RESUMEN
Inflammation plays a pivotal role in the pathogenesis of primary and post-essential thrombocythemia or post-polycythemia vera myelofibrosis (MF) in close cooperation with the underlying molecular drivers. This inflammatory state is induced by a dynamic spectrum of inflammatory cytokines, although recent evidence points to the participation of additional soluble inflammatory mediators. Damage-associated molecular patterns (DAMPs) represent endogenous signals released upon cell death or damage which trigger a potent innate immune response. We assessed the contribution of two prototypical DAMPs, HMGB1 and S100A8/A9, to MF inflammation. Circulating HMGB1 and S100A8/A9 were elevated in MF patients in parallel to the degree of systemic inflammation and levels increased progressively during advanced disease stages. Patients with elevated DAMPs had higher frequency of adverse clinical features, such as anemia, and inferior survival, suggesting their contribution to disease progression. Monocytes, which are key players in MF inflammation, were identified as a source of S100A8/A9 but not HMGB1 release, while both DAMPs correlated with cell death parameters, such as serum LDH and cell-free DNA, indicating that passive release is an additional mechanism leading to increased DAMPs. HMGB1 and S100A8/A9 promote inflammation through binding to Toll-like receptor (TLR) 4, whereas the former also binds TLR2. Monocytes from MF patients were shown to be hyperactivated at baseline, as reflected by higher CD11b and tissue factor exposure and increased expression levels of proinflammatory cytokines IL-1ß and IL-6. Patient monocytes showed preserved TLR4 and TLR2 expression and were able to mount normal or even exacerbated functional responses and cytokine upregulation following stimulation of TLR4 and TLR2. Elevated levels of endogenous TLR ligands HMGB1 and S100A8/A9 coupled to the finding of preserved or hyperreactive TLR-triggered responses indicate that DAMPs may promote monocyte activation and cytokine production in MF, fueling inflammation. Plasma IL-1ß and IL-6 were elevated in MF and correlated with DAMPs levels, raising the possibility that DAMPs could contribute to cytokine generation in vivo. In conclusion, this study highlights that, in cooperation with classic proinflammatory cytokines, DAMPs represent additional inflammatory mediators that may participate in the generation of MF inflammatory state, potentially providing novel biomarkers of disease progression and new therapeutic targets.
Asunto(s)
Alarminas , Calgranulina A , Calgranulina B , Proteína HMGB1 , Inflamación , Monocitos , Mielofibrosis Primaria , Humanos , Proteína HMGB1/sangre , Proteína HMGB1/metabolismo , Calgranulina A/sangre , Calgranulina B/sangre , Masculino , Femenino , Monocitos/inmunología , Monocitos/metabolismo , Anciano , Persona de Mediana Edad , Alarminas/metabolismo , Alarminas/inmunología , Inflamación/inmunología , Mielofibrosis Primaria/inmunología , Mielofibrosis Primaria/metabolismo , Anciano de 80 o más Años , Receptores Toll-Like/metabolismo , Citocinas/metabolismo , Adulto , Receptor Toll-Like 4/metabolismo , BiomarcadoresRESUMEN
Myeloproliferative neoplasms (MPN) are hematological diseases associated with genetic driver mutations in the JAK2, CALR, and MPL genes and exacerbated oncoinflammatory status. Analyzing public microarray data from polycythemia vera (n = 41), essential thrombocythemia (n = 21), and primary myelofibrosis (n = 9) patients' peripheral blood by in silico approaches, we found that pro-inflammatory and monocyte-related genes were differentially expressed in MPN patients' transcriptome. Genes related to cell activation, secretion of pro-inflammatory and pro-angiogenic mediators, activation of neutrophils and platelets, coagulation, and interferon pathway were upregulated in monocytes compared to controls. Together, our results suggest that molecular alterations in monocytes may contribute to oncoinflammation in MPN.
Asunto(s)
Monocitos , Trastornos Mieloproliferativos , Transcriptoma , Humanos , Monocitos/metabolismo , Monocitos/inmunología , Trastornos Mieloproliferativos/genética , Trastornos Mieloproliferativos/sangre , Inflamación/genética , Inflamación/sangre , Perfilación de la Expresión Génica/métodos , Policitemia Vera/genética , Policitemia Vera/sangre , Janus Quinasa 2/genética , Mielofibrosis Primaria/genética , Mielofibrosis Primaria/sangre , Trombocitemia Esencial/genética , Trombocitemia Esencial/sangre , Receptores de Trombopoyetina/genética , Regulación Neoplásica de la Expresión GénicaRESUMEN
Background: Among the chronic myeloproliferative neoplasms (MPNs) not associated with BCR-ABL mutations are polycythemia vera, primary myelofibrosis, and essential thrombocythemia. These diseases are caused by mutations in genes, such as the JAK2, MPL, and CALR genes, which participate in regulating the JAK-STAT signaling pathway. Objective: This study aimed to establish the frequencies of mutations in the JAK2, MPL, and CALR genes in a group of Colombian patients with a negative clinical diagnosis of BCR-ABL chronic myeloproliferative neoplasms. Methods: The JAK2 V617F and MPL W515K mutations and deletions or insertions in exon 9 of the CALR gene were analyzed in 52 Colombian patients with polycythemia vera, primary myelofibrosis, and essential thrombocythemia. Results: The JAK2V617F mutation was carried by 51.9% of the patients, the CALR mutation by 23%, and the MPL mutation by 3.8%; 23% were triple-negative for the mutations analyzed. In these neoplasms, 6 mutation types in CALR were identified, one of which has not been previously reported. Additionally, one patient presented a double mutation in both the CALR and JAK2 genes. Regarding the hematological results for the mutations, significant differences were found in the hemoglobin level, hematocrit level, and platelet count among the three neoplasms. Conclusion: Thus, this study demonstrates the importance of the molecular characterization of the JAK2, CALR and MPL mutations in Colombian patients (the genetic context of which remains unclear in the abovementioned neoplasms) to achieve an accurate diagnosis, a good prognosis, adequate management, and patient survival.
Antecedentes: Entre las neoplasias mieloproliferativas crónicas no asociadas con mutaciones BCR-ABL se encuentran la policitemia vera, la mielofibrosis primaria y la trombocitemia esencial. Estas enfermedades están causadas por mutaciones en genes, como los genes JAK2, MPL y CALR, que participan en la regulación de la vía de señalización JAK-STAT. Objetivo: Establecer las frecuencias de mutaciones en los genes JAK2, MPL y CALR en un grupo de pacientes colombianos con diagnóstico clínico negativo de NMP BCR-ABL. Metodos: Se analizaron las mutaciones y deleciones o inserciones JAK2 V617F y MPL W515K en el exón 9 del gen CALR en 52 pacientes colombianos con policitemia vera, mielofibrosis primaria y trombocitemia esencial. Resultados: La mutación JAK2V617F la portaban el 51.9% de los pacientes, la mutación CALR el 23.0% y la mutación MPL el 3.8%; El 23.0% fueron triple negativos para las mutaciones analizadas. En estas neoplasias se identificaron seis tipos de mutación en CALR, uno de los cuales no ha sido reportado previamente. Además, un paciente presentó una doble mutación tanto en el gen CALR como en el JAK2. En cuanto a los resultados hematológicos para las mutaciones, se encontraron diferencias significativas en el nivel de hemoglobina, el nivel de hematocrito y el recuento de plaquetas entre las tres neoplasias. Conclusiones: Así, este estudio demuestra la importancia de la caracterización molecular de las mutaciones JAK2, CALR y MPL en pacientes colombianos (cuyo contexto genético aún no está claro en las neoplasias antes mencionadas) para lograr un diagnóstico certero, un buen pronóstico, un manejo adecuado y una mejoría del paciente. supervivencia.
Asunto(s)
Calreticulina , Janus Quinasa 2 , Trastornos Mieloproliferativos , Receptores de Trombopoyetina , Humanos , Colombia , Janus Quinasa 2/genética , Mutación , Trastornos Mieloproliferativos/genética , Trastornos Mieloproliferativos/metabolismo , Policitemia Vera/genética , Mielofibrosis Primaria/genética , Receptores de Trombopoyetina/genética , Trombocitemia Esencial/genética , Calreticulina/genéticaRESUMEN
Myelofibrosis (MF) is a clonal hematopoietic stem cell disorder classified among chronic myeloproliferative neoplasms, characterized by exacerbated myeloid and megakaryocytic proliferation and bone marrow fibrosis. It is induced by driver (JAK2/CALR/MPL) and high molecular risk mutations coupled to a sustained inflammatory state that contributes to disease pathogenesis. Patient outcome is determined by stratification into risk groups and refinement of current prognostic systems may help individualize treatment decisions. Circulating cell-free (cf)DNA comprises short fragments of double-stranded DNA, which promotes inflammation by stimulating several pathways, including inflammasome activation, which is responsible for IL-1ß and IL-18 maturation and release. In this work, we assessed the contribution of cfDNA as a marker of disease progression and mediator of inflammation in MF. cfDNA was increased in MF patients and higher levels were associated with adverse clinical outcome, a high-risk molecular profile, advanced disease stages and inferior overall survival, indicating its potential value as a prognostic marker. Cell-free DNA levels correlated with tumor burden parameters and markers of systemic inflammation. To mimic the effects of cfDNA, monocytes were stimulated with poly(dA:dT), a synthetic double-stranded DNA. Following stimulation, patient monocytes released higher amounts of inflammasome-processed cytokine, IL-18 to the culture supernatant, reflecting enhanced inflammasome function. Despite overexpression of cytosolic DNA inflammasome sensor AIM2, IL-18 release from MF monocytes was shown to rely mainly on the NLRP3 inflammasome, as it was prevented by NLRP3-specific inhibitor MCC950. Circulating IL-18 levels were increased in MF plasma, reflecting in vivo inflammasome activation, and highlighting the previously unrecognized involvement of this cytokine in MF cytokine network. Monocyte counts were higher in patients and showed a trend towards correlation with IL-18 levels, suggesting monocytes represent a source of circulating IL-18. The close correlation shown between IL-18 and cfDNA levels, together with the finding of enhanced DNA-triggered IL-18 release from monocytes, suggest that cfDNA promotes inflammation, at least in part, through inflammasome activation. This work highlights cfDNA, the inflammasome and IL-18 as additional players in the complex inflammatory circuit that fosters MF progression, potentially providing new therapeutic targets.
Asunto(s)
Ácidos Nucleicos Libres de Células , Mielofibrosis Primaria , Humanos , Inflamasomas/metabolismo , Citocinas/metabolismo , Interleucina-18/metabolismo , Proteína con Dominio Pirina 3 de la Familia NLR/metabolismo , Mielofibrosis Primaria/genética , Inflamación/inducido químicamente , ADN , Progresión de la EnfermedadRESUMEN
OBJECTIVE: To analyze the karyotype test and myeloid panel with next-generation sequencing findings in patients with myelofibrosis, and to compare transplant characteristics in patients referred for bone marrow transplantation. METHODS: Retrospective, single-center study with patients diagnosed with myelofibrosis treated at Hospital Israelita Albert Einstein between 2010 and 2020. RESULTS: A total of 104 patients with myelofibrosis were examined. Patients who had not been submitted to tests in our service were excluded. The final sample comprised 69 patients. Of these 69, 56 were submitted to karyotyping and 22 to myeloid panel with next-generation sequencing. Karyotype was normal in 60% of the patients and altered in 40%. The prevalence of high-risk molecular mutations was higher in patients referred for bone marrow transplantation (100% versus 50%). The median follow-up of transplant patients was 2.4 years and the overall survival at 2 years was 80% (95%CI: 62-100%). CONCLUSION: The molecular analysis enables estimating the patient's risk and thus instituting more aggressive treatment such as bone marrow transplant for patients at higher risk, being a relevant tool to guide therapy. Given the significance of molecular analysis for therapeutic decision-making in myelofibrosis, collection and disclosure of data on the prevalence of cytogenetic changes and findings of next-generation sequencing in affected patients is important.
Asunto(s)
Trasplante de Células Madre Hematopoyéticas , Mielofibrosis Primaria , Humanos , Mielofibrosis Primaria/genética , Mielofibrosis Primaria/diagnóstico , Mielofibrosis Primaria/terapia , Estudios Retrospectivos , Mutación , Trasplante de Células Madre Hematopoyéticas/efectos adversos , PronósticoAsunto(s)
Translocación Genética , Cariotipo , Trombocitosis , Leucemia Mieloide , Citogenética , Mielofibrosis PrimariaRESUMEN
Contexto: Mielofibrose é uma neoplasia maligna rara que pode se desenvolver como doença primária, sendo uma doença mieloproliferativa crônica caracterizada pela falha da medula óssea e proliferação clonal de células mieloides associada com excesso de fibras de reticulina e/ou colágeno, e algum grau de atipia no megacariócito. O quadro clínico pode evoluir com esplenomegalia, anemia, sintomas constitucional (fadiga, sudorese noturna, febre), caquexia, dor óssea, infarto esplênico, prurido, trombose e sangramentos. A incidência na União Europeia e EUA é de 0,3 casos por 100.000 habitantes. Não há dados epidemiológicos robustos no Brasil. Ruxolitinibe é um inibidor seletivo das Janus Quinases associadas (JAKs) JAK1 e JAK2. A desregulação da via JAK-STAT tem sido associada a vários tipos de câncer e aumento da proliferação e sobrevida de células malignas. TECNOLOGIA: Ruxolitinibe. PERGUNTA: O uso de ruxolitinibe no tratamento da mielofibrose risco intermediário-2 ou alto (classificação IPSS), em adultos, com contagem plaquetária acima de 100.000/mm3 é eficaz e seguro quando comprado ao placebo ou à melhor terapia disponível? EVIDÊN
Asunto(s)
Humanos , Trasplante de Células Madre Hematopoyéticas/efectos adversos , Mielofibrosis Primaria/complicaciones , Mielofibrosis Primaria/tratamiento farmacológico , Inhibidores de las Cinasas Janus/uso terapéutico , Sistema Único de Salud , Brasil , Análisis Costo-Beneficio/economíaRESUMEN
CONTEXTO: Mielofibrose é uma neoplasia maligna rara que pode se desenvolver como doença primária, sendo uma doença mieloproliferativa crônica caracterizada pela falha da medula óssea e proliferação clonal de células mieloides associada com excesso de fibras de reticulina e/ou colágeno, e algum grau de atipia no megacariócito. O quadro clínico pode evoluir com esplenomegalia, anemia, sintomas constitucional (fadiga, sudorese noturna, febre), caquexia, dor óssea, infarto esplênico, prurido, trombose e sangramentos. A incidência na União Europeia e EUA é de 0,3 casos por 100.000 habitantes. Não há dados epidemiológicos robustos no Brasil. Ruxolitinibe é um inibidor seletivo das Janus Quinases associadas (JAKs) JAK1 e JAK2. A desregulação da via JAK-STAT tem sido associada a vários tipos de câncer e aumento da proliferação e sobrevida de células malignas. TECNOLOGIA: Ruxolitinibe. PERGUNTA: O uso de ruxolitinibe no tratamento da mielofibrose risco intermediário-2 ou alto (classificação IPSS), em adultos, com contagem plaquetária acima de 100.000/mm3 é eficaz e seguro quando comprado ao
Asunto(s)
Humanos , Quinasas Janus/antagonistas & inhibidores , Mielofibrosis Primaria/tratamiento farmacológico , Sistema Único de Salud , Brasil , Análisis Costo-Beneficio/economíaRESUMEN
Background: Primary erythrocytosis is a rare myeloproliferative disorder in dogs and cats characterized by an autonomous proliferation of erythroid precursors in the bone marrow, with low to normal serum erythropoietin concentration, resulting in elevated red blood cell count, hematocrit and hemoglobin concentration. Clinical signs are associated with increased blood volume and viscosity, and may include erythema, hyperemic mucous membranes and neurological signs such as seizures and ataxia. In veterinary medicine, the diagnosis should be made by exclusion of secondary or relative causes, after complementary exams. This report aims to describe a case of primary erythrocytosis in a bitch. Case: A 4-year-old mixed-breed bitch was referred to the Veterinary Medical Teaching Hospital from UFRGS with 3 convulsive episodes related by the owner. A previous abdominal ultrasonography revealed splenomegaly and the electrocardiogram showed no abnormalities. No alterations were observed at the physical examination. The laboratorial blood tests demonstrated a persistent erythrocytosis, with high hematocrit, hemoglobin and red blood cells count, thrombocytopenia and neutropenia, and total plasmatic protein within the reference interval. The bone marrow cytology revealed reduced cellularity, normal myeloid:erythroid ratio, erythroid hyperplasia, mild myeloid hyperplasia and moderate myelofibrosis. The serum erythropoietin measurement was within the reference range, and the blood gas analysis detected a slight decrease in partial oxygen pressure. Therefore, no evidence of secondary conditions was observed and the diagnosis of primary erythrocytosis could be made. Discussion: Since there is no definitive method, the diagnosis of primary erythrocytosis could be based on the exclusion of all secondary and relative causes of erythrocytosis. The absence of clinical signs of dehydration and high serum albumin levels were findings that conduced for the exclusion of the relative form of the disturbance. The echocardiography and the abdominal ultrasonography ruled out any cardiopulmonary condition or kidney neoplasm, the most common causes of absolute secondary erythrocytosis. The persistently high hematocrit levels and red blood cell counts are significant for the suspicion of primary erythrocytosis, although thrombocytopenia and neutropenia are not commonly reported. The clinical signs of seizure were correlated with increased blood viscosity and reduced blood flow at the central nervous system. The blood gas analysis discarded the occurrence of systemic hypoxia, and the normal levels of erythropoietin gives higher evidence of the occurrence of an autonomous proliferation of the erythroid precursors within the bone marrow. The bone marrow cytology confirmed erythroid hyperplasia and the reduced cellularity that could be attributed to myelofibrosis. Myelofibrosis was described in humans with polycythemia vera, but there are no reports in veterinary, and this occurrence must be elucidated. An identical mutation in the JAK2 gene was observed in humans with polycythemia vera and dogs with primary erythrocytosis, and occurs in more than 50% of humans with myelofibrosis. Further investigations are necessary for veterinary medicine. In conclusion, the systematic approach of all organic systems and the assessment of complementary exams are necessary for the diagnostic of primary erythrocytosis in dogs. This condition should be considered in the differential diagnosis of any erythrocytosis, considering the guarded prognosis of this hematologic disorder.
Asunto(s)
Animales , Femenino , Perros , Policitemia/veterinaria , Eritropoyetina/análisis , Mielofibrosis Primaria/veterinaria , Esplenomegalia/veterinaria , Ultrasonografía/veterinariaRESUMEN
Toll-like receptors (TLRs) are a family of transmembrane receptors whose signaling control cellular processes of cell proliferation, survival, apoptosis, angiogenesis, remodeling, and repair of tissues. Polymorphisms in TLR genes can change the balance between pro and anti-inflammatory cytokines, modulating the risk of infection, chronic inflammation, and cancer. Although many studies have demonstrated the direct involvement of TLR signaling in the benefit of tumor cells in certain cancers, little is known about the influence of these gene polymorphisms on myeloproliferative neoplasms (MPNs). In this context, the objective of the study was to investigate a possible association between the TLR polymorphisms and the development of MPNs. 167 patients diagnosed with MPN and 222 healthy controls from the same region were evaluated. Genomic DNA was extracted and the TLR2 (rs5743708), TLR4 (rs4986790, rs4986791), TLR9 (rs5743836, rs187084) and JAK2V617F polymorphisms were genotyped by PCR-RFLP. The statistical analysis was performed by OpenEpi and SNPstat software. The JAK2V617F mutation was found in 68.32% of patients. TLR9-1486C/T CT genotype was less frequent in patients with polycythemia vera (PV) (OR 0.39, 95% CI 0.20-0.78, P = 0.025). When haplotype frequencies were analyzed, -1237T/-1486C (TLR9) was also less frequent in men (OR 0.58, 95% CI 0.36-0.94) and JAK negative men patients (OR 0.43, 95% CI 0.21-0.88). We can infer that the TLR9-1486 CT genotype could be associated with protection for PV and the TLR9-1237T/-1486C haplotype, protection for men, as well as for JAK negative men patients with MPN. There were no associations between TLR2 and TLR4 gene polymorphisms and MPN.
Asunto(s)
Neoplasias de la Médula Ósea/genética , Janus Quinasa 2/genética , Receptor Toll-Like 9/genética , Receptores Toll-Like/genética , Adulto , Anciano , Neoplasias de la Médula Ósea/metabolismo , Femenino , Haplotipos/genética , Humanos , Janus Quinasa 2/metabolismo , Masculino , Persona de Mediana Edad , Trastornos Mieloproliferativos/genética , Policitemia Vera/genética , Polimorfismo de Nucleótido Simple/genética , Mielofibrosis Primaria/genética , Trombocitemia Esencial/genética , Receptor Toll-Like 2/genética , Receptor Toll-Like 2/metabolismo , Receptor Toll-Like 4/genética , Receptor Toll-Like 4/metabolismo , Receptor Toll-Like 9/metabolismo , Receptores Toll-Like/metabolismoRESUMEN
La panmielosis aguda con mielofibrosis (PMAF) es un raro desorden hematológico, definido como un subtipo de leucemia aguda. Se reporta un paciente masculino de 31 años de edad con historia de decaimiento marcado, fiebre vespertina y gingivorragia. El examen físico muestra palidez cutáneo mucosas, esplenomegalia ligera y en exámenes complementarios pancitopenia con 5 por ciento de blastos. En el medulograma no se obtuvo material y la impronta sugiere leucemia mieloide aguda no promielocítica. El estudio de inmunofenotipo por citometría de flujo confirma incremento de mieloblastos positivo para (CD34, CD13, CD17, CD117, CD38) y disminuidos en (CD11c y HLA-DR), con una mielofibrosis marcada en biopsia de medula ósea sin la presencia de blastos. Recibe tratamiento de inducción con esquema 3 + 7 (Citosar + Rubidomicina) después del cual el paciente se encuentra en remisión hematológica con persistencia de la fibrosis medular. Posteriormente inicia tratamiento con lenalidomida, Bifosfonatos (Ácido Zoledronico) y se encuentra en remisión hematológica 11 meses después del diagnóstico, hasta marzo 2020. Se realizan estudios de histocompatibilidad (HLA) para trasplante alogénico(AU)
Acute panmyelosis with myelofibrosis (PMAF) is a rare hematologic disorder, defined as a subtype of acute leukemia. A 31-year-old male patient with a history of marked decay, evening fever, and gingivorrhagia is reported. The physical examination showed mucous skin paleness, slight splenomegaly and the complementary examinations showed pancytopenia with 5 percent blasts. In the medullogram no material was obtained and the imprint suggests non-promyelocytic acute myeloid leukemia. Immunophenotype study by flow cytometry confirmed an increase in myeloblasts positive for (CD34, CD13, CD17, CD117, CD38) and decreased in (CD11c and HLA-DR), with marked myelofibrosis in bone marrow biopsy without the presence of blasts. He received induction treatment with a 3 + 7 scheme (Citosar + Rubidomycin) after which the patient was in hematological remission with persistence of spinal fibrosis. Later, he started treatment with lenalidomide, bisphosphonates (Zoledronic Acid) and was in hematological remission 11 months after diagnosis, until March 2020. Histocompatibility studies (HLA) were performed for allogeneic transplantation(AU)
Asunto(s)
Humanos , Leucemia Mieloide Aguda/tratamiento farmacológico , Leucemia Mieloide Aguda/epidemiología , Enfermedades Mielodisplásicas-Mieloproliferativas/diagnóstico , Mielofibrosis PrimariaRESUMEN
BACKGROUND: Philadelphia-negative myeloproliferative neoplasms (Ph-MPN) are chronic hematological disorders characterized by the overproduction of one or more mature myeloid blood cell lineages. Classical Ph-MPN are polycythemia vera (PV), essential thrombocytopenia (ET) and primary myelofibrosis (PMF). AIM: To assess the epidemiological, clinical and diagnostic characteristics of Ph-MPN in Chile. MATERIAL AND METHODS: Retrospective review of medical records of all patients referred as MPN from 2012 to 2017. Patients with (9;21) translocation were excluded. RESULTS: Data of 462 cases with a median age of 69 years from 10 public hospitals was reviewed. ET was the most frequently Ph-MNP found. The incidence of Ph-MPN was 1.5 x 100.000 cases. The JAK2 V617F mutation study was performed in 96% of patients and only 30% had a bone marrow biopsy. Thrombotic events were observed in 29% of patients. Bleeding events were observed in 7%. Five-year overall survival was 87%. CONCLUSIONS: ET is the most frequent Ph-MPN. The mean incidence was lower than reported in the literature, in part because of a sub diagnosis.
Asunto(s)
Trastornos Mieloproliferativos , Policitemia Vera , Mielofibrosis Primaria , Trombocitemia Esencial , Anciano , Chile/epidemiología , Humanos , Janus Quinasa 2/genética , Mutación , Trastornos Mieloproliferativos/diagnóstico , Trastornos Mieloproliferativos/epidemiología , Trastornos Mieloproliferativos/genética , Policitemia Vera/diagnóstico , Policitemia Vera/epidemiología , Policitemia Vera/genética , Mielofibrosis Primaria/diagnóstico , Mielofibrosis Primaria/epidemiología , Mielofibrosis Primaria/genética , Trombocitemia Esencial/diagnóstico , Trombocitemia Esencial/genéticaRESUMEN
BACKGROUND: Philadelphia-negative myeloproliferative neoplasms (Ph-MPN) are chronic hematological disorders characterized by the overproduction of one or more mature myeloid blood cell lineages. Classical Ph-MPN are polycythemia vera (PV), essential thrombocytopenia (ET) and primary myelofibrosis (PMF). AIM: To assess the epidemiological, clinical and diagnostic characteristics of Ph-MPN in Chile. MATERIAL AND METHODS: Retrospective review of medical records of all patients referred as MPN from 2012 to 2017. Patients with (9;21) translocation were excluded. RESULTS: Data of 462 cases with a median age of 69 years from 10 public hospitals was reviewed. ET was the most frequently Ph-MNP found. The incidence of Ph-MPN was 1.5 x 100.000 cases. The JAK2 V617F mutation study was performed in 96% of patients and only 30% had a bone marrow biopsy. Thrombotic events were observed in 29% of patients. Bleeding events were observed in 7%. Five-year overall survival was 87%. CONCLUSIONS: ET is the most frequent Ph-MPN. The mean incidence was lower than reported in the literature, in part because of a sub diagnosis.
Asunto(s)
Trastornos Mieloproliferativos , Policitemia Vera , Mielofibrosis Primaria , Trombocitemia Esencial , Anciano , Chile/epidemiología , Humanos , Janus Quinasa 2/genética , Mutación , Trastornos Mieloproliferativos/diagnóstico , Trastornos Mieloproliferativos/epidemiología , Trastornos Mieloproliferativos/genética , Policitemia Vera/diagnóstico , Policitemia Vera/epidemiología , Policitemia Vera/genética , Mielofibrosis Primaria/diagnóstico , Mielofibrosis Primaria/epidemiología , Mielofibrosis Primaria/genética , Trombocitemia Esencial/diagnóstico , Trombocitemia Esencial/genéticaRESUMEN
Abstract Background and objective: in the global scientific literature, the frequency of JAK2 is highly heterogenous in chronic myeloproliferative neoplasms. The objective of this study was to analyze the prevalence of the JAK2 mutation in primary myelofibrosis (PMF) and compare it according to the detection method used, from 2007-2018. Materials and methods: a systematic review with meta-analysis, using 21 searches in three multidisciplinary databases. The PRISMA guideline phases of identification, screening, selection and inclusion were applied. Reproducibility and evaluation of the methodological quality were ensured. The analyses were based on frequencies and meta-analysis for the prevalence of the mutation with its 95% confidence interval. Results: twenty-nine studies with 744 patients were included, mainly from Korea, Brazil and China. The most commonly used technique was AS-PCR, and the prevalence of JAK2 with this technique ranged from 33.3 to 71.4%; with real-time PCR ranging from 42.9 to 77.3%, sequencing from 14.3-57.4%, and ARMS from 36.4-83.3%. The prevalence of JAK2 showed no statistically significant differences according to the type of diagnostic test used. Conclusion: high frequencies of the JAK2V617F mutation are seen in PMF, which shows that this entity should not be diagnosed solely based on clinical and hematological characteristics, but also on the patients' genetic screening.
Resumen Antecedentes y objetivo: en la literatura científica mundial la frecuencia de JAK2 presenta una alta heterogeneidad en las neoplasias mieloproliferativas crónicas. El objetivo de esta investigación fue analizar la prevalencia de la mutación JAK2 en mielofibrosis Primaria (MFP) y compararla según la técnica de detección en los años 2007-2018. Material y métodos: revisión sistemática con metaanálisis, usando 21 búsquedas en tres bases de datos multidisciplinarias. Se aplicaron las fases de identificación, tamización, elección e inclusión de la guía PRISMA. Se garantizó reproducibilidad y evaluación de la calidad metodológica. Los análisis se basaron en frecuencias y metaanálisis para la prevalencia de la mutación con su intervalo de confianza de 95%. Resultados: se incluyeron 29 estudios con 744 pacientes, los cuales provienen principalmente de Corea, Brasil y China. La técnica más empleada fue AS-PCR, las prevalencias de JAK2 con esta técnica oscilaron entre 33.3 y 71.4%; con PCR en tiempo real entre 42.9 y 77.3%, con secuenciación de 14.3-57.4% y en ARMS de 36.4-83.3%. La prevalencia de JAK2 no presentó diferencias estadísticamente significativas según el tipo de prueba diagnóstica utilizada. Conclusión: se evidencian altas frecuencias de la mutación JAK2V617F en MFP, lo que evidencia que el diagnóstico de esta entidad no debe realizarse únicamente por características clínicas y hematológicas sino también por la tamización genética de los pacientes.
Asunto(s)
Humanos , Masculino , Femenino , Metaanálisis , Pacientes , Pruebas Genéticas , Prevalencia , Janus Quinasa 2 , Mielofibrosis Primaria , MutaciónRESUMEN
ABSTRACT Background: The classical BCR-ABL1-negative myeloproliferative neoplasms (MPNs) are Polycythemia Vera (PV), Essential Thrombocythemia (ET) and Primary Myelofibrosis (PMF). In developing countries, there are few reports that truly reveal the clinical setting of these patients. Therefore, we aimed to characterize a single center MPN population with a special focus on the correct diagnosis based on the recent review of the WHO criteria for the diagnosis of myeloid neoplasms. Methods: This retrospective study analyzed data from medical records of patients with classical BCR-ABL1-negative MPNs diagnosed from January 1997 to October 2017 and followed at the University Hospital of Ribeirão Preto Medical School. Results: A total of 162 patients were assessed, 61 with PV, 50 with ET, and 51 with PMF. The mutational status analysis revealed that 113 (69.3%) harbored the JAK2V617F mutation, 23 (14.1%), the CALR mutation, and 12 (7.4%) had a triple-negative status. None of the patients were found to have mutations on the thrombopoietin receptor gene (MPL), including some ET and PMF patients who were not tested. Among the PV patients, 57 (93.5%) were positive for the JAK2V617F mutation, one (1.6%) presented an in-frame deletion JAK2 exon 12 mutation and one (1.6%) presented a missense JAK2 exon 9 mutation, not previously described. The overall survival was lower in the triple-negative patients with PMF, when compared to the JAK2V617F or CALR-mutated (p= 0.002). Conclusion: The frequency of somatic mutations and survival in our cohort, stratified according to the respective disease, was consistent with the literature data, despite some limitations. Further prospective epidemiological studies of MPN cohorts are encouraged in developing countries.
Asunto(s)
Humanos , Masculino , Adulto , Persona de Mediana Edad , Anciano , Anciano de 80 o más Años , Policitemia Vera , Leucemia Mieloide Crónica Atípica BCR-ABL Negativa , Mielofibrosis Primaria , Trombocitemia Esencial , Trastornos MieloproliferativosRESUMEN
Genomic characterization of patients with myeloproliferative neoplasms (MPN) may lead to better diagnostic classification, prognostic assessment, and treatment decisions. These goals are particularly important in myelofibrosis (MF). We performed target Next Generation Sequencing for a panel of 255 genes and Chromosome Microarray Analysis (CMA) in 27 patients with MF. Patients were classified according to genomic findings and we compared the performance of a personalized prognostication system with IPSS, MIPSS70 and MIPSS70 + v2. Twenty-six patients presented mutations: 11.1% had single driver mutations in either JAK2, CALR or MPL; 85.2% had mutations in non-restricted genes (median: 2 per patient). CMA was abnormal in 91.7% of the 24 cases with available data. Copy-Number-Neutral Loss-of-Heterozygosity was the most common finding (66.7%). Del13q was the most frequent copy number variation, and we could define a 2.4 Mb minimally affected region encompassing RB1, SUCLA2 and CLLS2 loci. The largest genomic subgroup consisted of patients with mutations in genes involved with chromatin organization and splicing control (40.7%) and the personalized system showed better concordance and accuracy than the other prognostic systems. Comprehensive genomic characterization reveals the striking genetic complexity of MF and, when combined with clinical data, led, in our cohort, to better prognostication performance.
Asunto(s)
Variaciones en el Número de Copia de ADN , Genómica , Trastornos Mieloproliferativos/genética , Mielofibrosis Primaria/genética , Adulto , Anciano , Anciano de 80 o más Años , Brasil , Proteínas de Unión al Calcio/genética , Calreticulina/genética , Moléculas de Adhesión Celular/genética , Estudios de Cohortes , Femenino , Secuenciación de Nucleótidos de Alto Rendimiento/métodos , Humanos , Janus Quinasa 2/genética , Pérdida de Heterocigocidad/genética , Masculino , Análisis por Micromatrices/métodos , Persona de Mediana Edad , Mutación , Trastornos Mieloproliferativos/clasificación , Mielofibrosis Primaria/clasificación , PronósticoRESUMEN
INTRODUÇÃO: A mielofibrose é um distúrbio mieloproliferativo clonal, caracterizado por hematopoiese ineficiente e fibrose da medula óssea. A doença pode apresentar de novo (mielofibrose primária) ou após uma policitemia vera previamente conhecida ou trombocitemia essencial. As manifestações clínicas incluem anemia, esplenomegalia e caquexia. O distúrbio ocorre quando as células-tronco do sangue desenvolvem mutações somáticas nos genes JAK2, MPL, CALR e TET2. Outros genes também podem estar envolvidos. Embora a mielofibrose possa ocorrer em qualquer idade, ela geralmente se desenvolve após os 50 anos. O tratamento visa aliviar sinais e sintomas e pode incluir medicamentos, transfusões de sangue, quimioterapia, radioterapia e cirurgia. O transplante de medula óssea ou de células-tronco pode melhorar os sintomas e curar a doença. PERGUNTA: O uso de ruxolitinibe no tratamento da mielofibrose de risco intermediário-2 ou alto, classificada de acordo com a avaliação pelo Sistema de Pontuação de Prognóstico Internacional (IPSS - International Prognostic Scoring System), é eficaz, seguro e custo-efetivo quando comparado ao placebo ou à melhor terapia disponível? EVIDÊNCIAS CIENTÍFICAS: ruxolitinibe parece fornecer benefícios no alívio dos sintomas da doença (OR 15,3 (IC95% 6,9 - 33,7). Dados de longo prazo do estudo COMFORT-I e II demonstraram diferença estatisticamente significativa na sobrevida global, favorecendo o ruxolitinibe (essa diferença durou cerca de cinco anos). Os benefícios do ruxolitinibe na redução do tamanho do baço em ≥ 35% foram observados em todos os subtipos de MF e em pacientes com risco intermediário 2 ou doença de alto risco. A anemia foi o evento adverso (EA) de grau 3 ou 4 mais frequentemente relatado em ambos os ensaios de fase 3, seguido de trombocitopenia. Esses EAs raramente levavam à descontinuação e eram geralmente gerenciados por modificações de dose ou transfusões sanguíneas. AVALIAÇÃO ECONÔMICA: no cenário onde o custo do comparador é a média das APACs 03.04.03.003-1 e 03.04.03.004-0, o tratamento com ruxolitinibe apresentou uma Razão de Custo Utilidade Incremental (RCUI) de R$ 298.767 por anos de vida ajustado por qualidade (AVAQ) salvo. Considerando apenas os dados de sobrevida global de cinco anos do estudo COMFORT-II ajustado pelo cruzamento, o tratamento resultaria em uma RCUI de R$ 308.394 por AVAQ salvo. O demandante não incluiu os custos da leucemia visto que progressão da mielofibrose primária para leucemia pode ser frequente. Não foi incluído na análise de sensibilidade a variação do custo do tratamento, sendo este, o segundo fator mais impactante. AVALIAÇÃO DE IMPACTO ORÇAMENTÁRIO: a análise apresentou o valor incremental de cerca de R$ 44 milhões no primeiro ano após a incorporação, e um total acumulado de R$ 300 milhões em cinco anos. A principal limitação dos dados é a população elegível. Não há dados epidemiológicos publicados no Brasil e algumas suposições, como os dados de prevalência do Distrito Federal ser representativo para todo o território brasileiro, foram assumidas pelo demandante. Na literatura internacional a prevalência de qualquer MF variou 0,51/ 100.000 a 2,7/100.000 pacientes. O impacto da incorporação de ruxolitinibe no SUS é incerto. MONITORAMENTO DO HORIZONTE TECNOLÓGICO: foi identificado o medicamento oral momelotinibe, um Inibidor de JAK-1 e JAK-2. Na pesquisa também foi detectado o medicamento fedratinibe, um inibidor de JAK 2 que tem como alvo a mutação JAK2V617F e FLT3ITD, que obteve o registro no FDA em 2019, indicado para pacientes com MFP, Pós- PVMF ou Pós- TEMF, previamente tratados com ruxolitinibe. CONSIDERAÇÕES: evidências de baixa qualidade mostraram que o ruxolitinibe apresentou superioridade em comparação com o placebo ou a melhor terapia disponível no tratamento de MFP, Pós- PVMF ou Pós- TEMF, com taxas mais altas de controle da esplenomegalia, melhora dos sintomas e qualidade de vida. Existe uma incerteza acerca da sobrevida global, mas em geral, pacientes tratados com ruxolitinibe apresentaram maior sobrevida que o controle. As respostas foram mantidas por um período médio inferior a cinco anos e o benefício ocorreu independentemente do subtipo de mielofibrose, faixa etária, presença ou ausência da mutação JAK2 V617F, níveis de hemoglobina e contagem de plaquetas. RECOMENDAÇÃO PRELIMINAR DA CONITEC: após análise das evidências o plenário considerou que o ruxolitinibe é paliativo e não substitutivo, além de apresentar eventos adversos que necessitam de intervenções como transfusões sanguíneas. Apesar de ter apresentado benefícios na melhoria dos sintomas constitucionais da doença, qualidade de vida e redução do baço, o medicamento não pode ser considerado como custo-efetivo em comparação com a MTD. Pelo exposto, a Conitec, em sua 85ª reunião ordinária, no dia 04 de fevereiro de 2020, recomentou a não incorporação no SUS do ruxolitinibe para o tratamento da mielofibrose em pacientes com risco intermediário-2 a alto com contagem de plaquetas ≥50.000/mm3. A matéria foi disponibilizada em consulta pública. CONSULTA PÚBLICA: o Relatório de Recomendação da Conitec foi disponibilizado por meio da Consulta Pública nº 04/2020 entre os dias 21/02/2020 e 17/03/2020. Foram recebidas 1.347 contribuições, sendo 284 técnico-científicas e 1.063 contribuições de experiência ou opinião. Não foram adicionadas na CP referências que alterassem as análises da evidência apresentada neste relatório. Foram acrescentadas informações de diretrizes internacionais que indicaram o ruxolitinibe como tratamento de 1ª linha em pacientes com mielofibrose. Tanto nas contribuições de experiência e opinião, quanto as técnico-científicas apontaram a melhora na qualidade de vida e nos sintomas constitucionais da doença. RECOMENDAÇÃO FINAL: Os membros da Conitec presentes na 87ª reunião ordinária, no dia 04 de junho de 2020, deliberaram, por unanimidade, recomendar a não incorporação do ruxolitinibe para tratamento de pacientes com mielofibrose primária, mielofibrose pós policitemia vera ou mielofibrose pós trombocitemia essencial, de risco intermediário-2 ou alto e com contagem de plaquetas superior a 50.000/mm3. Foi assinado o Registro de Deliberação nº 523/2020. DECISÃO: não incorporar o ruxolitinibe para tratamento de pacientes com mielofibrose primária, mielofibrose pós policitemia vera ou mielofibrose pós trombocitemia essencial, de risco intermediário-2 ou alto, no âmbito do Sistema Único de Saúde - SUS, conforme a Portaria nº 20, publicada no Diário Oficial da União nº 113, seção 1, página 35, em 16 de junho de 2020.
Asunto(s)
Humanos , Quinasas Janus/antagonistas & inhibidores , Mielofibrosis Primaria/tratamiento farmacológico , Evaluación de la Tecnología Biomédica , Sistema Único de Salud , Brasil , Análisis Costo-Beneficio/economíaRESUMEN
Abstract Introduction Ruxolitinib has been approved for the treatment of myelofibrosis (MF). In this study, we present safety and efficacy findings from an analysis of 104 patients with intermediate- and high-risk MF in a Brazilian cohort of the JUMP study who received treatment with ruxolitinib. Methods JUMP is a single-arm, open-label, phase IIIb, expanded-access study. The primary endpoint was to evaluate the safety and tolerability (frequency, duration, and severity of adverse events [AEs]) of ruxolitinib. Results All of the 104 patients received the treatment. Median duration of exposure was 35.8 months. The most common hematologic AEs were anemia (57.7), thrombocytopenia (38.5%), neutropenia (11.5%), and leukopenia (9.6%). Second malignancies (all grades) occurred in 19.2% of patients (n = 20). Serious AEs were reported in 62.5% of patients (n = 65). The proportions of patients with ≥50% reduction from baseline in palpable spleen length at weeks 24 and 48 were 62.7% and 69.2%, respectively. The mean change from the baseline in the Functional Assessment of Cancer Therapy (FACT)-Lymphoma total score was 10.8 [15.6%] at week 4, 12.6 [14.1%] at week 24, and 12.2 [14.3%] at week 48. The mean change from the baseline for the Functional Assessment of Chronic Illness Therapy (FACIT)-Fatigue scale was 3.9 [42.8%] at week 4, 4.9 [29.9%] at week 24, and 4.7 [28%] at week 48. At week 48, the estimated progression-free survival, leukemia-free survival, and overall survival probabilities were 91%, 91% and 93%, respectively Overall, 21 deaths were observed in the present study. Conclusion Findings from this study suggest that ruxolitinib could be evaluated as a standard-of-care treatment for the MF population in need of a viable treatment option. NCT01493414
Asunto(s)
Humanos , Masculino , Adulto , Persona de Mediana Edad , Anciano , Anciano de 80 o más Años , Quimioterapia , Mielofibrosis Primaria/terapia , Policitemia , Esplenomegalia , Trombocitosis , BrasilRESUMEN
RAS-pathway mutations are recurrent events in myeloid malignancies. However, there is limited data on the significance of RAS-pathway mutations in patients with myelofibrosis (MF). We analyzed next-generation sequencing data of 16 genes, including RAS-pathway genes, from 723 patients with primary and secondary MF across three international centers and evaluated their significance. N/KRAS variants were present in 6% of patients and were typically sub-clonal (median VAF = 20%) relative to other genes variants. RAS variants were associated with advanced MF features including leukocytosis (p = 0.02), high somatic mutation burden (p < 0.01) and the presence of established "molecular high-risk" (MHR) mutations. MF patients with N/KRAS mutations had shorter 3-year overall survival (OS) (34% vs 58%, p < 0.001) and higher incidence of acute myeloid leukemia at 3 years (18% vs 11%, p = 0.03). In a multivariate Cox model, RAS mutations were associated with decreased OS (HR 1.93, p < 0.001). We created a novel score to predict OS incorporating RAS mutations, and it predicted OS across training and validation cohorts. Patients with intermediate risk/high-risk DIPSS with RAS mutations who received ruxolitinib had a nonsignificant longer 2-year OS relative to those who did not receive ruxolitinib. These data demonstrate the importance of identifying RAS mutations in MF patients.