Clonal Cytogenetic Abnormalities Research Articles

Long-term survival after unrelated donor marrow transplantation for aplastic anaemia after optimized conditioning regimen: a retrospective multicentre cohort study

Almost all acquired severe aplastic anaemia is immune mediated and characterised by hypocellular bone marrow and ≥2 affected haematopoietic lineages. The optimal preparartive regimen for unrelated donor transplantation remains to be established. We aimed to study long-term outcomes after unrelated donor transplantation for severe aplastic anaemia with de-escalation of cyclophosphamide (Cy) dose in steps of 50mg/kg (150, 100, 50, 0mg/kg) in combination with total body irradiation (TBI) 2Gy, anti-thymocyte globulin (ATG) and fludarabine. Ninety-six patients with severe aplastic anaemia aged ≤65 years with adequate organ function enrolled on a trial of human leukocyte antigen (HLA)-matched or 1 HLA-locus mismatched unrelated donor marrow transplantation conducted between 02/2006 and 12/2013 in the United States (NCT00326417). Exclusion criteria were Karnofsky performance status of less than 60, clonal cytogenetic abnormalities and inherited marrow failure syndormes. The primary outcome was day-100 engraftment (achievement of absolute neutrophil recovery to at least 0.5×109/L without subsequent decline) and day-100 survival. The trial determined the lowest effective Cydose as 50mg/kg (n=38) for day-100 engraftment and survival. Cy dose 100mg/kg (n=41) was also acceptable. Accrual to Cy doses 150mg/kg (n=15) and 0mg/kg (n=3) was terminated early for toxicities. The current study is an extended follow up of patients enrolled on the trial (NCT00326477) and includes 76 of 96 patients alive ≥1 year after transplantation. There were 20 deaths in the first year after transplantation (Cy 0mg/kg [n=2], Cy 50mg/kg [n=1], Cy 100mg/kg [n=10], Cy 150mg/kg [n=7]). Patients were followed prospectively from transplantation and data reported using standardized data collection forms until death, loss to follow up or last contact through November 2023. The incidence of graft failure was calculated using the cumulative incidence estimator and the probability of survival using the Kaplan-Meier estimator. The median follow up of the cohort is 8.02 (IQR) 5.16-10.12) years. With Cy 50mg/kg, there was one graft failure and five deaths ≥1 year after transplantation. With Cy 100mg/kg there was only one late death and no graft failure. The 8-year probabilities of survival were 85.0% (95% CI 67.3-93.5) and 75.6% (95% CI 59.4-86.1) after Cy50mg/kg and 100mg/kg, respectively, P=0.31. With Cy 0mg/kg and 150mg/kg, there were no graft failures or death ≥1 year after transplantation. Regardless of Cy dose 12 of 15 patients aged ≥50 years died. Cy 50mg/kg or 100mg/kg with TBI 2Gy, ATG and fludarabine are effective conditioning regimens for unrelated donor marrow transplants for aplastic anaemia. Identification of an optimized transplantation approach for patients aged ≥50 years is needed. US National Institutes of Health.

Clinical Features of Clonal Cytogenetic Abnormalities in Philadelphia-negative Cells Developed During Tyrosine Kinase Inhibitor Treatment.

Most clonal cytogenetic abnormalities of Philadelphia-negative cells (CCA/Ph-) occurring during tyrosine kinase inhibitor (TKI) treatment are transient, and the development of secondary myelodysplastic syndrome (MDS)/acute myeloid leukemia (AML) is rare, but the frequency and clinical significance in Japanese patients are still unknown. We herein report four patients who developed CCA/Ph- during TKI therapy and were diagnosed with secondary MDS/AML. The duration from TKI therapy initiation to MDS/AML onset ranged from 3 to 48 months, and the survival ranged from 5 to 84 months. The occurrence of CCA/Ph- with MDS/AML may be associated with a poor prognosis, and careful follow-up is recommended for patients who receive TKI therapy.

Results of a Phase II Study of Cladribine, Low Dose Cytarabine and Venetoclax, Alternating with Azacitidine and Venetoclax in Patients with Higher Risk Chronic Myelomonocytic Leukemia or Myelodysplastic Syndromes

INTRODUCTION: Clinical responses to hypomethylating agents (HMAs) in patients (pts) with higher-risk myelodysplastic syndromes (HR-MDS) and myeloproliferative chronic myelomonocytic leukemia (CMML) remain short-lived, with high risk of transformation to acute myeloid leukemia (AML). Prior data suggests use of the purine analogue cladribine can induce monocyte apoptosis and is active in AML, particularly in combination with low dose cytarabine (LDAC) and venetoclax. We aimed to evaluate the safety and activity of cladribine, LDAC and venetoclax in HR-MDS and CMML. METHODS: We designed a phase II basket clinical trial of cladribine combined with LDAC and venetoclax alternating with azacitidine and venetoclax for pts with HR-MDS or CMML. Pts were divided into 4 cohorts: cohort A: MDS with int-1 to high risk by IPSS and >5% blasts with prior HMA-failure (HMA-F); cohort B: CMML-1/CMML-2 with prior HMA-F; cohort C: previously untreated MDS with Int-2 or High risk by IPSS and >10% bone marrow (BM) blasts; cohort D: previously untreated CMML-2 or CMML-1 with at least one high-risk feature (extramedullary disease, splenomegaly of >5cm below costal margin, platelets <100x10 9/L, Hgb level <10g/dL, WBC >13x10 9/L, clonal cytogenetic abnormality [other than monosomy Y]). HMA-F was defined as no response after 6 cycles of therapy with HMA or relapse/progression after any number of cycles. Induction consisted of cladribine 5mg/m 2 daily IV on days 1-3, cytarabine 20mg s.c bid days 1-5 and venetoclax 400mg daily days 1-5. Re-induction was allowed in pts not achieving response after induction. Consolidations consisted of azacitidine 75mg/m 2 daily days 1-7 with venetoclax 400mg daily days 1-7 alternating with cladribine 5mg/m 2 days 1-3, cytarabine 20mg s.c bid days 1-5 and venetoclax 400mg days 1-5 every two 28-day cycles. The primary end point was to evaluate safety, efficacy, and tolerability of the combination. Responses were evaluated following 2006 IWG criteria. The Kaplan-Meir product-limit method was used to estimate median survival. RESULTS: Between October 2022 and June 2023, 20 pts have been treated: 10, 5, 3 and 2 in cohorts A, B, C and D, respectively. Thirteen pts had MDS, and 7 had CMML. Median age was 74 years (range 52-83). Among MDS pts, 8 (62%) had int-2 and 5 (38%) had high risk by IPSS. By the Molecular IPSS, 10 (79%) had very high, 1 (8%) had high, 1 (8%) had moderate high and 1 (8%) had low risk. Among CMML pts, 4 (57%) had high, 2 (29%) had intermediate-2 and 1 (14%) had intermediate-1 risk by the CPSS Molecular score. Among HMA-F cohorts, median number of prior therapies was 1 (range 1-4), median cycles of prior HMA was 6 (range 2-63) and 4 (27%) pts had failure to prior venetoclax therapy. Most common adverse events (AEs) were hypoalbuminemia (40%), nausea (40%), sinus bradycardia (40%), alanine aminotransferase increase (35%), constipation (35%), lower extremity edema (35%), fatigue (35%) and hypocalcemia (35%) Most common grade 3-4 AEs were leukopenia (20%) and febrile neutropenia (15%). The 4-week and 8-week cumulative incidences of mortality were 0%. Median number of cycles was 2 (range 1-6). Median cycles to best response was 1 (range 1-3). Among HMA naïve pts (cohorts C and D), the ORR was 80% (n=4): CR in 2 (40%), mCR in 2 (40%). Based on 2023 IWG response criteria, responses in cohort C (n=3) included: CR in 2 (67%) and CR bilineage (CRbi) in 1 (33%). Based on 2015 IWG MDS/MPN criteria, responses in cohort D (n=2) included optimal marrow response and clinical benefit in 1 (50%) and 1 (50%) pts, respectively. Among HMA-F pts (cohorts A and B) the ORR was 20%: 1 CR (10%) and 1 (10%) mCR with HI. Median follow up is 5.3 months (95% CI 2.4-81). Median EFS is 2.1 months in cohorts A and B and not reached in C and D (Fig 1A). Median OS has not been reached for all cohorts (Fig 1B). At the time of data cut-off, all pts in cohorts C and D discontinued study to proceed with hematopoietic stem-cell transplantation (HSCT). Among cohorts A and B, 2 pts (13%) discontinued study to proceed with HSCT, 5 (33%) due to transformation to AML, 2 (13%) due to no response, 2 (13%) due to physician choice, 1 (7%) due to patient choice and 2 (13%) pts remain on study. CONCLUSIONS: Preliminary data suggests the use of cladribine, LDAC and venetoclax can be safely administered in pts with very high risk MDS and CMML with early promising results in pts with de novo disease.

Trisomy 5: A Rare Isolated Finding in Pediatric B-lymphoblastic Leukemia

Background and Objectives: In acute leukemia, all diagnostic criteria and treatment protocols are based on cytogenetic and molecular genetic findings. Despite recent advances in molecular biology, cytogenetic studies still play a pivotal role in the sub-classification of B-lymphoblastic leukemia (B-ALL). B-ALL is characterized by clonal cytogenetic abnormalities with numerical chromosomal aberrations being more common. An extra copy of chromosome 5 is common to see in cases with hyper diploidy. However, a gain of chromosome 5 as a sole anomaly is exceptionally rare in B-ALL. To date, trisomy 5 as a sole abnormality is reported in few cases only. We aimed to report the clinicopathologic profile of this rare finding to increase knowledge and highlight the disease course of these patients.
 Methods: We report a case of a 14-year boy presented with fever, lethargy and episodes of nasal bleeding for two weeks. He was admitted to the pediatric oncology unit at Indus hospital and health network, Karachi. Flowcytometry performed on peripheral blood using 8-color flowcytometry. Conventional karyotyping was performed by GTG banding. FISH panel was comprised of dual color dual fusion probes for BCR::ABL1 and ETV6::RUNX1 whereas break apart probe for KMT2A (Metasystem, Germany). Digital image analysis for karyotyping and FISH was done on Leica Biosystems, Cytovision MB8.
 Results: Flowcytometry results were consistent with B-ALL. Cytogenetic analysis on his bone marrow aspirate revealed trisomy 5 as a sole abnormality with no evidence of any other clonal cytogenetic abnormality. FISH studies for BCR::ABL1, ETV6::RUNX1 and KMT2A showed no evidence of gene rearrangements.
 Conclusion: Trisomy 5 is a very rare cytogenetic aberration. Only few cases reported in children. Inferior outcome is reported in both children and adults. The increasing number of reported cases raises the possibility of a distinct cytogenetic entity. Its prognostic and therapeutic implications are yet to be explored.

Rare cytogenetic abnormalities in MDS evolving from fanconi anemia-A case report

Fanconi anemia (FA) is a genetically heterogenous rare autosomal recessive disorder. Mutations in FANCA gene are the most frequent among FA patients accounting for 60-65%. FA is characterised by congenital malformations, progressive bone marrow failure (BMF) and increased risk of myelodysplastic syndrome (MDS) and acute myeloid leukemia (AML). The risk of developing hematological abnormalities in FA patients is around 98% by 40 years of age. The risk of clonal cytogenetic abnormalities during BMF is around 67% by 30 years of age and risk of developing MDS or AML is 52% by 40 years of age. The frequent chromosomal abnormalities are 1q+, monosomy 7 and gains of 3q. Partial duplications/triplications of chromosome 1q are known to represent a nonrandom chromosomal anomaly in myeloid disorders.

IPSS-Molecular but Not Individual Mutations Predicts Outcomes of Patients with Myelodysplastic Syndrome (MDS) after Allogeneic Hematopoietic Cell Transplantation (Allo-HCT): A Mayo Clinic Cohort

The decision to offer Allo-HCT in MDS relies on prognostic scoring models which include clonal cytogenetic (CG) abnormalities, blood counts (cytopenias), and % of marrow blasts (i.e. revised international prognostic scoring system, IPSS-R). Recently, an updated clinical-molecular prognostic model combining genomic profiling with hematologic and CG parameters, namely IPSS-Molecular (IPSS-M), showed better prognostic discrimination across all clinical endpoints and re-stratified almost one-half of patients (pts) vs. IPSS-R. Hence, we evaluated the impact of IPSS-M, CG risk group and individual mutations on Allo-HCT outcomes. The analysis included 191 consecutive MDS pts undergoing Allo-HCT who had available next generation sequencing (NGS) analysis performed at Mayo Clinic (at diagnosis (Dx, n=164 or prior to Allo-HCT, n=162) between 11/2015 and 1/2022. Median age at Allo-HCT was 64 (18-75) yrs, and 112 (58.6%) were male. At Dx, 126 (77%) pts had at least one pathogenic genetic alteration, including (>5% incidence) ASXL1 (28.0%), TP53 (18.9%), TET2 (14.6%), SRSF2(12.2%), U2FA1 (12.2%), DNMT3A (8.5%), BCOR (7.9%), RUNX1 (6.7%), and SF3B1 5.5%; a similar mutational pattern was present at Allo-HCT: ASXL1 (28%),TET2 (15.2%) U2AF1 (13.4%), TP53 (12.2%), SRSF2 (11%), RUNX1(9.8%), DNMT3A (7.3%), SETBP1 (7.3%), SF3B1 (6.7%), BCOR (6.7%), STAG2 (5.5%), and JAK2 (5.5%). Most pts (156, 81.7%) received at least 1 line of therapy, and 45 (23.6%) had >5% marrow blasts at Allo-HCT. The majority (134, 70%) received reduced intensity conditioning. Graft versus host disease (GVHD) prophylaxis consisted of methotrexate/tacrolimus in 138 (77.5%) and post-transplant cyclophosphamide in 40 (22.5%). HCT comorbidity index was >3 in 113 (59%). IPSS-M risk group was calculated and reclassified from IPSS-R into very low (1, 0.6%), low (24, 14.7%), moderate low (34, 20.9%), moderate high (41, 25.2%), high (29, 17.8%), very high (34, 20.9%), mainly for IPSS-R intermediate and high-risk groups (Fig. 1). Median F/U after Allo-HCT was 18.8 (0.4-76.8) months. The 100-day and 1-year non-relapse mortality (NRM) were 7.9% and 18.1%, respectively. The 2-year incidence of death and relapse were 40.1% (95% confidence intervals (CI) 33.5-48%) and 21.6% (95%CI 16.4-28.4%), respectively. Cumulative incidences of grade III-IV acute GVHD was 10% and 1-year cumulative incidence of extensive chronic GVHD was 12%. In multivariable analysis, IPSS-M predicted mortality [Hazard ratio (HR) (per 1 risk category) 1.21, 95%CI 1.00-1.47, p=0.049] and relapse (HR=1.47, 95%CI 1.13-1.92, p=0.004), but not NRM (HR 0.95, 95%CI 0.74-1.22). The 1-year mortality rates for very low/low, moderate-low, moderate-high, high/very high risks were 21%, 24%, 32%, and 37%, respectively (Fig. 1). Individual mutations had minimal independent association with outcome in the multivariable model. For mortality, only ASXL1 at Dx (HR 0.48, 95%CI 0.26-0.91, p=0.024) and SF3B1 at Allo-HCT (HR 2.51, 95%CI= 1.06-5.96, p=0.037) were significant. TP53 at Dx had a borderline association (HR 0.46, 95% CI= 0.942.69, p=0.086). Also, there was no significant association of individual mutation with relapse (including TP53 at Allo-HCT, HR 1.77, p=0.085). Only SF3B1 at Allo-HCT correlated with NRM (HR 3.16, 95%CI= 1.22-8.17, p=0.018). Conversely, CG risk group remained strongly associated with mortality (p=0.007) and relapse (p=0.003), particularly poor/very poor (P/VP) risk CG (Mortality: HR 2.46, 95%CI 1.44-4.19, p=0.001; Relapse: HR 3.46, 95%CI 1.70-7.05, p=0.0006). There was no association of CG risk with NRM. We demonstrate value of IPSS-M risk stratification in predicting outcomes after Allo-HCT for MDS, re-stratifying pts into more discrete prognostic groups that predict mortality and relapse risk. Hence, IPSS-M could inform post allo-HCT decision including future maintenance strategies to prevent relapse in high/very high IPSS-M. CG risk group (esp. P/VP risk), a core component of IPSS-M, independently contributes to outcome prediction both within the model and individually. Disease risk does not predict NRM, and individual mutations have limited association with outcome, suggesting allo-HCT may mitigate the poor prognostic impact of high-risk oncogenic mutations present at Dx, including TP53 and ASXL1. An updated analysis on mutational complexity will be shown at the meeting. Figure 1View largeDownload PPTFigure 1View largeDownload PPT Close modal

Outcomes of Hematologic Complications in Shwachman Diamond Syndrome: High Risk Features and Implications for Surveillance

Background Shwachman Diamond syndrome (SDS) is characterized by genetic predisposition to bone marrow failure and TP53-mutated myeloid malignancies. Data are scarce to guide surveillance strategies. Objectives This study aims to characterize the presentation and outcomes of hematologic complications in 218 patients with SDS with the goal of informing surveillance. Design/Method Data was obtained from medical records of 218 study subjects with biallelic mutations in SBDS/DNAJC21/ EFL1, or heterozygous mutations in SRP54 consented to the SDS Registry or the Bone Marrow Failure/MDS study which are longitudinal prospective cohort studies. Results The median age of the study cohort was 12.2 years (yr) (range 0.1-52.8 yr). Of 204 patients with SBDS mutations, 12 developed severe BMF requiring transplant (median age 2.9 yr, range 0.4-39.5), 16 developed MDS (median age 15.9 yr, range 0.5-45), 11 developed AML (median age 27.7 yr, range 9.4-47.3) and 2 developed lymphoma (ages 17.0 and 23.8 yr). Of the 48 subjects with SBDS mutations who were adults >18 years (median 25.5, range 18.5-52.8), 16 (33%) developed a myeloid malignancy. Of 20 patients with an SRP54 mutation, 1 developed AML at age 15.2. One patient with biallelic EFL1 mutations died of BMF at age 0.7 yr. Further analysis focused on patients with SBDS mutations. Five patients with MDS and 1 patient with AML were on G-CSF at the time of malignancy diagnosis. Only 2 patients who developed AML had had surveillance, but neither included somatic mutation analysis. The diagnosis of SDS was unrecognized prior to malignancy diagnosis for 5 with MDS (age range 13.8 to 21.5 yr) and 2 with AML (age 37.8 and 47.3 yr). Three patients were diagnosed with MDS on surveillance marrow exam. All patients with AML presented with symptoms which led to diagnosis. Of the 16 patients who initially presented with MDS, 5 progressed to AML. Median survival for those who presented with MDS was 1.3 yr (range 0.2-14.9). Ten were deceased, 4 were alive with median follow up of 3.4 yr (range 1.0-14.9). Two additional patients were <100 days out from HSCT. Of 9 patients with MDS who proceeded to HSCT without prior cytoreductive therapy, 4 were alive with a median follow up of 3.1 yr (range 0.2-14.4) post-HSCT, 5 were deceased from treatment related mortality (TRM) (n=2), relapsed/refractory disease (n=2) or osteosarcoma at 10 years post-HSCT (n=1). Of 6 patients who received cytoreductive therapy, 3 died prior to HSCT with active disease (n=2) or TRM (n=1). Of the 3 who proceeded to HSCT post-cytoreductive therapy, 2 are alive at 0.1 and 0.7 yr post HSCT, and 1 died of TRM. One patient who received no therapy died 7.7 years post-diagnosis. Median survival following AML diagnosis was 1 year (range 0.2-5.6). Of the 11 patients with AML, 8 died with relapsed/refractory disease, 1 died of TRM, and 2 survive in remission at 2 and 5.6 years post-AML diagnosis. Of the two patients who proceeded directly to HSCT, one is alive 5.6 years post-HSCT. Nine patients received a variety of cytoreductive regimens for AML, including AraC/Idarubicin, hypomethylating agents +/- venetoclax, of whom 6 were able to proceed to HSCT. None of the 9 adult patients >18 years with SBDS mutations and AML survived. Eight patients with SDS undergoing surveillance marrow exams developed high risk features (HRF), including progressive dysplasias, dropping blood counts with rising marrow cellularity, high risk clonal cytogenetic abnormalities, and large or rapidly growing TP53 clones. Median age of patients with HRF was 19.7 yrs (range 1.3-40.9). All 6 patients transplanted for HRF are alive and well with a median follow up of 1.8 yr (0.1-4.5) post-BMT (Figure 1); 2 patients are currently undergoing evaluation for HSCT. None of the patients transplanted for HRF developed grade 3 or 4 GVHD. One patient with a large TP53 clone prior to transplant is alive without a detectable TP53 clone 0.9 years post-BMT. Conclusions AML carries a poor prognosis for patients with SBDS mutations, so early referral for novel therapies should be considered. Marrow surveillance including morphology, cytogenetics, FISH, and somatic mutation analysis identified patients who developed HRF. Survival was excellent for patients transplanted for HRF. Although SDS is rare and patient numbers are small, these data show that regular comprehensive marrow surveillance can identify HRF to inform the need for closer monitoring or transplant prior to progression to malignancy. Figure 1View largeDownload PPTFigure 1View largeDownload PPT Close modal

Cytogenetic profile of adult acute myeloid leukemia in Egypt: a single-center experience

BackgroundAcute myeloid leukemia (AML) is a diverse disease characterized by the expansion of blasts of myeloid lineage. Cytogenetic testing is the cornerstone for risk stratification of AML patients. Geographical and environmental factors may play a very important role in the development of leukemia and several differences in genetic profile may be seen among different ethnicities. In our study, we evaluated cytogenetic findings of adult AML patients in South Egypt.MethodsCytogenetic testing (karyotyping and M-FISH) was performed for 120 adult patients with AML. Twenty metaphases were analyzed for each patient.ResultsIn our study, the median age of AML patients was 36.5 years, with an age range between 18 and 86 years. 56.7% of patients had normal karyotypes and 43.3% of patients had clonal cytogenetic abnormalities. t (15;17) was the most detected structural abnormality, and + 8 was the most detected numerical abnormality. Regarding cytogenetic risk stratification, 65% of patients were in the intermediate-risk category.ConclusionThe cytogenetic profile of AML patients in our locality showed some differences and some similarities with cytogenetic profiles in different Arab, Asian and Western countries. Further studies are needed using advanced techniques such as next-generation sequencing and optical genome mapping to elucidate more ethnic and geographic genetic heterogeneity among different countries.

33714 Palisaded neutrophilic and granulomatous dermatitis in the setting of SRSF2-mutated chronic myelomonocytic leukemia: Case report and review of the literature

Palisaded neutrophilic and granulomatous dermatitis (PNGD) is a rare cutaneous histopathologic reaction pattern associated with several underlying disorders. Few cases of PNGD have been associated with hematologic malignancies, in particular with chronic myelomonocytic leukemia (CMML), a malignant hematopoietic disorder with features of myeloproliferative neoplasm and myelodysplastic syndrome. CMML is characterized by peripheral blood monocytosis and bone marrow dysplasia, and can be supported by an acquired clonal cytogenetic abnormality most commonly in TET2, SRSF2, ASXL1, RUNX1, NRAS, and CBL. We present a patient with a papulosquamous rash on the neck, chest, and shoulders with histomorphological features on the spectrum of PNGD. Subsequent lab workup demonstrated a persistent mild monocytosis, raising concern for CMML. The patient was referred to hematology-oncology for a bone marrow biopsy, which ultimately led to her diagnosis. Cytogenic studies of the bone marrow biopsy demonstrated mutations in SRSF2, IDH2, and ASXL1, which were strongly supportive of this diagnosis. After discussion at a multidisciplinary tumor board, treatment directed at the skin eruption alone was recommended. She was started on prednisone taper and demonstrated marked clinical improvement. PNGD in the context of CMML has been scarcely reported, with only 4 prior reports in the literature. Our patient is the fifth reported case, and the fourth case with confirmed underlying SRSF2 mutation. This is likely a novel and reproducible clinical-histopathologic-molecular subtype of reactive granulomatous disease. The findings in this case strengthen the previously made association between PNGD and SRSF2-mutated CMML, and may help better define a unique recognizable subtype for dermatopathologists.

Evaluation of miR-145 and miR-146a as potential biomarkers for diagnosis of Myelodysplastic Syndrome

Objective: Myelodysplastic syndromes (MDS) are a group of heterogeneous hematopoietic stem cell disorders characterized by ineffective hematopoiesis, bone marrow dysplasia, and peripheral cytopenias. microRNAs (miRNAs) are small non-coding RNAs that play key roles in post-transcriptional regulation of gene expression and have been determined potential in disease diagnostics and therapeutics owing to their stability. Recent evidence suggests that haploinsufficiency of the miR-145 and miR-146a, encoded from 5q Common Deleted Region (CDR) may contribute to the phenotype in MDS. Although, interstitial del(5q) is the most common chromosomal abnormality in MDS, these findings are inconsistent in Turkish patients. Therefore, we aimed to investigate assess the diagnostic value of miR-145/miR-146a and their relation with del(5q) or monosomy 5 in MDS. Methods: In order to determine the association between del(5q) and expression miR-145/miR-146a, conventional cytogenetics (CC), FISH, and qRT-PCR methods were performed for 24 patients with MDS and 20 healthy individuals. Additionally, ROC curves were generated to evaluate putative diagnostic value of miRNAs. Results: Cytogenetic examination revealed clonal cytogenetic abnormalities in 43.4% of cases. miR-146a decreased in 23 of 24 patients regardless of chromosome 5 abnormalities (p

Cytogenetic Risk Stratification of B-Acute Lymphoblastic Leukemia and Its Correlation with Other Prognostic Factors.

Purpose of current study was to categorize WHO defined B-Acute Lymphoblastic Leukemia (B-ALL) cases into 3 cytogenetic risk groups (good, intermediate and poor) and to see their correlation with age, NCI risk criteria and treatment response. Clinical and diagnostic details were collected for 78 newly diagnosed B-ALL patients which included bone marrow morphology, flow cytometry immunophenotyping, karyotyping, FISH and RT-PCR. Study cohort comprised 44/78 (56.4%) children including 3 infants and 34/78 (43.6%) adults. Median age for paediatric group was 6 years (3 months-17 years) and for adults was 40.5 years (18 to 75 years). According to NCI risk criteria, excluding infants, 54 (72%) were high risk and 21 (28%) were standard risk. Clonal cytogenetic abnormality was detected in 59/78 cases (75.6%), while 19/78 (24.4%) cases showed normal karyotype. There was significant association of cytogenetic risk groups to age distribution (p value < 0.001) and NCI risk groups (p value < 0.001). There was no significant correlation of CNS involvement with cytogenetic risk groups (p = 0.064). Association of Day 8 steroid response and Day 15 bone marrow status with cytogenetic risk groups was significant (p = 0.006 and p = 0.003 respectively). Post treatment bone marrow status on Day 33 and Day 79 was available for 52 and 42 cases respectively. 9 adults died during induction phase. Day 33 post induction morphological remission was achieved in 51/52 cases (98%) and 1/52 (2.0%) were not in remission. Day 79 post induction morphological remission was achieved in 41/42 cases (98%) and 1/42 (2.0%) were not in remission. Day 33 or End of induction flow MRD (measurable residual disease) was negative in 39/52 (75.0%) patients and positive in 13/52 (25.0%) patients. Day 79 flow MRD was negative in 37/42 (88.1%) and positive in 5/42 (11.9%). Cytogenetic risk groups showed statistically significant Day 33 and Day 79 treatment response (morphologic remission: p = 0.009 and 0.003, flow MRD: p = 0.004 and p = 0.012 respectively). We concluded that cytogenetic risk groups showed statistically significant association with age, NCI risk criteria and treatment response.

Chronic myelomonocytic leukemia: 2022 update on diagnosis, risk stratification, and management

Chronic myelomonocytic leukemia (CMML) is a clonal hematopoietic stem cell disorder with overlapping features of myelodysplastic syndromes and myeloproliferative neoplasms, with an inherent risk for leukemic transformation (~15% over 3-5 years). Diagnosis is based on the presence of sustained (>3months) peripheral blood monocytosis (≥1× 109 /L; monocytes ≥10%), usually with accompanying bone marrow dysplasia. Clonal cytogenetic abnormalities occur in ~30% of patients, while >90% have somatic gene mutations. Mutations involving TET2 (~60%), SRSF2 (~50%), ASXL1 (~40%), and the oncogenic RAS pathway (~30%) are frequent, while the presence of ASXL1 and DNMT3A mutations and the absence of TET2 mutations negatively impact overall survival. Molecularly integrated prognostic models include the Groupe Français des Myélodysplasies, Mayo Molecular Model (MMM), and the CMML specific prognostic model. Risk factors incorporated into the MMM include presence of truncating ASXL1 mutations, absolute monocyte count >10× 109 /L, hemoglobin <10g/dL, platelet count <100 × 109 /L, and the presence of circulating immature myeloid cells. The MMM stratifies CMML patients into four groups: high (≥3 risk factors), intermediate-2 (2 risk factors), intermediate-1 (1 risk factor), and low (no risk factors), with median survivals of 16, 31, 59, and 97 months, respectively. Hypomethylating agents such as 5-azacitidine and decitabine are commonly used, with overall response rates of ~40%-50% and complete remission rates of ~7%-17%; with no impact on mutational allele burdens. Allogeneic stem cell transplant is the only potentially curative option but is associated with significant morbidity and mortality.

Analysis of Clonal Cytogenetic Abnormalities in Persistent Cytopenia: Relation of Degree of Dysplasia and Prognosis

Analysis of Clonal Cytogenetic Abnormalities in Persistent Cytopenia: Relation of Degree of Dysplasia and Prognosis

Clonal cytogenetic abnormalities in donor-derived cells after sex mismatched allogeneic stem cell transplantation

Clonal cytogenetic abnormalities (CCA) in donor-derived cells after stem cell transplant (SCT) are typically reported in donor-derived cell neoplasms, but CCA also may reflect a constitutional abnormality in the donor or may be present in a recipient without overt hematological malignancy. We reviewed 8515 tests on 2035 patients, who had allogenic sex mismatched SCT and underwent serial cytogenetic analysis between 2006 and 2020 in our institution. A constitutional CCA was observed in 3 patients: inv(10), t(1;5), and t(13;14). A somatic CCA without overt neoplasia was detected in 12 patients: del(7q) (n = 6), del(20q) (n = 3), der(11)t(11;11) (n = 1), t(1;9) (n = 1), dup(6p)(n = 1). In this group, four patients with cytopenia had del(7q), and an association between del(7q) and an adverse overall survival (OS) was observed [HR:5.99; 95%CI 1.23–29.92). Four patients had a donor-derived cell neoplasm: myelodysplastic syndrome (n = 3) and acute myeloid leukemia (n = 1), and all four neoplasms had loss of 7q. In our cohort, ∼1% of the patients (19/2,035) had CCA in donor-derived cells. Balanced constitutional CCA can pose a reproductive risk to donor. Loss of 7q is the most common somatic CCA, in donor-derived cells.

Chronic Eosinophilic Leukemia: Diagnosis and Therapy

Introduction In the 2017 World Health Organization (WHO) classification, chronic eosinophilic leukemia, not otherwise specified (CEL, NOS), is included as one of 7 distinct diagnostic entities under the major category of myeloproliferative neoplasms (MPNs).1 WHO defining criteria for CEL, NOS include: (a) peripheral blood eosinophilia >1.5×109/L; (b) evidence of clonal cytogenetic or molecular genetic abnormality, and/or (c) presence of excess myeloblasts (

Clonal Cytogenetic Abnormalities in Myeloid Neoplasms Arising from Fanconi Anemia — a Single Center Study from India

Fanconi anemia (FA) is a genomic instability disease caused by defective DNA repair which predisposes patients into developing myelodysplastic syndrome (MDS) or acute myeloid leukemia (AML). Identification of clonal abnormalities in FA patients is vital to detect transformation before the onset of a high-grade MDS/leukemia.We analyzed bone marrow (BM) samples from a series of 50 patients with FA who were diagnosed at the Christian Medical College, Vellore, India from January 2005 - July 2017 by peripheral chromosome breakage analysis (CBA) or FANCD2 ubiquitination analysis of peripheral blood or dermal fibroblasts. Inclusion in the current study was based on the availability of karyotyping samples performed on the BM aspirate collected at diagnosis. Peripheral blood and dermal fibroblasts were collected at diagnosis for CBA and FANCD2 western blot.All 50 patients evaluated had phenotypic features suggestive of FA. There were 28 patients who had increased CBA scores alone while 21 had both increased CBA scores as well as defective FANCD2 ubiquitination. One patient with negative CBA score showing hematopoietic mosaicism with defective FANCD2 ubiquitination pattern in dermal fibroblasts alone was also included in the study.The median age at diagnosis was 16 years (range 1-35) and 35 (70%) were male. Abnormal karyotypes were obtained in 38 patients while the remaining (n=12) showed a normal karyotype. Examination of bone marrow aspirate and trephine was consistent with MDS in 29 (MDS-RS-MLD n= 3; MDS-EB n= 10; MDS-U n=12; h-MDS n=4), while the remaining had either AML (n=8) or a hypoplastic marrow (n=13). The 12 patients who had a normal karyotype were predominantly hypoplastic (n=8) or had either MDS (n=3) or AML (n=1). Abnormalities of chromosomes 1 and 7 were the most commonly reported chromosome aberration and was seen in 17 patients each (45%). A partial deletion 5q was present in 7 (18%) patients while gains of chromosomes 8 and 21 were seen in 5 and 6 patients respectively. Complex karyotypes involving abnormalities of 3 or more chromosomes were seen in 16 (42%) patients who had MDS/AML. FA gene mutation analysis of 8 patients showed FANCA gene mutations in 7 patients (4-abnormal KT, 3-normal KT) while 1 patient with abnormal karyotype had a mutation in the FANCJ gene.Post treatment karyotypes were available in 2 patients with AML and 1 patient with MDS which showed persistence of the leukemic clone identified at diagnosis (n=1) or clonal evolution (n=1, gain of chromosome 9) while the third patient showed a new clone after treatment which retained two of the three abnormalities documented at diagnosis.Using the Revised International Prognostic Scoring system for MDS majority of the patients (n=20) with MDS were classified in the poor or very poor risk groups while the remaining patients were in the good (n=6) or intermediate (n=3) risk group.Five of the 8 patients with AML were classified as poor risk according to the refined MRC cytogenetic classification while 3 were grouped in the intermediate risk group.Among the 13 patients showing a hypoplastic marrow, one patient had monosomy 7 which has been shown to have an increased risk of transformation to MDS/AML. One patient who had gain of 1q due to an unbalanced translocation transformed to AML in 9 months.We report a distinct pattern of chromosome abnormalities in patients with FA-MDS/AML consistent with previous reports, underscoring the need for inclusion of karyotype analysis in the laboratory evaluation strategy of FA patients for early detection of transformation to hematologic malignancies. [Display omitted] DisclosuresNo relevant conflicts of interest to declare.

MDS and AML in Shwachman-Diamond Syndrome: Clinical Features and Outcomes

Genetic predisposition to MDS and AML is recognized in a growing subset of patients, but data to inform medical management and outcomes are sparse. Shwachman-Diamond syndrome (SDS) is an inherited marrow failure syndrome associated with increased risk of myelodysplasia (MDS) and acute myeloid leukemia (AML). The aim of this multi-institutional retrospective study was to investigate clinical features, treatment, and outcomes of 37 patients with SDS who developed MDS or AML. Diagnosis of SDS was established by SBDS genetic testing (n=30), exocrine pancreatic dysfunction (n=5), or data were unavailable (n=2). Nine individuals presented with AML (4 male, 5 female), 26 with MDS (13 male and 13 female), one male with refractory cytopenia (RC), and one male with isolated persistent somatic TP53 mutation. Eight of 26 MDS patients, had MDS-EB1 or EB2 at diagnosis, of whom two progressed to AML. Three patients initially presenting with early MDS progressed to MDS-EB1, MDS-EB2, or AML. Median age (years) at diagnosis of early MDS was 13.8 (range 0.5-28.8), for MDS-EB1/2 was 16 (range 9-30) and for AML was 33 (range 5.5-47). Nine patients with MDS and 1 patient with AML were receiving G-CSF chronically prior to diagnosis of MDS/AML.Complex cytogenetics, (>3 cytogenetic abnormalities per clone), were noted in 8/9 AML cases. One AML patient presented with normal cytogenetics. Complex clonal cytogenetic abnormalities were noted in 5 of 6 patients with MDS-EB1/EB2 for whom reports were available. Cytogenetic data were available for 16 MDS cases and clonal abnormalities were noted in 10. Aberrations involving chromosome 7 were most common. The patient with the somatic TP53 mutation had normal cytogenetics. Centralized bone marrow pathology review is currently ongoing.Follow up data were available for 8 patients with AML; 6 are deceased. Six received chemotherapy with intent to proceed to hematopoietic stem cell transplant (HSCT), of whom 5 failed to achieve remission and died with disease without proceeding to transplant. One AML patient proceeded to HSCT with progressive disease post-chemotherapy, but died with relapsed disease. One patient proceeded to HSCT without prior chemotherapy and was in remission at day 30 post-HSCT. The sole long-term surviving AML patient achieved remission with chemotherapy and underwent HSCTs with 3 separate stem cell infusions due to primary graft failure after the initial two infusions. He remains alive in remission more than 4 years after diagnosis. Notably this surviving AML patient was the only AML patient with normal cytogenetics at diagnosis.Follow up data are available for 6 of 8 patients presenting with MDS-EB1/EB2, 4 of whom are deceased. One patient who presented with MDS-EB1 is alive with relapsed disease after HSCT and one patient is in remission 100 days after HSCT.Follow up data are available for 17 of 18 early MDS patients, 7 of whom are deceased including three who had progressed to MDS-EB1, MDS-EB2, or AML. Four of the 7 deceased patients had received a HSCT. One individual with MDS died of hepatic failure unrelated to MDS. Seven MDS patients are alive in remission after HSCT without prior chemotherapy. Treatment was not reported for an additional 2 surviving patients. One patient receiving a hypomethylating agent is alive with stable disease 4.8 years from diagnosis. The patients with RC and with a TP53 clonal abnormality are alive at 6.5 years and 1.7 years from diagnosis respectively.In summary,prognosis is poor for patients with SDS who develop AML or MDS-EB1/2, with few long-term survivors due to resistant disease and treatment-related complications. Outcomes are better if transplanted for MDS prior to acquisition of increased blasts, with 10 of 17 (59%) subjects surviving (median follow up 6 years, range 1.5-11.2). AML often presents in adulthood highlighting the need for continued surveillance of SDS patients with bone marrow examinations including cytogenetics and FISH. These data demonstrate the importance of early detection of clonal evolution in this leukemia predisposition syndrome. Better markers for risk stratification are needed to identify patients who would benefit from early transplant prior to advanced clonal disease. Novel therapeutic strategies, such as targeted therapies, are urgently needed to improve outcomes of SDS patients with advanced MDS or AML. DisclosuresDiNardo:Daiichi-Sankyo: Honoraria, Research Funding; Agios: Honoraria, Research Funding; Novartis: Honoraria, Research Funding; Celgene: Honoraria, Research Funding; AbbVie: Honoraria, Research Funding. Norkin:Celgene: Honoraria, Research Funding. Shimamura:TransCellular Therapeutics: Other: Spouse is majority shareholder .

Allogeneic Hematopoietic Stem-Cell Transplantation for GATA2 Deficiency Using a Busulfan-Based Regimen

Background: GATA2 deficiency is an increasingly recognized bone marrow failure syndrome responsible for: MonoMAC, monocytopenia with atypical mycobacterial infection (MAC); DCML, dendritic cell, monocyte and lymphoid cell deficiency; Emberger syndrome with lymphedema and monosomy 7; and familial myelodysplastic syndrome (MDS)/acute myelogenous leukemia (AML). GATA2 deficiency can be reversed by hematopoietic stem cell transplantation (HSCT). However, the intensity of conditioning required to ensure engraftment and reverse the myelodysplastic syndrome (MDS) characteristic of the disease remains controversial.Methods: We carried out a prospective study of allogeneic HSCT in 22 patients (mean age 26 years; range 17 to 45 years) with GATA2 deficiency, or the MonoMac syndrome, using a myeloablative, busulfan-based conditioning regimen. All 22 patients had MDS and two had AML. Eleven patients had clonal cytogenetic changes in the bone marrow. There were two matched related donor (MRD) recipients, 13 matched unrelated donor (URD) recipients, and 7 haploidentical related donor recipients. MRD and URD recipients received conditioning with 4 days of busulfan (days -6 to -3) to target an AUC between 3600 and 4800 min*microm/L and 4 days of fludarabine 40 mg/m2/day (days -6 to -3). Haploidentical related donor recipients received low-dose cyclophosphamide for two days (days -6 and -5), fludarabine 30 mg/m2/day for 5 days (days -6 to -2), 2-3 days of busulfan depending upon cytogenetics, along with 200 cGY total body irradiation (TBI) on day -1. MRD and URD recipients received tacrolimus and short course methotrexate for post-transplant graft-versus-host disease (GVHD) prophylaxis, whereas haploidentical recipients received high-dose post-transplant cyclophosphamide (PT/CY) followed by tacrolimus and mycophenolate mofetil for GVHD prophylaxis.Results: Nineteen of the 22 patients are alive with resolution of the clinical phenotype and correction of the bone marrow MDS with eradication of the cytogenetic changes at a median follow-up of 23 months (range, 6 to 48 months) giving an overall disease-free survival of 86 percent. The three deaths all occurred in the URD group. Of the three deaths, one resulted from refractory acute myelogenous leukemia (AML), and two from complications related to treatment for GVHD. There was a 26 percent incidence of grade III-IV acute GVHD (aGVHD) in the MRD and URD groups, and no grade III-IV aGVHD in the haploidentical related donor cohort. Similarly, there was a 46 percent incidence of chronic GVHD (cGVHD) in the MRD and URD cohort, whereas two of the 7 (28 percent) of the haploidentical related donor recipients had cGVHD.Conclusions: Despite overall disease-free survival of 86 percent with eradication of the clonal cytogenetic abnormalities in the bone marrow, GVHD remains a limitation in the MRD and URD cohorts treated with standard post-transplant tacrolimus/methotrexate prophylaxis for GVHD. We are currently de-escalating the busulfan dosing based on the AUC in all cohorts and incorporating PT/CY in the MRD and URD cohorts to decrease toxicity and reduce the incidence of aGVHD and cGVHD. Together with our previous studies using a nonmyeloablative regimen, it appears that when GATA2 deficiency patients are transplanted when they have a hypocellular bone marrow with MDS and without cytogenetic changes, a nonmyeloablative regimen results in reliable engraftment in GATA2 deficiency since the GATA2 deficient marrow has a proliferative disadvantage. However, with clonal progression and unfavorable cytogenetic changes and/or a hypercellular marrow, where the malignant clone has a proliferative advantage, a higher dose regimen results in more reliable engraftment and eradication of the clone. Studies to identify the precise level of conditioning for the stages of the disease are ongoing. DisclosuresNo relevant conflicts of interest to declare.

The Chronicles of Myelodysplastic/ Myeloproliferative Legacy - Chronic Myelomonocytic Leukemia

Chronic myelomonocytic leukemia is a heterogeneous syndrome with features of both myelodysplastic syndromes (MDS) and myeloproliferative neoplasms (MPN). The varied clinical presentations add to the distinctiveness of the disease. This heterogeneity should invigorate the search for reliable predictors of evolution and progression of disease. We report a case series from a tertiary care centre in Kerala, South India. This was a retrospective observational study of all cases of CMML, which was diagnosed in the departments of Pathology and Clinical Haematology &amp; Haemato- oncology of our institution between January 2017 to May 2020. The clinical presentation, laboratory investigations, and treatment details were noted. Nine cases of CMML were encountered during the study period. The mean age of study subjects was 70.4 years with a female predilection. Fever and weight loss were the most common clinical presentations. Four patients were classified as CMML- 2, three patients as CMML- 1, and two as CMML- 0. Based on the WBC count, five patients were classified as dysplastic and four as proliferative subtypes. Two patients had grade 1/3 (one case each of CMML- 2 and CMML- 1) and one patient had grade 2/3 fibrosis (a case of CMML- 1) in the bone marrow. Thirty-three percentage patients had clonal cytogenetic abnormalities, the commonest being trisomy 8. Renal function was deranged in three patients and two patients had a deranged liver function and hepatomegaly. Four patients underwent treatment with hypomethylating agents or cytoreduction with hydroxyurea. One of the patients (CMML- 2 with marked leucocytosis) succumbed to disease.

Paroxysmal nocturnal hemoglobinuria and myelodysplastic syndrome: Disappearance of cytogenetic abnormalities

Paroxysmal nocturnal hemoglobinuria (PNH) is a rare life-threatening disease resulting from clonal hematopoietic stem cell evolution. There is a strong link between PNH and other acquired bone marrow failure syndromes, including myelodysplastic syndrome (MDS). Cytogenetic, morphological abnormalities or both are observed in the range of MDS/PNH diagnosis. Herein, we investigate cytogenetic abnormalities in PNH patients. We found two patients with PNH clones and MDS-associated abnormalities that later disappeared. The first patient, originally diagnosed with MDS and Trisomy 6, developed a large PNH clone. At the time of PNH diagnosis, the abnormal cytogenetic clone was no longer detectable despite persistent trilineage dysplasia. In the second patient, a large PNH clone and MDS-defining abnormality were detected at diagnosis, without evidence of dysplasia. No cytogenetic abnormalities were evident after complement inhibition. Our report adds significant information on the complex link between MDS and PNH, suggesting that distinction between these entities may be difficult in some cases. Especially in transplant eligible patients, the clinical phenotype may be the leading feature for treatment decisions in the era of complement inhibition. Lastly, the transient presence of cytogenetic abnormalities is a unique characteristic of our patients’ course that needs to be further elucidated in larger studies.