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Szuber N, Orazi A, Tefferi A. Chronic neutrophilic leukemia and atypical chronic myeloid leukemia: 2024 update on diagnosis, genetics, risk stratification, and management. Am J Hematol 2024; 99:1360-1387. [PMID: 38644693 DOI: 10.1002/ajh.27321] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2024] [Accepted: 03/18/2024] [Indexed: 04/23/2024]
Abstract
Chronic neutrophilic leukemia (CNL) is a rare BCR::ABL1-negative myeloproliferative neoplasm (MPN) defined by persistent mature neutrophilic leukocytosis and bone marrow granulocyte hyperplasia. Atypical chronic myeloid leukemia (aCML) (myelodysplastic "[MDS]/MPN with neutrophilia" per World Health Organization [WHO]) is a MDS/MPN overlap disorder featuring dysplastic neutrophilia and circulating myeloid precursors. Both manifest with frequent hepatosplenomegaly and less commonly, bleeding, with high rates of leukemic transformation and death. The 2022 revised WHO classification conserved CNL diagnostic criteria of leukocytosis ≥25 × 109/L, neutrophils ≥80% with <10% circulating precursors, absence of dysplasia, and presence of an activating CSF3R mutation. ICC criteria are harmonized with those of other myeloid entities, with a key distinction being lower leukocytosis threshold (≥13 × 109/L) for cases CSF3R-mutated. Criteria for aCML include leukocytosis ≥13 × 109/L, dysgranulopoiesis, circulating myeloid precursors ≥10%, and at least one cytopenia for MDS-thresholds (ICC). In both classifications ASXL1 and SETBP1 (ICC), or SETBP1 ± ETNK1 (WHO) mutations can be used to support the diagnosis. Both diseases show hypercellular bone marrow due to a granulocytic proliferation, aCML distinguished by dysplasia in granulocytes ± other lineages. Absence of monocytosis, rare/no basophilia, or eosinophilia, <20% blasts, and exclusion of other MPN, MDS/MPN, and tyrosine kinase fusions, are mandated. Cytogenetic abnormalities are identified in ~1/3 of CNL and ~15-40% of aCML patients. The molecular signature of CNL is a driver mutation in colony-stimulating factor 3 receptor-classically T618I, documented in >80% of cases. Atypical CML harbors a complex genomic backdrop with high rates of recurrent somatic mutations in ASXL1, SETBP1, TET2, SRSF2, EZH2, and less frequently in ETNK1. Leukemic transformation rates are ~10-25% and 30-40% for CNL and aCML, respectively. Overall survival is poor: 15-31 months in CNL and 12-20 months in aCML. The Mayo Clinic CNL risk model for survival stratifies patients according to platelets <160 × 109/L (2 points), leukocytes >60 × 109/L (1 point), and ASXL1 mutation (1 point); distinguishing low- (0-1 points) versus high-risk (2-4 points) categories. The Mayo Clinic aCML risk model attributes 1 point each for: age >67 years, hemoglobin <10 g/dL, and TET2 mutation, delineating low- (0-1 risk factor) and high-risk (≥2 risk factors) subgroups. Management is risk-driven and symptom-directed, with no current standard of care. Most commonly used agents include hydroxyurea, interferon, Janus kinase inhibitors, and hypomethylating agents, though none are disease-modifying. Hematopoietic stem cell transplant is the only potentially curative modality and should be considered in eligible patients. Recent genetic profiling has disclosed CBL, CEBPA, EZH2, NRAS, TET2, and U2AF1 to represent high-risk mutations in both entities. Actionable mutations (NRAS/KRAS, ETNK1) have also been identified, supporting novel agents targeting involved pathways. Preclinical and clinical studies evaluating new drugs (e.g., fedratinib, phase 2) and combinations are detailed.
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MESH Headings
- Humans
- Leukemia, Neutrophilic, Chronic/genetics
- Leukemia, Neutrophilic, Chronic/diagnosis
- Leukemia, Neutrophilic, Chronic/therapy
- Leukemia, Myeloid, Chronic, Atypical, BCR-ABL Negative/genetics
- Leukemia, Myeloid, Chronic, Atypical, BCR-ABL Negative/diagnosis
- Leukemia, Myeloid, Chronic, Atypical, BCR-ABL Negative/therapy
- Mutation
- Risk Assessment
- Receptors, Colony-Stimulating Factor/genetics
- Carrier Proteins
- Nuclear Proteins
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Affiliation(s)
- Natasha Szuber
- Department of Hematology, Maisonneuve-Rosemont Hospital, Montreal, Quebec, Canada
| | - Attilio Orazi
- Department of Pathology, Texas Tech University Health Sciences Center, El Paso, Texas, USA
| | - Ayalew Tefferi
- Department of Internal Medicine, Division of Hematology, Mayo Clinic, Rochester, Minnesota, USA
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Willekens C, Chahine C, Dragani M, Khalife‐Hachem S, Bigenwald C, Rossignol J, Castilla‐Llorente C, Danu A, Michot J, Saada V, Cotteret S, Marzac C, Renneville A, Plo I, Broutin S, Bosselut N, Cassinat B, Lazarovici J, Droin N, De Botton S. When monoclonal gammopathy-associated chronic neutrophilic leukemia is a reactive process distinct from a clonal myeloproliferative neoplasm: Lessons from mistakes. EJHAEM 2023; 4:823-826. [PMID: 37601857 PMCID: PMC10435719 DOI: 10.1002/jha2.713] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/21/2023] [Revised: 05/10/2023] [Accepted: 05/10/2023] [Indexed: 08/22/2023]
Affiliation(s)
- Christophe Willekens
- Département d'HématologieGustave RoussyUniversité Paris‐SaclayVillejuifFrance
- Inserm U1287Gustave RoussyUniversité Paris‐SaclayVillejuifFrance
| | - Claude Chahine
- Département d'HématologieGustave RoussyUniversité Paris‐SaclayVillejuifFrance
| | - Matteo Dragani
- Département d'HématologieGustave RoussyUniversité Paris‐SaclayVillejuifFrance
| | | | - Camille Bigenwald
- Département d'HématologieGustave RoussyUniversité Paris‐SaclayVillejuifFrance
| | - Julien Rossignol
- Département d'HématologieGustave RoussyUniversité Paris‐SaclayVillejuifFrance
| | | | - Alina Danu
- Département d'HématologieGustave RoussyUniversité Paris‐SaclayVillejuifFrance
| | - Jean‐Marie Michot
- Département d'Innovation Thérapeutique et d'Essais PrécocesGustave RoussyUniversité Paris‐SaclayVillejuifFrance
| | - Veronique Saada
- Département de Biologie et Pathologie MédicalesGustave RoussyUniversité Paris‐SaclayVillejuifFrance
| | - Sophie Cotteret
- Département de Biologie et Pathologie MédicalesGustave RoussyUniversité Paris‐SaclayVillejuifFrance
| | - Christophe Marzac
- Département de Biologie et Pathologie MédicalesGustave RoussyUniversité Paris‐SaclayVillejuifFrance
| | - Aline Renneville
- Inserm U1287Gustave RoussyUniversité Paris‐SaclayVillejuifFrance
- Département de Biologie et Pathologie MédicalesGustave RoussyUniversité Paris‐SaclayVillejuifFrance
| | - Isabelle Plo
- Inserm U1287Gustave RoussyUniversité Paris‐SaclayVillejuifFrance
| | - Sophie Broutin
- Département de Biologie et Pathologie MédicalesGustave RoussyUniversité Paris‐SaclayVillejuifFrance
| | - Nelly Bosselut
- AP‐HPHôpital Saint‐Louis, Service de Biologie CellulaireParisFrance
| | - Bruno Cassinat
- AP‐HPHôpital Saint‐Louis, Service de Biologie CellulaireParisFrance
| | - Julien Lazarovici
- Département d'HématologieGustave RoussyUniversité Paris‐SaclayVillejuifFrance
| | - Nathalie Droin
- Inserm U1287Gustave RoussyUniversité Paris‐SaclayVillejuifFrance
| | - Stephane De Botton
- Département d'HématologieGustave RoussyUniversité Paris‐SaclayVillejuifFrance
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A case of plasma cell neoplasm-associated chronic neutrophilic leukemia with ASXL1 and JAK2V617F mutations. Ann Hematol 2022; 101:1879-1881. [PMID: 35419626 DOI: 10.1007/s00277-022-04834-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2021] [Accepted: 01/20/2022] [Indexed: 11/01/2022]
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Szuber N, Elliott M, Tefferi A. Chronic neutrophilic leukemia: 2022 update on diagnosis, genomic landscape, prognosis, and management. Am J Hematol 2022; 97:491-505. [PMID: 35089603 DOI: 10.1002/ajh.26481] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2022] [Accepted: 01/26/2022] [Indexed: 11/09/2022]
Abstract
DISEASE OVERVIEW Chronic neutrophilic leukemia (CNL) is a rare, often aggressive myeloproliferative neoplasm (MPN) defined by persistent mature neutrophilic leukocytosis, bone marrow granulocyte hyperplasia, and frequent hepatosplenomegaly. The 2013 seminal discovery of oncogenic driver mutations in colony-stimulating factor 3 receptor (CSF3R) in the majority of patients with CNL not only established its molecular pathogenesis but provided a diagnostic biomarker and rationale for pharmacological targeting. DIAGNOSIS In 2016, the World Health Organization (WHO) recognized activating CSF3R mutations as a central diagnostic feature of CNL. Other criteria include leukocytosis of ≥25 × 109 /L comprising >80% neutrophils with <10% circulating precursors and rare blasts, and absence of dysplasia or monocytosis, while not fulfilling criteria for other MPN. MANAGEMENT There is currently no standard of care for management of CNL, due in large part to the rarity of disease and dearth of formal clinical trials. Most commonly used therapeutic agents include conventional oral chemotherapy (e.g., hydroxyurea), interferon, and Janus kinase (JAK) inhibitors, while hematopoietic stem cell transplant remains the only potentially curative modality. DISEASE UPDATES Increasingly comprehensive genetic profiling in CNL, including new data on clonal evolution, has disclosed a complex genomic landscape with additional mutations and combinations thereof driving disease progression and drug resistance. Although accurate prognostic stratification and therapeutic decision-making remain challenging in CNL, emerging data on molecular biomarkers and the addition of newer agents, such as JAK inhibitors, to the therapeutic arsenal, are paving the way toward greater standardization and improvement of patient care.
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Affiliation(s)
- Natasha Szuber
- Department of Hematology Maisonneuve‐Rosemont Hospital Montreal Quebec Canada
| | - Michelle Elliott
- Division of Hematology, Department of Internal Medicine Mayo Clinic Rochester Minnesota USA
| | - Ayalew Tefferi
- Division of Hematology, Department of Internal Medicine Mayo Clinic Rochester Minnesota USA
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Gao JP, Zhai LJ, Gao XH, Min FL. Chronic neutrophilic leukemia complicated with monoclonal gammopathy of undetermined significance: A case report and literature review. J Clin Lab Anal 2022; 36:e24287. [PMID: 35170077 PMCID: PMC8993655 DOI: 10.1002/jcla.24287] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2021] [Revised: 01/31/2022] [Accepted: 02/01/2022] [Indexed: 12/27/2022] Open
Abstract
BACKGROUND Study of the molecular biological characteristics of chronic neutrophilic leukemia complicated with plasma cell disorder (CNL-PCD) and lymphocytic proliferative disease (CNL-LPD). METHODS The clinical data of a patient with chronic neutrophilic leukemia complicated with monoclonal gammopathy of undetermined significance (CNL-MGUS) in our hospital were reviewed, and the Chinese and/or English literature about CNL-PCD and CNL-LPD in PubMed and the Chinese database CNKI in the past 10 years was searched to analyze the molecular biological characteristics of this disease. RESULTS A 73-year-old male had persistent leukocytosis for 18 months. The white blood cell count was 46.77 × 109/L and primarily composed of mature neutrophils; hemoglobin: 77 g/L; platelet count: 189 × 109/L. Serum immunofixation electrophoresis showed IgG-λ monoclonal M protein. A CT scan showed splenomegaly. Next-generation sequencing (NGS) showed that CSF3R T618I, ASXL1 and RUNX1 mutations were positive. It was diagnosed as CNL-MGUS. We summarized 10 cases of CNL-PCD and 1 case of CNL-LPD who underwent genetic mutation detection reported in the literature. The CSF3R mutational frequency (7/11, 63.6%) was lower than that of isolated CNL. The ASXL1 mutations were all positive (3/3), which may represent a poor prognostic factor. The SETBP1 mutation may promote the progression of CNL-PCD. We also found JAK2, RUNX1, NRAS, etc. in CNL-PCD. CONCLUSIONS Chronic neutrophilic leukemia may be more inclined to coexist with plasma cell disorder. The CSF3R mutation in CNL-PCD is still the most common mutated gene compared with isolated CNL. Mutations in SETBP1 and ASXL1 may be poor prognostic factors for CNL-PCD.
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Affiliation(s)
- Jia-Pei Gao
- Department of Hematology, Affiliated Hospital of Yangzhou University, Yangzhou University, Yangzhou, China
| | - Li-Jia Zhai
- Department of Hematology, Affiliated Hospital of Yangzhou University, Yangzhou University, Yangzhou, China
| | - Xiao-Hui Gao
- Department of Hematology, Affiliated Hospital of Yangzhou University, Yangzhou University, Yangzhou, China
| | - Feng-Ling Min
- Department of Hematology, Affiliated Hospital of Yangzhou University, Yangzhou University, Yangzhou, China
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Han Q, Tao L, Jiang X, Chen H, Liu C, Sun M. An atypical chronic neutrophilic leukemia patient harboring ASXL1 and NRAS mutations associated with monoclonal plasma cell dyscrasia presenting as hemopericardium. Ann Hematol 2020; 100:273-275. [PMID: 32052135 DOI: 10.1007/s00277-020-03961-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2020] [Accepted: 02/06/2020] [Indexed: 10/25/2022]
Affiliation(s)
- Qiaoyan Han
- Department of Haematology, Jingjiang People's Hospital, the Seventh Affiliated Hospital of Yangzhou University, 28 East Zhongzhou Road, Jingjiang, 214500, Jiangsu Province, China
| | - Lan Tao
- Department of Haematology, Jingjiang People's Hospital, the Seventh Affiliated Hospital of Yangzhou University, 28 East Zhongzhou Road, Jingjiang, 214500, Jiangsu Province, China
| | - Xin Jiang
- Department of Haematology, Jingjiang People's Hospital, the Seventh Affiliated Hospital of Yangzhou University, 28 East Zhongzhou Road, Jingjiang, 214500, Jiangsu Province, China
| | - Haoyue Chen
- Department of Haematology, Jingjiang People's Hospital, the Seventh Affiliated Hospital of Yangzhou University, 28 East Zhongzhou Road, Jingjiang, 214500, Jiangsu Province, China
| | - Chunhua Liu
- Department of Haematology, Jingjiang People's Hospital, the Seventh Affiliated Hospital of Yangzhou University, 28 East Zhongzhou Road, Jingjiang, 214500, Jiangsu Province, China
| | - Miao Sun
- Department of Haematology, Jingjiang People's Hospital, the Seventh Affiliated Hospital of Yangzhou University, 28 East Zhongzhou Road, Jingjiang, 214500, Jiangsu Province, China.
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Szuber N, Elliott M, Tefferi A. Chronic neutrophilic leukemia: 2020 update on diagnosis, molecular genetics, prognosis, and management. Am J Hematol 2020; 95:212-224. [PMID: 31769070 DOI: 10.1002/ajh.25688] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2019] [Accepted: 11/22/2019] [Indexed: 12/14/2022]
Abstract
DISEASE OVERVIEW Chronic neutrophilic leukemia (CNL) is a rare, often aggressive myeloproliferative neoplasm (MPN) defined by persistent mature neutrophilic leukocytosis, bone marrow granulocyte hyperplasia, and frequent hepatosplenomegaly. The seminal discovery of oncogenic driver mutations in colony-stimulating factor 3 receptor (CSF3R) in the majority of patients with CNL in 2013 anchored a new scientific framework, deepening our understanding of its molecular pathogenesis, providing a diagnostic biomarker, and rationalizing the use of pharmacological targeting. DIAGNOSTIC CRITERIA In 2016, the World Health Organization (WHO) included the presence of activating CSF3R mutations as a central diagnostic feature of CNL. Other criteria include leukocytosis of ≥25 × 109 /L comprising >80% neutrophils with <10% circulating precursors and rare blasts, and absence of dysplasia or monocytosis, while not fulfilling criteria for other MPN. DISEASE UPDATES Increasingly comprehensive genetic profiling of CNL has disclosed a complex genomic landscape and additional prognostically relevant mutational combinations. Though prognostic determination and therapeutic decision-making remain challenging, emerging data on prognostic markers and the use of newer therapeutic agents, such as JAK inhibitors, are helping to define state-of-the-art management in CNL.
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Affiliation(s)
- Natasha Szuber
- Department of HematologyMaisonneuve‐Rosemont Hospital Montreal Quebec Canada
| | - Michelle Elliott
- Department of Internal Medicine, Division of HematologyMayo Clinic Rochester Minnesota
| | - Ayalew Tefferi
- Department of Internal Medicine, Division of HematologyMayo Clinic Rochester Minnesota
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Haefliger S, Juskevicius D, Höller S, Buser U, Dirnhofer S, Tzankov A. How to resolve a clinical and molecular puzzle: concomitant monoclonal gammopathy of undetermined significance (MGUS) with neutrophilia and clonal hematopoiesis of indeterminate potential (CHIP). Ann Hematol 2019; 98:2431-2432. [PMID: 31432215 DOI: 10.1007/s00277-019-03786-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2019] [Accepted: 08/14/2019] [Indexed: 11/27/2022]
Affiliation(s)
- Simon Haefliger
- Institute of Pathology, University of Basel, University Hospital Basel, Schönbeinstrasse 40, CH 4031, Basel, Switzerland
| | - Darius Juskevicius
- Institute of Pathology, University of Basel, University Hospital Basel, Schönbeinstrasse 40, CH 4031, Basel, Switzerland
| | - Sylvia Höller
- Institute of Pathology, University of Basel, University Hospital Basel, Schönbeinstrasse 40, CH 4031, Basel, Switzerland
| | - Ulrich Buser
- Institute of Pathology, University of Basel, University Hospital Basel, Schönbeinstrasse 40, CH 4031, Basel, Switzerland
| | - Stefan Dirnhofer
- Institute of Pathology, University of Basel, University Hospital Basel, Schönbeinstrasse 40, CH 4031, Basel, Switzerland
| | - Alexandar Tzankov
- Institute of Pathology, University of Basel, University Hospital Basel, Schönbeinstrasse 40, CH 4031, Basel, Switzerland.
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Dao KHT, Tyner JW, Gotlib J. Recent Progress in Chronic Neutrophilic Leukemia and Atypical Chronic Myeloid Leukemia. Curr Hematol Malig Rep 2018; 12:432-441. [PMID: 28983816 DOI: 10.1007/s11899-017-0413-y] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
PURPOSE OF REVIEW We reviewed recent diagnostic and therapeutic progress in chronic neutrophilic leukemia (CNL) and atypical chronic myeloid leukemia (aCML). We summarized recent genetic data that may guide future efforts towards implementing risk-adapted therapy based on mutational profile and improving disease control and survival of affected patients. RECENT FINDINGS Recent genetic data in CNL and aCML prompted modifications to the World Health Organization (WHO) diagnostic criteria, which have improved our understanding of how CNL and aCML are different diseases despite sharing common findings of peripheral granulocytosis and marrow myeloid hyperplasia. The overlap of recurrently mutated genes between aCML and CMML support considering CSF3R-T618I mutated cases as a distinct entity, either as CNL or CNL with dysplasia. Ongoing preclinical and clinical studies will help to further inform the therapeutic approach to these diseases. Our understanding of CNL and aCML has greatly advanced over the last few years. This will improve clarity for the diagnosis of these diseases, provide a strategy for risk stratification, and guide risk-adapted therapy.
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Affiliation(s)
- Kim-Hien T Dao
- Knight Cancer Institute, Hematology and Medical Oncology, Oregon Health & Science University, Portland, OR, USA.
| | - Jeffrey W Tyner
- Knight Cancer Institute, Department of Cell, Developmental and Cancer Biology, Oregon Health and Science University, Portland, OR, USA
| | - Jason Gotlib
- Stanford Cancer Institute, Stanford University, Stanford, CA, USA
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Szuber N, Tefferi A. Chronic neutrophilic leukemia: new science and new diagnostic criteria. Blood Cancer J 2018; 8:19. [PMID: 29440636 PMCID: PMC5811432 DOI: 10.1038/s41408-018-0049-8] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2017] [Revised: 12/01/2017] [Accepted: 12/11/2017] [Indexed: 12/12/2022] Open
Abstract
Chronic neutrophilic leukemia (CNL) is a distinct myeloproliferative neoplasm defined by persistent, predominantly mature neutrophil proliferation, marrow granulocyte hyperplasia, and frequent splenomegaly. The seminal discovery of oncogenic driver mutations in CSF3R in the majority of patients with CNL in 2013 generated a new scientific framework for this disease as it deepened our understanding of its molecular pathogenesis, provided a biomarker for diagnosis, and rationalized management using novel targeted therapies. Consequently, in 2016, the World Health Organization (WHO) revised the diagnostic criteria for CNL to reflect such changes in its genomic landscape, now including the presence of disease-defining activating CSF3R mutations as a key diagnostic component of CNL. In this communication, we provide a background on the history of CNL, its clinical and hemopathologic features, and its molecular anatomy, including relevant additional genetic lesions and their significance. We also outline the recently updated WHO diagnostic criteria for CNL. Further, the natural history of the disease is reviewed as well as potential prognostic variables. Finally, we summarize and discuss current treatment options as well as prospective novel therapeutic targets in hopes that they will yield meaningful improvements in patient management and outcomes.
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Affiliation(s)
- Natasha Szuber
- Department of Internal Medicine, Division of Hematology, Mayo Clinic, Rochester, Minnesota, USA
| | - Ayalew Tefferi
- Department of Internal Medicine, Division of Hematology, Mayo Clinic, Rochester, Minnesota, USA.
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11
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Mark TM, Pekle K. Clonal plasma cells keep strange company. Leuk Lymphoma 2016; 57:744-5. [PMID: 26727550 DOI: 10.3109/10428194.2015.1106539] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Affiliation(s)
- Tomer M Mark
- a Division of Hematology and Oncology , Weill Cornell Medical College , New York , NY , USA
| | - Karen Pekle
- a Division of Hematology and Oncology , Weill Cornell Medical College , New York , NY , USA
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