt of therapy (HMA or IC) (P = .017), CR/CRi (P = .037) and receipt of AHSCT (p < .001). CONCLUSION We show that active treatment with IC improves survival, but it is mostly tied to receipt of AHSCT. IC is a reasonable approach in appropriate patients as it can provide an effective bridge to AHSCT. Other treatment strategies such as molecularly targeted therapy and novel agents are desperately needed.
Collapse
Affiliation(s)
- Franco Castillo Tokumori
- University of South Florida, Morsani College of Medicine, Department of Internal Medicine. Tampa, FL; H. Lee Moffitt Cancer Center & Research Institute, Department of Malignant Hematology. Tampa, FL.
| | - Najla Al Ali
- H. Lee Moffitt Cancer Center & Research Institute, Department of Malignant Hematology. Tampa, FL
| | - Onyee Chan
- H. Lee Moffitt Cancer Center & Research Institute, Department of Malignant Hematology. Tampa, FL
| | - David Sallman
- H. Lee Moffitt Cancer Center & Research Institute, Department of Malignant Hematology. Tampa, FL
| | - Seongseok Yun
- H. Lee Moffitt Cancer Center & Research Institute, Department of Malignant Hematology. Tampa, FL
| | - Kendra Sweet
- H. Lee Moffitt Cancer Center & Research Institute, Department of Malignant Hematology. Tampa, FL
| | - Eric Padron
- H. Lee Moffitt Cancer Center & Research Institute, Department of Malignant Hematology. Tampa, FL
| | - Jeffrey Lancet
- H. Lee Moffitt Cancer Center & Research Institute, Department of Malignant Hematology. Tampa, FL
| | - Rami Komrokji
- H. Lee Moffitt Cancer Center & Research Institute, Department of Malignant Hematology. Tampa, FL
| | - Andrew T Kuykendall
- H. Lee Moffitt Cancer Center & Research Institute, Department of Malignant Hematology. Tampa, FL
| |
Collapse
|
9
|
Pasca S, Chifotides HT, Verstovsek S, Bose P. Mutational landscape of blast phase myeloproliferative neoplasms (MPN-BP) and antecedent MPN. INTERNATIONAL REVIEW OF CELL AND MOLECULAR BIOLOGY 2022; 366:83-124. [PMID: 35153007 DOI: 10.1016/bs.ircmb.2021.02.008] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Myeloproliferative neoplasms (MPN) have an inherent tendency to evolve to the blast phase (BP), characterized by ≥20% myeloblasts in the blood or bone marrow. MPN-BP portends a dismal prognosis and currently, effective treatment modalities are scarce, except for allogeneic hematopoietic stem cell transplantation (allo-HSCT) in selected patients, particularly those who achieve complete/partial remission. The mutational landscape of MPN-BP differs from de novo acute myeloid leukemia (AML) in several key aspects, such as significantly lower frequencies of FLT3 and DNMT3A mutations, and higher incidence of IDH1/2 and TP53 in MPN-BP. Herein, we comprehensively review the impact of the three signaling driver mutations (JAK2 V617F, CALR exon 9 indels, MPL W515K/L) that constitutively activate the JAK/STAT pathway, and of the other somatic non-driver mutations (epigenetic, mRNA splicing, transcriptional regulators, and mutations in signal transduction genes) that cooperatively or independently promote MPN progression and leukemic transformation. The MPN subtype, harboring two or more high-molecular risk (HMR) mutations (epigenetic regulators and mRNA splicing factors) and "triple-negative" PMF are among the critical factors that increase risk of leukemic transformation and shorten survival. Primary myelofibrosis (PMF) is the most aggressive MPN; and polycythemia vera (PV) and essential thrombocythemia (ET) are relatively indolent subtypes. In PV and ET, mutations in splicing factor genes are associated with progression to myelofibrosis (MF), and in ET, TP53 mutations predict risk for leukemic transformation. The advent of targeted next-generation sequencing and improved prognostic scoring systems for PMF inform decisions regarding allo-HSCT. The emergence of treatments targeting mutant enzymes (e.g., IDH1/2 inhibitors) or epigenetic pathways (BET and LSD1 inhibitors) along with new insights into the mechanisms of leukemogenesis will hopefully lead the way to superior management strategies and outcomes of MPN-BP patients.
Collapse
Affiliation(s)
- Sergiu Pasca
- Leukemia Department, The University of Texas MD Anderson Cancer Center, Houston, TX, United States
| | - Helen T Chifotides
- Leukemia Department, The University of Texas MD Anderson Cancer Center, Houston, TX, United States
| | - Srdan Verstovsek
- Leukemia Department, The University of Texas MD Anderson Cancer Center, Houston, TX, United States
| | - Prithviraj Bose
- Leukemia Department, The University of Texas MD Anderson Cancer Center, Houston, TX, United States.
| |
Collapse
|
10
|
Genetic factors rather than blast reduction determine outcomes of allogeneic HCT in BCR-ABL-negative MPN in blast phase. Blood Adv 2021; 4:5562-5573. [PMID: 33170935 DOI: 10.1182/bloodadvances.2020002727] [Citation(s) in RCA: 28] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2020] [Accepted: 10/05/2020] [Indexed: 12/22/2022] Open
Abstract
There is a limited understanding of the clinical and molecular factors associated with outcomes of hematopoietic cell transplantation (HCT) in patients with BCR-ABL-negative myeloproliferative neoplasms in blast phase (MPN-BP). Using the Center for International Blood and Marrow Transplant Research database, we evaluated HCT outcomes in 177 patients with MPN-BP. Ninety-five (54%) had sufficient DNA for targeted next-generation sequencing of 49 genes clinically relevant in hematologic malignancies. At 5 years, overall survival (OS), cumulative incidence of relapse, and nonrelapse mortality of the study cohort was 18%, 61%, and 25%, respectively. In a multivariable model, poor-risk cytogenetics was associated with inferior OS (hazard ratio [HR], 1.71; 95% CI, 1.21-2.41) due to increased relapse (HR, 1.93; 95% CI, 1.32-2.82). Transplants using mobilized peripheral blood (PB) were associated with better OS (HR, 0.60; 95% CI, 0.38-0.96). No difference in outcomes was observed in patients undergoing HCT with PB/BM blasts <5% vs those with active leukemia. Among the 95 patients with molecular data, mutation of TP53, present in 23%, was the only genetic alteration associated with outcomes. In a multivariate model, TP53-mutant patients had inferior OS (HR, 1.99; 95% CI, 1.14-3.49) and increased incidence of relapse (HR, 2.59; 95% CI, 1.41-4.74). There were no differences in the spectrum of gene mutations, number of mutations, or variant allele frequency between patients undergoing HCT with PB/BM blasts <5% vs those with active leukemia. Genetic factors, namely cytogenetic alterations and TP53 mutation status, rather than degree of cytoreduction predict outcomes of HCT in MPN-BP. No meaningful benefit of conventional HCT was observed in patients with MPN-BP and mutated TP53.
Collapse
|
11
|
Outcome of patients with IDH1/2-mutated post-myeloproliferative neoplasm AML in the era of IDH inhibitors. Blood Adv 2021; 4:5336-5342. [PMID: 33112940 DOI: 10.1182/bloodadvances.2020001528] [Citation(s) in RCA: 36] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2020] [Accepted: 06/08/2020] [Indexed: 02/07/2023] Open
Abstract
Key Points
IDH1/2-inhibitor–based combinations conferred significant clinical responses in patients with IDH1/2-mutated post–MPN AML. Complete remission was achieved in 3/7 patients (1 attaining MRD–) with new IDH1/2-mutated post–MPN AML treated with IDH1/2-i combinations.
Collapse
|
12
|
Shahin OA, Chifotides HT, Bose P, Masarova L, Verstovsek S. Accelerated Phase of Myeloproliferative Neoplasms. Acta Haematol 2021; 144:484-499. [PMID: 33882481 DOI: 10.1159/000512929] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2020] [Accepted: 11/09/2020] [Indexed: 12/27/2022]
Abstract
BACKGROUND Myeloproliferative neoplasms (MPNs) can transform into blast phase MPN (leukemic transformation; MPN-BP), typically via accelerated phase MPN (MPN-AP), in ∼20-25% of the cases. MPN-AP and MPN-BP are characterized by 10-19% and ≥20% blasts, respectively. MPN-AP/BP portend a dismal prognosis with no established conventional treatment. Allogeneic hematopoietic stem cell transplantation (allo-HSCT) is the sole modality associated with long-term survival. SUMMARY MPN-AP/BP has a markedly different mutational profile from de novo acute myeloid leukemia (AML). In MPN-AP/BP, TP53 and IDH1/2 are more frequent, whereas FLT3 and DNMT3A are rare. Higher incidence of leukemic transformation has been associated with the most aggressive MPN subtype, myelofibrosis (MF); other risk factors for leukemic transformation include rising blast counts above 3-5%, advanced age, severe anemia, thrombocytopenia, leukocytosis, increasing bone marrow fibrosis, type 1 CALR-unmutated status, lack of driver mutations (negative for JAK2, CALR, or MPL genes), adverse cytogenetics, and acquisition of ≥2 high-molecular risk mutations (ASXL1, EZH2, IDH1/2, SRSF2, and U2AF1Q157). The aforementioned factors have been incorporated in several novel prognostic scoring systems for MF. Currently, elderly/unfit patients with MPN-AP/BP are treated with hypomethylating agents with/without ruxolitinib; these regimens appear to confer comparable benefit to intensive chemotherapy but with lower toxicity. Retrospective studies in patients who acquired actionable mutations during MPN-AP/BP showed positive outcomes with targeted AML treatments, such as IDH1/2 inhibitors, and require further evaluation in clinical trials. Key Messages: Therapy for MPN-AP patients represents an unmet medical need. MF patients, in particular, should be appropriately stratified regarding their prognosis and the risk for transformation. Higher-risk patients should be monitored regularly and treated prior to progression to MPN-BP. MPN-AP patients may be treated with hypomethylating agents alone or in combination with ruxolitinib; also, patients can be provided with the option to enroll in rationally designed clinical trials exploring combination regimens, including novel targeted drugs, with an ultimate goal to transition to transplant.
Collapse
Affiliation(s)
- Omar A Shahin
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Helen T Chifotides
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Prithviraj Bose
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Lucia Masarova
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Srdan Verstovsek
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| |
Collapse
|
13
|
Shah MV, Saliba RM, Varma A, Ciurea SO, Oran B, Olson A, Bose P, Bashir Q, Masarova L, Alousi AM, Srour S, Mehta RS, Daver N, Pemmaraju N, Verstovsek S, Champlin RE, Popat UR. Allogeneic stem cell transplant for patients with myeloproliferative neoplasms in blast phase: improving outcomes in the recent era. Br J Haematol 2021; 193:1004-1008. [PMID: 33821472 DOI: 10.1111/bjh.17423] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2020] [Revised: 02/25/2021] [Accepted: 02/28/2021] [Indexed: 11/29/2022]
Affiliation(s)
- Mithun V Shah
- Department of Stem Cell Transplantation and Cellular Therapy, Houston, TX, USA.,Division of Hematology, Mayo Clinic, Rochester, MN, USA
| | - Rima M Saliba
- Department of Stem Cell Transplantation and Cellular Therapy, Houston, TX, USA
| | - Ankur Varma
- Department of Stem Cell Transplantation and Cellular Therapy, Houston, TX, USA
| | - Stefan O Ciurea
- Department of Stem Cell Transplantation and Cellular Therapy, Houston, TX, USA
| | - Betul Oran
- Department of Stem Cell Transplantation and Cellular Therapy, Houston, TX, USA
| | - Amanda Olson
- Department of Stem Cell Transplantation and Cellular Therapy, Houston, TX, USA
| | - Prithviraj Bose
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Qaiser Bashir
- Department of Stem Cell Transplantation and Cellular Therapy, Houston, TX, USA
| | - Lucia Masarova
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Amin M Alousi
- Department of Stem Cell Transplantation and Cellular Therapy, Houston, TX, USA
| | - Samer Srour
- Department of Stem Cell Transplantation and Cellular Therapy, Houston, TX, USA
| | - Rohtesh S Mehta
- Department of Stem Cell Transplantation and Cellular Therapy, Houston, TX, USA
| | - Naval Daver
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Naveen Pemmaraju
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Srdan Verstovsek
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Richard E Champlin
- Department of Stem Cell Transplantation and Cellular Therapy, Houston, TX, USA
| | - Uday R Popat
- Department of Stem Cell Transplantation and Cellular Therapy, Houston, TX, USA
| |
Collapse
|
14
|
Abruzzese E, Niscola P. Current clinical strategies and emergent treatment landscapes in leukemic transformation of Philadelphia-negative myeloproliferative neoplasms. Expert Rev Hematol 2020; 13:1349-1359. [PMID: 33226274 DOI: 10.1080/17474086.2020.1850251] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
Introduction: Transformation to acute myeloid leukemia (AML) of Philadelphia chromosome-negative (Ph-) chronic myeloproliferative neoplasms (MPN) represents a challenging medical concern and an unmet clinical need, since it charts a very poor outcome and a low rate of response to standard treatments with the exception of allogeneic hematopoietic stem cell transplantation (HSCT). Recent novel insights into the molecular disease pathways and the genomic features characterizing the transformation of Ph-MPN have led to new therapeutic individualized approaches with the potential to modify the clinical management of these difficult-to-treat patients. Areas covered: Literature review (MeSH headings/PubMed) of risk factors of MPNs progression and treatment options for transformed disease with traditional standard approaches, and novel and investigational agents was performed. One or combinations of related subject headings like transformed MPN, epigenetics, molecular alterations, HSCT, ruxolitinib, azacytidine, decitabine, gliterinib, novel agents, personalized therapy was screened. Informative papers were selected by the appropriate actual evidence and suggesting strategies for improving outcomes in the future. Expert opinion: Current and emerging treatments for transformed Ph-MPN, are presented. Novel targeted or experimental agents to be used both before HSCT, to induce blast-free state, or to modify the disease prognosis and improve survival and quality of life are critically reviewed.
Collapse
Affiliation(s)
| | - Pasquale Niscola
- Hematology, S. Eugenio Hospital, Tor Vergata University , Rome, Italy
| |
Collapse
|
15
|
Patel AA, Odenike O. Genomics of MPN progression. HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2020; 2020:440-449. [PMID: 33275731 PMCID: PMC7727554 DOI: 10.1182/hematology.2020000129] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/13/2023]
Abstract
The Philadelphia chromosome-negative (Ph-) myeloproliferative neoplasms (MPNs) are a heterogenous group of hematopoietic stem cell diseases characterized by activated JAK/STAT signaling and a variable propensity toward myelofibrotic and leukemic transformation. Acquisition of somatic mutations in addition to the canonical JAK2, MPL, and CALR mutations found in MPNs is an important catalyst in the clonal evolution and progression of these disorders. In recent years, our increasing understanding of the molecular landscape of Ph- MPNs has generated important prognostic information that informs our approach to risk stratification and therapeutic decision-making. This review will focus on the critical impact of genomics on our approach to management of advanced Ph- MPNs.
Collapse
Affiliation(s)
- Anand A Patel
- Section of Hematology/Oncology, Department of Medicine, The University of Chicago Medicine, Chicago, IL
| | - Olatoyosi Odenike
- Section of Hematology/Oncology, Department of Medicine, The University of Chicago Medicine, Chicago, IL
| |
Collapse
|
16
|
Bose P, Verstovsek S, Cortes JE, Tse S, Gasior Y, Jain N, Jabbour EJ, Estrov Z, Alvarado Y, DiNardo CD, Pemmaraju N, Kornblau SM, Kadia TM, Daver NG, Naqvi K, Short NJ, Masarova L, Villareal J, Pierce SA, Nogueras-Gonzalez G, Huang X, Garcia-Manero G, Kantarjian HM, Ravandi F. A phase 1/2 study of ruxolitinib and decitabine in patients with post-myeloproliferative neoplasm acute myeloid leukemia. Leukemia 2020; 34:2489-2492. [PMID: 32099037 DOI: 10.1038/s41375-020-0778-0] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2019] [Revised: 02/13/2020] [Accepted: 02/17/2020] [Indexed: 02/03/2023]
Affiliation(s)
- Prithviraj Bose
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Srdan Verstovsek
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Jorge E Cortes
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Susan Tse
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Yvonne Gasior
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Nitin Jain
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Elias J Jabbour
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Zeev Estrov
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Yesid Alvarado
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Courtney D DiNardo
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Naveen Pemmaraju
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Steven M Kornblau
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Tapan M Kadia
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Naval G Daver
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Kiran Naqvi
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Nicholas J Short
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Lucia Masarova
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - John Villareal
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Sherry A Pierce
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | | | - Xuelin Huang
- Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | | | - Hagop M Kantarjian
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Farhad Ravandi
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX, USA.
| |
Collapse
|
17
|
Bose P, Verstovsek S. Management of myelofibrosis after ruxolitinib failure. Leuk Lymphoma 2020; 61:1797-1809. [PMID: 32297800 PMCID: PMC8565616 DOI: 10.1080/10428194.2020.1749606] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2020] [Revised: 03/16/2020] [Accepted: 03/25/2020] [Indexed: 12/12/2022]
Abstract
Over the last decade, the Janus kinase1/2 (JAK1/2) inhibitor ruxolitinib has emerged as a cornerstone of myelofibrosis (MF) management. Ruxolitinib improves splenomegaly and symptoms regardless of driver mutation status, and confers a survival advantage in patients with intermediate-2/high risk MF. However, cytopenias remain problematic, and evidence for a robust anti-clonal effect is lacking. Furthermore, the median duration of spleen response to ruxolitinib in clinical trials is approximately 3 years, and ruxolitinib does not appear to affect the risk of leukemic transformation. There is no therapy approved specifically for patients whose disease 'progresses' on ruxolitinib, defining which remains challenging. The recent regulatory approval of the JAK2 inihibitor fedratinib partially fulfills this unmet need, but much remains to be done. Other JAK inhibitors and a plethora of novel agents are being studied in the ruxolitinib 'failure' setting, as well as 'add-on' therapies to ruxolitinib in patients having a 'sub-optimal' response.
Collapse
Affiliation(s)
- Prithviraj Bose
- Department of Leukemia, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Srdan Verstovsek
- Department of Leukemia, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| |
Collapse
|
18
|
Barbui T, Vannucchi AM, Guglielmelli P, De Stefano V, Rambaldi A. An agenda for future research projects in polycythemia vera and essential thrombocythemia. Haematologica 2020; 105:1999-2003. [PMID: 32467140 PMCID: PMC7395271 DOI: 10.3324/haematol.2019.246207] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2020] [Accepted: 04/14/2020] [Indexed: 01/13/2023] Open
Affiliation(s)
- Tiziano Barbui
- FROM Research Foundation, Papa Giovanni XXIII Hospital, Bergamo
| | - Alessandro Maria Vannucchi
- Center of Research and Innovation of Myeloproliferative Neoplasms (CRIMM), Azienda Ospedaliera Universitaria Careggi and Department of Experimental and Clinical Medicine, University of Florence, Florence
| | - Paola Guglielmelli
- Center of Research and Innovation of Myeloproliferative Neoplasms (CRIMM), Azienda Ospedaliera Universitaria Careggi and Department of Experimental and Clinical Medicine, University of Florence, Florence
| | - Valerio De Stefano
- Section of Hematology, Department of Radiological and Hematological Sciences, Catholic University and Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome
| | - Alessandro Rambaldi
- Department of Oncology and Hematology, University of Milan, Milan and Azienda Socio Sanitaria Territoriale Papa Giovanni XXIII, Bergamo, Italy
| |
Collapse
|
19
|
Patel AA, Cahill K, Charnot-Katsikas A, Liu H, Gurbuxani S, Thirman M, Kosuri S, Artz AS, Larson RA, Stock W, Segal J, Odenike O. Clinical outcomes of IDH2-mutated advanced-phase Ph-negative myeloproliferative neoplasms treated with enasidenib. Br J Haematol 2020; 190:e48-e51. [PMID: 32358888 DOI: 10.1111/bjh.16709] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2020] [Revised: 04/06/2020] [Accepted: 04/09/2020] [Indexed: 11/28/2022]
Affiliation(s)
- Anand A Patel
- Section of Hematology/Oncology, Department of Medicine, University of Chicago Medicine, Chicago, IL, USA
| | - Kirk Cahill
- Department of Medicine, University of Chicago Medicine, Chicago, IL, USA
| | | | - Hongtao Liu
- Section of Hematology/Oncology, Department of Medicine, University of Chicago Medicine, Chicago, IL, USA
| | - Sandeep Gurbuxani
- Department of Pathology, University of Chicago Medicine, Chicago, IL, USA
| | - Michael Thirman
- Section of Hematology/Oncology, Department of Medicine, University of Chicago Medicine, Chicago, IL, USA
| | - Satyajit Kosuri
- Section of Hematology/Oncology, Department of Medicine, University of Chicago Medicine, Chicago, IL, USA
| | - Andrew S Artz
- Section of Hematology/Oncology, Department of Medicine, University of Chicago Medicine, Chicago, IL, USA.,Department of Hematology and Hematopoietic Cell Transplantation, City of Hope National Medical Center, Duarte, CA, USA
| | - Richard A Larson
- Section of Hematology/Oncology, Department of Medicine, University of Chicago Medicine, Chicago, IL, USA
| | - Wendy Stock
- Section of Hematology/Oncology, Department of Medicine, University of Chicago Medicine, Chicago, IL, USA
| | - Jeremy Segal
- Department of Pathology, University of Chicago Medicine, Chicago, IL, USA
| | - Olatoyosi Odenike
- Section of Hematology/Oncology, Department of Medicine, University of Chicago Medicine, Chicago, IL, USA
| |
Collapse
|
20
|
Palandri F, Breccia M, Tiribelli M, Bonifacio M, Benevolo G, Iurlo A, Elli EM, Binotto G, Tieghi A, Polverelli N, Martino B, Abruzzese E, Bergamaschi M, Heidel FH, Cavazzini F, Crugnola M, Bosi C, Isidori A, Auteri G, Forte D, Latagliata R, Griguolo D, Cattaneo D, Trawinska M, Bartoletti D, Krampera M, Semenzato G, Lemoli RM, Cuneo A, Di Raimondo F, Vianelli N, Cavo M, Palumbo GA. Risk factors for progression to blast phase and outcome in 589 patients with myelofibrosis treated with ruxolitinib: Real-world data. Hematol Oncol 2020; 38:372-380. [PMID: 32271957 DOI: 10.1002/hon.2737] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2020] [Revised: 03/13/2020] [Accepted: 03/30/2020] [Indexed: 12/15/2022]
Abstract
The impact of ruxolitinib therapy on evolution to blast phase (BP) in patients with myelofibrosis (MF) is still uncertain. In 589 MF patients treated with ruxolitinib, we investigated incidence and risk factors for BP and we described outcome according to disease characteristics and treatment strategy. After a median follow-up from ruxolitinib start of 3 years (range 0.1-7.6), 65 (11%) patients transformed to BP during (93.8%) or after treatment. BP incidence rate was 3.7 per 100 patient-years, comparably in primary and secondary MF (PMF/SMF) but significantly lower in intermediate-1 risk patients (2.3 vs 5.6 per 100 patient-years in intermediate-2/high-risk patients, P < .001). In PMF and SMF cohorts, previous interferon therapy seemed to correlate with a lower probability of BP (HR 0.13, P = .001 and HR 0.22, P = .02, respectively). In SMF, also platelet count <150 × 109 /l (HR 2.4, P = .03) and peripheral blasts ≥3% (HR 3.3, P = .004) were significantly associated with higher risk of BP. High-risk category according to dynamic International Prognostic Score System (DIPSS) and myelofibrosis secondary to PV and ET Collaboration Prognostic Model (MYSEC-PM predicted BP in patients with PMF and SMF, respectively. Median survival after BP was 0.2 (95% CI: 0.1-0.3) years. Therapy for BP included hypomethylating agents (12.3%), induction chemotherapy (9.2%), allogeneic transplant (6.2%) or supportive care (72.3%). Patients treated with supportive therapy had a median survival of 6 weeks, while 73% of the few transplanted patients were alive at a median follow-up of 2 years. Progression to BP occurs in a significant fraction of ruxolitinib-treated patients and is associated with DIPSS and MYSEC-PM risk in PMF and SMF, respectively.
Collapse
Affiliation(s)
- Francesca Palandri
- Institute of Hematology "L. and A. Seràgnoli", Sant'Orsola-Malpighi University Hospital, Bologna, Italy
| | - Massimo Breccia
- Division of Cellular Biotechnologies and Hematology, University Sapienza, Rome, Italy
| | - Mario Tiribelli
- Division of Hematology and BMT, Department of Medical Area, University of Udine, Udine, Italy
| | | | - Giulia Benevolo
- Division of Hematology, Città della Salute e della Scienza Hospital, Torino, Italy
| | - Alessandra Iurlo
- Hematology Division, Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Elena M Elli
- Hematology Division, San Gerardo Hospital, ASST, Monza, Italy
| | - Gianni Binotto
- Unit of Hematology and Clinical Immunology, University of Padova, Padova, Italy
| | - Alessia Tieghi
- Department of Hematology, Azienda USL - IRCCS di Reggio Emilia, Reggio Emilia, Italy
| | - Nicola Polverelli
- Unit of Blood Diseases and Stem Cells Transplantation, Department of Clinical and Experimental Sciences, University of Brescia, ASST Spedali Civili of Brescia, Brescia, Italy
| | - Bruno Martino
- Division of Hematology, Azienda Ospedaliera 'Bianchi Melacrino Morelli', Reggio Calabria, Italy
| | | | - Micaela Bergamaschi
- Clinic of Hematology, Department of Internal Medicine (DiMI), IRCCS AOU San Martino-IST, Genoa, Italy
| | - Florian H Heidel
- Internal Medicine II, Hematology and Oncology, Friedrich-Schiller-University Medical Center, Jena, Germany
| | | | - Monica Crugnola
- Division of Hematology, Azienda Ospedaliero-Universitaria di Parma, Parma, Italy
| | - Costanza Bosi
- Division of Hematology, AUSL di Piacenza, Piacenza, Italy
| | - Alessandro Isidori
- Haematology and Haematopoietic Stem Cell Transplant Center, AORMN (Azienda Ospedaliera Ospedali Riuniti Marche Nord), Pesaro, Italy
| | - Giuseppe Auteri
- Institute of Hematology "L. and A. Seràgnoli", Sant'Orsola-Malpighi University Hospital, Bologna, Italy
| | - Dorian Forte
- Institute of Hematology "L. and A. Seràgnoli", Sant'Orsola-Malpighi University Hospital, Bologna, Italy
| | - Roberto Latagliata
- Division of Cellular Biotechnologies and Hematology, University Sapienza, Rome, Italy
| | - Davide Griguolo
- Division of Hematology and BMT, Department of Medical Area, University of Udine, Udine, Italy
| | - Daniele Cattaneo
- Hematology Division, Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | | | - Daniela Bartoletti
- Institute of Hematology "L. and A. Seràgnoli", Sant'Orsola-Malpighi University Hospital, Bologna, Italy
| | - Mauro Krampera
- Department of Medicine, Section of Hematology, University of Verona, Verona, Italy
| | | | - Roberto M Lemoli
- Clinic of Hematology, Department of Internal Medicine (DiMI), IRCCS AOU San Martino-IST, Genoa, Italy
| | - Antonio Cuneo
- Division of Hematology, University of Ferrara, Ferrara, Italy
| | - Francesco Di Raimondo
- Department of Scienze Mediche, Chirurgiche e Tecnologie Avanzate "G.F. Ingrassia", University of Catania, Catania, Italy
| | - Nicola Vianelli
- Institute of Hematology "L. and A. Seràgnoli", Sant'Orsola-Malpighi University Hospital, Bologna, Italy
| | - Michele Cavo
- Institute of Hematology "L. and A. Seràgnoli", Sant'Orsola-Malpighi University Hospital, Bologna, Italy
| | - Giuseppe A Palumbo
- Department of Scienze Mediche, Chirurgiche e Tecnologie Avanzate "G.F. Ingrassia", University of Catania, Catania, Italy
| |
Collapse
|
21
|
Gupta V, Cerquozzi S, Foltz L, Hillis C, Devlin R, Elsawy M, Grewal K, Hamm C, McNamara C, Sirhan S, Leber B. Patterns of Ruxolitinib Therapy Failure and Its Management in Myelofibrosis: Perspectives of the Canadian Myeloproliferative Neoplasm Group. JCO Oncol Pract 2020; 16:351-359. [PMID: 32134707 PMCID: PMC7359776 DOI: 10.1200/jop.19.00506] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Ruxolitinib improves splenomegaly and other disease-related symptoms in patients with myelofibrosis, but over time, many patients lose this benefit. It is difficult to determine whether this is due to resistance or intolerance to the drug; thus, we have used the more inclusive term of ruxolitinib failure. The survival of patients with myelofibrosis after ruxolitinib failure is poor but varies significantly by the pattern of the failure, underlining the need for a clinically appropriate classification. In this review, we propose diagnostic guidance for early recognition of the pattern of ruxolitinib failure and we recommend treatment options. The most frequent patterns of ruxolitinib failure are loss or failure to obtain a significant reduction in splenomegaly or symptom response, and the development or persistence of clinically significant cytopenias. Ruxolitinib dose modification and other ancillary therapies are sometimes helpful, and splenectomy is a palliative option in selected cases. Stem-cell transplantation is the only curative option for these patterns of failure, but its restricted applicability due to toxicity highlights the importance of ongoing clinical trials in this area. Recent approval of fedratinib by the US Food and Drug Administration provides an alternative option for patients with suboptimal or loss of spleen response. The transformation of myelofibrosis to accelerated or blast phase is an infrequent form of failure with an extremely poor prognosis, whereby patients who are ineligible for transplantation have limited treatment options.
Collapse
Affiliation(s)
- Vikas Gupta
- Princess Margaret Cancer Centre, University of Toronto, Toronto, Ontario, Canada
| | - Sonia Cerquozzi
- Tom Baker Cancer Centre, University of Calgary, Calgary, Alberta, Canada
| | - Lynda Foltz
- St Paul's Hospital, University of British Columbia, Vancouver, British Columbia, Canada
| | - Christopher Hillis
- Juravinski Cancer Centre, McMaster University, Hamilton, Ontario, Canada
| | - Rebecca Devlin
- Princess Margaret Cancer Centre, University of Toronto, Toronto, Ontario, Canada
| | | | - Kuljit Grewal
- Memorial University of Newfoundland, St John's, Newfoundland and Labrador, Canada
| | - Caroline Hamm
- Windsor Regional Cancer Program, Windsor, Ontario, Canada
| | - Caroline McNamara
- Princess Margaret Cancer Centre, University of Toronto, Toronto, Ontario, Canada
| | | | - Brian Leber
- Juravinski Cancer Centre, McMaster University, Hamilton, Ontario, Canada
| |
Collapse
|
22
|
Cahill KE, Karimi YH, Karrison TG, Jain N, Green M, Weiner H, Fulton N, Kadri S, Godley LA, Artz AS, Liu H, Thirman MJ, Le Beau MM, McNerney ME, Segal J, Larson RA, Stock W, Odenike O. A phase 1 study of azacitidine with high-dose cytarabine and mitoxantrone in high-risk acute myeloid leukemia. Blood Adv 2020; 4:599-606. [PMID: 32074275 PMCID: PMC7042987 DOI: 10.1182/bloodadvances.2019000795] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2019] [Accepted: 12/24/2019] [Indexed: 12/18/2022] Open
Abstract
In this phase 1 study, azacitidine (AZA) was given before high-dose cytarabine (HiDAC) and mitoxantrone (mito) based on the hypothesis that epigenetic priming with a hypomethylating agent before cytotoxic chemotherapy would improve response rates in patients with high-risk acute myeloid leukemia (AML), including relapsed/refractory disease. The primary objective was to establish the recommended phase 2 dose of AZA given before standard HiDAC/mito. In a dose escalation scheme, 46 patients (median age, 66 years) received AZA at 37.5, 50, or 75 mg/m2 subcutaneously or IV once daily on days 1 to 5 followed by HiDAC (3000 mg/m2) and mitoxantrone (30 mg/m2) once each on days 6 and 10 (the HiDAC/mito dose was reduced 33% in elderly subjects). Two dose-limiting toxicities occurred (both in the same patient): acute liver failure and kidney injury at the 50 mg/m2 dose. The 30-day induction death rate was 2.2% (1 of 46). The overall response rate, including complete remission and complete remission with incomplete count recovery, was 61% (28 of 46). Previously untreated patients aged ≥60 years with therapy-related AML and de novo AML were more likely to respond than untreated patients with AML progressing from an antecedent hematologic disorder (myelodysplastic syndrome and chronic myelomonocytic leukemia). Patients with favorable European Leukemia Network risk (P = .008), NPM1 mutations (P = .007), or IDH2 mutations (P = .03) were more likely to respond, and those with TP53 mutations (P = .03) were less likely to respond. The recommended phase 2 dose of AZA is 75 mg/m2 per day on days 1 to 5 followed by HiDAC (3000 mg/m2) and mitoxantrone (30 mg/m2) once each on days 6 and 10. This trial was registered at www.clinicaltrials.gov as #NCT01839240.
Collapse
Affiliation(s)
- Kirk E Cahill
- Department of Medicine, University of Chicago Medicine, Chicago, IL
| | - Yasmin H Karimi
- Department of Medicine, University of Chicago Medicine, Chicago, IL
| | - Theodore G Karrison
- Department of Public Health Sciences, University of Chicago, Chicago, IL; and
- Comprehensive Cancer Center
| | - Nitin Jain
- Section of Hematology/Oncology, Department of Medicine, and
| | - Margaret Green
- Section of Hematology/Oncology, Department of Medicine, and
| | - Howard Weiner
- Section of Hematology/Oncology, Department of Medicine, and
| | - Noreen Fulton
- Section of Hematology/Oncology, Department of Medicine, and
| | - Sabah Kadri
- Department of Pathology, University of Chicago Medicine, Chicago, IL
| | - Lucy A Godley
- Comprehensive Cancer Center
- Section of Hematology/Oncology, Department of Medicine, and
| | - Andrew S Artz
- Comprehensive Cancer Center
- Section of Hematology/Oncology, Department of Medicine, and
| | - Hongtao Liu
- Comprehensive Cancer Center
- Section of Hematology/Oncology, Department of Medicine, and
| | - Michael J Thirman
- Comprehensive Cancer Center
- Section of Hematology/Oncology, Department of Medicine, and
| | - Michelle M Le Beau
- Comprehensive Cancer Center
- Section of Hematology/Oncology, Department of Medicine, and
| | - Megan E McNerney
- Comprehensive Cancer Center
- Department of Pathology, University of Chicago Medicine, Chicago, IL
| | - Jeremy Segal
- Comprehensive Cancer Center
- Department of Pathology, University of Chicago Medicine, Chicago, IL
| | - Richard A Larson
- Comprehensive Cancer Center
- Section of Hematology/Oncology, Department of Medicine, and
| | - Wendy Stock
- Comprehensive Cancer Center
- Section of Hematology/Oncology, Department of Medicine, and
| | - Olatoyosi Odenike
- Comprehensive Cancer Center
- Section of Hematology/Oncology, Department of Medicine, and
| |
Collapse
|
23
|
Cruz NM, Gergis U, Silver RT. Myelofibrosis: best practices, controversies and 2019 update. Expert Rev Hematol 2019; 13:71-84. [PMID: 31709843 DOI: 10.1080/17474086.2020.1691519] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Introduction: Recent advances in the prognostic scheme and treatment of primary and secondary myelofibrosis (MF) have resulted in an overwhelming amount of clinical information to assimilate. The authors believe a comprehensive review that summarizes the most recent published literature, could serve as guidelines for the practicing hematologist.Areas covered: The authors provide a summary of landmark articles regarding epidemiology, symptoms, and pathogenesis of disease. The authors conducted a systematic literature review to answer questions regarding differences between primary myelofibrosis (PMF) and secondary myelofibrosis (SMF), appropriate use and selection of the current risk-stratification models, early versus late treatment of MF and current practices in allogeneic hematopoietic stem cell transplantation (allo-HCT) for MF. The authors conclude the article with their clinical opinion based on their experience and literature review. The purpose of this article is to identify current practices, address any variation, identify and investigate conflicting results and produce statements to guide decision-making.Expert opinion: In this section, the authors advocate for and provide examples of a standardized way of incorporating future discoveries in the pathogenesis and risk-stratification models of MF. They also discuss the importance of using only one risk-stratification model for PMF and one for SMF and their reasoning for early instead of late treatment of MF.
Collapse
Affiliation(s)
- Nicole M Cruz
- Division of Hematology & Medical Oncology, Weill Cornell Medicine, New York, NY, USA
| | - Usama Gergis
- Division of Hematology & Medical Oncology, Weill Cornell Medicine, New York, NY, USA
| | - Richard T Silver
- Division of Hematology & Medical Oncology, Weill Cornell Medicine, New York, NY, USA.,Richard T. Silver, M.D. Myeloproliferative Neoplasms (MPN) Center, Weill Cornell Medical College, New York, NY, USA
| |
Collapse
|
24
|
Schieber M, Crispino JD, Stein B. Myelofibrosis in 2019: moving beyond JAK2 inhibition. Blood Cancer J 2019; 9:74. [PMID: 31511492 PMCID: PMC6739355 DOI: 10.1038/s41408-019-0236-2] [Citation(s) in RCA: 49] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2018] [Revised: 02/26/2019] [Accepted: 03/15/2019] [Indexed: 02/08/2023] Open
Abstract
Myelofibrosis (MF) is a myeloproliferative neoplasm characterized by ineffective clonal hematopoiesis, splenomegaly, bone marrow fibrosis, and the propensity for transformation to acute myeloid leukemia. The discovery of mutations in JAK2, CALR, and MPL have uncovered activated JAK-STAT signaling as a primary driver of MF, supporting a rationale for JAK inhibition. However, JAK inhibition alone is insufficient for long-term remission and offers modest, if any, disease-modifying effects. Given this, there is great interest in identifying mechanisms that cooperate with JAK-STAT signaling to predict disease progression and rationally guide the development of novel therapies. This review outlines the latest discoveries in the biology of MF, discusses current clinical management of patients with MF, and summarizes the ongoing clinical trials that hope to change the landscape of MF treatment.
Collapse
Affiliation(s)
- Michael Schieber
- Robert H. Lurie Comprehensive Cancer Center, Division of Hematology/Oncology, Department of Medicine, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - John D Crispino
- Robert H. Lurie Comprehensive Cancer Center, Division of Hematology/Oncology, Department of Medicine, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Brady Stein
- Robert H. Lurie Comprehensive Cancer Center, Division of Hematology/Oncology, Department of Medicine, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA.
| |
Collapse
|
25
|
Niscola P, Noguera NI, Catalano G, Cupelli L, Fratoni S, Giovannini M, Mazzone C, Neri B, Scaramucci L, Trawinska MM, de Fabritiis P, Abruzzese E. Double remission of simultaneously occurring secondary AML and CLL by venetoclax monotherapy. Acta Oncol 2019; 58:888-890. [PMID: 30848978 DOI: 10.1080/0284186x.2019.1585943] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Affiliation(s)
- Pasquale Niscola
- Hematology Unit, Saint’ Eugenio Hospital, Tor Vergata University of Rome, Rome, Italy
| | - Nélida Inés Noguera
- Neuro Oncohematology Unit, Santa Lucia Foundation and Department of Biomedicine and Prevention, Tor Vergata University of Rome, Rome, Italy
| | - Gianfranco Catalano
- Hematology Unit, Saint’ Eugenio Hospital, Tor Vergata University of Rome, Rome, Italy
| | - Luca Cupelli
- Hematology Unit, Saint’ Eugenio Hospital, Tor Vergata University of Rome, Rome, Italy
| | - Stefano Fratoni
- Department of Pathology, Saint’ Eugenio Hospital, Rome, Italy
| | - Marco Giovannini
- Hematology Unit, Saint’ Eugenio Hospital, Tor Vergata University of Rome, Rome, Italy
| | - Carla Mazzone
- Hematology Unit, Saint’ Eugenio Hospital, Tor Vergata University of Rome, Rome, Italy
| | - Benedetta Neri
- Hematology Unit, Saint’ Eugenio Hospital, Tor Vergata University of Rome, Rome, Italy
| | - Laura Scaramucci
- Hematology Unit, Saint’ Eugenio Hospital, Tor Vergata University of Rome, Rome, Italy
| | | | - Paolo de Fabritiis
- Hematology Unit, Saint’ Eugenio Hospital, Tor Vergata University of Rome, Rome, Italy
| | - Elisabetta Abruzzese
- Hematology Unit, Saint’ Eugenio Hospital, Tor Vergata University of Rome, Rome, Italy
| |
Collapse
|
26
|
SOHO State of the Art Updates and Next Questions: Myelofibrosis. CLINICAL LYMPHOMA MYELOMA & LEUKEMIA 2019; 19:191-199. [PMID: 30987952 DOI: 10.1016/j.clml.2019.03.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/14/2019] [Accepted: 03/12/2019] [Indexed: 01/09/2023]
Abstract
The discovery of a mutation in the Janus Kinase 2 gene in 2005 spurred significant progress in the field of myeloproliferative neoplasms. A comprehensive description of genomic factors at play in the malignant clone in myeloproliferative neoplasms, particularly myelofibrosis (MF), have recently led to more precise, personalized prognostic tools. Despite this, understanding of the disease pathogenesis remains relatively limited. We continue to lack a detailed description of the interaction between the hematopoietic stem cell clone, abnormal bone marrow niche cells, and circulating signaling molecules and an understanding of how they cooperate to promote cell proliferation, fibrogenesis, and extramedullary hematopoiesis. Despite our knowledge gaps, recent research in MF has led to promising clinical translation. In this article, we summarize recent insights into MF pathophysiology, progress in the development of novel therapeutics, and opportunities for further advancement of the field.
Collapse
|
27
|
Iurlo A, Cattaneo D, Gianelli U. Blast Transformation in Myeloproliferative Neoplasms: Risk Factors, Biological Findings, and Targeted Therapeutic Options. Int J Mol Sci 2019; 20:ijms20081839. [PMID: 31013941 PMCID: PMC6514804 DOI: 10.3390/ijms20081839] [Citation(s) in RCA: 38] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2019] [Revised: 04/09/2019] [Accepted: 04/11/2019] [Indexed: 01/24/2023] Open
Abstract
Myeloproliferative neoplasms represent a heterogenous group of disorders of the hematopoietic stem cell, with an intrinsic risk of evolution into acute myeloid leukemia. The frequency of leukemic evolution varies according to myeloproliferative neoplasms subtype. It is highest in primary myelofibrosis, where it is estimated to be approximately 10–20% at 10 years, following by polycythemia vera, with a risk of 2.3% at 10 years and 7.9% at 20 years. In essential thrombocythemia, however, transformation to acute myeloid leukemia is considered relatively uncommon. Different factors are associated with leukemic evolution in myeloproliferative neoplasms, but generally include advanced age, leukocytosis, exposure to myelosuppressive therapy, cytogenetic abnormalities, as well as increased number of mutations in genes associated with myeloid neoplasms. The prognosis of these patients is dismal, with a medium overall survival ranging from 2.6–7.0 months. Currently, there is no standard of care for managing the blast phase of these diseases, and no treatment to date has consistently led to prolonged survival and/or hematological remission apart from an allogeneic stem cell transplant. Nevertheless, new targeted agents are currently under development. In this review, we present the current evidence regarding risk factors, molecular characterization, and treatment options for this critical subset of myeloproliferative neoplasms patients.
Collapse
Affiliation(s)
- Alessandra Iurlo
- Hematology Division, Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, and University of Milan, 20122 Milan, Italy.
| | - Daniele Cattaneo
- Hematology Division, Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, and University of Milan, 20122 Milan, Italy.
| | - Umberto Gianelli
- Division of Pathology, Department of Pathophysiology and Transplantation, Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, and University of Milan, 20122 Milan, Italy.
| |
Collapse
|