Adult Myelodysplastic Syndrome Research Articles

Pediatric Myelodysplastic Syndrome.

Myelodysplastic syndromes (MDSs) are rare in children and have unique clinical manifestations and implications. To review the clinical features, pathogenesis, and classification of pediatric MDS. Published literature and personal experience. Pediatric MDS vastly differs from adult MDS. Evaluation for the presence of an underlying germline predisposition syndrome is critical for optimal classification and management. Because of the rarity of cases, resources to aid with the recognition, diagnosis, and management of pediatric MDS are limited, and multi-institutional collaborative studies are needed for the future.

Superior survival after unrelated allogeneic stem cell transplantation with low-dose ATG compared to low-dose TBI in myeloablative fludarabine/busulfan-based regimen for MDS on behalf of the adult MDS Working Group of the JSTCT

The fludarabine/intravenous busulfan 12.8 mg/kg (FB4) regimen is an effective conditioning regimen in allogeneic hematopoietic stem cell transplantation for myelodysplastic syndrome (MDS); however, limited data is available on the prognostic impact of FB4 with low-dose anti-thymoglobulin (ATG ≤ 5 mg/kg) or low-dose total body irradiation (TBI ≤ 4 Gy). Therefore, we retrospectively evaluated the outcomes in 280 adults with de novo MDS who underwent their first transplantation from an unrelated donor between 2009 and 2018. Median age was 61 years (range, 16 to 70 years). In the FB4 alone (FB4), FB4 plus ATG (FB4-ATG), and FB4 plus TBI (FB4-TBI) groups, 3-year overall survival (OS) rates were 39.9, 64.8, and 43.7 %; 3-year non-relapse mortality (NRM) were 32.1, 22.1, and 27.1%; and 3-year relapse incidences were 34.7, 21.2, and 28.9%, respectively. The multivariate analyses showed that FB4-ATG group significantly correlated with better OS (hazard Ratio [HR], 0.51; 95% confidence interval [CI], 0.27-0.95; P=0.032) than FB4 group. FB4-ATG group tended to correlate with lower NRM (HR, 0.36;95% CI, 0.13-1.06; P=0.063) than FB4 group. In comparison with FB4-TBI group, FB4-ATG group showed better OS (HR 0.52, 95% CI 0.27-0.99, P=0.049) and NRM (HR 0.034, 95% CI 0.11-0.92, P=0.034). No significant differences were observed in OS and NRM between the FB4-TBI and FB4 groups. The present study demonstrated that the FB4 plus low-dose ATG regimen improved OS and NRM, but FB4 plus low-dose TBI regimen had no clear benefit over FB4 alone, in MDS patients who used unrelated donors.

Higher prevalence of poor prognostic markers at a younger age in adult patients with myelodysplastic syndrome – evaluation of a large cohort in India

BackgroundThe karyotype is a major determinant of prognosis in myelodysplastic syndrome (MDS). Details of the cytogenetic profile of MDS in South Asia are limited because cytogenetic services are not widely available.MethodsWe performed a retrospective analysis of the cytogenetic and clinicopathologic profile of adult primary MDS seen consecutively at a tertiary-care centre in South India between 2003 and 2017. Patients were re-categorised according to the 2022 World Health Organisation (WHO) and the International Consensus classifications (ICC).ResultsThere were 936 patients aged 18–86 years (median age 53, 65% males), with MDS with del 5q, low blasts and increased blasts in 7.5%, 58.4% and 34.1% respectively. Clonal abnormalities were seen in 55% of patients, with solitary abnormalities in 29.8% and complex karyotypes (CK, ≥ 3 abnormalities) in 15%. The most frequent abnormalities were monosomy 7/deletion 7q (16.1%), deletion 5q (14.5%), trisomy 8 (11.5%), and deletion 20q (5.1%). Cytogenetic prognosis groups were distributed as follows: very good, 2%; good, 55.6%; intermediate, 16.2%; poor, 15%; very poor, 11.2%. Clinical (IPSS-R) risk stratification (842 patients) showed: very low-risk, 3.9%; low-risk, 30.9%; intermediate-risk, 24.2%; high-risk, 21%; very high-risk, 20%. Age-adjustment (IPSS-RA) raised the very low-risk group to 12.4%; the other groups decreased by 1–3% each.ConclusionThe most significant finding of this cytogenetic analysis of MDS in India is that abnormal karyotypes with poor prognosis markers including monosomy 7 and CK were more frequent than in most other reports, among patients who were overall younger. Trisomy 8, deletion 20q, the IPSS-R intermediate-risk and both high-risk groups were more common than in the West. Trisomy 8 was less common than in South-East Asia while CK and deletion 20q were comparable. Evaluation of such large cohorts highlights the unique features of MDS in different parts of the world. These findings suggest that there could be differences in predisposing factors, environmental or genetic, and emphasise the need for further exploration to better understand the varied nature of MDS.

MDS-712 High Proportion of Adolescent and Young Adult Myelodysplastic Syndrome in a Developing Country: An Epidemiological Study Using the Jordan Cancer Registry and the SEER Database From 2007-2019

MDS-712 High Proportion of Adolescent and Young Adult Myelodysplastic Syndrome in a Developing Country: An Epidemiological Study Using the Jordan Cancer Registry and the SEER Database From 2007-2019

Prospective genetic germline evaluation in a consecutive group of adult patients aged

Relevance of germline (GL) predisposition in myelodysplastic syndromes (MDSs) was stressed in both 2022 WHO and International Consensus classifications, but its incidence is probably underestimated, especially in young adult patients. We selected a cohort of 31 consecutive de novo MDS patients with unusual young age (<60 years). We performed exome sequencing (ES) on DNA extracted from noninvasive sources (peripheral blood and saliva), filtering for a panel of 344 genes specifically tailored for detecting GL variants related to clonal and nonclonal cytopenia. We observed at least one high- or low-confidence GL MDS variant in 7/31 (22.6%) and 9/31 (29.0%) of cases, respectively. Four of 31 patients (12.9%) confirmed having established MDS/AML predisposing disorders. We found heterozygous variants in genes involved in DNA repair/cancer predisposition (ATM, ATR, FANCM, PARN, BRCA1, BRCA2, CHEK2, MSH2) in 9/31 (29.0%) casesand variants affecting ribosome biogenesis (SBDS), hematopoietic stem cell (GATA2), and megakaryocyte (ANKRD26) differentiation in single cases. Two cases had variants in RBBP6, a gene previously described exclusively in familial myeloproliferative neoplasms. Lastly, four cases had variants in genes related to inherited anemias (CUBN and PIEZO1 genes). Our results showed that "young" MDS patients aged 40-60 years carried reported and unreported GL variants with an unexpectedly high proportion, and these events co-occurred with somatic mutations recurrent in myeloid neoplasms. We explored the "no man's land" of the young adult MDS cases adopting a practical and scalable diagnostic tool, capable to detect GL variants avoiding invasive methods.

Impact of Early Cytomegalovirus Reactivation After Allogeneic Hematopoietic Stem Cell Transplantation on Relapse in Patients With Myelodysplastic Syndrome: A Nationwide Retrospective Study From Adult Myelodysplastic Syndrome Working Group of the JSTCT

Cytomegalovirus (CMV) reactivation is a prominent complication associated with adverse outcomes in allogeneic hematopoietic stem cell transplantation (HSCT). However, CMV reactivation after allogeneic HSCT may be associated with a lower incidence of relapse in some hematological malignancies. This study analyzed the Japanese registry data from 1082 patients with myelodysplastic syndrome (MDS) who underwent their first allogeneic HSCT and survived for 100 days after transplantation without graft failure or disease relapse to investigate this association. Patients who received cord blood transplants, demonstrated in vivo T cell depletion, underwent prophylactic anti-CMV treatment, or diagnosed with secondary MDS were excluded. CMV reactivation measured by pp65 antigenemia within 100 days after allogeneic HSCT was observed in 57.5% of patients, with a median time of 46 days from transplant. The 5-yr overall survival and cumulative incidence of relapse (CIR) in the cohort were 60.5% and 15.6%, respectively. The 5-yr CIR showed no significant difference between patients with and without CMV reactivation (14.4% versus 17.2%; P = .185). Interestingly, CMV reactivation within 100 days was significantly associated with a lower 5-yr CIR (7.6% versus 16.4%; P = .002) in patients with <5% myeloblasts in the bone marrow (BM) just before HSCT. Furthermore, this relevancy confirmed even when excluding patients with Grade II to IV acute GVHD (Hazard ratio: 0.38; 95% confidential intervals: 0.18–0.801; P = .011). Our findings indicate a correlation between early CMV reactivation and MDS relapse, based on the proportion of myeloblasts in the BM. These results may contribute to the development of effective CMV prophylaxis post-HSCT.

Early transfusion patterns improve the Molecular International Prognostic Scoring System (IPSS-M) prediction in myelodysplastic syndromes.

The Molecular International Prognostic Scoring System (IPSS-M) is the new gold standard for diagnostic outcome prediction in patients with myelodysplastic syndromes (MDS). This study was designed to assess the additive prognostic impact of dynamic transfusion parameters during early follow-up. We retrieved complete transfusion data from 677 adult Swedish MDS patients included in the IPSS-M cohort. Time-dependent erythrocyte transfusion dependency (E-TD) was added to IPSS-M features and analyzed regarding overall survival and leukemic transformation (acute myeloid leukemia). A multistate Markov model was applied to assess the prognostic value of early changes in transfusion patterns. Specific clinical and genetic features were predicted for diagnostic and time-dependent transfusion patterns. Importantly, transfusion state both at diagnosis and within the first year strongly predicts outcomes in both lower (LR) and higher-risk (HR) MDSs. In multivariable analysis, 8-month landmark E-TD predicted shorter survival independently of IPSS-M (p<0.001). A predictive model based on IPSS-M and 8-month landmark E-TD performed significantly better than a model including only IPSS-M. Similar trends were observed in an independent validation cohort (n=218). Early transfusion patterns impacted both future transfusion requirements and outcomes in a multistate Markov model. The transfusion requirement is a robust and available clinical parameter incorporating the effects of first-line management. In MDS, it provides dynamic risk information independently of diagnostic IPSS-M and, in particular, clinical guidance to LR MDS patients eligible for potentially curative therapeutic intervention.

Red Blood Cell Transfusion Dependence Is Associated with Greater Healthcare Resource Utilization, Higher Medical Cost, and Poorer Prognosis in Patients with Lower-Risk Myelodysplastic Syndromes: A 28-Year Retrospective Observation Study Result

Myelodysplastic syndromes (MDS) encompass a heterogeneous group of myeloid neoplasms characterized by cytopenia due to inefficient hematopoiesis, with a considerable risk of progression to acute myeloid leukemia (AML) or early mortality. In lower-risk MDS (LR-MDS) patients, anemia and its associated complications have been the focus of clinical attention. A significant portion of these patients eventually develop red blood cell transfusion dependence (RBC TD), which has been linked to a poorer prognosis. Given the limited efficacy of available treatments in reducing RBC TD, most patients face increased risks of chronic anemia and various complications. Moreover, RBC TD is known to be associated with reduced overall survival (OS) and leukemia-free survival (LFS). This study aimed to assess the impact of RBC TD on the socioeconomic burden and clinical prognosis of LR-MDS patients, utilizing an electronic medical records (EMR) database spanning nearly 30 years of MDS patient data. This retrospective observational study examined adult MDS patients (≥ 18 years of age) treated at Samsung Medical Center in the Republic of Korea. Eligible patients were diagnosed with MDS between Sep 1, 1994, to Apr 1, 2022 (index period), with the observation period spanning from Sep 1, 1994, to Sep 1, 2022. Baseline assessments included estimation of revised international prognostic scoring system (IPSS-R) scores, categorizing patients with very low, low or intermediate risks as lower-risk MDS (LR-MDS). TD was defined as the occurrence of any 16-week period with RBC transfusion of ≥ 2 units per 8 weeks, without consecutive 56-day period without transfusion. Healthcare resource utilization (HCRU), medical costs, and prognosis indicators including overall survival (OS) and AML-free survival (AFS) were analyzed and compared between patients who experiencing TD and those not (non-TD). Out of 831 MDS patients, 349 (42.0%) were classified as lower-risk at baseline. Among LR-MDS patients, 29.5% (103/349) experienced TD while 23.3% (194/831) experienced TD in the entire study population. The median age at diagnosis of MDS was 63 (ranging from 18 to 89), and 65.3% (543/831) were male. In LR-MDS patients, there were no significant differences in either baseline age (61 vs 63, P=0.16) or gender (71.8% vs 61.0% males, P=0.053) between TD and non-TD groups. However, TD group exhibited significantly higher median erythropoietin (EPO) level than non-TD group (290.5U/L vs. 112U/L, P&amp;lt;0.001) among LR-MDS patients with available baseline serum EPO levels (76 TD and 178 non-TD). Among the 76 TD LR-MDS patients with baseline serum EPO levels, 51 (67.1%) exhibited &amp;gt; 200U/L, which is considered a clinical threshold for erythropoiesis-stimulating agent (ESA) treatment. As shown in Table 1, RBC TD was consistently associated with greater HCRU and higher medical costs, especially in LR-MDS patients. TD LR-MDS patients had higher rates of outpatient department and emergency room visits (15676 vs. 8303 visits and 587 vs. 328 visits per 1000 person-years [PY], respectively), and increased hospitalizations (709 vs. 456 per 1000 PY), with longer hospital stays (13343 vs. 8272 days per 1000 PY). Furthermore, TD LR-MDS patients required over four-times of packed RBC units than non-TD patients (31107 vs. 7073 units per 1000 PY). Consequently, TD LR-MDS patients incurred higher total medical cost than their non-TD counterpart (13.5 million vs. 6.1 million USD per 1000 PY). Median OS (58.4 months vs. 103.1 months) and AFS (52.7 months vs. 102.7 months) were both significantly shorter in the TD group compared to the non-TD group among LR-MDS patients, while the differences in OS and AFS did not reach the level of significance in the entire study population (Table 1 and Figure 1). Notably, median OS after the first documented RBC TD event was 33.8 months (95% confidence interval: 24.7-58.5 months) in LR-MDS patients. The findings of this study indicate that RBC TD can be a strong predictor of increased HCRU and medical costs, as well as decreased OS and AFS over a 20-year period following the initial diagnosis of LR-MDS. Given that a majority of LR-MDS patients experiencing TD may not be eligible for ESA treatment due to elevated EPO levels exceeding 200U/L, and the use of cytotoxic agents is not usually recommended for these patients, these results highlight a substantial unmet need for alternative treatment options to address RBC TD in LR-MDS patients.

Effect of Early Cytomegalovirus Reactivation on Relapse in Adult Patients with Myelodysplastic Syndromes after Allogeneic Hematopoietic Stem Cell Transplantation: A Registry Study from the Japan Society for Transplantation and Cellular Therapy (JSTCT)

Background Cytomegalovirus reactivation (CMVR) is a well-known complication contributing to morbidity and mortality in patients undergoing allogeneic hematopoietic stem cell transplantation (HSCT). Previous studies have demonstrated that CMVR is associated with poor clinical outcomes following HSCT. However, some studies have shown that CMVR following HSCT may have a recurrence-suppressing effect on hematological diseases, including acute myeloid leukemia and acute lymphoblastic leukemia. Conversely, data on the relevance between CMVR and relapse in patients with myelodysplastic syndromes (MDS) following HSCT remain limited and inconclusive. This nationwide retrospective study aimed to examine the association between CMVR and MDS relapse following HSCT. Methods This study was conducted by the Adult Myelodysplastic Syndromes Working Group of the Japan Society for Transplantation and Cellular Therapy (JSTCT). Clinical data were collected by the JSTCT and the Japanese Data Center for Hematopoietic Cell Transplantation employing the Transplant Registry Unified Management Program (TRUMP). Overall, 1,082 patients aged ≥16 years who were diagnosed with de novo MDS, underwent initial allogeneic HSCT between 2010 and 2018, and survived until 100 days post-transplant without disease relapse were examined. Patients who received cord blood transplantation, in vivo T-cell depletion, and prophylactic anti-CMV treatment were excluded. CMVR was defined as the initiation of CMV preemptive or definitive therapy within 100 days post-transplant. Patients underwent pp65 antigenemia monitoring commencing at the time of neutrophil engraftment after HSCT. Preemptive therapy was typically instituted upon the detection of a minimum of 2 CMV pp65 antigen-positive cells per 50,000 white blood cells. In analysis, CMVR and acute/chronic graft-versus-host disease (GVHD) were evaluated as time dependent covariates. This retrospective study was approved by the Data Management Committee of the JSTCT and the ethics committee of the Ehime University School of Medicine. Results Of the 1,082 patients, 622 (57.5%) experienced CMVR. The median time from HSCT to the onset of CMVR was 46 (range, 4-97) days. In contrast, reactivation beyond 100 days after HSCT was observed in 20 patients (1.8%). End-organ disease due to CMV infection was detected in 79 (7.3%) patients with a median of 61 (range, 19-385) days. CMV infections included enteritis (n = 65), retinitis (n = 5), pneumonitis (n = 4), hepatitis (n = 3), and others (n = 3). Of the whole cohort, the 5-year cumulative incidence of relapse (CIR), non-relapse mortality (NRM), disease-free survival, and overall survival (OS) were 15.6%, 26.7%, 57.7%, and 60.5%, respectively. The OS of patients with CMVR was significantly lower than that of patients without CMVR (P = 0.047). A total of 423 patients died at the time of analysis, and no difference in the cause of death was found between patients with and without CMVR. Then, the effect of CMVR on relapse after HSCT was analyzed by patient, disease, and transplant characteristics. Interestingly, in patients with &amp;lt;5% bone marrow blast count at the time of HSCT, CMVR was significantly associated with a lower CIR (5-year CIR, 7.6% vs. 16.4%; P = 0.002). On the contrary, no difference in the CIR was found between patients with and without CMVR in the group with ≥5% bone marrow blast count (5-year CIR, 19.4% vs. 18.0%; P = 0.72). Moreover, the OS of patients with CMVR was significantly lower than that of patients without CMVR in the group with ≥5% bone marrow blast count (P = 0.009). However, the OS of patients with &amp;lt;5% bone marrow blast count was similar between with and without CMVR (P = 0.82). In the multivariate analysis, CMVR was significantly associated with a lower CIR in the group with &amp;lt;5% bone marrow blast count (hazard ratio [HR], 0.40; 95% confidence interval [CI], 0.23-0.70; P = 0.001). Furthermore, in the analysis excluding patients with grade II-IV acute GVHD, CMVR was similarly associated with a lower CIR in the group with &amp;lt;5% bone marrow blast count (HR, 0.38; 95% CI, 0.18-0.80; P = 0.011). Conclusion This study presents that CMVR may have different effects on MDS relapse depending on the bone marrow blast count at the time of HSCT. Although more studies are needed to understand the underlying mechanisms of this association, these findings may serve as a basis for devising effective CMV prophylaxis after HSCT.

Early-Onset Myelodysplastic Syndromes (MDS) with Ring Sideroblasts (RS) without SF3B1 Mutations in Adults: Enrichment with Germline Variants in Genes Responsible for Congenital Sideroblastic Anemias

Introduction: Acquired mutations in SF3B1 gene in myeloid neoplasms are classically associated with the presence of RS in Pearl Stain, ineffective erythropoiesis, and favorable prognosis. Nevertheless, in up to 20-25% of adults diagnosed with MDS with RS (WHO 2017), mutations in SF3B1 are not found, and molecular grounds for the presence of RS remain to be ascertained. The objective of our study was to investigate whether the presence of RS could be associated with germline variants in genes responsible for congenital sideroblastic anemia (CSA). Methods: Patients diagnosed with de novo MDS between 16-60 years of age without previous organ dysfunction were recruited from 32 centers of GEMSD since 2016. Whole exomes were sequenced using HiSeq4000-NovaSeq6000-Illumina, paired tumor-germline samples. Mean depth was 100x, with 150 million reads per sample and quality Q30a&amp;gt;95%. Variants were analyzed using a bioinformatics pipeline: filtering intronic and synonymous variants and those with a population frequency &amp;gt;1%. The mutational state of SF3B1 was determined by Sanger Sequencing and Next Generation Sequencing (NGS). Germline variants were categorized according to American College of Molecular Genetics (ACMG) criteria. The list of genes related to CSA explored in this study is shown in Table 1. Results: Among 239 cases of adults diagnosed with early-onset MDS (mean age at diagnosis: 48 years, range 16-60), 58 (24%) patients presented with RS in bone marrow (mean RS: 28%). Of these 58 patients, acquired mutations in SF3B1 were not found in 32 (55%). Nine out of these 32 (25%) harbored a germline variant (two variants in one case) in genes responsible for CSA (Table 2): SLC25A38 (n=2), STEAP3 (n=2) FECH, ALAS2, GLRX5, SLC19A2, TRNT1 and IARS2. This frequency was statistically higher than in the SF3B1 and RS mutated group (n=23), with only one case with a germline variant in a CSA gene (p=0.013). It was also higher than in the non-RS cases (n=181), with only one case in this group (p&amp;lt;0.001). Using the Fisher's exact test, commonly used to perform enrichment, the odds ratios were also significant (p=0.033 and p&amp;lt;0.0001), respectively. Among patients with RS, those carrying a CSA gene germline variant were younger (43 vs. 54 years, p=0.04), had a higher rate of neutropenia (1.8 vs. 2.6 x 10E9/L, p=0.02), and thrombocytopenia (151 vs. 259 x 10E9/L, p=0.03) than MDS-RS patients with SF3B1 mutated. Furthermore, MDS-RS with a germline variant in CSA genes had a lower mean percentage of RS than patients who acquired the mutation in SF3B1 (14% vs. 38%; p=0.003). Conclusions: In our series, the frequency of MDS-RS without SF3B1 mutations is higher in early-onset adult MDS than the one reported in MDS in advanced age. Whole exome analysis allowed us to describe, for the first time, a significant enrichment of variants in genes causing CSA in young adults with RS and without acquired mutation in SF3B1.

Single-unit unrelated cord blood transplantation versus HLA-matched sibling transplantation in adults with advanced myelodysplastic syndrome: A registry-based study from the adult MDS working group of the Japanese society for transplantation and cellular therapy.

Allogeneic hematopoietic stem cell transplantation (HCT) remains the only potential curative therapeutic modality for advanced myelodysplastic syndrome (MDS). Within HCT, the advancement of cord blood transplantation (CBT) procedures has resulted in a drastic expansion of CBT as a donor source for MDS. However, data comparing matched sibling donors (MSDs) HCT with CBT for advanced MDS, which was defined as refractory anemia with an excess of blasts (RAEB)-1 and RAEB-2 according to the World Health Organization classification at the time of HCT, have not been explored. We retrospectively compared survival and other posttransplant outcomes in 999 adult patients with advanced MDS after receiving allogeneic HCT in Japan between 2011 and 2020, using either MSD (n=331) or single-unit unrelated cord blood (UCB) (n=668). In the multivariate analysis, there were no significant differences in overall survival (hazard ratio [HR], 1.10; 95% confidence interval [CI], 0.90-1.34; P=0.347), disease-free survival (HR, 1.01; 95% CI, 0.84-1.23; P=0.845), relapse (HR, 0.88; 95% CI, 0.68-1.15; P=0.370), or non-relapse mortality (HR, 1.15; 95% CI, 0.87-1.50; P=0.310) between MSD recipients and UCB recipients. UCB was significantly associated with lower neutrophil (HR, 0.28; 95% CI, 0.24-0.33; P<0.001) and lower platelet (HR, 0.29; 95% CI, 0.23-0.36; P<0.001) recovery compared to MSD. UCB was significantly associated with a lower incidence of chronic graft-versus-host disease (GVHD) (HR, 0.57; 95% CI, 0.44-0.75; P<0.001) and extensive chronic GVHD (HR, 0.46; 95% CI, 0.32-0.67; P<0.001) compared to MSD. Similar results were observed after adjusting for differences between MSD and UCB recipients by propensity score matching analysis. Our study demonstrated that single CBT and MSD HCT had similar survival outcomes for adult patients with advanced MDS despite the lower hematopoietic recovery in CBT recipients and higher chronic GVHD in MSD recipients.

Treosulfan for acute myeloid leukaemia and myelodysplastic syndrome in adults, and malignant and non-malignant haematological diseases in children.

Treosulfan for acute myeloid leukaemia and myelodysplastic syndrome in adults, and malignant and non-malignant haematological diseases in children.

Incidence of cardiac events in patients with MDS or AML receiving azacitidine or decitabine within a large community health system.

e19074 Background: Hypomethylating agents (HMA) such as decitabine and azacitidine are frontline therapies for myelodysplastic syndrome (MDS) and acute myeloid leukemia (AML). Limited data exist on subsequent cardiovascular (CV) events. Johnson et al. reported 170 patients receiving HMA + venetoclax with a CV event rate of 20%. Aims: To investigate the incidence of CV events in patients receiving HMA. Methods: We analyzed adult AML and MDS patients with &gt; 1 dose of azacitidine or decitabine from 1/2018-12/2020. New CV events were defined as new atrial fibrillation, acute coronary syndrome, cardiomyopathy, congestive heart failure, myocarditis, or pericarditis. Competing risks regression identified baseline predictors associated with time to first CV event while accounting for the competing event of death. Results: 94 patients with no CV history were evaluated which consisted of a mean age 69 +/- 12 years and 50% male. 56% had MDS and 44% AML. Patients with BMI ≥ 30 accounted for 38.3% of the sample. 44 (47%) patients had baseline echocardiogram assessments prior to initiation of HMA with EF of 61+/- 8%; 57 (61%) had a documented prescription of beta-blocker, ACE-I, or ARB at time of HMA initiation. In the 94 patients, 16 new cardiac events occurred. Median survival after therapy initiation was 14.8 months. In a competing risks univariate analysis, lower prior EF (after adjusting for no EF performed) and absence of pre-chemotherapy beta-blocker, ACE-I, or ARB were significantly associated with having a new cardiac event post chemotherapy start (hazard ratio per 5-unit decrease = 1.62 (1.33-1.99), p&lt;0.01 and HR=2.89 (1.08-7.77), p=0.03, respectively). Baseline BMI did not affect risk of a new CV event on HMA therapy (HR per 5 units=1.08 (0.78-1.50), p=0.63). Total HMA dose did not show significance as a predictor for CV events (HR=0.99 (0.987-1.009), p=0.72). Conclusions: We observed a CV event incidence of 19% at 3 years after the start of HMAs. Among patients receiving HMA chemotherapy, those with a lower baseline EF and those not on beta-blocker, ACE-I or ARB therapy prior to initiation of HMA had a higher incidence of cardiotoxicity. Neither pre-HMA BMI nor total HMA dose received appeared to predict risk for CV events. Further research is warranted evaluating the association between HMAs and cardiotoxicity. [Table: see text]

Clinical, Hematological, and Cytogenetic Profile of Myelodysplastic Syndromes in Adults: A Three-year Cross-sectional Study.

Myelodysplastic syndromes (MDS) are a group of clonal hematological disorders with a diverse clinico-hematological profile. Studies in India have shown a different biology from the West. This study aimed to assess the clinicopathologic profile of MDS patients, classify them according to the World Health Organization classification system, categorize them into International Prognostic Scoring System (IPSS) and the revised IPSS prognostic subgroups, and evaluate the treatment outcome. A cross-sectional study was conducted on 48 patients diagnosed with MDS from January 2017 to December 2019 from Rajagiri Hospital, India. Clinical, hematological, and cytogenetic features were analyzed. The patients were stratified according to the IPSS and revised IPSS and were followed-up for a minimum of six months. The patients most affected were those in the seventh decade of life. We found a slight female preponderance and a mean age of 57.5 years in females and 67.7 years in males. Anemia was the most common manifestation of MDS. On the other hand, thrombocytopenia was found to be the least common cytopenia. MDS with multilineage dysplasia was the most common subtype. Cytogenetic abnormalities were seen in 29.5% of cases. Most of the patients were in the low-risk prognostic categories. Our patients were older when compared to those of other Indian studies, with most in the low-risk categories which were like Western data.

Is Klotho Gene a Biomarker to Pathogenesis of Myelodysplastic Syndrome in Elderly Patient? A New Hypothesis

An important new biomarker for cancer is the Klotho, an anti-aging target, associated to proliferation and apoptosis of tumor cells. In this study, we hypothesized that the Myelodysplastic syndrome (MDS) pathogenesis, an elderly hematopoietic disease, can be affect by block of the Klotho expression, increasing ROS production in the medullary microenvironment, attenuating the DNA damage in HSCs, and leading to reduced count of blood cell precursors, characterizing the cytopenic profile of MDS patient. The absence or negative regulation of Klotho may be a poor prognostic marker of MDS, especially when patients are stratified by age. We believed that younger adult MDS patients show a higher Klotho expression while compared to old adults MDS patients, demonstrating that its expression is decreased with increasing age, representing a more aggressive disease. To confirm this hypothesis, an extensive clinical case-control study can be performed on bone marrow cell samples of MDS patients to show differential expression of Klotho gene and protein, and as this target can be modulate in this disease (based on promoter region methylation analysis). These approaches may define the Klotho as a new pathologic marker to MDS in elderly and improve future potential therapies.

Application of Newly Developed IPSS-M and Comparison of Different Prognostic Systems in Patients with Myelodysplastic Syndrome

Introduction: A risk-adapted treatment strategy is of crucial importance in patients with myelodysplastic syndromes (MDS). With the rapid development of high through-put technology like next generation sequence (NGS), multiple mutations have been revealed as significant factors in MDS. However, previous risk prognostic scoring systems such as the International Prognostic Scoring System (IPSS), the revised IPSS (IPSS-R), and the World Health Organization-classification-based Prognostic Scoring System (WPSS) did not integrate molecular abnormalities. The newly published IPSS-Molecular (IPSS-M) model, which combining genomic profiling with hematologic and cytogenetic parameters in the IPSS-R system (including bone marrow blasts, platelets and hemoglobin), was recently developed to evaluate the associations with leukemia-free survival (LFS), leukemic transformation, and overall survival (OS). This model is considered to be a valuable tool for clinical decision-making. However, it has not yet been widely validated in the clinic. This study is to further validate the prognostic power of IPSS-M based on the real-world data, and to compare the prognostic value of different scoring systems in patients with MDS. Methods：A population of 255 adult MDS was considered. The IPSS-M Web calculator (https://mds-risk-model.com) was used to calculator a tailored IPSS-M score of each patient, and the risk category was therefore divided correspondingly. We then compared the IPSS-M prognostic power to that of IPSS, IPSS-R, and WPSS. The receiver operating characteristic curve (ROC) was used to evaluate the efficiency of the prognostic models. The Spearman's rank correlation rho was used to evaluate the relevance of different tools. Kaplan-Meier (K-M) survival curve with Log-Rank analysis was performed in the study. Results: Median follow-up was 33.2 (95%CI: 27.8-41.1, reverse K-M) months for the whole cohort. Median OS was 28.3 (21.3-35, K-M) months. We mapped at least one oncogenic gene alteration in 75% of patients with MDS, and found that TET2 (23%), ASXL1 (19%), TP53 (15%), DNMT3A (10%), U2AF1 (9%), SF3B1(9%), EZH2 (9%), RUNX1 (5%), WT1 (5%) and SETBP1(5%) are the top 10 genes with the highest mutation frequency (Fig. 1a). Similar with the other three prognostic systems, IPSS-M risk classification was statistically significant for OS (P<0.0001 for IPSS-M, P=0.00061 for IPSS, P<0.0001 for IPSS-R and WPSS) and LFS (P<0.0001 for IPSS-M, IPSS, IPSS-R and WPSS) (Fig 1b). However, no prognostic tool predicted the probability of achieving an objective response. Among the four risk stratification tools, WPSS was more superior in sensitivity and accuracy for OS, while IPSS-M was more superior for LFS (Fig. 1c). The Spearman's rho of IPSS-M with IPSS, IPSS-R and WPSS was 0.646, 0.786 and 0.729, respectively. This indicated that IPSS-M was more correlated with IPSS-R. The mapping C-index between IPSS-R and IPSS-M categories resulted in improved discrimination across the OS and LFS but not leukemic transformation (Fig. 2a). Additionally, it is also resulted in the re-stratification of 45% of MDS patients (114/255) (Fig. 2b). Of these, 85 (33%) were upstaged and 29 (11%) were down-staged. Among re-stratified patients, 19 of 80 (24%) had one mutated gene in IPSS-M, whereas 23 of 80 (29%) had two or more (Fig. 2c). Thus, patient re-stratification was not a single gene effect, but the cumulative contribution of the prognostic mutations for each patient. To further explore the effect of hypomethylation agents (HMAs) or best supportive care (BSC) on different groups, we analyzed the K-M survival curves of higher-risk (HR) and lower-risk (LR) groups stratified by IPSS-M and IPSS-R (Fig. 2d). The results showed that compared with BSC, HMAs did not improve OS and LFS either in HR or LR groups. In patients treated with HMAs, IPSS-M was more superior in both sensitivity and applicability than IPSS-R in OS, with the C-index value of 0.611 vs. 0.582. Conclusions: Overall all prognostic scoring systems well represent the prognostic risk of MDS patients. A highly significant correlation was found between the IPSS-M and IPSS-R risk classifications. IPSS-M provides relevant information for the implementation of risk-adapted strategies in MDS. Figure 1View largeDownload PPTFigure 1View largeDownload PPT Close modal

ERCC6L2 in Early-Onset Adult Myelodysplastic Syndrome without Pre-Existing Disorder

ERCC6L2 in Early-Onset Adult Myelodysplastic Syndrome without Pre-Existing Disorder

Germline and Somatic Defects in DDX41 and its Impact on Myeloid Neoplasms.

While DDX41 mutation (m) is one of the most prevalent predisposition genes in adult myelodysplastic syndrome (MDS)/acute myeloid leukemia (AML), most patients do not always present with a family history of MDS/AML. In this review, we will be highlighting epidemiological data on DDX41m, roles of DDX41 in oncogenesis, mechanisms of clonal evolution with somatic DDX41m, and clinical phenotypes and management of MDS/AML in patients harboring DDX41m. DDX41 encodes a DEAD-box helicase protein that is considered essential for cell growth and viability. High incidence of myeloid malignancies and other cancers in patients bearing DDX41m suggests that defects in DDX41 lead to loss of a tumor suppressor function, likely related to activities in RNA splicing and processing pathways. Seventy percent of cancer cases with DDX41m are associated with MDS/AML alone. More than 65% of familial cases harbor heterozygous germline frameshift mutations, of which p.D140Gfs*2 is the most common. A somatic DDX41m of the second allele is acquired in 70% of cases, leading to hematological malignancy. Myeloid neoplasms with DDX41m are typically characterized by long latency, high-risk disease at presentation with normal cytogenetics and without any additional molecular markers. Recent reports suggests that a subgroup of these patients have an indolent clinical course and have a better long-term survival compared to favorable or intermediate risk AML. Distinct clinical/pathologic features and favorable outcomes in MDS/AML highlight the need for standardized classification and gene specific guidelines that could assist in management decisions in patients with DDX41m.

P779: OPTIMIZING TREATMENT OUTCOMES FOR CHILDREN WITH HIGHER-RISK MYELODYSPLASTIC SYNDROME UNDERGOING ALLOGENEIC HEMATOPOIETIC STEM CELL TRANSPLANTATION

Background: Myelodysplastic syndrome (MDS) are rare clonal hematopoietic disorders in children. Risk stratification system for adults is unfit for children. Refractory anemia with excess blasts(RAEB), acute myeloid leukemia with myelodysplasia-related changes(AML-MRC), monosomy 7 and complex karyotype always indicate poor prognosis. Hypomethylating agent (HMA) improved survivals of high-risk MDS in adults, and decitabine as part of conditioning regimen for allogenetic hematopoietic stem cell transplantation(allo-HSCT) was associated with favorable outcomes. However, these findings have not been tested in pediatric cohorts broadly. Aims: To evalute the efficacy and safety of hypomethylating agents as a part of pre-transplant treatments and contidioning regimens in children with higher-risk MDS. Methods: Patients from 1 to 14 years of age who were diagnosed with higher-risk MDS and underwent allo-HSCT consecutively between February 2019 and August 2020 in Pediatric Blood Diseases Center were enrolled. All identified patients were retrospectively reviewed with a collection of clinical data, laboratory test results, and outcome. Results: We reviewed 18 pediatric patients with higher-risk MDS, including 7 with RAEB, 8 with AML-MRC, and 3 with refractory cytopenia of childhood with monosomy 7. Regardless of initial diagnosis, monosomy 7 is the most common cytogenetic aberration (8/18, 44.4%). Next-generation sequencing (NGS) was performed on 15 specimens and the most frequent detection of mutation gene was SETBP1, followed by ETV6. Before transplantation, ten patients received monotherapies or combined chemotherapies with HMA, two patients received AML-like chemotherapies, and nine of those achieved bone marrow complete remission. The stem cell sources came from matched sibling donor (n=1), haploidentical donor (n=11), and unrelated cord blood (n=6), respectively. Low-dose decitabine-containing myeloablative conditioning regimens were administered in all cases. About 50% of patients (n=9) experienced Grade II- IV acute graft versus host diseases post-transplant. The cumulative incidence of transplantation-related mortality (TRM) was 11.1%. During a median follow-up of 10.5 (range, 2–36) months after transplantation, 15 of 18 patients were alive. At time of last follow-up, all survivors had resolution of hematologic disorder without relapse. Summary/Conclusion: In summary, administration of hypomethylating agents to allogeneic SCT resulted in excellent outcomes in children with higher-risk MDS.

Apoptosis in myelodysplasia: Association with patient age, bone marrow cellularity and karyotypes

Background: Myelodysplastic syndrome (MDS) comprises a heterogeneous group of clonal hematopoietic stem cell diseases, characterized by dysplasias and apoptosis in bone marrow (BM) and cytopenias in peripheral blood. In this study, we analyzed apoptosis in MDS to verify associations with patient age, bone marrow cellularity and karyotypes and to investigate the role of apoptosis in MDS pathogenesis. Methods: Bone marrow cells were collected from 81 patients with primary MDS, of which 60 were adults and 21 children. BM cells were also collected from 10 healthy donors for bone marrow transplants, 5 adults and 5 children, as controls. The patients and controls came from public onco-hematology institutions in Rio de Janeiro. The percentage of apoptotic BM cells was assessed by flow cytometry using two combinations: annexin V-FITC/CD34PE/CD45PerCP and annexin V-FITC/CD14PE/CD45PerCP in BM cells. Cytogenetic analysis was performed by G-banding. Results: The comparison between adult and pediatric patients showed that these patients show a similar behavior with regard to apoptotic cells percentages in BM samples. Apoptosis occurs independently of BM cellularity, being more prominent in patients with hyper/normocellular BM. Patients with normal karyotypes, del(5q), del(17p) had higher apoptosis rates than patients with del(11q) and complex karyotypes. Cells committed to a differentiation program were associated with high rates of apoptosis, suggesting that apoptosis may be a consequence of inefficient hematopoiesis, such that the hematopoietic system may eliminate dysplastic cells at the beginning of the disease. Conclusions: Our results suggest that apoptosis is an important characteristic of BM cells from adult and pediatric MDS patients and may be a consequence of inefficient hematopoiesis. In addition, we suggest that apoptosis is not the main mechanism associated with hypocellular MDS, and it occurs preferentially in MDS cases of hyper/normocellular BM and is associated with a good prognosis. Keywords: Myelodysplastic Syndrome; Apoptosis; Patient age; Bone marrow cellularity; Karyotypes.