Myelodysplatic Syndrome Research Articles

T-Cell Depletion with Both Reduced Dose Anti-Thymocyte Globulin and Reduced Dose Post-Transplant Cyclophosphamide in Haploidentical Peripheral Blood Stem Cell Transplantation for Acute Leukemia and Myelodysplatic Syndrome

Graft-versus-host disease (GVHD) prophylaxis in allogeneic hematopoietic stem cell transplantation from HLA haplo-identical familial donor (haplo-HSCT) is based on in vivo T-cell depletion with either anti-thymocyte globulin (ATG) or post-transplant cyclophosphamide (PTCy). ATG has made significant contributions to enabling haplo-HSCT. However, the benefit of ATG may be often mitigated by higher risk of viral reactivation, including cytomegalovirus (CMV) and Epstein-Barr virus (EBV) due to a slower immune reconstitution. PTCy revolutionized HLA-mismatched HSCT and rapidly became the standard-of-care. However, it also has problems due to a cytokine release syndrome (CRS) -like symptoms and excessive cytotoxicity leading to the risk of acute cardiotoxicity and the possibility of alleviated graft-versus-leukemia effect. Considering a demand for more optimal in vivo T-cell depletion, we tried to combine both ‘lower-dose’ ATG and ‘lower-dose’ PTCy before and after stem cell infusion, respectively, hoping they can mitigate their individual limitations while maintaining the effectiveness of in vivo T-cell depletion. We retrospectively included 60 adults with acute leukemia or myelodysplastic syndrome who underwent haplo-HSCT following busulfan (3.2 mg/kg/day for 4 days as myeloablative and for 2 days as reduced intensity conditioning) and fludarabine (a total of 160 mg/m 2) between January 2019 and June 2023. Among them, 32 received a novel combination of ATG (a total of 3.0, 3.5, or 4.0 mg/kg depending on the absolute lymphocyte count level on days -3) and PTCy (50mg/kg on day +3 and 30mg/kg on day +4) compared to 28 patients who received ATG only (2.5 mg/kg/day from days -3 to -1, a total of 7.5 mg/kg) as in vivo T-cell depletion. Most patients received cyclosporine and mycophenolate mofetil as GVHD prophylaxis. The median follow-up duration for all patients was 8 months (median 9 months in the ATG/PTCy group and 7.5 months in the ATG group, respectively; P = 0.744). Baseline characteristics including age, sex, disease status, modified EBMT score, and the intensity of conditioning, were well-balanced except slightly higher infused CD34+ cells in the ATG/PTCy group (median 5.2 vs. 4.7 x 10 6/kg, P = 0.042). The cumulative incidence of acute GVHD at day +100 and moderate to severe chronic GVHD at 1 year were significantly lower in the ATG/PTCy group compared to the ATG group, respectively [grades II-IV acute GVHD: 20.4% (95% confidence interval [CI], 4.3-33.8%) vs. 48.4% (95% CI, 25.2-64.4%), P = 0.014; grades III-IV acute GVHD: 7.5% (95% CI, 0-17.1%) vs 31.1% (95% CI, 10.5-46.9%), P = 0.019; and moderate to severe chronic GVHD: 9.5% (95% CI, 0-21.2%) vs. 60% (95% CI, 23.3-79.1%), P = 0.007]. The ATG/PTCy group had a tendency of less incidence and severity of the haplo-fever. Multivariate analysis showed a significantly higher GRFS (hazard ratio 0.35, P = 0.002) and OS (hazard ratio 0.4, P = 0.014) for an ATG/PTCy group. The use of dual T-cell depletion with the reduced dose ATG in combination with the reduced dose PTCy showed a significantly superior early transplant outcome over with ATG of 7.5 mg/kg in terms of both GVHD and survival outcomes.

Ghosal Hematodiaphyseal Dysplasia: Implications of Late Diagnosis and Unusual Presentation in Adults

Ghosal Hematodiaphyseal Dysplasia (GHDD) is a rare autosomal recessive disorder characterized by bone modeling failure, resulting in thickening of bone cortices with predominant diaphyseal involvement and responsive anemia to steroids. Late diagnosis of GHDD in adulthood can lead to significant morbidity and suboptimal response to steroids. Moreover, GHDD often mimics more common hematological disorders like myelodysplastic syndrome and myelofibrosis, leading to treatments such as transfusions, splenectomy, and hematopoietic stem cell transplantation. Early diagnosis is critical to enable the patient to receive the appropriate treatment. We present a case series of three Indian patients from different families with genetically proven GHDD. Despite experiencing symptoms from early childhood, all patients were diagnosed in adulthood. None of them were born out of a consanguineous marriage . Two of them, aged 43 and 56, are the oldest reported GHDD patients to date. They initiated steroid treatment in their 5th and 6th decades of life, respectively. Unlike previously reported cases, these two patients required additional drugs like Thalidomide along with steroids, and their response to treatment was not as rapid. The first patient, a 43-year-old male, had a history of anemia since childhood and became transfusion dependent after 15 years of age. He developed bicytopenia and later pancytopenia with hypocellular bone marrow , along with splenohepatomegaly and extramedullary hematopoiesis in the paravertebral and presacral areas, a novel finding in GHDD cases. Whole exome sequencing revealed a missense mutation in the TBXA2 gene. The second patient, a 56-year-old male, had a history of anemia since childhood and underwent splenectomy at 46 due to massive splenomegaly and transfusion dependency. However, his transfusion dependency persisted, and bone marrow biopsy suggested myelofibrosis. However he was negativefor myeloid mutations including JAK2. Subsequently, genetic testing revealed a homozygous missense mutation in the TBXAS1 gene. He also developed paraplegia and bladder incontinence, attributed to extramedullary hematopoiesis, which improved with steroid treatment The third patient a 23 year old man with history of anemia, lower limb tenderness and ecchymosis at 14 months of age. Evaluation then had shown hyperostosis of diaphysis of long bones of lower limbs with sparing of metaphysis and bicytopenia. Was on regular transfusions till 9 years. Re-evaluation with bone marrow studies at 9 years revealed a varying cellular marrow with dysplastic megakaryocytes and diagnosed as pediatric myelodysplatic syndrome ,He was on steroids till 13 years and he did not require further transfusions.He stopped steroids for 1 year following which there was a fall in Hb levels and recurrence of pain in both lower limbs with inability to squat. In view of history of steroid responsive anemia and thickening of diaphysis in X-rays GHDD was suspected and confirmed by genetic testing. He was restarted on steroids and there was a good response to steroids within 4 week with normalisation of hemoglobin levels . Late diagnosis of GHDD in adulthood can lead to severe complications and suboptimal treatment response. These cases highlight the importance of early diagnosis to prevent unnecessary interventions and improve patient outcomes. Unusual presentations, like extramedullary hematopoiesis, can further complicate the diagnostic process. Clinicians should maintain a high index of suspicion for GHDD in cases of refractory anemia or myelofibrosis-like features, especially in adults with an earlier history of anemia. Early recognition and appropriate management are crucial to mitigate morbidity and improve patients' quality of life

Dr. Elihu H. Estey (1946–2021)

Dr. Elihu H. Estey (1946–2021)

Survival Improvement over Time of 960 s-AML Patients Included in 13 EORTC-GIMEMA-HOVON Trials.

Simple SummarySecondary acute myeloid leukemia (s-AML) refers to the development of AML following myelodysplatic syndrome or other hematological malignancies, or after a solid tumors, or nonmalignant diseases or following exposure to environmental or occupational carcinogens. Here, we report data from 960 s-AML patients who were treated in 13 EORTC collaborative trials conducted between May 1986 and January 2008. The main aims of our study were (1) to assess whether overall survival of s-AML patients improved over time, (2) to identify initial disease features associated with overall survival. We observed that overall survival of younger patients improved over the years, in parallel with introduction of high-dose cytarabine in induction remission chemotherapy. This suggests that this strategy should be further investigated in younger patients with s-AML. Furthermore, this study confirmed that the sAML patients having adverse cytogenetic risk features and those with high white blood cells at diagnosis had a dismal survival, regardless of their age group.We report the outcomes of secondary acute myeloid leukemia (s-AML) patients included in one of 13 European Organisation for Research and Treatment of Cancer (EORTC) collaborative AML trials using intensive remission-induction chemotherapy. Among 8858 patients treated between May 1986 and January 2008, 960 were identified as having s-AML, either after MDS (cohort A; n = 508), occurring after primary solid tumors or hematologic malignancies other than MDS (cohort B; n = 361), or after non-malignant conditions or with a history of toxic exposure (cohort C; n = 91). Median age was 64 years, 60 years and 61 years in cohort A, B and C, respectively. Among patients ≤60 years and classified in the cohorts A or B (n = 367), the 5-year overall survival (OS) rate was 28%. There was a systematic improvement in the 5-year OS rate over three time periods (p < 0.001): 7.7% (95% CI: 1.3–21.7%) for patients treated before 1990 (period 1: n = 26), 23.3% (95% CI: 17.1–30.0%) for those treated between 1990 and 2000 (period 2: n = 188) and 36.5% (95% CI: 28.7–44.3%) for those treated in 2000 or later (period 3: n = 153). In multivariate analysis, male gender (HR = 1.39; p = 0.01), WBC ≥ 25 × 109/L (HR = 2.00; p < 0.0001), age 46-60 years (HR = 1.65; p < 0.001) and poor-risk cytogenetics (HR = 2.17; p < 0.0001) were independently associated with shorter OS, while being treated during period 2 (HR = 0.50, p = 0.003) or period 3 (HR = 0.43; p = 0.0008). Having received high-dose cytarabine (HD-AraC) (n = 48) in the induction chemotherapy (HR = 0.54, p = 0.012) was associated with a longer OS. In contrast, among patients >60 years of age (n = 502), the OS was dismal, and there was no improvement over time.

Treatment with Decitabine Followed By Prednisone for Myelodysplatic Syndrome Concomitant with Sjogren's Syndrome

Myelodysplastic Syndrome (MDS) is rarely concomitant with Sjögren's syndrome (SS) with only 9 previously reported cases in the literature. A case of a previously healthy 31-year-old Chinese female presenting with dysplasia affecting all three lineages without blasts excess showed by bone marrow examination is reported. Autoimmune workup revealed positive antinuclear antibodies and Anti-SSA. Lip biopsy revealed findings consistent with SS. A diagnosis of SS associated with MDS of the refractory cytopenia with multilineage dysplasia (RCMD) subtype was established, and decitabine for five days at 20mg/m2 per day was initiated with only slight increase in platelet counts. Four weeks later, another cycle of decitabine for five days at 20mg/m2 per day was performed. Unfortunately, infection occurred, and the patient suffered from thrombocytopenia and leucopenia. Then the patient received the treatment of Biapenem and Vancomycin Hydrochloride along with granulocyte colony stimulating factor followed by platelet infusion for two weeks. Significant clinical and laboratory response was achieved. In hopes of improving both response rates and durability of response, the third cycle of decitabine for five days at 20mg/m2 per day was performed with again an excellent clinical and laboratory response. However the patient refused further cycle of decitabine due to cost consideration, then prednisone at 10mg per day was used as a basic treatment for SS. It was an amazing feat that the patient was in a state of remission for two years. MDS with SS tends to be incurable. Decitabine alone with prednisone may serve as an effective option to those patients. DisclosuresNo relevant conflicts of interest to declare.

18-CENTIMETER PULMONARY METASTATIC UTERINE LEIOMYOSARCOMA: IS THAT EVEN POSSIBLE?

SESSION TITLE: Lung Cancer 1 SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: 10/09/2018 01:15 PM - 02:15 PM INTRODUCTION: Uterine Leiomyosarcoma (ULS) is an extremely rare malignancy that arises from the smooth muscle of uterine wall. They are estimated to occur in 6 out of every 1,000,000 women in the US. We report a case of ULS in a 69 year old female with metastasis to lung and high grade treatment related Myelodysplatic Syndrome (MDS) CASE PRESENTATION: 69 year old female with no significant past medical history, presented in 2005 with chronic pelvic pain and dysfunctional uterine bleeding. Further workup led to diagnosis of a moderately differentiated ULS, which measured 13 cm. She was treated with total abdominal hysterectomy but declined adjuvant chemotherapy. Five years later, she presented again: this time complaining of shortness of breath and weight loss. Computerized Tomography (CT) showed a large 18 cm mass replacing the entire left lung. She underwent resection and pathological analysis demonstrated high grade metastatic sarcoma. This time she agreed to chemotherapy and received a total of 8 cycles of doxorubicin and dacarbazine achieving great clinical response. Once she reached maximum dose of doxorubicin, she was left on dacarbazine as a single agent and completed 74 doses. Five years after initiating treatment, therapy was discontinued due to development of high-grade MDS. She was started on Azacitidine regimen at that time and, as of today, continues to follow up with her oncologist. DISCUSSION: The novelty in this case is dual. First of all, 5 year survival for metastatic ULS is reported from 8-17% (2). Our patient has survived for 12 years; whereas the longest reported survival in the literature is only 9 years. Secondly, a metastatic tumor larger than the primary is extremely unusual in ULS. There are no cases reported with this characteristic. In our review we did not find literature describing the average size of pulmonary metastasis, in fact, multiple lung lesions are more common than a single lesion making this 18 cm secondary tumor exceptionally unique. CONCLUSIONS: ULS is a very aggressive tumor that accounts for less than 1% of all malignancies. It most commonly metastasizes to the lung, followed by peritoneum, bone and liver (1). Several risk factors have been described including: Increasing age, African American race, Tamoxifen use and pelvic radiation. Although ULS is a rare disease process, the nuances in each reported case help to shed light on the pathogenesis and ultimately lead to improved treatment modalities. We urge clinicians to use our case as reference and to report personal experiences as well. Reference #1: Tropé CG, Abeler VM, Kristensen GB. Diagnosis/treatment of sarcoma of the uterus. A review. Acta Oncol 2012; 51:694. Reference #2: Sandberg AA. Updates on the cytogenetics and molecular genetics of bone and soft tissue tumors: leiomyosarcoma. Cancer Genet Cytogenet 2005; 161:1. Reference #3: Park JY, Kim DY, Suh DS, et al. Prognostic factors and treatment outcomes of patients with uterine sarcoma: analysis of 127 patients at a single institution, 1989-2007. J Cancer Res Clin Oncol 2008; 134:1277. DISCLOSURES: No relevant relationships by Fernando Figueroa Rodriguez, source=Web Response No relevant relationships by Daniel Keena, source=Web Response

A Case Report of a Patient with Myelodysplastic Syndrome Who Has Lower Back Pain

Objectives This case aims to describe management of a patient with myelodysplasitc syndrome who has lower back pain. Methods A 75-year-old female patient with myelodysplasitc syndrome was hospitalized from February 28, 2018 to March 14, 2018. The patient was treated with Azacitidine at Bundangjyesaeng Hospital, and lower back pain worsened without any reason. The patient was willing to undergo traditional Korean medical treatment, and Wonyuksayuk-tang was chosen considering both hematopoiesis dysfunction and lower back pain. Results The patient was diagnosed with myelodysplatic syndrome after bone marrow aspiration and biopsy at Bundangjyesaeng Hospital. After the Wonyuksayuk-tang treatment, platelet levels increased about 50% compared with initial blood test results. In addition, lower back pain and general weakness were slightly improved. Conclusion It is important to manage the quality of life of patients with myelodysplastic syndrome. This case suggests that traditional Korean medicine has a beneficial effect on the management of myelodysplastic syndrome. Keywords: myelodysplastic syndrome, lower back pain, Wonyuksayuk-tang

The Frequency of SF3B1 Mutations in Thai Patients with Myelodysplastic Syndrome

Genetic mutations in genes encoding critical component of RNA splicing machinery including SF3B1 are frequently identified and recognized as the pathogenesis in the development of myelodysplatic syndrome (MDS). In this study, PCR sequencings specific for SF3B1 exon 13, 14, 15, and 16 were performed to analyse genomic DNA isolated from bone marrow samples of 72 newly diagnosed MDS patients. We found that 10 of 72 (14%) patients harbor SF3B1 missense mutations including E622D (1/72), R625C/G (2/72), H662Q (1/72), K666T (1/72), K700E (4/72) and G740E (1/72), respectively. Mutations were predominantly located on exon 14 and 15 of SF3B1 coding sequence. Interestingly, patients with SF3B1 mutations exhibited higher platelet counts (195×109/L VS. 140×109/L, p-value = 0.025) as well as lower hemoglobin levels (81 g/L VS. 92 g/L, p-value = 0.009) and associated with ring sideroblast phenotype (p-value < 0.001) when compared with patients without the SF3B1 mutation. In summary, we reported the frequency of SF3B1 mutations in Thai patients with different subtypes of MDS. SF3B1 mutations were predominantly occurred in MDS-RS and considered as favourable prognosis value. This study further highlighted the clinical important of SF3B1 mutations analysis for the classification of MDS.

Vaccination with NY-ESO-1 in Combination with Decitabine for Patients with MDS

Background: The identification of suitable target antigens for immunotherapy in myeloid cancer has been a challenge. NY-ESO-1 is a recognized target in solid tumors, but in myeloid cancers expression is silenced by dense promoter hypermethylation. We have demonstrated standard dose decitabine induced expression of NY-ESO-1 in the circulating blasts of AML patients. The level of expression was sufficient to trigger a cytotoxic response in NY-ESO-1 specific CD8+ T cells. We have previously reported our preliminary data demonstrating that vaccination against NY-ESO-1 in combination with decitabine is safe and resulted in NY-ESO-1 specific cellular immune responses in the first six treatment-na•ve myelodysplatic syndrome (MDS) patients on study. We now update our results following complete study accrual.Methods: We performed a phase I trial of NY-ESO-1 vaccine (anti-DEC-205-NY-ESO-1 fusion protein (CDX-1401) with poly-ICLC adjuvant; Celldex Therapeutics) in combination with decitabine (20 mg/m2/day x 5 days). Patients were enrolled on an IRB-approved protocol. All patients signed informed consent and were treated in accordance with the Declaration of Helsinki. Enrolled patients had intermediate/high-risk MDS by IPSS, were > 18 years old, had ECOG performance status < 2, and adequate hepatic and renal function. Patients with uncontrolled medical illness, HIV-positivity, auto-immunity or recent corticosteroid/radiation therapy were excluded. Patients were vaccinated on day -14, received decitabine on day 1 and were re-vaccinated on day 14 of each cycle. Four cycles of therapy were planned. Peripheral blood was obtained pre-treatment, twice weekly, and at end of treatment (EOT). CD11b+ myeloid cells were isolated from each sample. Immune monitoring was performed at baseline and end of treatment.Results: Nine patients (median age 64y, range 57-71) have been enrolled and treated on study; all have completed therapy. As previously reported, adverse events were decitabine and disease related. We quantified LINE-1 (surrogate for global methylation) and NY-ESO-1 promoter methylation in the CD11b+ myeloid population throughout treatment. The methylation nadir for LINE-1 and NY-ESO-1 occurred between days 8 and 18 of each decitabine cycle. Changes in LINE-1 and NY-ESO-1 methylation were correlated for eight patients (R2 = 0.91-0.99, p < 0.0001). We observed that 7/9 patients demonstrated induced expression NY-ESO-1 mRNA (by nested RT-PCR) in CD11b+ cells. There was no baseline humoral immunity to NY-ESO-1. Seroconversion was observed in two subjects, both of whom demonstrated induced NY-ESO-1 expression. 7/9 and 5/9 patients demonstrated NY-ESO-1 specific CD4+ and CD8+ T-cell responses respectively following vaccination. There were no significant changes in the frequency of CD25+ FOXP3 positive T-regulatory cells from baseline to the end of therapy. NY-ESO-1 specific T-cell recognition of myeloid cells with induced antigen expression will be analyzed.Conclusion: Circulating myeloid cells exhibit decreased global and NY-ESO-1 promoter methylation. A majority of treated patients show induction of NY-ESO-1 mRNA in the myeloid compartment with vaccination induced CD4+ and CD8+ T-cell responses in a majority of patients. Patients without evidence of induced expression in circulating myeloid cells had poor cellular immune response to vaccination. These data indicate that MDS patients receiving standard decitabine may benefit from immunological targeting of reactivated NY-ESO-1. [Display omitted] DisclosuresKarpf:Astex Pharmaceuticals: Research Funding. Wang:Incyte: Speakers Bureau; Immunogen: Research Funding. Griffiths:Astex Pharmaceuticals: Consultancy, Research Funding; Celgene Inc: Consultancy, Honoraria; Alexion Pharmaceuticals: Consultancy, Honoraria.

Cytopenia of Unknown Cause Post Allogeneic Stem Cell Transplant As a Predictor of Clinical Outcome

Temporary or long-lasting decrease of one or more blood cell lineages following allogeneic hematopoietic stem cell transplant (allo-HSCT) can lead to increased morbidity and mortality. Post-transplant cytopenia is often secondary to drug toxicity, viral infections, graft versus host disease (GVHD), or relapse. Less is known about the significance of cytopenia of unknown cause. Here we retrospectively analyzed 91 consecutive adult patients (median age 46 years; range: 19-63) who had received allo-HSCT conditioned with myeloablative fludarabine/ I.V. busulfan at our institution. Diagnoses included: acute myeloid leukemia (AML) or myelodysplatic syndrome (MDS) (n=57), acute lymphoblastic leukemia (ALL) (n=15), chronic myeloid leukemia (CML) (n=9), non-Hodgkin lymphoma (NHL) (n=5), B cell chronic lymphocytic leukemia (B-CLL) (n=2), myelofibrosis (n=1), unclassified myeloproliferative neoplasms (MPN) (n=2). Stem cell source was granulocyte-colony stimulating factor (G-CSF) mobilized peripheral blood stem cells (PBSC) in 81, bone marrow in 8 and cord blood in 2 patients. Median follow up for the entire cohort was 20 months (range 1-162 months). Patients with cytopenia of unknown cause were identified if they had full donor chimerism, negative cytomegalovirus (CMV) by molecular analysis, no active infections, acute GVHD <grade II, no chronic GVHD, no drug myelotoxicity, and at least one of the following: transfusion dependence for greater than 2 weeks, absolute neutrophil count (ANC) <1.5 x109/L, hemoglobin <8.5 g/dl or platelets <50 x103/L . Of 91 patients, 28 (31%) did not have any cytopenia post transplant, 48 (53%) had cytopenia of known cause (GVHD, n=9; infection, n=11; drug, n=2; relapse, n=25; graft failure, n=1). The remaining 15 patients (16%) had cytopenia of unknown cause. Of these 15, 9 cases had neutropenia, 6 thrombocytopenia (4 requiring platelet transfusion) and 2 had anemia (1 requiring red blood cell transfusion). Only one blood lineage was decreased in 13 patients and 2 lineages in 2 patients. Median onset of cytopenia was 60 days (range: 30-360 days) and median duration of cytopenia was 14 days (range: 14-150 days). When we compared the group of patients with cytopenia of unknown cause to the one without any cytopenia, no differences in patient characteristics, donor type, CD34+ cell dose, or stem cell source were found. A log-rank analysis did not show significant differences in overall survival (OS) (p=0.08) or progression free survival (PFS) (p=0.2) between the two groups. However, patients with cytopenia of unknown cause more frequently developed subsequent acute GVHD (53% vs 25%, p=0.06) and had a significantly higher risk of death due to infection compared to patients without cytopenia (p=0.04). Our results suggest that patients with cytopenia of unknown cause after allo-HSCT may have a worse outcome possibly due to a higher risk of acute GVHD and infections. Further studies are warranted on larger multicenter or registry data to establish the prognostic role of post-transplant cytopenia. DisclosuresNo relevant conflicts of interest to declare.

Linezolid Induced Twice Pure Red Cell Aplasia in a Patient with Central Nervous System Infection after Allogeneic Stem Cell Transplantation.

Linezolid (LZD), severed as the first oxazolidinone antibiotic, was active against multidrug-resistant gram-positive strains. LZD can induce thrombocytopenia, anemia and leukocytopenia. Currently, reports on pure red cell aplasia (PRCA) cases induced by LZD are relatively rare (4-7). In this paper, we reported a patient with PRCA twice induced by LZD. A 37-year-old man was diagnosed with myelodysplatic syndrome (MDS) and underwent allo-HSCT from an unrelated donor with ABO blood type and leukocyte antigen (HLA)-matching. After HSCT for 2 years, the patient suffered from refractory fever and headache. He was first treated with empirical antifungal agent and antibiotics for central nervous system (CNS) infection, but then changed to LZD therapy for little effect. Twenty-eight days after LZD treatment, the symptom improved significantly but the hemoglobin declined to 70 g/L and the reticulocyte level was only 0.23%. The LZD therapy was stopped and the fever and headache symptoms reoccurred 1 week latter. Then, erythropoietin (EPO) and halved dosage of LZD were used for treatment. The CNS infection and the anemia symptom relieved gradually and the level of hemoglobin and reticulocyte declined again. After blood transfusion, the half dose of LZD was sustained without anaemia recovery. In summary, patients with anemia, myelosuppressants history or potential abnormal proliferation of T cells may suffer PRCA with long term LZD treatment. The monitoring of complete blood count and reticulocyte count were necessary during LZD therapy. If the clinical condition permits, LZD dosage reduction and blood transfusion should be considered.

Abstract B125: Mutant SF3B1 downregulates proteins involved in differentiation, including ABCB7

Abstract Refractory Anemia with Ringed Sideroblasts (RARS), a subtype of Myelodysplatic Syndrome (MDS), occurs with a high frequency of hotspot mutations in HEAT (Huntingtin, Elongation factor 3, protein phosphatase 2A, Targets of rapamycin 1 domains) domains of SF3B1. This protein component of the U2 snRNP complex of the spliceosome is essential in the proper selection and usage of 3' splice sites. RNAseq analysis of MDS and other tumor types in which SF3B1 hotspot mutations have been found show that alternative 3' splice site usage is the predominant cause of RNA transcript aberration. These modifications can result in mRNAs encoding novel peptides, or they can introduce premature termination codons into the pre-mRNA, most likely directing it to the Nonsense Mediated Decay (NMD) pathway for degradation. Using a predictive tool to determine the likelihood of a given aberrant transcript to be targeted for NMD, we determined that nearly 50% of the SF3B1-mutant-associated aberrant transcripts were candidates for degradation. We confirmed this experimentally by treating isogenic Nalm-6 cells (engineered by AAV homology to express SF3B1 K700E or K700K) with or without cycloheximide, an agent known to inhibit translation and RNA degradation by NMD. Investigation of the resulting RNAseq data showed significant rescue of gene expression only for the transcripts predicted to be NMD targets. Ingenuity Pathway Analysis indicated that many of the downregulated genes in SF3B1 mutant samples were involved in differentiation, which has been shown to be dysregulated in MDS. We tested the idea that such modifications in the transcriptome confer selective advantage or impair differentiation in SF3B1 mutant cells. We began by manipulating the expression of ABCB7, one of the genes identified in our RNAseq analysis to be downregulated by aberrant splicing and subsequent NMD. ABCB7 is a mitochondrial transporter important in cellular iron metabolism and, indirectly, in heme production. Additionally, loss of function of ABCB7 is causal in X-linked sideroblastic anemia and has been implicated in RARS MDS. We discovered in our SILAC proteomic analysis that ABCB7 protein was dramatically decreased in K700E SF3B1 Nalm-6 cells relative to K700K Nalm-6, in agreement with our RNAseq analysis. Using doxycycline-inducible shRNA expression, we knocked down ABCB7 mRNA and protein expression in TF-1 erythroblasts. These cells show significant decreases in erythropoeitin (EPO)-induced differentiation when expressing exogenous K700E SF3B1, but not K700R (a very conservative mutation) or WT SF3B1. With direct knock down of ABCB7, we observed a similar phenotype - impairment of EPO-induced differentiation in ABCB7 shRNA-induced cells by Day 7, with no overall decline in cell viability. Interestingly, knock down of SF3B1 expression with shRNA also reduces ABCB7 mRNA. However, it also promotes cell death. This is consistent with the heterozygous nature of SF3B1 hotspot mutations; severe loss of SF3B1 function is deleterious. We propose that hotspot SF3B1 mutants promote aberrant splicing of multiple genes, inducing a general “spliceosomal sickness” in addition to downregulating key genes (e.g. ABCB7) responsible for erythroid differentiation impairment, such as that observed in RARS. Citation Format: Rachel B. Darman, Samantha A. Perino, Michael Seiler, Shouyong Peng, Jacob Feala, Peter Fekkes, Gregg F. Keaney, Kaiko Kunii, Linda Lee, Kian Huat Lim, Yoshiya Oda, Khin Myint, Esther A. Obeng, Ermira Pazolli, Eun Sun Park, John Yuan Wang, Markus Warmuth, Lihua Yu, Ping Zhu, Yoshiharu Mizui, Benjamin L. Ebert, Peter G. Smith, Silvia Buonamici. Mutant SF3B1 downregulates proteins involved in differentiation, including ABCB7. [abstract]. In: Proceedings of the AACR-NCI-EORTC International Conference: Molecular Targets and Cancer Therapeutics; 2015 Nov 5-9; Boston, MA. Philadelphia (PA): AACR; Mol Cancer Ther 2015;14(12 Suppl 2):Abstract nr B125.

Management of Antibiotic-Associated Diarrhea After C. difficile Infection With a Serum-Derived Bovine Immunoglobulin Preparation

Clostridium difficile infection (CDI) has a high mortality, morbidity and large economic cost and can cause mild diarrhea to a fulminant, life threatening colitis. Antibiotics, though effective can lead to antibiotic-associated diarrhea (AAD). Serum-derived bovine immunoglobulin (SBI) has been shown to bind/neutralize toxins A&B from hypervirulent ribotypes in vitro and reduce CDI-induced mortality by 50% in a low-protein fed mouse model. Due to these activities and its reported efficacy in managing chronic loose and frequent stools, SBI was administered to 4 patients with CDI experiencing AAD. Patient 1 (89 yrs Caucasian female) had a history of severe CDI in 2012 unresponsive to metronidazole requiring vancomycin for 2-wks and a 1-mo taper. Following a urinary tract infection resolved with antibiotics, CDI reoccurred and was resolved with additional vancomycin, but the patient had AAD unresponsive to loperamide. Patient 2 (76 yrs Caucasian male) had CDI-induced colitis treated with a 20-day course of metronidazole, but had continued diarrhea. Probiotics had no effect. Patient 3 (59 yrs Caucasian female) had a history of chronic IBS-C, controlled by lubiprostone. After an upper respiratory tract infection treated with amoxicillin/clavulanic acid, she developed severe, watery, foul smelling stools (8-12/d) within 48 hrs. The patient was switched to azithromycin and discontinued lubiprostone. Despite switching to azithromycin, it did not stop her diarrhea and was found to be CDI positive by PCR. Patient 4 (89 yrs Caucasian male) had myelodysplatic syndrome, ASCVD s/p CABG, was hospitalized with acute exacerbations of COPD treated with IV piperacillin/tazobactam, and developed diarrhea on day 4. PCR stool analysis revealed CDI and the patient was switched to oral vancomycin. Post-discharge, his diarrhea persisted after 5 days of vancomycin therapy. Patient 1 was given SBI 5g BID and after 1-week had improved stool consistency/frequency and a better sense of well-being. Patient 2 received SBI 5g TID for 9-d and it managed chronic loose and frequent stools. Patient 3 dosed with SBI 5g BID had normal stool frequency/consistency within 72 hrs. He was maintained asymptomatically on SBI for 30-d. Despite a positive CDI stool test by PCR, routine colonoscopy 6-wks later revealed no clinical signs of disease. Watery stools in Patient 4 were managed with the combination of 200mg fidaxomicin BID and SBI 5g BID after 48 hrs. After the 10-day course of fidaxomicin, SBI was continued for an additional 14-d with no recurrent symptoms. It is hypothecized that SBI may help restore normal barrier function by binding to microbial components produced after antibiotic therapy, thereby reducing immune activation which degrades the intestinal barrier. These cases suggest that SBI is useful in helping nutritionally manage AAD.

FDA Approval Summary: Olaparib Monotherapy in Patients with Deleterious Germline BRCA-Mutated Advanced Ovarian Cancer Treated with Three or More Lines of Chemotherapy.

On December 19, 2014, the FDA approved olaparib capsules (Lynparza; AstraZeneca) for the treatment of patients with deleterious or suspected deleterious germline BRCA-mutated (gBRCAm) advanced ovarian cancer who have been treated with three or more prior lines of chemotherapy. The BRACAnalysis CDx (Myriad Genetic Laboratories, Inc.) was approved concurrently. An international multicenter, single-arm trial enrolled 137 patients with measurable gBRCAm-associated ovarian cancer treated with three or more prior lines of chemotherapy. Patients received olaparib at a dose of 400 mg by mouth twice daily until disease progression or unacceptable toxicity. The objective response rate (ORR) was 34% with median response duration of 7.9 months in this cohort. The most common adverse reactions (≥20%) in patients treated with olaparib were anemia, nausea, fatigue (including asthenia), vomiting, diarrhea, dysgeusia, dyspepsia, headache, decreased appetite, nasopharyngitis/pharyngitis/upper respiratory infection, cough, arthralgia/musculoskeletal pain, myalgia, back pain, dermatitis/rash, and abdominal pain/discomfort. Myelodysplatic syndrome and/or acute myeloid leukemia occurred in 2% of the patients enrolled on this trial.

Systemic lupus erythematosus (SLE) and its complications: A case study

Systemic Lupus Erythematosus (SLE) is a chronic, unpredictable and relapsing disease, predominantly affecting women of childbearing age. For severe cases of SLE, the usage of high dose toxic medications leads to a high risk of development of complications. The following case demonstrates the difficulty of managing SLE and the complications that follow. Case presentation: KR is a 21 year old Indian female who was admitted for the chief complaint of bilateral leg swelling. She also presented with frothy urine and haematuria and diagnosed with acute nephritis and acute myelodysplatic syndrome with pancytopenia. To these, she was treated with frusemide, haemodialysis and prednisolone. Later on, her renal function worsened and was switched to IV methylprednisolone. She developed E.Coli pyelonephritis and bacteremia. Further development of autoimmune haemolytic anemia and thrombocytopenia necessitated the provision of haematinics. Discovery of severe hypertension lead to a multidrug antihypertensive regimen. A few days later, KR developed seizures likely caused by steroid toxicity, to which methylprednisolone was ceased. Phenytoin was administered to prevent fitting. However, due to her hypoalbuminemia and renal impairment she experienced phenytoin toxicity and developed nystagmus, to which phenytoin was temporarily ceased. She was continuously warded until significant improvement and was discharged. However her blood pressure is still uncontrolled. She was asked to return at a later date to do a renal biopsy. Clinical evaluation: The timeliness and choice of treatment for treating the infections were questionable. Administration of IV Immunoglobulin was untimely and not using the usual regimen for autoimmune diseases. Miscalculation of plasma phenytoin concentration lead to phenytoin toxicity. Also, KR’s uncontrolled blood pressure was not properly solved before discharge.

Azacitidine in Patients with Treatment-Related Acute Myeloid Leukemia: Retrospective Analysis of the Austrian Azacitidine Registry

Azacitidine in Patients with Treatment-Related Acute Myeloid Leukemia: Retrospective Analysis of the Austrian Azacitidine Registry

The PARP inhibitor Olaparib disrupts base excision repair of 5-aza-2'-deoxycytidine lesions.

Decitabine (5-aza-2′-deoxycytidine, 5-azadC) is used in the treatment of Myelodysplatic syndrome (MDS) and Acute Myeloid Leukemia (AML). Its mechanism of action is thought to involve reactivation of genes implicated in differentiation and transformation, as well as induction of DNA damage by trapping DNA methyltranferases (DNMT) to DNA. We demonstrate for the first time that base excision repair (BER) recognizes 5-azadC-induced lesions in DNA and mediates repair. We find that BER (XRCC1) deficient cells are sensitive to 5-azadC and display an increased amount of DNA single- and double-strand breaks. The XRCC1 protein co-localizes with DNMT1 foci after 5-azadC treatment, suggesting a novel and specific role of XRCC1 in the repair of trapped DNMT1. 5-azadC-induced DNMT foci persist in XRCC1 defective cells, demonstrating a role for XRCC1 in repair of 5-azadC-induced DNA lesions. Poly (ADP-ribose) polymerase (PARP) inhibition prevents XRCC1 relocation to DNA damage sites, disrupts XRCC1–DNMT1 co-localization and thereby efficient BER. In a panel of AML cell lines, combining 5-azadC and Olaparib cause synthetic lethality. These data suggest that PARP inhibitors can be used in combination with 5-azadC to improve treatment of MDS and AML.

Serum iron metabolism and erythropoiesis in patients with myelodysplastic syndrome not receiving RBC transfusions

Dysregulation of hepcidin, a key iron regulating hormone, is important in the pathogenesis of iron overload in patients with myelodysplatic syndrome (MDS). However, most studies of hepcidin levels are complicated by concomitant RBC transfusions. To evaluate the relationship between iron metabolism and erythropoiesis, we measured serum levels of hepcidin, growth-differentiation factor-15 (GDF15) and other markers of erythropoiesis in 107 subjects with MDS not receiving RBC transfusions. Patients with MDS had significantly higher levels of hepcidin than normals. However, their hepcidin-ferritin ratio was markedly decreased compared to normals (P<0.001) and varied substantially between MDS subtypes (P=0.011). GDF15 levels positively correlated with percent of bone marrow erythroblasts (P<0.001), soluble transferrin receptor (sTfR) (P=0.018), and also with transferrin saturation (ISAT) (P=0.038). The hepcidin-ferritin ratio negatively correlated with serum erythropoietin (EPO) levels (P<0.001), and also with GDF15 levels (P=0.014). Colony forming cells (CFC) were evaluated in 70 subjects. Those with serum ferritin (SF) levels <500 ng/ml had significantly more BFU-E than subjects with SF ≥ 500 ng/L (P=0.007), but numbers of granulocyte/macrophage-colony-forming cells (CFU-GM) were similar (P=0.190). Our data indicate serum hepcidin levels are inappropriately low in patients MDS not receiving RBC transfusions. GDF15 levels correlated with low hepcidin levels and may contribute to iron overload in this setting. Iron overload may in turn suppress erythropoiesis by imparing the proliferative capacity of the erythroid progenitor cells.

Outcomes of patients with myelodysplatic syndrome and chronic myelomonocytic leukemia post clofarabine failure

The outcome of patients with myelodysplastic syndrome (MDS) and chronic myelomonocytic leukemia (CMML) post clofarabine is unknown. We reviewed 109 patients with MDS or CMML with a median age of 67 years, treated with a clofarabine-based chemotherapy as frontline (n = 38) or salvage (n = 71) therapy. A total of 58 (53%) patients received salvage therapy after clofarabine failure: 13 allogeneic stem cell transplant (ASCT), 18 high-dose cytarabine-containing regimen, 10 hypomethylating agents and 17 investigational treatments. Eight patients achieved complete remission (CR) and three had stable disease for an overall response rate of 19%. With a median follow-up of 3 months from clofarabine failure, 12 patients (11%) remained alive, 5 remain in CR, 4 of them after ASCT. The median overall survival post clofarabine failure was 4 months with a 1-year survival rate of 23%. This outcome is predictable, with patients with high-risk disease at the time of clofarabine failure having the worse survival. To date, patients with MDS continue to have a short survival after failure of all available therapies. Ultimately, patients who are candidates for additional treatments should be offered novel approaches. In conclusion, the outcome of patients with MDS and CMML post clofarabine failure is poor. The pattern is similar to patients with MDS post hypomethylating agent failure and predictable using University of Texas M. D. Anderson Cancer Center global scoring system.

The Effect Of CMV Reactivation On Relapse and Survival In Patients With AML and MDS After Allogeneic Stem Cell Transplant (allo-HCT)

Introduction The effect of CMV reactivation after allo-HCT on relapse and overall survival (OS) in patients with acute myeloid leukemia (AML) and myelodysplatic syndrome (MDS) is controversial (Green et al blood 2013, Elmaagacli et al Blood 2011, and Erard et al Hematologica 2006). Methods We retrospectively analyzed the effect of CMV reactivation on OS and cumulative incidence of relapse (CIR) and non-relapse mortality (NRM) in AML and MDS patients older than &gt; 18 years who had received allo-HCT between 2005-2011 and had not died within 30 days of receiving allo-HCT at MD Anderson Cancer Center. The effect of any CMV antigenemia on allo-HCT outcomes was evaluated by comparing any CMV antigenemia with no CMV antigenemia. Because of potential immunomodulatory effect of CMV infection, the effect of prolonged antigenemia (defined as CMV antigenemia with duration more than 12 days, the median duration of antigenemia for the cohort) on transplant outcomes was analyzed by comparing patients with prolonged antigenemia with patients with no CMV antigenemia or CMV antigenemia with ≤ 12 days. All patients underwent surveillance by pp65 antigenemia test. Preemtive therapy was initiated for &gt; 3 pp65 Ag cells/million WBC's. Kaplan-Meier survival curves were used to estimate OS and the log-rank test was used to assess group differences. CIR and NRM were determined using the competing risks method; competing risk for CIR was death and for NRM was relapse. Group differences in CIR and NRM were assessed using Gray's test. Results Table 1 shows baseline characteristics. Comparing R+/D+, R-/D-, R-/D+, and R+/D- groups, the incidence of any CMV antigenemia after HCT was 48%, 16.7%, 13.5%, and 50.9%, respectively (p&lt;0.0001) and the incidence of CMV disease was 1.0%, 1.9%, 2.7%, and 4.5%, respectively (p = 0.05). When any CMV antigenemia was compared with no CMV antigenemia post allo-HCT, CMV reactivation had no effect on OS (p &gt; 0.15) and CIR (p &gt; 0.61) in all cohort as well as AML and MDS subgroups. Comparing any antigenemia vs. no antigenemia, CIR at 3 years was 34.6% vs. 35.2% in all cohort, 36.7% vs. 36.6% in AML patients, and 29.5% vs. 30.0% in MDS patients, respectively. In patients with CMV antigenemia, duration of antigenemia ranged from 1 to 535 days (median 12 days). We then investigated the effect of prolonged CMV antigenemia on transplant outcomes. Patients with CMV antigenemia &gt; 12 days compared with combined group of ≤ 12 days or no CMV antigenemia had a lower cumulative incidence of relapse and a higher NRM, resulting in a similar OS (Fig. 1). Such a difference was seen in AML but not in MDS subgroup. We then investigated the effect of duration of CMV antigenemia in patients with CMV reactivation. Comparing 1-12 days of antigenemia vs. more than 12 days of antigenemia, CIR at 3 years was 41.9% vs. 26.7% (p = 0.003) in all cohort, 45.8% vs. 26.4% (p = 0.001) in AML patients, and 32.1% vs. 27.4% (p = 0.68) in MDS patients, respectively. Conclusion Prolonged CMV antigenemia is associated with decreased relapse in patients with AML, but not in MDS. Lower relapse is offset by increased NRM resulting in no change in OS. In contrast with published data, lower rate of relapse was not found when any antigenemia was compared with no antigenemia. Disclosures: No relevant conflicts of interest to declare.