Diagnosis Of Myelodysplastic Syndrome Research Articles

Comprehensive Genomic Characterization of ASXL1 C.1934dupG (p.G646fs*12) Versus Other ASXL1 mutations in Myeloid Neoplasia

Introduction: ASXL1 mutations are frequently seen across the clinical spectrum of myeloid neoplasia. The most commonly identified ASXL1 mutation represents a single base duplication within an 8-guanine repeat at nucleotide position 1934 (c.1934dupG). Due to technical limitations of sequencing homopolymer regions, the ASXL1 c.1934dupG variant has been identified as potential artifact in some sequencing assays, though modern next generation sequencing assays and bioinformatics pipelines can generally accurately detect this mutation. However, a comprehensive comparison of ASXL1 c.1934dupG mutations versus non-c.1934dupG ASXL1 mutations have not been performed to date. Thus, we sought to explore a large dataset to determine if any biologic differences existed between these two groups.Methods: Comprehensive genomic profiling by FoundationOne ®Heme testing was performed on patient samples with known or suspected myeloid neoplasms (MN). All MN patients ≥18 years old with 1 or more mutation were identified by internal database query. Patients were categorized as acute myeloid leukemia (AML), myelodysplastic syndrome (MDS), non-chronic myeloid leukemia myeloproliferative neoplasms (MPN), or MDS/MPN overlap based on mutation and outside clinical and pathology data. Mutations with variant allele fractions (VAF) >1% were included for analysis, except for the ASXL1 c.1934dupG variant, which was only reported if the VAF was ≥15%. Fisher's exact tests were used to evaluate proportional differences between categorical variables, and Mann-Whitney U tests were used for comparisons of continuous variables.Results: Truncating ASXL1 mutations were identified in 1,414 included patients, occurring in 18% of AML and 26% of chronic myeloid neoplasms. Twenty-eight (2%) patients had multiple ASXL1 mutations, and ASXL1 was the sole mutated gene in 52 patients (4%). The most common ASXL1 mutation was c.1934dupG (Figure 1A), and this was the sole or dominant ASXL1 mutation in 520 cases (37%). The remaining 894 patients (63%) had one or more mutations at other sites in the ASXL1 gene (ASXL1other), with p.E635Rfs, p.R693*, and codon 591 mutations being the most common.There were no significant differences in age, sex, or ancestry signatures between ASXL1c.1934dupG and ASXL1other. We noted slightly fewer ASXL1c.1934dupG mutations in patients with MDS (ASXL1c.1934dupG: ASXL1other 0.48:1) compared to AML (0.65:1, p = 0.03) and MPN (0.60:1, p = 0.01) and those in whom ASXL1 was the sole mutation (Figure 1B). However, these trends may have been due to VAF-based reporting thresholds, as ASXL1 VAFs were lower in singly mutated patients and those with an MDS diagnosis classification. Comparison of co-mutated genes with VAFs ≥15% between ASXL1c.1934dupG and ASXL1other revealed no significant difference in median non-ASXL1 mutations (each median 4, IQR 2-5, p = 0.74). When individual genes were assessed, co-mutation rates of STAG2 (p = 0.01) and KMT2A (p = 0.02) were higher in ASXL1c.1934dupG MNs, while SETBP1 (p = 0.01) mutations were more common with ASXL1other. In all MNs, the absolute differences in the frequency of mutations in ASXL1c.1934dupG versus ASXL1other were small. However, some differences emerged within phenotypic subgroups (Figure 1C). For instance, KMT2A rearrangements and STAG2 mutations were strongly associated with ASXL1c.1934dupG in MDS/MPN and MPN, with ASXL1c.1934dupG: ASXL1other ratios of 5:1 (p = 0.03) and 9:1 (p < 0.001), respectively. In contrast, AML patients with TP53 or SETBP1 mutations had a significantly higher mutation rate in ASXL1other (TP53: 11% vs. 3% in ASXL1c.1934dupG, p < 0.01; SETBP1: 14% vs. 7%, p=0.04). We further identified that other specific ASXL1 mutations were more commonly co-mutated in AML with TP53 (ASXL1 p.R693*, p < 0.001) or SETBP1 (ASXL1 p.R404*, p < 0.001).Conclusion: Our results confirm the ASXL1 c.1934dupG variant occurs in a similar patient population to other ASXL1 mutations, and further supports its pathogenicity in myeloid neoplasia. Subset analysis suggests that ASXL1c.1934dupG and ASXL1other may be associated with certain phenotypic and co-mutational tendencies. Thus, ASXL1 mutation site may be an important variable in some patients and should be considered in future mechanistic and clinical studies. Further study is warranted to determine whether clinical outcomes are affected by different ASXL1 mutations. [Display omitted] DisclosuresHaberberger: Foundation Medicine, Inc.: Current Employment. Ferguson: Foundation Medicine Inc: Current Employment, Other: ownership.

Excellent Prognosis of Low-Risk Myelodysplastic Syndromes (MDS) Without Detectable Myeloid-Related Mutations

BackgroundUnexplained cytopenia (UC) and low-risk myelodysplastic syndrome (MDS) are distinguished mainly by morphologic dysplasia, which sometimes shows inter-observer discrepancy. We hypothesized that gene mutations are strong prognostic factors for these low-risk patients. Materials and methodsWe enrolled patients from 4 medical centers with unexplained cytopenia of at least 1 lineage. Diagnosis of low-risk MDS was made according to WHO 2016 classification and a revised international prognostic scoring system (R-IPSS) score of ≤ 3.5. DNA was extracted from bone marrow or blood and sequenced by targeted next generation sequencing (NGS). ResultsOne hundred twenty-one patients were recruited: 25% with UC and 75% with low-risk MDS. Complete blood counts were similar, but low-risk MDS patients carried higher numbers of mutations (1 vs. 0; P = .04) than UC patients. Overall, the most frequent mutated genes were TET2 (14.6%), SF3B1 (12.2%), and ASXL1 (9.7%). Survival rates of low-risk MDS patients versus UC patients were not significantly different. UC patients and low-risk MDS patients without genetic abnormalities showed superior 5-year progression free survival compared to MDS patients with mutations (100% vs. 76.0%; P = .005). Overall, ASXL1 mutations were associated with decreased 4-year overall survival compared to wild-type (59% vs. 31%; P = .01). In a multivariate analysis, ASXL1 and DNMT3A mutations in low-risk MDS patients were associated with a higher risk of disease progression with hazard ratios of 7.88 (95% CI 1.76-35.32, P = .01) and 7.45 (95% CI 1.61-34.46, P = .01), respectively. ConclusionMutation detection is important for proper risk stratification of patients presenting with idiopathic cytopenia.

DIAGNOSTIC APPLICATION AND CLINICAL SIGNIFICANCE OF FCM WELLS SCORING SYSTEM IN MYELODYSPLASTIC SYNDROMES

Myelodysplastic syndromes (MDS) are group of clonal diseases of the hematopoietic system characterized by ineffective hematopoiesis, dysmyelopoiesis, a high frequency karyotype abnormalities and the risk of transformation into acute leukemias. Cytopenic and dysplastic changes are not pathognomonic for MDS, and there are many diseases that can imitate MDS. According to various sources, clonal karyotypic abnormalities are present only in 20-60% of MDS. The diagnosis of MDS is not difficult if blasts or sideroblasts are present in the bone marrow, or there are chromosomal aberrations as evidence of clonal hematopoiesis. The diagnostic problem arises in cases of MDS without sideroblasts, with normal karyotype and/or bone marrow hypoplasia. Since 2012, the ELNet Working Group has proposed and subsequently supplemented guidelines for Flow Cytometry as a complementary diagnostic tool. The aim of the study was to compare the results of the FCM Wells score MDS with the results of the İPSS-R score MDS The study included 30 patients initially diagnosed with MDS . The classification was carried out according to the WHO Classification of MDS 2016: MDS SLD-6 (20%), MDS-MLD-5 (16.7%), MDS RS-MLD-2 (6.7%), MDS-EB1-9 (30%), MDS EB2-8(27%). According to the IPPS-R, patients were scored based on blasts, cytogenetic examination, hemoglobin/platelet/absolute neutrophil count and scored as very-low, low, intermediate, high, very-high. Using the Wells evaluation criteria, which takes into account cytometric analysis of the cells of the main myelopoiesis lines, changes were found in the compartment of granulocytes in 93%, monocytes in 40% and erythrocytes in 73% of cases. High scores on the Wells scale (> 4) were obtained in 89% of (8/9) MDS-EB1, 100%(8/8) MDS-EB2, 80% (4/5) MDS MLD patients, 17% (1/6) MDS –SLD, 50%(1/2) MDS RS-MLD. According to IPPS-R, MDS patients received a score <1.5 very low risk group include 50%(3/6) MDS –SLD, 20%(1/5) MDS-MLD, score > 1.5-3 - Low risk group include MDS –SLD 50%(3/ 6), MDS-MLD-80% (4/5), MDS RS-MLD 50% (1/2), MDS-EB1-78%(7/ 9), score > 3- 4.5-intermediate risk qroup got MDS-EB1 22%(2/ 9), MDS EB2- 25% (2/8), MDS RS-MLD- 50%(1/2), Score > 4.5 respectively high risk group got patients MDS –SLD- 17%(1/6), MDS EB2- 50%(4/8), Score > 6 very high risk group got MDS EB2- 25%(2/8). The Pearson's correlation coefficient (PCC) showed high correlation between İPSS-R and FCM Wells score was 0.83, p<0.002. In our study, the FCM score had a positive correlation with the IPSS-R prediction. Expanded analysis of the main compartments of the bone marrow (early precursors of myelopoiesis, the population of granulocytes and monocytes, erythrocytes) using the Wells scale as an additional tool improves the diagnosis and distinguish low-grade MDS from non-clonal cytopenias.

Rare Case of Multiple Lineage Dysplasia Myelodysplastic Syndrome Presenting with Only Anemia: A Case Report

BACKGROUND: Myelodysplastic syndrome (MDS) is a heterogeneous group of hematopoietic stem cell disorders which is characterized by ineffective hematopoiesis and risk of progression into acute myeloid leukemia. The diagnosis and classification of MDS are determined from the findings of dysplasia in one or more cell lineage and the percentage of blast cell on bone marrow examination. However, it should be noted that an abnormality in one marrow cell lineage does not necessarily translate to the corresponding clinical phenotype. Here, we present a case of MDS with multilineage dysplasia (MLD) (erythrocyte, leukocyte, and thrombocyte) from bone marrow aspiration, but with anemia as the sole clinical manifestation (single cytopenia). CASE REPORT: A 78-year-old male patient came to our clinic on July 10, 2020, with chief complaint of worsening fatigue which started approximately 1 year before visit. His vital signs during the visit were stable and no other abnormalities observed other than pale conjunctivae. Complete blood count showed macrocytic anemia with no abnormalities in leukocyte count and thrombocyte count, which suggested a single cytopenia. Peripheral blood smear was negative for megaloblasts and hypersegmented neutrophils. The patient’s bone marrow examination showed MDS with MLD. This result was in contrast to complete blood count examination which only showed anemia (single cytopenia). CONCLUSION: This case showed that there could be discrepancy between clinical manifestations of the cytopenia with bone marrow dysplasia, which highlighted the importance of conducting bone marrow examination to properly classify MDS type.

A geno-clinical decision model for the diagnosis of myelodysplastic syndromes

AbstractThe differential diagnosis of myeloid malignancies is challenging and subject to interobserver variability. We used clinical and next-generation sequencing (NGS) data to develop a machine learning model for the diagnosis of myeloid malignancies independent of bone marrow biopsy data based on a 3-institution, international cohort of patients. The model achieves high performance, with model interpretations indicating that it relies on factors similar to those used by clinicians. In addition, we describe associations between NGS findings and clinically important phenotypes and introduce the use of machine learning algorithms to elucidate clinicogenomic relationships.

Programmed necroptosis is upregulated in low-grade myelodysplastic syndromes and may play a role in the pathogenesis

Myelodysplastic syndrome (MDS) is characterized by persistent cytopenias and evidence of morphologic dysplasia in the bone marrow (BM). Excessive hematopoietic programmed cell death (PCD) and inflammation have been observed in the bone marrow of patients with MDS, and are thought to play a significant role in the pathogenesis of the disease. Necroptosis is a major pathway of PCD that incites inflammation; however, the role of necroptosis in human MDS has not been extensively investigated. To assess PCD status in newly diagnosed MDS, we performed immunofluorescence staining with computational image analysis of formalin-fixed, paraffin-embedded BM core biopsies using cleaved caspase-3 (apoptosis marker) and necroptosis markers (receptor-interacting serine/threonine-protein kinase 1 [RIPK1], phospho-mixed lineage kinase domain-like protein [pMLKL]). Patients with MDS, but not controls without MDS or patients with de novo acute myeloid leukemia, had significantly increased expression of RIPK1 and pMLKL but not cleaved caspase-3, which was most evident in morphologically low-grade MDS (<5% BM blasts) and in MDS with low International Prognostic Scoring System risk score. RIPK1 expression highly correlated with the distribution of CD71+ erythroid precursors but not with CD34+ blast cells. We found that necroptosis is upregulated in early/low-grade MDS relative to control participants, warranting further study to define the role of necroptosis in the pathogenesis of MDS and as a potential biomarker for the diagnosis of low-grade MDS.

MDS-259: Myelodysplastic Syndrome in Uzbekistan: A Study of Prevalence

Context: Myelodysplastic syndromes (MDS) are a heterogeneous group of clonal diseases of the blood system characterized by cytopenia, signs of impaired myelopoiesis, and a high risk of transformation into acute myeloblastic leukemia (AML). Objective: Study the characteristics of the incidence of MDS among the population of Uzbekistan. Design: Retrospective analysis of the medical records of registered patients with MDS in our center for the period of 2010–2020. Setting: The diagnosis of MDS was verified taking into account the generally accepted criteria according to WHO (2017) on the basis of results of a general specialized clinical examination of patients and laboratory methods. Statistical processing of the data was performed using the “Statistic for Windows, 2017” application package. Main Outcomes Measures: The average number of patients in Uzbekistan amounted to 20.3 new cases per year. In 2010, the primary incidence of MDS was 9 cases per year, 4 cases each in 2011 and 2012, 6 each in 2013 and 2014, and 5 in 2015. Since 2016, the primary incidence of MDS has increased sharply and amounted to 33 new cases in the current year: 39 in 2017, 34 in 2018, and 52 in 2019, while in 2020, 14 new cases were registered in only two months. For 2010–2020, the total number of registered patients with MDS was 206 cases: males - 107, females - 99. The indicator of the primary incidence of MDS for 2016–2020 in comparison with 2010–2015 increased by 5.1 times, and the median age of patients at the time of diagnosis verification was 50.9±4.05 years (men - 50.1±4.2 years, women - 49.6±4.3 years). The highest incidence of MDS was recorded among the age category from 41 to 70 (n = 132); the lowest was among patients under 20 years of age (n=9). Conclusion: An increasing number of new cases in recent years is associated with an improvement in the diagnosis of MDS, which is typical for the category of people in older age groups.

AML-317: Role of KIR Genotype in Acute Myeloid Leukemia Treated with Stem Cell Transplant

Context: Natural killer (NK) cells play a major role in tumor surveillance, defense against viruses, and graft-versus-tumor effects after stem cell transplant (SCT). In acute myeloid leukemia (AML) and myelodysplastic syndromes (MDS), the donor KIR genotype is not routinely considered when choosing a donor. Objective: To evaluate the relevance of the KIR genotype in a series of patients with AML/MDS submitted to SCT. Design: Retrospective cohort. Setting: Single-center study in a private referral hospital. Patients or Other Participants: Donors of any age and adult patients with a diagnosis of AML or MDS; 17 patients underwent haploidentical-SCT, and 18 patients underwent unrelated histoidentical-SCT, from 2015 to 2020. KIR genotype was assessed in donors. Main Outcome Measures: The association of KIR genotype and OS, RFS, EFS, and GVHD (III/IV and/or chronic). We consider patient ligands, donor KIR haplotype, B content, KIR inhibitor mismatches, presence of KIR2DS1 or KIR3DS1, activating KIRs matches, mismatching in KIR ligands, and the KIR-score. Secondary outcomes included KIR haplotype and GVHD and the association of KIR2DS2, KIR2DS4, and KIR2DL2 mismatch and KIR3DL2 with cytomegalovirus (CMV) reactivation. Results: Thirty-five patients and donors were included; median follow-up was 388 days. Median patient age was 51 years (range 19–71); median donor age was 32 years (range 13–48). Diagnoses were AML (n=30) and SMD (n=5). One-year OS was 64% in haploidentical-SCT and 80% in unrelated histoidentical-SCT. KIR genotype was Bx in 75% of donors. KIR2DL1-mismatch was associated with non-significant improvements in 2-year OS (84% vs 55%, p=0.18) and PFS (84% vs 60%, p=0.21). Regarding mismatches in KIR ligands, the presence of mismatches in the GVH direction was associated with an increased risk of GVHD (50% vs 14%; P=0.08). The absence of the KIR2DS2 gene resulted in a higher risk of CMV reactivation, 80% (12/15) vs 45% (9/20) in the KIR2DS2-positive group (p=0.005). Patients with CMV reactivation had a trend toward higher incidence of GVHD (28% vs 7%, p=0.20). Conclusions: KIR genotyping can provide useful information to select donors in AML/MDS. Larger cohort studies are needed to confirm these findings.

MDS-308: Mutational Profile of Patients Diagnosed with Myelodysplastic Syndromes, First Experiences in a Center of Argentina

Context: Myelodysplastic syndromes (MDS) and chronic myelomonocytic leukemia (CMML) are heterogeneous myeloid malignant clonal disorders. Different mutations can be associated with higher risks of these diseases, specific characteristics, and responses to certain treatments. Molecular findings obtained through next-generation sequencing (NGS) have gained importance in myeloid neoplasms, but local access is limited. We recently incorporated NGS technology in our center that will seek to identify mutations. Objective: To describe the mutational landscape of patients diagnosed with MDS and CMML locally. Design: We designed a prospective observational cohort study from July 2019 to July 2020 in adult patients diagnosed with MDS and CMML who underwent bone marrow biopsy with NGS at a private university reference hospital, Hospital Italiano, in Buenos Aires. Results: 24 adult patients with MDS and CMML diagnosis were included, 18 MDS and 6 CMML. The median age was 74 years (IQR: 60–78.25), 54% male. All patients were classified with IPSS-R. NGS was performed in all patients; 86.9% had at least one mutation. Among the most frequent genes were TET2, SRSF2, DNMT3A, and RUNX1. Five of six patients with CMML had a normal karyotype; all obtained at least three mutations, and SRF2 mutation was the most frequent. The most common mutational pathways involved in patients with adverse cytogenetics were DNA repair and transcription pathways (p = 0.019). The number of mutations in patients with high-risk IPSS-R was 3.5 vs 2 mutations in low-risk patients, which was not statistically significant. The mean Hb value in patients with 2 mutations or fewer was 10.3 mg/dl vs 9 mg/dl in patients with > 3 mutations (p = 0.069). Treatment was required in 50% of patients with 1–2 mutations and in 86% of patients with 3 mutations or more (p = 0.016). Conclusions: As described in the literature, most of our patients had mutations, the most frequent being epigenetic regulators and signal translation genes. The number of mutations was statistically correlated with the degree of anemia and with treatment indication. Recognizing mutations is crucial for clinical decisions, diagnosis, prognosis, and treatment. Although we have evaluated few patients, our data are comparable to those published and encourage us to continue working to improve the care of our patients.

Combined utility of CD177, P53, CD105 and c-kit immunohistochemical stains improves the detection of myelodysplastic syndrome

The diagnosis of myelodysplastic syndrome (MDS) relies primarily on identifying peripheral blood cytopenia and morphologic dysplasia as well as detecting cytogenetic aberrations in a subset of patients. Accumulating data points to the importance of examining certain immunophenotypic changes characteristic of MDS, most of which are tested by flow cytometry. The role of immunohistochemistry in the diagnostic workup of MDS is less known. In this study, we used immunohistochemistry to survey the expression patterns of CD177, P53, CD105 and c- kit in a cohort of MDS bone marrow specimens (n = 57) and compared the results with a control group of patients who had cytopenia for other benign conditions (n = 49). MDS cases showed significant higher rates of: CD177-loss (13/57, 23% vs 1/49, 2%; P = .0016), P53 overexpression (8/57, 14% vs none; P = .005) and the presence of clusters of CD105-positive cells (6/57, 11% vs none; P = .021). Increased c-kit-positive cells was more common in MDS patients, but not statistically significant (17/57, 30% vs 8/49, 16%; P = .102). On multivariate analysis, only loss of CD177 expression was significantly higher in MDS group (P = .014). These findings suggest that a panel of immunohistochemical stains could serve as an adjunct tool in investigating unexplained cytopenias and warrant further comparative studies with flow cytometry.

Profile of patients with Myelodysplastic syndrome: A report from a tertiary care teaching hospital from Eastern India

Objectives: Myelodysplastic syndrome (MDS) is a group of myeloid neoplasms. The clinical manifestations and treatments vary depending on the subtype and risk stratification of the disease. There is a paucity of data on Indian patients with MDS. This study was undertaken to understand MDS with regard to their clinical presentation, pathological, cytogenetic profiles and also to assess their therapeutic outcomes and prognosis from our center in Eastern India. Materials and Methods: This is a prospective observational study conducted in the department of hematology at a tertiary care teaching hospital from eastern part of India. The diagnosis of MDS was made from the peripheral blood examination, bone marrow aspirate examination, cytogenetics, and Fluorescence in situ hybridization results, according to the WHO guidelines. Patients were risk stratified using Revised International Prognostic Scoring System (R-IPSS) and subsequent therapeutic planning was done, with either supportive therapy in the form of recombinant human erythropoiesis stimulating agents, colony stimulating factors, packed red blood cell support as needed for low risk MDS patients. High risk patients were treated with hypomethylating agents such as Azacytidine, Decitabine, or Lenalidomide. Results: The mean duration of follow-up of patients with MDS from the point of diagnosis was 1.8 years (range 4 months–6 years). The median OS was 1.33 years. The median OS in the analysis of our patient cohort with low, intermediate, high, and very high R-IPSS was 1.67 years, 1.33 years, 1.67 years, and 1.67 years, respectively. No patients of very low risk group were identified in our study. Conclusion: Our findings reflect that MDS-MLD with low or intermediate R-IPSS risk groups is the most common types of MDS. Although supportive therapy was used to treat patients irrespective of other therapy given (depending on the risk group of the patient), it was used alone even in higher risk groups due to logistic reasons in some cases. Those patients who received supportive care alone also had a good survival duration. However, a longer follow-up duration is required to firmly establish this outcome. The median age of patients (55 years) was also lower than established studies with a median overall survival of 1.67 years.

Management of the Older Patient with Myelodysplastic Syndrome.

No two diagnoses of myelodysplastic syndrome are genuinely alike, owing to differing and dynamic mutational topography and epigenetic aberrancy. Consequently, no two patients with myelodysplastic syndrome are identical and disease-specific and patient-specific factors are considered in formulating the optimal treatment, which includes few that are disease modifying. Age itself should not be an absolute contraindication to therapy, including intensive therapy such as allogeneic hematopoietic stem cell transplantation, which is the only curative therapy. However, age associates with an increased prevalence of frailty and comorbidities that must be considered and may preclude a path to cure. Palliative therapies are the mainstay for many patients with myelodysplastic syndrome, which is a disease of older adults with the majority of patients diagnosed at age ≥ 75 years. The older patient requires heightened attention to end organ function/reserve and drug-drug interactions as well as insurance, income, cost, and socioeconomic and psychosocial issues that influence management. Many prior studies have included relatively younger populations or have not specifically performed high-quality subgroup analyses of older patients. In this review, we discuss the available standard-of-care therapies for myelodysplastic syndrome as they specifically relate to the older population and assess the emerging therapeutics that may further the pursuit for personalized treatment and improve both the outcomes and quality of life of the older patient with myelodysplastic syndrome.

Acquired elliptocytosis in a patient with myelodysplastic syndrome harbouring a novel unbalanced whole‐arm translocation, der(14;20)(q10;p10)

An 81-year-old male was referred to our hospital due to dyspnoea. He was found to have pancytopenia (haemoglobin concentration 79 g/l, platelets 117 × 109/l, white blood cells 1.6 × 109/l) and mean corpuscular volume of 106.6 fl. A peripheral blood film revealed marked elliptocytosis (top image). Bone marrow examination showed a hypocellular bone marrow (blast cells 1.2%) with dyserythropoiesis and dysmegakaryopoiesis. Chromosomal analysis showed 46,XY,der(14;20)(q10;p10),+mar[2]/47,idem,+8[17]/46,XY[1] (lower image). A diagnosis of myelodysplastic syndrome (MDS) with multilineage dysplasia was made. Acquired elliptocytosis due to MDS is the most likely diagnosis in this case since the patient had no history of anaemia. He was started on erythropoietin-stimulating agent monotherapy; however, he chose to discontinue the treatment in order to avoid frequent outpatient treatment during to the COVID-19 pandemic, and returned to the clinic nearest to his home for supportive care alone.

The utility of a myeloid mutation panel for the diagnosis of myelodysplastic syndrome and myelodysplastic/myeloproliferative neoplasm.

The diagnosis of myelodysplastic syndromes (MDS) and myelodysplastic/myeloproliferative neoplasms (MDS/MPN) is based on morphology and cytogenetics/FISH findings per 2017 WHO classification. With rare exceptions, somatic mutations have not been incorporated as the diagnostic criteria. We analyzed the utility of mutational analysis with a targeted 54-gene or 40-gene next-generation sequencing (NGS) panel in the diagnosis of MDS and MDS/MPN. We retrospectively collected92 patientswho presented withunexplained cytopenia with or withoutcytosis, including 32 low-grade MDS (MDS-L), 18 high-grade MDS (MDS-H), 5 therapy-related MDS (MDS-TR), 19 MDS/MPN, and 18 negative cases. Of 92 patients, 197 somatic mutations involving 38 genes were detectedand hadvariant allele frequency (VAF) ranging from 3%to99%.The most common mutated genes wereTET2, ASXL1, RUNX1, TP53, SRSF2, and SF3B1. MDS-L, MDS-H, MDS-TR, and MDS/MPN showed an average number of somatic mutations with a mean VAF of 1.9/33%, 2.6/30%, 2/36%, and 4/41%,respectively. SF3B1 mutations were exclusively observed in MDS-L and MDS/MPN. TP53 gene mutations were more frequently seen in MDS-H and MDS-TR. Among 34 patients with a diagnosis of MDS or MDS/MPN with normal cytogenetics, 31 patients (91%) had at least 1 mutation and 24 patients (71%) had ≥2 mutations with ≥10% VAF. A myeloid mutational panel provides additional evidence of clonality besides cytogenetics/FISH studies in the diagnosis of cytopenia with or without cytosis. Two or more mutations with ≥10% VAF highly predicts MDS and MDS/MPN with a positive predictive value of 100%.

2021 BSH guidelines for the management of adult myelodysplastic syndromes: a practical approach to a challenging disease.

Myelodysplastic syndromes (MDS) are a group of haematological malignancies with extremely variable biologic, genetic and clinical characteristics.1 The outcome of MDS patients is very heterogeneous, some having a near-normal life expectancy while others die within a few months of their diagnosis. The median age of patients at diagnosis is advanced, ranging between 70 and 75 years, thus further complicating the management of these complex syndromes, since non-haematological comorbidities frequently coexist in the elderly and tolerability of treatments is limited.2 Given the heterogeneity of the disease pathobiology and the highly variable disease course, prognostic risk stratification is of crucial importance in clinical decision-making.3 To drive appropriate counselling and individualisation of treatment decisions, several prognostic scoring systems based on clinical and haematological parameters have been developed. Principal scoring systems currently used in Europe are the International Prognostic Scoring System (IPSS), and the revised IPSS (R-IPSS), which are based on the evaluation of peripheral blood cytopenias, bone marrow blast count and cytogenetic features.4 In daily practice, reliability of these scores is limited by the variability of morphological evaluation and, less frequently, by non-informative cytogenetic findings in a proportion of patients. Moreover, other factors including the clonal mutational status have been reported to influence the prognosis of MDS patients, and to affect the clinical outcome.5, 6 In any case, diagnostic procedures and evaluation of prognosis are not covered by these guidelines as they will be published in a separate British Society for Haematology (BSH) document. Unlike the previous edition, the 2021 BSH guidelines also do not include recommendations for CMML, for which dedicated guidelines will follow. The 2021 updated BSH guidelines for the Management of Adult Myelodysplastic Syndromes provide clear, simple and practical recommendations to approach patients with such a challenging diagnosis.7 Given the heterogeneity of the disease, the importance of establishing an individual risk-adapted treatment strategy is crucial; nonetheless, transfusion requirements and infectious complications are common to almost all patients, sooner or later. The guidelines first exhaustively describe the supportive measures that should be adopted with most patients; in particular, recommendations are reported the for prevention of fungal infection, a common complication in neutropenic patients, and for transfusion thresholds and policies to be adopted to improve patient quality of life (QoL) on the one hand, saving blood products on the other. Then, individual planning of therapeutic options is described extensively, also by means of simplified algorithms. Although standard care for MDS is constantly changing, recommendations for the initial treatment choice are still based on IPSS and R-IPSS risk evaluation, and, importantly, on patient’s preference. Therapeutic measures for most lower risk patients aim to decrease the transfusion burden and improve QoL, whereas recommendations for higher risk patients aim to prolong their life. This distinction is clearly represented in these guidelines; for each group updated treatment strategies are reported, some reflecting the 2014 BSH document. Still relevant is the recommendation that the initial MDS diagnosis should be discussed by a multidisciplinary team, including a transplantation expert, as allogeneic transplantation remains the only potentially curative option. Worthy of note, in this setting recommendations for cytoreduction in advanced MDS with hypomethylating agents (HMA) or chemotherapy before transplant are still debated, although inferior survival outcomes for patients with excess BM blasts (> 5%) at the time of transplant have been reported. Moreover, it is important that clinicians review MDS cases regularly in multidisciplinary meetings to determine if a patient can become a possible transplant candidate and/or can possibly take part in a clinical trial. Patients’ details should also be made available to national and international dedicated registries, ‘to maximize information about the patient’s history and treatment of MDS in order to benefit future patients’. In general, the guidelines are proposed to improve the quality of care of patients as well as to help physicians in their daily practice. The BSH guidelines for the management of MDS represent a timely update and make a valid contribution for the diagnosis and treatment of this heterogeneous group of blood disorders.

British Society for Haematology guidelines for the management of adult myelodysplastic syndromes.

British Society for Haematology guidelines for the management of adult myelodysplastic syndromes.

Prognostic Implication of Bone Marrow Abnormality of Appendicular Skeletons Detected By Low-Dose Multidetector Computed Tomography in Patients with Myelodysplastic Syndrome

BackgroundA number of prognostic systems have been developed and validated in patients with myelodysplastic syndrome (MDS). However, the use of the current scoring systems including international prognostic scoring system (IPSS) in determining the prognosis among MDS patient has various conflicting views pertaining to the inclusion of patients with different outcomes. Abnormal red marrow distribution in appendicular skeletons (AS) based on magnetic resonance imaging (MRI) has been described in the literature; however, these findings have not been confirmed. We examined the prognostic implication of medullary abnormalities of AS detected by low-dose whole-body multidetector computed tomography (MDCT) in patients with MDS.Patients and methods147 consecutive patients with MDS diagnosed between January 2009 and May 2017 at Kameda Medical Center were recruited. Diagnosis and classification of MDS were made per 2008 WHO criteria. MDCT studies were performed at the diagnosis of MDS and before the start of any chemotherapy. MDCT images were acquired as previously reported. Medullary pattern of AS were categorized into three groups: (1) Fatty marrow pattern; (2) Focal/scattered marrow pattern; (3) diffuse marrow pattern. To examine if the value of MDCT findings on appendicular marrow has incremental predictive value when the conventional risk factors were controlled, we constructed a receiver operating characteristics (ROC) curve for two logistic regression models. Model 1 was constructed with only conventional risk factors while Model 2 was constructed with conventional risk factors plus MDCT findings.ResultsOf the 147 patients with MDS, there were 47 (32.0%) with fatty, 51 (34.7%) with focal/scattered and 49 (33.3%) with diffuse marrow patterns. Fatty pattern was seen more among non-RAEB patients (76.5%), focal/scattered pattern was about equal while diffuse pattern was more in RAEB patients with 65.3% (P<0.001). The development of AML differed significantly between groups and the highest occurred with diffuse pattern, 30 (61.2%), (P<0.001). Among those with AML, death occurred among 28 (93.3%) . The median LFS was not reached (NR) for fatty pattern, but was 29.2 and 11.1 months for the focal/scattered and diffuse marrow patterns respectively (P<0.001). Similarly, the median OS was NR for fatty pattern but was 40.9 and 14.6 months for the focal/scattered and diffuse marrow patterns respectively (P<0.001). Among the 82 low-risk patients, median survivals of fatty, focal/scattered, and diffuse pattern differed significantly and were NR, 35.2 and 18.2 months respectively for LFS (P<0.001), and NR, 50.9 and 26.3 months respectively for OS (P<0.001). Similarly, for the 65 patients with high-risk MDS, median time were NR, 11.2 and 8.3 months for LFS (P<0.001), and NR, 19.1 and 11.4 months for OS (P<0.001), respectively for fatty, focal/scattered, and diffuse patterns. At multivariate analysis, both focal/scattered and diffuse patterns of medullary marrow of AS remained independently associated with shorter LFS and OS. ROC curve was developed based on the conventional risk model as well as the conventional risk model plus MDCT findings for LFS and OS. Although AUC comparisons showed statistical significance in neither LFS (P=0.108) nor OS (P=0.138), net reclassification improvement (NRI) and integrated discrimination improvement (IDI) were significant for both LFS (NRI 0.43 [95% CI;0.12-0.74], P=0.007 and IDI 0.06 [95% CI; 0.02-0.10], P=0.002) and OS (NRI 0.52 [95% CI; 0.21-0.83], P<0.001 and IDI 0.07 [95% CI; 0.03-0.11], P<0.001).ConclusionOur findings showed a novel method for prognostication of MDS using the medullary findings of AS using MDCT. The prognostic impact of medullary abnormality of AS detected by MDCT has not been described previously. Our findings indicate that the MDCT of appendicular bone marrow is predictive of the prognosis in patients with MDS and has a potential for improving the risk stratification of MDS in conjunction with preexisting scoring systems. [Display omitted] DisclosuresKitadate:Pfizer: Research Funding; Fujimoto: Research Funding; Otsuka: Research Funding; Novartis: Research Funding; Toyama kagaku: Research Funding; Chugai: Research Funding; Asahi Kasei: Research Funding; Eisai: Research Funding; Kyowa Kirin: Research Funding.

Treatment Sequence of Lenalidomide (LEN) and Hypomethylating Agents (HMAs) and the Impact on Clinical Outcomes for Patients with Myelodysplastic Syndromes (MDS)

Introduction: MDS comprise a heterogeneous group of hematological malignancies with 10,000-20,000 cases diagnosed in the US annually. Although erythropoiesis-stimulating agents are often used in lower-risk (LR) MDS, 3 agents are approved for the treatment of MDS in the US: HMAs (azacitidine and decitabine) and LEN. Given the limited response rates and ultimate treatment failure with these drugs, they are used in sequence. Despite being available for over a decade, there are little data on the impact of their sequencing on clinical outcomes. One small single-center study by Zeidan et al (2015) in 63 patients with non-del(5q) LR-MDS concluded that LEN is optimally positioned before azacitidine when the drugs are in sequence. The current study aimed to look at this question using a real-world MDS patient dataset not restricted to non-del(5q) LR-MDS patients who were treated with an HMA followed by LEN (HMA-LEN) or LEN followed by an HMA (LEN-HMA).Methods: Adults with a diagnosis of MDS (ICD-9: 238.72-238.75 and ICD-10: D46) were identified from a large US payer claims database from Jan 1, 2008 to Dec 31, 2016. The index date was defined as the first claim for LEN or HMA as first-line therapy (1L). Patients had to have ≥ 2 claims of their 1L and ≥ 1 claim of second-line therapy (2L), with ≥ 6 months of follow-up data available from index date. Patients in a clinical trial were excluded. Transfusion dependence (TD) was defined as ≥ 2 claims for transfusion event during an 8-week period at any time prior to start of 1L (with ≥ 1 claim within the 8-week pre-index period) or within 90 days of start of 1L. Transfusion independence (TI) was defined as ≥ 8 weeks without a claim for a transfusion event. Overall treatment discontinuation was identified when there was a ≥ 90-day gap between last claim in last line of therapy and end of follow-up or study period. Date of insurance disenrollment was identified in patients with a ≥ 90-day gap from last observed claim for any healthcare resource to end of data availability. As date of death was not available, time from index date to date of insurance disenrollment served as a proxy for survival with the assumption that older patients with chronic conditions are unlikely to change insurance and have high healthcare burden. Time from index date to discontinuation and disenrollment were adjusted for potential confounders at start of 1L. The covariates used in Cox proportional hazard models included gender, age, payer, region, Charlson Comorbidity Index, cytopenias (anemia, thrombocytopenia, neutropenia), and the SEER-Medicare MDS Risk Score (SMMRS) category (a proxy measure for the International Prognostic Scoring System developed for SEER-Medicare MDS analyses).Results: Out of 6,009 MDS patients, there were 89 HMA-LEN patients and 96 LEN-HMA patients (Table); 41 (46%) and 46 (48%) were TD at initiation of 1L, respectively. Median age was 74 years for both groups. The LEN-HMA patients had a lower rate of cytopenias at baseline (29.2% vs 12.5%; P= 0.005) but similar distribution of SMMRS categories (P= 0.161). Patients treated with LEN-HMA had a longer time to overall treatment discontinuation (29.0 vs 19.0 months; P= 0.009; Fig 1) and a lower adjusted risk of treatment discontinuation (hazard ratio [HR] 0.52; 95% CI 0.29-0.91; P= 0.023). Among patients with TD, rates of TI were directionally higher in the LEN-HMA cohort during 1L (37.0% vs 34.1%), 2L (41.3% vs 22.0%), and overall therapy (56.5% vs 46.3%; P= 0.343), but were not statistically significant. Alternatively, examining the mean number of transfusions 6 months prior to and after 1L initiation showed no difference before treatment (1.68 vs 1.99; P= 0.452), but while on therapy, the LEN-HMA cohort had a lower transfusion frequency (2.10 vs 3.98; P= 0.002). Looking at survival in relation to insurance disenrollment, median time to disenrollment was longer in LEN-HMA patients (1.87 vs 1.34 years; P < 0.001; Fig 2), and these patients had a lower adjusted risk of disenrollment (HR 0.64; 95% CI 0.44-0.92; P= 0.017).Conclusions: Patients receiving LEN-HMA remained on treatment longer and had lower frequency of transfusions while on therapy. These patients also demonstrated additional clinical benefit through improvements in survival, as measured by the proxy of adjusted time to insurance disenrollment. Observational data from a nationally representative database directionally confirm the benefits of the LEN-HMA treatment sequence in MDS patients. [Display omitted] DisclosuresZeidan:AbbVie, Otsuka, Pfizer, Gilead, Celgene, Ariad, Incyte: Consultancy, Honoraria; Takeda: Speakers Bureau; Otsuka: Consultancy. Klink:Cardinal Health and HealthCore (Anthem): Employment; Janssen, BMS, Celgene, EMD Serono, Ipsen, Kite, Merck, Novartis, Vertex, Amgen, Astellas, Heron, AbbVie, Array: Consultancy. Feinberg:Cardinal Health: Employment. McGuire:Celgene: Employment, Equity Ownership.

Diagnostic Value of Flow Cytometry Technique By European Leukemianet for Idiopathic Cytopenia of Undetermined Significance

Introduction: Myelodysplastic syndromes (MDS) are heterogeneous hematological disorders characterized by hematopoietic dysplasia and/or chromosomal aberrations. However, the diagnosis of dysplasia is subjective and chromosomal aberrations are not always present. Thus, the diagnosis of MDS is not always straightforward when lacking specific characteristics. To resolve this diagnostic problem, a novel flow cytometry technique standardized by the European LeukemiaNet (ELN) working group for MDS [Haematologica 94: 1124, 2009] was proposed. However, this ELN MDS index has not been validated for the diagnosis of idiopathic cytopenia of undetermined significance (ICUS).Purpose: To determine the diagnostic value of the ELN MDS index for ICUS, we analyzed the diagnostic accuracy of morphology, cytogenetics, and flow cytometry for cytopenia.Methods: We investigated 253 consecutive patients who underwent bone marrow aspiration to examine the cause of cytopenia at our institute between 2012 and 2015. We used the ELN MDS index verified by Ogata et al. for low-grade MDS [Haematologica 94: 1066, 2009]. The ELN MDS index consists of the following four parameters: (1) CD34+ myeloblasts on all nucleated cells, ≥2.4%; (2) CD34+ B cells on all CD34+ cells, ≤5.0%; (3) lymphocyte/myeloblast CD45 MFI ratio, ≤4.0 or ≥7.8; and (4) granulocyte/lymphocyte SCC peak ratio, ≤6.0. When two or more parameters met the criteria, the patient was diagnosed with MDS by cytometry. We evaluated the accuracy of diagnosis with cytometry by using the clinical diagnosis as a standard reference. The clinical diagnosis was determined by more than two hematologists/specialists. Patients with MDS and ICUS were included in this study. ICUS was defined as follows: bone marrow blast, <5.0%; single- or multi-lineage dysplasia, <10%; and no detection of clonal chromosomal abberation characteristic to MDS.Results: A total of 253 bone marrow samples were evaluated (117 females). The median patient age was 66 years (range, 1-92 years). The clinical diagnosis was MDS in 60 patients (24 females; median age, 69 years; range, 30-91 years) and ICUS in 17 patients (9 females; median age, 76 years; range, 54-88 years). Other patients were identified to have non-MDS/non-ICUS diseases and were used as a control group. MDS subcategories were as follows: RCUD (n = 14), RARS (n = 3), RCMD (n = 10), RAEB-1 (n = 9), RAEB-2 (n = 12), MDS-U (n = 8), and 5q− syndrome (n = 4). Two or more criteria of the ELN MDS index were met in 34 MDS (56.7%; 34/60) and 4 ICUS patients (23.5%; 4/17). Positivity with the ELN MDS index among the MDS subcategories varied as follows: 6 RCUD (42.9%; 6/14), 1 RARS (33.3%; 1/3), 5 RCMD (50.0%; 5/10), 7 RAEB-1 (77.8%; 7/9), 12 RAEB-2 (100%; 12/12), 2 MDS-U (25.0%; 2/8), and 1 5q− syndrome cases (25.0%; 1/4). When cutoff scores were set as the ELN MDS index of ≥2, sensitivities for diagnoses of MDS and ICUS were 56.7% (34/60) and 25.0% (4/16), specificities were 83.1% (147/177) and 83.1% (147/177), positive predictive values were 53.1% (34/64) and 11.8% (4/34), and negative predictive values were 85.0% (147/173) and 92.5% (147/159), respectively.Conclusion: Application of the ELN MDS index in MDS revealed sensitivity and specificity in line with those of previous studies, while 25.0% of ICUS patients were indicated to have MDS. This prevalence of MDS in ICUS may correspond to 27.5% (33/120) of patients with ICUS who had genetically clonal evidence identified by targeted sequencing of 22 MDS-associated genes [Kwok et al., Blood 2015; 126: 2355]. Our data suggest that the ELN MDS index is a practical tool to identify a subset of ICUS patients with MDS trait. [Display omitted] DisclosuresNo relevant conflicts of interest to declare.

MYC Rearrangements in Myeloid Neoplasms

Background:8q24 /MYC rearrangements are an important mechanism of MYC protein dysregulation and most frequently occur in lymphoid neoplasms. Induced MYC expression in murine bone marrowrapidly induces leukemia and preferentially stimulates myeloid leukemogenesis in the absence of anti-apoptotic mutations (Luo et al, Blood, 2006). However, clinical data on patients with myeloid neoplasms and MYC rearrangement is very limited.Methods:We searched out databases for all cases with 8q24/ MYC rearrangements in the past 11 years and identified eight cases of myeloid neoplasms with MYC rearrangements which were confirmed by FISH analysis with MYC break apart rearrangement probe. The clinical and laboratory data, response to treatment and patient outcome were obtained through medical records. All samples were collected following institutional guidelines with informed consent in accordance with the Declaration of Helsinki.Results:Patients' clinical, pathological, and cytogenetic features are summarized in Table 1. There were 5 males and 3 females, with a median age of 60 years. Three patients were diagnosed with acute myeloid leukemia (AML), 1 with myelodysplastic syndrome (MDS) with excess blasts-2, and 4 with blastic plasmacytoid dendritic cell neoplasm (BPDCN).Flow cytometry immunophenotyping was performed in all 8 patients. Of the 3 patients with AML, case #1 had aberrant expression of CD2 and cCD3, cases #2-3 had an aberrant expression of CD7. Case #4 had a myeloid phenotype. The immunophenotype of cases #5-8 were consistent with BPDCN with expression of CD2, CD4, and bright 123. MYC immunohistochemistry stain was performed in 5 patients, the percentage of cells with MYC expression was variable, but largely correlated with the percentage of blasts in the bone marrow.Case #1 showed a normal diploid karyotype, but FISH revealed a cryptic der(14)ins(8;14)(q24;q32q32); Cases #4 and #8 had t(8;14)(q24;q32) as the sole chromosomal abnormality; the other 5 cases had a complex karyotype. The partner chromosomes for 8q24 were 14q32 (cases # 1, 4 and 8), 6p21 (case #5), Xq24 (case #6), 3p25 (case #7), and unknown in cases #2 and #3. FISH showed MYC rearrangement in a median of 80% cells (ranges, 4.5% -97%).The treatments were summarized in Table 1. Three AML patients did not response to chemotherapies or had a quick relapse after a short remission, all 3 patients died within 1 year. Case #4 (MDS) developed AML at 1 month and died at 2.2 months after the diagnosis of MDS. Of the four BPDCN patients, case #4 had an early death due to infection, the other 3 patients responded well to ALL-based regimens (Hyper-CVAD, n=2; COG ALL L0434, n=1), two were alive and in complete remission, one had been in remission but died of pulmonary hemorrhage at 26 months.Conclusions:8q24/ MYC rearrangement occurs rarely in myeloid neoplasms, often with partner genes other than the ones encoding immunoglobulin. Patients with AML/MDS were often resistant to chemotherapies, while patients with BPDCN responded well to ALL-based regimens. [Display omitted] DisclosuresPemmaraju:cellectis: Research Funding; stemline: Consultancy, Honoraria, Research Funding; LFB: Consultancy, Honoraria; affymetrix: Research Funding; roche diagnostics: Consultancy, Honoraria; novartis: Consultancy, Honoraria, Research Funding; Incyte Corporation: Consultancy, Honoraria; abbvie: Research Funding.