Factors In Myelodysplastic Syndromes Research Articles

The AST/ALT (De Ritis) ratio as a significant prognostic factor in myelodysplastic syndrome

Background: The aspartate transaminase (AST)/alanine transaminase (ALT) ratio, also termed the De Ritis ratio, has been demonstrated to have an association with poor prognosis in several cancer types. However, its prognostic value in patients with myelodysplastic syndrome (MDS) remains unclear. Methods: A total of 265 MDS patients were divided into two groups by R. The clinical, laboratory, and follow-up data of patients with MDS were collected, while the relationship between AST/ALT ratio and overall survival (OS) and leukemia-free survival (LFS) were also analyzed. Results: The results showed that higher AST/ALT ratio was associated with higher age, β2-microglobulin level, and number of co-mutations (>4). Moreover, the high AST/ALT group had a significantly shorter OS and LFS than the low AST/ALT group. Multivariate analysis involving the Revised International Prognostic Scoring System (IPSS-R) showed that a higher AST/ALT ratio was an independent adverse factor for OS or LFS; however, the same was not noted in the multivariate analysis involving the new Molecular International Prognostic Scoring System (IPSS-M). Conclusions: Our study suggests that the AST/ALT ratio could be a simple and economic prognostic indicator for MDS and be used as a supplement to IPSS-R, especially when lacking of karyotype or mutation data.

Multi-Omics Factor Analysis (MOFA) Identifies Transposable Element Expression As a Risk Factor and Inflammaging As a Protective Factor in Myelodysplastic Syndromes

Introduction Myelodysplastic syndromes (MDS) are haematological diseases characterised by clonal proliferation due to genetic and epigenetic alterations within haematopoietic stem and progenitor cells. Thus far, the prediction of a patient's overall survival (OS) and event-free survival (EFS) has been dependent predominantly on the degree of peripheral blood cytopenias, bone marrow blast percentage, cytogenetics, and genetic features. However, this may overlook other biological phenotypes, including, for example, the expression of transposable elements (TEs), ageing, and immunology profile. In this study, we present a comprehensive analysis of three data modalities (clinical, genotypic, and transcriptomic) and eight different views derived from these modalities to identify the hidden factors that significantly impact MDS prognosis. Methods Three (immunology, ageing, and cellular composition) out of eight views of the data were derived from RNA-seq by applying singscore, a gene set scoring tool developed by Foroutan et al., 2018, on RNA-seq gene expression from bone marrow samples of 94 MDS patients obtained from Shiozawa et al., 2017 (Fig 1.A). Each of these three views was carried forward in the workflow by a number of gene sets. The other five views were clinical numeric data, clinical categorical data, TE expression, genotype data, and known AML/MDS antigens (obtained from TANTIGEN 2.0), expressed in at least 10% of MDS samples in the study. We then employed Multi-Omics Factor Analysis (MOFA), a computational framework developed by Argelaguet et al., 2018, to uncover hidden phenotypic states within a multi-omic dataset. Through MOFA, we generated factors representing specific biological data modalities, establishing connections between features across these different categories. The total variance ( R2) that can be attributed to specific factors is also exhibited by MOFA. Results Factors were ranked based on their explained variance. We present the 10 factors with a threshold of variance explained of 2% from the 15 default factors generated by MOFA (Fig 1.A). Factor 1 was one of the factors that linked the most categories of data: immunology, cellular composition, ageing, and TEs. Most notably, Factor 1 was aligned with features of less differentiated cells (more HSC-like and less GMP-like). We observed that samples represented by high Factor 1 scores also had a higher expression of SINE:Alu elements. (Fig 1.A). Moreover, Factor 1 aligns the following immunology features: increased T-helper 1 (Th1) cells, macrophages, and T regulatory cells. The relationship between Th1 and SINE elements is particularly interesting, given the role of Th1 cell activation in host defence against infection that may be modulated by SINE activation. Factor 2 comprised of ageing and clinical categorical data, which showed that less inflammaging may lead to a poorer EFS ( P=0.00023) (Fig 1.B). Factor 4 linked immunology, cellular decomposition, ageing and clinical categorical data. The following features mainly influenced Factor 4: increased HSC-like cells, decreased CD8+ T cells, decreased immunosenescence and increased inflammatory chemokines. Using Kaplan-Meier plots to predict OS, we observed that patients with more HSC-like cells, fewer leukocytes and T cells, and less immunosenescence and inflammaging were linked to poorer EFS ( P=0.0001) and OS ( P=0.00017, data not shown). Furthermore, Factor 9 comprised solely of the TEs category and exhibited a correlation between increased TE expression and poorer EFS ( P=0.0074) and OS ( P=0.0065, data not shown) (Fig 1.B). Conclusions Our analysis using MOFA on a diverse set of biological data modalities uncovered hidden factors in MDS, providing insights into the complex interplay between various biological layers. Notably, we identified TE expression as a risk factor and inflammaging as a protective factor in MDS. HSC-like cells and specific immunological profiles were also associated with significantly poor OS and EFS. This study contributes to a deeper understanding of MDS pathogenesis and identifies potential prognostic markers for this disease. It also elucidates the importance of considering the relationships between different pathways, markers, and mutations in predicting patient outcomes, highlighting the efficacy of a comprehensive approach that goes beyond all the scoring systems described thus far for MDS.

Microenvironment Profiling in Myelodysplastic Syndromes and Its Relationship to Clonal Hematopoiesis and Disease Progression

Microenvironment Profiling in Myelodysplastic Syndromes and Its Relationship to Clonal Hematopoiesis and Disease Progression

Allogeneic stem cell transplantation may overcome the adverse impact of myelofibrosis on the prognosis of myelodysplastic syndrome

PurposeMyelofibrosis (MF) may serve as a poor prognostic factor in myelodysplastic syndromes (MDS). This study explored the impact of allogeneic hematopoietic stem cell transplantation (allo-HSCT) on the outcome of MDS patients with MF.Patients and MethodsThree hundred and sixteen MDS patients were enrolled in this retrospective study. Based on the degree of MF, we divided the patients into 2 groups: grade 0–1 (MF-0/1) and grade 2–3 (MF-2/3) groups. The clinical features, treatments, and prognosis in MDS patients with MF were analyzed.ResultsForty-three (13.6%) patients were diagnosed as MF-2/3. Complex karyotypes were more common in the MF-2/3 compared to MF-0/1 groups (P = 0.002). The overall response rate (ORR) of cytoreduction was 49.0%, along with 53.3% in the MF-0/1 and 16.7% in MF-2/3 groups (P = 0.017). In total, 141 patients underwent allo-HSCT, including 121 in the MF-0/1 and 20 in MF-2/3 groups. The median time to neutrophil reconstruction was 12 (range: 7–34) and 14 (range: 10–45) days (P = 0.005), and platelet reconstruction was 14 (range: 8–68) and 18 (range: 8–65) days (P = 0.045) in the MF-0/1 and MF-2/3 groups, respectively. However, the cumulative incidence of neutrophil and platelet engraftment achieved at day + 30 was not different between the two groups (P = 0.107, P = 0.303, respectively). Non-relapse mortality, relapse, and acute and chronic graft-versus-host disease were similar between the two groups (all P > 0.05). Among patients with allo-HSCT, the 2-year overall survival (OS) was 68.5% (95% CI: 60.1–76.9%) and 68.4% (95% CI: 47.4–89.4%) in the MF-0/1 and MF-2/3 groups, respectively, (P = 0.636). Among patients without allo-HSCT, the 2-year OS was 49.9% (95% CI: 40.7–59.1%) and 19.2% (95% CI: 0–39.6%) in the MF-0/1 and MF-2/3 groups, respectively, (P = 0.002). In multivariate cox analysis, complex karyotype was an unfavorable factor for relapse (HR, 4.16; P = 0.006), disease-free survival (DFS) (HR, 2.16; P = 0.020), and OS (HR, 2.47; P = 0.009) post-transplantation.ConclusionPatients with MF-2/3 have more complex karyotypes and lower ORR of cytoreduction in MDS. Among patients without allo-HSCT, patients with MF-2/3 have a worse prognosis than those with MF-0/1. However, the adverse impact of MF on prognosis may be overcome by allo-HSCT.

The Prognostic Value of Monosomal Karyotype (MK) in High-Risk Patients with Myelodysplastic Syndromes Treated with 5-Azacitidine

INTRODUCTIONCytogenetic abnormalities constitute an important prognostic factor in myelodysplastic syndromes (MDS). Recently, a new cytogenetic group termed monosomal karyotype (MK), defined by the presence ≥ 2 autosomal monosomies or one autosomal monosomy plus at least one structural abnormality in the same clone, has been introduced and was associated with worse outcome in patients with acute myeloid leukemia (AML). 5-Azacitidine (AZA) is a front-line treatment for high-risk patients (intermediate-2 or high IPSS risk) with MDS and AML who are ineligible for intensive chemotherapy. The prognostic impact of MK+ in AZA-treated patients remains unclear. In this study, we investigated the incidence and prognostic impact of MK in MDS patients treated with AZA. METHODSThis retrospective study of the Hellenic MDS Study Group included 405 intermediate-2 or high risk MDS patients treated with AZA. Extensive biostatistical analysis performed in this study included Kaplan-Meier survival analysis and Cox regression. The level of statistical significance was set at a probability value of less than 0.050 (P <0.050). RESULTSThe median age of patients was 74 years (range: 33 - 89). Baseline patient characteristics are presented in Table 1. MK was identified in 66 out of 405 (16.3%) patients, most of whom had complex karyotype. The overall response rate in the entire cohort was 46.2% (CR: 17.2%, PR: 11.2%, and HI: 17.8%). Stable disease (SD) was achieved by 24.8% of patients, while 29.0% had progression of disease (PD) or treatment failure. ORR was not different between MK+ and MK- patients (46.6% vs 46.2%). During a follow-up time period of 18.0 months, the duration of response was 1 - 41 months (median: 11) in the entire cohort, 9.5 months (range: 3 - 28) in MK+ patients and 11 months (range: 1 - 41) in MK- patients. The estimated median time to transformation to AML for MK+ patients was 17 months (95% confidence interval [CI] = 12.4-21.6) vs. 23 months (95% CI = 18.8-27.2) for MK- patients (P=0.025) (Figure 1a). Multivariate Cox regression analysis revealed that performance status (hazard ration [HR]=2.0, 95% CI = 1.5-2.8, P <0.001), IPSS-R (HR=1.5, 95% CI = 1.2 - 1.9, P <0.001) and MK (HR=1.8, 95% CI = 1.2-2.7, P=0.002) were independently associated with overall survival (OS). The estimated median OS for MK+ patients was 12 months [95% CI = 7.8-16.2] vs. 18 months; [95% CI = 15.3-20.7] for MK- patients (P <0.001) (Figure 1b). In a subgroup consisting of high and very-high risk patients according to IPSS-R, MK- patients showed better OS rates that MK+ patients (estimated median OS: 17 months; 95% CI = 14.1-19.9 vs. 12 months, 95% CI = 6.6 - 17.4, P=0.002) (Figure 1c). CONCLUSIONSMK is associated with reduced OS in patients with intermediate-2 or high risk MDS treated with AZA. In MDS with high or very high IPSS-R risk score, MK can further distinguish patients with poorer outcome. [Display omitted] DisclosuresNo relevant conflicts of interest to declare.

Erythropoietin as an independent prognostic factor in myelodysplastic syndromes.

To assess the level of erythropoietin (EPO) in blood sera of patients with different subtypes of myelodysplastic syndromes (MDS) from different risk subgroups and to determine its prognostic role. EPO was measured by enzyme-linked immunosorbent assay in peripheral blood of 54patients with different MDS subtypes according to the French-American-British (FAB) classification. The comparison group consisted of 15healthy individuals. Complete blood count (hemoglobin, leukocyte and platelet levels) was determined and bone marrow cells were characterized morphologically. The overall and leukemia-free survivals were estimated by Kaplan- Meier method. The level of ЕРО in MDS was reliably higher in comparison with healthy persons (p< 0.01, Mann- Whitney test). No statistically significant difference was found in serum EPO concentration between the groups of patients with low- and high-risk MDS (603.5pg/ml vs 721.0pg/ml; p> 0.05). In transfusion-dependent patients, the level of EPO was significantly higher than in other patients, which may be due to increased endogenous EPO secretion resulting from chronic hypoxia. A negative correlation was revealed between EPO level and Hb level as well as between EPO level and percentage of blast cells in bone marrow in high-risk MDS patients but not in patients with less aggressive variants of MDS. Instead, patients with low-risk MDS had a negative relationship between concentrations of EPO and tumor necrosis factor alpha (p= 0.06, Kendall's tau test). No significant difference was found between EPO concentration in cases differing by bone marrow cellularity or the presence of cytogenetic abnormalities. An EPO concentration below 200pg/ml was a predictor of shorter overall survival in patients with all MDS subtypes (p< 0.05, Mann- Whitney test). In patients with all FAB disease subtypes, there was no relationship between the leukemia-free survival and serum EPO concentration. This study shows that lower serum EPO level may be considered as one of the additional adverse prognostic factors in MDS patients.

Myeloid-derived suppressor cell cytokine secretion as prognostic factor in myelodysplastic syndromes.

Myeloid-derived suppressor cells (MDSCs) are a heterogeneous population of immature myeloid cells that play a critical immunosuppressive role in the tumour micro-environment. Although biological research on MDSCs has made progress, the relationship between the secretion of cytokines by MDSCs and poor prognosis is not clear, and there are no criteria to measure the functional status of MDSCs. Here, we detected the mRNA expression of IL-10, IL-12, TGF-β and TNF-α in MDSCs and the levels of these cytokines in MDSC culture supernatants of patients with myelodysplastic syndromes, and quantified the functional status of MDSCs by IL-10/IL-12 ratio and TGF-β/TNF-α ratio. We found that the ratio of IL-10/IL-12 and TGF-β/TNF-α was significantly higher in higher-risk MDS than in lower-risk MDS and normal control groups. The TGF-β/TNF-α ratio in MDSCs was positively correlated with the percentage of blast cells and was negatively correlated with the percentage of CD3+CD8+ T lymphocytes. Meanwhile, the TGF-β/TNF-α ratio was higher in patients with a lower absolute neutrophil count. It suggested that MDSCs in higher-risk MDS have a stronger immunosuppressive effect and might be related to poor prognosis. Quantifying the functional status of MDSCs with IL-10/IL-12 and TGF-β/TNF-α ratio might help to evaluate the balance of cellular immunity of MDSCs in MDS.

Decoding Bone Marrow Fibrosis in Myelodysplastic Syndromes

BackgroundBone marrow fibrosis (BMF), a poor prognostic factor in myelodysplastic syndromes (MDS), in the context of new risk stratifications of MDS has not been fully explored. We examined the relationship between BMF in MDS and survival outcomes, and explored the landscape of somatic gene mutations in the setting of BMF. Patients and MethodsWe retrospectively evaluated 2624 MDS patients for BMF who were divided into 2 groups: grade 0-2 BMF (96%) and severe/grade 3 BMF (4%) based on analysis presented. Commonly MDS tested acquired somatic mutations were also compared between those 2 groups of patients with available next-generation sequencing data. ResultsOnly grade 3 BMF was associated with worse overall survival independent from the Revised International Prognostic Scoring System (IPSS-R) (hazard ratio = 1.6; 95% confidence interval, 1.2-1.9; P < .005). More patients with severe BMF were classified as MDS-EB1 and -EB2 by the World Health Organization 2016 classification, a higher-risk International Prognostic Scoring System score, and a high/very high IPSS-R risk category than patients with grade 0-2 BMF. A complex karyotype, higher bone marrow myeloblasts, lower platelets, and higher rate of elevated lactate dehydrogenase were observed more often in patients with severe BMF. No differences in response to hypomethylating agents or lenalidomide were observed. Among somatic gene mutations tested in MDS, TP53 mutation and SETBP1 were more frequent in patients with grade 3 BMF. ConclusionThe presence of grade 3 BMF is associated with reduced overall survival independent from IPSS-R; however, BMF grade did not affect response to hypomethylating agent or lenalidomide treatment. TP53 and SETBP1 mutations occurred with greater frequency among patients with severe fibrosis.

Comprehensive analysis of isolated der(1;7)(q10;p10) in a large international homogenous cohort of patients with myelodysplastic syndromes.

The karyotype is a strong independent prognostic factor in myelodysplastic syndromes (MDS). Since the implementation of the new comprehensive cytogenetic scoring system for MDS, chromosome 7 anomalies are no longer generally assigned to poor risk features but are thoroughly separated. However, der(1;7)(q10;p10), hereinafter der(1;7), is merged into the group labeled "any other single" and belongs to the intermediate risk group, just by definition due to lack of adequate clinical data. The aim of our international collaborative was to clarify the "real" prognostic impact of der(1;7) on a homogenous and well-documented data base. We performed detailed analysis of 63 MDS patients with isolated der(1;7) constituting the largest cohort hitherto reported. Furthermore, clinical data are compared with those of patients with isolated del(7q) and isolated monosomy 7. Median overall survival (OS) of patients with der(1;7) is 26 months (hazard ratio (HR) 0.91 for del(7q) vs der(1;7) and 2.53 for monosomy 7 vs der(1;7)). The der(1;7) is associated with profound thrombocytopenia most probably causing the reduced OS which is in striking contrast to the low risk for AML transformation (HR 3.89 for del(7q) vs der(1;7) and 5.88 for monosomy 7 vs der(1;7)). Molecular karyotyping indicates that der(1;7) is generated in a single step during mitosis and that a chromosomal imbalance rather than a single disrupted gene accounts for malignancy. Thus, the current cytogenetic scoring system assigning isolated der(1;7) to the intermediate risk group is now confirmed by a sufficient data set.

SOX7 methylation is an independent prognostic factor in myelodysplastic syndromes

ObjectiveSOX7 downregulation caused by its promoter methylation was associated with poor survival in several types of human solid tumors. However, the pattern of SOX7 methylation and its clinical significance are less studied in hematological malignancies. Herein, we evaluated the methylation pattern of SOX7 in myelodysplastic syndrome (MDS) and determined its clinical implication in patients with MDS. MethodsSOX7 methylation was determined by real-time quantitative methylation-specific PCR (RQ-MSP) in 99 MDS patients. Bisulfite sequencing PCR was applied to confirm the results of RQ-MSP. ResultsSOX7 methylation was detected in 55.6% of 99 patients but not in healthy donors. No correlation was found between SOX7 methylation and clinical parameters including patient age, gender, white blood cell count, hemoglobin, and platelet count. However, patients with SOX7 methylation harbored more U2AF1 mutation than patients without SOX7 methylation (P = 0.015). Kaplan-Meier curves indicated that the patients with SOX7 methylation presented reduced overall survival (OS) (P = 0.034). Furthermore, subgroup analysis indicated that SOX7 methylation was associated with poor OS in male patients (P = 0.034) and in patients older than 60 years (P = 0.019). According to the multivariate analysis, SOX7 methylation remained as an independent prognosis factor in MDS patients both as dichotomous (HR = 2.14, P = 0.041) and as continuous (HR = 1.55, P = 0.042) variable. Importantly, SOX7 methylation was significantly increased during progression from MDS to secondary acute myeloid leukemia (sAML). ConclusionsOur findings demonstrated that SOX7 methylation conferred adverse prognosis in MDS patients and was associated with leukemia progression.

The Wilms' tumor gene-1 is a prognostic factor in myelodysplastic syndrome: a meta analysis.

Previous studies have suggested that Wilms’ tumor gene-1 (WT1) may be related to a decrease in both relapse-free survival (RFS) and overall survival (OS) for patients with myelodysplastic syndrome (MDS). Therefore, we conducted a meta-analysis on the utility of WT1 as a prognostic indicator of MDS. Published reports were searched in the following databases: Cochrane Library, PubMed, Embase, and Web of Science. The meta-analysis was conducted using the Cochrane Collaboration RevMan 5.2 software. Six publications with 450 total patients met the inclusion criteria and were subjected to further examination. The results showed a reduction in both overall survival (OS) and leukemia-free survival (LFS) with increasing WT1 expression levels: 1-year OS (odds ratio, OR = 0.16; 95% CI = 0.08–0.34, P < 0.001), 3-year OS (OR = 0.21; 95% CI = 0.09–0.47, P < 0.001), 5-year OS (OR = 0.24; 95% CI = 0.06–0.92, P = 0.04), 1-year LFS (OR = 0.06; 95% CI = 0.02–0.18; P < 0.001), 3-year LFS (OR = 0.20; 95% CI = 0.09–0.46; P < 0.001), and 5-year LFS (OR = 0.12; 95% CI = 0.04–0.38; P < 0.001). In terms of patients receiving hematopoietic stem cell transplantation, the cumulative incidence of relapse (CIR) was higher in the WT1 over-expression group than in the low-expression group: 1-year CIR (OR = 13.69; 95% CI = 2.99–62.62; P < 0.001), 3-year CIR (OR = 6.52; 95% CI = 2.31–18.40, P < 0.001). In conclusion, WT1 over-expression is a prognostic factor for MDS.

Prognostic classification of MDS is improved by the inclusion of FISH panel testing with conventional cytogenetics

Cytogenetics is a critical independent prognostic factor in myelodysplastic syndromes (MDS). Conventional cytogenetics (CC) and Fluorescence in situ hybridization (FISH) Panel Testing are extensively used for the prognostic stratification of MDS, although the FISH test is not yet a bona fide component of the International Prognostic Scoring System (IPSS). The present study compares the utility of CC and FISH to detect chromosomal anomalies and in prognostic categorization. GTG-Banding and FISH Panel Testing specifically for -5/-5q, -7/-7q, +8 and -20q was performed on whole blood or bone marrow samples from 136 patients with MDS. Chromosomal anomalies were found in 40 cases by CC, including three novel translocations. FISH identified at least one anomaly in 54/136 (39.7%) cases. More than one anomaly was found in 18/54 (33.3%) cases, therefore, overall FISH identified 75 anomalies of which 32 (42.6%) were undetected by CC. FISH provided additional information in cases with CC failure and in cases with a normal karyotype. Further, in ten cases with an abnormal karyotype, FISH could identify additional anomalies, increasing the number of abnormalities per patient. Although CC is the gold standard in the cytogenetic profiling of MDS, FISH has proven to be an asset in identifying additional abnormalities. The number of anomalies per patient can predict the prognosis in MDS and hence, FISH contributed towards prognostic re-categorization. The FISH Panel testing should be used as an adjunct to CC, irrespective of the adequacy of the number of metaphases in CC, as it improves the prognostic classification of MDS.

Chronic hepatitis C as an adverse prognostic factor in myelodysplastic syndromes.

e18557 Background: Chronic hepatitis C virus (HCV) infection has been associated with hematologic malignancies such as B-cell non-Hodgkin lymphoma. In contrast, there is very little known about the relationship between HCV and myeloid malignancies such as myelodysplastic syndromes (MDS) and acute myeloid leukemia (AML). To determine the effect of HCV on MDS/AML clinical outcomes we conducted a retrospective analysis in a large inner city cohort of patients (pts) Methods: 478 pts with MDS and MDS-transformed AML were identified between 1997 and 2016; 13 pts were HCV-positive (HCV+/MDS) and 465 were HCV-negative (HCV-/MDS). Demographics, hematologic parameters, cytogenetics, IPSS-R scores and molecular profiles were compared for both groups (grp). Survival (surv) analysis was done using the Kaplan-Meier method Results: HCV+/MDS had significantly worse surv than HCV-/MDS pts on univariate analysis (UA) (median surv 16 vs 52 months, HR 2.8, 95% CI 1.4-5.5, p &lt; 0.01). Difference remained strongly significant after exclusion of HIV-coinfected pts (HR 2.7, p = 0.02) and pts w/ AML on presentation (HR 3.1, p &lt; 0.01). Cytopenias were worse in HCV+/MDS (mean Hgb level 8.2 vs 9.4 g/dl, p = 0.04; mean plt count 64 vs 139 103/µL, p = 0.03). Average IPSS-R score was higher in HCV+/MDS pts (5.5 vs 3.8, p = 0.02). IDH1 mutation was more prevalent in HCV+/MDS (25% vs 2%, p &lt; 0.01). Differences in age between HCV+/MDS and HCV-/MDS were non-significant (mean 64 vs 69 respectively, p = 0.2). Male-to-female ratio was higher in HCV+/MDS but difference was non-significant (2.3 vs 0.9, p = 0.2). Interestingly, high HCV viral load and cirrhosis did not correlate with poor surv in the HCV+/MDS grp, suggesting deleterious effect occurs even in early stages of HCV infection. Conclusions: Our analysis suggests that chronic HCV infection strongly correlates with worse surv in UA and is associated with lower blood counts and higher IPSS-R scores at the time of diagnosis of MDS. We observed a high rate of MDS refractory to standard therapies and speculate that HCV may affect biology of the disease. Larger studies are warranted to determine the effect of HCV on surv in this population and to provide a rationale for trials of anti-HCV drugs concomitantly with MDS Tx.

Prognostic pre-transplant factors in myelodysplastic syndromes primarily treated by high dose allogeneic hematopoietic stem cell transplantation: a retrospective study of the MDS subcommittee of the CMWP of the EBMT.

Many pre-transplant factors are known to influence the outcome of allogeneic stem cell transplantation (SCT) treatment in myelodysplastic syndromes (MDS). However, patient cohorts are often heterogeneous by disease stage and treatment modalities, which complicates interpretation of the results. This study aimed to obtain a homogeneous patient cohort by including only de novo MDS patients who received upfront allogeneic SCT after standard high dose myelo-ablative conditioning. The effect of pre-transplant factors such as age, disease stage, transfusions, iron parameters and comorbidity on overall survival (OS), non-relapse mortality (NRM), and relapse incidence (RI) was evaluated in 201 patients. In this cohort, characterized by low comorbidity and a short interval between diagnosis and transplantation, NRM was the most determinant factor for survival after SCT (47 % after 2-year follow-up). WHO classification and transfusion burden were the only modalities with a significant impact on overall survival after SCT. Estimated hazard ratios (HR) showed a strongly increased risk of death, NRM and RI, in patients with a high transfusion-burden (HR 1.99; P = 0.006, HR of 1.89; P = 0.03 and HR 2.67; P = 0.03). The HR’s for ferritin level and comorbidity were not significantly increased.

Spliceosomal component Sf3b1 is essential for hematopoietic differentiationin zebrafish.

SF3B1 (Splicing factor 3b, subunit 1) is one of the most commonly mutated factors in myelodysplastic syndrome (MDS). Although the genetic correlation between SF3B1 mutations and MDS etiology are quite strong, no invivo model currently exists to explore how SF3B1 loss alters blood cell development. Using zebrafish mutants, we show here that proper function of Sf3b1 is required for all hematopoietic lineages. As in MDS patients, zebrafish sf3b1 mutants develop a macrocytic-anemia-like phenotype due to a block in maturation at a late progenitor stage. The mutant embryos also develop neutropenia, because their primitive myeloid cells fail to mature and turn on differentiation markers such as l-plastin and myeloperoxidase. In contrast, production of definitive hematopoietic stem and progenitor cells (HSPCs) from hemogenic endothelial cells within the dorsal aorta is greatly diminished, whereas arterial endothelial cells are correctly fated. Notch signaling, imperative for the endothelial-to-hematopoietic transition, is also normal, indicating that HSPC induction is blocked in sf3b1 mutants downstream or independent of Notch signaling. The data demonstrate that Sf3b1 function is necessary during key differentiation fate decisions in multiple blood cell types. Zebrafish sf3b1 mutants offer a novel animal model with which to explore the role of splicing in hematopoietic development and provide an excellent invivo system with which to delve into the question of why and how Sf3b1 dysfunction is detrimental to hematopoietic differentiation, which could improve MDS diagnosis and treatment.

Prognostic Impact of Adverse Karyotype and Treatment in Patients with Myelodysplastic Syndrome and Acute Myeloid Leukemia

INTRODUCTIONKaryotype is a key prognostic factor in myelodysplastic syndromes (MDS) and acute myeloid leukemia (AML). Adverse karyotype (AK) significantly influences on response to treatment, prognosis and survival in older MDS and AML patients(pts)1,2.AIMSEvaluate the frequency of adverse karyotype over the total number of patients (pts) diagnosed with MDS and AML in our institution, demographic features, treatment received and overall survival (OS) estimates. Second, to analyze prognostic factors associated to OS in this cohort of pts.PATIENTS AND METHODSA retrospective and observational analysis was performed including all consecutive cases of MDS and AML with adverse karyotype. Period of analysis was from 2008-2015 for AML and from 1990-2015 for MDS pts. Adverse karyotype was defined as categories Intermediate-II and adverse from European LeukemiaNet recommendations in AML3, whereas IPSS4 was used for MDS pts. Complex and monosomal karyotype (CK/MK) were defined by the presence of ≥3karyotypic abnormalities in the absence of recurrent cytogenetic alterations based on the WHO classification, and the presence of ≥2 distinct autosomal monosomies or a single autosomal monosomy associated with at least 1 structural abnormality; respectively. Patients were stratified based on type of treatment received: active [intensive chemotherapy(IC)/azacitidine (AZA) followed or not by allogeneic transplant) vs supportive care (SC; including pts not candidates to active treatment due to comorbidity, poor ECOG status or advanced age >70).RESULTSA total of 98 pts were identified (N=49 cases of MDS and AML each). Median age at diagnosis was 65 years (range: 14-89). Demographic and baseline characteristics are described in table 1. The frequency of AK from the global cohort of MDS and AML from our institution was 20% and 19% respectively. Ten out of 49 (21%) pts with AML displayed recurrent cytogenetic alteration according to WHO classification [t(9;11) and other alterations in MLL, t(6;9), inv(3) or t(3;3)] and 28/49 (57%) and 18/49 (38%) had a CK or MK, respectively. In the MDS cohort, 25/49 pts (51%) had a chromosome 7 abnormality and 30/49 (61%) presented with a MK. Globally (AML and MDS), almost half of pts (49.8%) had a MK. Most pts <65y received active treatment (as previously stated) as compared to pts >65y (69% vs 37%; p<0.001). After 49 months median follow-up (range: 1-100), 22% pts (22/98) are alive with a median OS of 9 months for the global series (95% CI, 5.6-12.3). Median OS for pts treated with intensive chemotherapy, azacitidine or SC was 11 (CI 95%; 3.2-20.7), 14 (IC 95%; 10-17) and 5 months (IC 95%; 2-7); respectively (p=0.001). No difference in OS was observed between AML or MDS cases. Age >65y, KC, MK and treatment received (SC) had a negative impact on OS (p<0.05 all cases). In multivariate analysis, only the presence of MK [HR: 1.7, 95% IC (1.06-2.7); p=0.02] and receiving active treatment [HR: 0.49, 95% IC (0.3-0.8), p=0.006] remained statistical significant for OS.DISCUSSIONAdverse, and particularly MK predict poor survival in AML/MDS. Both IC and AZA offer significant survival advantage over SC.

Eritropoietina Sérica como Marcador Prognóstico em Síndrome Mielodisplásica

This myelodysplastic syndromes are a heterogeneous entity characterized by dysplasia, hypercellular bone marrow, cytopenias and risk of transformation to acute leukaemia. Prognostic factors, such as bone marrow fibrosis, lactate dehydrogenase and 2-microglobulin elevation have been described, but treatment is mainly based in the International Prognostic Scoring System. Our aim was to analyze serum's erythropoietin at diagnosis in de novo myelodysplastic syndromes patients, through its impact in overall survival and possible implementation as prognostic marker. Clinical and laboratorial data from 102 patients with de novo myelodysplastic syndromes diagnosed between October/2009 and March/2014 were collected. Survival analysis was performed according to serum erythropoietin level stratification, using Kaplan-Meier methodology. Our 102 patients had a median age of 74 years, with a male:female ratio of 0.8. Mean erythropoietin was significantly lower in refractory cytopenia with unilineage dysplasia patients in contrast with the higher values observed in 5q- syndrome (p < 0.05). Eleven patients progressed to acute leukaemia; these have higher mean erythropoietin values (p < 0.05). In addition, elevated serum erythropoietin was associated with lower survival rates (p = 0.0336). Predictive value of serum erythropoietin was maintained after Cox regression adjustment. In multivariate analysis, serum erythropoietin is an independent survival predictor (p < 0.001). Serum erythropoietin is a predictive factor for response to therapy with subcutaneous erythropoietin, and patients with myelodysplastic syndromes with higher values of erythropoietin have poorer response to administration of erythropoietin even at higher doses. Our sample shows that serum erythropoietin also has prognostic value, and in all myelodysplastic syndromes subtypes. Moreover, alone or in combination with other factors or prognostic indices, erythropoietin may enhance the prognostic indices such as the International Prognostic Scoring System, since high levels are associated with progression to acute leukemia and hence lower survival. This study suggests that increased erythropoietin levels at diagnosis can by itself be a poor prognosis factor inmyelodysplastic syndromes patients, with higher values in patients with progression to acute leukaemia and decreased overall survival.

Azacitidine Treatment For Patients With Myelodysplastic Syndromes and Acute Myeloid Leukemia Harboring Chromosome 3q Abnormalities

BackgroundKaryotype is one of the key prognosis factors in myelodysplastic syndromes (MDS) and acute myeloid leukemia (AML). Chromosome 3q abnormalities, including aberrant expression of EVI-1, represent a small subset of patients and are associated with a poor outcome in both MDS and AML patients treated with conventional treatment. Azacitidine is the current standard of care for high-risk MDS and is also active in AML. Given that AZA may provide responses in patients with poor chances of response to conventional treatment as patients with monosomy 7 and given the strong epigenetic modifications related to EVI-1 dysregulation, AZA may represent an interesting option for patients with 3q abnormalities. Therefore, we analyzed the outcome of patients with Chromosome 3q abnormalities treated with Azacitidine. Patients and methodsThis is a retrospective multicenter study. Patients were included if 1/ Diagnosis of MDS, CMML, or AML, including therapy related neoplasms 2/ harbored chromosome 3q abnormalities and/or EVI-1 overexpression by PCR 3/ received at least one cycle of azacitidine for either frontline or relapse treatment. Response was evaluated according IWG 2006 criteria. This cohort of patients was compared to 406 high risk MDS and AML patients without 3q abnormalities included in the French AZA compassional program. ResultsA total of 184 patients were analyzed. Median age was 64 years. According to WHO classification, patients presented RA/RCMD/RAEB-1 28% of cases, RAEB-2/CMML-2 31% of cases, and AML 41% of cases. Median bone marrow blast count was 15%. Cytogenetics were inv(3)/t(3;3) 22%, del(3q)/monosomy 3 26%, t(3q26;x) 20%, EVI-1 overexpression without 3q abnormality 14%, t(3q21;x) 4% and other 3q abnormalities 14%. 58% of patients had complex karyotype. Azacitidine was used frontline for 67% of patients, 33% being previously treated with intensive chemotherapy. Median number of cycle of azacitidine was 5 (1-33). Overall response rate was 47% (Complete or Partial response 27%). 31 patients (25% of patients younger than 70y) bridged to allogeneic transplantation. With a median follow-up of 16 months, median overall survival was 10.5 months. Younger age (below 65y, 13m vs 10m, p=0.052), low bone marrow blast count (below 20%, 13m vs 8m, p=0.001), presence of t(3q21;x) (74 vs 10 months, p=0.008), few cytogenetic abnormalities (below 3, 14m vs 9m, p=0.003), and use of Azacitidine frontline (13m vs 8 m, p=0.029) were associated with a better survival. Long term survival remains limited with a 3 years survival probability below 10%. Interestingly, baseline characteristics and prognosis of patients with EVI-1 overexpression without 3q cytogenetic abnormality were comparable with patients with 3q26 cytogenetic abberation. Then, we compared our cohort with MDS/AML patients without 3q abnormalities, their overall response rate was 30% (41% for HR MDS, 15% for AML, including 11% CR/PR), and median OS was 10.5 months (15 months for HR MDS and 7 months for AML). When we merged the 2 cohorts and performed multivariate analyses, presence of 3q abnormality had no prognosis impact on either response or survival. ConclusionAzacitidine seems to limit the dismal outcome associated with 3q abnormalities and thus represents a good alternative to conventional chemotherapy including for patients eligible for allogeneic transplantation. Moreover, our data showed that 3q group is heterogeneous with a favorable outcome for the small subset of patients with 3q21 abnormalities. Disclosures:Prebet:CELGENE: Honoraria. Off Label Use: Use of azacitidine in acute myeloid leukemia.

The Evaluation of iron overload through hepcidin level and its related factors in myelodysplastic syndromes

We chose hepcidin and its related factors as evaluating indicators to determine the degrees of iron overload in myelodysplastic syndromes (MDS) patients. A total of 73 patients and 28 healthy volunteers were enrolled in this study. We performed enzyme-linked immunosorbent assay to measure both bone marrow and peripheral blood serum hepcidin. Real-time quantitative polymerase chain reaction was used to determine the gene expression of growth differentiation factor 15 and twisted gastrulation 1. Serum ferritin (SF), C-reactive protein (CRP), and erythropoietin were measured by routine standard laboratory assays. CD4+ and CD19+ lymphocytes and Th polarization were detected by flow cytometry. Twenty-four MDS patients were measured their cardiac and liver iron deposition levels through magnetic resonance imaging (MRI) T2* examination. No significant difference was found between the bone marrow hepcidin levels and peripheral blood hepcidin levels (P = 0.134). Stratified according to different World Health Organization subtypes, refractory anemia with ringed sideroblasts patients had the lowest hepcidin levels (105.40 ± 5.13 ng/ml), while refractory anemia with excess blasts-1 had the highest levels (335.71 ± 25.16 ng/ml). Stratified according to International Prognostic Scoring System and WHO Classification-based Prognostic Scoring System, there was a significant difference of hepcidin levels between low-risk group and high-risk group in two systems, respectively (P = 0.033 and 0.009). The hepcidin levels of CD4+ high-expression group were demonstrated higher than the normal expression groups (P = 0.02), but the CD19+ high-expression group did not show the same result (P = 0.206). Meanwhile, patients with a Th1 polarization trend had a high level of hepcidin versus normal group (P < 0.001). Liver iron concentration (LIC) measured by MRI T2* had a closer correlation (r = 0.582, P < 0.001) to hepcidin than serum ferritin, by stepwise regression. C-reactive protein and LIC seemed to be the key determinants of hepcidin, by multivariate regression. Inflammation plays an important role in the regulation of hepcidin expression. T-lymphocyte activation and Th polarization trend might participate in the regulatory mechanism partly. The capability of organ iron load assessment of MRI T2* seems better than that of SF. It seems that hepcidin with CRP and LIC measured by MRI T2* are potential indicators of iron overload in MDS patients.

P-117 Comparison of old and new prognostic factors in myelodysplastic syndromes

P-117 Comparison of old and new prognostic factors in myelodysplastic syndromes