1
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Jilg S, Schwaab J, Sockel K, Crodel CC, Brueckl V, Stegelmann F, Jentzsch M, Sasca D, Moyses M, Fuhrmann S, Gundel D, Caduc M, Teichmann LL, Heidel F, Al-Ali HK, Petrides PE. MoReLife - real-life data support the potential of momelotinib as a safe and effective treatment option for cytopenic myelofibrosis patients. Ann Hematol 2024:10.1007/s00277-024-05908-4. [PMID: 39073589 DOI: 10.1007/s00277-024-05908-4] [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: 05/20/2024] [Accepted: 07/19/2024] [Indexed: 07/30/2024]
Abstract
Recurrent problems of patients with myelofibrosis (MF) are cytopenias, debiliating disease-related symptoms and splenomegaly. Whereas the latter are usually addressed by the JAK1/2 inhibitors ruxolitinib and fedratinib, cytopenias often remain critical. Momelotinib, a JAK1/2 inhibitor recently approved for the treatment of anemic MF patients, was shown to improve anemia via a direct inhibition of activin A receptor type I. In this German-wide, multicenter, retrospective analysis the safety and efficacy profile of momelotinib was evaluated in a real world setting within a cohort of 60 MF patients independent of pre-treatment. The median duration of treatment was 12 weeks. As a new, but manageable safety finding, creatinine increase (CTC°1-2) was detected in 10/60 patients (17%). Interestingly, not only hemoglobin levels increased in 84% of patients, but also platelet values (67%). In the cohort of transfusion-dependent individuals (n = 38), transfusion requirement improved in 15 patients (39%) with 8 reaching transfusion independency (21%). Transfusion independency was achieved within a median of 4 weeks (range 2-12). Spleen size decreased in 13/53 individuals (25%) with a median response time of 6 weeks. Thereof, 11 patients had been pre-treated with JAK inhibitor(s) (85%). Clinical improvement was detected in 24/51 symptomatic individuals (47%) with a median response time of 4 weeks. 5 patients stopped treatment due to side effects (8%), 6 patients due to a worsening of clinical symptoms (10%). Taken together, the MoReLife analysis identifies momelotinib as potent and safe therapeutic option also for heavily pre-treated cytopenic MF patients under real world conditions.
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Affiliation(s)
- Stefanie Jilg
- Onkologie Erding, Bajuwarenstr.3, Erding, Germany.
- Department of Medicine III, Klinikum rechts der Isar, Technische Universität München, Munich, Germany.
| | - Juliana Schwaab
- Department of Hematology and Oncology, University Hospital Mannheim, Mannheim, Germany
| | - Katja Sockel
- Medical Clinic and Policlinic I, University Hospital Dresden, TU Dresden, Dresden, Germany
| | - Carl C Crodel
- Abteilung Hämatologie und Internistische Onkologie, Klinik für Innere Medizin II, Universitätsklinikum Jena, Jena, Germany
| | - Valeska Brueckl
- Department of Hematology and Oncology, University Hospital Erlangen, Friedrich- Alexander-University Erlangen-Nürnberg, Erlangen, Germany
| | - Frank Stegelmann
- Department of Internal Medicine III, University Hospital of Ulm, Ulm, Germany
| | - Madlen Jentzsch
- Medizinische Klinik I - Hämatologie, Hämostaseologie und Infektiologie, Zelltherapie, Leipzig, Germany
| | - Daniel Sasca
- Department of Hematology, Oncology and Pneumology, University Medical Center Mainz, Mainz, Germany
| | - Margarete Moyses
- Department of Internal Medicine II, Medical University Hospital, Tübingen, Germany
| | | | - Daniel Gundel
- Hämatologisch-Onkologische Praxis Würzburg, Würzburg, Germany
| | - Madlen Caduc
- Department of Hematology, Oncology, Hemostaseology, and Stem Cell Transplantation, Faculty of Medicine, RWTH Aachen University, Aachen, Germany
- Center for Integrated Oncology, Aachen Bonn Cologne Düsseldorf (CIO ABCD), Aachen, Germany
| | - Lino L Teichmann
- Department of Medicine III, University Hospital Bonn, Bonn, Germany
| | - Florian Heidel
- Hematology, Hemostasis, Oncology and Stem Cell Transplantation, Hannover Medical School (MHH), Hannover, Germany
| | - Haifa K Al-Ali
- Krukenberg Cancer Center, University Hospital of Halle, Halle, Germany
| | - Petro E Petrides
- Hematology Oncology Center Munich, Munich, Germany
- Ludwig Maximilians University Munich, Munich, Germany
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2
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Aguirre LE, Jain A, Ball S, Ali NA, Volpe VO, Tinsley-Vance S, Sallman D, Sweet K, Lancet J, Padron E, Yun S, Kuykendall A, Komrokji R. Triple-Negative Myelofibrosis: Disease Features, Response to Treatment and Outcomes. CLINICAL LYMPHOMA, MYELOMA & LEUKEMIA 2024; 24:459-467. [PMID: 38548563 DOI: 10.1016/j.clml.2024.03.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/21/2024] [Revised: 03/06/2024] [Accepted: 03/06/2024] [Indexed: 06/22/2024]
Abstract
BACKGROUND Myelofibrosis is the most aggressive subtype among classical BCR::ABL1 negative myeloproliferative neoplasms. About 90% of cases are driven by constitutive activation of 1 of 3 genes impacting the JAK/STAT pathway: JAK2, CALR, and MPL. Triple-negative myelofibrosis (TN-MF) accounts for only 5%-10% of cases and carries the worst outcomes. Little has been described about this subset of disease. Given the marked heterogeneity surrounding disease biology, clonal architecture, clinical presentation, and poor outcomes in TN-MF, identification of features of interest and assessment of treatment response are areas in need of further investigation. PATIENTS AND METHODS We collected and evaluated baseline clinical and molecular parameters from 626 patients with a diagnosis of myelofibrosis who presented to the H. Lee Moffitt Cancer Center in Tampa (Florida, US) between 2003 and 2021 and compared them based on presence or absence of the three classical phenotypic driver mutations. RESULTS A small proportion of patients (6%) harbored TN-MF which correlated with inferior outcomes, marked by a 4-year reduction in overall survival time compared to the non-TN cohort (mOS 37.4 months vs. 85.7 months; P = .009) and higher rates of leukemic transformation. More pronounced thrombocytopenia and anemia, lower LDH, EPO levels, as well as lower percentage of marrow blasts at baseline were more commonly seen in TN-MF (P < .05). Similarly, patients with TN-MF had higher risk disease per DIPSS+ and GIPSS. Mutations impacting RNA splicing, epigenetic modification and signaling, specifically SRSF2, SETBP1, IDH2, CBL, and GNAS, were more commonly seen among those lacking a classical phenotypic driver. The prevalence of co-mutant ASXL1/SRSF2 clones was significantly higher in TN-MF as was trisomy 8. TN patients had fewer responses (46.2% vs. 63.4%) and shorter duration of response to ruxolitinib. CONCLUSION TN-MF is invariably associated with significantly decreased survival and more aggressive clinical behavior with higher rates of leukemic transformation and shorter duration of response to ruxolitinib. Mutations impacting RNA splicing, epigenetic modification and signaling (SRSF2, SETBP1, IDH2, CBL, and GNAS) are more common in TN-MF, which likely drive its aggressive course and may account for suboptimal responses to JAK inhibition.
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Affiliation(s)
- Luis E Aguirre
- Department of Medical Oncology, Adult Leukemia Program, Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA.
| | - Akriti Jain
- Leukemia and Myeloid Disorders Program, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH
| | - Somedeb Ball
- Division of Hematology and Oncology, Vanderbilt Ingram Cancer Center, Vanderbilt University School of Medicine, Nashville, TN
| | - Najla Al Ali
- Department of Malignant Hematology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL
| | - Virginia O Volpe
- Department of Medical Oncology, Adult Leukemia Program, Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA
| | - Sara Tinsley-Vance
- Department of Malignant Hematology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL
| | - David Sallman
- Department of Malignant Hematology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL
| | - Kendra Sweet
- Department of Malignant Hematology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL
| | - Jeffrey Lancet
- Department of Malignant Hematology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL
| | - Eric Padron
- Department of Malignant Hematology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL
| | - Seongseok Yun
- Department of Malignant Hematology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL
| | - Andrew Kuykendall
- Department of Malignant Hematology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL
| | - Rami Komrokji
- Department of Malignant Hematology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL.
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3
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Patel N, Mirza H, Bai P, Shah V, Patel H, Khealani M, Kukreja G, Obulareddy SJ. Aplastic Anemia Mimicking Myelofibrosis: A Diagnostic Dilemma. Cureus 2023; 15:e49445. [PMID: 38149134 PMCID: PMC10751010 DOI: 10.7759/cureus.49445] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2023] [Accepted: 11/26/2023] [Indexed: 12/28/2023] Open
Abstract
Hematological disorders pose a diagnostic challenge due to overlapping clinical features, as demonstrated by the difficulty in differentiating between aplastic anemia (AA) and primary myelofibrosis (PM). Myeloproliferative disorders, characterized by aberrant proliferation of bone marrow stem cells, present complexities in diagnosis, often requiring a comprehensive evaluation to distinguish between disorders with similar manifestations. The distinctions between myelofibrosis and AA lie not only in clinical presentations but also in genetic and molecular markers, necessitating a nuanced diagnostic approach. We present a case of a 37-year-old male initially diagnosed with myelofibrosis based on a history of pancytopenia, warm submandibular and submental swelling, and negative BCR-ABL and JAK2 mutations. Further examination revealed empty fragmented cells, hypoplastic bone marrow, and suppressed erythropoiesis and myelopoiesis. Subsequent core biopsy showed increased megakaryocytes, prompting a revised diagnosis of AA. This case underscores the importance of a meticulous diagnostic journey, incorporating physical examination, genetic testing, and advanced imaging to unravel the complexities of hematological disorders. The intricacies of this case prompt a reevaluation of diagnostic paradigms, highlighting the limitations of relying solely on specific mutations for diagnosis. The absence of BCR-ABL and JAK2 mutations in AA raises questions about its genetic landscape, necessitating further exploration. Immunological considerations, given the immune-mediated nature of AA, provide a foundation for future research into immune dysregulation and potential therapeutic interventions. The clinical management challenges posed by AA underscore the need for personalized treatment strategies, guided by a deeper understanding of its underlying pathophysiology. Advanced imaging techniques, in conjunction with traditional diagnostic methods, emerge as crucial tools for enhancing diagnostic accuracy in hematological disorders. This case serves as a paradigm for ongoing medical education, multidisciplinary collaboration, and innovative approaches in the evolving landscape of hematology, emphasizing the imperative for continuous refinement in diagnostic strategies and patient care.
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Affiliation(s)
- Neel Patel
- Public Health, Icahn School of Medicine at Mount Sinai, New York, USA
| | - Hamza Mirza
- Biology, New Jersey City University, Jersey City, USA
| | - Payal Bai
- Public Health, Icahn School of Medicine at Mount Sinai, New York, USA
| | - Vedant Shah
- Internal Medicine, Smt. Nathiba Hargovandas Lakhmichand (NHL) Municipal Medical College, Ahmedabad, IND
| | - Harsh Patel
- Clinical Research Management, Rutgers University, Newark, USA
| | - Milan Khealani
- Hospital Medicine, Mayo Clinic Health System, Mankato, USA
| | - Geetika Kukreja
- Internal Medicine/Hematology-Oncology, Henry Ford Health System, Clinton Township, USA
| | - Sri J Obulareddy
- Hematology Oncology, University of Arkansas for Medical Sciences, Little Rock, USA
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4
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Gurban P, Mambet C, Botezatu A, Necula LG, Neagu AI, Matei L, Pitica IM, Nedeianu S, Chivu-Economescu M, Bleotu C, Ataman M, Mocanu G, Saguna C, Pavel AG, Stambouli D, Sepulchre E, Anton G, Diaconu CC, Constantinescu SN. Leukemic conversion involving RAS mutations of type 1 CALR-mutated primary myelofibrosis in a patient treated for HCV cirrhosis: a case report. Front Oncol 2023; 13:1266996. [PMID: 37841434 PMCID: PMC10570518 DOI: 10.3389/fonc.2023.1266996] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2023] [Accepted: 09/04/2023] [Indexed: 10/17/2023] Open
Abstract
Somatic frameshift mutations in exon 9 of calreticulin (CALR) gene are recognized as disease drivers in primary myelofibrosis (PMF), one of the three classical Philadelphia-negative myeloproliferative neoplasms (MPNs). Type 1/type 1-like CALR mutations particularly confer a favorable prognostic and survival advantage in PMF patients. We report an unusual case of PMF incidentally diagnosed in a 68-year-old woman known with hepatitis C virus (HCV) cirrhosis who developed a progressive painful splenomegaly, without anomalies in blood cell counts. While harboring a type 1 CALR mutation, the patient underwent a leukemic transformation in less than 1 year from diagnosis, with a lethal outcome. Analysis of paired DNA samples from chronic and leukemic phases by a targeted next-generation sequencing (NGS) panel and single-nucleotide polymorphism (SNP) microarray revealed that the leukemic clone developed from the CALR-mutated clone through the acquisition of genetic events in the RAS signaling pathway: an increased variant allele frequency of the germline NRAS Y64D mutation present in the chronic phase (via an acquired uniparental disomy of chromosome 1) and gaining NRAS G12D in the blast phase. SNP microarray analysis showed five clinically significant copy number losses at regions 7q22.1, 8q11.1-q11.21, 10p12.1-p11.22, 11p14.1-p11.2, and Xp11.4, revealing a complex karyotype already in the chronic phase. We discuss how additional mutations, detected by NGS, as well as HCV infection and antiviral therapy, might have negatively impacted this type 1 CALR-mutated PMF. We suggest that larger studies are required to determine if more careful monitoring would be needed in MPN patients also carrying HCV and receiving anti-HCV treatment.
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Affiliation(s)
- Petruta Gurban
- Cellular and Molecular Pathology Department, Stefan S. Nicolau Institute of Virology, Romanian Academy, Bucharest, Romania
- Cytogenomic Medical Laboratory Ltd., Bucharest, Romania
| | - Cristina Mambet
- Cellular and Molecular Pathology Department, Stefan S. Nicolau Institute of Virology, Romanian Academy, Bucharest, Romania
- Department of Radiology, Oncology, and Hematology, Faculty of Medicine, Carol Davila University of Medicine and Pharmacy, Bucharest, Romania
- Hematology Department, Emergency University Clinical Hospital, Bucharest, Romania
| | - Anca Botezatu
- Molecular Virology Department, Stefan S. Nicolau Institute of Virology, Romanian Academy, Bucharest, Romania
| | - Laura G. Necula
- Cellular and Molecular Pathology Department, Stefan S. Nicolau Institute of Virology, Romanian Academy, Bucharest, Romania
| | - Ana I. Neagu
- Cellular and Molecular Pathology Department, Stefan S. Nicolau Institute of Virology, Romanian Academy, Bucharest, Romania
- Department of Radiology, Oncology, and Hematology, Faculty of Medicine, Carol Davila University of Medicine and Pharmacy, Bucharest, Romania
| | - Lilia Matei
- Cellular and Molecular Pathology Department, Stefan S. Nicolau Institute of Virology, Romanian Academy, Bucharest, Romania
| | - Ioana M. Pitica
- Cellular and Molecular Pathology Department, Stefan S. Nicolau Institute of Virology, Romanian Academy, Bucharest, Romania
| | - Saviana Nedeianu
- Cellular and Molecular Pathology Department, Stefan S. Nicolau Institute of Virology, Romanian Academy, Bucharest, Romania
| | - Mihaela Chivu-Economescu
- Cellular and Molecular Pathology Department, Stefan S. Nicolau Institute of Virology, Romanian Academy, Bucharest, Romania
| | - Coralia Bleotu
- Cellular and Molecular Pathology Department, Stefan S. Nicolau Institute of Virology, Romanian Academy, Bucharest, Romania
| | - Marius Ataman
- Cellular and Molecular Pathology Department, Stefan S. Nicolau Institute of Virology, Romanian Academy, Bucharest, Romania
| | - Gabriela Mocanu
- Department of Hematology, Coltea Clinical Hospital, Bucharest, Romania
| | - Carmen Saguna
- Department of Radiology, Oncology, and Hematology, Faculty of Medicine, Carol Davila University of Medicine and Pharmacy, Bucharest, Romania
- Department of Hematology, Coltea Clinical Hospital, Bucharest, Romania
| | - Anca G. Pavel
- Cytogenomic Medical Laboratory Ltd., Bucharest, Romania
| | | | - Elise Sepulchre
- De Duve Institute, Université Catholique de Louvain, Brussels, Belgium
| | - Gabriela Anton
- Molecular Virology Department, Stefan S. Nicolau Institute of Virology, Romanian Academy, Bucharest, Romania
| | - Carmen C. Diaconu
- Cellular and Molecular Pathology Department, Stefan S. Nicolau Institute of Virology, Romanian Academy, Bucharest, Romania
| | - Stefan N. Constantinescu
- De Duve Institute, Université Catholique de Louvain, Brussels, Belgium
- SIGN (Cell Signalling and Molecular Hematology), Ludwig Institute for Cancer Research Brussels, Brussels, Belgium
- Walloon Excellence in Life Sciences and Biotechnology (WELBIO) Department, WEL Research Institute, Wavre, Belgium
- Nuffield Department of Medicine, Ludwig Institute for Cancer Research, Oxford University, Oxford, United Kingdom
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5
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Mroczkowska-Bękarciak A, Wróbel T. BCR::ABL1-negative myeloproliferative neoplasms in the era of next-generation sequencing. Front Genet 2023; 14:1241912. [PMID: 37745842 PMCID: PMC10514516 DOI: 10.3389/fgene.2023.1241912] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2023] [Accepted: 08/22/2023] [Indexed: 09/26/2023] Open
Abstract
The classical BCR::ABL1-negative myeloproliferative neoplasms such as polycythemia vera (PV), essential thrombocythemia (ET), and myelofibrosis (MF) are clonal diseases with the presence of characteristic "driver mutations" in one of the genes: JAK2, CALR, or MPL. The search for mutations in these three genes is required for the diagnosis of MPNs. Nevertheless, the progress that has been made in the field of molecular genetics has opened a new era in medicine. The search for additional mutations in MPNs is helpful in assessing the risk stratification, disease progression, transformation to acute myeloid leukemia (AML), or choosing the right treatment. In some cases, advanced technologies are needed to find a clonal marker of the disease and establish a diagnosis. This review focuses on how the use of new technologies like next-generation sequencing (NGS) helps in the diagnosis of BCR::ABL1-negative myeloproliferative neoplasms.
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6
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Chapman SP, Duprez E, Remy E. Logical modelling of myelofibrotic microenvironment predicts dysregulated progenitor stem cell crosstalk. Biosystems 2023; 231:104961. [PMID: 37392989 DOI: 10.1016/j.biosystems.2023.104961] [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: 03/17/2023] [Revised: 06/16/2023] [Accepted: 06/17/2023] [Indexed: 07/03/2023]
Abstract
Primary myelofibrosis is an untreatable age-related disorder of haematopoiesis in which a break in the crosstalk between progenitor Haematopoietic Stem Cells (HSCs) and neighbouring mesenchymal stem cells causes HSCs to rapidly proliferate and migrate out of the bone marrow. Around 90% of patients harbour mutations in driver genes that all converge to overactivate haematopoietic JAK-STAT signalling, which is thought to be critical for disease progression, as well as microenvironment modification induced by chronic inflammation. The trigger to the initial event is unknown but dysregulated thrombopoietin (TPO) and Toll-Like Receptor (TLR) signalling are hypothesised to initiate chronic inflammation which then disrupts stem cell crosstalk. Using a systems biology approach, we have constructed an intercellular logical model that captures JAK-STAT signalling and key crosstalk channels between haematopoietic and mesenchymal stem cells. The aim of the model is to decipher how TPO and TLR stimulation can perturb the bone marrow microenvironment and dysregulate stem cell crosstalk. The model predicted conditions in which the disease was averted and established for both wildtype and ectopically JAK mutated simulations. The presence of TPO and TLR are both required to disturb stem cell crosstalk and result in the disease for wildtype. TLR signalling alone was sufficient to perturb the crosstalk and drive disease progression for JAK mutated simulations. Furthermore, the model predicts probabilities of disease onset for wildtype simulations that match clinical data. These predictions might explain why patients who test negative for the JAK mutation can still be diagnosed with PMF, in which continual exposure to TPO and TLR receptor activation may trigger the initial inflammatory event that perturbs the bone marrow microenvironment and induce disease onset.
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Affiliation(s)
- S P Chapman
- I2M, Aix-Marseille University, CNRS, Marseille, France
| | - E Duprez
- Epigenetic Factors in Normal and Malignant Haematopoiesis Lab., CRCM, CNRS, INSERM, Institut Paoli Calmettes, Aix Marseille University, 13009 Marseille, France
| | - E Remy
- I2M, Aix-Marseille University, CNRS, Marseille, France.
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7
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Chifotides HT, Verstovsek S, Bose P. Association of Myelofibrosis Phenotypes with Clinical Manifestations, Molecular Profiles, and Treatments. Cancers (Basel) 2023; 15:3331. [PMID: 37444441 PMCID: PMC10340291 DOI: 10.3390/cancers15133331] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2023] [Revised: 06/15/2023] [Accepted: 06/17/2023] [Indexed: 07/15/2023] Open
Abstract
Myelofibrosis (MF) presents an array of clinical manifestations and molecular profiles. The two distinct phenotypes- myeloproliferative and myelodepletive or cytopenic- are situated at the two poles of the disease spectrum and are largely defined by different degrees of cytopenias, splenomegaly, and distinct molecular profiles. The myeloproliferative phenotype is characterized by normal/higher peripheral blood counts or mildly decreased hemoglobin, progressive splenomegaly, and constitutional symptoms. The myeloproliferative phenotype is typically associated with secondary MF, higher JAK2 V617F burden, fewer mutations, and superior overall survival (OS). The myelodepletive phenotype is usually associated with primary MF, ≥2 cytopenias, modest splenomegaly, lower JAK2 V617F burden, higher fibrosis, greater genomic complexity, and inferior OS. Cytopenias are associated with mutations in epigenetic regulators/splicing factors, clonal evolution, disease progression, and shorter OS. Clinical variables, in conjunction with the molecular profiles, inform integrated prognostication and disease management. Ruxolitinib/fedratinib and pacritinib/momelotinib may be more suitable to treat patients with the myeloproliferative and myelodepletive phenotypes, respectively. Appreciation of MF heterogeneity and two distinct phenotypes, the different clinical manifestations and molecular profiles associated with each phenotype alongside the growing treatment expertise, the development of non-myelosuppressive JAK inhibitors, and integrated prognostication are leading to a new era in patient management. Physicians can increasingly tailor personalized treatments that will address the unique unmet needs of MF patients, including those presenting with the myelodepletive phenotype, to elicit optimal outcomes and extended OS across the disease spectrum.
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Affiliation(s)
| | | | - Prithviraj Bose
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA; (H.T.C.); (S.V.)
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8
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Biological drivers of clinical phenotype in myelofibrosis. Leukemia 2023; 37:255-264. [PMID: 36434065 PMCID: PMC9898039 DOI: 10.1038/s41375-022-01767-y] [Citation(s) in RCA: 17] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2022] [Revised: 11/10/2022] [Accepted: 11/14/2022] [Indexed: 11/27/2022]
Abstract
Myelofibrosis (MF) is a myeloproliferative disorder that exhibits considerable biological and clinical heterogeneity. At the two ends of the disease spectrum are the myelodepletive or cytopenic phenotype and the myeloproliferative phenotype. The cytopenic phenotype has a high prevalence in primary MF (PMF) and is characterized by low blood counts. The myeloproliferative phenotype is typically associated with secondary MF (SMF), mild anemia, minimal need for transfusion support, and normal to mild thrombocytopenia. Differences in somatic driver mutations and allelic burden, as well as the acquisition of non-driver mutations further influences these phenotypic differences, prognosis, and response to therapies such as JAK2 inhibitors. The outcome of patients with the cytopenic phenotype are comparatively worse and frequently pose a challenge to treat given the inherent exacerbation of cytopenias. Recent data indicate that an innate immune deregulated state that hinges on the myddosome-IRAK-NFκB axis favors the cytopenic myelofibrosis phenotype and offers opportunity for novel treatment approaches. We will review the biological and clinical features of the MF disease spectrum and associated treatment considerations.
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9
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Severe ARDS due to Ruxolitinib discontinuation syndrome: case presentation and literature review. Heliyon 2022; 8:e11782. [DOI: 10.1016/j.heliyon.2022.e11782] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2022] [Revised: 06/06/2022] [Accepted: 11/14/2022] [Indexed: 11/30/2022] Open
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10
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Pemmaraju N, Garcia JS, Potluri J, Harb JG, Sun Y, Jung P, Qin QQ, Tantravahi SK, Verstovsek S, Harrison C. Addition of navitoclax to ongoing ruxolitinib treatment in patients with myelofibrosis (REFINE): a post-hoc analysis of molecular biomarkers in a phase 2 study. THE LANCET HAEMATOLOGY 2022; 9:e434-e444. [DOI: 10.1016/s2352-3026(22)00116-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/03/2022] [Revised: 04/01/2022] [Accepted: 04/06/2022] [Indexed: 12/20/2022]
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11
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Villani L, Rosti V, Massa M, Campanelli R, Catarsi P, Carolei A, Abbà C, de Silvstri A, Gale RP, Barosi G. VEGFA rs3025020 Polymorphism Contributes to CALR -Mutation Susceptibility and Is Associated with Low Risk of Deep Vein Thrombosis in Primary Myelofibrosis. TH OPEN 2021; 5:e513-e520. [PMID: 34778698 PMCID: PMC8577885 DOI: 10.1055/s-0041-1739293] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2021] [Accepted: 07/15/2021] [Indexed: 11/27/2022] Open
Abstract
Background
Single nucleotide polymorphisms (SNPs) in vascular endothelial growth factor A (
VEGFA
) are associated with susceptibility to several diseases including cancer. Correlations between
VEGFA rs3025020
genotypes with clinical and laboratory features of primary myelofibrosis (PMF) are unstudied.
Methods
DNA was analyzed by real-time polymerase chain reaction for
VEGFA rs3025020
genotypes in a cohort of 844 subjects with PMF and in two cohorts of normal subjects (
N
= 247 and
N
= 107).
Results
Frequency of
rs3025020
minor allele (T) was not significantly different in subjects with PMF compared with normals; however, the T-allele was more frequent in PMF subjects with a calreticulin (
CALR
)-mutated genotype compared with normals (35 vs. 27%; OR = 1.47 [95% CI, 1.09, 1.98]
p
= 0.011), especially in subjects with a
CALR-
type 2/type 2-like mutation (43 vs. 27%; OR = 2.01 [1.25, 3.24]
p
= 0.004).
CALR
mutants with the
rs3025020
TT genotype had higher CXCR4 expression on CD34-positive blood cells, and those who carried CT/TT genotypes had lower platelet concentrations compared with other genotypes at diagnosis. Overall, subjects with the
rs3025020
CT/TT genotype had a lower cumulative incidence of deep vein thrombosis in typical sites (1.6 vs. 4.2%; OR = 0.37 [0.15, 0.90]
p
= 0.029) and longer interval from diagnosis to first thrombosis (HR = 0.37 [0.14, 0.95]
p
= 0.039).
Conclusion
Persons with PMF and the
VEGFA rs3025020
minor T-allele are more likely to have a
CALR
mutation compared with other somatic driver mutations and lower cumulative incidence and hazard for deep vein thrombosis in typical sites.
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Affiliation(s)
- Laura Villani
- Center for the Study of Myelofibrosis, Laboratory of Biochemistry, Biotechnology and Advanced Diagnostics, Istituto di Ricovero e Cura a Carattere Scientifico Policlinico S. Matteo Foundation, Pavia, Italy
| | - Vittorio Rosti
- Center for the Study of Myelofibrosis, Laboratory of Biochemistry, Biotechnology and Advanced Diagnostics, Istituto di Ricovero e Cura a Carattere Scientifico Policlinico S. Matteo Foundation, Pavia, Italy
| | - Margherita Massa
- Laboratory of Biochemistry, Biotechnology and Advanced Diagnostics, Istituto di Ricovero e Cura a Carattere Scientifico Policlinico San Matteo Foundation, Pavia, Italy
| | - Rita Campanelli
- Center for the Study of Myelofibrosis, Laboratory of Biochemistry, Biotechnology and Advanced Diagnostics, Istituto di Ricovero e Cura a Carattere Scientifico Policlinico S. Matteo Foundation, Pavia, Italy
| | - Paolo Catarsi
- Center for the Study of Myelofibrosis, Laboratory of Biochemistry, Biotechnology and Advanced Diagnostics, Istituto di Ricovero e Cura a Carattere Scientifico Policlinico S. Matteo Foundation, Pavia, Italy
| | - Adriana Carolei
- Center for the Study of Myelofibrosis, Laboratory of Biochemistry, Biotechnology and Advanced Diagnostics, Istituto di Ricovero e Cura a Carattere Scientifico Policlinico S. Matteo Foundation, Pavia, Italy
| | - Carlotta Abbà
- Center for the Study of Myelofibrosis, Laboratory of Biochemistry, Biotechnology and Advanced Diagnostics, Istituto di Ricovero e Cura a Carattere Scientifico Policlinico S. Matteo Foundation, Pavia, Italy
| | - Annalisa de Silvstri
- Biometry & Clinical Epidemiology, Scientific Direction, Istituto di Ricovero e Cura a Carattere Scientifico Policlinico San Matteo Foundation, Pavia, Italy
| | - Robert Peter Gale
- Department of Immunology and Inflammation, Centre for Haematology Research, Imperial College London, London SW7 2BU, United Kingdom
| | - Giovanni Barosi
- Center for the Study of Myelofibrosis, Laboratory of Biochemistry, Biotechnology and Advanced Diagnostics, Istituto di Ricovero e Cura a Carattere Scientifico Policlinico S. Matteo Foundation, Pavia, Italy
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The Power of Extracellular Vesicles in Myeloproliferative Neoplasms: "Crafting" a Microenvironment That Matters. Cells 2021; 10:cells10092316. [PMID: 34571965 PMCID: PMC8464728 DOI: 10.3390/cells10092316] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2021] [Revised: 08/30/2021] [Accepted: 09/01/2021] [Indexed: 12/14/2022] Open
Abstract
Myeloproliferative Neoplasms (MPN) are acquired clonal disorders of the hematopoietic stem cells and include Essential Thrombocythemia, Polycythemia Vera and Myelofibrosis. MPN are characterized by mutations in three driver genes (JAK2, CALR and MPL) and by a state of chronic inflammation. Notably, MPN patients experience increased risk of thrombosis, disease progression, second neoplasia and evolution to acute leukemia. Extracellular vesicles (EVs) are a heterogeneous population of microparticles with a role in cell-cell communication. The EV-mediated cross-talk occurs via the trafficking of bioactive molecules such as nucleic acids, proteins, metabolites and lipids. Growing interest is focused on EVs and their potential impact on the regulation of blood cancers. Overall, EVs have been suggested to orchestrate the complex interplay between tumor cells and the microenvironment with a pivotal role in "education" and "crafting" of the microenvironment by regulating angiogenesis, coagulation, immune escape and drug resistance of tumors. This review is focused on the role of EVs in MPN. Specifically, we will provide an overview of recent findings on the involvement of EVs in MPN pathogenesis and discuss opportunities for their potential application as diagnostic and prognostic biomarkers.
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Nasillo V, Riva G, Paolini A, Forghieri F, Roncati L, Lusenti B, Maccaferri M, Messerotti A, Pioli V, Gilioli A, Bettelli F, Giusti D, Barozzi P, Lagreca I, Maffei R, Marasca R, Potenza L, Comoli P, Manfredini R, Maiorana A, Tagliafico E, Luppi M, Trenti T. Inflammatory Microenvironment and Specific T Cells in Myeloproliferative Neoplasms: Immunopathogenesis and Novel Immunotherapies. Int J Mol Sci 2021; 22:ijms22041906. [PMID: 33672997 PMCID: PMC7918142 DOI: 10.3390/ijms22041906] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2021] [Revised: 02/07/2021] [Accepted: 02/08/2021] [Indexed: 02/07/2023] Open
Abstract
The Philadelphia-negative myeloproliferative neoplasms (MPNs) are malignancies of the hematopoietic stem cell (HSC) arising as a consequence of clonal proliferation driven by somatically acquired driver mutations in discrete genes (JAK2, CALR, MPL). In recent years, along with the advances in molecular characterization, the role of immune dysregulation has been achieving increasing relevance in the pathogenesis and evolution of MPNs. In particular, a growing number of studies have shown that MPNs are often associated with detrimental cytokine milieu, expansion of the monocyte/macrophage compartment and myeloid-derived suppressor cells, as well as altered functions of T cells, dendritic cells and NK cells. Moreover, akin to solid tumors and other hematological malignancies, MPNs are able to evade T cell immune surveillance by engaging the PD-1/PD-L1 axis, whose pharmacological blockade with checkpoint inhibitors can successfully restore effective antitumor responses. A further interesting cue is provided by the recent discovery of the high immunogenic potential of JAK2V617F and CALR exon 9 mutations, that could be harnessed as intriguing targets for innovative adoptive immunotherapies. This review focuses on the recent insights in the immunological dysfunctions contributing to the pathogenesis of MPNs and outlines the potential impact of related immunotherapeutic approaches.
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Affiliation(s)
- Vincenzo Nasillo
- Department of Laboratory Medicine and Pathology, Diagnostic Hematology and Clinical Genomics, AUSL/AOU Policlinico, 41124 Modena, Italy; (G.R.); (B.L.); (E.T.); (T.T.)
- Correspondence: ; Tel.: +39-059-422-2173
| | - Giovanni Riva
- Department of Laboratory Medicine and Pathology, Diagnostic Hematology and Clinical Genomics, AUSL/AOU Policlinico, 41124 Modena, Italy; (G.R.); (B.L.); (E.T.); (T.T.)
| | - Ambra Paolini
- Section of Hematology, Department of Medical and Surgical Sciences, University of Modena and Reggio Emilia, AOU Policlinico, 41124 Modena, Italy; (A.P.); (F.F.); (M.M.); (A.M.); (V.P.); (A.G.); (F.B.); (D.G.); (P.B.); (I.L.); (R.M.); (R.M.); (L.P.); (M.L.)
| | - Fabio Forghieri
- Section of Hematology, Department of Medical and Surgical Sciences, University of Modena and Reggio Emilia, AOU Policlinico, 41124 Modena, Italy; (A.P.); (F.F.); (M.M.); (A.M.); (V.P.); (A.G.); (F.B.); (D.G.); (P.B.); (I.L.); (R.M.); (R.M.); (L.P.); (M.L.)
| | - Luca Roncati
- Institute of Pathology, Department of Medical and Surgical Sciences, University of Modena and Reggio Emilia, AOU Policlinico, 41124 Modena, Italy; (L.R.); (A.M.)
| | - Beatrice Lusenti
- Department of Laboratory Medicine and Pathology, Diagnostic Hematology and Clinical Genomics, AUSL/AOU Policlinico, 41124 Modena, Italy; (G.R.); (B.L.); (E.T.); (T.T.)
| | - Monica Maccaferri
- Section of Hematology, Department of Medical and Surgical Sciences, University of Modena and Reggio Emilia, AOU Policlinico, 41124 Modena, Italy; (A.P.); (F.F.); (M.M.); (A.M.); (V.P.); (A.G.); (F.B.); (D.G.); (P.B.); (I.L.); (R.M.); (R.M.); (L.P.); (M.L.)
| | - Andrea Messerotti
- Section of Hematology, Department of Medical and Surgical Sciences, University of Modena and Reggio Emilia, AOU Policlinico, 41124 Modena, Italy; (A.P.); (F.F.); (M.M.); (A.M.); (V.P.); (A.G.); (F.B.); (D.G.); (P.B.); (I.L.); (R.M.); (R.M.); (L.P.); (M.L.)
| | - Valeria Pioli
- Section of Hematology, Department of Medical and Surgical Sciences, University of Modena and Reggio Emilia, AOU Policlinico, 41124 Modena, Italy; (A.P.); (F.F.); (M.M.); (A.M.); (V.P.); (A.G.); (F.B.); (D.G.); (P.B.); (I.L.); (R.M.); (R.M.); (L.P.); (M.L.)
| | - Andrea Gilioli
- Section of Hematology, Department of Medical and Surgical Sciences, University of Modena and Reggio Emilia, AOU Policlinico, 41124 Modena, Italy; (A.P.); (F.F.); (M.M.); (A.M.); (V.P.); (A.G.); (F.B.); (D.G.); (P.B.); (I.L.); (R.M.); (R.M.); (L.P.); (M.L.)
| | - Francesca Bettelli
- Section of Hematology, Department of Medical and Surgical Sciences, University of Modena and Reggio Emilia, AOU Policlinico, 41124 Modena, Italy; (A.P.); (F.F.); (M.M.); (A.M.); (V.P.); (A.G.); (F.B.); (D.G.); (P.B.); (I.L.); (R.M.); (R.M.); (L.P.); (M.L.)
| | - Davide Giusti
- Section of Hematology, Department of Medical and Surgical Sciences, University of Modena and Reggio Emilia, AOU Policlinico, 41124 Modena, Italy; (A.P.); (F.F.); (M.M.); (A.M.); (V.P.); (A.G.); (F.B.); (D.G.); (P.B.); (I.L.); (R.M.); (R.M.); (L.P.); (M.L.)
| | - Patrizia Barozzi
- Section of Hematology, Department of Medical and Surgical Sciences, University of Modena and Reggio Emilia, AOU Policlinico, 41124 Modena, Italy; (A.P.); (F.F.); (M.M.); (A.M.); (V.P.); (A.G.); (F.B.); (D.G.); (P.B.); (I.L.); (R.M.); (R.M.); (L.P.); (M.L.)
| | - Ivana Lagreca
- Section of Hematology, Department of Medical and Surgical Sciences, University of Modena and Reggio Emilia, AOU Policlinico, 41124 Modena, Italy; (A.P.); (F.F.); (M.M.); (A.M.); (V.P.); (A.G.); (F.B.); (D.G.); (P.B.); (I.L.); (R.M.); (R.M.); (L.P.); (M.L.)
| | - Rossana Maffei
- Section of Hematology, Department of Medical and Surgical Sciences, University of Modena and Reggio Emilia, AOU Policlinico, 41124 Modena, Italy; (A.P.); (F.F.); (M.M.); (A.M.); (V.P.); (A.G.); (F.B.); (D.G.); (P.B.); (I.L.); (R.M.); (R.M.); (L.P.); (M.L.)
| | - Roberto Marasca
- Section of Hematology, Department of Medical and Surgical Sciences, University of Modena and Reggio Emilia, AOU Policlinico, 41124 Modena, Italy; (A.P.); (F.F.); (M.M.); (A.M.); (V.P.); (A.G.); (F.B.); (D.G.); (P.B.); (I.L.); (R.M.); (R.M.); (L.P.); (M.L.)
| | - Leonardo Potenza
- Section of Hematology, Department of Medical and Surgical Sciences, University of Modena and Reggio Emilia, AOU Policlinico, 41124 Modena, Italy; (A.P.); (F.F.); (M.M.); (A.M.); (V.P.); (A.G.); (F.B.); (D.G.); (P.B.); (I.L.); (R.M.); (R.M.); (L.P.); (M.L.)
| | - Patrizia Comoli
- Pediatric Hematology/Oncology Unit and Cell Factory, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Policlinico San Matteo, 27100 Pavia, Italy;
| | - Rossella Manfredini
- Centre for Regenerative Medicine “S. Ferrari”, University of Modena and Reggio Emilia, 41125 Modena, Italy;
| | - Antonino Maiorana
- Institute of Pathology, Department of Medical and Surgical Sciences, University of Modena and Reggio Emilia, AOU Policlinico, 41124 Modena, Italy; (L.R.); (A.M.)
| | - Enrico Tagliafico
- Department of Laboratory Medicine and Pathology, Diagnostic Hematology and Clinical Genomics, AUSL/AOU Policlinico, 41124 Modena, Italy; (G.R.); (B.L.); (E.T.); (T.T.)
| | - Mario Luppi
- Section of Hematology, Department of Medical and Surgical Sciences, University of Modena and Reggio Emilia, AOU Policlinico, 41124 Modena, Italy; (A.P.); (F.F.); (M.M.); (A.M.); (V.P.); (A.G.); (F.B.); (D.G.); (P.B.); (I.L.); (R.M.); (R.M.); (L.P.); (M.L.)
| | - Tommaso Trenti
- Department of Laboratory Medicine and Pathology, Diagnostic Hematology and Clinical Genomics, AUSL/AOU Policlinico, 41124 Modena, Italy; (G.R.); (B.L.); (E.T.); (T.T.)
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Nasillo V, Riva G, Paolini A, Forghieri F, Roncati L, Lusenti B, Maccaferri M, Messerotti A, Pioli V, Gilioli A, Bettelli F, Giusti D, Barozzi P, Lagreca I, Maffei R, Marasca R, Potenza L, Comoli P, Manfredini R, Maiorana A, Tagliafico E, Luppi M, Trenti T. Inflammatory Microenvironment and Specific T Cells in Myeloproliferative Neoplasms: Immunopathogenesis and Novel Immunotherapies. Int J Mol Sci 2021. [PMID: 33672997 DOI: 10.3390/ijms22041906.pmid:33672997;pmcid:pmc7918142] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/09/2023] Open
Abstract
The Philadelphia-negative myeloproliferative neoplasms (MPNs) are malignancies of the hematopoietic stem cell (HSC) arising as a consequence of clonal proliferation driven by somatically acquired driver mutations in discrete genes (JAK2, CALR, MPL). In recent years, along with the advances in molecular characterization, the role of immune dysregulation has been achieving increasing relevance in the pathogenesis and evolution of MPNs. In particular, a growing number of studies have shown that MPNs are often associated with detrimental cytokine milieu, expansion of the monocyte/macrophage compartment and myeloid-derived suppressor cells, as well as altered functions of T cells, dendritic cells and NK cells. Moreover, akin to solid tumors and other hematological malignancies, MPNs are able to evade T cell immune surveillance by engaging the PD-1/PD-L1 axis, whose pharmacological blockade with checkpoint inhibitors can successfully restore effective antitumor responses. A further interesting cue is provided by the recent discovery of the high immunogenic potential of JAK2V617F and CALR exon 9 mutations, that could be harnessed as intriguing targets for innovative adoptive immunotherapies. This review focuses on the recent insights in the immunological dysfunctions contributing to the pathogenesis of MPNs and outlines the potential impact of related immunotherapeutic approaches.
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Affiliation(s)
- Vincenzo Nasillo
- Department of Laboratory Medicine and Pathology, Diagnostic Hematology and Clinical Genomics, AUSL/AOU Policlinico, 41124 Modena, Italy
| | - Giovanni Riva
- Department of Laboratory Medicine and Pathology, Diagnostic Hematology and Clinical Genomics, AUSL/AOU Policlinico, 41124 Modena, Italy
| | - Ambra Paolini
- Section of Hematology, Department of Medical and Surgical Sciences, University of Modena and Reggio Emilia, AOU Policlinico, 41124 Modena, Italy
| | - Fabio Forghieri
- Section of Hematology, Department of Medical and Surgical Sciences, University of Modena and Reggio Emilia, AOU Policlinico, 41124 Modena, Italy
| | - Luca Roncati
- Institute of Pathology, Department of Medical and Surgical Sciences, University of Modena and Reggio Emilia, AOU Policlinico, 41124 Modena, Italy
| | - Beatrice Lusenti
- Department of Laboratory Medicine and Pathology, Diagnostic Hematology and Clinical Genomics, AUSL/AOU Policlinico, 41124 Modena, Italy
| | - Monica Maccaferri
- Section of Hematology, Department of Medical and Surgical Sciences, University of Modena and Reggio Emilia, AOU Policlinico, 41124 Modena, Italy
| | - Andrea Messerotti
- Section of Hematology, Department of Medical and Surgical Sciences, University of Modena and Reggio Emilia, AOU Policlinico, 41124 Modena, Italy
| | - Valeria Pioli
- Section of Hematology, Department of Medical and Surgical Sciences, University of Modena and Reggio Emilia, AOU Policlinico, 41124 Modena, Italy
| | - Andrea Gilioli
- Section of Hematology, Department of Medical and Surgical Sciences, University of Modena and Reggio Emilia, AOU Policlinico, 41124 Modena, Italy
| | - Francesca Bettelli
- Section of Hematology, Department of Medical and Surgical Sciences, University of Modena and Reggio Emilia, AOU Policlinico, 41124 Modena, Italy
| | - Davide Giusti
- Section of Hematology, Department of Medical and Surgical Sciences, University of Modena and Reggio Emilia, AOU Policlinico, 41124 Modena, Italy
| | - Patrizia Barozzi
- Section of Hematology, Department of Medical and Surgical Sciences, University of Modena and Reggio Emilia, AOU Policlinico, 41124 Modena, Italy
| | - Ivana Lagreca
- Section of Hematology, Department of Medical and Surgical Sciences, University of Modena and Reggio Emilia, AOU Policlinico, 41124 Modena, Italy
| | - Rossana Maffei
- Section of Hematology, Department of Medical and Surgical Sciences, University of Modena and Reggio Emilia, AOU Policlinico, 41124 Modena, Italy
| | - Roberto Marasca
- Section of Hematology, Department of Medical and Surgical Sciences, University of Modena and Reggio Emilia, AOU Policlinico, 41124 Modena, Italy
| | - Leonardo Potenza
- Section of Hematology, Department of Medical and Surgical Sciences, University of Modena and Reggio Emilia, AOU Policlinico, 41124 Modena, Italy
| | - Patrizia Comoli
- Pediatric Hematology/Oncology Unit and Cell Factory, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Policlinico San Matteo, 27100 Pavia, Italy
| | - Rossella Manfredini
- Centre for Regenerative Medicine "S. Ferrari", University of Modena and Reggio Emilia, 41125 Modena, Italy
| | - Antonino Maiorana
- Institute of Pathology, Department of Medical and Surgical Sciences, University of Modena and Reggio Emilia, AOU Policlinico, 41124 Modena, Italy
| | - Enrico Tagliafico
- Department of Laboratory Medicine and Pathology, Diagnostic Hematology and Clinical Genomics, AUSL/AOU Policlinico, 41124 Modena, Italy
| | - Mario Luppi
- Section of Hematology, Department of Medical and Surgical Sciences, University of Modena and Reggio Emilia, AOU Policlinico, 41124 Modena, Italy
| | - Tommaso Trenti
- Department of Laboratory Medicine and Pathology, Diagnostic Hematology and Clinical Genomics, AUSL/AOU Policlinico, 41124 Modena, Italy
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