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Peng J, He S, Yang X, Huang L, Wei J. Plasmacytoid dendritic cell expansion in myeloid neoplasms: A novel distinct subset of myeloid neoplasm? Crit Rev Oncol Hematol 2023; 192:104186. [PMID: 37863402 DOI: 10.1016/j.critrevonc.2023.104186] [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: 12/30/2022] [Revised: 10/06/2023] [Accepted: 10/16/2023] [Indexed: 10/22/2023] Open
Abstract
Plasmacytoid dendritic cells (pDCs) are a specific dendritic cell type stemming from the myeloid lineage. Clinically and pathologically, neoplasms associated with pDCs are classified as blastic plasmacytoid dendritic cell neoplasm (BPDCN), mature plasmacytoid dendritic myeloid neoplasm (MPDMN) and pDC expansion in myeloid neoplasms (MNs). BPDCN was considered a rare and aggressive neoplasm in the 2016 World Health Organization (WHO) classification. MPDMN, known as mature pDC-derived neoplasm, is closely related to MNs and was first recognized in the latest 2022 WHO classification, proposing a new concept that acute myeloid leukemia cases could show clonally expanded pDCs (pDC-AML). With the advances in detection techniques, an increasing number of pDC expansion in MNs have been reported, but whether the pathogenesis is similar to that of MPDMN remains unclear. This review focuses on patient characteristics, diagnosis and treatment of pDC expansion in MNs to gain further insight into this novel and unique provisional subtype.
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Affiliation(s)
- Juan Peng
- Department of Hematology, Tongji Hospital, Tongji Medical college, Huazhong University of Science and Technology, Wuhan 430000, Hubei, China; Immunotherapy Research Center for Hematologic Diseases of Hubei Province, Wuhan, Hubei 430030, China
| | - Shaolong He
- Department of Hematology, Tongji Hospital, Tongji Medical college, Huazhong University of Science and Technology, Wuhan 430000, Hubei, China; Department of Hematology, Shanxi Bethune Hospital, Shanxi Academy of Medical Sciences, Tongji Shanxi Hospital, Third Hospital of Shanxi Medical University, Taiyuan 030032, China
| | - Xingcheng Yang
- Department of Hematology, Tongji Hospital, Tongji Medical college, Huazhong University of Science and Technology, Wuhan 430000, Hubei, China; Immunotherapy Research Center for Hematologic Diseases of Hubei Province, Wuhan, Hubei 430030, China
| | - Liang Huang
- Department of Hematology, Tongji Hospital, Tongji Medical college, Huazhong University of Science and Technology, Wuhan 430000, Hubei, China; Immunotherapy Research Center for Hematologic Diseases of Hubei Province, Wuhan, Hubei 430030, China.
| | - Jia Wei
- Department of Hematology, Tongji Hospital, Tongji Medical college, Huazhong University of Science and Technology, Wuhan 430000, Hubei, China; Immunotherapy Research Center for Hematologic Diseases of Hubei Province, Wuhan, Hubei 430030, China; Department of Hematology, Shanxi Bethune Hospital, Shanxi Academy of Medical Sciences, Tongji Shanxi Hospital, Third Hospital of Shanxi Medical University, Taiyuan 030032, China; Sino-German Joint Oncological Research Laboratory, Shanxi Bethune Hospital, Shanxi Academy of Medical Sciences, 030032 Taiyuan, Shanxi, China.
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2
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Wirtz D, Du W, Zhu J, Wu Y, Kiemen A, Wan Z, Hanna E, Sun S. Mechano-induced homotypic patterned domain formation by monocytes. RESEARCH SQUARE 2023:rs.3.rs-3372987. [PMID: 37790337 PMCID: PMC10543314 DOI: 10.21203/rs.3.rs-3372987/v1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/05/2023]
Abstract
Matrix stiffness and corresponding mechano-signaling play indispensable roles in cellular phenotypes and functions. How tissue stiffness influences the behavior of monocytes, a major circulating leukocyte of the innate system, and how it may promote the emergence of collective cell behavior is less understood. Here, using tunable collagen-coated hydrogels of physiological stiffness, we show that human primary monocytes undergo a dynamic local phase separation to form highly regular, reversible, multicellular, multi-layered domains on soft matrix. Local activation of the β2 integrin initiates inter-cellular adhesion, while global soluble inhibitory factors maintain the steady state domain pattern over days. Patterned domain formation generated by monocytes is unique among other key immune cells, including macrophages, B cells, T cells, and NK cells. While inhibiting their phagocytic capability, domain formation promotes monocytes' survival. We develop a computational model based on the Cahn-Hilliard equation of phase separation, combined with a Turing mechanism of local activation and global inhibition suggested by our experiments, and provides experimentally validated predictions of the role of seeding density and both chemotactic and random cell migration on domain pattern formation. This work reveals that, unlike active matters, cells can generate complex cell phases by exploiting their mechanosensing abilities and combined short-range interactions and long-range signals to enhance their survival.
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Du W, Zhu J, Wu Y, Kiemen AL, Sun SX, Wirtz D. Mechano-induced homotypic patterned domain formation by monocytes. BIORXIV : THE PREPRINT SERVER FOR BIOLOGY 2023:2023.07.27.550819. [PMID: 37546904 PMCID: PMC10402173 DOI: 10.1101/2023.07.27.550819] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 08/08/2023]
Abstract
Matrix stiffness and corresponding mechano-signaling play indispensable roles in cellular phenotypes and functions. How tissue stiffness influences the behavior of monocytes, a major circulating leukocyte of the innate system, and how it may promote the emergence of collective cell behavior is less understood. Here, using tunable collagen-coated hydrogels of physiological stiffness, we show that human primary monocytes undergo a dynamic local phase separation to form highly patterned multicellular multi-layered domains on soft matrix. Local activation of the β2 integrin initiates inter-cellular adhesion, while global soluble inhibitory factors maintain the steady-state domain pattern over days. Patterned domain formation generated by monocytes is unique among other key immune cells, including macrophages, B cells, T cells, and NK cells. While inhibiting their phagocytic capability, domain formation promotes monocytes' survival. We develop a computational model based on the Cahn-Hilliard equation, which includes combined local activation and global inhibition mechanisms of intercellular adhesion suggested by our experiments, and provides experimentally validated predictions of the role of seeding density and both chemotactic and random cell migration on pattern formation.
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4
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Roussel X, Garnache Ottou F, Renosi F. Plasmacytoid Dendritic Cells, a Novel Target in Myeloid Neoplasms. Cancers (Basel) 2022; 14:cancers14143545. [PMID: 35884612 PMCID: PMC9317563 DOI: 10.3390/cancers14143545] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2022] [Revised: 07/12/2022] [Accepted: 07/18/2022] [Indexed: 02/01/2023] Open
Abstract
Plasmacytoid dendritic cells (pDC) are the main type I interferon producing cells in humans and are able to modulate innate and adaptive immune responses. Tumor infiltration by plasmacytoid dendritic cells is already well described and is associated with poor outcomes in cancers due to the tolerogenic activity of pDC. In hematological diseases, Blastic Plasmacytoid Dendritic Cells Neoplasm (BPDCN), aggressive leukemia derived from pDCs, is well described, but little is known about tumor infiltration by mature pDC described in Myeloid Neoplasms (MN). Recently, mature pDC proliferation (MPDCP) has been described as a differential diagnosis of BPDCN associated with acute myeloid leukemia (pDC-AML), myelodysplastic syndrome (pDC-MDS) and chronic myelomonocytic leukemia (pDC-CMML). Tumor cells are myeloid blasts and/or mature myeloid cells from related myeloid disorders and pDC derived from a clonal proliferation. The poor prognosis associated with MPDCP requires a better understanding of pDC biology, MN oncogenesis and immune response. This review provides a comprehensive overview about the biological aspects of pDCs, the description of pDC proliferation in MN, and an insight into putative therapies in pDC-AML regarding personalized medicine.
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Affiliation(s)
- Xavier Roussel
- INSERM, EFS BFC, UMR1098 RIGHT, University of Bourgogne Franche-Comté, 25000 Besancon, France;
- Department of Clinical Hematology, University Hospital of Besançon, 25000 Besançon, France
- Correspondence: (X.R.); (F.R.)
| | - Francine Garnache Ottou
- INSERM, EFS BFC, UMR1098 RIGHT, University of Bourgogne Franche-Comté, 25000 Besancon, France;
- Etablissement Français du Sang Bourgogne Franche-Comté, Laboratoire d’Hématologie et d’Immunologie Régional, 25020 Besançon, France
| | - Florian Renosi
- INSERM, EFS BFC, UMR1098 RIGHT, University of Bourgogne Franche-Comté, 25000 Besancon, France;
- Etablissement Français du Sang Bourgogne Franche-Comté, Laboratoire d’Hématologie et d’Immunologie Régional, 25020 Besançon, France
- Correspondence: (X.R.); (F.R.)
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5
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Mangaonkar AA, Patnaik MM. Role of the bone marrow immune microenvironment in chronic myelomonocytic leukemia pathogenesis: novel mechanisms and insights into clonal propagation. Leuk Lymphoma 2022; 63:1792-1800. [PMID: 35377828 DOI: 10.1080/10428194.2022.2056175] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Recent studies in chronic myelomonocytic leukemia (CMML) involving clonal dendritic cell (DC) aggregates and association with systemic immune dysregulation have highlighted novel and potentially targetable pathways of disease progression. CMML DC aggregates are populated by heterogeneous cell types such as CD123+ plasmacytoid dendritic cells (pDCs), CD11c + myeloid-derived DCs (mDCs), myeloid-derived suppressor cells (MDSCs), monocytes, and associate with an immune checkpoint called indoleamine 2,3-dioxygenase (IDO). Systemically, these IDO + DC aggregates are associated with immune tolerance marked by regulatory T cell expansion, likely mediated by aberrant DC-T cell interactions occurring within the bone marrow (BM) microenvironment. Somatic mutational events in CMML such as ASXL1 and NRAS mutations cooperate to induce T cell exhaustion and contribute toward disease progression to acute myeloid leukemia (AML). In this review, we explore the role of aging-induced alterations in the BM immune microenvironment, aberrant innate immune and proinflammatory signaling, and the adaptive immune system in CMML.
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Affiliation(s)
| | - Mrinal M Patnaik
- Department of Medicine, Division of Hematology, Mayo Clinic, Rochester, MN, USA
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Eisenwort G, Sadovnik I, Keller A, Ivanov D, Peter B, Berger D, Stefanzl G, Bauer K, Slavnitsch K, Greiner G, Gleixner KV, Sperr WR, Willmann M, Sill H, Bettelheim P, Geissler K, Deininger M, Rülicke T, Valent P. Phenotypic characterization of leukemia-initiating stem cells in chronic myelomonocytic leukemia. Leukemia 2021; 35:3176-3187. [PMID: 33785864 PMCID: PMC7611912 DOI: 10.1038/s41375-021-01227-z] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2020] [Revised: 02/04/2021] [Accepted: 03/11/2021] [Indexed: 12/27/2022]
Abstract
Chronic myelomonocytic leukemia (CMML) is a stem cell-derived neoplasm characterized by dysplasia, uncontrolled expansion of monocytes, and substantial risk to transform to secondary acute myeloid leukemia (sAML). So far, little is known about CMML-initiating cells. We found that leukemic stem cells (LSC) in CMML reside in a CD34+/CD38- fraction of the malignant clone. Whereas CD34+/CD38- cells engrafted NSGS mice with overt CMML, no CMML was produced by CD34+/CD38+ progenitors or the bulk of CD34- monocytes. CMML LSC invariably expressed CD33, CD117, CD123 and CD133. In a subset of patients, CMML LSC also displayed CD52, IL-1RAP and/or CLL-1. CMML LSC did not express CD25 or CD26. However, in sAML following CMML, the LSC also expressed CD25 and high levels of CD114, CD123 and IL-1RAP. No correlations between LSC phenotypes, CMML-variant, mutation-profiles, or clinical course were identified. Pre-incubation of CMML LSC with gemtuzumab-ozogamicin or venetoclax resulted in decreased growth and impaired engraftment in NSGS mice. Together, CMML LSC are CD34+/CD38- cells that express a distinct profile of surface markers and target-antigens. During progression to sAML, LSC acquire or upregulate certain cytokine receptors, including CD25, CD114 and CD123. Characterization of CMML LSC should facilitate their enrichment and the development of LSC-eradicating therapies.
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MESH Headings
- Aged
- Aged, 80 and over
- Animals
- Antigens, CD34/immunology
- Antigens, CD34/metabolism
- Apoptosis
- Case-Control Studies
- Cell Proliferation
- Female
- Humans
- Leukemia, Myeloid, Acute/etiology
- Leukemia, Myeloid, Acute/metabolism
- Leukemia, Myeloid, Acute/pathology
- Leukemia, Myelomonocytic, Chronic/complications
- Male
- Mice
- Mice, Inbred NOD
- Mice, SCID
- Middle Aged
- Neoplastic Stem Cells/drug effects
- Neoplastic Stem Cells/immunology
- Neoplastic Stem Cells/metabolism
- Neoplastic Stem Cells/pathology
- Phenotype
- Prognosis
- Tumor Cells, Cultured
- Xenograft Model Antitumor Assays
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Affiliation(s)
- Gregor Eisenwort
- Department of Medicine I, Division of Hematology and Hemostaseology, Medical University of Vienna, Vienna, Austria
- Ludwig Boltzmann Institute for Hematology and Oncology, Medical University of Vienna, Vienna, Austria
| | - Irina Sadovnik
- Department of Medicine I, Division of Hematology and Hemostaseology, Medical University of Vienna, Vienna, Austria
- Ludwig Boltzmann Institute for Hematology and Oncology, Medical University of Vienna, Vienna, Austria
| | - Alexandra Keller
- Department of Medicine I, Division of Hematology and Hemostaseology, Medical University of Vienna, Vienna, Austria
| | - Daniel Ivanov
- Department of Medicine I, Division of Hematology and Hemostaseology, Medical University of Vienna, Vienna, Austria
| | - Barbara Peter
- Department of Medicine I, Division of Hematology and Hemostaseology, Medical University of Vienna, Vienna, Austria
- Ludwig Boltzmann Institute for Hematology and Oncology, Medical University of Vienna, Vienna, Austria
| | - Daniela Berger
- Department of Medicine I, Division of Hematology and Hemostaseology, Medical University of Vienna, Vienna, Austria
- Ludwig Boltzmann Institute for Hematology and Oncology, Medical University of Vienna, Vienna, Austria
| | - Gabriele Stefanzl
- Department of Medicine I, Division of Hematology and Hemostaseology, Medical University of Vienna, Vienna, Austria
- Ludwig Boltzmann Institute for Hematology and Oncology, Medical University of Vienna, Vienna, Austria
| | - Karin Bauer
- Department of Medicine I, Division of Hematology and Hemostaseology, Medical University of Vienna, Vienna, Austria
- Ludwig Boltzmann Institute for Hematology and Oncology, Medical University of Vienna, Vienna, Austria
| | - Katharina Slavnitsch
- Ludwig Boltzmann Institute for Hematology and Oncology, Medical University of Vienna, Vienna, Austria
- Institute of Laboratory Animal Science, University of Veterinary Medicine Vienna, Vienna, Austria
| | - Georg Greiner
- Ludwig Boltzmann Institute for Hematology and Oncology, Medical University of Vienna, Vienna, Austria
- Department of Laboratory Medicine, Medical University of Vienna, Vienna, Austria
- Ihr Labor, Medical Diagnostic Laboratories, Vienna, Austria
| | - Karoline V Gleixner
- Department of Medicine I, Division of Hematology and Hemostaseology, Medical University of Vienna, Vienna, Austria
- Ludwig Boltzmann Institute for Hematology and Oncology, Medical University of Vienna, Vienna, Austria
| | - Wolfgang R Sperr
- Department of Medicine I, Division of Hematology and Hemostaseology, Medical University of Vienna, Vienna, Austria
- Ludwig Boltzmann Institute for Hematology and Oncology, Medical University of Vienna, Vienna, Austria
| | - Michael Willmann
- Ludwig Boltzmann Institute for Hematology and Oncology, Medical University of Vienna, Vienna, Austria
- Department for Companion Animals and Horses, Clinic for Internal Medicine, University of Veterinary Medicine Vienna, Vienna, Austria
| | - Heinz Sill
- Department of Internal Medicine, Division of Hematology, Medical University of Graz, Graz, Austria
| | | | - Klaus Geissler
- Medical School, Sigmund Freud University, Vienna, Austria
| | - Michael Deininger
- Division of Hematologic Malignancies, Department of Internal Medicine, University of Utah, Salt Lake City, UT, USA
| | - Thomas Rülicke
- Ludwig Boltzmann Institute for Hematology and Oncology, Medical University of Vienna, Vienna, Austria
- Institute of Laboratory Animal Science, University of Veterinary Medicine Vienna, Vienna, Austria
| | - Peter Valent
- Department of Medicine I, Division of Hematology and Hemostaseology, Medical University of Vienna, Vienna, Austria.
- Ludwig Boltzmann Institute for Hematology and Oncology, Medical University of Vienna, Vienna, Austria.
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Renneville A, Patnaik MM, Chan O, Padron E, Solary E. Increasing recognition and emerging therapies argue for dedicated clinical trials in chronic myelomonocytic leukemia. Leukemia 2021; 35:2739-2751. [PMID: 34175902 DOI: 10.1038/s41375-021-01330-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2021] [Revised: 06/11/2021] [Accepted: 06/14/2021] [Indexed: 02/06/2023]
Abstract
Chronic myelomonocytic leukemia (CMML) is a clonal hematopoietic stem cell disorder with overlapping features of myelodysplastic syndromes (MDS) and myeloproliferative neoplasms (MPN). Median overall survival of this aggressive myeloid malignancy is only 2-3 years, with a 15-30% risk of acute leukemic transformation. The paucity of clinical trials specifically designed for CMML has made therapeutic management of CMML patients challenging. As a result, treatment paradigms for CMML patients are largely borrowed from MDS and MPN. The standard of care still relies on hydroxyurea, hypomethylating agents (HMA), and allogeneic stem cell transplantation, this latter option remaining the only potentially curative therapy. To date, approved drugs for CMML treatment are HMA, including azacitidine, decitabine, and more recently the oral combination of decitabine and cedazuridine. However, HMA treatment does not meaningfully alter the natural course of this disease. New treatment approaches for improving CMML-associated cytopenias or targeting the CMML malignant clone are emerging. More than 25 therapeutic agents are currently being evaluated in phase 1 or phase 2 clinical trials for CMML and other myeloid malignancies, often in combination with a HMA backbone. Several novel agents, such as sotatercept, ruxolitinib, lenzilumab, and tagraxofusp have shown promising clinical efficacy in CMML. Current evidence supports the idea that effective treatment in CMML will likely require combination therapy targeting multiple pathways, which emphasizes the need for additional new therapeutic options. This review focuses on recent therapeutic advances and innovative treatment strategies in CMML, including global and molecularly targeted approaches. We also discuss what may help to make progress in the design of rationally derived and disease-modifying therapies for CMML.
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Affiliation(s)
| | - Mrinal M Patnaik
- Division of Hematology, Department of Internal Medicine, Mayo Clinic, Rochester, MN, USA
| | - Onyee Chan
- Department of Malignant Hematology, Moffitt Cancer Center, Tampa, FL, USA
| | - Eric Padron
- Department of Malignant Hematology, Moffitt Cancer Center, Tampa, FL, USA
| | - Eric Solary
- INSERM U1287, Gustave Roussy Cancer Campus, Villejuif, France. .,Faculty of Medicine, Université Paris-Sud, Le Kremlin-Bicêtre, France. .,Department of Hematology, Gustave Roussy Cancer Campus, Villejuif, France.
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8
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Fultang L, Gneo L, De Santo C, Mussai FJ. Targeting Amino Acid Metabolic Vulnerabilities in Myeloid Malignancies. Front Oncol 2021; 11:674720. [PMID: 34094976 PMCID: PMC8174708 DOI: 10.3389/fonc.2021.674720] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2021] [Accepted: 04/26/2021] [Indexed: 01/02/2023] Open
Abstract
Tumor cells require a higher supply of nutrients for growth and proliferation than normal cells. It is well established that metabolic reprograming in cancers for increased nutrient supply exposes a host of targetable vulnerabilities. In this article we review the documented changes in expression patterns of amino acid metabolic enzymes and transporters in myeloid malignancies and the growing list of small molecules and therapeutic strategies used to disrupt amino acid metabolic circuits within the cell. Pharmacological inhibition of amino acid metabolism is effective in inducing cell death in leukemic stem cells and primary blasts, as well as in reducing tumor burden in in vivo murine models of human disease. Thus targeting amino acid metabolism provides a host of potential translational opportunities for exploitation to improve the outcomes for patients with myeloid malignancies.
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Affiliation(s)
- Livingstone Fultang
- Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, United Kingdom
| | - Luciana Gneo
- Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, United Kingdom
| | - Carmela De Santo
- Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, United Kingdom
| | - Francis J Mussai
- Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, United Kingdom
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Laboratory Evaluation and Pathological Workup of Neoplastic Monocytosis - Chronic Myelomonocytic Leukemia and Beyond. Curr Hematol Malig Rep 2021; 16:286-303. [PMID: 33945086 DOI: 10.1007/s11899-021-00625-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/21/2021] [Indexed: 10/21/2022]
Abstract
PURPOSE OF REVIEW Monocytosis is a distinct but non-specific manifestation of various physiologic and pathologic conditions. Among hematopoietic stem cell neoplasms, depending on the criteria used for disease classification, monocytosis may be a consistent and integral component of diseases such as chronic myelomonocytic leukemia or acute myeloid leukemia with monocytic differentiation, or it may represent an inconsistent finding that often provides a clue to the underlying genetic changes driving the neoplasm. The purpose of this review is to provide the readers with a laboratory-based approach to neoplastic monocytosis. RECENT FINDINGS In-depth elucidation of the genomic landscape of myeloid neoplasms within the past few years has broadened our understanding of monocytosis and its implications for diagnosis and prognosis. Genetic findings also shed light on potential disease response - or lack thereof - to various therapeutic agents used in the setting of myeloid neoplasms. In this review, we provide our approach to diagnose neoplastic monocytosis in the context of case-based studies while incorporating the most recent literature on this topic.
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Tremblay D, Rippel N, Feld J, El Jamal SM, Mascarenhas J. Contemporary Risk Stratification and Treatment of Chronic Myelomonocytic Leukemia. Oncologist 2021; 26:406-421. [PMID: 33792103 PMCID: PMC8100553 DOI: 10.1002/onco.13769] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2021] [Accepted: 03/25/2021] [Indexed: 12/19/2022] Open
Abstract
Chronic myelomonocytic leukemia (CMML) is a hematologic malignancy characterized by absolute monocytosis, one or more lineage dysplasia, and proliferative features including myeloid hyperplasia, splenomegaly, and constitutional symptoms. Because of vast clinical heterogeneity in presentation and course, risk stratification is used for a risk-adapted treatment strategy. Numerous prognostic scoring systems exist, some of which incorporate mutational information. Treatment ranges from observation to allogeneic hematopoietic stem cell transplantation. Therapies include hydroxyurea for cytoreduction, hypomethylating agents, and the JAK1/2 inhibitor ruxolitinib to address splenomegaly and constitutional symptoms. Recently, oral decitabine with cedazuridine was approved and represents a convenient treatment option for CMML patients. Although novel therapeutics are in development for CMML, further work is needed to elucidate possible targets unique to the CMML clone. In this review, we will detail the pathophysiology, risk stratification, available treatment modalities, and novel therapies for CMML, and propose a modern treatment algorithm. IMPLICATIONS FOR PRACTICE: Chronic myelomonocytic leukemia (CMML) is a clinically heterogenous disease, which poses significant management challenges. The diagnosis of CMML requires bone marrow biopsy and aspirate with thorough evaluation. Risk stratification and symptom assessment are essential to designing an effective treatment plan, which may include hypomethylating agents (HMAs) in intermediate or high-risk patients. The recently approved oral decitabine/cedazuridine provides a convenient alternative to parenteral HMAs. Ruxolitinib may be effective in ameliorating proliferative symptoms and splenomegaly. Allogeneic stem cell transplantation remains the only treatment with curative potential; however, novel therapies are in clinical development which may significantly alter the therapeutic landscape of CMML.
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Affiliation(s)
- Douglas Tremblay
- Tisch Cancer Institute, Icahn School of Medicine at Mount SinaiNew YorkNew YorkUSA
| | - Noa Rippel
- Department of Medicine, Icahn School of Medicine at Mount SinaiNew YorkNew YorkUSA
| | - Jonathan Feld
- Tisch Cancer Institute, Icahn School of Medicine at Mount SinaiNew YorkNew YorkUSA
| | - Siraj M. El Jamal
- Department of Pathology, Molecular and Cell‐Based Medicine, Icahn School of Medicine at Mount SinaiNew YorkNew YorkUSA
| | - John Mascarenhas
- Tisch Cancer Institute, Icahn School of Medicine at Mount SinaiNew YorkNew YorkUSA
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11
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Mangaonkar AA, Tande AJ, Bekele DI. Differential Diagnosis and Workup of Monocytosis: A Systematic Approach to a Common Hematologic Finding. Curr Hematol Malig Rep 2021; 16:267-275. [PMID: 33880680 PMCID: PMC8057007 DOI: 10.1007/s11899-021-00618-4] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/23/2021] [Indexed: 12/19/2022]
Abstract
Purpose of Review Monocytosis is a frequently encountered clinical condition that needs appropriate investigation due to a broad range of differential diagnoses. This review is meant to summarize the latest literature in the diagnostic testing and interpretation and offer a stepwise diagnostic approach for a patient presenting with monocytosis. Recent Findings Basic studies have highlighted the phenotypic and functional heterogeneity in the monocyte compartment. Studies, both translational and clinical, have provided insights into why monocytosis occurs and how to distinguish the different etiologies. Flow cytometry studies have illustrated that monocyte repartitioning can distinguish chronic myelomonocytic leukemia, a prototypical neoplasm with monocytosis from other reactive or neoplastic causes. Summary In summary, we provide an algorithmic approach to the diagnosis of a patient presenting with monocytosis and expect this document to serve as a reference guide for clinicians.
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Affiliation(s)
| | - Aaron J Tande
- Division of Infectious Diseases, Mayo Clinic, Rochester, MN, USA
| | - Delamo I Bekele
- Division of Rheumatology, Department of Medicine, Mayo Clinic, Rochester, MN, USA
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12
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Lasho T, Patnaik MM. Novel therapeutic targets for chronic myelomonocytic leukemia. Best Pract Res Clin Haematol 2021; 34:101244. [PMID: 33762099 DOI: 10.1016/j.beha.2021.101244] [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
Chronic myelomonocytic leukemia (CMML) is a rare, age-related myeloid neoplasm with overlapping features of myelodysplastic syndromes/myeloproliferative neoplasms. Although gene mutations involving TET2, ASXL1 and SRSF2 are common, there are no specific molecular alterations that define the disease. Allogeneic stem cell transplant is the only curative option, with most patients not qualifying, due to advanced age at diagnosis and comorbidities. The only approved treatment options are hypomethylating agents; drugs that fail to alter the disease course or affect mutant allele burdens. Clinically CMML can be sub-classified into proliferative (pCMML) and dysplastic (dCMML) subtypes, with pCMML being associated with signaling mutations, myeloproliferative features, and a shorter overall survival. Given the paucity of effective treatment strategies there is a need for rationally informed and biomarker driven studies. This report will discuss current and prospective therapies for CMML and discuss the role for personalized therapeutics.
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Affiliation(s)
- Terra Lasho
- Division of Hematology, Department of Internal Medicine, Mayo Clinic, Rochester, MN, USA
| | - Mrinal M Patnaik
- Division of Hematology, Department of Internal Medicine, Mayo Clinic, Rochester, MN, USA.
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13
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McCullough KB, Kuhn AK, Patnaik MM. Treatment advances for pediatric and adult onset neoplasms with monocytosis. Curr Hematol Malig Rep 2021; 16:256-266. [PMID: 33728588 DOI: 10.1007/s11899-021-00622-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/03/2021] [Indexed: 10/21/2022]
Abstract
PURPOSE OF REVIEW For decades, the management of chronic myelomonocytic leukemia (CMML) or juvenile myelomonocytic leukemia (JMML) has been largely inextricable from myelodysplastic syndromes (MDS), myeloproliferative neoplasms, and acute myeloid leukemia. Hallmarks of these diseases have been the emergence of unique genomic signatures and discouraging responses to available therapies. Here, we will critically examine the current options for management and review the rapidly developing opportunities based on advances in CMML and JMML disease biology. RECENT FINDINGS Few clinical trials have exclusively been done in CMML, and in JMML, the rarity of the disease limits wide scale participation. Recent case series in JMML suggest that hypomethylating agents (HMAs) are a viable option for bridging to curative intent with allogeneic hematopoietic stem cell transplant or as posttransplant maintenance. Emerging evidence has demonstrated targeting the RAS-pathway via MEK inhibition may also be considered. In CMML, treatment with HMAs is largely derived from data inclusive of MDS patients, including a small number of patients with dysplastic CMML variants. Based on CMML disease biology, additional therapeutic targets being investigated include inhibitors of splicing, CD123/dendritic cell axis, inherent GM-CSF progenitor cell hypersensitivity, and targeting the JAK/STAT pathway. Current evidence is also expanding for oral HMAs. The management of CMML and JMML is rapidly evolving and clinicians must be aware of the genetic landscape and expanding treatment options to ensure these rare populations are afforded therapeutic interventions best suited to their needs.
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Affiliation(s)
- Kristen B McCullough
- Department of Pharmacy Services, Mayo Clinic, 200 1st Street SW, Rochester, MN, 55905, USA.
| | - Alexis K Kuhn
- Department of Pharmacy Services, Mayo Clinic, 200 1st Street SW, Rochester, MN, 55905, USA
| | - Mrinal M Patnaik
- Division of Hematology, Department of Medicine, Mayo Clinic, Rochester, MN, USA
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Hasserjian RP, Buckstein R, Patnaik MM. Navigating Myelodysplastic and Myelodysplastic/Myeloproliferative Overlap Syndromes. Am Soc Clin Oncol Educ Book 2021; 41:328-350. [PMID: 34010050 DOI: 10.1200/edbk_320113] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Myelodysplastic syndromes (MDS) and MDS/myeloproliferative neoplasms (MPNs) are clonal diseases that differ in morphologic diagnostic criteria but share some common disease phenotypes that include cytopenias, propensity to acute myeloid leukemia evolution, and a substantially shortened patient survival. MDS/MPNs share many clinical and molecular features with MDS, including frequent mutations involving epigenetic modifier and/or spliceosome genes. Although the current 2016 World Health Organization classification incorporates some genetic features in its diagnostic criteria for MDS and MDS/MPNs, recent accumulation of data has underscored the importance of the mutation profiles on both disease classification and prognosis. Machine-learning algorithms have identified distinct molecular genetic signatures that help refine prognosis and notable associations of these genetic signatures with morphologic and clinical features. Combined geno-clinical models that incorporate mutation data seem to surpass the current prognostic schemes. Future MDS classification and prognostication schema will be based on the portfolio of genetic aberrations and traditional features, such as blast count and clinical factors. Arriving at these systems will require studies on large patient cohorts that incorporate advanced computational analysis. The current treatment algorithm in MDS is based on patient risk as derived from existing prognostic and disease classes. Luspatercept is newly approved for patients with MDS and ring sideroblasts who are transfusion dependent after erythropoietic-stimulating agent failure. Other agents that address red blood cell transfusion dependence in patients with lower-risk MDS and the failure of hypomethylating agents in higher-risk disease are in advanced testing. Finally, a plethora of novel targeted agents and immune checkpoint inhibitors are being evaluated in combination with a hypomethylating agent backbone to augment the depth and duration of response and, we hope, improve overall survival.
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Affiliation(s)
| | - Rena Buckstein
- Division of Hematology/Oncology, Sunnybrook Odette Cancer Center, Toronto, Ontario, Canada
| | - Mrinal M Patnaik
- Division of Hematology, Department of Internal Medicine, Mayo Clinic, MN
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