Spatial-transcriptomic profiling: a new lens for understanding myelofibrosis pathophysiology

Abstract

Myelofibrosis (MF) is a complex myeloproliferative neoplasm characterized by abnormal hematopoietic stem cell proliferation and subsequent bone marrow (BM) fibrosis. First documented in the late 19th century, MF has since been extensively studied to unravel its pathophysiology, clinical phenotypes, and therapeutic interventions. MF can be classified into primary and secondary forms, both driven by mutations in genes such as JAK2, CALR, and MPL, which activate the JAK-STAT signaling pathway. These driver mutations are frequently accompanied by additional non-driver mutations in genes like TET2, SRSF2, and TP53, contributing to disease complexity. The BM microenvironment, consisting of stromal cells, extracellular matrix, and cytokines such as TGF-β and TNF-α, plays a critical role in fibrosis and aberrant hematopoiesis. Clinically, MF manifests with symptoms ranging from anemia, splenomegaly, and fatigue to severe complications such as leukemic transformation. Splenomegaly, caused by extramedullary hematopoiesis, leads to abdominal discomfort and early satiety. Current therapeutic strategies include JAK inhibitors like Ruxolitinib, which target the JAK-STAT pathway, alongside supportive treatments such as blood transfusions, erythropoiesis-stimulating agents and developing combinatorial approaches. Allogeneic hematopoietic stem cell transplantation remains the only curative option, though it is limited to younger, high-risk patients. Recently approved JAK inhibitors, including Fedratinib, Pacritinib, and Momelotinib, have expanded the therapeutic landscape. Spatially Resolved Transcriptomics (SRT) has revolutionized the study of gene expression within the spatial context of tissues, providing unprecedented insights into cellular heterogeneity, spatial gene regulation, and microenvironmental interactions, including stromal-hematopoietic dynamics. SRT enables high-resolution mapping of gene expression in the BM and spleen, revealing molecular signatures, spatial heterogeneity, and pathological niches that drive disease progression. These technologies elucidate the role of the spleen in MF, highlighting its transformation into a site of abnormal hematopoietic activity, fibrotic changes, and immune cell infiltration, functioning as a "tumor surrogate." By profiling diverse cell populations and molecular alterations within the BM and spleen, SRT facilitates a deeper understanding of MF pathophysiology, helping identify novel therapeutic targets and biomarkers. Ultimately, integrating spatial transcriptomics into MF research promises to enhance diagnostic precision and therapeutic innovation, addressing the multifaceted challenges of this disease.

Keywords: Jak inhibitors; Myelofibrosis; Myeloproliferative neoplasms; Personalized medicine; Spatial transcriptomics; Spleen.

Fig. 1

Pathophysiological relationship between MF, BM fibrosis, and splenomegaly. The diagram illustrates the progression from BM fibrosis leading to disrupted hematopoiesis, compensatory splenic involvement with extramedullary hematopoiesis, and the subsequent clinical manifestations, including cytopenias, splenic enlargement, and increased risk of leukemic transformation

Fig. 2

Representation of the spleen’s role as a tumor surrogate in MF due to the engraftment of clonal cells. This diagram emphasizes the spleen’s compensatory function in hematopoiesis, leading to splenomegaly, EMH, and potential leukemic transformation, underscoring the spleen’s involvement in disease progression

Fig. 3

Overview of the spatial transcriptomics workflow, detailing the key steps from sample collection to data analysis and biological interpretation. The diagram highlights the integration of various advanced technologies such as CosMX, GeoMX, Xenium, HybISS, seq-FISH, and Slide-seq/Slide-seqV2, etc. in the spatial mapping of gene expression within tissue samples