Daniele Cattaneo

Effects of first- and second-generation tyrosine kinase inhibitor therapy on glucose and lipid metabolism in chronic myeloid leukemia patients: a real clinical problem?

Background Tyrosine kinase inhibitors (TKIs) have dramatically changed the prognosis of patients with chronic myeloid leukemia (CML). They have a distinct toxicity profile that includes glycometabolic alterations: i.e. diabetes mellitus (DM), impaired fasting glucose (IFG), and the metabolic syndrome (MS). The aim of this study was to evaluate the prevalence of these alterations in a cohort of CML-chronic phase patients treated with imatinib, dasatinib or nilotinib. Methods The study involved 168 consecutive CML-chronic phase patients with no history of DM/IFG or MS. Anthropometric and metabolic parameters were assessed, and DM/IFG and MS were diagnosed based on the criteria of the American Diabetes Association and the National Cholesterol Education Program-Adult Treatment Panel III, respectively. Results The nilotinib group had significantly higher levels of fasting plasma glucose, insulin, C-peptide, insulin resistance, and total and LDL cholesterol than the imatinib and dasatinib groups. DM/IFG were identified in 25% of the imatinib- and dasatinib-treated patients, and 33% of those in the nilotinib cohort (p = 0.39 vs imatinib and p = 0.69 vs dasatinib). A diagnosis of MS was made in 42.4% of the imatinib-treated patients, 37.5% of the dasatinib-treated patients, and 36.1% of the nilotinib-treated patients (p = 0.46 vs imatinib and p = 0.34 vs dasatinib). Conclusions Treatment with nilotinib does not seem to induce DM/IFG or the MS to a significantly higher extent than imatinib or dasatinib, though it causes a worse glycometabolic profile. These findings suggest the need for a close monitoring of glucose and lipid metabolism and a multidisciplinary approach in patients treated with nilotinib.

Imatinib and ruxolitinib association: first experience in two patients

We report the first case of 2 patients with a previous diagnosis of post-polycythemic (PV) myelofibrosis who developed chronic myeloid leukemia (CML) seven years later, both treated with an association of a tyrosine-kinase inhibitor (imatinib) and a JAK1/JAK2 inhibitor (ruxolitinib). In 1992, a 46-

Molecular analyses in the diagnosis of myeloproliferative neoplasm-related splanchnic vein thrombosis

Dear Editor, Myeloproliferative neoplasms (MPNs) are characterized by proliferation of mature blood elements, progressive stromal alterations and/or evolution to acute myeloid leukemia. Significant morbidity and mortality are due to an increased risk of thrombosis, either arterial or venous [1]. Clinical manifestations may vary widely; in particular, venous thrombosis can occur not only in common sites, but also in unusual sites, including cerebral [2] or splanchnic district (SVT), the latter showing a prevalence ranging between 1 and 23 %. As the occurrence of SVT can be related to MPNs in about half of the cases, the search for JAK2 V617F mutation should be performed in all SVT patients, even in the presence of normal blood cell counts [3, 4]. However, this mutation is not detectable in all MPN patients, rendering this biomarker far from being an optimal diagnostic test in SVT-related MPN cases. Regarding MPL, its mutations have been documented in a significantly lower number of SVT patients [5, 6]. Finally, after the description of calreticulin (CALR) mutations [7, 8], Turon et al. [9] and Haslam et al. [10] have recently evaluated their incidence in two cohorts of SVT patients of different etiologies, but they detected them in only 1.9% and in 0% of all cases, respectively. To gain further insights, we retrospectively evaluated a consecutive series of 29 patients from our hospital between 1979 and 2013 with a diagnosis of MPN-related SVT. All our cases were evaluated for JAK2 V617F and MPL mutations. In 27 patients out of 29, JAK2 V617F mutation was detected, and we also evaluated JAK2 allele burden: it varied widely and the median value was 27 % (range 4.8– 97 %). The two JAK2-negative patients were evaluated for MPL mutations, and one of them carried a rare mutant variant, W515K. In the other patient, CALR was subsequently evaluated but did not carry any mutation. All these features are reported in Table 1. These molecular data are in line with previous findings in the literature and stress the critical role of searching for JAK2 V617F mutation in all SVT patients [3, 4]. However, this diagnostic test alone is not always enough: indeed, two patients of ours did not carry this mutation. As a consequence, in JAK2-negative cases, the next step should be to search for CALR and, if negative, also for MPL mutations, even though in the literature the latter have been reported in only 3.4 % of SVT cases [5, 6, 10]. Furthermore, our data show that JAK2 allele burden varies widely in MPN-related SVT patients, thus not representing a useful tool to distinguish between the different BCR-ABL1negative MPNs. Regarding CALR mutations, in the only A. Iurlo (*) :D. Cattaneo : E. Fermo :A. Cortelezzi Oncohematology Division, IRCCS Ca’ Granda – Maggiore Policlinico Hospital Foundation and University of Milan, Milan, Italy e-mail: aiurlo@policlinico.mi.it

Splanchnic vein thrombosis in myeloproliferative neoplasms: Risk factors for recurrences in a cohort of 181 patients

We retrospectively studied 181 patients with polycythaemia vera (n=67), essential thrombocythaemia (n=67) or primary myelofibrosis (n=47), who presented a first episode of splanchnic vein thrombosis (SVT). Budd–Chiari syndrome (BCS) and portal vein thrombosis were diagnosed in 31 (17.1%) and 109 (60.3%) patients, respectively; isolated thrombosis of the mesenteric or splenic veins was detected in 18 and 23 cases, respectively. After this index event, the patients were followed for 735 patient years (pt-years) and experienced 31 recurrences corresponding to an incidence rate of 4.2 per 100 pt-years. Factors associated with a significantly higher risk of recurrence were BCS (hazard ratio (HR): 3.03), history of previous thrombosis (HR: 3.62), splenomegaly (HR: 2.66) and leukocytosis (HR: 2.8). Vitamin K-antagonists (VKA) were prescribed in 85% of patients and the recurrence rate was 3.9 per 100 pt-years, whereas in the small fraction (15%) not receiving VKA more recurrences (7.2 per 100 pt-years) were reported. Intracranial and extracranial major bleeding was recorded mainly in patients on VKA and the corresponding rate was 2.0 per 100 pt-years. In conclusion, despite anticoagulation treatment, the recurrence rate after SVT in myeloproliferative neoplasms is high and suggests the exploration of new avenues of secondary prophylaxis with new antithrombotic drugs and JAK-2 inhibitors.

High rate of recurrent venous thromboembolism in patients with myeloproliferative neoplasms and effect of prophylaxis with Vitamin K antagonists

The optimal duration of treatment with vitamin K antagonists (VKA) after venous thromboembolism (VTE) in patients with Philadelphia-negative myeloproliferative neoplasms (MPNs) is uncertain. To tackle this issue, we retrospectively studied 206 patients with MPN-related VTE (deep venous thrombosis of the legs and/or pulmonary embolism). After this index event, we recorded over 695 pt-years 45 recurrences, venous in 36 cases, with an incidence rate (IR) of 6.5 per 100 pt-years (95% confidence interval (CI): 4.9–8.6). One hundred fifty-five patients received VKA; the IR of recurrent thrombosis per 100 pt-years was 4.7 (95% CI: 2.8–7.3) on VKA and 8.9 (95% CI: 5.7–13.2) off VKA (P=0.03). In patients receiving VKA, the IR of recurrent thrombosis per 100 pt-years was 5.3 (95% CI: 3.2–8.4) among 108 patients on long-term VKA and 12.8 (95% CI: 7.3–20.7) after discontinuation among the 47 who ceased treatment (P=0.008), with a doubled risk of recurrence after stopping VKA (hazard ratio: 2.21, 95% CI: 1.19–5.30). The IR of major bleeding per 100 pt-years was 2.4 (95%: CI: 1.1–4.5) on VKA and 0.7 (95% CI: 0.08–2.5) off VKA (P=0.08). In conclusion, in MPN patients with VTE recurrent thrombosis is significantly reduced by VKA and caution should be adopted in discontinuation; however, the incidence of recurrence on treatment remains high, calling for clinical trials aimed to improve prophylaxis in this setting.

Cooperation between pathologists and clinicians allows a better diagnosis of Philadelphia chromosome-negative myeloproliferative neoplasms.

As no specific genetic lesions have yet been identified, the diagnosis of Philadelphia chromosome-negative myeloproliferative neoplasms is based on a simultaneous evaluation of the clinical, morphological and molecular features defined by the updated WHO classification, which allow most cases of full-blown disease to be classified. Nevertheless, about 10–15% of the patients have unclassifiable myeloproliferative neoplasms, most of whom are in the prodromal (early) phase of disease and identified by the presence of the JAK2 mutation, but lack the complete phenotype required by the WHO classification. The detection of these prodromal phases is extremely important in order to prevent dramatic thrombo-hemorrhagic complications and improve prognosis.

Marked eosinophilia as initial presentation of breast implant-associated anaplastic large cell lymphoma

Nicola Orofino, Francesca Guidotti, Daniele Cattaneo, Mariarita Sciumè, Umberto Gianelli, Agostino Cortelezzi and Alessandra Iurlo Oncohematology Division, IRCCS Ca’ Granda – Maggiore Policlinico Hospital Foundation, University of Milan, Milan, Italy; Hematopathology Service, Division of Pathology, Department of Pathophysiology and Transplantation, University of Milan and IRCCS Ca’ Granda – Maggiore Policlinico Hospital Foundation, Milan, Italy; Oncohematology Unit of the Elderly, IRCCS Ca’ Granda – Maggiore Policlinico Hospital Foundation, Milan, Italy

Imatinib and polypharmacy in very old patients with chronic myeloid leukemia: effects on response rate, toxicity and outcome

Background About 40% of all patients with chronic myeloid leukemia are currently old or very old. They are effectively treated with imatinib, even though underrepresented in clinical studies. Furthermore, as it happens in the general population, they often receive multiple drugs for associated chronic illnesses. Aim of this study was to assess whether or not in imatinib-treated patients aged >75 years the exposure to polypharmacy (5 drugs or more) had an impact on cytogenetic and molecular response rates, event-free and overall survival, as well as on hematological or extra-hematological toxicity. Methods 296 patients at 35 Italian hematological institutions were evaluated. Results Polypharmacy was reported in 107 patients (36.1%), and drugs more frequently used were antiplatelets, diuretics, proton pump inhibitors, ACE-inhibitors, beta-blockers, calcium channel blockers, angiotensin II receptors blockers, statins, oral hypoglycemic drugs and alpha blockers. Complete cytogenetic response was obtained in 174 patients (58.8%), 78 (26.4%) within 6 month, 63 (21.3%) between 7 and 12 months. Major molecular response was obtained in 153 patients (51.7%), 64 (21.6%) within the 12 month. One hundred and twenty-eight cases (43.2%) of hematological toxicity were recorded, together with 167 cases (56.4%) of extra-hematological toxicity. Comparing patients exposed to polypharmacy to those without, no difference was observed pertaining to the dosage of imatinib, cytogenetic and molecular responses and hematological and extra-hematological toxicity. Conclusion Notwithstanding the several interactions reported in the literature between imatinib and some of the medications considered herewith, this fact does not seem to have a clinical impact on response rate and outcome.

PDGFB hypomethylation is a favourable prognostic biomarker in primary myelofibrosis.

Primary myelofibrosis (PMF) is a myeloproliferative neoplasm characterised by the clonal proliferation of the haematopoietic precursors together with the progressive development of bone marrow fibrosis. This stromal alteration is an important clinical issue and specific prognostic markers are not currently available. In bone marrow biopsies from 58 PMF patients, we explored the methylation pattern of genes encoding cytokines involved in the stromal reaction, namely platelet-derived growth factor-beta (PDGFB), transforming growth factor-beta (TGFB) and basic fibroblast growth factor (FGF2). We also evaluated the methylation profile of the Long Interspersed Nucleotide Element 1 (LINE-1). PDGFB, FGF2 and LINE-1, but not TGFB, were significantly differently methylated in PMF compared to controls. Significantly, PDGFB hypomethylation (<16%) was correlated with a favourable PMF prognosis (grade of marrow fibrosis, p=0.03; International Prognostic Scoring Systems p=0.01 and Dynamic International Prognostic Scoring Systems, p=0.02). Although the basis of the association of PDGFB hypomethylation with favourable prognosis remains to be clarified, we speculate that hypomethylation in PMF could represent the effect of acquired somatic mutations in genes involved in epigenetic regulation of the genome.

Clinical and morphologic features in five post-polycythemic myelofibrosis patients treated with ruxolitinib

Dear Editor,Myelofibrosis (MF), either primary (PMF) or secondary topolycythemia vera (post-PV MF), is associated with a dismalprognosis in terms of overall survival (OS) and quality of life(QoL) [1]. Its clinical management is still complicated, and atpresent,theonlycurativetreatmentisrepresentedbyallogenichematopoietic stem cell transplantation. However, the thera-peutic landscape of MF has dramatically changed with theintroduction of JAK1/2 inhibitors as ruxolitinib. The COM-FORT trials showed that ruxolitinib is effective in reducingsplenomegalyandMF-relatedsymptoms,thereforeimprovingQoL[2,3];morerecently,longer-termfollow-upstudiesdem-onstrated also an OS advantage [4, 5].Here, we describe the clinical and morphologic features offivepost-PVMFcasesselectedamong15MFpatientstreatedwith ruxolitinib in our institution. To our knowledge, onlyisolated reports described the morphologic changes occurringin ruxolitinib-treated patients, mostly focusing on modifica-tions in marrow fibrosis degree [6–9].The main clinical and morphologic features of these casespre- and on-treatment are summarized in Table 1. After amedian treatment of 22.1 months, all cases showed improve-mentinIPSS, constitutionalsymptoms, and spleensize, asso-ciated with a slight reduction in the JAK2 allele burden. Inaddition,pre-treatment leukocytosisnormalizedoratleast de-creased in two cases (patients 1 and 5, respectively). Regard-ing ruxolitinib dosage, it varied among the patients, as it waschosen initially according to their platelets counts and thenmodified mainly because of hematological toxicities. Fourpatients are still alive, and one died because of leukemic evo-lution after 22.1 months of treatment.Interestingly, three patients showed complex karyotypes,either before or on-treatment: however, differently fromPMF [10], this did not represent a negative predictive factorof response to therapy.How to evaluate bone marrow (BM) changes duringruxolitinibtherapyiscurrentlydebated.Wecomparedindetailcellularity, hematopoietic lineages, and stromal modificationsin both pre- and on-treatment BM biopsies.Beforetreatment,allcasesshowedmarkedlyincreasedcel-lularity(85–95%)andpolymorphicmegakaryocytes,formingloose and tight clusters; three cases displayed significant in-creasedmyeloid/erythroid(M:E)ratio(>8:1).ThreehadMF-2fibrosis and two MF-3. On-treatment biopsies showed de-creased cellularity in two cases, with reduction of both mye-loid and erythroid lineages. The M:E ratio normalized or atleast decreased in all patients, whereas megakaryocytes’ mor-phology showed only minor changes. In three cases, multifo-cal decrease of marrow fibrosis was documented but only inone the overall fibrosis downgraded from MF-3 to MF-2.In summary, although the small number of cases does notallow definite conclusions, the efficacy of ruxolitinib in post-PV MF is strongly suggested. As in PMF patients, clinicalresponse is quick and sustained in most cases. However,