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. 2019 Jan 1;37(1):7-11.
doi: 10.1200/JCO.18.00331. Epub 2018 Nov 7.

Managing Clonal Hematopoiesis in Patients With Solid Tumors

Kelly L Bolton  1 , Nancy K Gillis  2 , Catherine C Coombs  3 , Koichi Takahashi  4 , Ahmet Zehir  1 , Rafael Bejar  5 , Guillermo Garcia-Manero  4 , Andrew Futreal  4 , Brian C Jensen  3 , Luis A Diaz Jr  1 , Dipti Gupta  1 , Simon Mantha  1 , Virginia Klimek  1 , Elli Papaemmanuil  1 , Ross Levine  1 , Eric Padron  2
Affiliations

Managing Clonal Hematopoiesis in Patients With Solid Tumors

Kelly L Bolton et al. J Clin Oncol. .
No abstract available

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Figures

FIG 1.
FIG 1.
Flow diagram of our general management strategies for patients with solid tumors with findings of clonal hematopoiesis (CH). (*) We currently consider high-risk CH that, when detected as an incidental finding, would warrant work-up for an underlying hematologic disorder as the following: CH in the presence of significant blood count abnormalities, the presence of a single CH mutation at a high variant allele fraction (> 10%) or multiple CH mutations. Ongoing research efforts will likely further refine this and/or identify additional high-risk features, such as hotspot TP53 mutations, DNMT3A R882 variants, and so forth. (†) Cytopenia work-up including history and physical, comprehensive metabolic panel; peripheral smear; thyroid-stimulating hormone, ferritin, folate, haptoglobin, lactate dehydrogenase, vitamin B1, vitamin B6, vitamin B12, methylmalonic acid, and copper levels; prothrombin time or partial thromboplastin time; and international normalized ratio. Specific for anemia, we suggest measuring the following: reticulocyte count, flow cytometry for paroxysmal nocturnal hemoglobinuria (if low haptoglobin and/or high lactate dehydrogenase in appropriate clinical context), serum protein electrophoresis, and serum immunofixation. Specific for thrombocytopenia we suggest measuring immature platelet fraction. Specific for neutropenia, we suggest measuring antineutrophil antibody level. (‡) For patients anticipated to have a poor prognosis (< 6 to 12 months) from their primary solid tumor, we would not suggest further work-up for CH. (§) Monitoring interval can be determined by the treating clinician, though we would suggest 3- to 12-month evaluations (more frequently for patients receiving ongoing cytotoxic therapy, and less frequently for patients in long-term follow-up). Current guidelines recommend targeting a blood pressure less than 130/80 mm Hg, lifestyle modifications, and pharmacotherapy with a thiazide diuretic, calcium channel blocker, or angiotensin-converting enzyme inhibitor/angiotensin receptor blocker. Preclinical and clinical studies suggest statins have potent anti-inflammatory effects, including suppression of interleukin-1β release, and should be prescribed to all patients with an estimated 10-year atherosclerotic CVD risk greater than 7.5%., BM, bone marrow; CVD, cardiovascular disease.
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