Prognostic factors in the myelodysplastic syndromes: importance of initial data on peripheral blood counts, bone marrow cytology, trephine biopsy and chromosomal analysis.

Abstract

An analysis of clinical, haematological, histological and cytogenetic data was performed in 85 consecutive patients with myelodysplastic syndromes (MDS). The criteria for diagnosis of refractory anaemia (RA), acquired idiopathic sideroblastic anaemia (AISA) and chronic myelomonocytic leukaemia (CMML) were clearly defined, since the inclusion criteria provided by the FAB co-operative group are imprecise. None of these patients has received chemotherapy during the follow-up period. The median survival of the whole group was only 15 months, with less than 10% of the patients surviving after 5 years. Fifteen patients (17.6%) were still alive at time of analysis, 31 (36.5%) have developed acute myeloid leukaemia (AML) and only one of them is still alive; 30 (35.3%) died of infectious and/or haemorrhagic complications. Patients who developed AML had a shorter survival (median survival time 9.5 versus 15 months) but this difference was not significant (P = 0.10). Factors with prognostic value are in order of significance: abnormal localized immature myeloid precursors (= ALIP) in the trephine biopsy, circulating myeloblasts, excess of blasts in the bone marrow smears, age, FAB classification and granulocyte count. In comparison to refractory anaemia with excess of blasts (RAEB), CMML and RAEB in transformation (RAEBt), patients with RA and AISA had a lower incidence of evolution to AML (11% versus 56%), but a higher mortality rate from infections and/or bleeding (59.2% versus 29%). ALIP negative cases were only found among patients with RA and AISA, whereas ALIP positivity was observed in all cases of RAEB and RAEBt, in 10/11 patients with CMML and in almost half the cases of RA and AISA. In RA and AISA patients survival was significantly different between ALIP positive and ALIP negative cases (P = 0.009). Among MDS patients, ALIP negative cases developed significantly less AML than ALIP positive cases (5% versus 44%), but a similar percentage of mortality from infectious and/or haemorrhagic complications was seen in both groups (33% versus 36.5%). Chromosomal analysis proved to be of no significant prognostic value, although a trend for shorter survival was observed in patients with complex karyotype anomalies or without mitoses. Because of their prolonged survival, antileukaemic chemotherapy is contra-indicated in ALIP negative patients (median survival 50 months). Nevertheless they only constitute a minor subgroup of MDS cases. Prognosis in ALIP positive patients is poor (median survival 12.5 months); in these patients therapeutic trials with cytostatic drugs or with inducers of differentiation of myeloid precursor cells seem to be justified.