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Guarina A, Farruggia P, Mariani E, Saracco P, Barone A, Onofrillo D, Cesaro S, Angarano R, Barberi W, Bonanomi S, Corti P, Crescenzi B, Dell'Orso G, De Matteo A, Giagnuolo G, Iori AP, Ladogana S, Lucarelli A, Lupia M, Martire B, Mastrodicasa E, Massaccesi E, Arcuri L, Giarratana MC, Menna G, Miano M, Notarangelo LD, Palazzi G, Palmisani E, Pestarino S, Pierri F, Pillon M, Ramenghi U, Russo G, Saettini F, Timeus F, Verzegnassi F, Zecca M, Fioredda F, Dufour C. Diagnosis and management of acquired aplastic anemia in childhood. Guidelines from the Marrow Failure Study Group of the Pediatric Haemato-Oncology Italian Association (AIEOP). Blood Cells Mol Dis 2024; 108:102860. [PMID: 38889660 DOI: 10.1016/j.bcmd.2024.102860] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2024] [Revised: 05/28/2024] [Accepted: 05/28/2024] [Indexed: 06/20/2024]
Abstract
Acquired aplastic anemia (AA) is a rare heterogeneous disorder characterized by pancytopenia and hypoplastic bone marrow. The incidence is 2-3 per million population per year in the Western world, but 3 times higher in East Asia. Survival in severe aplastic anemia (SAA) has improved significantly due to advances in hematopoietic stem cell transplantation (HSCT), immunosuppressive therapy, biologic agents, and supportive care. In SAA, HSCT from a matched sibling donor (MSD) is the first-line treatment. If a MSD is not available, options include immunosuppressive therapy (IST), matched unrelated donor, or haploidentical HSCT. The purpose of this guideline is to provide health care professionals with clear guidance on the diagnosis and management of pediatric patients with AA. A preliminary evidence-based document prepared by a group of pediatric hematologists of the Bone Marrow Failure Study Group of the Italian Association of Pediatric Hemato-Oncology (AIEOP) was discussed, modified and approved during a series of consensus conferences that started online during COVID 19 and continued in the following years, according to procedures previously validated by the AIEOP Board of Directors.
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Affiliation(s)
- A Guarina
- Pediatric Onco-Hematology Unit, A.R.N.A.S. Civico Hospital, Palermo, Italy
| | - P Farruggia
- Pediatric Onco-Hematology Unit, A.R.N.A.S. Civico Hospital, Palermo, Italy
| | - E Mariani
- Scuola di Specializzazione in Pediatria, University of Milano-Bicocca, Milan, Italy; Pediatric Hematology and Bone Marrow Transplant Unit, Fondazione IRCCS San Gerardo dei Tintori, Monza, Italy
| | - P Saracco
- Hematology Unit, "Regina Margherita" Children's Hospital, Turin, Italy
| | - A Barone
- Pediatric Onco-Hematology Unit, University Hospital, Parma, Italy
| | - D Onofrillo
- Hematology Unit, Hospital of Pescara, Pescara, Italy
| | - S Cesaro
- Pediatric Hematology Oncology Department of Mother and Child, Azienda Ospedaliera Universitaria Integrata, Verona, Italy
| | - R Angarano
- Pediatric Oncology-Hematology Unit, AOU Policlinico, Bari, Italy
| | - W Barberi
- Hematology, Department of Hematology, Oncology and Dermatology, AOU Policlinico Umberto I, Sapienza University of Rome, Rome, Italy
| | - S Bonanomi
- Pediatric Hematology and Bone Marrow Transplant Unit, Fondazione IRCCS San Gerardo dei Tintori, Monza, Italy
| | - P Corti
- Pediatric Hematology and Bone Marrow Transplant Unit, Fondazione IRCCS San Gerardo dei Tintori, Monza, Italy
| | - B Crescenzi
- Hematology and Bone Marrow Transplantation Unit, Hospital of Perugia, Perugia, Italy
| | - G Dell'Orso
- Hematology Unit, IRCCS Giannina Gaslini Children Hospital, Genoa, Italy
| | - A De Matteo
- Oncology Hematology and Cell Therapies Department, AORN Santobono-Pausilipon, Naples, Italy
| | - G Giagnuolo
- Oncology Hematology and Cell Therapies Department, AORN Santobono-Pausilipon, Naples, Italy
| | - A P Iori
- Hematology and HSCT Unit, University La Sapienza, Rome, Italy
| | - S Ladogana
- Pediatric Onco-Hematology Unit, Casa Sollievo della Sofferenza Hospital, San Giovanni Rotondo, Italy
| | - A Lucarelli
- Pediatric Emergency Department, Giovanni XXIII Pediatric Hospital, University of Bari, Bari, Italy
| | - M Lupia
- Hematology Unit, IRCCS Giannina Gaslini Children Hospital, Genoa, Italy
| | - B Martire
- Pediatrics and Neonatology Unit, Maternal-Infant Department, "Monsignor A.R. Dimiccoli" Hospital, Barletta, Italy
| | - E Mastrodicasa
- Hematology and Bone Marrow Transplantation Unit, Hospital of Perugia, Perugia, Italy
| | - E Massaccesi
- Hematology Unit, IRCCS Giannina Gaslini Children Hospital, Genoa, Italy
| | - L Arcuri
- Hematology Unit, IRCCS Giannina Gaslini Children Hospital, Genoa, Italy
| | - M C Giarratana
- Hematology Unit, IRCCS Giannina Gaslini Children Hospital, Genoa, Italy
| | - G Menna
- Oncology Hematology and Cell Therapies Department, AORN Santobono-Pausilipon, Naples, Italy
| | - M Miano
- Hematology Unit, IRCCS Giannina Gaslini Children Hospital, Genoa, Italy
| | - L D Notarangelo
- Medical Direction, Children's Hospital, ASST-Spedali Civili, Brescia, Italy
| | - G Palazzi
- Department of Mother and Child, University Hospital of Modena, Modena, Italy
| | - E Palmisani
- Hematology Unit, IRCCS Giannina Gaslini Children Hospital, Genoa, Italy
| | - S Pestarino
- Hematology Unit, IRCCS Giannina Gaslini Children Hospital, Genoa, Italy
| | - F Pierri
- HSCT Unit, IRCCS Giannina Gaslini Children Hospital, Genoa, Italy
| | - M Pillon
- Maternal and Child Health Department Pediatric Hematology, Oncology and Stem Cell Transplant Center, University of Padua, Padua, Italy
| | - U Ramenghi
- Hematology Unit, "Regina Margherita" Children's Hospital, Turin, Italy
| | - G Russo
- Division of Pediatric Hematology/Oncology, University of Catania, Catania, Italy
| | - F Saettini
- Centro Tettamanti, Fondazione IRCCS San Gerardo dei Tintori, Monza, Italy
| | - F Timeus
- Pediatrics Department, Chivasso Hospital, Turin, Italy
| | - F Verzegnassi
- Institute for Maternal and Child Health, IRCCS Burlo Garofolo, Trieste, Italy
| | - M Zecca
- Pediatric Hematology/Oncology, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - F Fioredda
- Hematology Unit, IRCCS Giannina Gaslini Children Hospital, Genoa, Italy
| | - C Dufour
- Hematology Unit, IRCCS Giannina Gaslini Children Hospital, Genoa, Italy.
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2
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Strauss JD, Brown DW, Zhou W, Dagnall C, Yuan JM, Im A, Savage SA, Wang Y, Rafati M, Spellman SR, Gadalla SM. Telomere length and clonal chromosomal alterations in peripheral blood of patients with severe aplastic anaemia. Br J Haematol 2024. [PMID: 39103182 DOI: 10.1111/bjh.19681] [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: 03/06/2024] [Accepted: 07/21/2024] [Indexed: 08/07/2024]
Abstract
Severe aplastic anaemia (SAA) is a rare and life-threatening bone marrow failure disorder. We used data from the transplant outcomes in aplastic anaemia study to characterize mosaic chromosomal alterations (mCAs) in the peripheral blood of 738 patients with acquired SAA and evaluate their associations with telomere length (TL) and survival post-haematopoietic cell transplant (HCT). The median age at HCT was 20.4 years (range = 0.2-77.4). Patients with SAA had shorter TL than expected for their age (median TL percentile for age: 35.7th; range <1-99.99). mCAs were detected in 211 patients (28.6%), with chr6p copy-neutral loss of heterozygosity (6p-CNLOH) in 15.9% and chr7 loss in 3.0% of the patients; chrX loss was detected in 4.1% of female patients. Negative correlations between mCA cell fraction and measured TL (r = -0.14, p = 0.0002), and possibly genetically predicted TL (r = -0.07, p = 0.06) were noted. The post-HCT 3-year survival probability was low in patients with chr7 loss (39% vs. 72% in patients with chr6-CNLOH, 60% in patients with other mCAs and 70% in patients with no mCAs; p-log rank = 0.001). In multivariable analysis, short TL (p = 0.01), but not chr7 loss (p = 0.29), was associated with worse post-HCT survival. TL may guide clinical decisions in patients with SAA.
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Affiliation(s)
- Joshua D Strauss
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, Bethesda, Maryland, USA
- Department of Epidemiology, School of Public Health, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Derek W Brown
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, Bethesda, Maryland, USA
| | - Weiyin Zhou
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, Bethesda, Maryland, USA
- Leidos Biomedical Research, Frederick National Laboratory for Cancer Research, Frederick, Maryland, USA
| | - Casey Dagnall
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, Bethesda, Maryland, USA
- Leidos Biomedical Research, Frederick National Laboratory for Cancer Research, Frederick, Maryland, USA
| | - Jian-Min Yuan
- Department of Epidemiology, School of Public Health, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
- Cancer Epidemiology and Prevention Program, UPMC Hillman Cancer Center, Pittsburgh, Pennsylvania, USA
| | - Annie Im
- Division of Hematology/Oncology, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Sharon A Savage
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, Bethesda, Maryland, USA
| | - Youjin Wang
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, Bethesda, Maryland, USA
| | - Maryam Rafati
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, Bethesda, Maryland, USA
| | - Stephen R Spellman
- Center for International Blood and Marrow Transplant Research, NMDP, Minneapolis, Minnesota, USA
| | - Shahinaz M Gadalla
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, Bethesda, Maryland, USA
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3
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Rafati M, McReynolds LJ, Wang Y, Hicks B, Jones K, Spellman SR, He M, Bolon YT, Arrieta-Bolaños E, Saultz JN, Lee SJ, Savage SA, Gadalla SM. Hemophagocytic Lymphohistiocytosis Gene Variants in Severe Aplastic Anemia and Their Impact on Hematopoietic Cell Transplantation Outcomes. Transplant Cell Ther 2024; 30:770.e1-770.e10. [PMID: 38810947 PMCID: PMC11296907 DOI: 10.1016/j.jtct.2024.05.017] [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: 03/24/2024] [Revised: 05/20/2024] [Accepted: 05/23/2024] [Indexed: 05/31/2024]
Abstract
Germline genetic testing for patients with severe aplastic anemia (SAA) is recommended to guide treatment, including the use of immunosuppressive therapy and/or adjustment of hematopoietic cell transplantation (HCT) modalities. Hemophagocytic lymphohistiocytosis (HLH) is a life-threatening hyperinflammatory condition often associated with cytopenias with autosomal recessive (AR) or X-linked recessive (XLR) inheritance. HLH is part of the SAA differential diagnosis, and genetic testing may identify variants in HLH genes in patients with SAA. The impact of pathogenic/likely pathogenic (P/LP) variants in HLH genes on HCT outcomes in SAA is unclear. In this study, we aimed to determine the frequency of HLH gene variants in a large cohort of patients with acquired SAA and to evaluate their association(s) with HCT outcomes. The Transplant Outcomes in Aplastic Anemia project, a collaboration between the National Cancer Institute and the Center for International Blood and Marrow Transplant Research, collected genomic and clinical data from 824 patients who underwent HCT for SAA between 1989 and 2015. We excluded 140 patients with inherited bone marrow failure syndromes and used exome sequencing data from the remaining 684 patients with acquired SAA to identify P/LP variants in 14 HLH-associated genes (11 AR, 3 XLR) curated using American College of Medical Genetics and Genomics/Association of Molecular Pathology (ACMG/AMP) criteria. Deleterious variants of uncertain significance (del-VUS) were defined as those not meeting the ACMG/AMP P/LP criteria but with damaging predictions in ≥3 of 5 meta-predictors (BayesDel, REVEL, CADD, MetaSVM, and/or EIGEN). The Kaplan-Meier estimator was used to calculate the probability of overall survival (OS) after HCT, and the cumulative incidence calculator was used for other HCT outcomes, accounting for relevant competing risks. There were 46 HLH variants in 49 of the 684 patients (7.2%). Seventeen variants in 19 patients (2.8%) were P/LP; 8 of these were loss-of-function variants. Among the 19 patients with P/LP HLH variants, 16 (84%) had monoallelic variants in genes with AR inheritance, and 3 had variants in XLR genes. PRF1 was the most frequently affected gene (in 8 of the 19 patients). We found no statistically significant differences in transplantation-related factors between patients with and those without P/LP HLH variants. The 5-year survival probability was 89% (95% confidence interval [CI], 72% to 99%) in patients with P/LP HLH variants and 70% (95% CI, 53% to 85%) in those with del-VUS HLH variants, compared to 66% (95% CI, 62% to 70%) in those without variants (P = .16, log-rank test). The median time to neutrophil engraftment was 16 days for patients with P/LP HLH variants and 18 days in those with del-VUS HLH variants or without variants combined (P = .01, Gray's test). No statistically significant associations between P/LP HLH variants and the risk of acute or chronic graft-versus-host disease were noted. In this large cohort of patients with acquired SAA, we found that 2.8% of patients harbored a P/LP variant in an HLH gene. No negative effects of HLH gene variants on post-HCT survival were noted. The small number of patients with P/LP HLH variants limits the study's ability to provide conclusive evidence; nonetheless, our data suggest that there is no need for special transplantation considerations for patients with SAA carrying P/LP variants.
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Affiliation(s)
- Maryam Rafati
- Clinical Genetics Branch, Division of Cancer Epidemiology and Genetics, National Cancer Institute, Bethesda, Maryland.
| | - Lisa J McReynolds
- Clinical Genetics Branch, Division of Cancer Epidemiology and Genetics, National Cancer Institute, Bethesda, Maryland
| | - Youjin Wang
- Clinical Genetics Branch, Division of Cancer Epidemiology and Genetics, National Cancer Institute, Bethesda, Maryland
| | - Belynda Hicks
- Cancer Genomics Research Laboratory, Division of Cancer Epidemiology and Genetics, National Cancer Institute, Bethesda, Maryland; Leidos Biomedical Research, Frederick National Laboratory for Cancer Research, Frederick, Maryland
| | - Kristine Jones
- Cancer Genomics Research Laboratory, Division of Cancer Epidemiology and Genetics, National Cancer Institute, Bethesda, Maryland; Leidos Biomedical Research, Frederick National Laboratory for Cancer Research, Frederick, Maryland
| | - Stephen R Spellman
- Center for International Blood and Marrow Transplant Research, National Marrow Donor Program, Minneapolis, Minnesota
| | - Meilun He
- Center for International Blood and Marrow Transplant Research, National Marrow Donor Program, Minneapolis, Minnesota
| | - Yung-Tsi Bolon
- Center for International Blood and Marrow Transplant Research, National Marrow Donor Program, Minneapolis, Minnesota
| | - Esteban Arrieta-Bolaños
- Institute for Experimental Cellular Therapy, University Hospital Essen, Essen, Germany; German Cancer Consortium (DKTK), partner site Essen/Düsseldorf, Heidelberg, Germany
| | - Jennifer N Saultz
- Division of Hematology/Medical Oncology, Oregon Health & Science University, Portland, Oregon
| | - Stephanie J Lee
- Center for International Blood and Marrow Transplant Research, Medical College of Wisconsin, Milwaukee, Wisconsin; Clinical Research Division, Fred Hutchinson Cancer Center, Seattle, Washington
| | - Sharon A Savage
- Clinical Genetics Branch, Division of Cancer Epidemiology and Genetics, National Cancer Institute, Bethesda, Maryland
| | - Shahinaz M Gadalla
- Clinical Genetics Branch, Division of Cancer Epidemiology and Genetics, National Cancer Institute, Bethesda, Maryland
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4
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Godley LA, DiNardo CD, Bolton K. Germline Predisposition in Hematologic Malignancies: Testing, Management, and Implications. Am Soc Clin Oncol Educ Book 2024; 44:e432218. [PMID: 38768412 DOI: 10.1200/edbk_432218] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/22/2024]
Abstract
Although numerous barriers for clinical germline cancer predisposition testing exist, the increasing recognition of deleterious germline DNA variants contributing to myeloid malignancy risk is yielding steady improvements in referrals for testing and testing availability. Many germline predisposition alleles are common in populations, and the increasing number of recognized disorders makes inherited myeloid malignancy risk an entity worthy of consideration for all patients regardless of age at diagnosis. Germline testing is facilitated by obtaining DNA from cultured skin fibroblasts or hair bulbs, and cascade testing is easily performed via buccal swab, saliva, or blood. Increasingly as diagnostic criteria and clinical management guidelines include germline myeloid malignancy predisposition, insurance companies recognize the value of testing and provide coverage. Once an individual is recognized to have a deleterious germline variant that confers risk for myeloid malignancies, a personalized cancer surveillance plan can be developed that incorporates screening for other cancer risk outside of the hematopoietic system and/or other organ pathology. The future may also include monitoring the development of clonal hematopoiesis, which is common for many of these cancer risk disorders and/or inclusion of strategies to delay or prevent progression to overt myeloid malignancy. As research continues to identify new myeloid predisposition disorders, we may soon recommend testing for these conditions for all patients diagnosed with a myeloid predisposition condition.
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Affiliation(s)
- Lucy A Godley
- Robert H. Lurie Comprehensive Cancer Center, Division of Hematology/Oncology, Northwestern University, Chicago, IL
| | - Courtney D DiNardo
- Department of Leukemia, University of Texas, MD Anderson Cancer Center, Houston, TX
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Piekarska A, Pawelec K, Szmigielska-Kapłon A, Ussowicz M. The state of the art in the treatment of severe aplastic anemia: immunotherapy and hematopoietic cell transplantation in children and adults. Front Immunol 2024; 15:1378432. [PMID: 38646536 PMCID: PMC11026616 DOI: 10.3389/fimmu.2024.1378432] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2024] [Accepted: 03/22/2024] [Indexed: 04/23/2024] Open
Abstract
Acquired aplastic anemia (AA) is an immune-mediated bone marrow (BM) failure where marrow disruption is driven by a cytotoxic T-cell-mediated autoimmune attack against hematopoietic stem cells. The key diagnostic challenge in children, but also in adults, is to exclude the possible underlying congenital condition and myelodysplasia. The choice of treatment options, either allogeneic hematopoietic cell transplantation (alloHCT) or immunosuppressive therapy (IST), depends on the patient's age, comorbidities, and access to a suitable donor and effective therapeutic agents. Since 2022, horse antithymocyte globulin (hATG) has been available again in Europe and is recommended for IST as a more effective option than rabbit ATG. Therefore, an update on immunosuppressive strategies is warranted. Despite an improved response to the new immunosuppression protocols with hATG and eltrombopag, some patients are not cured or remain at risk of aplasia relapse or clonal evolution and require postponed alloHCT. The transplantation field has evolved, becoming safer and more accessible. Upfront alloHCT from unrelated donors is becoming a tempting option. With the use of posttransplant cyclophosphamide, haploidentical HCT offers promising outcomes also in AA. In this paper, we present the state of the art in the management of severe AA for pediatric and adult patients based on the available guidelines and recently published studies.
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Affiliation(s)
- Agnieszka Piekarska
- Department of Hematology and Transplantology, Medical University of Gdansk, Gdansk, Poland
| | - Katarzyna Pawelec
- Department of Oncology, Pediatric Hematology, Clinical Transplantology and Pediatrics, Medical University of Warsaw, Warsaw, Poland
| | | | - Marek Ussowicz
- Department of Pediatric Bone Marrow Transplantation, Oncology and Hematology, Wroclaw Medical University, Wroclaw, Poland
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6
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Hwang SM. Genomic testing for germline predisposition to hematologic malignancies. Blood Res 2024; 59:12. [PMID: 38485837 PMCID: PMC10923764 DOI: 10.1007/s44313-024-00012-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2024] [Accepted: 02/27/2024] [Indexed: 03/18/2024] Open
Abstract
Germline predisposition (GPD) to hematological malignancies has gained interest because of the increased use of genetic testing in this field. Recent studies have suggested that GPD is underrecognized and requires appropriate genomic testing for an accurate diagnosis. Identification of GPD significantly affects patient management and has diverse implications for family members. This review discusses the reasons for testing GPD in hematologic malignancies and explores the considerations necessary for appropriate genomic testing. The aim is to provide insights into how these genetic insights can inform treatment strategies and genetic counseling, ultimately enhancing patient care.
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Affiliation(s)
- Sang Mee Hwang
- Department of Laboratory Medicine, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Gumiro 173 Beongil-82, Bundanggu, Seongnam, Gyeonggido, 13620, South Korea.
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7
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Yoshida N. Recent advances in the diagnosis and treatment of pediatric acquired aplastic anemia. Int J Hematol 2024; 119:240-247. [PMID: 36867357 DOI: 10.1007/s12185-023-03564-4] [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: 01/31/2023] [Revised: 02/08/2023] [Accepted: 02/08/2023] [Indexed: 03/04/2023]
Abstract
Acquired aplastic anemia (AA) in children is a rare bone marrow failure that requires several special considerations for its diagnosis and treatment compared with that in adults. The most common issue is the differential diagnosis with refractory cytopenia of childhood and inherited bone marrow failure syndromes, which is crucial for making decisions on the appropriate treatment for pediatric AA. In addition to detailed morphological evaluation, a comprehensive diagnostic work-up that includes genetic analysis using next-generation sequencing will play an increasingly important role in identifying the underlying etiology of pediatric AA. When discussing treatment strategies for children with acquired AA, the long-term sequelae and level of hematopoietic recovery that affect daily or school life should also be considered, although the overall survival rate has reached 90% after immunosuppressive therapy or hematopoietic cell transplantation (HCT). Recent advances in HCT for pediatric patients with acquired AA have been remarkable, with the successful use of upfront bone marrow transplantation from a matched unrelated donor, unrelated cord blood transplantation or haploidentical HCT as salvage treatment, and fludarabine/melphalan-based conditioning regimens. This review discusses current clinical practices in the diagnosis and treatment of acquired AA in children based on the latest data.
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Affiliation(s)
- Nao Yoshida
- Department of Hematology and Oncology, Children's Medical Center, Japanese Red Cross Aichi Medical Center Nagoya First Hospital, 3-35 Michishita-cho, Nakamura-ku, Nagoya, Aichi, 453-8511, Japan.
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8
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Trottier AM, Feurstein S, Godley LA. Germline predisposition to myeloid neoplasms: Characteristics and management of high versus variable penetrance disorders. Best Pract Res Clin Haematol 2024; 37:101537. [PMID: 38490765 DOI: 10.1016/j.beha.2024.101537] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2023] [Revised: 01/07/2024] [Accepted: 01/24/2024] [Indexed: 03/17/2024]
Abstract
Myeloid neoplasms with germline predisposition have been recognized increasingly over the past decade with numerous newly described disorders. Penetrance, age of onset, phenotypic heterogeneity, and somatic driver events differ widely among these conditions and sometimes even within family members with the same variant, making risk assessment and counseling of these individuals inherently difficult. In this review, we will shed light on high malignant penetrance (e.g., CEBPA, GATA2, SAMD9/SAMD9L, and TP53) versus variable malignant penetrance syndromes (e.g., ANKRD26, DDX41, ETV6, RUNX1, and various bone marrow failure syndromes) and their clinical features, such as variant type and location, course of disease, and prognostic markers. We further discuss the recommended management of these syndromes based on penetrance with an emphasis on somatic aberrations consistent with disease progression/transformation and suggested timing of allogeneic hematopoietic stem cell transplant. This review will thereby provide important data that can help to individualize and improve the management for these patients.
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Affiliation(s)
- Amy M Trottier
- Division of Hematology, Department of Medicine, QEII Health Sciences Centre, Dalhousie University, Halifax, NS, Canada
| | - Simone Feurstein
- Department of Internal Medicine, Section of Hematology, Oncology and Rheumatology, Heidelberg University Hospital, Heidelberg, Germany
| | - Lucy A Godley
- Division of Hematology/Oncology, Department of Medicine, The Robert H. Lurie Comprehensive Cancer Center, Northwestern University, Chicago, IL, USA.
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9
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Williams LS, Williams KM, Gillis N, Bolton K, Damm F, Deuitch NT, Farhadfar N, Gergis U, Keel SB, Michelis FV, Panch SR, Porter CC, Sucheston-Campbell L, Tamari R, Stefanski HE, Godley LA, Lai C. Donor-Derived Malignancy and Transplantation Morbidity: Risks of Patient and Donor Genetics in Allogeneic Hematopoietic Stem Cell Transplantation. Transplant Cell Ther 2024; 30:255-267. [PMID: 37913908 PMCID: PMC10947964 DOI: 10.1016/j.jtct.2023.10.018] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2023] [Revised: 10/18/2023] [Accepted: 10/26/2023] [Indexed: 11/03/2023]
Abstract
Allogeneic hematopoietic stem cell transplantation (allo-HSCT) remains a key treatment option for hematologic malignancies (HMs), although it carries significant risks. Up to 30% of patients relapse after allo-HSCT, of which up to 2% to 5% are donor-derived malignancies (DDMs). DDMs can arise from a germline genetic predisposition allele or clonal hematopoiesis (CH) in the donor. Increasingly, genetic testing reveals that patient and donor genetic factors contribute to the development of DDM and other allo-HSCT complications. Deleterious germline variants in CEBPA, DDX41, GATA2, and RUNX1 predispose to inferior allo-HSCT outcomes. DDM has been linked to donor-acquired somatic CH variants in DNMT3A, ASXL1, JAK2, and IDH2, often with additional new variants. We do not yet have evidence to standardize donor genetic sequencing prior to allo-HSCT. The presence of hereditary HM disorders should be considered in patients with myeloid malignancies and their related donors, and screening of unrelated donors should include family and personal history of cytopenia and HMs. Excellent multidisciplinary care is critical to ensure efficient timelines for screening and necessary discussions among medical oncologists, genetic counselors, recipients, and potential donors. After allo-HSCT, HM relapse monitoring with genetic testing effectively results in genetic sequencing of the donor, as the transplanted hematopoietic system is donor-derived, which presents ethical challenges for disclosure to patients and donors. We encourage consideration of the recent National Marrow Donor Program policy that allows donors to opt-in for notification about detection of their genetic variants after allo-HSCT, with appropriate genetic counseling when feasible. We look forward to prospective investigation of the impact of germline and acquired somatic genetic variants on hematopoietic stem cell mobilization/engraftment, graft-versus-host disease, and DDM to facilitate improved outcomes through knowledge of genetic risk.
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Affiliation(s)
- Lacey S Williams
- Lombardi Clinical Cancer Center, Georgetown University, Washington, District of Columbia.
| | - Kirsten M Williams
- Aflac Cancer and Blood Disorders Center, Children's Healthcare of Atlanta, Emory University, Atlanta, Georgia
| | - Nancy Gillis
- Department of Cancer Epidemiology and Department of Malignant Hematology, H Lee Moffitt Cancer Center and Research Institute, Tampa, Florida
| | - Kelly Bolton
- Siteman Cancer Center, Washington University in St. Louis, St. Louis, Missouri
| | - Frederik Damm
- Hematology, Oncology, and Cancer Immunology, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Natalie T Deuitch
- National Human Genome Research Institute, National Institutes of Health, Bethesda, Maryland
| | - Nosha Farhadfar
- Division of Hematology/Oncology, University of Florida College of Medicine, Gainesville, Florida
| | - Usama Gergis
- Department of Medical Oncology, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania
| | - Siobán B Keel
- Fred Hutchinson Cancer Center, Seattle, Washington; Department of Medicine, University of Washington, Seattle, Washington
| | | | - Sandhya R Panch
- Fred Hutchinson Cancer Center, Seattle, Washington; Department of Medicine, University of Washington, Seattle, Washington
| | - Christopher C Porter
- Aflac Cancer and Blood Disorders Center, Children's Healthcare of Atlanta, Emory University, Atlanta, Georgia
| | | | - Roni Tamari
- Memorial Sloan Kettering, New York, New York
| | - Heather E Stefanski
- Center for International Blood and Marrow Transplant Research, National Marrow Donor Program/Be The Match, Minneapolis, Minnesota
| | - Lucy A Godley
- Division of Hematology/Oncology and the Robert H. Lurie Comprehensive Cancer Center, Northwestern University, Chicago, Illinois
| | - Catherine Lai
- Perelman Center for Advanced Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
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10
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Cobaleda C, Godley LA, Nichols KE, Wlodarski MW, Sanchez-Garcia I. Insights into the Molecular Mechanisms of Genetic Predisposition to Hematopoietic Malignancies: The Importance of Gene-Environment Interactions. Cancer Discov 2024; 14:396-405. [PMID: 38426560 PMCID: PMC10913756 DOI: 10.1158/2159-8290.cd-23-1091] [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: 09/26/2023] [Revised: 11/20/2023] [Accepted: 12/01/2023] [Indexed: 03/02/2024]
Abstract
SUMMARY The recognition of host genetic factors underlying susceptibility to hematopoietic malignancies has increased greatly over the last decade. Historically, germline predisposition was thought to primarily affect the young. However, emerging data indicate that hematopoietic malignancies that develop in people of all ages across the human lifespan can derive from germline predisposing conditions and are not exclusively observed in younger individuals. The age at which hematopoietic malignancies manifest appears to correlate with distinct underlying biological pathways. Progression from having a deleterious germline variant to being diagnosed with overt malignancy involves complex, multistep gene-environment interactions with key external triggers, such as infection and inflammatory stimuli, driving clonal progression. Understanding the mechanisms by which predisposed clones transform under specific pressures may reveal strategies to better treat and even prevent hematopoietic malignancies from occurring.Recent unbiased genome-wide sequencing studies of children and adults with hematopoietic malignancies have revealed novel genes in which disease-causing variants are of germline origin. This paradigm shift is spearheaded by findings in myelodysplastic syndrome/acute myeloid leukemia (MDS/AML) as well as acute lymphoblastic leukemia, but it also encompasses other cancer types. Although not without challenges, the field of genetic cancer predisposition is advancing quickly, and a better understanding of the genetic basis of hematopoietic malignancies risk affects therapeutic decisions as well as genetic counseling and testing of at-risk family members.
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Affiliation(s)
- Cesar Cobaleda
- Immune System Development and Function Unit, Centro de Biología Molecular Severo Ochoa (CBM, CSIC-UAM), Madrid, Spain
| | - Lucy A. Godley
- Division of Hematology/Oncology, Department of Medicine, The Robert H. Lurie Comprehensive Cancer Center, Northwestern University, Chicago, Illinois
| | - Kim E. Nichols
- Division of Cancer Predisposition, St. Jude Children's Research Hospital, Memphis, Tennessee
| | - Marcin W. Wlodarski
- Department of Hematology, St. Jude Children's Research Hospital, Memphis, Tennessee
| | - Isidro Sanchez-Garcia
- Experimental Therapeutics and Translational Oncology Program, Instituto de Biología Molecular y Celular del Cáncer, CSIC/Universidad de Salamanca, Salamanca, Spain
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11
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Gutierrez-Rodrigues F, Patel BA, Groarke EM. When to consider inherited marrow failure syndromes in adults. HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2023; 2023:548-555. [PMID: 38066926 PMCID: PMC10727017 DOI: 10.1182/hematology.2023000488] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/18/2023]
Abstract
The inherited bone marrow failure syndromes (IBMFS) are a heterogenous group of disorders caused by germline mutations in related genes and characterized by bone marrow failure (BMF), disease specific organ involvement, and, in most cases, predisposition to malignancy. Their distinction from immune marrow failure can often be challenging, particularly when presentations occur in adulthood or are atypical. A combination of functional (disease specific assays) and genetic testing is optimal in assessing all new BMF patients for an inherited etiology. However, genetic testing is costly and may not be available worldwide due to resource constraints; in such cases, clinical history, standard laboratory testing, and the use of algorithms can guide diagnosis. Interpretation of genetic results can be challenging and must reflect assessment of pathogenicity, inheritance pattern, clinical phenotype, and specimen type used. Due to the progressive use of genomics, new IBMFS continue to be identified, widening the spectrum of these disorders.
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Affiliation(s)
| | - Bhavisha A Patel
- Hematology Branch, National Heart, Lung and Blood Institute, National Institutes of Health, Bethesda, MD
| | - Emma M Groarke
- Hematology Branch, National Heart, Lung and Blood Institute, National Institutes of Health, Bethesda, MD
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12
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Agarwal S. Minimal intensity conditioning strategies for bone marrow failure: is it time for "preventative" transplants? HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2023; 2023:135-140. [PMID: 38066900 PMCID: PMC10727038 DOI: 10.1182/hematology.2023000470] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/18/2023]
Abstract
Hematopoietic cell transplantation (HCT) can cure blood dyscrasias and reduce the risk of hematologic cancers in patients with inherited bone marrow failure syndromes (IBMFS). However, because of its high mortality rate, HCT is generally reserved until patients with IBMFS manifest life-threatening cytopenias or myeloid malignancy, at which point outcomes are poor. Screening tests that accurately predict transformation and enable timely intervention are lacking. These unknowns and risks limit the use of HCT in patients with IBMFS, sometimes until significant disease-related sequelae have occurred. A major goal for IBMFS is to reduce cellular therapy-related complications to the point that earlier intervention can be considered before significant transfusion exposure, occurrence of comorbidities, or malignant transformation. In recent decades, disease-specific allogeneic HCT trials have yielded significant improvements in outcomes in IBMFS conditions, including Fanconi anemia and dyskeratosis congenita. This is in large part due to marked reductions in conditioning intensity to address the increased sensitivity of these patients to cytotoxic chemotherapy and radiation. The success of these approaches may also indicate an ability to leverage intrinsic fitness defects of hematopoietic stem and progenitor cells across IBMFS disorders. Now with advances in tracking somatic genetic evolution in hematopoiesis and tailored minimal intensity conditioning regimens, this question arises: is it time for preventative HCT for IBMFS?
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Affiliation(s)
- Suneet Agarwal
- Division of Hematology/Oncology and Stem Cell Program, Boston Children's Hospital, Pediatric Oncology, Dana-Farber Cancer Institute, Department of Pediatrics, Harvard Medical School, Boston, MA
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13
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Niewisch MR. Clinical manifestations of telomere biology disorders in adults. HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2023; 2023:563-572. [PMID: 38066848 PMCID: PMC10726987 DOI: 10.1182/hematology.2023000490] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/18/2023]
Abstract
Telomere biology disorders (TBDs) are a spectrum of inherited bone marrow failure syndromes caused by impaired telomere function due to pathogenic germline variants in genes involved in telomere maintenance. TBDs can affect many organ systems and are often thought of as diseases of childhood. However, TBDs may present in mid- or even late adulthood with features similar to but not always the same as the childhood-onset TBDs. Adult-onset TBDs are often cryptic with isolated pulmonary, liver, or hematologic disease, or cancer, and may lack the classic disease-defining triad of abnormal skin pigmentation, nail dysplasia, and oral leukoplakia. Diagnostics include detection of very short leukocyte telomeres and germline genetic testing. Notably, adult-onset TBDs may show telomeres in the 1st to 10th percentile for age, and some cases may not have an identifiable genetic cause. TBD genetic etiology includes all modes of inheritance, with autosomal dominant the most frequent in adult-onset disease. Variable symptom onset due to incomplete penetrance, variable expressivity, and genetic anticipation add to the diagnostic challenges. Adult-onset TBDs are likely underrecognized, but their correct identification is of utmost importance, since affected patients are faced with numerous clinical complications, including but not limited to an increased risk of malignancies requiring close surveillance for early detection. Currently lung, liver, or hematopoietic cell transplants are the only curative therapeutic approaches but can be complicated by comorbidities, despite improved medical care. This review highlights the challenges of identifying adult-onset TBDs and addresses currently recommended clinical screening measures and therapy options.
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Affiliation(s)
- Marena R. Niewisch
- Department of Pediatric Hematology and Oncology, Hannover Medical School, Hannover, Germany
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14
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Gurnari C, Robin M, Godley LA, Drozd-Sokołowska J, Włodarski MW, Raj K, Onida F, Worel N, Ciceri F, Carbacioglu S, Kenyon M, Aljurf M, Bonfim C, Makishima H, Niemeyer C, Fenaux P, Zebisch A, Hamad N, Chalandon Y, Hellström-Lindberg E, Voso MT, Mecucci C, Duarte FB, Sebert M, Sicre de Fontbrune F, Soulier J, Shimamura A, Lindsley RC, Maciejewski JP, Calado RT, Yakoub-Agha I, McLornan DP. Germline predisposition traits in allogeneic hematopoietic stem-cell transplantation for myelodysplastic syndromes: a survey-based study and position paper on behalf of the Chronic Malignancies Working Party of the EBMT. Lancet Haematol 2023; 10:e994-e1005. [PMID: 37898151 DOI: 10.1016/s2352-3026(23)00265-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2023] [Revised: 08/15/2023] [Accepted: 08/18/2023] [Indexed: 10/30/2023]
Abstract
The recent application of whole exome or whole genome sequencing unveiled a plethora of germline variants predisposing to myeloid disorders, particularly myelodysplastic neoplasms. The presence of such variants in patients with myelodysplastic syndromes has important clinical repercussions for haematopoietic stem-cell transplantation, from donor selection and conditioning regimen to graft-versus-host disease prophylaxis and genetic counselling for relatives. No international guidelines exist to harmonise management approaches to this particular clinical scenario. Moreover, the application of germline testing, and how this informs clinical decisions, differs according to the expertise of individual clinical practices and according to different countries, health-care systems, and legislations. Leveraging the global span of the European Society for Blood and Marrow Transplantation (EBMT) network, we took a snapshot of the current European situation on these matters by disseminating an electronic survey to EBMT centres experienced in myelodysplastic syndromes transplantation. An international group of haematologists, transplantation physicians, paediatricians, nurses, and experts in molecular biology and constitutional genetics with experience in myelodysplastic syndromes contributed to this Position Paper. The panel met during multiple online meetings to discuss the results of the EBMT survey and to establish suggested harmonised guidelines for such clinical situations, which are presented here.
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Affiliation(s)
- Carmelo Gurnari
- Department of Biomedicine and Prevention, University of Rome Tor Vergata, Rome, Italy; Department of Translational Hematology and Oncology Research, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Marie Robin
- Department of Hematology and Bone Marrow Transplantation, Hôpital Saint-Louis, AP-HP, University Paris, Paris, France
| | - Lucy A Godley
- Section of Hematology and Oncology, Departments of Medicine and Human Genetics, The University of Chicago, Chicago, IL, USA
| | - Joanna Drozd-Sokołowska
- Department of Hematology, Transplantation and Internal Medicine, Medical University of Warsaw, Warsaw, Poland
| | - Marcin W Włodarski
- Department of Hematology, St Jude Children's Research Hospital, Memphis, TN, USA
| | - Kavita Raj
- University College London NHS Foundation Trust, London, UK
| | - Francesco Onida
- Hematology Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Nina Worel
- Department of Transfusion Medicine and Cell Therapy, Medical University of Vienna, Vienna, Austria
| | | | - Selim Carbacioglu
- Department of Paediatric Oncology, Haematology and Stem Cell Transplantation, University Children's Hospital Regensburg, Regensburg, Germany
| | - Michelle Kenyon
- Department of Haematological Medicine, King's College Hospital NHS Foundation Trust, London, UK
| | - Mahmoud Aljurf
- Division of Hematology, Stem Cell Transplantation and Cellular Therapy, Oncology Center, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
| | - Carmem Bonfim
- Pediatric Blood and Marrow Transplantation Division and Pele Pequeno Principe Research Institute, Hospital Pequeno Principe, Curitiba, Brazil
| | - Hideki Makishima
- Department of Pathology and Tumor Biology, Kyoto University, Kyoto, Japan
| | - Charlotte Niemeyer
- Department of Pediatrics and Adolescent Medicine, Division of Pediatric Hematology and Oncology, Medical Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Pierre Fenaux
- Department of Hematology and Bone Marrow Transplantation, Hôpital Saint-Louis, AP-HP, University Paris, Paris, France; INSERM U944, CNRS UMR7212, Paris, France; Saint-Louis Hospital, Hematology Laboratory, AP-HP, Paris, France
| | - Armin Zebisch
- Division of Hematology and Otto Loewi Research Center for Vascular Biology, Immunology and Inflammation, Division of Pharmacology, Medical University of Graz, Graz, Austria
| | - Nada Hamad
- Department of Hematology, St Vincent's Hospital Sydney, NSW, Australia
| | - Yves Chalandon
- Division of Hematology, Bone Marrow Transplant Unit, University Hospital of Geneva and Faculty of Medicine, University of Geneva, Geneva, Switzerland
| | - Eva Hellström-Lindberg
- Center for Hematology and Regenerative Medicine, Department of Medicine Huddinge, Karolinska Institutet and Department of Hematology, Karolinska University Hospital, Stockholm, Sweden
| | - Maria Teresa Voso
- Department of Biomedicine and Prevention, University of Rome Tor Vergata, Rome, Italy
| | - Cristina Mecucci
- Institute of Hematology and Center for Hemato-Oncology Research, University and Hospital of Perugia, Perugia, Italy
| | | | - Marie Sebert
- Department of Hematology and Bone Marrow Transplantation, Hôpital Saint-Louis, AP-HP, University Paris, Paris, France; INSERM U944, CNRS UMR7212, Paris, France; Saint-Louis Hospital, Hematology Laboratory, AP-HP, Paris, France
| | - Flore Sicre de Fontbrune
- Department of Hematology and Bone Marrow Transplantation, Hôpital Saint Louis, AP-HP, Université Paris Cité, Centre National de Reference des Aplasies Médullaires Acquises et Constitutionnelles, Paris, France
| | - Jean Soulier
- INSERM U944, CNRS UMR7212, Paris, France; Saint-Louis Hospital, Hematology Laboratory, AP-HP, Paris, France
| | - Akiko Shimamura
- Dana-Farber/Boston Children's Cancer and Blood Disorders Center, Boston, MA, USA
| | | | - Jarosław P Maciejewski
- Department of Translational Hematology and Oncology Research, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Rodrigo T Calado
- Department of Medical Imaging, Hematology, and Oncology, Ribeirão Preto Medical School, University of São Paulo, Brazil
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15
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DeZern AE, Brodsky RA. Combining PTCy and ATG for GvHD prophylaxis in non-malignant diseases. Blood Rev 2023; 62:101016. [PMID: 36244884 DOI: 10.1016/j.blre.2022.101016] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2022] [Revised: 09/13/2022] [Accepted: 09/20/2022] [Indexed: 11/21/2022]
Abstract
Bone marrow transplantation for non-malignant diseases such as aplastic anemia and hemoglobinopathies is a burgeoning clinical area. The goal of these transplants is to correct the hematopoietic defect with as little toxicity as possible. This requires mitigation of transplant-specific toxicities such as graft versus host disease, given this is not needed in non-malignant disorders. This review details current clinical outcomes in the field with a focus on post-transplantation cyclophosphamide and anti-thymoglobulin as intensive graft versus host disease prophylaxis to achieve that goal.
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Affiliation(s)
- Amy E DeZern
- Division of Hematologic Malignancies, The Johns Hopkins University School of Medicine, 1650 Orleans Street, CRBI Room 3M87, Baltimore, MD 21287-0013, United States of America.
| | - Robert A Brodsky
- Division of Hematology, The Johns Hopkins University School of Medicine, 720 Rutland Avenue | Ross 1025, Baltimore, MD 21205, United States of America.
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16
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Yan J, Jin T, Wang L. Hematopoietic stem cell transplantation of aplastic anemia by relative with mutations and normal telomere length: A case report. World J Clin Cases 2023; 11:7200-7206. [PMID: 37946752 PMCID: PMC10631418 DOI: 10.12998/wjcc.v11.i29.7200] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2023] [Revised: 09/09/2023] [Accepted: 09/26/2023] [Indexed: 10/13/2023] Open
Abstract
BACKGROUND Immunosuppressive therapy and matched sibling donor hematopoietic stem cell transplantation (MSD-HSCT) are the preferred treatments for aplastic anemia (AA). CASE SUMMARY In this report, we describe a 43-year-old male patient with severe AA who carried BRIP1 (also known as FANCJ), TINF2, and TCIRG1 mutations. Screening of the family pedigree revealed the same TINF2 mutation in his mother and older brother, with his older brother also carrying the BRIP1 variant and demonstrating normal telomere length and hematopoietic function. The patient was successfully treated with oral cyclosporine A, eltrombopag, and acetylcysteine, achieving remission 4 years after receiving MSD-HSCT from his older brother. CONCLUSION This case provides a valuable clinical reference for individuals with suspected pathogenic gene mutations, normal telomere length, and hematopoietic function, highlighting them as potential donors for patients with AA.
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Affiliation(s)
- Jin Yan
- School of Medicine, Jianghan University, Wuhan 430056, Hubei Province, China
- Department of Hematology, The Central Hospital of Wuhan, Wuhan 430014, Hubei Province, China
| | - Ting Jin
- Department of Hematology, The Central Hospital of Wuhan, Wuhan 430014, Hubei Province, China
| | - Li Wang
- Department of Hematology, The Central Hospital of Wuhan, Wuhan 430014, Hubei Province, China
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17
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Godley LA. Germ line risk variants: beyond cancer. Blood 2023; 142:616-617. [PMID: 37590029 DOI: 10.1182/blood.2023021165] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/18/2023] Open
Affiliation(s)
- Lucy A Godley
- Robert H. Lurie Comprehensive Cancer Center and Northwestern University
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18
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Uria-Oficialdegui ML, Navarro S, Murillo-Sanjuan L, Rodriguez-Vigil C, Benitez-Carbante MI, Blazquez-Goñi C, Salinas JA, Diaz-de-Heredia C. Dyskeratosis congenita: natural history of the disease through the study of a cohort of patients diagnosed in childhood. Front Pediatr 2023; 11:1182476. [PMID: 37593443 PMCID: PMC10427857 DOI: 10.3389/fped.2023.1182476] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2023] [Accepted: 07/14/2023] [Indexed: 08/19/2023] Open
Abstract
Background Dyskeratosis congenita (DC) is a multisystem and ultra-rare hereditary disease characterized by somatic involvement, bone marrow failure, and predisposition to cancer. The main objective of this study is to describe the natural history of DC through a cohort of patients diagnosed in childhood and followed up for a long period of time. Material and methods Multicenter, retrospective, longitudinal study conducted in patients followed up to 24 years since being diagnosed in childhood (between 1998 and 2020). Results Fourteen patients were diagnosed with DC between the ages of 3 and 17 years (median, 8.5 years). They all had hematologic manifestations at diagnosis, and nine developed mucocutaneous manifestations during the first decade of life. Seven presented severe DC variants. All developed non-hematologic manifestations during follow-up. Mutations were identified in 12 patients. Thirteen progressed to bone marrow failure at a median age of 8 years [range, 3-18 years], and eight received a hematopoietic stem cell transplant. Median follow-up time was 9 years [range, 2-24 years]. Six patients died, the median age was 13 years [range, 6-24 years]. As of November 2022, eight patients were still alive, with a median age of 18 years [range, 6-32 years]. None of them have developed myeloblastic syndrome or cancer. Conclusions DC was associated with high morbidity and mortality in our series. Hematologic manifestations appeared early and consistently. Non-hematologic manifestations developed progressively. No patient developed cancer possibly due to their young age. Due to the complexity of the disease multidisciplinary follow-up and adequate transition to adult care are essential.
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Affiliation(s)
- M. L. Uria-Oficialdegui
- Pediatric Hematology and Oncology Division, Hospital Universitari Vall d´Hebron, Barcelona, Spain
| | - S. Navarro
- Pediatric Division, Hospital Universitario SonEspases, Palma de Mallorca, Spain
| | - L. Murillo-Sanjuan
- Pediatric Hematology and Oncology Division, Hospital Universitari Vall d´Hebron, Barcelona, Spain
| | - C. Rodriguez-Vigil
- Pediatric Oncohaematology Unit, Paediatric Division, Hospital Universitario Miguel Servet, Zaragoza, Spain
| | - M. I. Benitez-Carbante
- Pediatric Hematology and Oncology Division, Hospital Universitari Vall d´Hebron, Barcelona, Spain
| | | | - J. A. Salinas
- Pediatric Division, Hospital Universitario SonEspases, Palma de Mallorca, Spain
| | - C. Diaz-de-Heredia
- Pediatric Hematology and Oncology Division, Hospital Universitari Vall d´Hebron, Barcelona, Spain
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19
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Tometten M, Kirschner M, Meyer R, Begemann M, Halfmeyer I, Vieri M, Kricheldorf K, Maurer A, Platzbecker U, Radsak M, Schafhausen P, Corbacioglu S, Höchsmann B, Matthias Wilk C, Hinze C, Chromik J, Heuser M, Kreuter M, Koschmieder S, Panse J, Isfort S, Kurth I, Brümmendorf TH, Beier F. Identification of Adult Patients With Classical Dyskeratosis Congenita or Cryptic Telomere Biology Disorder by Telomere Length Screening Using Age-modified Criteria. Hemasphere 2023; 7:e874. [PMID: 37096215 PMCID: PMC10121438 DOI: 10.1097/hs9.0000000000000874] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2022] [Accepted: 03/08/2023] [Indexed: 04/26/2023] Open
Abstract
Telomere biology disorders (TBD) result from premature telomere shortening due to pathogenic germline variants in telomere maintenance-associated genes. In adults, TBD are characterized by mono/oligosymptomatic clinical manifestations (cryptic TBD) contributing to severe underdiagnosis. We present a prospective multi-institutional cohort study where telomere length (TL) screening was performed in either newly diagnosed patients with aplastic anemia (AA) or if TBD was clinically suspected by the treating physician. TL of 262 samples was measured via flow-fluorescence in situ hybridization (FISH). TL was considered suspicious once below the 10th percentile of normal individuals (standard screening) or if below 6.5 kb in patients >40 years (extended screening). In cases with shortened TL, next generation sequencing (NGS) for TBD-associated genes was performed. The patients referred fell into 6 different screening categories: (1) AA/paroxysmal nocturnal hemoglobinuria, (2) unexplained cytopenia, (3) dyskeratosis congenita, (4) myelodysplastic syndrome/acute myeloid leukemia, (5) interstitial lung disease, and (6) others. Overall, TL was found to be shortened in 120 patients (n = 86 standard and n = 34 extended screening). In 17 of the 76 (22.4%) standard patients with sufficient material for NGS, a pathogenic/likely pathogenic TBD-associated gene variant was identified. Variants of uncertain significance were detected in 17 of 76 (22.4%) standard and 6 of 29 (20.7%) extended screened patients. Expectedly, mutations were mainly found in TERT and TERC. In conclusion, TL measured by flow-FISH represents a powerful functional in vivo screening for an underlying TBD and should be performed in every newly diagnosed patient with AA as well as other patients with clinical suspicion for an underlying TBD in both children and adults.
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Affiliation(s)
- Mareike Tometten
- Department of Hematology, Oncology, Hemostaseology and Stem Cell Transplantation, Medical Faculty, RWTH Aachen University, Aachen, Germany
- Center for Integrated Oncology Aachen Bonn Cologne Düsseldorf (CIO ABCD), Germany
| | - Martin Kirschner
- Department of Hematology, Oncology, Hemostaseology and Stem Cell Transplantation, Medical Faculty, RWTH Aachen University, Aachen, Germany
- Center for Integrated Oncology Aachen Bonn Cologne Düsseldorf (CIO ABCD), Germany
| | - Robert Meyer
- Center for Integrated Oncology Aachen Bonn Cologne Düsseldorf (CIO ABCD), Germany
- Institute for Human Genetics and Genomic Medicine, Medical Faculty, RWTH Aachen University, Aachen, Germany
| | - Matthias Begemann
- Center for Integrated Oncology Aachen Bonn Cologne Düsseldorf (CIO ABCD), Germany
- Institute for Human Genetics and Genomic Medicine, Medical Faculty, RWTH Aachen University, Aachen, Germany
| | - Insa Halfmeyer
- Department of Hematology, Oncology, Hemostaseology and Stem Cell Transplantation, Medical Faculty, RWTH Aachen University, Aachen, Germany
- Center for Integrated Oncology Aachen Bonn Cologne Düsseldorf (CIO ABCD), Germany
| | - Margherita Vieri
- Department of Hematology, Oncology, Hemostaseology and Stem Cell Transplantation, Medical Faculty, RWTH Aachen University, Aachen, Germany
- Center for Integrated Oncology Aachen Bonn Cologne Düsseldorf (CIO ABCD), Germany
| | - Kim Kricheldorf
- Department of Hematology, Oncology, Hemostaseology and Stem Cell Transplantation, Medical Faculty, RWTH Aachen University, Aachen, Germany
- Center for Integrated Oncology Aachen Bonn Cologne Düsseldorf (CIO ABCD), Germany
| | - Angela Maurer
- Department of Hematology, Oncology, Hemostaseology and Stem Cell Transplantation, Medical Faculty, RWTH Aachen University, Aachen, Germany
- Center for Integrated Oncology Aachen Bonn Cologne Düsseldorf (CIO ABCD), Germany
| | - Uwe Platzbecker
- Clinic for Hematology, Cellular Therapy, and Hemostaseology, University Hospital Leipzig, Germany
| | - Markus Radsak
- Department of Hematology, Medical Oncology, and Pneumology, University Medical Center of the Johannes Gutenberg University, Mainz, Germany
| | - Philippe Schafhausen
- Department of Oncology, Hematology, and Bone Marrow Transplantation with Section of Pneumology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Selim Corbacioglu
- Department of Pediatric Hematology, Oncology and Stem Cell Transplantation, University of Hospital Regensburg, Germany
| | - Britta Höchsmann
- Institute of Transfusion Medicine and Immunogenetics, University of Ulm, Germany
- Institute of Clinical Transfusion Medicine and Immunogenetics, German Red Cross Blood Transfusion Service Baden-Württemberg-Hessen and University Hospital Ulm, Germany
| | - C. Matthias Wilk
- Department of Medical Oncology and Hematology, University Hospital Zurich, University of Zurich, Switzerland
| | - Claas Hinze
- Department of Pediatric Rheumatology and Immunology, University Hospital Muenster, Germany
| | - Jörg Chromik
- Department of Medicine, Hematology and Oncology, Goethe-University, Frankfurt, Germany
| | - Michael Heuser
- Department of Hematology, Hemostasis, Oncology, and Stem Cell Transplantation, Hannover Medical School, Hannover, Germany
| | - Michael Kreuter
- Center for Interstitial and Rare Lung Diseases, Thoraxklinik, University of Heidelberg, German Center for Lung Research (DZL), Heidelberg, Germany
- Academic Center for Pulmonary Medicine, Departments of Pneumology, Mainz University Medical Center, and of Pulmonary, Critical Care & Sleep Medicine, Marienhaus Clinic Mainz, Germany
| | - Steffen Koschmieder
- Department of Hematology, Oncology, Hemostaseology and Stem Cell Transplantation, Medical Faculty, RWTH Aachen University, Aachen, Germany
- Center for Integrated Oncology Aachen Bonn Cologne Düsseldorf (CIO ABCD), Germany
| | - Jens Panse
- Department of Hematology, Oncology, Hemostaseology and Stem Cell Transplantation, Medical Faculty, RWTH Aachen University, Aachen, Germany
- Center for Integrated Oncology Aachen Bonn Cologne Düsseldorf (CIO ABCD), Germany
| | - Susanne Isfort
- Department of Hematology, Oncology, Hemostaseology and Stem Cell Transplantation, Medical Faculty, RWTH Aachen University, Aachen, Germany
- Center for Integrated Oncology Aachen Bonn Cologne Düsseldorf (CIO ABCD), Germany
| | - Ingo Kurth
- Center for Integrated Oncology Aachen Bonn Cologne Düsseldorf (CIO ABCD), Germany
- Institute for Human Genetics and Genomic Medicine, Medical Faculty, RWTH Aachen University, Aachen, Germany
| | - Tim H. Brümmendorf
- Department of Hematology, Oncology, Hemostaseology and Stem Cell Transplantation, Medical Faculty, RWTH Aachen University, Aachen, Germany
- Center for Integrated Oncology Aachen Bonn Cologne Düsseldorf (CIO ABCD), Germany
| | - Fabian Beier
- Department of Hematology, Oncology, Hemostaseology and Stem Cell Transplantation, Medical Faculty, RWTH Aachen University, Aachen, Germany
- Center for Integrated Oncology Aachen Bonn Cologne Düsseldorf (CIO ABCD), Germany
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20
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Feurstein S. Emerging bone marrow failure syndromes- new pieces to an unsolved puzzle. Front Oncol 2023; 13:1128533. [PMID: 37091189 PMCID: PMC10119586 DOI: 10.3389/fonc.2023.1128533] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2022] [Accepted: 03/22/2023] [Indexed: 04/25/2023] Open
Abstract
Inherited bone marrow failure (BMF) syndromes are genetically diverse - more than 100 genes have been associated with those syndromes and the list is rapidly expanding. Risk assessment and genetic counseling of patients with recently discovered BMF syndromes is inherently difficult as disease mechanisms, penetrance, genotype-phenotype associations, phenotypic heterogeneity, risk of hematologic malignancies and clonal markers of disease progression are unknown or unclear. This review aims to shed light on recently described BMF syndromes with sparse concise data and with an emphasis on those associated with germline variants in ADH5/ALDH2, DNAJC21, ERCC6L2 and MECOM. This will provide important data that may help to individualize and improve care for these patients.
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21
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Chen RL, Ip PP, Shaw JJ, Wang YH, Fan LH, Shen YL, Joseph NA, Chen TE, Chen LY. Anti-Thymocyte Globulin (ATG)-Free Nonmyeloablative Haploidentical PBSCT Plus Post-Transplantation Cyclophosphamide Is a Safe and Efficient Treatment Approach for Pediatric Acquired Aplastic Anemia. Int J Mol Sci 2022; 23:ijms232315192. [PMID: 36499545 PMCID: PMC9739033 DOI: 10.3390/ijms232315192] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2022] [Revised: 11/29/2022] [Accepted: 11/30/2022] [Indexed: 12/11/2022] Open
Abstract
Most cases of acquired aplastic anemia (AA) arise from autoimmune destruction of hematopoietic stem and progenitor cells. Human leukocyte antigen (HLA)-haploidentical nonmyeloablative hematopoietic stem cell transplantation (HSCT) plus post-transplantation cyclophosphamide (PTCy) is increasingly applied to salvage AA using bone marrow as graft and anti-thymocyte globulin (ATG) in conditioning. Herein, we characterize a cohort of twelve AA patients clinically and molecularly, six who possessed other immunological disorders (including two also carrying germline SAMD9L mutations). Each patient with SAMD9L mutation also carried an AA-related rare BCORL1 variant or CTLA4 p.T17A GG genotype, respectively, and both presented short telomere lengths. Six of the ten patients analyzed harbored AA-risky HLA polymorphisms. All patients recovered upon non-HSCT (n = 4) or HSCT (n = 8) treatments. Six of the eight HSCT-treated patients were subjected to a modified PTCy-based regimen involving freshly prepared peripheral blood stem cells (PBSC) as graft and exclusion of ATG. All patients were engrafted between post-transplantation days +13 and +18 and quickly reverted to normal life, displaying a sustained complete hematologic response and an absence of graft-versus-host disease. These outcomes indicate most AA cases, including of the SAMD9L-inherited subtype, are immune-mediated and the modified PTCy-based regimen we present is efficient and safe for salvage.
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Affiliation(s)
- Rong-Long Chen
- Department of Pediatric Hematology and Oncology, Koo Foundation Sun Yat-sen Cancer Center, Taipei 11259, Taiwan
- Correspondence:
| | - Peng Peng Ip
- Institute of Molecular Biology, Academia Sinica, Taipei 115024, Taiwan
| | - Jy-juinn Shaw
- School of Law, National Yang Ming Chiao Tung University, Hsinchu City 30093, Taiwan
| | - Yun-Hsin Wang
- Department of Chemistry, Tamkang University, Tamsui, New Taipei City 251301, Taiwan
| | - Li-Hua Fan
- Department of Pharmacy, Koo Foundation Sun Yat-sen Cancer Center, Taipei 11259, Taiwan
| | - Yi-Ling Shen
- Institute of Molecular Biology, Academia Sinica, Taipei 115024, Taiwan
| | - Nithila A. Joseph
- Institute of Molecular Biology, Academia Sinica, Taipei 115024, Taiwan
| | - Tsen-Erh Chen
- Institute of Molecular Biology, Academia Sinica, Taipei 115024, Taiwan
| | - Liuh-Yow Chen
- Institute of Molecular Biology, Academia Sinica, Taipei 115024, Taiwan
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22
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Savage SA, Jones K, Teshome K, Lori A, McReynolds LJ, Niewisch MR. Next-generation sequencing errors due to genetic variation in WRAP53 encoding TCAB1 on chromosome 17. Hum Mutat 2022; 43:1856-1859. [PMID: 36116037 PMCID: PMC9771914 DOI: 10.1002/humu.24469] [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: 06/15/2022] [Revised: 08/17/2022] [Accepted: 09/12/2022] [Indexed: 01/24/2023]
Abstract
Next-generation sequencing (NGS) is a valuable tool, but has limitations in sequencing through repetitive runs of single nucleotides (homopolymers). Pathogenic germline variants in WRAP53 encoding telomere Cajal body protein 1 (TCAB1) are a known cause of dyskeratosis congenita. We identified a significant NGS error in WRAP53, c.1562dup, p.Ala522Glyfs*8 (rs755116516 G>-/GG/GGG) that did not validate by Sanger sequencing. This error occurs because rs755116516 G>-/GG/GGG (Chr17:7,606,714) is polymorphic, and variants at this site challenge the ability of NGS to accurately call the correct number of nucleotides in a homopolymer run. This was further complicated by the fact that chr17:7,606,721 (rs769202794) is multiallelic G>A, C, T, and that chr17:7,606,722 is also multiallelic (rs7640C>A/G/T and rs373064567C>delC). In addition to the expert interpretation of potentially clinically actionable variants, it recommended that all variants in regions of the genome with homopolymers be validated by Sanger sequencing before clinical action.
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Affiliation(s)
- Sharon A. Savage
- Clinical Genetics Branch, Division of Cancer Epidemiology and Genetics, National Cancer Institute, Bethesda, MD, USA
| | - Kristine Jones
- Cancer Genomics Research Laboratory, Division of Cancer Epidemiology and Genetics, National Cancer Institute, Bethesda, MD, USA
- Leidos Biomedical Research, Inc. Frederick National Laboratory for Cancer Research, Frederick, MD, USA
| | - Kedest Teshome
- Cancer Genomics Research Laboratory, Division of Cancer Epidemiology and Genetics, National Cancer Institute, Bethesda, MD, USA
- Leidos Biomedical Research, Inc. Frederick National Laboratory for Cancer Research, Frederick, MD, USA
| | | | - Lisa J. McReynolds
- Clinical Genetics Branch, Division of Cancer Epidemiology and Genetics, National Cancer Institute, Bethesda, MD, USA
| | - Marena R. Niewisch
- Clinical Genetics Branch, Division of Cancer Epidemiology and Genetics, National Cancer Institute, Bethesda, MD, USA
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23
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Playing with fire: unrecognized AA genetic predisposition. Blood 2022; 140:805-807. [PMID: 36006677 DOI: 10.1182/blood.2022017531] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2022] [Accepted: 07/01/2022] [Indexed: 11/20/2022] Open
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