Fibrogenesis in Primary Myelofibrosis: Diagnostic,Clinical, and Therapeutic Implications

Primary myelofibrosis is a stem cell-derived clonal malignancy characterized by unchecked proliferation of myeloid cells, resulting in bone marrow fibrosis, osteosclerosis, and pathologic angiogenesis. Bone marrow fibrosis (BMF) plays a central role in the pathophysiology of the disease. This review describes current issues regarding BMF in primary myelofibrosis, including the pathophysiology and impact of abnormal deposition of excess collagen and reticulin fibers in bone marrow spaces, the modified Bauermeister and the European Consensus grading systems of BMF, and the prognostic impact of BMF on the overall outcome of patients with primary myelofibrosis. The impact of novel therapeutic strategies, including JAK-STAT inhibitors and allogeneic stem cell transplant, on BMF is discussed.

Implications for Practice:

Bone marrow fibrosis (BMF) plays an important role in the pathophysiology and the clinical outcomes of patients with primary myelofibrosis. The severity of BMF correlates with the clinical manifestations of the disease and impacts the survival in patients with myelofibrosis. Treatment with ruxolitinib has been shown to reverse BMF and to continue that trend with ongoing treatment. Further studies to fully understand the mechanisms of fibrosis, to further explore the ability of currently available agents (e.g., JAK-STAT inhibitors) to stabilize and/or reverse fibrosis, and to develop additional fibrosis-targeted therapies are warranted.     

The Treatment Landscape of Myelofibrosis Before and After Ruxolitinib Approval

Introduction/BackgroundMyelofibrosis (MF) is a chronic myeloproliferative neoplasm that presents with a heterogeneous clinical phenotype and prognosis. Before the US Food and Drug Administration approval of ruxolitinib, treatment options were varied and had limited effect. The increased use of ruxolitinib has drastically altered the MF treatment landscape. In this study, we aimed to clarify the clinical situations in which ruxolitinib is being used and analyze its effect on this landscape.Patients and MethodsWe retrospectively assessed treatment choices for MF patients treated at our institution (n = 309). This population was divided into 2 cohorts on the basis of a diagnosis before (cohort BR: n = 174) or after (cohort AR: n = 135) ruxolitinib approval. Cohorts were further stratified for comparison according to presenting clinical factors.ResultsExpectedly, the first-line use of ruxolitinib markedly increased after its approval. AR patients were less likely to receive erythropoiesis-stimulating agents (ESAs; P = .0003) and thalidomide (P = .003) than BR patients. In patients with MF-related symptoms and/or splenomegaly, increased use of ruxolitinib was associated with decreased use of first-line ESA (P = .03) or thalidomide (P = .03). In anemic patients, increased use of first-line ruxolitinib was associated with a decreased use of thalidomide (P = .007). In patients with severe leukocytosis, ruxolitinib use did not significantly increase and hydroxyurea was the preferred first-line agent.ConclusionOverall, the increased use of ruxolitinib appears to have come predominantly at the expense of thalidomide and ESAs, while not having a large effect on the first-line use of hydroxyurea.     

骨髓间充质干细胞移植治疗再生障碍性贫血22例临床观察

 【摘要】　目的　探讨骨髓间充质干细胞（BMSC）移植治疗再生障碍性贫血（AA）患者的疗效和安全性。方法　22例AA患者,中位年龄31岁（12～70岁）,包括重型AA 11例,非重型AA 11例;12例曾接受免疫抑制治疗,均无效。从健康供者骨髓中分离培养BMSC,静脉输注给患者,每次输注细胞数为1×106／kg,每周输注1～2次。观察治疗前后患者外周血细胞计数、骨髓细胞学、骨髓活检、外周血CD+3 CD+4、CD+3 CD+8 T淋巴细胞亚群比例及临床症状等,观察治疗相关不良反应。结果　22例患者接受BMSC输注的中位次数为16次（5～83次）,中位治疗时间13个月（2～33个月）,中位随访23个月（2～34个月）。其中1例患者基本治愈,9例缓解,3例明显进步,3例患者贫血和出血症状好转、输血间隔延长,6例无效;总有效率72.7 %（16／22）。3例曾接受标准方案免疫抑制治疗无效的患者中,2例缓解。14例患者在治疗前外周血CD+4／CD+8细胞比值倒置,治疗后10例恢复正常。所有患者均未出现明显的治疗相关不良反应。结论　BMSC治疗有助于改善AA患者的骨髓造血功能,短期观察未发现不良反应,值得进一步深入及扩大研究。     

吡柔比星联合COP四周方案治疗侵袭性非霍奇金淋巴瘤骨髓浸润

 目的　观察吡柔比星（THP）联合COP 4周方案（CTOP-28）诱导缓解治疗侵袭性非霍奇金淋巴瘤（NHL）骨髓浸润的近期疗效和患者不良反应。方法　回顾性分析2002年1月至2007年1月收治的初治侵袭性NHL骨髓浸润患者65例,比较CHOP 3周方案（CHOP-21）和CTOP-28方案的近期疗效和不良反应。CHOP-21方案：环磷酰胺750 mg／m2 （第1天）、长春新碱1.4 mg／m2 （最大量2 mg,第1天）、多柔比星50 mg／m2 （第1天）、泼尼松100 mg（第1天至第5天）;CTOP-28方案：环磷酰胺750 mg／m2 （第1、15天）、长春新碱1.4 mg／m2 （最大量2mg, 第1、8、15、22天）、吡柔比星25 mg／m2 （第1、2、15、16天）、泼尼松40 mg／m2 （第1天至第28天）。结果　CHOP-21方案组30例完全缓解12例（40 %）,CTOP-28方案组35例完全缓解28例（80 %）,后者显著高于前者（P＜0.05）。CTOP-28方案Ⅲ、Ⅳ度血液毒性的发生率（100.0 %）显著高于CHOP-21方案（50.0 %）（P＜0.05）;CTOP-28方案心脏毒性发生率（8.57 %）与CHOP-21方案相当（10.0 %）（P＞0.05）,均为Ⅰ、Ⅱ度毒性;胃肠毒性和肝肾脏毒性两种方案相当,均为Ⅰ、Ⅱ度;两种方案均未出现治疗相关死亡。结论　THP联合COP 4周方案是治疗初始侵袭性NHL骨髓浸润的高效、安全的方法。     

自体骨髓移植治疗淋巴瘤合并自身免疫性疾病的探讨

 目的　探讨淋巴瘤并发类风湿关节炎（RA）患者进行自体骨髓移植治疗的疗效、安全性及移植后免疫重建过程。方法　对1例临床诊断非霍奇金淋巴瘤（NHL）ⅢB、RA患者,诱导治疗反应良好后,行预处理方案BCEA,回输自体骨髓,给予粒细胞集落刺激因子（G-CSF）等综合治疗,术后补行选择性淋巴结放疗,观察移植前后患者的临床表现、实验室指标的变化及免疫重建的过程。结果　移植后28 d造血功能恢复,2个月后关节肿全部消失,红细胞沉降率正常,CRP、IgMRF均转为阴性。患者出院后3个月恢复正常工作,随访13年NHL及RA无复发。结论　淋巴瘤并发RA患者进行自体骨髓移植治疗安全性好,中短期疗效显著,为淋巴瘤并发其他自身免疫病的治疗提供了新的可选择的治疗方法。     

潜匿性真性红细胞增多症与真性红细胞增多症鉴别诊断

目的：对比分析潜匿性真性红细胞增多症（mPV）和真性红细胞增多症（PV）的特点,探讨mPV 早期诊断的方法。方法收集符合诊断标准的男性初诊 PV、mPV 患者各100例,均行促红细胞生成素（EPO）、中性粒细胞碱性磷酸酶（NAP）、 JAK2 V617F 基因检测及骨髓组织活组织检查（BMB）。半年后追踪未经特殊治疗两组患者的血红蛋白（Hb）及 JAK2 V617F 基因突变负荷量变化情况。结果PV 组与 mPV 组 EPO 分别为（3.4±0.7）、（3.2±0.6） U／ml,NAP 积分分别为（276±20）、（278±21）分, BMB 造血容积分别为（78±10）%、（76±9）%,巨核细胞数分别为（53±6）、（51±5）个／张切片,差异均无统计学意义（均 P＞0.05）。 JAK2 V617F 基因突变负荷量分别为（89.2±9.4）%、（78.1±8.6）%,差异有统计学意义（P＜0.05）。 mPV 组中未经特殊治疗的半年后达 PV 水平（Hb≥185 g／L）的37例患者 Hb 平均水平为（194±8）g／L,JAK2 V617F 负荷量为（90.7±9.1）%。结论 PV、mPV 患者的 EPO、NAP 积分及骨髓组织形态学无差异,而 JAK2 V617F 基因突变负荷量有差异。未经特殊治疗的 mPV 患者 Hb 水平半年后多数可达到典型 PV 的诊断水平,JAK2 V617F 基因突变负荷量随之增加。     

Graft Failure after T Cell Depleted HLA Identical Allogeneic Bone Marrow Transplantation: Risk Factors in Leukemic Patients

In a retrospective analysis of T cell depleted bone marrow transplantation, we have looked at different parameters in order to determine risk-factors of graft-failure after allogeneic bone marrow transplantation for leukemia. Fifty-one patients with acute leukemia or chronic my-eloid leukemia have been analysed. For 33 of them, the pretransplant conditioning regimen consisted of fractionated total body irradiation (TBI) at 12 Gy prior to cyclophosphamide (120 mg/kg). The other patients received various reinforced preparative regimens. T-cell depletion consisted of treating marrow cells with pan-T monoclonal antibodies (CD2+CD3 or CD2-CD5-CD7) followed by complement mediated cytolysis. No post-transplant immu-nosuppressive prophylaxis was administered except for the first nine patients who received Methotrexate alone. In this group of 51 patients, 12 died within 3 months from graft-related complications and 10 developed graft failure (no engraftment or rejection). Among the possible risk factors associated with this failure, two graft-related parameters appeared significant: the number of CFU-GM progenitors and the number of viable T cells injected with the marrow inoculum. No correlation with graft failure was found with other parameters including diagnosis, disease status at transplant, conditioning regimen, age, sex, and CMV status of donor/host pairs. However, the interpretation must remain cautious because of the relatively small samples in each group.     

急性淋巴细胞白血病骨髓细胞单核细胞趋化蛋白-1的表达及其意义

 【摘要】　目的　探讨单核细胞趋化蛋白-1（CCL2）在B系急性淋巴细胞白血病（B-ALL）患者骨髓中的表达及其对白血病细胞增殖和黏附的影响。方法　提取30例B-ALL患者（试验组）及30例非血液肿瘤患者（对照组）骨髓基质细胞（BMMSC）及骨髓单个核细胞（BMMNC）,采用酶联免疫吸附法（ELISA）定量检测细胞培养上清液CCL2的质量浓度,反转录-聚合酶链反应（RT-PCR）检测CCL2基因mRNA水平;四甲基偶氮唑蓝比色（MTT）法检测细胞增殖及黏附;流式细胞术进行白血病细胞计数。结果　试验组的CCL2蛋白质量浓度[（780.12±129.61）pg／ml]明显高于对照组[（120.49±25.21）pg／ml]（t＝4.96,P＝0.00）;BMMSC体外培养上清液的CCL2蛋白质量浓度[（572.38±35.39）pg／ml]明显高于BMMNC[（193.85±15.45）pg／ml]（t＝5.37,P＝0.00）。在体外,CCL2不能单独刺激白血病细胞增殖,但在BMMSC+BMMNC共培养体系中,CCL2能刺激白血病细胞增殖,且随质量浓度增加,其增殖作用增强。CCL2在体外能增强白血病细胞与BMMSC 黏附,且与质量浓度呈正相关（r＝0.824,P＝0.02）。结论　B-ALL患者骨髓中CCL2水平增高,主要是由BMMSC分泌,白血病细胞能促进BMMSC 分泌CCL2,CCL2在BMMSC 环境下能刺激白血病细胞增殖,促进白血病细胞与BMMSC黏附,这些作用与CCL2 浓度呈正相关。     

Myeloproliferative and lymphoproliferative disorders: State of the art

Myeloproliferative neoplasms (MPNs), including polycythemia vera (PV), essential thrombocythemia (ET), and primary myelofibrosis (PMF), are clonal disorders complicated mainly by vascular events and transformation to myelofibrosis (for PV and ET) or leukemia. Although secondary malignancies, in particular, lymphoproliferative disorders (LPNs), are rare, they occur at a higher frequency than found in the general population, and there has been recent scientific discussion regarding a hypothetical relationship between treatment with JAK inhibitors in MPN and the risk of development of LPN. This has prompted increased interest regarding the coexistence of MPN and LPN. This review focuses on the role of JAK2 and the JAK/STAT pathway in MPN and LPN, whether there is a role for the genetic background in the occurrence of both MPN and LPN and whether there is a role for cytoreductive drugs in the occurrence of both MPN and LPN. Furthermore, whether an increased risk of lymphoma development is limited to patients who receive the JAK inhibitor ruxolitinib, is a more general phenomenon that occurs following JAK1/2 inhibition or is associated with preferential JAK1 or JAK2 targeting is discussed.     

Idiopathic Thrombocytopenic Purpura in HIV Infection: Therapeutic Possibilities of Intravenous Immunoglobulins

Summary

Idiopathic thrombocytopenic purpura is often present in HIV infections and may occur at any stage with frequently severe hemorrhagic risks.

In order to evaluate the possible beneficial therapeutic effects of intravenous immunoglobulins at doses of 1 g/Kg/day, the author compared two groups of 10 HIV positive patients each, with severe thrombocytopenia treated with randomized therapy.

The different results obtained in the two groups were significant both for the restoration and the maintenance of the platelet count and therefore for the duration of the hemorrhagic disorders.     

Microsatellite Instability Assessment by Immunohistochemistry in Acute Myeloid Leukemia: A Reappraisal and Review of the Literature

BackgroundMicrosatellite instability (MSI) is caused by defects in DNA mismatch repair (MMR) components. Inactivation of any MMR gene(s), including hMLH1, hMSH2, hMSH6, and hPMS2, can result in MSI. Immunohistochemistry (IHC) is a sensitive and specific screening tool for MSI that can detect loss of expression of one or more MMR components. Of the four MMR markers, hMLH1 and hMSH2 are considered most informative of MSI status. There has been renewed interest in MSI status in view of its favorable association with response to immune checkpoint inhibitors in some cancers. MMR expression patterns in acute myeloid leukemia (AML) have not been evaluated systematically.MethodsWe used clinically-validated IHC assays to assess the expression of hMLH1, hMSH2, hMSH6, and/or hPMS2 in formalin-fixed paraffin-embedded tissue sections of bone marrow core biopsies from patients diagnosed with AML. Mutation profiling was performed using next-generation sequencing to assess for mutations in MMR genes.ResultsThe study group included 236 patients with AML, including a cohort treated on a clinical trial of azacitidine and nivolumab (NCT02397720). In addition, hMSH6, and/or hPMS2 expression was assessed in 99 AML patients with diploid karyotype. All patients, except two, had retained expression of all MMR markers assessed: One patient from the azacytidine+nivolumab group had zonal patchy loss of staining of hMLH1 and, to a lesser extent, a similar staining pattern of hMSH2; and one patient from the AML with diploid karyotype group had loss of hMSH2 but retained expression of hMLH1, hMSH6 and hPMS2. In addition, a retrospective analysis on a separate cohort of 139 patients with primary AML, on which next generation sequencing profiling was performed, identified 14 cases with alterations in MMR genes.Conclusion and remarksMMR loss is a rare event in AML, thus does not appear to underlie response patterns to anti-PD1 therapy.     

胃癌病人骨髓微小转移灶的定量检测及临床意义

自１９９３年２月开始，采用抗上皮细胞单克隆抗体（抗ＥＭＡ单抗）为探针，利用免疫组化染色技术对胃癌患者进行骨髓内微小转移灶的临床研究。经对６５例胃癌患者的检测，阳性细胞检出率为５８．４％，对阳性结果患者进行了综合治疗对照观察，治疗前、后阳性结果有显著性变化，治疗前阳性细胞平均数为９．４５，治疗后为２．１８，经统计学分析治疗前、后阳性细胞数发现率有显著性变化（ｔ＝２．７７Ｐ＜０．００５）。分析结果表明，此项技术不但对胃癌病人有无血道转移提供客观依据，而且对临床的综合治疗也有重要的指导意义。     

Clinical Relevance of Minimal Residual Cancer in Patients with Solid Malignancies

With the advent of new therapeutic modalities, the treatment options for oncologists can vary greatly depending upon the aggressiveness of the patient's cancer. Patients may receive no therapy, adjuvant therapy, aggressive adjuvant therapy (taxane based), monoclonal antibody therapy (e.g. Herceptin) or bone marrow transplantation. It is now mandatory to determine accurate prognostic patient profiles at diagnosis and during therapy to determine who would benefit most from a particular therapeutic regimen or to determine who should be shifted into more aggressive therapy. We now have ultra-sensitive methods of tumor cell detection that can determine the presence of minimal residual cancer (MRC) in marrow, stem cell product (SCP) and lymph node to help create these prognostic profiles. The author has conducted a critical review of the literature regarding the type of testing used to detect MRC, the incidence of MRC in marrow, SCP, and lymph node, and the clinical significance of MRC at diagnosis and during therapy.To date it is now clear that immunohistochemistry is a very useful diagnostic tool with adequate sensitivity to detect MRC. The presence of MRC at diagnosis in marrow and/or lymph node is associated with a poor prognosis for a number of disorders including breast cancer, neuroblastoma, gastrointestinal tumors, and lung cancer. In addition, the presence of MRC during therapy in marrow and/or SCP is associated with a very poor prognosis for patients with breast cancer. The use of testing for MRC in the patient provides prognostic information that may be of use to the oncologist.     

Haematologic toxicities associated with the addition of bevacizumab in cancer patients

Background

Bevacizumab is currently approved for the treatment of several malignancies. Haematologic toxicities are not among the main concerns associated with bevacizumab, but they have been occasionally reported. We performed a meta-analysis to determine the incidence and risk of haematologic toxicities associated with bevacizumab.

Methods

Pubmed databases from 1966 to September 2010 were searched for studies reported, as well as American Society of Clinical Oncology meetings. Bevacizumab randomised clinical trials with adequate safety data profile were included. Statistical analyses were conducted to calculate the summary incidence, relative risk (RR) and 95% confidence intervals (CI).

Results

15,263 patients were included. The incidence of bevacizumab-associated all-grade and high-grade haematologic toxicities were, respectively: anaemia: 18.7% and 3.9%; neutropenia: 25.0% and 18.5%; and thrombocytopenia: 13.9% and 3.4%. Febrile neutropenia incidence was 3.8%. Compared to placebo/control arms, bevacizumab was associated with a decreased risk of all-grade (RR = 0.81; 95%CI 0.68-0.96; p = .016) and high-grade (RR = 0.73; 95%CI 0.60-0.89; p = .002) anaemia, and increased risks of all-grade (RR = 1.15; 95%CI 1.01-1.30; p = .033) and high-grade (RR = 1.08; 95%CI 1.02-1.13; p = .005) neutropenia, all-grade thrombocytopenia (RR = 1.22; 95%CI 1.00-1.48; p = .047) and febrile neutropenia (RR = 1.31; 95%CI 1.08-1.58; p = .006).

Conclusions

Bevacizumab is associated with a lower risk of anaemia and increased risks of neutropenia, thrombocytopenia and febrile neutropenia.     

乳腺癌患者骨髓中人乳腺珠蛋白mRNA的检测及其临床意义

目的探讨乳腺癌患者骨髓中人乳腺珠蛋白（hMAM）mRNA的表达及其临床意义。方法应用巢式RT—PCR技术,同时检测75例乳腺癌患者、15例乳腺良性病变患者和8例健康人骨髓中hMAMmRNA的表达,分析hMAMmRNA表达与临床病理因素、Ki67、p53和血管内皮生长因子（VEGF）的关系。结果RT—PCR检测的敏感度达到10^-6。75例乳腺癌患者中,21例检测出hMAMmRNA阳性表达,阳性表达率为28．0％。hMAMmRNA阳性表达与乳腺癌腋窝淋巴结转移和PR状况有关（P〈0．05）,与年龄、肿瘤大小、临床分期和ER状况无关（P〉0．05）;与乳腺癌组织Ki67表达呈正相关（X^2=4．936,P=0．026）。乳腺良性病变患者和健康人骨髓中,未检测到hMAMmRNA表达。结论应用RT—PCR方法检测乳腺癌骨髓中hMAMmRNA的表达,敏感度高、特异性好。hMAMmRNA可作为检测乳腺癌患者骨髓中播散肿瘤细胞的分子指标之一,可为乳腺癌患者的治疗和预后判断提供帮助。