Cases Of Myelodysplastic Syndrome Research Articles

TP53 Mutations in Acute Leukemias and Myelodysplastic Syndromes: Insights and Treatment Updates.

TP53 mutations are found in 5%-10% of de novo myelodysplastic syndrome (MDS) and AML cases. By contrast, in therapy related MDS and AML, mutations in TP53 are found in up to 30%-40% of patients. The majority of inactivating mutations observed in MDS and AML are missense mutations localized in a few prevalent hotspots. TP53 missense mutations together with truncating mutations or chromosomal loss of TP53 determine a loss-of-function effect on normal p53 function. Clonal expansion of TP53-mutant clones is observed under the selection pressure of chemotherapy or MDM2 inhibitor therapy. TP53-mutant clones are resistant to current chemotherapy, and when responses to treatment have been observed, they have correlated poorly with overall survival. The most heavily investigated and targeted agent for patients with TP53-mutant MDS and AML has been APR-246 (eprenetapopt) a p53 reactivator, in combination with azacitidine, but also in triplets with venetoclax. Despite positive results in phase II trials, a phase III trial did not confirm superior response or improved survival. Other agents, like magrolimab (anti-CD47 antibody), failed to demonstrate improved activity in TP53-mutant MDS and AML. Agents whose activity is not dependent on a functional apoptosis system like anti-CD123 antibodies or cellular therapies are in development and may hold promises. Delivering prognostic information in a dismal disease like TP53-mutated MDS and AML is particularly challenging. The physician should balance hope and realism, describing the trajectory of possible treatments and at the same time indicating the poor outcome, together with promoting adaptive coping in patients and elaborating on the nature of the disease.

DNA methyltransferases-associated long non-coding RNA PRKCQ-AS1 regulate DNA methylation in myelodysplastic syndrome.

Myelodysplastic syndrome (MDS) is a group of clonal hematopoietic stem cell disorders. DNA hypermethylation is considered to be the key mechanism of pathogenesis for MDS. Studies have demonstrated that DNA methylation can be regulated by the co-effect between long non-coding RNAs (lncRNAs) and DNA methyltransferases (DNMTs). The aim of this study was to identify DNMTs-associated differentially expressed (DE) lncRNAs, which may be a novel diagnostic and therapeutic target for MDS. Two gene expression profile datasets (GSE4619 and GSE19429) were downloaded from the Gene Expression Omnibus (GEO) database. Systematic bioinformatics analysis was conducted. Then we verified the expression of PRKCQ-AS1 in MDS patients and features in SKM-1 cells. Bioinformatics analysis revealed that the DNMT-associated DE-lncRNA PRKCQ-AS1 was functionally related to DNA methylation. The target genes of PRKCQ-AS1 associated with DNA methylation are mainly methionine synthetase (MTR) and ten-eleven-translocation 1 (TET1). Moreover, the high expression of PRKCQ-AS1 was verified in real MDS cases. Further cellular analysis in SKM-1 cells revealed that overexpressed PRKCQ-AS1 promoted methylation levels of long interspersed nuclear element 1 (LINE-1) and cell proliferation, and apparently elevated both mRNA and protein levels of MTR and TET1, while knockdown of PRKCQ-AS1 showed opposite trend in SKM-1 cells. DNMT-associated DE-lncRNA PRKCQ-AS1 may affects DNA methylation levels by regulating MTR and TET1.

Validation and comparison of 5th edition World Health Organization classification (WHO 2022) and International Consensus Classification proposals for MDS-SFB31.

The criteria of myelodysplastic syndromes (MDS) with mutated SFB31 (MDS-SFB31) proposed by the 5th edition of the WHO classification (WHO 2022) and the International Consensus Classification (ICC) need validation. We analysed 125 consecutive MDS cases with SFB31 mutation or ring sideroblasts (RS) ≥15% without excess blasts. We found that SFB31-negative MDS with RS had significantly different clinical features and worse prognosis. According to WHO 2022, the detection of ≥15% RS may substitute for SF3B1 mutation and our analyses support this proposal for similar prognosis of two groups after excluding high-risk genetic features referred by WHO 2022. Patients with variant allele frequency (VAF) <10% SFB31 tend to have briefer survival, supporting the VAF 10% threshold of ICC. Patients with multilineage dysplasia (MLD) had significantly shorter OS than those with single lineage dysplasia. MLD is still a powerful morphological marker of worse outcome in WHO 2022 and ICC-defined MDS-SF3B1.

UBTF tandem duplications in pediatric myelodysplastic syndrome and acute myeloid leukemia: implications for clinical screening and diagnosis.

Recent genomic studies in adult and pediatric acute myeloid leukemia (AML) demonstrated recurrent in-frame tandem duplications (TD) in exon 13 of upstream binding transcription factor (UBTF). These alterations, which account for ~4.3% of AMLs in childhood and about 3% in adult AMLs under 60, are subtype-defining and associated with poor outcomes. Here, we provide a comprehensive investigation into the clinicopathological features of UBTF-TD myeloid neoplasms in childhood, including 89 unique pediatric AML and 6 myelodysplastic syndrome (MDS) cases harboring a tandem duplication in exon 13 of UBTF. We demonstrate that UBTF-TD myeloid tumors are associated with dysplastic features, low bone marrow blast infiltration, and low white blood cell count. Furthermore, using bulk and single-cell analyses, we confirm that UBTF-TD is an early and clonal event associated with a distinct transcriptional profile, whereas the acquisition of FLT3 or WT1 mutations is associated with more stem celllike programs. Lastly, we report rare duplications within exon 9 of UBTF that phenocopy exon 13 duplications, expanding the spectrum of UBTF alterations in pediatric myeloid tumors. Collectively, we comprehensively characterize pediatric AML and MDS with UBTF-TD and highlight key clinical and pathologic features that distinguish this new entity from other molecular subtypes of AML.

Leukopenia that successfully treated by Ustekinumab in patient with psoriatic arthritis

Introduction:Psoriatic Arthritis (PsA) is an immune-mediated disease. The effectiveness of biologics has changed therapeutic strategies for psoriasis. We report a case of leukopenia in a patient with psoriatic arthritis (PsA) who was treated with Ustekinumab. Case presentation: A 36- year- old Syrian female presented for a follow up concerning treatment of psoriatic arthritis. She was diagnosed with psoriatic arthritis according to the CASPAR criteria. She was treated with Methotrexate, then Sulfasalazine. On presentation, the physical examination revealed tender in metacarpals, proximal interphalengal joints and distal interphalengal joints of both hands. Laboratory analysis showed: white blood cells (WBC) :3500 /mm3, (Neut:23% n = 40-65%, Lymp:65% n= 25-40%), erythrocyte sedimentation rate (ESR): 40 mm/h1, and C-reactive protein (CRP): 9.3 mg/L . Given the patient’s ongoing disease activity, and the presence of leukopenia, we started with Ustekinumab 45 mg subcutaneous. After the third dose of Ustekinumab, evaluation showed improvement in her peripheral arthritis and normal laboratory findings. Discussion: Patients with psoriasis had higher total white blood cell and neutrophil. Ustekinumab has good efficacy against disease activity as well as a favourable safety profile. In literature, we found a case of myelodysplastic syndrome associated with inflammatory bowel disease treated with Ustekinumab. Another case of constitutional neutropenia and psoriasis vulgaris treated with Ustekinumab. Conclusion: This is the first case of leukopenia associated with PsA successfully treated with Ustekinumab. UST treatment might be recommended for leukopenia associated with PsA, but further researches are recommended.

Clinical study of the efficacies of ruxolitinib plus low-dose PTCY for acute GVHD prevention after haploidentical transplantation in malignant hematological diseases

Objective: To investigate and verify a novel acute graft versus host disease (aGVHD) prevention protocol in the context of haploidentical hematopoietic stem cell transplantation (haplo-HSCT) . Methods: Patients who underwent haplo-HSCT in our center between January 2022 and December 2022 were included. All patients received reduced doses of cyclophosphamide, Rabbit anti-human tymoglobulin, ruxolitinib, methotrexate, cyclosporine, and MMF to prevent aGVHD. The transplantation outcomes, complications, and survival rate of all patients were investigated. Results: A total of 52 patients with haplo-HSCT were enrolled, 29 (55.8%) male and 23 (44.2%) female, with a median age of 28 (5-59) years. There were 25 cases of acute myeloid leukemia, 17 cases of acute lymphocyte leukemia, 6 cases of myelodysplastic syndrome, 2 cases of chronic myeloid leukemia and 2 cases of myeloproliferative neoplasms. 98.1% of patients had successful engraftment. The incidence of Ⅱ-Ⅳ aGVHD and Ⅲ-Ⅳ aGVHD was 19.2% (95% CI 8.2% -30.3% ) and 7.7% (95% CI 0.2% -15.2% ), respectively. No patients experienced severe gastrointestinal mucositis. The Epstein-Barr virus and CMV reactivation rates were 40.4% and 21.3%, respectively. 9.6% of patients relapsed during followup, with 1-year overall survival, progression-free survival, and non-relapse mortality rates of 86.5% (95% CI 76.9% -96.1% ), 78.8% (95% CI 67.4% -90.3% ) and 11.5% (95% CI 2.6% -20.5% ), respectively. Conclusion: Ruxolitinib combined with a low dose of PTCY is a safe and effective first-line aGVHD prevention strategy.

Abstract A037: Investigating the role of the somatic DDX41 variant in the context of DDX41 hereditary myeloid malignancy syndromes (HMMS)

Abstract Heterozygous germline variants in DDX41 are identified in ~5% of patients with Myelodysplastic Syndrome (MDS) or Acute Myeloid Leukemia (AML). Recognition of the hereditary nature of such cancers and a better understanding of the factors that affect progression to malignancy has deep implications for health surveillance of patients and relatives that share a pathogenic DNA variant. DDX41 has a role in ribosome biogenesis and in opposing R-loop accumulation at promoters, but the mechanisms through which DDX41 loss drives cancer development are poorly understood. In a collaboration between Cambridge, UK and Mayo Clinic, USA we identified 85 patients with germline DDX41 variants [73/85 with germline pathogenic variants (GPV) and 12 with variants of uncertain significance (VUS)]. The majority were identified through targeted myeloid NGS upon presentation with AML (30/85) or MDS (44/85). Average age at diagnosis was 65 (35-93) with male predominance (57/85). The most common GPV was the NM_016222.4(DDX41):c.415_418dup; p.D140Gfs*2 (15/85). The majority (53.4% 39/73), also acquired a somatic variants in the other DDX41 allele (referred to as GPV+Som). The most common somatic variant (82% 32/39) was the R525H, a variant predicted to reduce the ATPase function of the helicase domain. We hypothesise that the markedly reduced DDX41 activity in cells with biallelic variants, is a key cause of progression to overt malignancy. In our cohort, we observed that somatic variants occurred at a similar frequency in association with start loss, truncating, splice, in-frame deletion, and missense GPV. However, whereas MDS was the predominant diagnosis within GPV (67.6% 23/34, AML 26.4% 9/34), AML was the most frequent diagnosis within GPV+Som (AML 51%.2 20/39, MDS 38.4% 15/39). Overall, there was a significantly higher likelihood of AML in the presence of a somatic variant (p&amp;lt;0.05), suggesting that there might be a dosage effect on the phenotype. This pattern was observed across all the GPV, with the exception of missense, suggesting that many might be benign polymorphysms. In addition, although somatic variants are typically subclonal (overall mean variant allele fraction VAF=9.87%, 3-27.8%), we observed a higher somatic VAF in AML over MDS cases (12.4% vs 7.7% respectively p&amp;lt;0.05). A lower bone marrow cellularity was also characteristic of GPV+Som vs GPV alone (mean observed/expected cellularity for age 0.9 vs 1.32 respectively p&amp;lt;0.05). In two cases, serial bone marrow morphology and NGS data were available, and we observed marked reduction in bone marrow cellularity upon acquisition of the R525H clone. The mechanisms of AML evolution appear different in DDX41 HMMS compared to sporadic cases. Interestingly, over half of our patients (21/34 GPV and 23/39 GPV+Som) did not exhibit additional somatic drivers. Our work suggests that acquisition of a somatic variant is a critical event in disease progression. Furthermore, the near universally subclonal nature of somatic variants suggest that they may affect disease phenotype through non-cell autonomous mechanisms. Citation Format: Ludovica Marando, Talha Badar, Yael Kusne, Audrey Morris, Terra Lasho, Abhishek Mangaonkar, Christy Finke, Carles Crawley, James M. Foran, Aref Al-Kali, Andrew King, Hassan Alkhateeb, Naseema Gangat, Chi Wong, Rong He, David Viswanatha, Faisal Basheer, Mark Litzow, Alejandro Ferrer, George Vassiliou, Mrinal Patnaik. Investigating the role of the somatic DDX41 variant in the context of DDX41 hereditary myeloid malignancy syndromes (HMMS) [abstract]. In: Proceedings of the AACR Special Conference in Cancer Research: Translating Cancer Evolution and Data Science: The Next Frontier; 2023 Dec 3-6; Boston, Massachusetts. Philadelphia (PA): AACR; Cancer Res 2024;84(3 Suppl_2):Abstract nr A037.

177Lu]Lu-DOTA-TATE in newly diagnosed patients with advanced grade 2 and grade 3, well-differentiated gastroenteropancreatic neuroendocrine tumors: Primary analysis of the phase 3 randomized NETTER-2 study.

LBA588 Background: Currently, there is no universally accepted first line (1L) therapy for higher grade, well-differentiated gastroenteropancreatic neuroendocrine tumors (GEP-NETs) and an unmet medical need remains in these patients (pts). Radioligand therapy (RLT) is an innovative cancer treatment that crosses the traditional domains of systemic, radiation or surgical therapies. The Phase 3 NETTER-2 study (NCT03972488) evaluated [177Lu]Lu-DOTA-TATE (hereafter 177Lu-DOTATATE) as 1L treatment in pts with Grade (G) 2 and G3 advanced GEP-NETs. This is the first trial to assess 1L RLT in any solid tumor. Methods: Eligible pts were newly diagnosed with somatostatin receptor-positive high G2 or G3 (Ki-67 ≥10% and ≤55%) advanced GEP-NETs within the last 6 months prior to enrollment. Pts were randomized (2:1) to receive 4 cycles of 177Lu-DOTATATE (4 × 7.4 GBq) plus 30 mg octreotide long-acting release (LAR) at 8-weekly intervals during 177Lu-DOTATATE treatment then every 4 weeks (177Lu-DOTATATE arm), or 60 mg octreotide LAR every 4 weeks (control arm), stratified by grade (G2 vs G3) and tumor origin (pancreas vs other). The primary endpoint was progression-free survival (PFS), centrally assessed using RECIST 1.1. Objective response rate (ORR), a key secondary endpoint, was tested hierarchically after PFS. Results: Overall, 226 pts were randomized to the 177Lu-DOTATATE (n = 151) or control (n = 75) arms. Most tumors originated in the pancreas (54.4%) or small intestine (29.2%); G3 tumors were reported in 35.0% of pts. Median cumulative dose of 177Lu-DOTATATE was 29.2 GBq, with 87.8% of pts receiving all 4 doses. Median PFS (95% confidence interval [CI]) was significantly prolonged by ~14.3 months from 8.5 months (7.7, 13.8) in the control arm to 22.8 months (19.4, not estimable) in the 177Lu-DOTATATE arm; stratified hazard ratio 0.276 (95% CI: 0.182, 0.418; p &lt; 0.0001). The ORR was significantly higher in the 177Lu-DOTATATE arm (43.0%) vs the control arm (9.3%); stratified odds ratio 7.81 (95% CI: 3.32, 18.4; p &lt; 0.0001). PFS and ORR results were consistent across all pre-specified demographic and prognostic subgroups. Among adverse events of special interest to RLT, G3/4 leukopenia, anemia and thrombocytopenia occurred in ≤3 pts each in the 177Lu-DOTATATE arm. One case of myelodysplastic syndrome was reported (177Lu-DOTATATE arm). Conclusion: 177Lu-DOTATATE significantly prolonged PFS and demonstrated a clinically meaningful ORR, compared with high-dose octreotide LAR, in pts with newly diagnosed advanced G2 and G3 GEP-NETs. Safety was in line with the established profile of 177Lu-DOTATATE. This is the first randomized study to demonstrate efficacy of RLT as 1L treatment in any malignancy and will change clinical practice. Further investigations of RLT as a therapeutic option in other settings is warranted. Clinical trial information: NCT03972488 .

O-11 A rare cause of thyroid cancer - Li Fraumeni 2 syndrome

Abstract Introduction Thyroid cancer often originates from follicular cells, and papillary thyroid cancer (PTC) is the most common type. There is a familial predisposition in some cases of thyroid cancer. However, a minority of cases have thyroid cancer syndrome (e.g., familial polyposis, MEN 2, or Cowden syndrome). Many known genetic susceptibility genes are RET/PTC, BRAF, RAS, TERT, and TP53. We want to present a case of Li Fraumeni type 2 syndrome as a rare cause of thyroid cancer. Clinical Case A 69-year-old female patient with a history of PTC is admitted to the endocrinology department for follow-up. In 1976, this patient had a thyroid lobectomy, but the pathology result is unknown, and she takes 75 mcg of levothyroxine daily. In 1999, she was diagnosed with rectal cancer. The patient had a completion thyroidectomy in 2002, and the pathology was compatible with PTC. In 2014, she was diagnosed with right breast noninvasive ductal cancer. Cases of cancer were also quite common in her family history. The results of laboratory tests revealed normal TSH levels with negative thyroglobulin and anti-thyroglobulin levels. Neck ultrasonography showed no rest gland and pathological LAP. We requested genetic analysis (55 genes) for familial cancer syndromes. As a result of the analysis, 2 genes were found to be heterozygous. The c.599T&amp;gt;c heterozygous variant in the CHEK 2 gene was found (Figure 1). It was evaluated as pathogenic in the database review. Another heterozygous mutation in the BRIP1 gene, which was evaluated as a VUS also detected. Conclusion The CHEK 2 gene is a DNA-repairing protein kinase at position 22.q12.1. It is responsible for TP53 stabilization, genome maintenance, and apoptosis. CHEK2 phosphorylates p53 in response to DNA damage, leading to cell cycle arrest and stabilization (Figure 2). The mutation(CHEK 2 c.599T&amp;gt;c) we detected in this case has been considered possibly pathogenic in the academic databases. There are reported CHEK 2 c.599T&amp;gt;c cases on the CLINVAR site; the first report is from 2013. Classic Li-Fraumeni syndrome is a rare autosomal dominant syndrome caused by TP53 gene mutation. The chromosome location on classical Li fraumeni is 17p13.1. Li-Fraumeni type 2 develops due to the CHEK 2 gene mutation on chromosome 22q12.1. The results of a mutation of the CHEK2 gene are breast cancer, prostate cancer, PTC, colon cancer, kidney cancer, adrenocortical cancer, lung cancer, and rare cases of myelodysplastic syndromes. There are no data on thyroid-specific mortality in carriers of the CHEK2 mutations, and it is not yet known whether thyroid cancer in this population is more aggressive or has a better outcome.The familial syndromes should also be considered if PTC is detected in breast, colon, and prostate cancer patients. Studies on Li-Fraumeni type 2 syndrome are scarce, and considering the prevalence in European countries, further investigations of this syndrome and screening in patients with multiple cancers in the family should be warranted.Figure 1.Genetic sequencing image of the case

Acute Diarrhea in Early Post-Transplant Period in Living Donor Kidney Transplant Recipients

Background: Acute diarrhea is common in Myanmar. People are so used to diarrhea at least once a year that they do not think diarrhea as an important problem. Acute diarrhea in early post-operative period in renal transplant recipient may result in pre-renal failure and delay graft function. This study aimed to identify the prevalence of diarrhea, its severity and response to treatment in early post-operative period (3 weeks after transplant) in living donor kidney transplant (LDKT) recipients. Patients and Methods: LDKT recipients having acute diarrhea in early post-transplant period at two transplant centers (Mingaladon and Nay Pyi Taw) in Myanmar were analyzed over 10 years period; from 2013 to 2023 September. Acute diarrhea is defined as three or more semisolid or liquid stools per day for a minimum of 1 day duration. It was a hospital based observational study. After obtaining diet history and physical examination, laboratory tests were done. Clinical parameters (diet, fever, features of oral candidiasis, features of dehydration, examination of abdomen), stool examination (stool inspection, stool examination for ova and cyst, stool for Clostridium difficle toxin, stool culture), blood tests (total WBC count, serum creatinine, liver function tests) and blood trough level for Tacrolimus and mycophenolate mofetil were done. Management was given according to algorithm and their response to treatment was recorded. Dose modification of immunosuppressants were done depending on full blood count and blood level of them. Results: A total of 230 LDKT recipients were observed; among them, thirteen percent (30/230) of recipients developed acute diarrhea in early post-operative period. The age ranged from 14 to 73 years. A majority of them had mild form; mild dehydration without significant changes in hemodynamic status. The peak onset of diarrhea was 4 to 5 days after transplant; majority resolved over one week. They did not have oral candidiasis. Abdominal examination was normal except mild tenderness over grafted kidney in all of them. Total WBC count and platelet count were normal except in two cases. Stool examination did not show trophozoite or cyst. Stool for Clostridium difficile toxin was not identified. With dietary modification and oral rehydration solution, their motion was back to normal in sixteen percent (5/30). Folic acid therapy with or without probiotics made resolution of diarrhea in 33.3% (10/30). Anti-infective therapy was given in 10% (3/30) of cases; norfloxacin to 2 cases. Intravenous colistin to one case as he had enterocolitis and septicemia due to Klebsiella pneumonia. His stool culture as well as blood culture showed Carbepenem resistant Klebsiella pneumonia; he was known case of myelodysplastic syndrome. Blood level of mycophenolate mofetil was normal; however, the dose was reduced in 2 cases owing to leucopenia or thrombocytopenia. Blood tacrolimus trough level was normal in two-third (20/30); and, it was high in one-third of them (20/30). They passed formed stool 24 - 48 hours after dose reduction of tacrolimus. Conclusion: In this study, 13% of the LDKT recipients had acute diarrhea in early post-operative period. Majority of them had mild form. Half of them recovered with oral rehydration solution, diet modification, folic acid and probiotics. Only one tenth of them had infective in origin and responded to anti-infective therapy. Raised blood tacrolimus trough level was found in one third of LDKT recipients with acute diarrhea; diarrhea improved dramatically after reduction of tacrolimus dose.

Integrating AI and ML in Myelodysplastic Syndrome Diagnosis: State-of-the-Art and Future Prospects.

Myelodysplastic syndrome (MDS) is composed of diverse hematological malignancies caused by dysfunctional stem cells, leading to abnormal hematopoiesis and cytopenia. Approximately 30% of MDS cases progress to acute myeloid leukemia (AML), a more aggressive disease. Early detection is crucial to intervene before MDS progresses to AML. The current diagnostic process for MDS involves analyzing peripheral blood smear (PBS), bone marrow sample (BMS), and flow cytometry (FC) data, along with clinical patient information, which is labor-intensive and time-consuming. Recent advancements in machine learning offer an opportunity for faster, automated, and accurate diagnosis of MDS. In this review, we aim to provide an overview of the current applications of AI in the diagnosis of MDS and highlight their advantages, disadvantages, and performance metrics.

Diagnostic Value of CD34 and CD117 Immunohistochemistry and Megakaryocyte Morphology in Myelodysplastic Syndromes: A Retrospective Case-control Study.

This study evaluated the diagnostic value of CD34 and CD117 immunohistochemistry(IHC) and megakaryocyte morphology in Myelodysplastic syndromes (MDS). In this study, CD34-positive individual cells (Type I) and small clusters (Type II) were observed in most cases (91.2%). Type II CD34-positive was seen in 24 (49%) MDS cases, and positive percentage was higher than in acute myelogenous leukemia (AML) or aplastic anemia (AA). Type II CD117-positive were observed in 44 (89.8%) MDS cases and Type I were observed in 5 (10.2%) MDS. Type II CD117-positive percentage was higher than in AML or AA. Megakaryocyte counts were normal or increased in most MDS cases except one. Although megakaryocyte counts of AML and AA were predominantly decreased, Most MDS patients (81.6%) had abnormal megakaryocyte, whereas almost none of megakaryocyte abnormality was found in AML and AA. In conclusion, combined detection of CD34 and CD117 and observation of megakaryocyte count and morphology are useful for the diagnosis of MDS.

Clinical and immunological features in ACKR1/DARC-associated neutropenia

AbstractACKR1/DARC-associated neutropenia (NP; ADAN; Online Mendelian Inheritance in Man 611862), caused by a variation in the ACKR1/DARC gene (rs2814778), is common in persons of African or Middle Eastern descent. In a cohort of 66 genetically confirmed subjects with ADAN, we show that absolute neutrophil counts (ANCs) may occasionally be lower than previously recognized (0.1 × 109-0.49 × 109/L for 9% of the subjects), which is similar to ANCs in severe congenital NP (SCNP). ANCs often normalized during inflammation, even mild. Individuals with ADAN (of 327 observed person-years) showed no cases of myelodysplastic syndrome (MDS), which is frequently encountered in SCNP. Unexpectedly, 22% presented with autoantibodies to neutrophils, compared with <1% in controls. Compared with healthy donors, subjects with ADAN demonstrated significantly lower human cationic antimicrobial protein-18/pro-leucin leucin-37 plasma levels; higher levels of nonclassical, proinflammatory, 6-sulfo LacNac-expressing monocytes; and differentially expressed plasma levels of 28 of the 239 analyzed cytokines related to immunity/inflammation, cell signaling, neutrophil activation, and angiogenesis. Collectively, more severe neutropenia in ADAN than previously assumed may complicate differential diagnoses compared with other SCNPs, and various (auto)immune/inflammatory reactions with a distinct profile may be a cause or consequence of this hereditary neutropenia.

Risk of Myelodysplastic Syndromes (MDS) in Adolescents and Young Adults with Cancers Treated with Chemotherapy with or without Radiotherapy

Introduction The risk of MDS among adolescents and young adults (AYA) with cancer treated with chemotherapy with or without radiotherapy in the US is not well understood. Method We interrogated NCI's Surveillance, Epidemiology and End Result (SEER)-17 registries to identify patients (pts) between the ages of 15-39 years (AYA) diagnosed with MDS at least one year after diagnosis of a primary unrelated cancer treated with chemotherapy and or radiotherapy over a twenty-year period (January 2000 to December 2020). All cancers, including MDS, were identified using ICD-O-3/WHO-2008 histology codes. We excluded all leukemia and MDS entities from index cancer sites. The risk of MDS was estimated by standardized incidence ratio (SIR), defined as the ratio of observed MDS cases in the AYA pts treated for first cancers to the expected number of MDS cases in the general US population during this period. A referent rate file for MDS incidence in age, gender, race and calendar-year matched US population available in SEER*Stat software (version 8.4.0) was used for SIR calculation. We calculated exact, 2-sided Poisson-based 95% confidence intervals (CIs) about the SIRs. We stratified the risk using 5- calendar year periods, and latency after index cancer diagnosis. SIR and time to MDS development was calculated for six most common index cancers using R(v4.2.2)-software. Result Of a total of 168,078 AYA pts eligible for analysis, with 1,290,803-person years at risk during 2000 to 2020, 66 pts developed MDS during this period. The median age at diagnosis of index cancer and MDS were 34 years (yrs) (interquartile range (IQR), 27-37 yrs) and 38 yrs (IQR, 32-44 yrs), respectively. There were 680% more cases of MDS in the AYA cohort compared to that expected in the matched general US population [SIR (95% CI): 7.80 (6.03-9.92), p&amp;lt;0.05)]. A higher SIR was observed for males (12.19) compared to females (5.82) and among all race/ethnicity, highest among black males [(SIR (95%CI): 18.99 (6.17-44.32), p&amp;lt;0.05]. We analyzed SIR for top-six index cancer sites that contributed to most MDS cases. Lymphomas [Non-Hodgkin (NHL) and Hodgkin (HL)] and breast accounted for 54.5% of all MDS cases. SIR for MDS in pts with NHL was 22.07 (95% CI: 12.61-35.84), in HL pts was 10.75 (95% CI: 4.64-21.18), and in breast cancer pts was 2.79 (95% CI:2.22-7.51). Even though the absolute number of cases was low, pts with brain, as well as bone and joint cancers had highest SIRs for MDS. When stratified by 5-calendar year periods, the SIR of MDS was elevated compared to general population through all periods and was highest during 2000-2005 (27.44; 95% CI: 11.03-56.53), and declined for the subsequent time periods. When analyzed by latency period, the SIR for MDS was highest at 1-3 years after index cancer diagnosis (21.46: 95% CI 13.45-32.50) and then showed a steady decline with increasing latency over a period of 15-20 years but never reached the rates observed in general population (Figure 1). Among the six most common index sites, pts with bone and joint cancer had earliest time to occurrence of MDS, whereas the longest latency to developing MDS was observed in pts with testicular cancer (Figure 2). Conclusion AYA cancer cohort treated with chemotherapy or radiotherapy have nearly 8-fold higher risk of future development of MDS compared to the same age matched general US population. This risk is highest during the initial 1-3 years of diagnosis of index cancer, declines over time, but never reaches the rates in the general population. These findings warrant further investigation to understand the biology behind this observation and have potential treatment and surveillance implications.

Final Results of the Phase Ib/II Study Evaluating Enasidenib in Combination with Venetoclax in Patients with IDH2-Mutated Relapsed/Refractory Myeloid Malignancies

BACKGROUND: Theisocitrate dehydrogenase 2 ( IDH2) gene is mutated in ∼10-15% cases of acute myeloid leukemia (AML) and ∼5% cases of myelodysplastic syndromes (MDS). Enasidenib (ENA) is an oral selective IDH2 inhibitor used for treatment of IDH2-mutated (m IDH2) relapsed/refractory (R/R) AML. Preclinical studies showed that m IDH2 AML cells are particularly sensitive to BCL2 inhibition with venetoclax (VEN) and combination of ENA and VEN is more effective than single agents in patient-derived xenograft models of m IDH2 AML. Based on this rationale, we conducted a phase Ib/II trial evaluating the safety and efficacy of ENA plus VEN in patients (pts) with m IDH2 R/R AML or MDS (NCT04092179). METHODS: This single-arm phase Ib/II trial was conducted at the Princess Margaret Cancer Centre and the University of Alberta Hospital in Canada. Pts ≥ 18 years with m IDH2 R/R AML or MDS, adequate organ function and ECOG performance status ≤ 2 were eligible. Participants were not eligible if they had prior exposure to IDH2 or BCL2 inhibitors. Pts were treated continuously by 28-day cycles of VEN 400 mg daily starting with a 3-day ramp-up on cycle 1 day 1 and with ENA 100 mg daily starting on cycle 1 day 15. The primary endpoints were safety, tolerability and recommended phase 2 dose (RP2D) for the phase Ib part and overall response rate (ORR) for the phase II part. ORR included complete remission (CR), CR with partial hematological recovery (CRh), CR with incomplete hematological recovery (CRi), morphologic leukemia-free state (MLFS) and partial remission (PR) as defined by the European Leukemia Network (ELN). Duration of response (DOR), overall survival (OS), pharmacokinetic (PK) analysis for VEN and bone marrow (BM) IDH2 variant allele frequency (VAF) by droplet digital PCR (ddPCR) were also evaluated. RESULTS: From November 2020 to July 2022, 27 pts were enrolled: 12 in the phase Ib and 15 in the phase II. Almost all pts had AML, except one with MDS who progressed on treatment with azacitidine. The data cutoff date was June 30, 2023. The median age was 70 years (range, 23 - 84) ( Table 1). Patients had a median of 1 prior line of treatment (range, 1-2) including 5 (19%) who had previously undergone allogeneic stem cell transplant (HSCT). Fifteen (56%) and 12 (44%) pts had R140Q and R172K/W IDH2 mutation (mut), respectively. The median BM IDH2 VAF at baseline was 23.4 (range 2.3 - 49.9). The most common (≥ 20%) grade 3-5 treatment emergent adverse events (TEAEs), regardless of attribution, were febrile neutropenia (41%), lung infection (22%) and thrombocytopenia (26%). Nausea, vomiting and diarrhea occurred each in 41% of pts, but were primarily grade 1-2 (only 1 pt with grade 3 diarrhea). Hyperbilirubinemia of any grade occurred in 48% pts, including grade 3 in 15%. No case of IDH inhibitor associated differentiation syndrome (IDH-DS) occurred in this study. Grade 3 leukocytosis without IDH-DS occurred in 2 (8%) pts. No patient discontinued ENA because of an adverse event and no treatment-related death was reported. The PK profile of VEN was not altered by ENA, and the RP2D was VEN 400 mg daily plus ENA 100 mg daily. Among 23 pts with R/R AML evaluable for response, the ORR was 70% (16/23), including 57% (13/23) CR ( Figure 1). In pts with R172 mut, the ORR and CR rates were 83% (10/12) and 67% (8/12), respectively, versus 55% (6/11) and 45% (5/11) in pts with R140 mut. m IDH2 VAF at baseline was similar between responders and non-responders. On follow-up BM samples, there was an association between response and decrease in m IDH2 VAF. Clearance of m IDH2 was observed in 47% (7/15) of analyzed responders. The median time to initial response was 1 month (range, 0.9 - 5.7), and the median time to best response was 2.8 months (range, 0.9 - 12.5). The median DOR was 16.6 months (95% CI 5.0 - NR) and pts received a median of 7 cycles of treatment (range, 1 - 32). With a median follow-up of 17.1 months (range, 0.9 - 31.4), 10 (38%) pts were alive, including 9 (35%) in ongoing remission. The median OS was 9.4 months (95% CI, 8.2 - NR) and the 2-year OS rate was 42% (95% CI, 27 - 66). Four pts proceeded to HSCT after achieving remission, of whom 2/4 (50%) are alive in remission on last follow-up. CONCLUSIONS: The combination of ENA and VEN is safe and well tolerated in pts with R/R m IDH2 myeloid malignancies. The ENA-VEN combination compares favorably to ENA single-agent in this patient population. Further studies of targeted combination therapies using IDH2 and BCL2 inhibitors are warranted.

The Epidemiology of Cardiovascular Disease in African American Patients with Myeloid Neoplasms: A SEER Data Analysis

Introduction: Cardiovascular disease (CVD) mortality rates are higher in cancer survivors compared to the general population. Numerous studies have reported racial disparities in CVD mortality among cancer survivors. However, there is a lack of research exploring CVD mortality specifically in African American (AA) patients (pts) with myelodysplastic syndromes (MDS) and myeloproliferative neoplasms (MPN). To address this gap, we conducted a comprehensive population-based study to analyze cardiovascular mortality in the AA population with MDS and MPN. Methods and Statistical analysis: In Surveillance, Epidemiology, and End Results (SEER) database using the 17 registries, we identified cases of essential thrombocythemia (ET), Polycythemia Vera (PV), Primary Myelofibrosis (PMF), and Myelodysplastic syndromes (MDS) in AA population diagnosed between 2001-2020, with the diagnosis age &amp;gt;=20. CVD deaths included deaths from heart diseases, hypertension without heart disease, cerebrovascular diseases, atherosclerosis, and diabetes mellitus, based on the SEER Causes of Death Register and International Classification of Diseases (10th Revision, ICD10). Death rates were calculated by dividing the number of deaths over person-years of follow-up. We also estimated the standardized mortality ratios (SMR by dividing the observed cardiovascular deaths rates in our sample over expected CVD death rates of general population with no cancer, matched to age, gender and ethnicity. All analyses were performed by SEER*Stat 8.4.1.2 and R 4.2.2. Results: The study included 8135 patients, with following diagnoses: ET (n= 2317), PV (n= 1231), PMF (n= 377) and MDS (n= 4210). Overall, 2640 of the total study population (32.45%) died, of which 39.5% were CVD deaths. The mean follow up for PV, ET, PMF and MDS cohorts was 6.44, 5.95, 3.67 and 3.82 years, respectively (Table 1). The CVD mortality rate per 1,000 person-years in PV, ET and PMF subgroups were 17.9, 14.95, and 29.6, respectively. Notably, the rate was highest in the MDS subgroup, 40.37 compared to other subgroups (P&amp;lt;0.01). Comparing the CVD mortality of each risk group to the general US AA population, we observed significantly increased CVD SMRs. These were highest in PMF and MDS (SMR, 3.07; 95% CI, 2.2-4.16 and 2.25; 95% CI, 2.08-2.43, respectively), followed by PV (SMR, 1.75; 95% CI, 1.47-2.06) and ET (SMR, 1.67; 95% CI, 1.45-1.92).When comparing CVD mortality to the general CVD mortality rate in the AA population, we found higher rates across all age groups, including SMR, 13.16; 95% CI, 4.27- 30.72 in 20-29 yrs, SMR, 5.4; 95% CI, 2.95- 9.06 in 30-39 yrs, (SMR, 2.20; 95% CI, 1.92- 2.52) in 60-69 yrs, (SMR, 1.87; 95% CI, 1.67- 2.1) in 70-79 yrs (Figure 1). Conclusion: Our analysis highlights the magnitude of CVD-related deaths in the AA population with MDS and MPN. Among studied subgroups, the impact was highest in patients with MDS. This could be explained by a shared mechanism of CVD pathogenesis with MDS and clonal hematopoiesis of indeterminate potential (CHIP). In addition, we report a higher risk of CVD mortality at younger ages in AA pts relative to older age group. Because CVD-related mortality is high in AA with MDS and MPN, introduction of preventative cardiology services after diagnosis might be warranted to improve survival.

Single-Hit TP53mut Is Associated with Poor Outcomes in Therapy-Related but Not De Novo Myelodysplastic Syndromes: Importance of Clinical History

BACKGROUND: Recent World Health Organization (WHO) classifications (5 th edition), International Consensus Classification (ICC) recognized TP53-mutated ( TP53mut) myeloid neoplasms (MNs) as a distinct subcategory, acknowledging their uniformly poor outcomes. However, there are critical differences between the two guidelines in how TP53 allelic status is assigned. Both WHO-5 and ICC acknowledged the poor outcome of multi-hit TP53mut but excluded single-hit TP53mut. These changes are driven by a pivotal study demonstrating favourable outcome of single-hit TP53mut, however this study predominantly included de novo myelodysplastic syndromes (MDS) cases (Bernard et al. Nat Med 2020). In contrast, we previously reported poor outcome of TP53mut therapy-related myeloid neoplasm (t-MN) irrespective of the allelic status of TP53 (Hiwase et al Blood 2022andShah et al BCJ 2023). Finally, the ICC removed the subcategory of “therapy-related,” substituting it with diagnostic qualifiers instead. The WHO has grouped t-MN with secondary MN and renamed it as “myeloid neoplasm post cytotoxic therapy,” with the assertion that only multi-hit T P53mut MDS occurring post-cytotoxic therapy have poor outcome compared with single-hit. METHODS: We analyzed one of the largest international cohorts of TP53mut MN (n=544) with full characterization of TP53mut allele status utilizing uniform ICC criteria and similar large numbers of de novo and t-MN cases managed at Mayo Clinic Enterprise (USA) and South Australian MDS Registry, Adelaide (Australia) with clinical, integrated genomic profiling, and long-term follow-up. RESULTS: In our cohort of TP53mut MN (n=544), 475 (87.3%) MN had TP53mut variant allele frequency (VAF) of ≥10% and thus satisfied ICC criteria for TP53mut MN. Majority of TP53mut t-MN presented with MDS (bone marrow (BM) blasts 0-9%) compared de novo MN (62% vs. 48%; P=0.0012). While acute myeloid leukemia (AML) (BM blasts ≥20%) were more prevalent in TP53mutde novo MN compared to t-MN (38% vs. 24%; P= 0.001) and there was no difference in frequency of MDS/AML (BM blasts 10-19%) between the two cohorts (14% vs. 14%; P=0.8) ( Figure 1A). Majority of TP53mut were observed in the DNA-binding domain in t-MN and de novo MN (95% vs. 96.2%; P=0.48). However, mutations in Tetramer Domain were more frequent in t-MN (4.3% vs. 0.3%; P=0.002), whereas those in the TAD2 domain were more frequent in de novo TP53mut MN (2.4 vs. 0%; P =0.006). Integrating the mutation, conventional G-banding cytogenetic, copy number variation (CNV), FISH, and SNP array analysis, TP53mut MDS (BM blast 0-9%; n=260) were classified as multi-hit (n=179, 68.9%) or multi-equivalent (n=35, 13.5%) and single-hit (n=46, 17.7%) (Arber et al. Blood 2022). Striking enrichment of multi-hit/multi-hit equivalent was observed in TP53mut t-MDS compared to de novo MDS (91% vs. 72%; P&amp;lt;0.0001). While single-hit TP53mut were prevalent in de novo MDS compared to t-MDS (28% vs. 9%; P&amp;lt;0.0001). Importantly, median overall survival (OS) of single-hit was significantly longer than multi-hit de novo MDS (25.4 vs. 7.2 months; P=0.0002). In contrast to this we did not observe OS difference between single-hit and multi-hit TP53mut t-MDS (11.6 vs. 10.9 months; P =0.73) ( Figure 1B). CONCLUSION: Our study based on a large international cohort of T53mut MN provides compelling evidence that in contrast to de novo MDS, single hit TP53mut t-MDS is associated with poor outcome. Our data supports the consideration of single hit t-MDS as a multi-hit equivalent.

Subunit-Specific Analysis of Cohesin-Mutant Myeloid Malignancies Reveals Distinct Ontogeny and Outcomes

Introduction:Loss of function mutations in the cohesin complex ring components and modulators STAG2, RAD21, SMC1A, SMC3, and PDS5B are recurrent genetic drivers in myelodysplastic syndromes (MDS), acute myeloid leukemia (AML), and MDS/myeloproliferative neoplasm (MPN) overlap syndromes. However, whether different cohesin subunit mutations share disease characteristics and prognostic impact is not well understood. Methods: We assembled a cohort of 4,439 patients with hematologic neoplasms at the Dana-Farber Cancer Institute (DFCI) and the Munich Leukemia Laboratory (MLL), and identified a subset of 790 cohesin-mutant patients, the largest cohesin-mutant cohort to date. We performed a retrospective analysis of the incidence, clinical presentation, genomic landscape, and clinical outcomes in a cohesin subunit-specific way. Results: STAG2 mutations were most common and present in 610 cases (diagnosed as MDS (50%), AML (36%), MDS/MPN (10%)), followed by RAD21 in 104 (20% MDS, 64% AML, 2% MDS/MPN), SMC3 in 26 (35% MDS, 42% AML, no MDS/MPN), SMC1A in 22 (27% MDS, 55% AML, 5% MDS/MPN), PDS5B in 16 (13% MDS, 38% AML and 6% MDS/MPN), and 12 cases with more than one mutated cohesin gene (50% MDS, 33% AML, 8% MDS/MPN). Within the DFCI cohort, 256 (82%) patients were diagnosed with a myeloid malignancy and 55 (18%) patients with a non-myeloid hematologic malignancy. We focused our subsequent analysis on 735 patients diagnosed with MDS, MDS/MPN or AML, and compared them to 3,649 cohesin-wildtype (WT) patients in the DFCI and MLL cohorts. We found that STAG2 mutations were acquired at the MDS stage and were associated with MDS with increased blasts (75% cases with MDS-IB1 or IB2) and secondary AML. We also noted their co-occurrence with secondary AML-type mutations, such as ASXL1 (64%, OR=5.5, FDR=5e-29), SRSF2 (45%, OR=7.4, FDR=5-e31) and RUNX1 (37%, OR=3.5, FDR=2e-13), and trisomy 8 (OR=10.6, FDR= 2.2e-50). In contrast, mutations in RAD21, SMC1A, SMC3 and PDS5B shared features with de novo AML, including co-occurrence with NPM1 (32%, OR 4.3, FDR=1e-6) and FLT3 (23%, OR= 2.8, FDR= 0.01), and association of RAD21 and SMC1A with t(8;21) AML (OR= 131;134; FDR= 3.8e-5;4.1e-19). Of note, both STAG2 and RAD21 mutations shared a mutational exclusivity with TP53 mutations (OR=0.04-0.06, FDR &amp;lt; 0.001, Figure 1A). We next assessed the impact of different cohesin mutations on clinical outcomes. We conducted independent analyses of overall survival (OS) and progression free survival (PFS) in MDS and AML. Given our observations that cohesin mutations were mutually exclusive with TP53 mutations, and the established prognostic impact of TP53 mutations, we compared the overall survival (OS) and AML-free survival (PFS) of patients with STAG2-mutant MDS (n=119) to TP53-mutant MDS (n=280) and cohesin/ TP53-WT MDS (n=1,023). With a median follow-up (FU) of 51.1 months we observed a significantly worse OS of STAG2-mutant MDS compared to cohesin and TP53-WT MDS (HR 1.44, CI= 1.10-1.89, p=0.007) and a similar risk of leukemic transformation as TP53-mutant MDS cases (median AML-PFS of 15.4 months for STAG2, and 12.1 months for TP53, p=0.3). Furthermore, STAG2-mutant AML (n=148) had significantly worse OS than AML without myelodysplasia related changes (MR) (n=1384) (HR= 0.62, 95% CI=0.5-0.76, p&amp;lt;0.001, median FU 42.8 months), and similar outcomes as AML-MR without TP53 mutations (n=567), (HR=1.25, 95% CI= 1.01-1.55, p=0.04). Importantly, this pattern was distinct from outcomes of RAD21-mutant AML (n=39), which was almost identical to AML-non-MR and significantly better than STAG2-mutant AML OS (HR= 0.56, 95% CI= 0.34-0.93, p=0.024) ( Figure 1B). The effects of STAG2 and RAD21 mutations on OS remained significant when censored for allogeneic stem cell transplantation. Our findings suggest that only STAG2 mutations confer a negative impact on MDS and AML, and this is attributed to secondary ontogeny. Conclusions: In summary, our study establishes a role for different cohesin subunit mutations in distinct subtypes of MDS and AML, which has significant prognostic implications and expands our current understanding of this important group of driver genes. The findings from our subunit-specific analysis demonstrate that while STAG2 mutations are characterized by secondary AML ontogeny arising from MDS and associated with a worse prognosis, RAD21 mutations are associated with de novo AML and better survival.

Somatic Mutations and DNA Hypermethylation at Enhancers and Promoters Identify Distinct Subtypes within Lower-Risk Myelodysplastic Syndromes

Myelodysplastic syndromes (MDS) are a group of heterogeneous disorders caused by the accumulation of somatic mutations in the hematopoietic stem and progenitor compartment. Besides del(5q), SF3B1 or TP53 mutations, referred to as defining genetic abnormalities, mutation patterning hardly structured the classification of MDS. Mutations in epigenetic factors occur early in the development of clonal hematopoiesis leading to precocious alterations of DNA methylation implicated in oncogenesis. Convergent DNA methylation patterns related to both mutations and microenvironment imprinting may induce specific gene expression profiles and contribute to phenotypic variations. To refine a pathophysiological classification of lower-risk MDS, we combined genetic profiling to DNA methylation and transcriptome data. Methods: We enrolled 543 lower-risk treatment-naïve MDS patients at diagnosis and performed DNA-sequencing of 24 genes. DNA methylation and RNA-sequencing data were generated in a representative subset of 175 cases with available material (75 MDS-SLD/MLD, 40 MDS-EB1, 53 MDS-RS-SLD/MLD, 5 MDS del(5q), 2 MDS-U) and 7 age-matched healthy controls. IPSS-R was very low, low or intermediate in 87.4%. During a median follow-up of 2 years, 16% of MDS cases progressed to AML (MDSp). Infinium EPIC 850K array allowed after filtering the examination of methylation of 723,612 CpG sites with enrichment at enhancers and promoters. Differentially methylated regions with differentially methylated CpG sites (DMR-CpG) between cases and controls were defined with a minimum of 2 probes, a Benjamini-Hochberg-adjusted P-value cut-off of 0.05, a false discovery rate of 0.001 and a mean Δβ-value &amp;gt;20% at CpG sites. Consensus motifs for transcription factors were identified using Homer. Results: Unsupervised clustering on genetic profiling of 543 patients identified distinct subsets of lower-risk MDS with different clinical features: one cluster (group A) was enriched in del(5q), three clusters were characterized by SF3B1 mutations, either isolated (group B) or associated with DNMT3A (group E) or TET2 (group F), while the two remaining clusters were enriched in either complex pattern of mutations (group C) or SRSF2 mutations (group D). Genetic clusters showed significantly different clinical outcomes, clusters C, D and E having lower overall survival and higher risk of progression to high risk MDS or AML compared to other clusters. In the subset of 175 cases, a total of 2,953 unique DMR-CpGs allowed a robust repartition of patient samples in 4 groups using the k-means method. The 4 methylation groups were clinically distinct in terms of age, hemoglobin, neutrophils, monocytes, platelets, BM blasts, WHO classification, IPSS-R, and mutation pattern. A significant correlation was found between genetic and methylation groups ( P&amp;lt;0.001). Hypomethylated CpGs defined group 4 which was enriched in MDS-RSwith low blast count and few co-mutations, while groups 1 and 3 demonstrated hypermethylated profiles driven by TET2/ IDH1-2 mutations and TET2/ SRSF2 mutations, respectively. TET2-mutated cases exhibited an increased proportion of hypermethylated DMR-CpGs at enhancers (DME) significantly enriched in C/EBP and ETS family transcription factor motifs. In MDS without evidence of progression, we identified 1,418 DME and their gene targets of which those significantly deregulated in RNA-seq were involved in the control of translation and response to TGF-β. By contrast, in MDS with rapid progression to AML, DMR-CpGs were significantly enriched at CpG islands and promoters ( P&amp;lt;0.0001) and a set of 10-20 genes downstream of these promoters were specifically deregulated. Conclusion: Somatic mutations and DNA methylation at enhancers and promoters identify distinct subsets of lower-risk MDS with different clinical behavior. Hypermethylation at enhancers with C/EBP or ETS family motifs is a hallmark of MDS and may account for changes in transcription factor recruitment and cell fate. Hypermethylation of promoters with downstream effects on gene expression may indicate a propensity to rapid evolution to AML.

Reclassification of Ascertain (ASTX727-02) Myelodysplastic Syndrome (MDS) Patients: Outcomes Including Clinical Response, Overall Survival (OS), and Leukemia Free Survival (LFS) Based on IPSS-R and IPSS-M Scoring Systems

Background: Oral decitabine/cedazuridine (ASTX727) is a fixed dose combination of decitabine (35 mg) and the cytidine deaminase inhibitor cedazuridine (100 mg) given once daily X 5 days on a 28-day cycle producing pharmacokinetic (PK) exposure equivalent to the standard intravenous (IV) decitabine regimen of 20 mg/m 2 daily X 5 days on a 28-day cycle. This was demonstrated in the pivotal ASCERTAIN study (Garcia-Manero, et al, ASH 2019) as it provided a PK bridge to existing decitabine data and demonstrated median OS was 31.7 mo. (Savona,et al. Intl. MDSF International Congress on MDS, 2021). Subjects were initially classified by the International Prognosis Scoring System (IPSS) for historical reasons, however IPSS-R and IPSS-M are enhancements to IPSS that provide dynamic risk assessment for predicting clinical outcomes in MDS. Here, the objective was to re-classify the MDS subjects enrolled on the ASCERTAIN study by IPSS-R and IPSS-M and measure the impact of informing patient outcomes based on re-calculated risk assessment. Methods: One hundred thirty-three subjects with MDS/CMML (chronic myelomonocytic leukemia) were enrolled in ASCERTAIN and were randomly assigned either IV decitabine for cycle 1 and oral decitabine/cedazuridine for cycle 2 or the opposite treatment sequence. All subjects continuing beyond cycle 2 received oral decitabine/cedazuridine for all subsequent cycles until treatment discontinuation for disease progression, toxicity, patient's decision, or HSCT. Whole blood collected prior to treatment was used for DNA isolation and molecular abnormalities identified using next-generation sequencing (NGS) hematologic malignancy panel of 179 genes including all genes commonly mutated in MDS. In the initial analysis of clinical outcomes, subjects were classified by IPSS with response assessment by IWG 2006 IPSS low and Int-1 risk levels were categorized as lower-risk MDS (LR-MDS), whereas IPSS Int-2 and high-risk categories were categorized as higher-risk MDS (HR-MDS). Subjects with sufficient data based on (e.g., available heme parameters, cytogenetics, NGS etc.) were reclassified by IPSS-R and IPSS-M. Subjects with IPSS-R score of ≤3.5 or IPSS-M of either very low, low, or moderate low were categorized as LR-MDS. Similarly subjects with IPSS-R score of &amp;gt;3.5 or an IPSS-M categorization of either moderate high, high, or very high were categorized as HR-MDS. Reclassified subjects were reassessed for CR (Complete Response), OS, and LFS and Harrell's concordance index (c-index) was used to describe the level of agreement between each scale and outcomes. Results: Based on the available data, the number of MDS subjects in the different risk classifications were the following: IPSS: 117, IPSS-R: 104, and IPSS-M: 105. Thirteen and 12 subjects on the IPSS could not be reclassified in the IPSS-R and IPSS-M, respectively, including 5 Int-1 and 2 low-risk MDS cases. CMML subjects were excluded from these analyses. Re-classification generally resulted in the upgrade of the subjects from LR-MDS to HR-MDS (Fig. 1). Thirty-one (26.5%) subjects from IPSS were reallocated in the IPSS-R to different risk categories; 3 (9.7%) were downgraded and 28 (90.3%) were upgraded. Similarly on reclassification with IPSS-M 34 (32.4%) of the patients reclassified; 5 (14.8%) were downgraded and 29 (85.3%) were upgraded. For IPSS LR-MDS, 23.2% of patients achieved CR, and 22.9% in the IPSS HR-MDS. Similarly, 21.6% patients achieved CR in the IPSS-R LR-MDS, and 23.9% in the IPSS-R HR-MDS; 26.3% patients achieved CR in the IPSS-M LR-MDS, and 20.9% in the IPSS-M HR-MDS. The c-index for the IPSS was .64 (OS) and .67 (LFS), IPSS-R was .70 (OS) and .71 (LFS), and .75 (OS) and .78 (LFS) for the IPSS-M (Table1). Conclusion: Reclassification from IPSS to IPSS-R or IPSS-M upgraded multiple subjects from a LR to a HR category, describing the ASCERTAIN patient population as a majority higher risk population with worse prognosis than previously assumed based on the IPSS. The efficacy as measured by the CR rates did not change when the LR and HR categories were defined by the different risk stratification systems. In contrast, the c-index improves with migration from IPSS to IPSS-R to IPSS-M, indicating an increased discriminatory ability of IPSS-M score in comparison to IPSS and IPSS-R, to predict patient outcomes.