Myelodysplastic Disorders Research Articles

Co-existence of Myelodysplastic Disorders and Plasma Cell Neoplasms: Case Series

Abstract Introduction/Objective The development of myelodysplastic syndrome (MDS) in patients with plasma cell neoplasm (PCN) receiving treatment is well reported. However, co-occurrence of both, without any chemotherapy history, is sparsely documented in the literature. We aim to highlight the possible association between both. Methods/Case Report Database search was done using Epic Slicer-Dicer for cases with biopsy proven co-existing MDS and PCN (from 2010-2022). The patients’ charts were reviewed to collect and analyze the clinical features. Results (if a Case Study enter NA) We identified 3 patients, all in their seventies on presentation: First patient: man, presented with unexplained chronic anemia. Serum protein electrophoresis (SPEP) showed elevated levels of monoclonal IgG kappa (4.2 g/dl). Evaluation of the BM biopsy revealed MDS with low blasts (WHO-5) with IgG plasma cell myeloma (56% Kappa-restricted plasma cells). Chromosome analysis revealed normal karyotype. Molecular studies were not done. Second patient: man, with Rheumatoid Arthritis and anemia. SPEP revealed biclonal IgG lambda (2.0 g/dl). BM biopsy indicated 5-8% lambda-restricted plasma cell proliferation. Anemia was managed with darbopoetin, but without improvement. The patient did not get chemotherapy. Follow-up BM biopsy was done, showing MDS with low blasts and ringed sideroblasts (WHO-5) alongside the PCN. FISH showed two abnormal IGH rearrangement populations. Chromosome analysis revealed normal karyotype. Molecular studies were not done. Third patient: woman, with pancytopenia. SPEP indicated monoclonal protein IgG lambda (1.8 g/dl). BM biopsy revealed 10% lambda-restricted plasma cell proliferation, coexisting with MDS with increased blasts grade 2 (WHO-5). Molecular studies showed: 2-FLT3 L601_K602insNFREYEYDL and ASXL1 E635fs*15. Chromosome analysis revealed normal karyotype. No in common clinical findings found during chart reviewing the cases. Conclusion Further investigating the underlying pathology, bone marrow microenvironment, and molecular and cytogenetics abnormalities in a larger number of patients with co-existing MDS and PCN is important. Also, if there was an association, it is important to study the sequence of occurrence between them.

Some characteristics of blood cells and bone marrow of myelodysplastic disorders patients with del(5q) at Bach Mai hospital in 2021 to 2023

Some characteristics of blood cells and bone marrow of myelodysplastic disorders patients with del(5q) at Bach Mai hospital in 2021 to 2023

A rare coexistence of Kaposi s sarcoma and myelodysplastic syndrome in an immunocompetent patient A fortuitous association

Kaposi's sarcom is an angiogenic tumor related to the Human Herpes Virus 8 . Its association with myelodysplastic syndrome had been rarely reported in the literature. Herein, we relate a case of coexistence of KS and MDS in a human immunodeficiency virus negative female patient, which is to our knowledge the fourth reported in the literature. Some data suggest that viral agents might be involved in the pathogenesis of MDS. The HHV8 is a virus with tropism for hematopoietic cells and expression of transforming viral genes that may affect cell proliferation and thus cause the trigger of myelodysplastic disorders. However, other studies on larger populations are necessary to determine the causal correlation between these two disorders.

Uncovering the Exclusivity of Diversity in Clinical Trial Participation

INTRODUCTION: Over the past several years, grant funding opportunities and clinical trial recruitment efforts have increasingly focused on enhancing the inclusion of diverse patient populations. Many define diversity as the inclusivity of people of different races, ethnicities, ages, genders, and socioeconomic backgrounds, while few studies have examined religious inclusivity in clinical trial participation. Our research sought to determine if religious exclusivity poses a barrier to clinical trial participation for Jehovah's Witnesses, whose core beliefs prohibit them from receiving certain blood products. The barriers for this group include provider misconceptions and unconscious bias about their ability to participate in research and investigators' concerns related to skewed data for patients unable to be transfused. METHOD: A clinical trial between November 2015 and April 2016 aimed to evaluate a blood substitute for adults with profound anemia unable to be transfused due to personal reasons or alloimmunization was analyzed to determine the percentage of eligible patients enrolled compared to the national average of 5%. The second aspect of our research was to determine how many patients with myeloid malignancies require transfusion support in general, as we believe this is a significant barrier that may be an unjustified inclusion criterion in many trials. This was conducted through an electronic search of our Electronic Medical Record (EMR) system to identify patients with primary myeloid malignancy diagnoses who were treated within our hematology oncology practice within the last seven years and required a blood transfusion. RESULTS: In the first analysis to determine the willingness of Jehovah's Witnesses to participate in a clinical research trial, 100% of the patients who were approached for participation (N=26) signed informed consent and were enrolled in the trial. Many of these patients were amenable to traveling long distances for this opportunity. Throughout these informed consent discussions, it was evident to the consenting physician that none of these patients were ever approached to participate in clinical trials. In the second portion of our research, from August 2017 through August 2022, 184 patients were identified as being treated for myeloid malignancies. Diagnoses included myelodysplastic disorders, chronic lymphocytic leukemia, chronic myelocytic leukemia, and acute myeloid leukemia. Only 37.5% of these patients required a blood transfusion of red cells or platelets, and 16% enrolled in therapeutic interventional clinical trials throughout that timeframe. CONCLUSION: Religion is an unacknowledged aspect of diversity by the medical community and poses an unnecessary barrier to clinical trial participation for certain religious groups. Our results identify a significant disparity in access to clinical trials for patients with myeloid malignancies where the inability to transfuse due to religious convictions is a common concern. Our pilot study's high clinical trial enrollment highlights that Jehovah's Witnesses are motivated to seek and receive the best medical care available when provided the opportunity. Inability to transfuse may not impact clinical trial results, especially as treatment options move away from cytotoxic agents to less myelosuppressive targeted therapies. Strategies to increase religious diversity should include better education of providers regarding religious restrictions and efforts made to accommodate patients by removing unnecessary eligibility criteria within trial designs. Potential religious barriers to clinical trial participation are not exclusive to Jehovah's Witnesses; practitioners of Hinduism, Judaism, and Islam should also be considered, especially given religious beliefs related to the use of animal products. Other barriers include strict clinical research scheduling, which may need to adapt to accommodate religious holidays and prayer times. We believe future clinical trial participation and efficacy will drastically increase by implementing the above strategies. Future research should examine providers' unconscious bias in approaching patients with known religious backgrounds about clinical trial opportunities. These actions are necessary to allow providers to successfully resolve the religious exclusivity of diversity initiatives in clinical trial participation.

P773: THE ELEVATION OF RED BLOOD CELL DISTRIBUTION IS AN INDEPENDENT PROGNOSTIC FACTOR FOR JUVENILE MYELOMONOCYTIC LEUKEMIA

Background: Juvenile myelomonocytic leukemia (JMML) is an overlapping myeloproliferative and myelodysplastic disorder of infants and early children. The existing clinical and laboratory prognostic features are inadequate to predict a worse outcome alone. New prognostic indicators are urgently needed since the great clinical heterogeneity. Red cell distribution width (RDW) is a parameter of the complete blood count (CBC) measured automatically by haematology analyzers to reflect the heterogeneity of erythrocyte size. In recent years, RDW has been suggested to have a high negative value for outcomes in various cancers. However, the role of RDW at diagnosis in patients with JMML is still unclear. Aims: Our aim is to investigate the prognostic role of RDW in children with JMML. Methods: We conducted a single center retrospective study to investigate the prognostic role of RDW in children with JMML. Seventy-seven patients were enrolled from January 1, 2008 to November 31, 2019. Survival rates were calculated and compared using Kaplan-Meier methods and log-rank tests. Univariate and Multivariate analysis was carried out according to the Cox proportional hazard regression model. Results: The mean red cell distribution width standard deviation (RDW-SD) for patients is 53.3(39.3-73.7) fl. Cox proportional hazard models showed that patients with RDW-SD >50.50fl at diagnosis were significantly associated with poor overall survival (OS) (HR = 5.22, CI = 1.50-18.21, P=0.010). The multivariate analysis demonstrated that the RDW-SD count was the independent risk factor for OS. Patients with PTPN11 mutation and RDW elevation displayed the worst survival rate, in comparison with other subgroups (P=0.00013). Summary/Conclusion: The results suggested that the elevated level of RDW is an independent prognostic factor for JMML. Furthermore, the PTPN11 mutation and a high RDW level may involve a synergy during the natural course of JMML.

Bone marrow ring sideroblasts in hematological diseases: an analysis of consecutive 1300 samples in a single institution.

The incidence of MDS-RS in Japan has been recognized as about 5% which is lower than that in European countries. Insufficient use of iron staining tests in Japan has been noted as one conceivable factor contributing to this apparently lower prevalence. To investigate this issue, we analyzed the proportion of ring sideroblasts (RS) in 1300 bone marrow samples from patients with hematological diseases at Kitasato University Hospital, including iron staining of all samples. Sixteen of 96 patients with MDS (16.7%) were diagnosed with MDS-RS, and this accounted for 26.2% of MDS without excess blasts. Some MDS-EB (22.9%) and AML-MRC (13.8%) patients also had ≥ 15% RS. In contrast, RS were rarely found in myeloid neoplasms without dysplasia and non-myeloid diseases: only 1 in 46 (2.2%) patients with AML without dysplasia, 2 in 93 (2.2%) with MPN, and 8 in 984 (0.8%) with non-myeloid diseases had ≥ 5% RS. These results indicate that prevalence of MDS-RS in Japan may be higher than conventionally recognized and that RS are principally restricted to myelodysplastic disorders. Further multicenter studies using consecutive bone marrow samples with iron staining tests will be required to confirm our findings.

A Severe Form of COVID-19 in an Infant with Underlining Undiagnosed Acute Myeloid Leukemia

The new global pandemic of coronavirus disease 2019 (COVID-19) is caused by the novel coronavirus designated as severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). It was first identified in December 2019, in an outbreak of respiratory illness of unknown in China. The virus spread rapidly all over the world, and on March 11, 2020 the World Health Organization (WHO) declared COVID-19 a global pandemic. Although childhood COVID-19 cases appeared early in the outbreak, the disease burden in children is far less than in adults. The clinical presentation in adults ranges from mild illness to severe pneumonia, acute respiratory distress syndrome, acute cardiac failure, and thromboembolic complications. Children experience critical illness far less than adults with lesser degree of admission to the intensive care unit and mortality. Here is reported the case of an 8-month infant who was admitted for a severe form of COVID-19 and contemporaneously was discovered an underlining, unknown before, myelodysplastic disorder. Concerning a child with severe form of COVID-19, a high index of suspicion should be maintained towards underling diseases which compromise the immune system such as the case of acute myeloid leukemia.

The KDM5 Family of Histone Lysine Demethylases Are Targets of R-2-Hydroxyglutarate in IDH Mutant Tumors

Gain-of-function mutations in isocitrate dehydrogenase enzymes IDH1 and IDH2 occur in ∼10% of acute myeloid leukemias (AML) and >80% of gliomas. The mutant enzymes convert 2-oxoglutarate (2OG) to the oncometabolite R-2-hydroxyglutarate (R-2HG). R-2HG promotes cellular transformation by modulating the activities of 2OG-dependent dioxygenases (2OGDDs). The only functionally validated direct target of R-2HG is TET2, a 2OGDD myeloid tumor suppressor that catalyzes the conversion of 5-methylcytosine (5mC) to 5-hydroxymethylcytosine (5hmC).Interestingly, in clonal myeloid disorders the patterns of IDH and TET2 mutations are vastly different. TET2 mutations occur at similar frequencies in clonal hematopoiesis of unknown significance (CHIP), lower- and higher-grade myeloproliferative (MPN) and myelodysplastic (MDS) disorders, and primary and secondary AML. IDH mutations, on the other hand, are associated with higher-grade and blast-phase MPN and MDS and with de novo AML and are rare in CHIP and low-grade MDS. This suggests that mutant IDH promotes a more aggressive disease phenotype and that R-2HG has additional targets other than TET2 that contribute to its leukemogenic activity.To ask if the in vitro transforming activity of R-2HG directly correlates with TET2 inhibition, we treated TF-1 cells, a cytokine-dependent human AML cell line, with a dose range of cell-permeable esterified R-2HG. We found that R-2HG induces cytokine independence at concentrations that have no effect on 5hmC levels. To identify other 2OGDD myeloid tumor suppressors that could be contributing to R-2HG-mediated transformation, we performed a positive-selection CRISPR-Cas9 screen under cytokine-poor conditions in TF-1 cells. We identified three H3K4 histone lysine demethylases, KDM5A, KDM5C and KDM5D, as genes whose sgRNAs were enriched upon cytokine withdrawal. Triple knockout of KDM5A, KDM5C and KDM5D (TKO) in TF-1 cells induces robust cytokine independence. Likewise, treatment of TF-1 cells with KDM5c70, a specific inhibitor of KDM5 enzymes, strongly induces TF-1 cytokine independence. Of note, KDM5 inhibition has no effect on TET2 expression or 5hmC levels. We further found that R-2HG is a more potent inhibitor of KDM5A, KDM5C and KDM5D than of TET2. We then assessed the effect of mutant IDH1 expression, TKO, R-2HG treatment and KDM5c70 treatment on H3K4 trimethylation by ChIP-seq and found that each of these perturbations results in a significant enrichment in H3K4me3 peaks relative to controls.TET enzymes are not recurrently mutated in glioma and although there is a strong correlation between mutant IDH status and the CpG island methylator phenotype (CIMP), direct inhibition of TET2 by R-2HG has not been reproducibly demonstrated in glioma. To ask if TET2 activity is suppressed in IDH mutant glioma, we quantified 5hmC levels in a panel of primary IDH wild-type and IDH mutant glioma and AML samples by mass spectrometry. We found that, unlike in AML, in glioma there is no correlation between IDH1 mutation status and loss of 5hmC. We likewise saw no correlation between 5hmC levels and either IDH mutation status or intracellular R-2HG levels in patient derived xenograft (PDX) models of glioma. Given the lack of evidence that TET enzymes are tumor suppressor targets of R-2HG in IDH mutant glioma, we asked if mutant IDH positivity is associated with increased levels of H3K4 methylation in glioma. We performed ChIP-seq on a panel of IDH wild-type and IDH mutant glioma PDX lines and found H3K4me peaks to be highly enriched in the IDH mutant lines when compared to IDH wild-type lines. Trimethyl-H3K4 levels were likewise increased in isogenic normal human astrocyte (NHA) cells ectopically expressing mutant IDH1.Collectively, these data suggest that R-2HG inhibits KDM5 histone lysine demethylases to promote mutant IDH-mediated transformation in AML and glioma. These studies identify a novel direct target of R-2HG in IDH mutant tumors and provide a functional link between IDH mutations and dysregulated histone lysine methylation in cancer. DisclosuresNo relevant conflicts of interest to declare.

Myeloid Sarcoma of Appendix, Presenting as Acute Appendicitis: A Rare Case Presentation

Myeloid sarcoma is a malignant neoplasm, in which a tumor mass consisting of myeloid blasts with or without maturation occur at an anatomical site other than the bone marrow. Myeloid sarcoma is frequently, but not always, associated with acute myeloid leukemia, chronic myeloid leukemia, and other myelodysplastic disorders. Myeloid sarcomas involving the appendix are uncommon and myeloid sarcoma of the appendix presenting as acute appendicitis is rare. A 64-year-old Omani female presented to the emergency department with 1-day history of acute right lower abdominal pain. She was noted to have leukocytosis and thrombocytopenia in her pre-operative blood investigation, which prompted a 2-week prior history of a single episode of minor nosebleed. Abdominal imaging demonstrated findings suggestive of an acute appendicitis, with differential of mesenteric adenitis and/or focal fat infarction, for which she underwent laparoscopic appendectomy. Surgical pathology of the appendix showed myeloid sarcoma involving the entire appendix including the base. On further investigation, a peripheral blood smear revealed many circulating blasts. Patient was later diagnosed to have acute myeloid leukemia with inv (16) (p13.1 q22) genetic abnormality in a tertiary hospital. Acute appendicitis with leukemic infiltration in form of myeloid sarcoma as the initial manifestation of acute myeloid leukemia has been described in very few cases in the literature, and our case is the first case to be reported in Oman.

Transcriptome of DNA Repair Genes in CMML: Rationale for Targeting ERCC1 and CDKN1A As a Synthetic Lethality Approach

Background: Chronic myelomonocytic leukemia (CMML) is characterized by features of both myeloproliferative neoplasm and myelodysplastic syndrome (MDS). Despite the main role of DNA repair pathways in cancer, in myelodysplastic disorders, somatic mutations are not found in these pathways. The novel discovery of non-classical leukaemogenesis mediated by splicing defects, profound influence of epigenetic anomalies, deeper knowledge of the DNA repair network, and development of unbiased high-throughput sequencing approaches, prompted us to revisit whether these processes might be disrupted by non-mutational mechanisms in CMML and related myeloid disorders. Study aims: i) to screen the transcriptome of DNA repair genes in a CMML discovery cohort; ii) to validate their misregulation in an independent large CMML cohort; and iii) determining how those candidates behave through the spectrum of myeloid malignancies. Methods: RNA-seq was performed in the discovery cohort: 27 CMML bone marrow samples (BM) at diagnosis and 9 healthy BM samples, and in 7 patients treated with Azacitidine in BM collected before and after 4 cycles. RT-qPCR was used to validate 9 DEGs through the myeloid spectrum and in a CMML validation cohort: 74 additional CMML, 70 MDS, 66 AML , and 25 CML patients. Candidates were chosen based on clinical considerations: i) druggable oncogenes highly overexpressed ii) oncogenes infra-expressed with inhibitory molecules already being tested in myeloid neoplasms. Global pattern of DNA repair gene expression was compared with MDS and AML extracted from MILE study data. The DEGs methylation status was studied using available public data and we confirmed by pyrosequencing the methylation status of our main candidates. The CMML validation cohort was mutationally characterized by targeted sequencing of 18 CMML recurrently mutated genes. Alternative splice sites, skipped exons, mutually exclusive exons and retained introns were quantified using rMATS.Results: Of 27 CMML patients and 9 healthy donors, the expression of 30 genes was significantly different between the two groups (8 genes up-regulated and 22 down-regulated). Defects on genes predominantly unique to a single strand breaks repair pathway included: NEIL1 and OGG1 in base excision repair, XPA and MSS19 in nucleotide excision repair and RPA4 in mismatch repair. XRCC4 and MSH4 overexpression and PRKDC down-regulation were found as significant changes among the genes associated exclusively to double strand breaks repair. We next extracted the DNA repair transcriptional components from MILE study: 206 MDS, 47 ckAML and 73 healthy donors. MDS misregulation was characterized by upregulated genes while ckAML showed a global disruption, mostly downregulation of Homologous Recombination genes. Some genes showed opposite sense of misregulation depending on the myeloid entity: TDP1 was upregulated in CMML cases and downregulated in ckAML, and viceversa for BAP1 . CDK1 and EXO1 were upregulated in MDS cases but downregulated in ckAML cases. Statistically significant and direction-concordant dysregulation of CDKN1A, ERCC1, XRCC4, NEIL1, MSH4, PARP1 and BAP1 were confirmed in our independent CMML validation cohort. The methylation study showed a global demethylated status of our misregulated DNA repair genes in CMML. Either responder s (n=3) or non-responders (n=2) to azacitidine failed to achieve a substantial expression change in their DNA Repair DEGs. PARP1 infraexpresion was associated with TET2 mut cases. Lower CDKN1A and BAP1 expression was related to chromatin regulator mutations. SRSF2 mutations induced widespread aberrant splicing events in DNA repair genes in CMMLConclusions: We have identified by means of an unbiased high-throughput approach, and validated in an independent cohort, a subset of DNA repair genes consistently misregulated in CMML. The genes identified warrant further study as potential novel therapeutic targets, both directly and through modulation of associated compensatory pathways. CDKN1A and ERCC1 in particular emerge as realistic candidates for a synthetic lethality approach. Our findings suggest that the promise of PARP1 inhibition appears less pertinent to CMML than for other myeloid diseases. These differences might also partially explain the different genomic and phenotypic manifestations of different myeloid neoplasms, and shed insights into their distinctive biology. DisclosuresMaciejewski:Alexion Pharmaceuticals, Inc.: Consultancy, Membership on an entity's Board of Directors or advisory committees, Other: Speaker Fees; Apellis Pharmaceuticals: Consultancy; Ra Pharma: Consultancy.

Prognostic Significance of Minimal Residual Disease in Patients with Secondary Acute Myeloid Leukemia

BACKGROUNDSecondary acute myeloid leukemia (AML) is defined as AML that develops from a prior myelodysplastic or myeloproliferative disorder, or from exposure to chemotherapy, radiation, or environmental toxins. Patients with secondary AML have inferior prognosis compared to those with de novo AML,1 and are more likely to be elderly with increased comorbidities and worse performance status.2 The detection of minimal residual disease (MRD) also has independent prognostic value in patients with AML.3-6 In elderly AML patients, MRD predicts worse outcomes independent of the poor treatment risk factors associated with increased age.7Due to the similar disease pathogenesis between elderly AML and secondary AML patients, it is likely that MRD testing will have similar implications. However, there is limited data on the prognostic role of MRD testing in secondary AML. METHODSWe retrospectively analyzed de novo and secondary AML patients at Washington University Medical Center who received post-induction, post-consolidation, pre-transplant, or post-transplant MRD testing during their treatment. MRD testing was performed with multiparameter flow cytometry testing using the “different from normal” method at one reference laboratory,8,9 with positive MRD defined as detection of an abnormal myeloblast population above 0.1%. A total of 180 patients were included. Any patient with at least one positive MRD was considered “MRD positive.” Baseline pretreatment characteristics were compared between groups with Mann-Whitney, Chi-square, or Fisher's exact test, when appropriate. We evaluated overall survival (OS) and relapse rates in de novo and secondary AML patients stratified by MRD status using Kaplan-Meier curves and the log rank test, or cumulative incidence function, as appropriate. Multivariate Cox proportional hazards model was also fitted to determine if MRD testing has similar prognostic value across de novo and secondary AML patients. RESULTSOur analysis included 133 patients with de novo and 47 patients with secondary AML. Secondary AML patients were significantly older at age of diagnosis (mean age 59.85 versus 51.17, p<0.001), however had similar rates of MRD positivity (28% versus 29%, p=0.830). There was a trend toward poorer cytogenetic risk profiles and worse Karnofsky Performance Status in secondary AML (Table 1). In all patients, we confirmed that MRD positivity confers significantly worse OS (45.5% versus 70.8%, p=0.020) and relapse rates at 2 years (53% versus 25.5%, p=0.029) (Figure 1). In de novo AML patients, MRD positivity continued to demonstrate significantly worse 2-year OS (44.1% versus 76.3%, p=0.006) and relapse rates (57.6% versus 20.7%, p=0.008). However, in secondary AML patients, there were no differences in OS (p=0.69) or relapse rates (p=0.98) between MRD positive and negative patients. Multivariate analysis demonstrated significant interaction (p=0.042) between MRD status and AML subtypes. MRD positivity emerged as an independent prognostic indicator of worse OS in de novo patients (HR 2.8, 95% CI 1.524-5.405) but not in secondary patients (HR 1.5, 95% CI 0.188-2.336). DISCUSSIONWe confirm that MRD status is a poor prognostic indicator in all AML patients, and this also holds true in patients with de novo AML. However, we found that MRD status has less prognostic value in secondary AML patients. This may be due to the overall poor prognosis seen in secondary AML patients, suggesting that MRD monitoring in this group of patients may be less useful for risk stratification. However, our study is limited by the small sample size, particularly in the number of secondary AML patients who displayed MRD positivity (N=13). In addition, we defined MRD positivity across all time points of testing, which may decrease patient homogeneity. A larger study with increased follow-up is necessary to confirm our findings, as these results have important implications in risk-stratification and treatment of patients with secondary AML. [Display omitted] DisclosuresDiPersio:BMS, Asterias, Amphivena, Bluebird: Other: Travel, Accomodations, Expenses; Hemedicus, DAVA Oncology: Speakers Bureau; Celgene, Bioline, Vasculox, Cellworks, Rivervest: Consultancy; Magenta Therapeutics: Equity Ownership.

Development and validation of a disease risk stratification system for patients with haematological malignancies: a retrospective cohort study of the European Society for Blood and Marrow Transplantation registry

Diagnosis and remission status at the time of allogeneic haematopoietic stem-cell transplantation (HSCT) are the principal determinants of overall survival following transplantation. We sought to develop a contemporary disease-risk stratification system (DRSS) that accounts for heterogeneous transplantation indications. In this retrospective cohort study we included 55 histology and remission status combinations across haematological malignancies, including acute leukaemia, lymphoma, multiple myeloma, and myeloproliferative and myelodysplastic disorders. A total of 47 265 adult patients (aged ≥18 years) who received an allogeneic HSCT between Jan 1, 2012, and Dec 31, 2016, and were reported to the European Society for Blood and Marrow Transplantation registry were included. We divided EBMT patients into derivation (n=25 534), tuning (n=18 365), and geographical validation (n=3366) cohorts. Disease combinations were ranked in a multivariable Cox regression for overall survival in the derivation cohort, cutoff for risk groups were evaluated for the tuning cohort, and the selected system was tested on the geographical validation cohort. An independent single-centre US cohort of 660 patients transplanted between Jan 1, 2010, and Dec 31, 2015 was used to externally validate the results. The DRSS model stratified patients in the derivation cohort (median follow-up was 2·1 years [IQR 1·0-3·2]) into five risk groups with increasing mortality risk: low risk (reference group), intermediate-1 (hazard ratio for overall survival 1·26 [95% CI 1·17-1·36], p<0·0001), intermediate-2 (1·53 [1·42-1·66], p<0·0001), high (2·03 [1·86-2·22], p<0·0001), and very high (2·87 [2·63-3·13], p<0·0001). DRSS levels were also associated with a stepwise increase in risk across the tuning and geographical validation cohort. In the external validation cohort (median follow-up was 5·7 years [IQR 4·5-7·1]), the DRSS scheme separated patients into 4 risk groups associated with increasing risk of mortality: intermediate-2 risk (hazard ratio [HR] 1·34 [95% CI 1·04-1·74], p=0·025), high risk (HR 2·03 [95% CI 1·39-2·95], p=0·00023) and very-high risk (HR 2·26 [95% CI 1·62-3·15], p<0·0001) patients compared with the low risk and intermediate-1 risk group (reference group). Across all cohorts, between 64% and 65% of patients were categorised as having intermediate-risk disease by a previous prognostic system (ie, the disease-risk index [DRI]). The DRSS reclassified these intermediate-risk DRI patients, with 855 (6%) low risk, 7111 (51%) intermediate-1 risk, 5700 (41%) intermediate-2 risk, and 375 (3%) high risk or very high risk of 14 041 patients in a subanalysis combining the tuning and internal geographic validation cohorts. The DRI projected 2-year overall survival was 62·1% (95% CI 61·2-62·9) for these 14 041 patients, while the DRSS reclassified them into finer prognostic groups with overall survival ranging from 45·7% (37·4-54·0; very high risk patients) to 73·1% (70·1-76·2; low risk patients). The DRSS is a novel risk stratification tool including disease features related to histology, genetic profile, and treatment response. The model should serve as a benchmark for future studies. This system facilitates the interpretation and analysis of studies with heterogeneous cohorts, promoting trial-design with more inclusive populations. The Varda and Boaz Dotan Research Center for Hemato-Oncology Research, Tel Aviv University.

Malignant Post-Transplant Lymphoproliferative Disorder of Nasopharynx in Myelodysplastic Disorder

(1) Background: Post-transplant lymphoproliferative disorder (PTLD) is a hematological disease and occurs because of immunosuppression after organ transplantation. Only a few studies have reported PTLD in the nasopharynx. In most cases, PTLD developed after solid organ transplantation, and cases of PTLD after bone marrow transplantation, are uncommon. (2) Case presentation: We report the case of a 40-year-old woman with myelodysplastic disorder who underwent hematopoietic stem cell transplantation (HSCT). After 3 months, she developed low-grade fever, progressive nasal obstruction, and bloody rhinorrhea. Endoscopy revealed a mass completely occupying the nasopharynx. A polymorphic PTLD was diagnosed on the basis of histopathological examination results. Reduction in immunosuppression and low-dose radiotherapy were prescribed for treatment. After a 3-year follow-up, no recurrence of PTLD or myelodysplastic disorder was detected. (3) Conclusions: While nasopharyngeal PTLD is rare, a routine examination of the nasopharynx should be considered in the post-transplant follow-up of patients for early detection and treatment of PTLD.

Urticarial vasculitis.

Urticarial vasculitis is a rare clinicopathologic entity that is characterized by chronic or recurrent episodes of urticarial lesions. Skin findings of this disease can be difficult to distinguish visually from those of chronic idiopathic urticaria but are unique in that individual lesions persist for ≥24 hours and can leave behind dusky hyperpigmentation. This disease is most often idiopathic but has been linked to certain drugs, infections, autoimmune connective disease, myelodysplastic disorders, and malignancies. More recently, some authors have reported associations between urticarial vasculitis and COVID-19, as well as influenza A/H1N1 infection. Urticarial vasculitis can extend systemically as well, most often affecting the musculoskeletal, renal, pulmonary, gastrointestinal, and ocular systems. Features of leukocytoclastic vasculitis seen on histopathologic examination are diagnostic of this disease, but not always seen. In practice, antibiotics, dapsone, colchicine, and hydroxychloroquine are popular first-line therapies, especially for mild cutaneous disease. In more severe cases, immunosuppressives, including methotrexate, mycophenolate mofetil, azathioprine, and cyclosporine, as well as corticosteroids, may be necessary for control. More recently, select biologic therapies, including rituximab, omalizumab, and interleukin-1 inhibitors have shown promise for the treatment of recalcitrant or refractory cases.

First-line hypomethylating agents for patients with high risk chronic myelomonocytic leukaemia

Chronic myelomonocytic leukaemia is a rare clonal haemopoietic stem cell disorder that affects older adults, with a median age at presentation of 74 years.1 Chronic myelomonocytic leukaemia was first considered as a specific category of myeloid neoplasms in the 2008 WHO classification. The two well-recognised subtypes of the disease include myeloproliferative and myelodysplastic chronic myelomonocytic leukaemia. In 2015 the International Working Group developed separate disease response criteria for chronic myelomonocytic leukaemia, other myelodysplastic syndromes, myeloproliferative neoplasms, and syndromes that overlap between myelodysplastic and myeloproliferative disorders.

Acute myeloid leukaemia with myelodysplasia-related change in a child living with human immunodeficiency virus infection, a transformation from underlying juvenile myelomonocytic leukaemia

Juvenile myelomonocytic leukaemia (JMML) is an aggressive clonal haematopoietic disorder that presents in early childhood. It is classified by the World Health Organization (WHO) as an overlap myeloproliferative or myelodysplastic disorder. The pathogenesis of JMML has been well-explained at the molecular level using clear diagnostic criteria. There is limited literature on JMML in the context of HIV infection. The only curative modality for the majority of patients with JMML is allogeneic haematopoietic stem cell transplant (HSCT). The role of other chemotherapeutic approaches is to ameliorate the disease but they are no substitute for allogeneic HSCT. We report a case of a 59-month-old child with vertically transmitted HIV-infection who was referred to the authors’ institution for further management.

Clinical significance of chromatin-spliceosome acute myeloid leukemia: a report from the Northern Italy Leukemia Group (NILG) randomized trial 02/06.

Secondary acute myeloid leukemia (sAML) after myelodysplastic or myeloproliferative disorders is a high-risk category currently identified by the clinical history or specific morphological and cytogenetic abnormalities. However, in the absence of these features, uncertainties to identify the secondary nature of some cases, otherwise defined as de novo AML, remain. In order to test whether a chromatinspliceosome (CS) mutational signature might better define the de novo AML group, we analyzed a prospective cohort of 413 newly diagnosed AML patients who were enrolled in a randomized clinical trial (NILG AML 02/06) and who provided samples for accurate cytogenetic and molecular characterization. Among clinically defined de novo AML, 17.6% carried CS mutations (CS-AML) and showed clinical characteristics closer to sAML (older age, lower white blood cell counts and higher rate of multilineage dysplasia). Outcomes in this group were adverse, more similar to those of sAML as compared to de novo AML (overall survival, 30% in CS-AML and 17% in sAML vs. 61% in de novo AML, P<0.0001; disease-free survival, 26% in CS-AML and 22% in sAML vs. 54% of de novo AML, P<0.001) and independently confirmed by multivariable analysis. Allogeneic transplant in first complete remission improved survival in both sAML and CS-AML patients. In conclusion, these findings highlight the clinical significance of identifying CS-AML for improved prognostic prediction and potential therapeutic implications. (NILG AML 02/06; clinicaltrials gov. Identifier: NCT00495287).

ETV6-ACSL6 fusion gene in myeloid neoplasms: clinical spectrum, current practice, and outcomes

BackgroundETV6-ACSL6 is a fusion gene rarely reported in myeloid malignancies, and its clinical characteristics, proper treatment strategies, and effect on prognosis are poorly understood.ResultsSixteen patients with the ETV6-ACSL6 fusion gene were identified, with a median age of 50 years. Twelve patients were male. Clinical diagnoses included chronic eosinophilic leukemia, not otherwise specified, acute myeloid leukemia, and other types of myeloproliferative and myelodysplastic disorders. Ten out of 12 patients had increased levels of eosinophils, and four out of five had increased levels of basophils in peripheral blood. Treatment with tyrosine kinase inhibitors was ineffective. The prognosis of the patients was poor, with seven patients dying within 1 year.ConclusionsPatients with the ETV6-ACSL6 fusion gene mainly present with myeloproliferative and myelodysplastic disorders, typically with increased eosinophils and/or basophils and poor survival. Intensive therapies such as allogenic stem cell transplantation should be an initial consideration for eligible patients.

Insights into the Involvement of Spliceosomal Mutations in Myelodysplastic Disorders from Analysis of SACY-1/DDX41 in Caenorhabditis elegans.

Mutations affecting spliceosomal proteins are frequently found in hematological malignancies, including myelodysplastic syndromes and acute myeloid leukemia (AML). DDX41/Abstrakt is a metazoan-specific spliceosomal DEAD-box RNA helicase that is recurrently mutated in inherited myelodysplastic syndromes and in relapsing cases of AML. The genetic properties and genomic impacts of disease-causing missense mutations in DDX41 and other spliceosomal proteins have been uncertain. Here, we conduct a comprehensive analysis of the Caenorhabditis elegans DDX41 ortholog, SACY-1 Biochemical analyses defined SACY-1 as a component of the C. elegans spliceosome, and genetic analyses revealed synthetic lethal interactions with spliceosomal components. We used the auxin-inducible degradation system to analyze the consequence of SACY-1 depletion on the transcriptome using RNA sequencing. SACY-1 depletion impacts the transcriptome through splicing-dependent and splicing-independent mechanisms. Altered 3' splice site usage represents the predominant splicing defect observed upon SACY-1 depletion, consistent with a role for SACY-1 in the second step of splicing. Missplicing events appear more prevalent in the soma than the germline, suggesting that surveillance mechanisms protect the germline from aberrant splicing. The transcriptome changes observed after SACY-1 depletion suggest that disruption of the spliceosome induces a stress response, which could contribute to the cellular phenotypes conferred by sacy-1 mutant alleles. Multiple sacy-1/ddx41 missense mutations, including the R525H human oncogenic variant, confer antimorphic activity, suggesting that their incorporation into the spliceosome is detrimental. Antagonistic variants that perturb the function of the spliceosome may be relevant to the disease-causing mutations, including DDX41, affecting highly conserved components of the spliceosome in humans.

Role of Autophagy in the Myelodysplastic Syndrome and Myeloproliferative Disorders

Role of Autophagy in the Myelodysplastic Syndrome and Myeloproliferative Disorders