High-risk Myelodysplastic Syndrome Patients Research Articles

Distinct Role of STAT3 and STAT5 Factors in MDS and AML

Introduction: Myelodysplastic Syndrome (MDS) refers to a heterogeneous group of clonal hematologic disorders characterized by hematopoietic dysfunctions and impaired differentiation in the hematopoietic stem and progenitor cells compartment. MDS is commonly referred to as a pre-leukemic stage due to the increased risk of progression to Acute Myeloid Leukemia (AML). AML is an aggressive hematologic malignancy characterized by the accumulation of immature myeloblasts in the bone marrow and the peripheral blood. Signal transducers and activators of transcription 3 and 5 (STAT3 and STAT5) are important regulators of several cellular processes including cell proliferation and survival. Abnormal STAT3 and STAT5 signaling has been implicated in various solid and hematologic malignancies, including MDS and AML, which renders them appealing targets for the development of novel therapeutic strategies. Materials: STAT3, STAT5A or STAT5B knock-downs have been generated in two AML (MOLM-13 and Kasumi-1) and two MDS (MDS92 and MDS-L, gift of Prof. Kaoru Tohyama) cell lines, using shRNAs through lenti-viral delivery. The 4 biological replicates with the highest levels of knock-downs for STAT5A, STAT5B or STAT3 have been selected for each cell line and mRNA sequencing has been performed. To define the genome-wide binding of STAT5A, STAT5B and STAT3 in the two conditions, CUT&Tag has been performed in wild type MOLM-13, Kasumi-1 and MDS-L cells. Additionally, ATAC sequencing has been carried out in the same cell lines to investigate the chromatin conformation changes between the two conditions. Furthermore, STAT3, STAT5A and STAT5B knock-downs have been conducted using shRNAs through lenti-viral delivery in CD34+ enriched cells, isolated from bone marrow mononuclear cells of 14 high-risk MDS patients and 14 secondary (MDS-related) AML patients. The samples have been processed for mRNA-Sequencing to model the leukemic transformation in primary human cells. Results: To elucidate the role of STAT3 and STAT5 in MDS to AML transformation, changes in STAT3 and STAT5 target gene networks have been identified. mRNA sequencing data from STAT3, STAT5A or STAT5B knock-downs in MDS and AML cell lines revealed a distinct role of the three factors in each state. The differential binding of each factor, explored through CUT&Tag, and the gene expression profiles in MDS and AML reciprocally reveal a different function of each factor, including pathways involved in cell cycle and apoptosis. Also, the direct and indirect target genes of STAT3, STAT5A and STAT5B in each condition, as well as a possible interplay between STAT3 and STAT5 activation in AML has been uncovered. The exploration of the chromatin accessibility landscapes between the MDS and AML conditions through ATAC sequencing has provided an insight into the chromatin conformation states, unveiling potential leukemia promoting networks, as well as the involvement of STAT3 and STAT5 pathways in the malignant transformation. Furthermore, a potential cross talk of STAT3 and STAT5 factors with the IKAROS family members, has been linked to AML transformation, as significant differential regulation has been detected between MDS and AML conditions after knock-down of STAT5A and STAT5B. The results are currently validated in primary hematopoietic cells of MDS and AML patients after STAT3, STAT5A or STAT5B knock-downs. Conclusions: Our results show a different role between the two STAT5 factors (STAT5A and STAT5B) in MDS and AML conditions and delineate the role of STAT5A, STAT5B and STAT3 factors and their target gene networks in leukemic transformation, thus providing novel targets for therapeutic management of MSD and AML. Funding: This project is funded by the European Union's Horizon 2020 research and innovation programme under the Marie Skłodowska-Curie grant agreement No 813091 (ARCH)

Evaluation of Disparities in Higher-Risk Myelodysplastic Syndromes (HR-MDS) Patient Treatment Patterns in a Large US Health System

BACKGROUND Myelodysplastic syndromes (MDS) are a heterogenous group of myeloid neoplasms. Patients may present with nonspecific signs and symptoms such as fatigue, infections, bleeding, and bruising. Bone marrow aspiration and biopsy are used to confirm diagnosis and are critical in the evaluation of bone marrow cell morphology and cellularity necessary for risk classification. Patients stratified as higher-risk MDS (HR-MDS) have worse overall survival and a higher risk of transformation to acute myeloid leukemia (AML). Treatment of HR-MDS can be challenging. While hypomethylating agents azacitidine and decitabine are the only approved drugs for HR-MDS, there are clinical and translational studies for other treatment approaches. The only curative treatment at present is hematopoietic stem cell transplantation (HSCT), for which only a portion of patients may qualify. This study sought to identify potential missed opportunities in care, including time to diagnosis (Dx) and treatment, by evaluating differences based on underlying sociodemographic and clinical characteristics of newly diagnosed patients with HR-MDS. METHODS This is a retrospective cohort study of commercial and Medicare Advantage health plan members with evidence of newly diagnosed HR-MDS in the Optum Research Database (ORD). Additional Optum datasets were linked to the standard ORD to allow for the inclusion of additional socioeconomic (SES) and social determinants of health (SDoH) variables. The study period was 1 January 2016 to 31 July 2022. Adults with ≥1 inpatient claim for HR-MDS or ≥2 outpatient claims for either MDS or HR-MDS (requiring at least 1 to be HR-MDS) on 2 separate dates between 1 January 2017 and 30 April 2022 were eligible for inclusion. The earliest HR-MDS claim was the index date. A period of 12 months prior to the index date was used to assess baseline characteristics. Patients were followed for at least 3 months post-index until the earliest of AML Dx, death, end of continuous enrollment, or end of the study period. RESULTS The study criteria were met by 1710 patients. Median age at HR-MDS Dx was 77 years, and 40% of patients had baseline Charlson comorbidity score ≥3; 22% had no claim for a bone marrow biopsy or aspiration in the 12 months prior to index or during variable follow-up. Patients were categorized hierarchically based on level of treatment received: HSCT occurred in 4% of patients, 33% had evidence of active treatment, 26% received MDS supportive treatment, and 37% had no treatment in the variable follow-up period. Patients who received HSCT had the lowest Charlson score (mean 1.3), followed by those who received active treatment (mean 2.2), no treatment (mean 2.3), and MDS supportive treatment (mean 2.8). Patients who received active treatment and those who received no treatment appeared to have a similar average age (76 years), similarities in baseline comorbidities (autoimmune conditions, diabetes, and hepatic and renal diseases), and similarities in underlying SDoH and SES characteristics. Male patients made up 58% of the total study population; the prevalence by sex varied within treatment groups where male patients were 64% of the active treatment group but only 54% of the MDS supportive treatment group (Fig. 1a). HSCT patients had the least likelihood of unmet SDoH need, whereas those in MDS supportive care generally had the lowest chance of no unmet need (Fig. 1b). Few patients (7%) had claims indicative of clinical trial participation after index; clinical trial participants were healthier (mean Charlson score 1.9 vs 2.4) and younger (only 37% were aged 75+ vs 64% of non-participants in this age group). Patients not participating in clinical trials were more likely to have unmet financial or housing security and transportation access challenges. White and Asian patients had the highest rates of whole blood transfusions (5.4 and 5.7 per 100 person-months, respectively), while Hispanic patients had the lowest rate (2.5 per 100 person-months). CONCLUSION A large proportion of HR-MDS patients had no evidence of active treatment during the variable follow-up. HSCT and clinical trial participation were low in the study; these patients were younger, had fewer comorbidities, and did not experience financial, housing, or transportation issues. To ensure guideline concordant care, there is a need to further contextualize drivers of treatment in clinical practice, including patients' preferences.

Psychometric Validation and Meaningful Change Threshold Determination of EORTC QLQ-C30 Physical Functioning and Promis SF v1.0-Fatigue 7a Functional Domain in Patients with High-Risk Myelodysplastic Syndromes Treated with Venetoclax and Azacitidine

Background : Patients with myelodysplastic syndromes (MDS) can experience fatigue, infection, anemia, bruising, and bleeding. Fatigue and physical functioning (PF) are often the most adversely impacted areas of patient health-related quality of life. The objective of this study was to generate quantitative evidence to determine whether the PF score from the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire Core 30 (EORTC QLQ-C30) and the Fatigue score from the Patient-Reported Outcome Measurement Information System - Fatigue Short Form 7a (PROMIS SF 7a) measures are suitable candidates for developing patient-reported endpoints for clinical trials in treatment-naïve patients with higher-risk MDS (HR-MDS). We also aimed to derive definitions for meaningful change for both PF and Fatigue scores to aid in interpretation of efficacy analyses using these scores. Methods : This analysis used aggregate data from the Phase 3 M15-954 study (NCT04401748), which is an ongoing, randomized, double-blind, placebo-controlled study evaluating the safety and efficacy of venetoclax in combination with azacitidine in treatment-naïve adult patients with HR-MDS. The EORTC QLQ-C30 and the PROMIS SF 7a questionnaires were administered on the first day of each 28-day cycle for the first 7 cycles and every 3 cycles thereafter, and at the treatment-completion visit. For both measures, the analyses evaluated item characteristics at baseline, whether the hypothesized structure was consistent with the scoring algorithms implemented in the trial, and the reliability and validity of scores; subsequently, definitions for meaningful improvement or deterioration were determined. Anchor-based analyses were used to generate definitions for meaningful deterioration or improvement from baseline to Cycle 4 Day 1 for EORTC QLQ-C30 PF domain, and Cycle 7 Day 1 for PROMIS SF 7a. Construct-aligned anchors were used for these analyses, with a change in Patient Global Impression of Severity (PGIS) - Physical Activities and in Patient Global Impression of Change (PGIC) - Physical Activities used as the anchor for the analyses of the EORTC QLQ-C30 PF scores and PGIS-Fatigue and PGIC-Fatigue used for the analyses of the PROMIS SF 7a scores. Results : Approximately 500 treatment-naïve higher-risk patients with MDS enrolled in the study were included in this analysis. Both EORTC QLQ-C30 PF and PROMIS SF 7a measures demonstrated adequate reliability and validity; both measures exceeded the cut-off for acceptable internal consistency reliability, test re-test reliability, and convergent validity with co-validators ( Table 1). The definition for deterioration for the EORTC QLQ-C30 PF domain was −13.33 (rounded to the nearest possible incremental change score), which was corroborated with the PGIC-Physical Activities ( Table 2). The correlation between the EORTC QLQ-C30 PF domain and PGIS-Physical Activities scores was −0.43, and the correlation between the EORTC QLQ-C30 PF domain and PGIC-Physical Activities scores was −0.34, indicating that these measures were sufficient to be used as anchors. For PROMIS SF 7a, the definition for deterioration and improvement was 3.90 and −3.50, respectively. Both results were also corroborated with the PGIC-Fatigue. The correlation between the PROMIS SF 7a and PGIS-Fatigue scores was 0.58, and the correlation between the PROMIS SF 7a and PGIC-Fatigue scores was 0.38, indicating that these measures were sufficient to be used as anchors. Conclusions : The psychometric evaluation of EORTC QLQ-C30 PF and PROMIS SF 7a Fatigue scores from M15-954 study's blinded data provides sufficient evidence of test re-test reliability, construct validity, responsiveness, and score interpretability and supports their use as endpoints for clinical trials in treatment-naïve HR-MDS patients for regulatory decision-making.

A Patient-Centered Programmatic Approach for Higher-Risk Myelodysplastic Syndromes (HR-MDS) in the US Community Oncology Setting

Introduction: Prompt diagnosis and treatment are critical for patients with higher-risk myelodysplastic syndromes (HR-MDS) given the high likelihood of progression to leukemia and adverse clinical outcomes. However, pre-diagnosis dynamics can contribute to delays in diagnosis, genetic testing, and treatment initiation, especially among patients receiving care in the community oncology setting. A patient-centered program has been designed and is proposed to be executed in 4 phases: understanding adherence to guideline-concordant care for HR-MDS patients; gaining perspectives to contextualize the patient experience; and implementing a program that can monitor the process for improving patient outcomes (Figure 1). The objectives of this study are to evaluate and address the gaps and disparities of care in the diagnostic and treatment journey of patients with HR-MDS treated in a community oncology setting in order to provide an evidence-based understanding of the patient characteristics and journey to testing, diagnosis, and treatment (Phase 1 of the program). Methods: This is a retrospective chart review including patients treated in the community oncology network and identified in the Integra PrecisionQ deidentified database. Patients were identified as diagnosed with HR-MDS between January 1, 2014 and June 30, 2022, using a combination of ICD codes and receipt of hypomethylating agents in line with National Comprehensive Cancer Network guidelines as their first treatment. Eligible patients had at least 3 months of follow-up and at least 6 months of look-back prior to HR-MDS diagnosis. Signs and symptoms such as fatigue, weight loss, bruise, chills, night sweats, anemia, thrombocytopenia, and neutropenia that initiated the HR-MDS diagnosis journey were collected by manual curation. Results: A total of 350 patients aged 18 years or older diagnosed with HR-MDS over the study period were selected. The majority of patients included in this sample were White (82.6%) and male (59.4%) (Table 1). More than 50% of the 350 patients were ≥75 years old at diagnosis and most of them (91%) were diagnosed by a hematologist/oncologist in an outpatient setting. The median time from first sign/symptom to bone marrow biopsy and treatment initiation were 19.3 months (interquartile range [IQR] 8.9, 44.3) and 22 months (IQR 11.4, 45.8), respectively. Of the 350 patients included in the study, 342 (97.7%) had at least 1 sign or symptom leading to HR-MDS diagnosis, with the majority of patients presenting with anemia (77.2%), followed by thrombocytopenia (66.4%), fatigue (64.3%), and neutropenia (43.3%). International Prognostic Scoring System (IPSS) scores were not documented for nearly half (43.7%) of the patients included in this chart review. Conclusions: This initial analysis highlights several challenges in the HR-MDS patient care journey, including long time intervals elapsed between first sign/symptom and bone marrow biopsy, leading to further treatment, accompanied by a relatively high absence of IPSS score documentation. These findings suggest several potential opportunities to optimize patient care, such as shortening the time from symptoms to diagnosis and time from diagnosis to treatment, utilization and documentation of IPSS score, and prompt treatment initiation. Ultimately, this program aims to utilize this Phase 1 data to identify the gaps in care and to formulate quality measures to optimize care and facilitate timely diagnosis and appropriate treatment initiation among HR-MDS patients.

Encouraging Efficacy Observed in Bexmab Study: A Phase 1/2 Study to Assess Safety and Efficacy of Bexmarilimab in Combination with Standard of Care in Myeloid Malignancies

Background Clever-1 (common lymphatic endothelial and vascular endothelial receptor-1) constitutes a novel macrophage checkpoint. The receptor contributes to immune tolerance by antigen clearing and T cell inhibition. In multiple models, tumor growth is significantly reduced when Clever-1 function is inhibited. Expression of Clever-1 on bone marrow (BM) cells is a prognostic factor for poor outcome in acute myeloid leukemia (AML) and suppression of Clever-1 signaling inhibits leukemia cell growth. Bexmarilimab (BEX), a humanized IgG4 monoclonal antibody, binds Clever-1 resulting in increased antigen presentation, secretion of proinflammatory cytokines and activation of T cells. Clever-1 is highly expressed on leukemic blasts and monocytes of AML and myelodysplastic syndrome (MDS) patients. Treatment of AML bone marrow cells with BEX alone or in combination with azacitidine/venetoclax results in enhanced antigen presentation capacity and increased activation markers on effector T cells with synergistic effect on cell death. Also, BEX treatment alone lowers blast metabolic fitness via interference with mitochondrial oxidation. The ongoing BEXMAB clinical study investigates safety and efficacy of BEX combined with standard of care (SoC) in patients with myeloid malignancies (NCT05428969). Method This is a Ph1/2 study, investigating BEX combined with azacitidine (doublet) in patients with higher risk MDS frontline or hypomethylating agent (HMA)-failed, and relapsed/refractory (r/r) AML patients. BEX is dosed Q1W in 28-day cycles until disease progression or intolerable toxicity. SoC azacitidine is administered as per label. During Ph1, BEX doses were escalated from 1.0 mg/kg to 6.0 mg/kg (Bayesian optimal interval [BOIN] design). BM was analyzed at the end of Cycle 1 and 3 followed by every three cycles. Ph2 will start with a dose optimization per malignancy followed by a dose expansion for efficacy evaluation (2-Stage design). Results Here we report data from the dose finding Ph1 of the doublet. As of 25 July 2023, 22 patients have been enrolled in the doublet (MDS n=5; MDS HMA failed n=5; r/r AML n=12). Baseline characteristics are shown in Table 1. 8/10 MDS/MDS HMA-failed patients were of high to very high risk based on rIPSS; of the r/r AML 7/12 patients had adverse risk based on ELN 2017. The median number of prior therapies for the MDS HMA-failed patients was 1 (range 1-2). The median number of prior therapies for the r/r AML patients was 2 (range 1-4) with all patients having failed prior HMA-containing therapies and 7/12 having received prior HMA plus venetoclax. The majority of observed adverse events (AE) were Grade 1-2 and no dose limiting toxicities have been reported. As of 25 July 2023, a total of 10 BEX related AEs have been reported (8% of all treatment emergent AEs) with four of these events of ≥ Grade 3, two being immune related (capillary leak syndrome and hemophagocytic lymphohistiocytosis). Sustained target engagement of soluble Clever-1 of up to 75% compared to baseline was seen at all tested dose levels in patient blood. Activity of BEX in patient BM was demonstrated using receptor binding assays with BEX treatment resulting in decreased blast Clever-1 expression at all dose levels of the doublet cohort. Increased immune activation as measured using HLA expression and T/NK cell numbers in patient BM was observed after BEX treatment across indications. Up to 2-3-fold increase of CD8 T and NK cells in the BM of BEX treated patients was observed. Preliminary efficacy shows objective responses in 8/15 evaluable patients across all tested BEX doses. Four were observed in patients with prior HMA-failure and four patients stayed on treatment > 6 months. Clinical activity for frontline MDS was seen as one complete remission (CR), marrow CR (mCR) and hematologic improvement for platelets (HI-P); for MDS with HMA failure as one CR, mCR and partial remission (PR); for r/r AML as two incomplete CRs (CRi). Based on accumulating data, responses are observed between end Cycle 1 and end Cycle 4 for all BEX doses. Conclusion Combining BEX plus azacitidine is well-tolerated and shows efficacy across indications. Additional clinical and pharmacodynamic data of the completed Ph1 of the study will be presented during the meeting. Ph2 of BEX plus azacitidine will open in the 2 nd half of 2023 in HMA-failed r/r AML and/or higher risk MDS patients.

Prognostic Value of Measurable Residual Disease in High-Risk Myelodysplastic Syndromes with Intensive Chemotherapy Treatment: Analysis of HOVON-SAKK Studies

Diagnosis of myelodysplastic syndromes (MDS) and accurate risk assessment to tailor treatment remains challenging. High-risk MDS (hrMDS) patients who are fit enough may benefit from intensive chemotherapy followed by post-remission consolidation. The HOVON-SAKK (HO) acute myeloid leukemia (AML) trials, designed to test novel drug combinations with an intensive treatment regimen, included hrMDS patients (RAEB and RAEB-T). Since these HO-trials have been executed with large patient cohorts for many years, they offer the unique possibility to study the outcome, risk classification, and relevance of measurable residual disease (MRD) in hrMDS. A pooled database is available from HOVON-SAKK of patients who were treated with intensive chemotherapy (studies containing MDS patients with IPSS ≥ 1.5 HO42A, HO81, HO92, HO102, and IPSS-R > 4.5 HO103, HO132). The database contained 3268 patients; 11% (364/3268) were hrMDS scored according to IPSS and IPPS-R. Three-year overall survival (OS) for hrMDS was 32% (standard error; SE 2%) compared to AML 46% (SE 1%). In total, 1074 AML and 75 hrMDS had reached complete remission (CR/CRi) and received a second induction cycle (C2). MRD after C2 based on multiparameter flow cytometry (Cloos et al., 2018, J. Vis.) with a cut-off of ≥0.1% for MRD positivity was assessed to evaluate the MRD status. We observed a trend of a higher MRD positivity rate for MDS compared to AML patients (MDS vs. AML: 32% (23/73) vs. 22% (232/1064), P = 0.055). Kaplan-Meier OS analysis showed a significant prognostic value of MRD in MDS, but not in the cumulative incidence of relapse (CIR) (log-rank test 0.011, Gray's test P = 0.124). Since the MDS classification has been changed, we re-classified MDS based on the ICC 2022 classification into AML, AML/MDS, and MDS. We reclassified 3035 patients at diagnosis, including 2605 AML, 258 MDS/AML, and 172 MDS. The three-year OS was 47% (SE 1%) for AML, 29% (SE 3%) for MDS/AML, and 33% (SE 4%) for MDS. After C2, 2215 patients had reached CR/CRi. A total of 1074 patients containing 984 AML, 57 AML/MDS, and 33 high-risk MDS patients with CR/CRi after C2, with a suitable bone marrow sample, were included in the MRD analysis. Most patients were treated according to HO132 (40-48%). As expected, MDS patients were older (median age, range; 60, 32-74), had lower bone marrow blast counts, and were predominantly of adverse risk. A trend of a higher proportion of MRD positivity after C2 was observed in the MDS group (33%; 11/33) as compared to AML (22%; 215/984) or MDS/AML (18%; 10/57). Three-year OS was 61% for AML (SE 1.6%), 42% (SE 6.6%), and 49% (8.7%) for AML/MDS and MDS, respectively (Figure 1A). Kaplan-Meier OS analysis and CIR showed a significant prognostic value of MRD for MDS (log-rank test P<0.001, Gray's test P = 0.015) and AML ( P<0.001; P<0.001) but not for MDS/AML patients ( P = 0.5, P = 0.342)(Figure 1B). Remarkably, the three-year OS of MRDpos in MDS was 18% (SE 12%) compared to MRDpos in AML 40% (SE 16%). The limitation of this study is the relatively small number of MDS patients according to the new ICC 2022 guidelines. In summary, MRD detection in the HOVON-SAKK trials shows the potential of MRD as a prognostic value in MDS patients treated on intensive induction regimens with a clinically validated and standardized assay.

Azacitidine Combination with Lenalidomide in Treating Higher-Risk Myelodysplastic Syndromes: A Single-Center, Phase 2 Trial

Background: Azacitidine, which works through the proteosomic destruction of DNA methyltransferase and resultant chromatin decondensation, is used primarily in patients with higher-risk myelodysplastic syndromes (MDS). Lenalidomide has been approved by the US Food and Drug Administration for the treatment of MDS patients with del(5q) cytogenetic abnormality. It has also shown activity in patients with higher-risk MDS and acute myeloid leukemia. In this trial, we assessed the efficacy and safety of combining azacytidine and lenalidomide in higher-risk MDS. Methods: This is a single-center, phase 2 trial. Aza (75mg/m 2/d on days 1-7 of a 28-day cycle) was administered in combination with lenalidomide (10 mg/day on days 1 to 21 every 28 days) for patients. The primary endpoint was the overall response rate (ORR). Secondary endpoints were overall survival (OS), progression-free survival (PFS), and adverse events (AEs). An MDS targeted-exome-seq panel including 37 driver genes was used for screening. Results: Between Oct 2020 to Apr 2023, a total of 41 MDS patients were enrolled. 32 patients were evaluable for efficacy. 23 (71.875%) responded to therapy: 7 achieved a complete response (CR) (21.875%), 12 a marrow CR (mCR) (37.5%), and 4 a hematologic improvement (HI) (12.5%), of whom 10 of the mCR patients also had a HI. The median follow-up was 5.6 months (1 to 27.4), the median overall survival (OS) was not reached, and the median progression-free survival was 12.2 months. The time to reach CR was 2 months (range, 1 to 4.5), and the median CR duration was 8+ months (range, 5 to 27.4) ( Table 1). 27 patients had at least one mutation, the most common being TET2 (n = 12), ASXL1 (n = 12), TP53 (n = 7), SRSF2 (n = 6), and RUNX1 (n = 6) ( Fig.1A). Compared with patients without mutations, CR/mCR rate was significantly higher for those with mutations in TP53 (100% v 48%; P =0 .025) ( Fig. 1B), ORR were numerically higher for those with TP53 (100% v 64%; P = 0.149) and TET2 (85% v 63%; P = 0.422) ( Fig. 1C). We also observed a reduction of VAF in TP53 and TET2 mutation after the combination treatment ( Fig. 1D & 1E). Common grade 3/4 nonhematologic adverse events included thrombocytopenia (18.75%), infection (12.5%), and febrile neutropenia (9.4%). Conclusion This trial demonstrated that the combination of azacytidine with a lenalidomide regimen is an effective therapy for higher-risk MDS patients, with high efficacy and well-tolerance. Patients with TP53 mutation appear more likely to achieve a CR/mCR.

ASXL1 mutations are associated with a response to alvocidib and 5-azacytidine combination in myelodysplastic neoplasms.

Inhibitors of anti-apoptotic BCL-2 family proteins in combination with chemotherapy and hypomethylating agents (HMA) are promising therapeutic approaches in acute myeloid leukemia (AML) and high-risk myelodysplastic syndromes (MDS). Alvocidib, a cyclin-dependent kinase 9 (CDK9) inhibitor and indirect transcriptional repressor of the anti-apoptotic factor MCL-1, has previously shown clinical activity in AML. Availability of biomarkers for response to the alvocidib + 5-azacytidine (5-AZA) could also extend the rationale of this treatment concept to high-risk MDS. In this study, we performed a comprehensive in vitro assessment of alvocidib and 5-AZA effects in N=45 high-risk MDS patients. Our data revealed additive cytotoxic effects of the combination treatment. Mutational profiling of MDS samples identified ASXL1 mutations as predictors of response. Further, increased response rates were associated with higher gene expression of the pro-apoptotic factor NOXA in ASXL1-mutated samples. The higher sensitivity of ASXL1 mutant cells to the combination treatment was confirmed in vivo in ASXL1Y588X transgenic mice. Overall, our study demonstrated augmented activity for the alvocidib + 5-AZA combination in higher-risk MDS and identified ASXL1 mutations as a biomarker of response for potential stratification studies.

Durable Responses and Survival in High-risk Myelodysplastic Syndrome and Acute Myeloid Leukemia Patients Receiving the Allogeneic Leukemia-derived Dendritic Cell Vaccine DCP-001.

Durable Responses and Survival in High-risk Myelodysplastic Syndrome and Acute Myeloid Leukemia Patients Receiving the Allogeneic Leukemia-derived Dendritic Cell Vaccine DCP-001.

Upregulation of S100A6 and its relation with CD34+ cells apoptosis in high-risk myelodysplastic syndromes patients

ObjectivesMyelodysplastic syndromes (MDS) are a group of myeloid malignancies characterized by peripheral blood cytopenia and hematopoietic dysplasia that often progress to acute myeloid leukemia (AML). Increased apoptosis of normal hematopoietic cells and decreased apoptosis of malignant clonal hematopoietic cells in patients with MDS is some of the mechanisms leading to ineffective hematopoietic cells in the bone marrow. S100 calcium-binding protein A6 (S100A6) is upregulated in many malignancies. The overexpression of S100A6 in these malignancies has been associated with proliferation, migration, and invasion phenotypes in cancer cells, and we aimed to investigate the expression of S100A6 in CD34+ cells and the relationship between S100A6 expression and apoptosis of CD34+ cells in high-risk patients with MDS. MethodsWe measured S100A6 mRNA expression in bone marrow (BM) CD34+ cells from high-risk patients with MDS using RT-PCR. Next, we examined S100A6 expression in CD34+ cells using flow cytometry. We also analyzed the correlation between CD34+ cell apoptosis and S100A6 expression in high-risk patients with MDS. ResultsOur data showed increased S100A6 mRNA expression in CD34+ cells in patients with MDS (1.05 ± 0.69 vs. 0.17 ± 0.12; P＜0.01). The expression of S100A6 in BM CD34+ cells also increased (58.40 ± 13.18 vs. 45.83 ± 15.01). The expression of S100A6 in CD34+ cells and apoptosis of CD34+ cells were negatively correlated in patients (r = −0.75; P < 0.01). ConclusionsCollectively, S100A6 may be a potential marker of CD34+ cells in high-risk patients with MDS and may participate in the pathological behaviors of CD34+ cells, such as evasion of apoptosis. Thus, S100A6 may be a potential target for eliminating minimal residual disease.

Disease Perception Is Correlated with Health-Related Quality of Life in Patients Suffering from Myelodysplastic Syndromes: Results of the Belgian Be-QUALMS Study

Patients with myelodysplastic syndromes suffer from an impaired quality of life that is only partially explained by physical symptoms. In an observational study, we aimed to investigate the impact of current MDS treatments and the influence of disease perception on quality of life. Serial measurement of health-related quality of life was performed by ‘the QUALMS’, a validated MDS-specific patient reported outcome tool. Disease perception was evaluated by means of the Brief Illness Perception Questionnaire (B-IPQ). We prospectively collected data on 75 patients that started on a new treatment and could not demonstrate a significant change in QUALMS score or B-IPQ score during treatment. Six out of eight items evaluated in the B-IPQ correlated significantly with QUALMS score. In this small sample, no significant difference in QUALMS score was found between lower vs. higher risk MDS patients or other studied variables, e.g., targeted hemoglobin showed no correlation with QUALMS score. In daily practice attention must be paid to initial formation of disease perception as it correlates independently with health-related quality of life and does not change during treatment (clinicaltrials.gov identifier: NCT04053933).

Age and sex associate with outcome in older AML and high risk MDS patients treated with 10-day decitabine

Treatment choice according to the individual conditions remains challenging, particularly in older patients with acute myeloid leukemia (AML) and high risk myelodysplastic syndrome (MDS). The impact of performance status, comorbidities, and physical functioning on survival is not well defined for patients treated with hypomethylating agents. Here we describe the impact of performance status (14% ECOG performance status 2), comorbidity (40% HCT-comorbidity index ≥ 2), and physical functioning (41% short physical performance battery < 9 and 17% ADL index < 6) on overall survival (OS) in 115 older patients (age ≥ 66 years) treated on a clinical trial with a 10-day decitabine schedule. None of the patient-related variables showed a significant association with OS. Multivariable analysis revealed that age > 76 years was significantly associated with reduced OS (HR 1.58; p = 0.043) and female sex was associated with superior OS (HR 0.62; p = 0.06). We further compared the genetic profiles of these subgroups. This revealed comparable mutational profiles in patients younger and older than 76 years, but, interestingly, revealed significantly more prevalent mutated ASXL1, STAG2, and U2AF1 in male compared to female patients. In this cohort of older patients treated with decitabine age and sex, but not comorbidities, physical functioning or cytogenetic risk were associated with overall survival.

Abstract IA09: Epigenomic landscapes of MDS

Abstract While significant progress has been made to understand the genetic landscape of MDS, less is known about the epigenetic makeup of this disease and how this may impact biology and response to azacitidine (AZA). To address this, we performed genomic, epigenomic and transcriptomic analysis on CD34+ cells from a multicenter cohort of 94 intermediate or higher risk MDS patients treated with AZA who had documented responses. DNA methylation (DNAme) by ERRBS, gene expression (GE) by RNA-seq, mutational profiling, and detailed clinical, cytogenetic and laboratory data were documented. Supervised and unsupervised analyses revealed that aberrant DNAme in MDS is not distributed randomly but rather is highly correlated with disease phenotypes, capturing clinically relevant heterogeneity, beyond what is identified by methodologies used in the past that focused solely on promoter regions. Moreover, this epigenetic information can be harnessed for the development of robust biomarkers predictive of AZA response and integrative approaches combining GE and DNAme data can further improve the predictive performance of these biomarkers, with an AUC score=0.92. Citation Format: Maria E. Figueroa. Epigenomic landscapes of MDS [abstract]. In: Proceedings of the AACR Special Conference: Acute Myeloid Leukemia and Myelodysplastic Syndrome; 2023 Jan 23-25; Austin, TX. Philadelphia (PA): AACR; Blood Cancer Discov 2023;4(3_Suppl):Abstract nr IA09.

The infusion of ex vivo, interleukin-15 and -21-activated donor NK cells after haploidentical HCT in high-risk AML and MDS patients-a randomized trial.

Clinical effect of donor-derived natural killer cell infusion (DNKI) after HLA-haploidentical hematopoietic cell transplantation (HCT) was evaluated in high-risk myeloid malignancy in phase 2, randomized trial. Seventy-six evaluable patients (aged 21-70 years) were randomized to receive DNKI (N = 40) or not (N = 36) after haploidentical HCT. For the HCT conditioning, busulfan, fludarabine, and anti-thymocyte globulin were administered. DNKI was given twice 13 and 20 days after HCT. Four patients in the DNKI group failed to receive DNKI. In the remaining 36 patients, median DNKI doses were 1.0 × 108/kg and 1.4 × 108/kg on days 13 and 20, respectively. Intention-to-treat analysis showed a lower disease progression for the DNKI group (30-month cumulative incidence, 35% vs 61%, P = 0.040; subdistribution hazard ratio, 0.50). Furthermore, at 3 months after HCT, the DNKI patients showed a 1.8- and 2.6-fold higher median absolute blood count of NK and T cells, respectively. scRNA-sequencing analysis in seven study patients showed that there was a marked increase in memory-like NK cells in DNKI patients which, in turn, expanded the CD8+ effector-memory T cells. In high-risk myeloid malignancy, DNKI after haploidentical HCT reduced disease progression. This enhanced graft-vs-leukemia effect may be related to the DNKI-induced, post-HCT expansion of NK and T cells. Clinical trial number: NCT02477787.

The value of serum IL-4 to predict the survival of MDS patients

BackgroundImmune indicators are routinely used for the detection of myelodysplastic syndrome (MDS), but these are not utilized as a reference indicator to assess prognosis in MDS-related prognostic evaluation systems, such as the World Health Organizational prognostic scoring system, the international prostate symptom score, and the revised international prostate symptom score.MethodsWe examined immune indicators, including cluster of differentiation (CD)3, CD4, CD8, CD56, CD19, interleukin (IL)-2, IL-4, IL-6, IL-10, tumor necrosis factor-a, and interferon-γ in 155 newly diagnosed MDS patients. We also conducted a correlation analysis with clinical indices.ResultsIL-4 was found to be a predictor of survival in these 155 patients using the receiver operating characteristic curve, with 5.155 as the cut-off point. Patients with serum IL-4 levels ≥ 5.155 had a lower overall survival (OS) than those with IL-45.155 at diagnosis. Furthermore, multivariate analysis revealed that IL-4 levels > 5.155 were an independent predictor of OS (hazard ratio: 0.237; 95% confidence interval, 0.114–0.779; P = 0.013). In addition, serum IL-4 expression in the three different scoring systems showed significant differences in the survival of medium- to high-risk MDS patients (P = 0.014, P < 0.001, P < 0.001).ConclusionsAccording to our study, IL-4 levels at the time of diagnosis can predict MDS prognosis in patients as a simple index reflecting host systemic immunity.

Evaluation of the outcomes of newly diagnosed patients with high-risk myelodysplastic syndrome according to the initial therapeutical strategies chosen in usual clinical practice

Myelodysplastic syndromes (MDS) are a heterogeneous group of diseases without a care standard and show variability in treatment outcomes. This Spanish, observational, prospective study ERASME (CEL-SMD-2012-01) assessed the evolution of newly diagnosed and treatment-naïve high-risk MDS patients (according to IPPS-R). 204 patients were included: median age 73.0 years, 54.4% males, 69.6% 0-1 ECOG, and 94.6% with comorbidities. Active treatment was the most common strategy (52.0%) vs. stem cell transplantation (25.5%) and supportive care/watchful-waiting (22.5%). Overall (median) event-free survival was 7.9 months (9.1, 8.3, and 5.3); progression-free survival: 10.1 months (12.9, 12.8, and 4.3); and overall survival: 13.8 months (15.4, 14.9; 8.4), respectively, with significant differences among groups. Adverse events (AEs) of ≥3 grade were reported in 72.6% of patients; serious AEs reported in 60.6%. 33.1% of patients died due to AEs. Three patients developed second primary malignant neoplasms (median: 8.2 months). Our study showed better outcomes in patients receiving active therapy early after diagnosis.

Clinical efficacy of azacytidine and venetoclax and prognostic impact of Tim-3 and galectin-9 in acute myeloid leukemia and high-risk myelodysplastic syndromes: A single-center real-life experience.

Treatment of acute myeloid leukemia (AML) and high-risk myelodysplastic syndromes (MDS) is difficult in older patients with comorbidities and high-risk disease factors. Venetoclax, the first-in-class Bcl-2 inhibitor, has proven efficacy and safety in combination with azacytidine for treatment of high-risk myeloid diseases. In this single-center real-life retrospective study, a total of 27 consecutive patients treated with azacytidine plus venetoclax were included, and clinical outcomes, hematological improvements, and biomarkers of responsiveness to therapy were compared to those observed in an historical cohort of 95 consecutive patients treated with azacytidine as single agent. Azacytidine plus venetoclax was effective and safe in older and frail AML and high-risk MDS patients, with median overall survival of 22.3months, higher than that reported in phase III trial (14.7months), and higher than that of historical cohort (5.94months). Progression-free survival was higher in patients treated with the drug combination compared to those treated with azacytidine as single agent (p = 0.0065). Clinical benefits might increase when azacytidine and venetoclax are administered as upfront therapy (p = 0.0500). We showed that Tim-3 expression could be a promising therapeutic target in refractory/relapsed patients, and galectin-9 a biomarker of responsiveness to therapy. Moreover, patients treated with azacytidine and venetoclax displayed a higher overall survival regardless the presence of negative prognostic markers at diagnosis (e.g., increased WT1 copies and/or normalized blast count). These encouraging results in a real-world setting supported efficacy and safety of azacytidine plus venetoclax as upfront therapy in AML and high-risk MDS, with clinical outcomes comparable to those of clinical trials when an appropriate venetoclax management with bone marrow assessment at every first, second, fourth, and eighth cycle, and dose adjustments for toxicities are performed.

Contingent Synergistic Interactions between Non-Coding RNAs and DNA-Modifying Enzymes in Myelodysplastic Syndromes.

Myelodysplastic syndromes (MDS) are a heterogeneous group of clonal hematopoietic stem cell disorders with maturation and differentiation defects exhibiting morphological dysplasia in one or more hematopoietic cell lineages. They are associated with peripheral blood cytopenias and by increased risk for progression into acute myelogenous leukemia. Among their multifactorial pathogenesis, age-related epigenetic instability and the error-rate DNA methylation maintenance have been recognized as critical factors for both the initial steps of their pathogenesis and for disease progression. Although lower-risk MDS is associated with an inflammatory bone marrow microenvironment, higher-risk disease is delineated by immunosuppression and clonal expansion. "Epigenetics" is a multidimensional level of gene regulation that determines the specific gene networks expressed in tissues under physiological conditions and guides appropriate chromatin rearrangements upon influence of environmental stimulation. Regulation of this level consists of biochemical modifications in amino acid residues of the histone proteins' N-terminal tails and their concomitant effects on chromatin structure, DNA methylation patterns in CpG dinucleotides and the tissue-specific non-coding RNAs repertoire, which are directed against various gene targets. The role of epigenetic modifications is widely recognized as pivotal both in gene expression control and differential molecular response to drug therapies in humans. Insights to the potential of synergistic cooperations of epigenetic mechanisms provide new avenues for treatment development to comfort human diseases with a known epigenetic shift, such as MDS. Hypomethylating agents (HMAs), such as epigenetic modulating drugs, have been widely used in the past years as first line treatment for elderly higher-risk MDS patients; however, just half of them respond to therapy and are benefited. Rational outcome predictors following epigenetic therapy in MDS and biomarkers associated with disease relapse are of high importance to improve our efforts in developing patient-tailored clinical approaches.

Abnormal platelet immunophenotypes and percentage of giant platelets in myelodysplastic syndrome: A pilot study.

Myelodysplastic syndrome (MDS) is a heterogeneous hematopoietic stem cell disorder with thrombocytopenia. Flow cytometric immunophenotyping of blood cells has been instrumental in diagnosis as co-criteria, but the data regarding platelets remains lacking. This study aims to determine if there is a difference in surface antigen levels on platelets by comparing surface antigen levels in MDS patients and healthy control subjects. Concurrently, as flow cytometric gating can reveal the diameter of cells, this study will investigate differences in giant platelet percentage by comparing these percentages in high- and low-risk MDS patients. Twenty newly diagnosed MDS patients were enrolled in this study. Platelet surface antigen levels were determined by measuring the binding capacity of antibodies with flow cytometry. Platelets of MDS patients were shown to have a lower level of CD61 and higher levels of CD31 and CD36 than healthy controls. Judged by forward scatter (FSC), MDS patients' platelets appeared to be larger than those of healthy control subjects, whereas the MFI adjusted by diameter (MFI/FSC ratio) of CD31, CD41a, CD42a, CD42b and CD61 on platelets were lower in MDS patients than in healthy control subjects. There was a significant quantity of giant platelets found in MDS patients, and the high-risk MDS patients tended to have a higher percentage of giant platelets than low-risk patients. Conclusions: All the results indicate that MDS patients exhibit a lower antigen presentation (MFI) adjusted by diameter on platelets than healthy controls and the giant platelets detected by flow cytometry might correlate with the condition of MDS.

Prognostic Role of Cleaved Caspase-3 Reflecting Apoptosis in MDS Patients

Background: Myelodysplastic syndrome (MDS) is a heterogenous, clonal disorder in hematopoiesis. Pathophysiology of MDS is not clear yet, but there is growing interest in association with cellular proliferation and apoptosis. We hypothesized that Ki-67 and cleaved caspase-3 could be prognostic markers representative of proliferation and apoptosis in MDS patients. Methods: We performed retrospective study using bone marrow samples from 76 MDS patients who was diagnosed between 2004 and 2014 at Seoul National University Hospital. We compared Ki-67 and cleaved caspase-3 to evaluate cellular proliferative and apoptotic activities using immunohistochemical testing (IHC). And we additionally analyzed Ki-67 and cleaved caspase-3 between patients with MDS, idiopathic cytopenia of undetermined significance (ICUS) and health controls (HCs) based on data previously studied. And we also compared difference according to MDS risk scoring system. Results: Cleaved caspase-3 was highest in MDS patients, followed by ICUS patients and HCs (2.70, 95% CI: 2.56-2.85 vs. 2.19, 95% CI: 1.85-2.54 vs. 1.45, 95% CI: 1.17-1.73, p < 0.001). Similarly, the mean Ki-67 grade was also highest in MDS patients, followed by ICUS patients and HCs (1.72, 95% CI: 1.55-1.90 vs. 1.58, 95% CI: 1.30-1.86 vs 1.05, 95% CI: 0.95-1.16, p = 0.001) (Figure). Higher cleaved caspase-3 grade was significantly associated with lower IPSS-R score (p = 0.020), whereas Ki-67 was not. Interestingly, TET2 mutation was associated with decreased cleaved caspase-3 levels (p = 0.030). In terms of survival, there is no significant difference according to cleaved caspase-3 or Ki-67. In addition, we divided patients with MDS into four groups: lower-risk MDS patients with lower caspase-3 levels (A group : n = 32), lower-risk MDS patients with higher caspase-3 levels (B group : n = 13), higher-risk MDS patients with lower caspase-3 levels (C group : n = 28), and higher-risk MDS patients with higher caspase-3 levels (D group : n= 2). We compared PFS and OS between the four groups and found that high-risk MDS patients with lower caspase-3 showed significantly worse PFS than the other groups (p < 0.001; A vs B, p = 0.655; B vs C, p = 0.018; A vs C, p < 0.001) Conclusion: Our results suggest that apoptotic activity gradually increases from HCs, patients with ICUS to patients with MDS. Therefore, we could predict apoptotic activity from cleaved caspase-3. In addition, higher apoptotic activity was associated with better MDS patient prognostic scores and survival outcomes. Further studies are needed to reveal the the differences in apoptotic activity between lower- and higher-risk MDS. Figure 1View largeDownload PPTFigure 1View largeDownload PPT Close modal