IPSS-R Risk Scores Research Articles

The Absolute Monocyte Count at Diagnosis Affects Prognosis in Myelodysplastic Syndromes Independently of the IPSS-R Risk Score.

The absolute monocyte count (AMC) is associated with mortality in a variety of medical conditions. Its prognostic impact in myelodysplastic syndromes (MDSs) is less well studied. Therefore, we investigated its potential prognostic value in a cohort from the Düsseldorf MDS registry in relationship to the revised international prognostic scoring system (IPSS-R). An AMC below the population's median (<0.2 × 109/L) was associated with several adverse disease features such as lower haemoglobin levels, lower count of neutrophils and platelets, and a higher percentage of blasts in the bone marrow. MDS patients with an AMC < 0.2 × 109/L had a significantly higher risk of progression into acute myeloid leukemia (AML). In a univariate, proportional hazards model the effect of the AMC as a continuous variable was modelled via p-splines. We found a U-shaped effect with the lowest hazard around 0.3 × 109/L. Accordingly, an AMC within the last quartile of the population (0.4 × 109/L) was associated with a reduced overall survival independently of IPSS-R, but not with the risk of secondary AML. Considering monocytopenia as a risk factor for AML progression in MDS may provide an additional argument for allogeneic transplantation or the use of hypomethylating agents in patients who are not clear candidates for those treatments according to current prognostic scoring systems and/or recommendations. Further studies are needed to assess the prognostic impact of the AMC in the context of prognostic scoring systems, considering the molecular risk profile, and to identify the mechanisms responsible for the higher mortality in MDS patients with a subtle monocytosis.

Efficacy and Safety of Danazol in Patients with Myelodysplastic Syndromes or Myelodysplastic/Myeloproliferative Neoplasms: A Multicenter Observational Study

Thrombocytopenia affects about two thirds of patients with myelodysplastic syndromes (MDS) and treatment is not standardized. Immunosuppressants, such as corticosteroids, cyclosporin or anti-thymocyte globulin show some efficacy, particularly in hypocellular cases, and eltrombopag was associated with a 47% PLT response. The androgen danazol may be beneficial in this setting given its anabolizing and immunomodulatory properties. In this observational multicenter study, 59 patients with MDS (53) or MDS/myeloproliferative neoplasms (MDS/MPN; 5 chronic myelomonocytic leukemia, CMML, 1 unclassified) treated with off-label danazol at 6 centers in Northern Italy were retrospectively evaluated. Response was assessed at 3-month intervals according to IWG 2018 criteria. Adverse events were registered according to CTCAE version 5. A two-tailed Fisher's exact test was used to calculate p values for differences in dichotomous variables, whereas Student's t test was used for continuous variables. Log Rank Mantel-Cox test was used for survival analysis. As shown in Table 1, patients were mainly males with a median age of 69 years (27-87), and were equally distributed between very low/low IPSS-R risk score (47%), and intermediate/higher risk (53%). Twenty percent (9/44 evaluable) of patients had a hypocellular bone marrow (<25% cellularity), and 26% (11/42) had WHO grade 2 fibrosis. All patients were thrombocytopenic (median 21 x 103/μL, range 2 - 98), 52% were anemic (median Hb 11.1 g/dL, 6.9 - 15.7), and 25% had received at least 1 red blood cell transfusion in the 8 weeks before danazol initiation. Danazol was administered for a median of 11.3 months (0.6 - 149.5) at a meandaily dose of 450 mg (range 125 - 600). Concomitant treatments were corticosteroids (34%), recombinant erythropoietin (rEPO 7%), and corticosteroids plus rEPO (3%). PLT response was obtained in 54% of evaluable patients (30/56) after a median of 3.3 months (1.3 - 24.6) from treatment start. Response was slightly higher in patients with greater baseline PLT levels (mean baseline PLT count 25 vs 19 x 103/mcL for responders vs non-responders, respectively, p 0.07), grade 0-1 fibrosis (64% response vs 27% in those with grade 2, p 0.07) and concomitant use of steroids (77% vs 45% response, p 0.06). Erythroid improvement was obtained in 7/16 (44%) patients after a median of 6.8 months (2.5 - 16.8), independently from concomitant rEPO or steroid administration. After a median of 17.2 months from initial PLT response, 78% of patients maintained it, whereas 22% relapsed. AEs occurred in 68% of cases, mainly grade 1-2, including creatinine increase (44%; 5% grade 3), transaminitis (36%), mood disorders (7%), and others. AEs required dose reduction in 11 (19%) and interruption in 4 (7%) of patients. Twenty-eight patients died during the follow up. PLT-responders had a significantly lower mortality rate compared to non-responders (10/27, 37%, vs 16/23, 70; p = 0.02) and a longer overall survival (p < 0.001, figure 1). In colcusion, danazol induced PLT response in more than half of MDS patients and erythroid improvement in 44%, including non-responders to steroids and cyclosporin, and independently of marrow cellularity. PLT response was significantly associated with a higher overall survival further suggesting a clinical impact on patient outcome. Figure 1View largeDownload PPTFigure 1View largeDownload PPT Close modal

Treatment Patterns and Overall Survival in Patients with Intermediate-Risk MDS: A Retrospective Analysis in the Spanish MDS Registry

Treatment Patterns and Overall Survival in Patients with Intermediate-Risk MDS: A Retrospective Analysis in the Spanish MDS Registry

MDS-370: Treatments and Outcomes for Patients with Myelodysplastic Syndromes (MDS) by Revised International Prognostic Scoring System (IPSS-R) Scores at the Huntsman Cancer Institute (HCI)

Context: IPSS-R is used to classify risk of disease progression and guide treatment decisions for patients with MDS. Recent data shows mutational profiling may improve the prognostic stratification of MDS. Minimal real-world evidence exists for this population. Objective: Assess treatment patterns and clinical outcomes in patients with MDS by IPSS-R risk scores. Design: A retrospective cohort study assessed real-world, patient-level data from adults diagnosed with MDS between 2010–2019 at HCI. All data were obtained from electronic medical records via chart review. Patients with intermediate to very-high IPSS-R scores comprised the higher-risk cohort. Results: Of 259 patients with MDS, 90 had an IPSS-R score at diagnosis, 65 patients who were not clinical trial participants were included. IPSS-R score distribution: 10/65 (15%) very low; 18/65 (28%) low, 14/65 (22%) intermediate, 15/65 (23%) high, and 8/65 (12%) very high. Average patient age was 68 years, 52% (n=34) of patients were female, 91% (n=59) were White, 8% (n=5) had autoimmune disorders, and 5% (n=3) had cerebrovascular disease. In the higher-risk cohort, hypomethylating agents (HMAs) were used to treat 62% (n=23) of patients (median 2 cycles), while 27% (n=10) received no MDS-directed therapy and 11% (n=4) received other MDS-related medications. Stem-cell transplant (SCT) was received more frequently (n=13, 35%) and sooner (median 4.8 months from diagnosis) by higher-risk patients compared with lower-risk patients (18%, n=5; median 15.0 months from diagnosis). Complete (CR) or partial response was achieved by 17% (n=4) of higher-risk patients treated with HMAs versus 7% (n=1) of lower-risk patients. Transfusion independence was achieved by 60% (n=3) of higher-risk and 100% (n=4) of lower-risk patients who received PLT or pRBC prior to treatment initiation. Disease progression or death occurred in 82% (n=53) of patients during the study period, with a median progression-free survival of 8.3 months and 25.3 months for higher-risk and lower-risk patients, respectively. Conclusions: These results show that higher-risk patients have a low likelihood of achieving and maintaining CR. Limited treatment options for patients with higher-risk MDS reveals a large unmet need. Specific genetic profiles may indicate the need for more aggressive treatments and management of relevant comorbidities.

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.

Prognostic impact of peripheral blood Wilms’ tumour 1 mRNA expression levels in response to azacytidine in MDS: A single-centre analysis

To determine the impact of peripheral blood (PB) Wilms’ tumour 1 (WT-1) mRNA levels in patients with primary myelodysplastic syndromes (MDS), we analysed the relationships between several clinical variables at the time of diagnosis and the haematological response of patients treated with azacytidine. We observed overall responses in 20 (63%) patients; there were no significant differences in clinical variables, including bone marrow blast counts, IPSS scores and IPSS-R risk scores, between responders and non-responders. The responders’ PB WT-1 mRNA levels were significantly lower than those of non-responders (P = 0.03). PB WT-1 mRNA expression could be a marker for predicting the response to azacytidine in patients with de novo MDS.

Mutations Based on Next-Generation Sequencing May be Complementally to Prognostic Risk in Myelodysplastic Syndromes

Objective: Established the value of somatic mutations based on next-generation sequencing (NGS) and explore factors associated with prognosis in myelodysplastic syndromes (MDS). Methods: From March 2012 to September 2019, 90 newly diagnosed MDS patients were treated and analysed by a sensitive NGS assay for mutations in 87 candidate genes and target regions. IPSSR higher risk include IPSS-R Intermediate, High, Very High subgroups (risk score &amp;gt;3.5), and IPSSR lower risk include IPSSR risk score ≤3.5. Results: A total of 90 MDS patients were recruited for this study (median age: 51.5 years; range: 16-70 years). Eighty-two (91.1%) patients harbored at least one mutation (median, 3 per patient; range, 0-11), and the most common mutations were found successively in the ASXL1 (28.9%), TP53 (21.1%), TET2 (18.9%), U2AF1 (17.8%), RUNX1 (15.6%), SETBP1 (13.3%), DNMT3A (13.3%), IDH1 (12.2%), NRAS (12.2%), KMT2D (11.1%), CBL (11.1%) and PTPN11 (11.1%) genes. The median follow-up was 32 months (range: 10-96 months). Thirty-seven (92.5%) had at least one point mutation in 40 patients with normal karyotype. ASXL1 and U2AF1 mutations had more frequently platelet levels of &amp;lt;50×109/L (P=0.047, P=0.023; respectively) and hemoglobin concentrations at &amp;lt;80 g/L (P=0.048, P=0.042; respectively). Compared with the lower risk MDS, more TP53 mutations (28% vs. 12.5%, P=0.048), RUNX1 mutations (22% vs. 7.5%, P=0.039), IDH1 mutations (18% vs. 5%, P=0.041), and IDH2 mutations (8% vs. 0, P=0.047) were found in the higher risk MDS. During the follow-up period, 37 (41.4%) patients translate to AML at a median follow-up of 24.5 months (range: 2-96 months). The median time of progress to AML from MDS diagnosis was 46 (2-96) months in MLD, 21 (2-37) months in EB1, and 18.5 (2-73) months in EB2. At 3-year follow-up, the probability of overall survival (OS) and cumulative incidence of AML transformation (CIAT) were 72.3% (95%CI 67.2%-77.8%) and 36.2% (95%CI 30.9%-41.5%), respectively. The univariate analysis results showed that ≥50 years old, IPSSR higher risk, ASXL1mutation, TP53 mutation, TET2 mutation, U2AF1 mutation, RUNX1 mutation, IDH1 mutation, IDH2 mutation, and ≥3 molecular mutations were poor factors for OS. The univariate analysis results associated with CIAT showed that IPSSR higher risk, TP53 mutation, RUNX1 mutation, IDH1 mutation, and IDH2 mutation were poor factors for CIAT.Multivariate adjust analysis showed that IPSSR higher risk, ASXL1 mutation, TP53 mutation, and RUNX1 mutation were independent prognosis factors associated with OS (HR=0.113, 95% CI: 0.093-0.199, P=0.003; HR=0.215, 95% CI: 0.103-0.623, P=0.025; HR=0.147, 95% CI: 0.084-0.506, P=0.012; HR=0.317, 95% CI: 0.122-0.661, P=0.013; respectively), and IPSSR higher risk, TP53 mutation, RUNX1 mutation, IDH1 mutation, and IDH2 mutation were independent prognosis factors associated with CIAT (HR=2.905, 95% CI: 1.155-6.312, P=0.023; HR=2.636, 95% CI: 1.024-5.023, P=0.004; HR=2.350, 95% CI: 1.043-5.789, P=0.024; HR=2.061, 95% CI: 1.036-4.078, P=0.003; HR=2.814, 95% CI: 1.073-5.359, P=0.005; respectively). Patients with mutations in one or more of the three independent survival prognostic genes (TP53, RUNX1, or ASXL1) defined as "mutation high risk" (n=48) and those without anyone of the three prognostic genes defined as "mutation low risk" (n=42). OS were significantly longer in the IPSSR both lower risk and higher risk patients with mutations low risk cohort than IPSSR lower risk patients with mutations high risk cohort (3-year OS, 95.7% vs. 47.1%, P=0.001; 79.9% vs. 47.1%, P=0.045; respectively). In the IPSSR lower risk with mutations high risk group, OS was significantly improved in the allo-HSCT cohort (3-year OS, 75.0% vs. 30.0%, P=0.042). In the IPSSR higher risk with mutations low risk group, no significant difference existed between the transplant and non-transplant arms for the probabilities of OS (3-year OS, 83.3% vs. 75.8%, P=0.972). Conclusions: Somatic mutations are common in MDS and are associated with prognosis. Mutation high risk may be complementally to IPSSR prognostic risk in MDS patients, and allo-HSCT can improved the survival in the IPSSR lower risk with mutations high risk group. Key words: myelodysplastic syndromes; somatic mutations; Prognostic dichotomization based on 3.5 of the revised international prognostic scoring system; overall survival; allogeneic stem cell transplantation. Disclosures No relevant conflicts of interest to declare.

Expression of CD47 and CALR in myeloproliferative neoplasms and myelodysplastic syndrome: Potential new therapeutical targets.

7557 Background: Myelodysplastic neoplasms (MPN) and myelodysplastic syndrome (MDS) are myeloid malignancies tendency to evolve into acute myeloid leukaemia. We investigate the expression and cellular localisation of pro-phagocytic CALR and anti-phagocytic CD47 in untreated and treated patients with essential thrombocythemia (ET), polycythemia vera (PV) myelofibrosis (MF), and in MDS patients in comparison with healthy controls. Methods: Mononuclear cells were collected by Ficoll separation, from peripheral blood of 27 MPN (8 PV, 16 ET, 3 MF); 14 MPN patients received cyto-reductive therapies (Hydroxyurea, Anagrelide or Ruxolitinib); 10 MDS patients and 4 controls. Cells were fractionised into 4 compartments: membrane, cytoplasm, cytosol and nucleus. Proteins were extracted using TRIzol, with CALR and CD47 protein expression analysed by western blotting. Results: CD47 showed higher expression of its overall protein on MPN cell membranes when compared with CALR (22% vs 13.9%). We observed a significant reduction of CALR expression in all MPN subtypes when patients were treated with cyto-reductive agents (ET- untreated 43.3% vs treated 2%, PV- 3.6% vs 2.2%, ET- 21% vs 11%). Interestingly we have observed a significant increase in CD47 cell membrane expression after treatment in MF and PV (CD47 in MF- untreated 11.8% vs treated 34.3%, PV-11.4% vs 35.9%). In MDS cells CD47 is overexpressed compared with controls (CD47- 11.31 vs 2.2 fold, respectively) and it mainly located to the membrane. Interestingly the degree of CD47 expression correlated to patients IPSS-R, increasing from low risk to high risk (low – 15.7%, intermediate 1 – 41.3%, intermediate 2 – 53.9% and high – 67.6%). CALR expression is also reduced in MDS cells comparing with controls when split by IPSS-R risk score (low – 9%, intermediate 1 – 11.9%, intermediate 2 – 17%, high – 17.9% Vs control - 29.1%). Conclusions: CD47, but not CALR, is overexpressed on the membrane of patients with MPN and MDS. In MDS, we observed a progressive increase in CD47 expression as the MDS evolve in accordance to the IPSS-R risk score. In MPN patients we observed a significant difference in CD47 expression across different MPN subtypes. The use of anti-CD47 antibodies could represent a new strategy to enhance the pro-phagocytic signal via increasing the CALR expression, and in combination with standard cyto-reduction therapy, might represent a new therapeutical strategy in both MPN and MDS.

Features and clinical significance of gene mutations in patients with myelodysplastic syndromes with ring sideroblasts

目的研究伴环状铁粒幼红细胞增多（RS）的骨髓增生异常综合征（MDS-RS）患者的基因突变特征及其临床意义。方法收集2001年1月至2019年6月于中国医学科学院血液病医院新诊断的255例原发性MDS-RS患者资料。129例采用一代测序、126例采用包含112个血液肿瘤相关基因的二代测序（NGS）进行基因突变分析。结果共193例（75.7%）检出SF3B1突变，其中SF3B1 K700E突变147例（76.2%）。非SF3B1基因突变较常见的有TET2（16.7%）、ASXL1（14.3%）、U2AF1（11.1%）、TP53（7.9%）、SETBP1（6.3%）和RUNX1（6.3%）。RS 5%～<15%患者SETBP1突变率显著高于RS≥15%患者（21.4%对4.5%，P＝0.044），其余基因突变率差异无统计学意义（P值均>0.05）。在114例NGS检出SF3B1突变的患者中，RS 5%～<15%患者SF3B1等位基因突变频率（VAF）与骨髓RS比例呈正相关（r＝0.486，P＝0.078）；RS≥15%组SF3B1突变型患者骨髓RS比例显著高于野生型患者［40.0%（15.0%～80.0%）对25.5%（15.0%～82.0%），P<0.001］，且SF3B1 VAF与骨髓RS比例呈正相关（P＝0.009，rs＝0.261）。全部患者SF3B1突变型与野生型年龄、ANC、PLT、平均红细胞体积、RS比例、IPSS-R染色体核型及IPSS-R预后分组等方面差异有统计学意义（P值均<0.05）。多因素分析显示，SF3B1突变是影响总生存（OS）时间的独立良好预后因素（HR＝0.265，95% CI 0.077～0.917，P＝0.036），TP53突变是独立不良预后因素（HR＝6.272，95% CI 1.725～22.809，P＝0.005）。根据SF3B1和TP53突变状态将MDS-RS患者分为四组：SF3B1和TP53均突变组、SF3B1和TP53均野生组、SF3B1野生伴TP53突变组及SF3B1突变伴TP53野生组，四组患者OS时间差异显著（P<0.001）。组间两两比较显示SF3B1突变伴TP53野生组OS时间显著长于SF3B1野生伴TP53突变组、SF3B1和TP53野生组，而与SF3B1和TP53均突变组比较差异无统计学意义。结论SF3B1突变在MDS-RS中的发生率较高，几乎均是错义突变，以K700E突变最为常见。SF3B1突变是MDS-RS患者生存的独立良好预后因素，TP53突变是独立不良预后因素，二者联合可更精细地指导MDS-RS患者预后分层。

Persistent Red Blood Cell (RBC) Transfusion Is Associated with Increased Mortality Risk in Transfusion-Dependent (TD) Patients with Myelodysplastic Syndromes (MDS) with Ring Sideroblasts (RS+)

Persistent Red Blood Cell (RBC) Transfusion Is Associated with Increased Mortality Risk in Transfusion-Dependent (TD) Patients with Myelodysplastic Syndromes (MDS) with Ring Sideroblasts (RS+)

Expression of CD47 and Calr in Myeloproliferative Neoplasms and Myelodysplastic Syndrome: Potential New Therapeutical Targets

Myelodysplastic neoplasms (MPN) and myelodysplastic syndrome (MDS) are myeloid malignancies characterized by either overproduction of mature blood cells or hyperplastic bone marrow and peripheral cytopenia, but both with a tendency to evolve into acute myeloid leukaemia. In solid tumours, calreticulin (CALR) overexpression produces a pro-phagocytic signal and is counteracted by concomitant expression of anti-phagocytic CD47, reflecting an apoptosis vs survival mechanism. Increases of both CALR and CD47 on the cell membrane have been observed in response to chemotherapy, however their role in myeloid malignancies is poorly understood. Aims: Investigate the expression and cellular localisation of CALR and CD47 in untreated and treated patients with essential thrombocythemia (ET), polycythemia vera (PV) myelofibrosis (MF), and in MDS patients in comparison with healthy controls. Methods: Mononuclear cells were collected by Ficoll separation, from peripheral blood of 27 MPN (8 PV, 16 ET, 3 MF); 14 MPN patients received cyto-reductive therapies (Hydroxyurea, Anagrelide or Ruxolitinib); 10 MDS patients and 4 controls. Cells were fractionised into 4 compartments: membrane, cytoplasm, cytosol and nucleus. Proteins were extracted using TRIzol, with CALR and CD47 protein expression analysed by western blotting. Results: Total CALR and CD47 protein expression increased in MPN samples compared with controls (CALR- 7.9 vs 5.1; CD47- 2.7 vs 2.2 fold, respectively). CD47 showed higher expression of its overall protein on MPN cell membranes when compared with CALR (22% vs 13.9%). We observed a significant reduction of CALR expression in all MPN subtypes when patients were treated with cyto-reductive agents (ET- untreated 43.3% vs treated 2%, PV- 3.6% vs 2.2%, ET- 21% vs 11%). Interestingly we have observed a significant increase in CD47 cell membrane expression after treatment in MF and PV (CD47 in MF- untreated 11.8% vs treated 34.3%, PV-11.4% vs 35.9%), suggesting an anti-phagocytic effect being induced by cytotoxic drugs in MF and PV cells. In ET cell membranes however, CD47 expression is reduced after cyto-reductive treatment (22% vs 16.6%), suggesting instead a prophagocytic effect. Similarly, in MDS cells CD47 is overexpressed compared with controls (CD47- 11.31 vs 2.2 fold, respectively) and it mainly located to the membrane. Interestingly the degree of CD47 expression correlated to patients IPSS-R, increasing from low risk to high risk (low - 15.7%, intermediate 1 - 41.3%, intermediate 2 - 53.9% and high - 67.6%). CALR expression is also reduced in MDS cells comparing with controls when split by IPSS-R risk score (low - 9%, intermediate 1 - 16.9%, intermediate 2 - 17%, high - 17.9% Vs control - 29.1%). Summary/Conclusion: CD47, but not CALR, is overexpressed on the membrane of patients with MPN and MDS. In MDS, we observed a progressive increase in CD47 expression as the MDS evolve in accordance to the IPSS-R risk score. This opposes previous studies in solid tumours, which showed significant increases of both CALR and CD47 as disease progresses, suggesting a role for CD47 as a strong antiphagocytic signal responsible for immune survival in MPN and MDS. All MPN patients showed decreased CALR expression during cyto-reduction therapy, but we observed a significant difference in CD47 expression across different MPN subtypes. In fact, treating MF and PV patients with cyto-reductive agents, increases CD47 expression leading to a stronger anti-phagocytic signal, while in ET we observed a reduction, suggesting a more pro-phagocytic reaction to cytotoxic drugs in ET. A larger cohort of patients is required to confirm our findings and allow a further stratification based of type of cyto-toxic drugs. The use of anti-CD47 antibodies could represent a new strategy to enhance the pro-phagocytic signal via increasing the CALR expression, and in combination with standard cyto-reduction therapy, might represent a new therapeutical strategy in both MPN and MDS. Disclosures No relevant conflicts of interest to declare.

Increased cardiovascular comorbidities in patients with myelodysplastic syndromes and chronic myelomonocytic leukemia presenting with systemic inflammatory and autoimmune manifestations

Myelodysplastic syndromes (MDS) and associated diseases, like chronic myelomonocytic leukemias (CMML), are heterogeneous, clonal disorders affecting the hematopoietic stem cells. They are characterized by dysplasia and a propensity to evolve toward acute myeloid leukemia. Systemic inflammatory and autoimmune manifestations (SIAMs) occur with a prevalence of 10% to 20% in myeloid malignancies, but the underlying pathogenetic mechanisms remain obscure. In this study, we aimed to characterize patient- and disease-based differences in MDS and CMML patients with and without SIAMs and explore the impact of SIAMs on progression and survival. We performed a retrospective, single-centre, and case-control study in a cohort of 93 patients diagnosed with MDS and CMML between 01/2008 and 12/2015. Thirty patients (32%) were identified with SIAMs: musculoskeletal and connective tissue (26.8%), vascular (19.5%), systemic autoinflammation (17%), skin (12.2%), gastrointestinal (9.8%), and others (14.6%). SIAMs were treated with glucocorticoids (60%), methotrexate (16.7%), biologicals (13.3%), and cyclosporine (3.3%). No significant differences between the SIAM and non-SIAM patients were observed in age, gender, or previous exposure to cancer treatment. Cardiovascular comorbidities were significantly more frequent in patients with SIAMs (63.1% vs 90%; OR 5.5; P < .01), but no differences were observed for other comorbidities or IPSS and IPSS-R risk scores. CMML and refractory anemia with excess blasts 1/2 subtypes were by tendency more frequent in patients with and refractory cytopenia with multilineage dysplasia (RCMD) in those without SIAMs. Finally, time to progression, leukemia free survival and overall survival were similar for both groups. Despite patient heterogeneity and small cohort size, we were able to identify a significant association of SIAMs with cardiovascular comorbidities but without influence on progression or survival.

The prognostic value of monosomal karyotype (MK) in higher‐risk patients with myelodysplastic syndromes treated with 5‐Azacitidine: A retrospective analysis of the Hellenic (Greek) Myelodysplastic syndromes Study Group

In this study, we investigated the incidence and prognostic impact of monosomal karyotype (MK) in 405 higher-risk Myelodysplastic Syndromes (MDS) patients treated with 5-AZA. The MK was present in 66 out of 405 (16.3%) patients, most of whom had complex karyotype (CK). MK was strongly associated with CK and the cytogenetic risk defined according to IPSS-R, as well as with high-risk disease, according to IPSS (P = .029), IPSS-R (P < .001), and WPSS (P < .001) classification systems. The overall response rate (ORR) was not different between MK+ and MK- patients (46.6% vs. 46.2%). At 28 months median follow-up, the median duration of response was 11 months in the entire cohort, 9.5 months in MK+ patients and 11 months in MK-patients (P = .024). The estimated median time to transformation to acute myeloid leukemia for MK+ patients was 17 months vs. 23 months for MK- patients (P = .025). The estimated median OS for MK+ patients was 12 months vs. 18 months for MK- patients (P < .001). Multivariate Cox regression analysis revealed that performance status (P < .001), IPSS-R (P < .001), and MK (P = .002) were independently associated with overall survival (OS). In a subgroup consisting of high and very-high risk patients according to IPSS-R, MK- patients showed better OS rates compared to MK+ patients (estimated median OS: 17 months vs. 12 months, P = .002). In conclusion, we found that MK is associated with reduced OS in patients with higher-risk MDS treated with 5-AZA. Furthermore, we showed that in MDS with high or very-high IPSS-R risk score, MK can further distinguish patients with worse outcome.

BCOR and BCORL1 mutations in Myelodysplastic Syndromes (MDS): Clonal Architecture and Impact on Outcomes

BackgroundSeveral recurrent somatic mutations have been identified in MDS and these mutations play an important role in disease pathophysiology and outcome. BCOR and BCORL1 are located on chromosome X and interact with histone deacetylases and other cell functions. The BCOR gene is mutated (BCORMUT) in 4-6% of MDS patients (pts) and is associated with poor outcome. BCORL1 mutations (BCORL1MUT ) are present in <1% of MDS pts with an unknown impact on OS. We investigated the clonal architecture of BCOR and BCORL1 in MDS and the impact of these mutations on clinical outcome.MethodsWe sequenced DNA samples from pts with MDS and related myeloid malignancies (MDS/myeloproliferative neoplasms (MPN) and secondary AML) for the presence of BCOR and BCORL1 mutations and 58 other genes that have been described as recurrently mutated in myeloid malignancies. The Revised International Prognostic Scoring System (IPSS-R) was calculated as descried previously. Overall survival (OS) was measured from the time of diagnosis to time of death or last follow up. Variant allele frequencies (VAFs) adjusted by zygosity were used to define architecture of driver clones.ResultsOf 621 included MDS pts, 29 (5%) had BCOR mutations and 13 (2%) had BCORL1 mutations. Patients with BCOR mutations were younger (median age 63 vs. 68 years, p= .04), and had a lower platelet counts at diagnosis (63 vs. 93 109/L, p = .01) compared to BCORWT pts. Cytogenetic risk categories per IPSS-R for BCORMUT was similar to BCORWT: very good 3% vs. 2%, good 65% vs. 62%, intermediate 10% vs. 17%, poor 13% vs. 7% and very poor 6% vs. 9%, respectively, p = .62). Risk categories per IPSS-R were also similar for BCORMUT compared toBCORWT:very low 10 vs. 16%, low 31 vs. 40%, intermediate 24 vs. 18%, high 17 vs. 14%, and very high 13 vs. 10%, respectively, p = .69). BCOR mutations were missense in 9 pts (31%), frameshift insertion/deletion in 10 (34%), stopgain in 8 (28%), and nonsense in 2 (6%). BCOR is commonly co-mutated with ASXL1 (p=.008), RUNX1 (p= .0001), NF1 (p =.002), ETV6 (p =.026), BCORL1 (p =.0001), MECOM (p =.021), RAD21 (p =.021), and CEBPA (p = .0001). Clonal architecture analysis identified BCOR mutations as ancestral, subclonal, and mosaic in 41%, 21% and 38% of cases respectively. The median OS for BCORMUT pts was 24.5 months compared to 17.9 months for BCORWT, p = .23). The impact of BCOR mutations on OS was neutral even after adjustment for age and IPSS-R risk categories.Pts with BCORL1MUT had lower WBC counts (median 2.7 vs. 4 109/L p = .02), and lower platelets counts at diagnosis (72 vs. 91 109/L, p = .02) compared to BCORL1WT pts. In cytogenetic analyses, BCORL1MUT was associated with a higher incidence of very good cytogenetics per IPSS-R (15% vs. 2%, p =.001). Further, BCORL1MUT were more likely to be classified in the intermediate risk group per IPSS-R (46 vs. 18%, p = .01) and less likely to be classified in the low risk group (7 vs. 40%, p = .01) compared to BCORL1WT. BCORL1 mutations were missense in 7 patients (53%), frameshift insertion/deletion in 3 (23%), stopgain in 1 (7%), and nonsense in 2 (15%). BCORL1 is commonly co-mutated with TET2 (p =.001), BCOR (p <.001) DHX29 (p = .001), C7orf55 (p =.02), and FLT3 (p =.03). Clonal architecture analysis identified BCORL1 mutations as ancestral, subclonal, and mosaic in 61%, 23% and 15% of patients respectively. The median OS for BCORL1MUTpts was longer compared to BCORL1WT, but was not significantly different (43.8 vs. 19.9, respectively, p = .16) even after adjustment for age and IPSS-R risk categories.ConclusionBCOR and BCORL1 mutations occur with low frequency in MDS. These mutations can be ancestral or subclonal. The impact of BCOR mutations on OS was neutral even after adjustment for age and IPSS-R risk scores. Although the median OS for pts with BCORL1MUT was longer compared to BCORL1WT,it was not statistically significant. A larger pt population with BCOL1 may show a positive impact of these mutations on OS. DisclosuresMukherjee:Celgene: Consultancy, Honoraria, Research Funding; Novartis: Consultancy, Honoraria, Research Funding; Ariad: Consultancy, Honoraria, Research Funding. Advani:Blinatumomab: Research Funding; Pfizer Inc.: Consultancy, Research Funding. Sekeres:Millenium/Takeda: Membership on an entity's Board of Directors or advisory committees; Celgene: Membership on an entity's Board of Directors or advisory committees.

Aberrant Patterns of Alternative Splicing Are Frequent Events and Harbor Prognostic Significance in Patients with Myelodysplastic Syndrome

▪BackgroundAberrant patterns of alternative splicing (AS) are reported in acute myeloid leukemia and other malignances, but have not yet been investigated in myelodysplastic syndrome (MDS). In addition, mutations in spliceosome genes are especially common in MDS. Therefore, it would be highly interesting to analyze the clinical and biological significance of aberrant AS in MDS.Materials and MethodsA total of 243 newly diagnosed MDS patients, including 78 with refractory anemia (RA), 22 with RA with ring sideroblasts(RARS), 76 with RA with excess blasts (RAEB), 24 with RAEB in transformation (RAEBT), and 43 with chronic myelomonocyticleukemia (CMMoL), who had complete clinical and genetic information were enrolled. We also included 20 healthy donors of hematopoietic stem cell transplantation for comparison. We extracted RNA from mononuclear cells (MNC) isolated from the bone marrow (BM), followed by hybridization on the microarrays of AffymetrixHuman Transcriptome Array 2.0, which contained > 6 million distinct probes covering coding, non-coding transcripts, and the exon-exon junctions among 67539 genes (44710 coding genesand 22829 noncoding genes). This comprehensive coverage of exons and junctions facilitated investigation of the splicing patterns of the genes. The aberrant AS was analyzed with the splicing index (SI) method using the default setting of AffymetrixTranscriptome Analysis Console version 3.0 software. The SI of a probe in a gene was derived from the ratio between MDS patients and normal controls in terms of the probe intensity divided by the gene expression level, ie. [intensityof probe A in gene A /gene A expression level]MDS/[intensity of probe A in gene A /gene A expression level]normal control. SI had to be less than -2 or more than 2 to be defined as an aberrant AS event.ResultsTotally 52730 of 67539 genes (78.1%) on the array were expressed in BM from both MDS patients and normal donor controls. Approximately 17565 of the 52730 expressed genes (33.3%) were differentially spliced between the MDS and normal marrow MNC (P < 0.05). As a whole, 88.9% of these aberrant spliced events were mapped to coding genome and 11.1% to noncoding regions. These aberrant AS exons fell into five common patterns, including exon skipping (57.8%), alternative donor sites (18.1%), alternative acceptor sites (17.8%), intron retention (5.6%) and mutually exclusive exons (0.7%). In average, when compared with the normal marrow MNC, there were 6.4 (4.8-12.0) more aberrant AS events in each AS gene (ASG) in the marrow MNC of 243 MDS patients.More aberrant AS events per ASG implied a more complex aberrant AS pattern.The numbers of aberrant AS events per ASG were not significantly associated with MDS subtypes and frequencies of spliceosome gene mutations. However, with a median follow up of 48.4 months, the patients with more aberrant AS events per ASG had a trend of shorter overall survival (OS) (median 20.1 vs 29.6 months, P=0.074) and a trend of shorter time to acute leukemic transformation (P=0.212) than the others (Fig.1). Further subgroup analysis showed a significantly shorter OS in the patients with more aberrant AS events per ASG than those with less events among RAEB patients (median OS: 10.8 months vs 16.9 months, P=0.007, Fig.2A). In addition, RA patients with more aberrant AS events per ASG had shorter time to acute leukemic transformation than RA patients with fewer aberrant AS events per ASG (P=0.006, Fig.2B). Among the patients without detectable mutations in spliceosome genes or genes related to epigenetic modification, those with more aberrant AS events per ASG also had a shorter OS than the others (median OS: 27.9 months vs not reached, P=0.013, Fig.3). Multivariate analysis in our cohort of 243 MDS patients revealed that higher aberrant AS events per ASG was an unfavorable prognostic factor for OS (P=0.016) independent of age, IPSS-R risk score, and mutations of SF3B1, ASXL1 and TP53.ConclusionTo our knowledge, we are the first to present the prognostic impact of aberrant AS pattern in MDS patients. Large prospective cohorts are needed to confirm our observations. [Display omitted] DisclosuresNo relevant conflicts of interest to declare.

Disease characteristics and prognosis of myelodysplastic syndrome presenting with isolated thrombocytopenia.

Patients with myelodysplastic syndrome (MDS) who present with isolated thrombocytopenia (TCP) constitute a poorly described subgroup. The aim of the present study was to retrospectively evaluate disease characteristics and prognosis in patients with MDS and isolated TCP at a tertiary care center. Fifty patients (12%) had isolated thrombocytopenia as the first presentation of MDS. Patients had varying MDS sub-classifications and cytogenetic profiles. The most common IPSS-R risk score was low (n=24), although half of the patients had either IPSS-R intermediate (n=18), high or very high risk disease (n=7). Leukemic transformation occurred in 10 patients and there were 14 deaths (28%) amongst all IPSS-R risk scores. Therapeutic agents used in this patient subgroup included hypomethylating agents and thrombopoietin receptor agonists. Overall, MDS with isolated TCP did not appear to have an inherently indolent course, as has been suggested previously. Future studies are needed to improve risk stratification, identify relevant contributors to disease pathogenesis, and better define treatment modalities.

Iron Chelation Is Associated with Improved Survival Adjusting for Disease and Patient Related Characteristics in Low/Int-1 Risk MDS at the Time of First Transfusion Dependence: A MDS-CAN Study

Iron Chelation Is Associated with Improved Survival Adjusting for Disease and Patient Related Characteristics in Low/Int-1 Risk MDS at the Time of First Transfusion Dependence: A MDS-CAN Study

Differences In Community and Academic Practice Patterns For Newly Diagnosed Myelodysplastic Syndromes (MDS) Patients In Minnesota: A Population Based Study

IntroductionExpanding treatment options for MDS have changed therapeutic decision-making for clinicians. To better characterize therapeutic choices in newly diagnosed MDS, we report the practice patterns captured during the first year of MDS diagnosis for patients enrolled in our statewide population-based study. We highlight a comparison of treatment in community and academic centers. MethodsAdults in Minnesota with MDS (AIMMS) is a statewide prospective population-based study conducted by the University of Minnesota (UMN), Mayo Clinic, and Minnesota Department of Health. Starting in April 2010, all newly diagnosed adult cases (ages 20+) of MDS were invited to participate. After patient enrollment, central review was performed consisting of independent hematopathology and cytogenetic review coupled with oncologist chart review assigning prognostic risk scores [International Prognostic Scoring System (IPSS) and IPSS-R (Revised)] and abstracting treatment exposures. All enrolled patients with one year follow-up were included in this analysis. Treatment was divided into supportive, active, transplant, or other. Supportive care included observation, growth factors, and transfusions. Active care included azacitidine, decitabine, lenalidomide, or 7+3 chemotherapy. Academic centers were defined as the UMN and Mayo Clinic; all other centers were designated as community based practices. ResultsThe median patient age was 73 years, with 68% males. IPSS and IPSS-R risk scores were calculated for 100% and 97% of patients, respectively.Treatment choices stratified by IPSS risk group showed 89% low risk, 53% INT-1, 31% INT-2, and 13% high risk with supportive care; active and transplant strategies were utilized for 9% low risk, 44% INT-1, 64% INT-2, and 88% high risk. INT-1 in the community received 70% supportive treatment, in academic 35%. Active treatment for INT-1 was 30% in community and 45% in academic. Community INT-2 received supportive care in 45% of cases, in academic 23%. Transplants were limited to academic centers, with the highest rate in INT-2 at 34%.Among community diagnoses, 100% of high risk, 52% INT-2, 26% INT-1, and 13% low risk were referred to an academic center. Comparison of age <65 and 65+ years showed 83% of transplants occurred in those <65. INT-2/high risk group patients <65 received 95% active therapy or transplant, compared to 51% of those 65+. DiscussionThis prospective, population based study provides a well-defined patient cohort based on central review of pathologic and clinical data. Evaluation of practice patterns during the first year after diagnosis showed higher utilization of active and transplant treatment strategies as IPSS risk score increased. Further, compared to community, higher utilization occurred for patients at academic centers, suggesting more aggressive treatment in these settings. Age was also a predictor of treatment choice. In addition, referral patterns followed IPSS score. Whether these treatment differences are driven by patient preference and/or translate into improved disease control and decreased mortality requires continued prospective analysis and will be detailed in future reports. DisclosuresNo relevant conflicts of interest to declare.

CD271+ Mesenchymal Stromal Cell Density Is High In Poor-Risk MDS and Independently Predicts Overall Survival

IntroductionWe have previously shown that CD271+ MSC density is increased in MDS; that MDS MSCs overexpress a key chemokine, CXCL12; and that CD271+ MSCs are in direct contact with CD34+ progenitors (Lab Invest. 92:1330), suggesting an active role for CD271+ MSCs in MDS biology. Amid increasing evidence of a role for MSCs in the hematopoietic stem cell niche and in myeloid neoplasia, we present a retrospective study of CD271+ MSC density in diagnostic bone marrow core biopsies of cytopenic patients with and without MDS. MethodsTissue microarrays (TMAs) were constructed using duplicate 1mm cores of the bone marrow core biopsy. Immunohistochemistry with anti-CD271 was visualized in red against hematoxylin counterstain. A CD271 density scoring schema (CD271Score) was developed: 1, scattered; 2, loose or partial network; 3, prominent uniform network involving >75% of core. Automated quantitation of CD271 density as % hematoxylin+ marrow (CD271Quant) was performed on 40x photomicrographs using CellProfiler 2.0 (www.cellprofiler.org). ResultsThe patient population (Table 1) was divided into diagnostic categories of benign (B9, n=61), low grade MDS (LGMDS, <5% marrow blasts, n=40), and high grade MDS (HGMDS, ≥5% marrow blasts and/or therapy-related, n=24). CD271 density varied with diagnostic category (Figure 1, X2 = 10.6, p = 0.0051 for CD271Score; X2= 8.0, p = 0.018 for CD271Quant). High CD271 density was overrepresented in the HGMDS group; in two-way comparisons, B9 and LGMDS differ from HGMDS but not each other (B9 vs HGMDS, X2 = 10.1, p = 0.0015 for CD271Score and X2 = 7.7 p = 0.0056 for CD271Quant; LGMDS vs HGMDS X2 = 2.5, p = 0.11 for CD271Score and X2 = 5.4, p = 0.021 for CD271Quant). Among patients with MDS, CD271 density also correlated with poorer risk as assessed by IPSS-R (Spearman's rho = 0.32, p = 0.019 for CD271Score; Spearman's rho = 0.28 p = 0.037 for CD271Quant). CD271Score was reproducible (intraobserver kappa value 0.72, p < 0.0001) and correlated with CD271Quant (Spearman's rho = 0.68, p < 0.0001). [Display omitted] Regarding the impact on overall survival (OS), univariate Cox regression confirmed the expected predictive value of IPSS-R (p<0.001); red blood cell transfusion within 3 months prior to diagnosis (p<0.001); and therapy-related MDS subtype (trend, p = 0.11). Kaplan Meyer plots revealed shorter OS in the high CD271Score category (Figure 2) and in the upper quartile of CD271Quant. On univariate Cox analysis, normalized CD271Quant (p = 0.037) but not CD271Score was statistically significant. Much of the effect on OS appeared to be in the upper quartile of CD271 density (HR 3.0, p = 0.023 for highest versus lowest quartile of CD271Quant). In the multivariate Cox proportional hazards model, normalized CD271Quant remained statistically significant (p=0.027) together with IPSS-R (p<0.001) and transfusion requirement (p=0.001). Median follow-up of MDS patients OS was 21.4 months (range, 1 day to 115 months) with 34 deaths among 64 patients. [Display omitted] ConclusionsIn the intact bone marrow core biopsy, a dense CD271+ MSC network, as assessed by two separate techniques (morphologic scoring by a pathologist or quantitation through automated image analysis), is associated with higher-risk diagnostic categories of MDS (refractory anemia with excess blasts, therapy-associated MDS) and with poor IPSS-R risk scores. Quantitative CD271+ MSC density is also associated with poorer OS, both on univariate analysis and in a Cox proportional hazards model including IPSS-R, transfusion, and therapy-related disease. Increased CD271+ MSC density may reflect an abnormal positive feedback loop between the myeloid clone and its dysfunctional mesenchymal niche. Disclosures:No relevant conflicts of interest to declare.