Current WHO Criteria Research Articles

SRSF2 Mutations Identify a Distinct Subtype of Myeloid Neoplasm Across Myelodysplastic Syndromes and Acute Myeloid Leukemia

Splicing factors are the most frequently mutated genes in myeloid neoplasms with myelodysplasia, including myelodysplastic syndromes (MDS), myelodysplastic/myeloproliferative neoplasms (MDS/MPN) and acute myeloid leukemia with myelodysplasia-related changes (AML-MDS). SF3B1 mutations was shown to be strongly associated with disease phenotype with ring sideroblasts, and SF3B1-mutant MDS has been proposed as a distinct disease subtype (Malcovati et al. Blood 2015). Conversely, SRSF2 has been found to be mutated in chronic myelomonocytic leukemia (CMML), and to be associated with multilineage dysplasia and excess blasts in MDS, as well as with clinico-pathological features of secondary AML (Linsdley et al. Blood 2015). In this study, we carried out a comprehensive mutation analysis in a well-annotated prospective cohort of 551 patients with myeloid neoplasms with myelodysplasia, and focused on clinical and molecular features of SRSF2-mutated patients with the aim to characterize patterns of co-occurring mutations and to identify genotype-phenotype correlations.A core panel of 54 genes recurrently mutated in myeloid neoplasms was analyzed using an Illumina HiSeq (Illumina Inc., CA, USA). Multivariable survival analyses were performed by means of Cox proportional hazards regression accounting for left censoring of the observation at the time of mutation assessment. Unsupervised hierarchical clustering analyses were performed in order to identify homogeneous groups of patients with respect to the variables of interest.Overall, 102 patients carrying SRSF2-mutation were identified, including 37 MDS (2 MDS with single lineage dysplasia, 9 with multilineage dysplasia, 6 with ring sideroblasts, 20 with excess blasts), 40 MDS/MPN (35 CMML, 5 MDS/MPN unclassified) and 25 AML-MDS. The median number of co-mutated genes was 2 (range 0 to 5); SRSF2 mutation was the unique mutation detected in 11 cases (5 AML-MDS, 4 MDS/MPN and 3 MDS). The most frequently co-mutated genes were TET2 (31/102 cases, 30%), ASXL1 (28%), IDH1/IDH2 (24%), RUNX1 (21%), STAG2 (14%) and CBL (10%). A significant association was found between co-mutation of TET2 and SRSF2 and myeloid neoplasm with monocytosis (P<.001), whereas STAG2 and IDH1/IDH2 mutations were significantly associated with MDS/AML-MDS phenotype (P=.044 and P=.001, respectively). We applied stepwise logistic regression, and confirmed that co-mutation of TET2 was a highly specific independent predictor of MDS/MPN phenotype within SRSF2-mutated myeloid neoplasms (OR=9.13, P<.001, positive predictive value: 0.85; specificity: 0.89).Then, we carried out uni- and multivariable Cox-regression analyses, and found that SRSF2-mutant MDS/MPN showed a significantly better prognosis compared to MDS (HR=.44, P=.008) and AML-MDS (HR=.47, P<.001). Conversely, having 20% or more bone marrow blasts or exceeding this threshold during follow-up did not affect survival of patients with SRSF2-mutated MDS or AML-MDS (HR=1.56, P=.15), suggesting that the proportion of bone marrow blasts does not recognize distinct subsets within SRSF2-mutated MDS and AML-MDS.Finally, we performed unsupervised hierarchical clustering analyses including current WHO classification criteria and gene mutations. This analysis identified one cluster including patients with MDS/MPN according to current WHO criteria, and a second cluster comprising patients with MDS or AML-MDS, in which a distinct subgroup including SRSF2-mutated patients was identified, irrespective of WHO bone marrow blast cut-offs.In conclusion, these results suggest that SRSF2 mutation is able to identify a distinct subset of myeloid neoplasms at the boundaries of MDS and AML, irrespective of current WHO classification criteria. Conversely, SRSF2-mutant MDS/MPN show different co-mutation patterns and clinical outcomes, supporting a classification in a separate category according to current WHO criteria. The recognition of a distinct entity with a unique molecular basis may significantly improve the diagnosis, classification and treatment of patients with these disorders. DisclosuresNo relevant conflicts of interest to declare.

A Novel Approach for Identifying Ischemic Cardiomyopathy.

Refer to the page 41-47 Since Burch et al.1) first introduced the terminology cardiomyopathy (ICM), it has been widely used in clinical practice. The condition may originate from prolonged ischemia, a single large infarct, or repeated micro-infarcts inducing left ventricular dysfunction and remodeling through apoptosis and fibrosis as a result of activation of the endothelin or renin-angiotensin-aldosterone system.2) It can be reversed after successful revascularization in the presence of a viable myocardium. However, there have been several debates about the actual existence of that kind of cardiomyopathy. Because traditionally cardiomyopathy is a result of a genetically or acquired disease-driven myopathic processes, current WHO criteria do not include in the classification of cardiomyopathy.3) But in many clinical practices and studies, an initial classification as or is widely used in patients with severely depressed left ventricular function. Use of the terminology ICM or non-ICM persists in spite of a lack of official guidelines because it can provide a simple and easily communicated understanding of the underlying pathogenesis and treatment options. A myocardium that is malfunctioning from prolonged ischemia can be improved after successful revascularization treatment, such as coronary artery bypass surgery. If a patient is classified as non-ICM, then a search for other causes must be begun. However, the current definition of is vague and cannot fully explain the cause of severely depressed left ventricular dysfunction.4) In addition, as a previous study showed, with post-myocardial infarction has a far different prognosis from without post-myocardial infarction5); the underlying causes of non-post myocardial infarction are very complex and cannot be easily explained by the concept of a hibernating myocardium. This complexity may explain the unexpected dearth of positive outcomes in the Surgical Treatment for Ischemic Heart Failure trial, such as improved survival, according to viability tests, following bypass surgery in patients with ICM.6) In this regard, a study done by Kim et al.7) provides important insight about possible misclassification as or based on the traditional definition using coronary angiography and a history of previous myocardial infarction. According to their observations with delayed hyper-enhancement (DHE)-cardiac magnetic resonance (CMR), some cases classified as had non-ischemic DHE patterns, such as midwall striae, patch, or subepicardial DHE. Also, a small portion of patients had ischemic DHE patterns, such as subendocardial DHE. They suggested that the classification of should be individualized after considering DHE-CMR findings. According to their observations, some patients with showed midwall linear DHE, which is a unique finding related to prognosis in cases.8) It provides new insight into the pathology of left ventricular dysfunction in these patients and also the pathophysiology of midwall DHE, which is believed to be from prior myocarditis or an increase in gadolinium diffusion distance due to high wall stress.9) However, no satisfactory explanation has been proposed because usually the amount of interstitial fibrosis is highest in the subepicardium, not the midwall, in patients.10) The study done by Kim et al.7) has a limitation in that identification of without prior myocardial infarction requires evaluation for the presence of myocardial perfusion defects because DHE only represents replacement fibrosis. Therefore, patients without DHE and with non-DHE regions also need to be characterized to explain severely depressed left ventricular systolic function. To overcome this limitation, inclusion of new parameters such as myocardial flow reserve or extracellular space volume fraction would be helpful. In addition, a large-scale study can provide clarity on the clinical characteristics of this discordant population.

Congenital Neutrophilia Arising from a T618I Germline Mutation in the CSF3R Gene

Recently, somatic mutations in the granulocyte colony-stimulating factor receptor (CSF3R) have been identified in the majority of patients with chronic neutrophilic leukemia (CNL). The T618I mutation is the most common of these mutations, and it has been suggested that this specific mutation be added to the current WHO criteria for the diagnosis of CNL. In vitro studies of cells transfected with the T618I mutation have demonstrated that the mutant receptor confers a hyperproliferative phenotype.We report here a case of congenital neutrophlia with an associated germline T618I CSF3R mutation. The patient, currently a 10 year old female, has had an elevated but stable leukocytosis (WBC 24,000 - 35,000) since birth, comprised of approximately 80% neutrophils. She has been healthy, with no increase in frequency of infections. Bone marrow studies performed at 5 months and 10 years of age have shown the marrow to be hypercellular, with normal karyotype/FISH (including BCR/ABL negative) and no dysplastic features. Additionally, no mutations have been detected in JAK2, MPL, CALR, PDGFA/B, and FGFR1.DNA was extracted from whole blood and buccal cells collected from the patient, and using next generation sequencing a T618I mutation in CSF3R was identified in both her buccal and blood cells, confirmed by Sanger sequencing. The T618I mutation was present at an approximately 50% allele frequency in both tissues. Using a combination of next generation and Sanger sequencing, the patient's DNA was also analyzed for the presence of mutations in ASXL1, SETBP1, and TET2; as these have been reported in combination with the T618I mutation in many cases of CNL. However, no such additional mutations were detected in our patient.Congenital neutrophilia arising from another activating mutation in CSF3R has previously been reported in a family from France (Plo et al., J Exp Med 2009). The mutation identified in that family was reported to be at amino acid position 617 (T617N) (numbering from the methionine 1, which includes the leader sequence, this correlates to a T640N mutation). Similar to the T618I mutation in our patient, none of the 12 affected family members (ages 8-80 years) progressed to an acute leukemia. Collectively, these observations suggest that activating CSF3R mutations, including the T618I mutation, may result in chronic neutrophilic leukemia but that subsequent disease progression may be due to other, cooperating mutations. DisclosuresNo relevant conflicts of interest to declare.

Abstract PL02-01: What we learned from immunotherapy in previous years

Abstract PL02-01: What we learned from immunotherapy in previous years

Risk Stratification in Women with Gestational Diabetes According to and Beyond Current WHO Criteria.

The pregnancy outcomes in women with gestational diabetes mellitus (GDM) and 'overt diabetes in pregnancy' were compared and the need for further subclassification was investigated with respect to postpartum outcome risk. Data from 944 women who had been uniformly diagnosed as having GDM in Munich, Germany, between 1998 and 2010, were re-classified into GDM and 'overt diabetes in pregnancy'. Pregnancy related outcomes in the offspring were derived from Bavarian birth registry data. Classification and regression trees were used to identify further GDM sub-phenotypes. In total, 88 women (9.3%) were re-classified as having 'overt diabetes in pregnancy'. Compared to women with GDM, women with 'overt diabetes in pregnancy' used insulin more frequently, and were at increased risk for large for gestational age infants [odds ratio 2.50 (95% confidence interval 1.02, 6.13)], preterm delivery [odds ratio 3.28 (1.02, 10.50)], and low APGAR-score at 5 min [odds ratio 12.70 (1.58, 102.2)]. In the 856 women with GDM, classification and regression tree analyses provided further risk stratification in that a combination of fasting glucose>5.3 mmol/l and 1-h glucose>11.1 mmol/l at GDM diagnosis predicted insulin requirement [OR 5.57 (3.75, 8.27) compared to the rest], and maternal body mass index (BMI)≥35 kg/m(2) predicted large for gestational age status. The new differentiation between GDM and 'overt diabetes in pregnancy' is a first step towards refining classification relevant to fetal and maternal postpartum risk. A combination of glucose levels and maternal BMI at diagnosis of GDM may provide further improvement.

CD4+ gain percentile curves for monitoring response to antiretroviral therapy in HIV-infected adults.

We constructed CD4 cell count gain percentile distributions standardized by baseline CD4 cell count and assessed the association between poor CD4 cell count gain and subsequent death and virological failure on antiretroviral therapy (ART). Secondary analysis of 10 years of clinical data from a cohort of adults initiated on ART at the Themba Lethu clinic in Johannesburg, South Africa. The generalized additive model for location, scale and shape was used to construct percentile curves for CD4 cell count gain standardized by baseline CD4 cell count in the first 28 months of ART. Cox proportional models were used to assess the association between lower percentiles (<50th) of CD4 cell count gain, and subsequent death and virological failure. Among 9640 nonpregnant adults 7406, with available CD4 cell count results for CD4 gain calculation at 4 months of ART, 843 (8.7%) died subsequently and 1101 (11.4%) experienced virologic failure, respectively. For CD4 gains below the third percentile, the adjusted hazard ratios at different time points ranged between 2.72 and 5.73 for death, and between 1.48 and 6.93 for virologic failure. The CD4 percentile curves revealed a gradient of increasing risk of subsequent death and virological failure, with lower CD4 gain percentiles and increasing time on ART, and were more informative than the WHO criteria for immunological failure or current CD4 cell count. Percentile curves of CD4 cell count gain provide a simple tool for healthcare workers in low-resource settings to monitor response to ART with improved information regarding risk of death and virological failure compared to current WHO criteria for immunological failure.

Expression of Neuroendocrine Markers in Different Molecular Subtypes of Breast Carcinoma

Background. Carcinomas of the breast with neuroendocrine features are incorporated in the World Health Organization classification since 2003 and include well-differentiated neuroendocrine tumors, poorly differentiated neuroendocrine carcinomas/small cell carcinomas, and invasive breast carcinomas with neuroendocrine differentiation. Neuroendocrine differentiation is known to be more common in certain low-grade histologic special types and has been shown to mainly cluster to the molecular (intrinsic) luminal A subtype. Methods. We analyzed the frequency of neuroendocrine differentiation in different molecular subtypes of breast carcinomas of no histologic special type using immunohistochemical stains with specific neuroendocrine markers (chromogranin A and synaptophysin). Results. We found neuroendocrine differentiation in 20% of luminal B-like carcinomas using current WHO criteria (at least 50% of tumor cells positive for synaptophysin or chromogranin A). In contrast, no neuroendocrine differentiation was seen in luminal A-like, HER2 amplified and triple-negative carcinomas. Breast carcinomas with neuroendocrine differentiation presented with advanced stage disease and showed aggressive behavior. Conclusions. We conclude that neuroendocrine differentiation is more common than assumed in poorly differentiated luminal B-like carcinomas. Use of specific neuroendocrine markers is thus encouraged in this subtype to enhance detection of neuroendocrine differentiation and hence characterize the biological and therapeutic relevance of this finding in future studies.

Clinical Features and Outcome Of Clonal Mastocytosis Secondary To Chronic Myelomonocytic Leukemia (SM- AHNMD/CMML) Given Diverse Therapies – A Single Institution Retrospective Study

BackgroundSystemic mastocytosis with associated clonal hematological non mast cell lineage disease (SM-AHNMD), though uncommon, is considered a distinct subcategory of systemic mastocytosis according to the 2008 World Health Organization classification. Prior studies indicate that acute myeloid leukemia with t(8;21) has a strong link to SM-AHNMD. Systematic investigation of systemic mastocytosis associated with chronic myelomonocytic leukemia (SM-CMML) is limited. Bone marrow clonal mast cell proliferation, without overt clinical presentation following CMML often poses a diagnostic challenge and treatment dilemma. The overall survival for SM or SM-AHNMD varies according to subcategories of AHNMD and/or the therapeutic strategies taken. With hypomethylating agents becoming standard therapy for CMML with median overall survival (OS) of 12 to 24 months, acquisition of clonal mast cell proliferation may result in earlier relapse or refractoriness to conventional therapy. We reviewed the clinicopathologic features, cytogenetic and molecular findings, and clinical course of 10 patients with SM-AHNMD specifically chronic myelomonocytic leukemia (SM-CMML). Methods and MaterialsThis retrospective study followed the guidelines of the Institutional Review Board (IRB). Cases diagnosed as SM-AHNMD at Moffitt Cancer Center from 1996 to 2013 were retrieved from the hospital electronic medical record and Cancer Registry. The diagnosis of SM- CMML was confirmed by histomorphology, laboratory data, phenotypic and molecular findings using current WHO criteria. Cases selected were CMML with concurrent or subsequent identification of a clonal mast cell proliferation (SM-CMML). Both solitary SM and SM-AHNMD other than CMML were excluded from this study. ResultsForty patients diagnosed with indolent, cutaneous or systemic mastocytosis were identified, of which 19 were SM- AHNMD. Among the 19 patients, 10 qualified for the study, based on the above criteria, with a median age of 71.4 years (range 43-82) and male: female ratio of 7:3. Nine of 10 patients had no prior evidence of extramedullary mast cell involvement. In one patient systemic lesions were identified 3 months prior to the diagnosis of CMML. Two patients were originally diagnosed with myelodysplastic syndrome [Refractory cytopenia with multilineage dysplasia and Refractory anemia with excess blasts-2], which subsequently were diagnosed as CMML-1 and CMML-2, respectively. The length of time from the original CMML presentation to the diagnosis of SM-AHNMD was widely variable ranging from concurrent to over 80 months. All cases fit the WHO major criterion of aggregates of spindled mast cells. In addition all cases stained positive for CD117 and mast cell tryptase and displayed aberrant staining with either CD2 and/or CD25. Serum tryptase was also elevated (>20ng/ml). Standard treatment protocols with azacitidine were used for CMML. After the diagnosis of SM-AHNMD was rendered the treatment strategies were variable. Key clinical and pathologic features at the time of diagnosis of SM-CMML along with treatment and outcome are summarized in Figure 1. Laboratory values at the time of CMML diagnosis are not shown. The median overall survival was 14.75 months (range 1.0 to 88 months) after CMML was diagnosed and 7.25 months (range 1.0 to 28 months) following diagnosis of SM-CMML. [Display omitted] ConclusionSM- CMML is a rare entity. Clinical presentation is extremely variable. The subtle morphologic features of a developing SM warrants careful histopathologic evaluation, judicious use of immunohistochemical stains and ancilliary techniques. Adherence to the current WHO criteria is important in the identification of these cases. Currently, established treatment guidelines for SM-AHNMD are non-existent. A large scale study is warranted to enrich physician experience in treatment of this rare entity and reduce the associated adverse outcomes. Disclosures:No relevant conflicts of interest to declare.

Outcome Of Patients With Abnl(17p) Acute Myeloid Leukemia After Allogeneic Hematopoietic Stem Cell Transplantation

PurposePatients with acute myeloid leukemia (AML) and abnormalities (abnl) of the short arm of chromosome 17 (17p) are considered to be at high risk of treatment failure after conventional chemotherapy. Small studies have suggested that this abnormality may portend a poor prognosis even after allogeneic hematopoietic stem cell transplantation (HSCT). The aim of this study was to assess the prognostic role of abnl(17p) in a larger cohort of patients with AML undergoing allogeneic HSCT, and to analyse the impact of disease status, conditioning regimen, and type of abnormality. Here, we present data on the outcome of 201 patients with abnl(17p) AML transplanted since 2000. Patients and MethodsWe performed a retrospective cohort analysis based on study-registries from two AML groups, HOVON and SAL, and transplant-registries of the Fred Hutchinson Cancer Research Center (FHCRC) and the German Cooperative Transplant Study Group (GCTSG). Inclusion criteria were AML diagnosed according to the current WHO criteria with 17p abnormalities and a first HSCT between January, 1, 2000 and January, 1, 2011. Overall survival (OS), event-free survival (EFS), cumulative incidence of relapse (CIR) and non-relapse-mortality (NRM) after HSCT are reported for the whole cohortand for patients receiving HSCT in first complete remission (CR1). We tested for center effects (FHCRC, HOVON, SAL, GCTSG) in a multivariate Cox regression model. ResultsData from 201 patients with full information on the karyotype were analysed. The median age was 54 years with a range from 2 years to 75 years. Five patients were younger than 18 years. Sixty-one percent of the patients suffered from de novo AML, while 26% had secondary AML and 11% therapy-related myeloid neoplasm. Complex and monosomal karyotypes were present in 90% and 77% of patients, respectively. Eighty-four patients (42%) were in CR1 at the time of HSCT. Seventy patients (35%) were treated with standard myeloablative conditioning (MAC) regimens while the remaining patients received reduced intensity conditioning (RIC). Donors were matched siblings in 34%, matched unrelated donors in 43% and partially matched or mismatched unrelated donors in 18% of the patients. Eight patients (4%) had a haploidentical donor.At the time of analysis 30 patients were alive with a median follow-up of 30 months (range 1 to 121 months). At three years, the probabilities of OS and EFS were 15% (95% CI, 10% to 20%) and 12% (95% CI, 7% to 16%), respectively, whereas the CIR was 49%. For patients transplanted in CR1 the probability of OS at three years was 22% (95% CI, 13% to 32%) compared to 9% (95% CI, 3% to 15%) for those with advanced disease (p=<.001). The main cause of treatment failure was relapse. The CIR at three years was 57% in patients who were transplanted in CR1 compared to 42% in patients with more advanced disease (p=.0912). Notably, 70% of the observed relapses occurred within the first six months after HSCT. NRM was also high within the first six months, mainly among patients with advanced disease (40% NRM in advanced stages compared to 14% in CR1; p=<.001). In multivariate analysis only age (HR=1.02; p=.01) and disease status (HR=0.52; p=.007) had a significant influence on OS. No significant differences in outcomes were observed between the different types of abnormalities regarding OS, EFS, CIR and NRM, but patients with a monosomal karyotype had worse outcome compared to patients with a non-MK karyotype (3-year OS 11% versus 29%, p=.003).The incidence of grade II to IV acute GvHD up to day 100 was 32% while grade III to IV occurred in 11% of the patients. Due to the high frequency of competing events (death or relapse before onset of GvHD) the cumulative incidence for chronic GvHD at one year was very low with 8%. ConclusionPatients with abnl(17p) AML have a poor outcome after HSCT. The observation of better outcome in patients with less advanced disease stages and without MK argues against primary resistance to allogeneic immune effects of 17p abnormalities. While transplantation in CR1 may still be considered the treatment of choice due to the lack of more promising alternatives, novel strategies to prevent relapse are highly warranted for this group of patients. For patients with abnl(17p) AML in more advanced stages experimental approaches should be considered. [Display omitted] [Display omitted] Disclosures:No relevant conflicts of interest to declare.

Real-World “myelodysplastic Syndrome-unclassifiable” and Its Comparison With “refractory Cytopenia With Multi-Lineage dysplasia” and “refractory anemia”

BackgroundIn routine myelodysplastic syndromes (MDS) practice, physicians do not submit bone marrow (BM) slides for central review. Instead, they rely on available BM reports to assess prognosis and make therapeutic decisions. Such practice is likely to introduce inaccuracies, especially in the diagnosis of MDS-unclassifiable (MDS-U). The objectives of the current study were to describe the natural history of MDS-U that is diagnosed based on routine BM and peripheral blood (PB) smear reports and compare its prognosis to refractory anemia (RA) or refractory cytopenia with multi-lineage dysplasia (RCMD), which were diagnosed in the same manner. MethodsMayo Clinic databases were reviewed to identify consecutive patients who meet current WHO criteria for MDS-U, RA and RCMD (Swerdlow et al. WHO classification of Tumors, Lyon 2008). No central review was required and diagnosis was based on routine Mayo Clinic pathology reports. Included in the current WHO-defined MDS-U are patients with findings of i) refractory cytopenia with unlineage dysplasia (RCUD) or RCMD with 1% blasts in the PB, 2) MDS with unilineage dysplasia and pancytopenia and 3) persistent cytopenia with ≤1% PB blasts, <5% BM blasts, <10% BM myeloid cell dysplasia and cytogenetic abnormalities considered presumptive evidence of MDS. Patients who had exposure to chemotherapy and/or radiotherapy were excluded. ResultsA total of 382 patients met WHO diagnostic criteria for MDS-U (n=146; 38%), RA (n=26; 7%), and RCMD (n=210; 55%). Presenting clinical characteristics for patients belonging to each one of these three categories are listed and compared in table 1. There was no difference between the three subgroups in age or gender distribution. Similarly, with the exception of thrombocytopenia that was more prevalent in RCMD, complete blood count and transfusion need at diagnosis were not significantly different between the groups. Risk distribution using conventional prognostic models for survival did not reveal significant differences between MDS-U, RCMD and RA. At the time of this analysis, 265 deaths and 25 leukemic transformations were documented. Overall and leukemia-free survival was similar between the three groups (Figure 1). IPSS and IPSS-R karyotypes (Figure 2&3), however delineate patients into distinct category (P=0.001 and P= 0.01) [Display omitted] [Display omitted] VariablesMDS-Un=146RAn=26RCMDn=210P valueAge: median (range) years71 (23-90)68 (57-90)73 (25-96)0.2Sex: Male (%)100 (68 %)17 (65 %)152 (72 %)0.6HGB: median (range)9.8 (5.6 -14.6)9.85 (6.6-13.4)9.7 (6.4-15.7)0.8WBC: median (range)3.3 (1.1-35)4.5 (1.3-10.7)3.85 (0.6-37)0.2ANC: median (range)2.7 (0.0-20)2.33 (0.48-8.88)1.86 (0.08-18.1)0.4Platelet count: median (range)132 (7-599)163 (14-447)93 (2-780)0.01Transfusion dependency (%)43 (29 %)7 (27 %)80 (38 %)0.2IPSSLowInte-1Inte-2High379316071810481372500.4IPSS-R (Karyotype)Very goodGoodIntermediatePoorVery poor68733126314810111333913140.5IPSS-RVery lowLowIntermediateHighVery high22503922138765031725336180.5WPSSVery lowLowIntermediateHighVery highNot applicable81071009566490Median Survival (months)IPSS KaryotypeGoodIntermediatePoor0.001382614IPSS-R KaryotypeVery goodGoodIntermediatePoorVery Poor0.043338281519IPSS-R-modifiedGood & very goodIntermediatePoor & very poor0.01352815 [Display omitted] ConclusionsDistinguishing between MDS-U, RCMD and RA, in daily practice, has limited clinical relevance. It might be simpler and more practical to consider MDS without excess blasts under one common morphologic category and utilize instead cytogenetic and molecular information for further prognostic stratification and identify patient subgroups with specific therapeutic needs.Myelodysplastic syndrome-unclassifiable (MDS-U) (n=146) compared with refractory anemia (RA) (n=26) and refractory cytopenia with multilineage dysplasia (RCMD) (n=210) Disclosures:No relevant conflicts of interest to declare.

Myelodysplastic/Myeloproliferative Neoplasms, Unclassifiable (MDS/MPN, U): Natural History and Clinical Outcome By Therapeutic Approach

BackgroundMyelodysplastic/myeloproliferative neoplasm, Unclassifiable (MDS/MPN-U) is a distinct entity among the myeloid neoplasms, characterized by the simultaneous presence of both dysplastic and proliferative features. The natural history, clinical characteristics, response to treatment and patient outcome of patients with MDS/MPN-U has not been well described, apart from the MDS/MPN-U provisional entity of Refractory Anemia with Ringed Sideroblasts and Thrombocytosis (RARS-T). AimsClinicopathologic features of 85 patients with MDS/MPN-U and without RARS-T were evaluated, along with clinical outcomes based on treatment strategy. MethodsAll patients with MDS/MPNs treated from July 1986 to February 2013 at MDACC were reviewed. Patients seen prior to 2006 with a recorded diagnosis of MDS/MPD or chronic MPD-U were reviewed by two hematopathologists and diagnoses were revised as appropriate according to the current WHO criteria. All RARS-T patients per WHO 2008 definition were excluded, and patients were excluded if the de novo presence of both myelodysplastic and proliferative features at diagnostic presentation per WHO criteria was unable to be confirmed. ResultsMDS/MPN-U patients were predominantly over the age of sixty (92%), with a median age of 70 years (range 22 – 90), and 61 patients (72%) were male. 29 patients (35%) had splenomegaly at presentation. Median presenting white blood cell (WBC) count was 17 x 10⁹/L (1 – 141 x 10⁹/L), median hemoglobin was 10 g/dL (5 – 15 g/dL), and median platelet (PLT) count was 85 x 10⁹/L (6 – 1168 x 10⁹/L). Of 56 patients with known JAK2 status, 17 patients (30%) had the presence of the JAK2 V617 mutation. The majority of patients had either diploid cytogenetics (49%) or trisomy 8 as the sole abnormality (15%); 10 patients (12%) had a complex karyotype.Median OS was 12.4 months (range 0.3 – 138.7). A uniquely favorable outcome was seen in the 11 patients presenting with a PLT count ≥ 450 x 10⁹/L, with median OS 52.5 vs 11.9 months (p<0.001) {Figure 1}. Other variables associated with favorable outcome included age <60 (p < 0.001), lack of circulating blasts (p = 0.023) and <5% bone marrow blasts (p = 0.017). Neither JAK2 V617F mutant status nor karyotype associated with outcome, and in multivariate analysis, only platelet count retained prognostic significance (p=0.001). Whereas the IWG-MF score was not prognostic, the MDS IPSS score imparted a statistically significant classification for the MDS/MPN-U cohort, with a median OS by IPSS score of 15.4, 17.7, 8.3 and 6.9 m, respectively (p = 0.039) {Figure 2}.Overall, 36 patients (42%) received hypomethylating agent (HMA) therapy. 13 (15%) were treated with an immunomodulatory approach (e.g. lenalidomide, interferon-α), five (6%) underwent splenectomy and five (6%) received stem cell transplant (SCT). HMA-treated patients had an OS of 16.4 vs 11.5 months with other approaches (p=0.57); patients on immunotherapy had a non-significant trend towards worse OS of 11.4 vs 15.4 months (p=0.07). The five patients receiving splenectomy had OS 51.1 m vs 10.0 mo (p=0.12), and with SCT 12.4 vs 12.5 months (p=0.16). [Display omitted] [Display omitted] ConclusionOverall, our analysis validates the diagnosis of MDS/MPN-U as a unique pathologic entity, with features and prognostic variables distinctive from either PMF or MDS. While no statistically significant differences in OS were identified based on therapy; in terms of the various diagnostic, prognostic and treatment strategies, MDS/MPN-U patients without RARS-T appear to have characteristics and outcome most analogous to MDS. The favorable outcome of surgical splenectomy among those MDS/MPN-U patients with splenomegaly suggests this may also be part of a a reasonable therapeutic approach. Disclosures:No relevant conflicts of interest to declare.

Germline Mutations in the Polyposis-Associated Genes BMPR1A, SMAD4, PTEN, MUTYH and GREM1 Are Not Common in Individuals with Serrated Polyposis Syndrome

BackgroundRecent reports have observed that individuals with serrated polyps, some of whom meet the clinical diagnostic criteria for Serrated Polyposis Syndrome (SPS), are among those who carry germline mutations in genes associated with polyposis syndromes including; (1) genes known to underlie hamartomatous polyposes (SMAD4, BMPR1A, and PTEN), (2) MUTYH-associated polyposis and (3) GREM1 in Hereditary Mixed Polyposis Syndrome (HMPS). The aim of this study was to characterise individuals fulfilling the current WHO criteria for SPS for germline mutations in these polyposis-associated genes.MethodsA total of 65 individuals with SPS (fulfilling WHO criteria 1 or 3), were recruited to the Genetics of Serrated Neoplasia study between 2000 and 2012, through multiple Genetics or Family Cancer Clinics within Australia, or from the New Zealand Familial Gastrointestinal Cancer Service. Individuals with SPS were tested for coding mutations and large deletions in the PTEN, SMAD4, and BMPR1A genes, for the MUTYH variants in exons 7 (Y179C) and 13 (G396D), and for the duplication upstream of GREM1.ResultsWe found no variants that were likely to be deleterious germline mutations in the SPS cases in the PTEN, SMAD4, and BMPR1A genes. A novel variant in intron 2 (c.164+223T>C) of PTEN was identified in one individual and was predicted by in silico analysis to have no functional consequences. One further individual with SPS was found to be mono-allelic for the MUTYH G396D mutation. No individuals carried the recently reported duplication within GREM1.ConclusionsGenes involved in the gastrointestinal hamartomatous polyposis, Hereditary Mixed Polyposis Syndrome and MUTYH-associated polyposis syndromes are not commonly altered in individuals with SPS.

The impact of adjuvant stereotactic radiosurgery on atypical meningioma recurrence following aggressive microsurgical resection

Patients with atypical meningioma often undergo gross-total resection (GTR) at initial presentation, but the role of adjuvant radiation therapy remains unclear. The increasing prevalence of stereotactic radiosurgery (SRS) in the modern neurosurgical era has led to the use of routine postoperative radiation therapy in the absence of evidence-based guidelines. This study sought to define the long-term recurrence rate of atypical meningiomas and identify the value of SRS in affecting outcome. The authors identified 228 patients with microsurgically treated atypical meningiomas who underwent a total of 257 resections at the Barrow Neurological Institute over the last 20 years. Atypical meningiomas were diagnosed according to current WHO criteria. Clinical and radiographic data were collected retrospectively. Median clinical and radiographic follow-up was 52 months. Gross-total resection, defined as Simpson Grade I or II resection, was achieved in 149 patients (58%). The median proliferative index was 6.9% (range 0.4%-20.6%). Overall 51 patients (22%) demonstrated tumor recurrence at a median of 20.2 months postoperatively. Seventy-one patients (31%) underwent adjuvant radiation postoperatively, with 32 patients (14%) receiving adjuvant SRS and 39 patients (17%) receiving adjuvant intensity modulated radiation therapy (IMRT). The recurrence rate for patients receiving SRS was 25% (8/32) and for IMRT was 18% (7/39), which was not significantly different from the overall group. Gross-total resection was predictive of progression-free survival (PFS; relative risk 0.255, p < 0.0001), but postoperative SRS was not associated with improved PFS in all patients or in only those with subtotal resections. Atypical meningiomas are increasingly irradiated, even after complete or near-complete microsurgical resection. This analysis of the largest patient series to date suggests that close observation remains reasonable in the setting of aggressive microsurgical resection. Although postoperative adjuvant SRS did not significantly affect tumor recurrence rates in this experience, a larger cohort study with longer follow-up may reveal a therapeutic benefit in the future.

The significance of diagnosing associated clonal mast cell diseases in patients with venom‐induced anaphylaxis and the role of bone marrow investigation

Hymenoptera venom allergy (HVA) represents a particular risk for exceptionally severe anaphylactic sting reactions in patients with clonal mast cell disorders (CMD). Nevertheless, conventional investigations are not sufficient to do accurate risk assessments. Increased levels of baseline serum tryptase (sBT) (>11.4 μg/L) is highly associated with severe anaphylactic reactions and with a possible underlying CMD. The measurement of baseline serum tryptase, thus, has opened the possibility to screen for CMD. In the present study, we sought to investigate whether bone marrow evaluation provides more accurate diagnosis in patients with HVA.Three patients of the same sex and similar age with HVA were enrolled in this clinical study. The patients underwent comprehensive allergy work-up including skin prick testing, measurements of serum total IgE concentrations and baseline serum tryptase. Bone-marrow biopsies were also performed in all three patients to assess underlying CMD.We evaluated characteristics of the bone marrow mast cells by pathology, flow cytometry and detection of D816V mutation by using current WHO-criteria, which led to changes in the final diagnosis compared to the assessments done by classical allergy work-up and measurements of sBT. Three distinct diagnostic outcomes including systemic mastocytosis, monoclonal mast cell activation syndrome and non-clonal HVA were revealed.We conclude that a bone marrow investigation is required for the correct diagnosis of hymenoptera venom-induced anaphylactic reactions in patients with elevated baseline tryptase levels (>11.4 μg/L), and this has important implications for management strategies.

Sensitivity and Specificity of Laboratory Parameters to Detect Early/Prefibrotic Myelofibrosis in 857 Patients with Essential Thrombocythemia. A Diagnostic Algorithm

Abstract 5148 INTRODUCTION.Patients presenting with a clinical picture of essential thrombocythemia (ET) can actually have an early/prefibrotic myelofibrosis (PMF), according to current WHO criteria, in about 18% of cases. Laboratory tests which are significantly different in early/prefibrotic PMF as compared with histologically confirmed ET (WHO-ET) include decreased gender-matched hemoglobin (Hb), increased white blood cell (WBC), platelet (PLT) counts and lactate dehydrogenase (LDH) values. AIM.To evaluate sensitivity (SE) and specificity (SP) of blood cell counts and LDH, at presentation, for the diagnosis of early/prefibrotic PMF vs. WHO-ET. METHODS.Five hundred thirty-six cases (50%) who had complete laboratory data measured at diagnosis constituted the exploratory set of our study and were derived from an international ET database. The discriminatory ability of Hb, WBC, PLT and LDH in correctly classifying patients in the early/prefibrotic PMF or WHO-ET groups was initially tested by plotting their Receiving Operating Characteristic (ROC) curves and comparing the relative Areas Under the Curve (AUC) with the value of 0.50 (which stands for the completely useless of the test). Three parameters with statistically significant discriminatory power were chosen (Hb, WBC and LDH) and thresholds searched in order to guarantee at least 90% of SE or SP. Finally, a diagnostic algorithm was designed.The validation set of this analysis was constituted by 321 patients with WHO-ET (n=62) or early/prefibrotic PMF (n=259) diagnosed by the same pathologist who confirmed the training set cohort and collected in the Institute for Pathology, University of Cologne, Germany. SE and SP for the same parameters and thresholds as well as the final diagnostic algorithm were applied to this set of patients to demonstrate the results' reproducibility. RESULTS.Sensitivity and specificity to recognize early/prefibrotic PFM have been evaluated by ROC curves. The best performance was found for LDH (AUC = 0.7059). WBC and Hb had super imposable curves, with AUC of 0.6279 and 0.6257, respectively. The worst performance was registered for PLT count: its AUC was only 0.5628, not significantly different from the reference value of 0.50 (p=0.154). Thresholds of Hb, WBC and LDH were searched to achieve at least 90% of SE or SP. HB < 12 g/dL for women or <13 g/dL for men, and WBC >= 13 x109/L had higher SP (92% and 91%, respectively). High SP is highly related to the presence of early/prefibrotic PMF (true positives).On the contrary, LDH < 200 mU/mL and WBC < 7 x109/L had good sensitivity (91% and 94%, respectively). High SE is highly related to the absence of early/prefibrotic PMF (true negatives). By applying these SE and SP values in a step-by-step algorithm, nearly half of patients (48%) could be classified as WHO-ET or early/prefibrotic PMF, assuming at each step a margin of error of less than 10%. For the remaining 50% of patients, laboratory results didn’t allow to suspect or exclude the presence of early/prefibrotic PMF.In the validation set of 321 patients classified by WHO 2008 as true ET or early/prefibrotic PMF (Cologne cohort) SP of anemia was 84%, WBC < 7 x109/L or >= 13 x109/L had 91% and 81% of SE and SP, respectively. LDH values < 200 mU/mL had 85% of SE. By applying the same flow-chart, 46% of patients were classified as WHO-ET or early/prefibrotic PMF. CONCLUSIONS.The present study provides clinicians with laboratory parameters that should increase suspicion of early/prefibrotic PMF in a patient with a working clinical diagnosis of ET. In fact, while patients presenting clinically with ET can now be discriminated as true ET or early/prefibrotic PMF by adopting the WHO 2008 criteria that require bone marrow histology, an algorithm including baseline anemia, WBC count and LDH, allows this differentiation in about 50% of patients with a good approximation. However, for a definitive proof, bone marrow histology is still an integral part for final diagnosis. Disclosures:Vannucchi:Novartis: Honoraria.

Heritability of optic disc diameters: a twin study

To assess the relative influence of genetic and environmental factors on optic disc size and cup/disc ratio in healthy eyes. A sample of 55 monozygotic and 50 dizygotic healthy twin pairs aged 20-46, all having the same sex within pairs (47 pairs were male) had optic discs measured from colour fundus photographs according to the Wisconsin Protocol. Structural equation modelling was used to estimate the relative contribution of genetic and environmental factors to the phenotype. Disc dimensions did not vary significantly by age or sex. After adjusting for age and sex, additive genetic factors (i.e. heritability) explained 77% (95% CI: 65-85%) of variation of vertical disc diameters, whereas estimated unshared environmental effect was 23% (95% CI: 15-35%). For vertical cup diameters, heritability accounted for 70% (95% CI: 55-80%) and environmental factors 30% (95% CI: 20-45%). For cup/disc ratio, additive genetic and unshared environmental factors explained 66% (95% CI: 48-77%) and 34% (95% CI: 23-52%) of the variations, respectively. In this healthy twin sample, we found that three quarters of the variations in vertical optic disc and optic cup diameters were attributable to genetic influence.

POD01 Misleading MRI in two recent patients with variant Creutzfeldt–Jakob disease emphasises the importance of tissue diagnosis

As the vCJD outbreak evolves we are alert to possible changes in the clinicopathological phenotype, investigations and genetic analysis. MRI typically shows high signal in the pulvinar nucleus on T2W...

Adding fever to WHO criteria for diagnosing pneumonia enhances the ability to identify pneumonia cases among wheezing children

ObjectiveTo examine the ability of the criteria proposed by the WHO to identify pneumonia among cases presenting with wheezing and the extent to which adding fever to the criteria alters...

Secondary gliosarcoma after diagnosis of glioblastoma: clinical experience with 30 consecutive patients

Gliosarcoma can arise secondarily, after conventional adjuvant treatment of high-grade glioma. The current literature on the occurrence of secondary gliosarcoma (SGS) after glioblastoma multiforme (GBM) is limited, with only 12 reported cases. The authors present a large series of histologically confirmed SGSs, with follow-up to describe the clinical and radiological presentation, pathological diagnosis, and treatment outcomes. Gliosarcoma cases were identified using the University of California, San Francisco's Departments of Neurological Surgery and Neuropathology databases. Through a retrospective chart review, cases of gliosarcoma were considered SGS if the following inclusion criteria were met: 1) the patient had a previously diagnosed intracranial malignant glioma that did not have gliosarcoma components; and 2) the histopathological tissue diagnosis of the recurrence confirmed gliosarcoma according to the most current WHO criteria. Extensive review of clinical, surgical, and pathology notes was performed to gather clinical and pathological data on these cases. Thirty consecutive patients in whom SGS had been diagnosed between 1996 and 2008 were included in the analysis. All patients had previously received a diagnosis of malignant glioma. For the initial malignant glioma, all patients underwent resection, and 25 patients received both external-beam radiation and chemotherapy. Three patients received radiotherapy alone, 1 patient was treated with chemotherapy alone, and 1 patient's tumor rapidly recurred as gliosarcoma, requiring surgical intervention prior to initiation of adjuvant therapy. The median time from diagnosis of the initial tumor to diagnosis of gliosarcoma was 8.5 months (range 0.5-25 months). All but 1 patient (who only had a biopsy) underwent a second operation for gliosarcoma; 8 patients went on to receive radiotherapy (4 had brachytherapy, 3 had external-beam radiation, and 1 had Gamma Knife surgery); and 14 patients received additional chemotherapy. The median length of survival from the time of gliosarcoma diagnosis was 4.4 months (range 0.7-46 months). The median survival from the time of the original GBM diagnosis was 12.6 months (range 5.7-47.4 months). Patients who had received concurrent and adjuvant temozolomide for GBM had worse outcomes than those who had not (4.3 and 10.5 months, respectively; p = 0.045). There was no difference in time to diagnosis of gliosarcoma in these 2 groups (8 and 8.5 months; p = 0.387). Two patients who had not received radiation therapy for GBM had an anecdotally very prolonged survival (20.9 and 46.4 months). The data underscore the difficulty associated with management of this disease. The strikingly poor survival of patients with SGS who had previously received combined radiation and temozolomide chemotherapy for GBM may reflect a unique molecular profile of GBM that eventually recurs as SGS. Further work will be required, controlling for multiple prognostic factors with larger numbers of patients.

Role of semen analysis in subfertile couples

To evaluate the associations between the results of the male partner's semen analysis (classified according to the World Health Organization [WHO] criteria) and fathering a child without any treatment. Prospective multicenter cohort study. Twenty subfertility centers in The Netherlands. A total of 3,345 consecutive couples presenting for subfertility. None. Associations between the results of the male partner's semen analysis, classified according to the WHO criteria, and fathering a child without any treatment within a time horizon of 1 year. Subsequently, we redefined semen quality criteria and reevaluated the associations. Follow-up data of 3,129 couples (94%) were available, of which 517 (17%) had a healthy pregnancy without treatment. The 1-year pregnancy rate in men with WHO normozoospermia did not differ significantly from that in men with WHO impaired semen (24% vs. 23%). In contrast, we observed lower chances of fathering a child for sperm concentrations <40 × 10(6)/mL, total sperm count <200 × 10(6), and sperm morphology <20% normal forms. With a multivariable regression model based on the redefined male semen subfertility criteria we were able to make a finer differentiation between subfertile men, with probabilities of fathering a child ranging from 7% to 41%. The current WHO criteria for semen quality do not discriminate between fertile and subfertile men. Our redefined and graded semen criteria have strong predictive value. If interpreted correctly, the fast and inexpensive semen analysis remains the gold standard for defining a man's role in subfertility.