Poor Prognosis In Myelodysplastic Syndrome Research Articles

ROBO1 deficiency impairs HSPC homeostasis and erythropoiesis via CDC42 and predicts poor prognosis in MDS.

Myelodysplastic syndrome (MDS) is a group of clonal hematopoietic neoplasms originating from hematopoietic stem progenitor cells (HSPCs). We previously identified frequent roundabout guidance receptor 1 (ROBO1) mutations in patients with MDS, while the exact role of ROBO1 in hematopoiesis remains poorly delineated. Here, we report that ROBO1 deficiency confers MDS-like disease with anemia and multilineage dysplasia in mice and predicts poor prognosis in patients with MDS. More specifically, Robo1 deficiency impairs HSPC homeostasis and disrupts HSPC pool, especially the reduction of megakaryocyte erythroid progenitors, which causes a blockage in the early stages of erythropoiesis in mice. Mechanistically, transcriptional profiling indicates that Cdc42, a member of the Rho-guanosine triphosphatase family, acts as a downstream target gene for Robo1 in HSPCs. Overexpression of Cdc42 partially restores the self-renewal and erythropoiesis of HSPCs in Robo1-deficient mice. Collectively, our result implicates the essential role of ROBO1 in maintaining HSPC homeostasis and erythropoiesis via CDC42.

High BM plasma S100A8/A9 is associated with a perturbed microenvironmentand poor prognosis in myelodysplastic syndromes.

S100A8/A9 is a proinflammatory protein and plays an essential role in the pathogenesis of myelodysplastic syndromes (MDS) via the S100A8/A9-Toll-like receptors axis. While S100A8/A9 levels have been used as biomarkers in many inflammatory diseases, their clinical relevance has not been conclusively resolved in MDS. To address this, we used an enzyme-linked immunosorbent assay to quantify S100A8/A9 heterodimers in bone marrow (BM) plasma from 215 MDS patients and compared S100A8/A9 levels across patients with various disease risks and genotypes. S100A8/A9 levels correlated with ASXL1 variant allele frequencies significantly. Moreover, mutant ASXL1 with concurrent RUNX1, STAG2, ZRSR2, or EZH2 mutations was associated with higher S100A8/A9 levels. We further showed that higher S100A8/A9 independently predicted inferior leukemia-free survival and overall survival in MDS patients, irrespective of age, Revised International Prognostic Scoring System subgroups, and known detrimental mutations. Lastly, through deep-sequenced transcriptomic analysis, we demonstrated that higher S100A8/A9 in the BM intimated a perturbed microenvironment with enhanced myeloid-derived suppressor cell-mediated tumor immune escape signal, altered metabolism, and impairment in the functions and quantities of CD8+ T cells and NK cells. S100A8/A9 in the BM microenvironment may be a potential biomarker in the prognostication of MDS and target for novel therapy.

P099 - Topic: AS06-Prognosis/AS06a-Prognostic factors of outcome and risk assessment: HIGH BM PLASMA S100A8/A9 IS ASSOCIATED WITH A PERTURBED MICROENVIRONMENT AND POOR PROGNOSIS IN MYELODYSPLASTIC SYNDROMES

P099 - Topic: AS06-Prognosis/AS06a-Prognostic factors of outcome and risk assessment: HIGH BM PLASMA S100A8/A9 IS ASSOCIATED WITH A PERTURBED MICROENVIRONMENT AND POOR PROGNOSIS IN MYELODYSPLASTIC SYNDROMES

Effects of Ker-050 on Iron Metabolism: Exploratory Analyses from an Ongoing Phase 2 Study in Patients with Myelodysplastic Syndromes

Background: Iron overload (IO) is an important clinical consequence of transfusion-dependent myelodysplastic syndromes (MDS). For patients with high transfusion burden (HTB), limited treatment options are available to effectively treat anemia and reduce transfusion dependence. Transfusion dependence is an independent predictor of poor prognosis in MDS. It is associated with IO and elevated ferritin, a marker of intracellular iron storage that also predicts poor prognosis in MDS. When adjusting for transfusion burden, each 500 µg/L increase in ferritin above 1000 µg/L is associated with a 30% greater risk of death (Malcovati et al. 2006). IO also disrupts osteoprogenitors and erythroid precursors within the osteohematopoietic niche, leading to abnormal bone turnover and ineffective erythropoiesis (Bulycheva 2015). While iron chelators have shown some efficacy in managing IO, they introduce toxicities and have little effect on transfusion burden. Unmet need remains for treatments that effectively address anemia, IO, and reduce transfusion dependence in patients with MDS, especially those with HTB. KER-050 is designed to alter signaling of TGF-β superfamily ligands, restoring balance to the osteohematopoietic niche, and promoting differentiation of erythroid and megakaryocytic precursors. It is a modified activin receptor type IIA ligand trap that inhibits TGF-β superfamily ligands, including activins A and B and growth and differentiation factors (GDFs) 8 and 11. To date, clinical data indicate that KER-050 induces sustained increases in reticulocytes and hemoglobin. Preliminary findings also show potential for KER-050 to induce erythroid response and reduce transfusion burden in patients with MDS, including those with HTB (Tan et al., 2022). KER-050 may also impact iron metabolism and this presentation explores the effects of KER-050 on indices of IO. Methods: This Phase 2 study is evaluating KER-050 in participants with very low- to intermediate-risk MDS. Data presented are from Part 1 Dose Escalation which included 16 weeks of KER-050 treatment across 5 cohorts (0.75 to 5 mg/kg). Iron chelator therapy was permitted at the discretion of the investigator provided patients had been on a stable dose for 8 weeks prior to C1D1. Markers of IO and hematopoiesis were assessed as exploratory endpoints over the 16-week treatment period. Analyses presented evaluate the effect of KER-050 on these markers. Baseline markers of bone turnover were also assessed. Results: A total of 31 patients were enrolled in Part 1 Dose Escalation; 26 were transfusion dependent, 18 with HTB (≥ 4 RBC units in 8 weeks prior to day 1). Seven HTB patients (38.9%) received iron chelator therapy. Baseline differences were noted in measures of iron status, erythropoiesis and bone turnover for non-transfused (NT), low transfusion burden (LTB), and HTB patients (Table 1). HTB patients had the highest baseline serum iron and ferritin levels. Preliminary findings indicate that KER-050 treatment was associated with decreases in serum ferritin for patients both with and without iron chelator therapy. Patients achieving transfusion independence (TI) experienced a 39.5% reduction (mean change: -619.4 ng/ml, range: -2118.4 to +243 ng/mL) in serum ferritin at Week 12 that was generally sustained at Week 16 and 20 (Figure 1). Similarly, over the same time period, serum iron and transferrin saturation (TSAT) decreased by 4.03 µmol/L (8.38%) and 5.3%, respectively, in patients achieving TI. Soluble transferrin receptor (sTfR) increased by 32.2% and remained elevated at subsequent visits. Summary: Preliminary data from the 16-week Dose Escalation in this ongoing phase 2 study reveal differences in baseline iron biomarkers indicative of increasing iron overload with increasing transfusion burden. While nearly half of HTB patients received iron chelator therapy, this group had markedly elevated ferritin compared to NT and LTB patients at baseline. KER-050 treatment was associated with reductions in serum ferritin, irrespective of the use of iron chelation. Patients achieving TI experienced decreases in ferritin, iron and TSAT concurrent with increases in sTfR that were generally maintained through follow-up. The data suggest that, in addition to improving hematopoiesis and transfusion burden in MDS patients, KER-050 may reduce iron overload, a serious clinical complication impacting the survival of these patients. Figure 1View largeDownload PPTFigure 1View largeDownload PPT Close modal

Decreased FOXO1 Expression Is Correlated with Poor Prognosis in Myelodysplastic Syndromes.

Myelodysplastic syndrome is one of the main hematological malignancies that threaten the health of the elderly. However, biomarkers which predict the progression and prognosis of MDS are still controversial and puzzling. FOXO1 gene plays an important role in a variety of intracellular functions, including tumor suppression and cellular immune regulation. However, there is no research report on the correlation between FOXO1 and the clinical features of MDS including immune environment. In this study, we observed that FOXO1 expression is associated with neutrophil count, blasts, chromosome and different MDS scoring systems. FOXO1 expression is closely related to MDS cell immune polarization, and the increase expression of FOXO1 is significantly related to the amplification of immune cell polarization ratio. In addition, FOXO1 expression is associated with progression-free survival and overall survival in MDS patients. Moreover, in a multivariate model FOXO1 low-expression was an independent predictor of poor survival in MDS. In summary, FOXO1 may play a candidate tumor suppressor in MDS, and FOXO1 is a useful independent prognostic predictor in MDS, and it may provide a candidate target therapy in future.

Predictive and prognostic value of gene mutations in myelodysplastic syndrome treated with hypomethylating agents: a meta-analysis

Although the effect of gene mutations on overall response rate (ORR) and overall survival (OS) in myelodysplastic syndrome (MDS) treated with hypomethylating agents (HMAs) has been explored, the effect is still controversial. We performed this meta-analysis to investigate the effect. The pooled odds ratio (OR) and 95% confidence interval (CI) for ORR and the pooled hazard ratio (HR) and 95%CI for OS were chosen to estimate the effect. The pooled OR of TET2 was 0.73 (95%CI: 0.59–0.91, p = 0.005) and the pooled OR of ASXL1 was 1.38 (95%CI: 1.12–1.71, p = 0.003). As for prognosis, the pooled HR of RUNX1 was 1.45 (95%CI: 1.15–1.85, p = 0.002). The pooled HR of TP53 was 2.30 (95%CI: 1.83–2.90, p < 0.001) and the pooled HR of U2AF1 was 1.41 (95%CI: 1.15–1.74, p = 0.001). There was no statistical difference shown in other genes. Therefore, TET2 mutation and ASXL1 wild-type were the predictor of better response to HMAs. Mutations of TP53, RUNX1, and U2AF1 were associated with poor prognosis in MDS.

U2AF1 mutation promotes tumorigenicity through facilitating autophagy flux mediated by FOXO3a activation in myelodysplastic syndromes

Mutations in the U2 small nuclear RNA auxiliary factor 1 (U2AF1) gene are the common feature of a major subset in myelodysplastic syndromes (MDS). However, the genetic landscape and molecular pathogenesis of oncogenic U2AF1S34F mutation in MDS are not totally understood. We performed comprehensive analysis for prognostic significance of U2AF1 mutations in acute myeloid leukemia (AML) cohort based on The Cancer Genome Atlas (TCGA) database. Functional analysis of U2AF1S34F mutation was performed in vitro. Differentially expressed genes (DEGs) and significantly enriched pathways were identified by RNA sequencing. The forkhead box protein O3a (FOXO3a) was investigated to mediate the function of U2AF1S34F mutation in cell models using lentivirus. Chromatin immunoprecipitation, immunoblotting analyses, and immunofluorescence assays were also conducted. U2AF1 mutations were associated with poor prognosis in MDS and AML samples, which significantly inhibited cell proliferation and induced cellular apoptosis in cell models. Our data identified that U2AF1-mutant cell lines undergo FOXO3a-dependent apoptosis and NLRP3 inflammasome activation, which induces pyroptotic cell death. Particularly, an increase in the level of FOXO3a promoted the progression of MDS in association with restored autophagy program leading to NLRP3 inflammasome activation in response to U2AF1S34F mutation. Based on the result that U2AF1S34F mutation promoted the transcriptional activity of Bim through upregulating FOXO3a with transactivation of cell cycle regulators p21Cip1 and p27Kip1, FOXO3a, a potentially cancer-associated transcription factor, was identified as the key molecule on which these pathways converge. Overall, our studies provide new insights that U2AF1S34F mutation functions the crucial roles in mediating MDS disease progression via FOXO3a activation, and demonstrate novel targets of U2AF1 mutations to the pathogenesis of MDS.

Elevated mature monocytes in bone marrow accompanied with a higher IPSS-R score predicts a poor prognosis in myelodysplastic syndromes

BackgroundMyelodysplastic syndromes (MDS) is a group of heterogeneous myeloid clonal diseases originating from hematopoietic stem cells. Clinically, elevated mature monocyte in bone marrow is often observed, but its clinical value still remains unclear.MethodsWe retrospectively analyzed a cohort of 216 MDS patients to explore the prognostic value of the percentage of mature monocyte in bone marrow (PMMBM). All patients were divided into elevated PMMBM group and the normal group by 6% PMMBM as the cut-off value.ResultsOur results showed that PMMBM> 6% was associated with inferior overall survival (OS) (P = 0.026) along with higher-risk IPSS-R (P = 0.025) and higher frequency of IDH2 mutation (P = 0.007). Multivariate analyses showed that besides older age (> 60 years) for OS, gender (male) for OS, lower neutrophil count (< 0.8 × 109/L) for OS, higher bone marrow blast percentage (> 5%) for OS and LFS, poorer karyotype for OS, elevated PMMBM was also an independent adverse prognostic factor for OS in MDS (P < 0.0001) but not for LFS (P = 0.736).ConclusionsThese findings indicate that increased PMMBM may assists Revised International Prognostic Scoring System (IPSS-R) to predict a poor outcome and provide a novel evaluation factor for MDS patients especially when their karyotype analyses fail.

SETD2 deficiency accelerates MDS-associated leukemogenesis via S100a9 in NHD13 mice and predicts poor prognosis in MDS

AbstractSETD2, the histone H3 lysine 36 methyltransferase, previously identified by us, plays an important role in the pathogenesis of hematologic malignancies, but its role in myelodysplastic syndromes (MDSs) has been unclear. In this study, low expression of SETD2 correlated with shortened survival in patients with MDS, and the SETD2 levels in CD34+ bone marrow cells of those patients were increased by decitabine. We knocked out Setd2 in NUP98-HOXD13 (NHD13) transgenic mice, which phenocopies human MDS, and found that loss of Setd2 accelerated the transformation of MDS into acute myeloid leukemia (AML). Loss of Setd2 enhanced the ability of NHD13+ hematopoietic stem and progenitor cells (HSPCs) to self-renew, with increased symmetric self-renewal division and decreased differentiation and cell death. The growth of MDS-associated leukemia cells was inhibited though increasing the H3K36me3 level by using epigenetic modifying drugs. Furthermore, Setd2 deficiency upregulated hematopoietic stem cell signaling and downregulated myeloid differentiation pathways in the NHD13+ HSPCs. Our RNA-seq and chromatin immunoprecipitation–seq analysis indicated that S100a9, the S100 calcium-binding protein, is a target gene of Setd2 and that the addition of recombinant S100a9 weakens the effect of Setd2 deficiency in the NHD13+ HSPCs. In contrast, downregulation of S100a9 leads to decreases of its downstream targets, including Ikba and Jnk, which influence the self-renewal and differentiation of HSPCs. Therefore, our results demonstrated that SETD2 deficiency predicts poor prognosis in MDS and promotes the transformation of MDS into AML, which provides a potential therapeutic target for MDS-associated acute leukemia.

Klotho Expression Predicts Poor Prognosis in Myelodysplastic Syndrome

Introduction: An important explanation for the occurrence of Myelodysplastic syndrome (MDS) in the elderly is related to hematopoietic stem-cell (HSC) senescence. Recent studies have identified aging-related alterations in mesenchymal stromal cells in MDS. During the aging process, the different HSC subtypes lose the ability to differentiate into lymphoid and myeloid precursor cells, causing a breakdown in the immune system balance. This process exposes HSC to important genotoxic factors and may induce genetic or epigenetic alterations because exposure to these factors increases the risk of hematological malignancies. A new biomarker for cancer is Klotho (α and β subtypes), which has been identified as an anti-aging gene that extended the lifespan in murine models when it was overexpressed. Several studies have demonstrated that αKlotho (KL) deficiency causes development of aging features, including increased proliferation, reduction in tumor cell apoptosis, and disruption of HSC development. Some studies have established an association between low expression of KL and risks of cancer (i.e. lymphoma) by inducing cell apoptosis, inhibiting tumor growth, and causing a decrease in insulin-like growth factor 1 receptor (IGF-1R) activation. In parallel to these studies, a recent study reported that KL downregulation was associated with the occurrence of anemia, the main clinical feature of MDS, in cancer patients. However, the expression profile of KL and βKlotho (KLB) genes in the bone marrow (BM) of healthy patients with different ages and the way in which the genes modulate the pathogenesis of MDS in the elderly are unknown. Methods: Total BM cell samples from 62 de novo MDS patients with a mean age of 66 ± 16 years old (10 MDS with single lineage dysplasia, 14 MDS with ring sideroblasts, 27 MDS with multilineage dysplasia, and 11 MDS with excess blasts based on World Health Organization's (WHO) 2016 classification) and from eleven healthy volunteer individuals were collected with informed consents. Healthy patients were stratified into young (n=6; mean 25 ± 6 years old) and elderly (n=5; mean 64 ± 9 years old) individuals. Pre-developed TaqMan gene expression assays for KL (Hs00934627_m1) and KLB (Hs00545621_m1) were used to quantify mRNA expression. Each sample was performed in duplicate, and the expression ratios were calculated using the 2−ΔCq method. Results: Our results demonstrate that the KL gene was expressed in the BM samples from all experimental groups. High KL expression was identified in MDS patients when compared to young (p &lt;0.001) and elderly (p &lt;0.001) controls (Figure 1A). In MDS, KL was downregulated in male patients (p=0.042) (Figure 1B), neutropenic MDS cases (p=0.003) (Figure 1C), MDS patients with transfusion dependence (p=0.001) (Figure 1D), and MDS with an excess of blasts (p=0.038) (Figure 1D), representing more aggressive diseases. A multiple regression was performed in order to predict KL expression from gender, absolute neutrophil count (ANC), transfusion dependence, and WHO 2016 classification. These variables significantly predicted KL expression (F [4, 27] = 3.396; p=0.023; r2=0.335). Transfusion dependence (p=0.027) and WHO 2016 classification (p=0.049) variables significantly added to the prediction. The KLB gene was only expressed in a total of 8/62 MDS patients. The feature that stood out in these patients was the presence of dyserythropoiesis (62.5%). No control sample expressed the KLB gene. Conclusions: Our results demonstrated an important expression profile of KL and KLB in BM of healthy young and old individuals and/or in MDS patients for the first time in contrast to a previous study in which it was demonstrated that human BM induces a negligible expression of these genes. Based on absence of differences between controls, our data showed that KL expression not was associated with the MDS pathogenesis-related senescence process, but its lower expression contributed to the poor prognostic MDS features, probably due to its high potential for affecting HSC number, function, and erythropoiesis. Additionally, low KLB expression in MDS patients with dyserythropoiesis suggests a compensatory response of the bone marrow environment to hematopoietic development block via clonal expansion, especially in the erythroid lineage. These approaches may define KL and KLB as new pathological markers of poor prognosis in MDS and improve future potential therapies. Disclosures No relevant conflicts of interest to declare.

Genetic defects of chromosome 5q and 7q in myeloid neoplasms

In myeloid neoplasms, deletions of the long arm of chromosome 5 del(5q) and 7 (-7/del(7q) ) are common karyotypic abnormalities. The concurrence of del(5q) and -7/del(7q) accounts for poor prognosis in myelodysplastic syndromes (MDS) and acute myeloid leukemia (AML). Comprehensive analysis of copy number abnormalities and genetic mutations related to del(5q) and -7/del(7q) revealed previously cryptic pathophysiology, leading to frequent hemizygous/homozygous mutations and haploinsufficiency. In addition, detailed somatic mutations on chr5q were detected using whole-exome sequencing. CSNK1A1 and G3BP1 are located within the common deleted regions (CDRs) (5q31.1-5q33.1), and another driver gene DDX41 is present in the more telomeric region (5q35.3). All the genes mentioned above exhibited haploinsufficiency because of deletions, and low expression of G3BP1 and DDX41 correlated with poor survival. The related mutational events outside of chr5q, TP53 mutation is most frequently observed in del(5q) cases. Regarding -7/del(7q), 3 CDRs were located in 7q22, 7q34, and 7q35-36. Somatic mutations of the corresponding genes to each CDR (CUX1: 7q22, LUC7L2: 7q34, EZH2: 7q35-36) were identified, indicating that the loss of function or haploinsufficiency might result in the downstream pathological consequences. These recent findings have remarkably offered insights into genetic and clinical consequences in MDS/AML cases with del(5q) and -7/del(7q).

HIV portends a poor prognosis in myelodysplastic syndromes

Even though HIV is associated with worse prognosis in many malignancies, the clinical course of myelodysplastic syndrome (MDS) in HIV + patients has not been well studied. Determining the clinical presentation and outcomes of MDS in these patients would be important for future diagnostic strategies, as anemia and other cytopenias are commonly seen in HIV + patients. Unique data mining software was used to identify cases of MDS or AML in adult patients who were also HIV + at Albert Einstein/Montefiore Medical Center between 1 January 2003 and 1 January 2017. Using Chi-Square and Fisher’s exact test, characteristics of the HIV + MDS patients were compared to 135 HIV − MDS patients from the same institution diagnosed between 1997 and 2011. Fourteen biopsy proven MDS patients were identified with concomitant HIV. HIV + MDS patients presented at a younger age (59 vs. 71 yrs, p = .001) had higher risk disease, faster progression to acute leukemia, and worse overall survival (median survival 11.2 vs. 69.1 mo, p < .001) compared to HIV − MDS controls. Additionally, there was a higher prevalence of clonal-hematopoiesis related mutations (ASXL1, DNMT3A) and a higher proportion of patients with high risk cytogenetics. Analysis of the largest single center cohort of HIV + MDS patients demonstrated that these individuals present at a significantly younger age and with higher risk disease than their HIV − counterparts.

Prognostic significance of monosomal karyotype in myelodysplastic syndrome: a meta-analysis

ABSTRACTObjectives: In myelodysplastic syndrome (MDS), the prognostic role of monosomal karyotype (MK), defined as at least two autosomal monosomies or a single monosomy associated with at least one additional structural abnormality, remained controversial. Therefore, we conducted a meta-analysis to address this issue.Methods: PubMed, Embase, Web of Science, Medline, and the Cochrane Library were retrieved. We extracted hazard ratios (HRs) and the corresponding 95% confidential intervals (CIs) for overall survival (OS) on patients with MK versus those without, as well as on MK patients with monosomies of chromosome 7 and/or 5 versus those without from the available studies.Results: Seventeen studies covering 7500 patients were included this meta-analysis. The pooled HRs indicated MK had a negative impact on OS in MDS (pooled HR: 2.484, 95%CI: 2.033–3.036, P < .001), in MDS patients undergoing allogeneic hematopoietic stem cell transplantation (allo-HSCT) (pooled HR: 2.150, 95%CI: 1.861–2.48, P < .001), and in MDS with complex karyotype (CK) (pooled HR: 2.56, 95%CI: 2.032–3.036, P = .01). However, monosomies of chromosome 5 and/or 7 had no impact on OS in MDS with MK (pooled HR: 1.330, 95%CI: 0.827–2.139, P = .240). Meta-regression indicated that therapy was the origin of the heterogeneity (P = .012).Discussion: Our meta-analysis indicated that MK has a negative impact on OS in MDS, in MDS patients undergoing allo-HSCT, and MDS with CK, but monosomies of chromosome 5 and/or 7 have no impact on OS in MDS with MK. The heterogeneity reflected the biologic and therapeutic heterogeneity of MDS.Conclusion: MK is associated with poor prognosis in MDS, the underlying mechanism needs further exploring.

Over-expression of CD200 predicts poor prognosis in MDS

BackgroundWe studied the expression of CD200 in a series of 101 patients with diagnosis of myelodysplastic syndrome (MDS), to evaluate its impact on outcome and its possible association with other known prognostic factors. Material/methodsThe CD200 was detected by flow cytometry, and the chromosome karyotypes were determined by G banding respectively. The Mann–Whitney U test was used to analyze the association among CD200 expression and clinical features. In addition, the overall survival and AML transformation of the MDS patients according to the expression level of CD200 was also explored. ResultsOverall, the flow cytometric analyses confirmed that expression of CD200 was high in this patient cohort compared to normal BM (p<0.01). The levels of CD200 in RCUD (20.3%±4.3%), RCMD (25.0%±4.5%), RAEB-1 (39.2%±4.9%), and RAEB-2 (43.2%±5.8%) groups were obviously higher than that of RARS group (6.8%±1.7%, P<0.05). Significant differences of CD200 expression were observed in the 4 groups of MDS according to IPSS risk(P<0.01). After 45-month follow-up, Kaplan-Meier analysis of patients with MDS in our study indicated that patients with high expression level of CD200 had a shorter overall survival and a high Leukemic transformation than those with low expression (p<0.01). ConclusionsIn conclusion, our findings provide firstly the evidence that CD200 is up-regulated and emerging as both a prognostic factor and a potential target of novel therapeutic approaches for MDS.

HIV Is Associated with a High Rate of Unexplained Multilineage Cytopenias and Portends a Poor Prognosis in Myelodysplastic Syndrome (MDS) and Acute Myeloid Leukemia (AML)

▪Introduction: While the presence of HIV portends a poor prognosis in many malignancies, its clinical association with MDS and AML has not been well studied, and is known primarily from small case reports and case series. We evaluated the prevalence and clinical course of unexplained cytopenias and clinically proven MDS/AML in a large cohort of HIV-positive (HIV+) patients (pts) seen at a single center, and compared their clinical course to MDS/AML in non-HIV (HIV-) pts.Methods: Data from 15,120 HIV+ pts seen between 1/1/1997 to 6/1/2016 was analyzed for hematologic parameters, HIV status (CD4 count, HIV viral load), chronic disease status and nutrient deficiencies. Anemia was defined as hemoglobin<10, thrombocytopenia as platelets<100 and neutropenia as absolute neutrophil count of <1800, as per the MDS IPSS criteria. Pts with no obvious causes for their cytopenias, such as advanced AIDS, opportunistic infections, chronic kidney disease or nutrient deficiency anemia were determined to have unexplained cytopenias. Furthermore, pts with multiple lineage cytopenias were assessed for evidence of primary bone marrow etiology.Results: Out of 13,277 HIV+ pts that had evaluable blood counts, 1075 pts (8.1%) had cytopenias affecting more than one lineage. 912 pts had bilineage cytopenias and 163 pts had a pancytopenia. This was significantly higher than the frequency of bi/trilineage cytopenias in a non-HIV elderly population that was recently analyzed; 8.1% in HIV+ pts vs 0.9% in non-HIV pts, p <0.0001. Out of a total of 466 cytopenic pts that had all evaluable blood test results, including HIV parameters and chronic disease labs, 119 pts (25.6%) were found to have unexplained bi/trilineage cytopenias with a CD4 count of >250 and HIV viral load <100. Pts with unexplained bi/trilineage cytopenias also presented at relatively younger age (median age 47 years (yrs) (range 24-70 yrs), than pts presenting with MDS.We also identified 10 MDS and 9 AML pts in our HIV+ cohort. Mean CD4 count for these cases was 340 cells/mm3, with only 4 pts < 200 cells/mm3. Median time to MDS or AML diagnosis from date of HIV diagnosis was 15.6 and 13.7 yrs respectively. All pts were receiving anti-retroviral therapy at the time of MDS or AML diagnosis. Only 3 MDS pts and 1 AML patient had a history of prior exposure to chemotherapy. Clinical characteristics of the HIV+ MDS pts (n=10) were compared to HIV- MDS pts (n=135) from the same institution diagnosed between 1997-2011. HIV+ MDS pts presented at a younger age (59.5 vs 70.6 yrs, p = 0.001) and also had significantly higher risk (Int-2/High) disease by IPSS (87.5% vs 17.8%, p <0.001). HIV+ AML pts also presented at a younger age compared with known historical data (56 vs 69 yrs, p = 0.002). Cytogenetic abnormalities were found in 6 of 7 (85.7%) evaluable HIV+ MDS pts, with monosomy 7 being the commonest alteration (71.4%). Six (60%) of the HIV+ MDS pts progressed to AML, with a mean time to progression of 10.4 months. Importantly, HIV+ MDS pts had significantly worse overall survival compared to controls (9.6 vs 58.2 mo, p < 0.001, Figure 1.). Univraiate analysis of MDS pts confirmed that HIV+ pts had statistically significant worse OS, higher risk cytogenetics and younger age at presentation. HIV+ AML pts exhibited poor overall survival of 9.5 mo (range 39-73 yrs).Conclusions: Anemia occurs in most HIV pts at some point in their course, however, bicytopenia and pancytopenia are generally thought to be uncommon, especially in pts with well-controlled disease. We demonstrated in our cohort an unexpectedly high prevalence of unexplained bi/trilieneage cytopenias, not associated with advanced HIV, chronic disease or nutrient deficiencies. This finding suggests the presence of an independent, HIV-specific, mechanism of hematopoietic suppression, acting either at the level of the stem cell, or the bone marrow milieu.We also report on the largest cohort of HIV+ MDS/AML cases in the literature and demonstrate that HIV+ pts who develop MDS and AML do so at a younger age, present with more advanced disease that is resistant to standard therapy, and have worse overall survival than a control cohort of HIV- pts. These data present evidence that suggests that MDS should be considered as a diagnosis early in HIV. Appropriate risk stratification and new therapeutic approaches are needed. [Display omitted] [Display omitted] DisclosuresNo relevant conflicts of interest to declare.

Prognostic significance of ASXL1 mutations in myelodysplastic syndromes and chronic myelomonocytic leukemia: A meta-analysis

Objectives: Although additional sex comb-like 1 (ASXL1) gene mutations have long been reported in myelodysplastic syndromes (MDSs) and chronic myelomonocytic leukemia (CMML), the prognostic significance has been controversial. Therefore, a meta-analysis to study the impact of ASXL1 mutations on patients with MDS and CMML is useful.Methods: The identified articles were retrieved from some common databases. We extracted hazard ratios (HRs) for overall survival (OS) and leukemic-free survival (LFS) and P-value of some clinical parameters, which compared AXSL1 mutations to those without from the available studies. Each individual HR and P-value was used to calculate the pooled HR and P-value.Results: Six studies covering 1689 patients were selected for this meta-analysis. The pooled HRs for OS and LFS were 1.45 (95% confidential interval (CI), 1.24–1.70) and 2.20 (95% CI, 1.53–3.17), respectively. When considering CMML patients alone the HR for OS was 1.50 (95% CI, 1.18–1.90). Additionally, ASXL1 mutations were more frequently found in male (P = 0.008), older (P = 0.019), and patients with lower platelets (P = 0.009) or hemoglobin level (P = 0.0015) and associated with other mutations such as EZH2, IDH1/2, RUNX1, and TET2.Discussion: Although our analysis has its limitation, it showed that ASXL1 mutations had significant inferior impact on OS and LFS for French–American–British-defined MDS patients. However, the influence of different types of ASXL1 mutations on patients with MDS still needs illustrating.Conclusion: ASXL1 mutations were associated with poor prognosis in MDS, which may contribute to risk stratification and prognostic assessment in the disease.

Red Blood Cell Transfusion Dependency and Hyperferritinemia Are Associated with Impaired Survival in Patients Diagnosed with Myelodysplastic Syndromes: Results from the First Polish MDS-PALG Registry.

Myelodysplastic syndromes (MDS) are a heterogeneous group of clonal stem cell disorders characterized by ineffective hematopoiesis, cytopenias and a risk of progression to acute myeloid leukemia (AML). Anemia is the most frequent cytopenia diagnosed in patients with MDS. Regular RBC transfusions are the only treatment option for about 40% of patients. Transfusion-dependent patients develop secondary iron overload. The influence of serum ferritin (SF) concentration on survival and acute myeloid leukemia transformation in MDS patients remains controversial. The data for the Central European population is scarce and so far there is no description for Poland. The aim of this study was to perform a retrospective analysis of the relationship of SF concentration with red blood cell transfusion dependency, survival and transformation to acute myeloid leukemia. We retrospectively evaluated the data of the 819 MDS patients (58% male; median age 70 years) included in the MDS Registry of the MDS Section of the Polish Adult Leukemia Group (PALG). Analyses were performed on 190 patients diagnosed with MDS, maximal 6 months before inclusion to the registry in order to avoid selection bias (a shorter survival of higher risk MDS patients). Patients with hyperferritinemia higher than 1000 ng/L vs. patients with SF concentration lower than 1000 ng/L had a median survival of 320 days vs. 568 days, respectively (p log-rank = 0.014). The following factors were found to significantly worsen survival: RBC-transfusion dependence (p = 0.0033; HR 2.67L), platelet transfusion dependence (p = 0.0071; HR 3.321), hemoglobin concentration lower than 10 g/dL (p = 0.0036; HR 2.97), SF concentration higher than 1000 ng/L (p = 0.0023; HR = 2.94), platelet count lower than 10 G/L (p = 0.0081 HR = 5.04), acute leukemia transformation (p = 0.0081; HR 1.968). Taking into account the relatively low number of patients in previous studies exploring hyperferritinemia in MDS, the results of the first Polish MDS Registry provide important insights. Hyperferritinemia higher than 1000 ng/L can be an important indicator of poor prognosis in MDS.

Clinical Implications of the SETBP1 Mutation in Patients With Primary Myelodysplastic Syndrome and its Stability During Disease Progression

Mutations of the SET binding protein 1 (SETBP1) gene have been identified in patients with myeloid neoplasms, but the clinical relevance of this mutation and its association with other gene mutations in myelodysplastic syndrome (MDS) and the stability during disease progression remains unclear. Mutations in SETBP1 gene at exon 4 were analyzed by polymerase chain reaction and direct sequencing in 430 MDS patients. The results were correlated with clinical features, cytogenetics, gene mutations and treatment outcomes. SETBP1 mutations were identified in 14 (3.3%) of the 430 patients with primary MDS based on the FAB classification and 8 (2.4%) of the 333 patients based on the WHO classification. The SETBP1 mutation was closely associated with higher white blood cell counts, isochromosome of 17q, monosomy 7, and mutations of ASXL1, EZH2 and SRSF2. With a median follow-up of 43.9 months, MDS patients, based on either the FAB or WHO classification, had a significantly poorer overall survival (OS) if they harbored SETBP1 mutation. Further, SETBP1 mutation was an independent poor prognostic factor for OS (HR = 1.842, CI 95%, 1.1018–3.332, P = 0.043) irrespective of age, sex, and the International Prognostic Scoring System. Sequential analysis showed that the original SETBP1 mutations in the eight SETBP1-mutated patients studied were retained while two of the 101 SETBP1-wild patients acquired novel SETBP1 mutations during follow-ups. The SETBP1 mutation is associated with poor prognosis in MDS. The mutation can be acquired during the clinical course suggesting it may play a role in disease progression. Am. J. Hematol. 89:181–186, 2014. © 2013 Wiley Periodicals, Inc.

Abnormal methylation of the sex-determining region Y-box 17 (SOX17) promoter predicts poor prognosis in myelodysplastic syndrome.

The sex-determining region Y-box 17 (SOX17) is a member of the high mobility group (HMG) transcription factor family, which plays critical roles in the regulation of development and stem/precursor cell function. Recent evidence demonstrated that SOX17 acts as a tumor-suppressor gene, at least partly though repression of Wnt pathway activity. Here we report that SOX17 methylation was detected in THP-1 and SKM-I cell lines and SOX17 mRNA levels was up-regulated by 5-aza-dC. To clarify the role of SOXI7 in MDS, methylation-specific PCR (MSP) was employed to examine the methylation status of SOX17 in 164 adult de novo MDS patients and 6 normal samples. We found that SOX17 methylation was presented in 58.5% (n = 96) of these patients and none of the normal samples. Methylation was correlated significantly with World Health Organization (WHO) subtypes and international prognostic scoring system (IPSS) risk group. Patients with advanced stages of WHO subtypes (69.6% vs. 44.4%, p = 0.001) and higher risk IPSS subgroups (69.8% vs. 48.8%, p = 0.010) exhibited a significantly higher frequency of SOX17 methylation. Though multivariate analysis indicated that SOX17 methylation status was not the independent factor that impacted overall survival (OS) (HR = 0.097), there were significant differences in marrow blast levels and the IPSS risk subgroups between patients with and without SOX17 methylation. These findings suggest that the hypermethylation of SOX17 promoter may be one of the early events in the development of MDS and predicts poor prognosis.

Clinical implications of the SETBP1 mutation in patients with primary myelodysplastic syndrome and its stability during disease progression

Mutations of the SET binding protein 1 (SETBP1) gene have been identified in patients with myeloid neoplasms, but the clinical relevance of this mutation and its association with other gene mutations in myelodysplastic syndrome (MDS) and the stability during disease progression remains unclear. Mutations in SETBP1 gene at exon 4 were analyzed by polymerase chain reaction and direct sequencing in 430 MDS patients. The results were correlated with clinical features, cytogenetics, gene mutations and treatment outcomes. SETBP1 mutations were identified in 14 (3.3%) of the 430 patients with primary MDS based on the FAB classification and 8 (2.4%) of the 333 patients based on the WHO classification. The SETBP1 mutation was closely associated with higher white blood cell counts, isochromosome of 17q, monosomy 7, and mutations of ASXL1, EZH2 and SRSF2. With a median follow‐up of 43.9 months, MDS patients, based on either the FAB or WHO classification, had a significantly poorer overall survival (OS) if they harbored SETBP1 mutation. Further, SETBP1 mutation was an independent poor prognostic factor for OS (HR = 1.842, CI 95%, 1.1018–3.332, P = 0.043) irrespective of age, sex, and the International Prognostic Scoring System. Sequential analysis showed that the original SETBP1 mutations in the eight SETBP1‐mutated patients studied were retained while two of the 101 SETBP1‐wild patients acquired novel SETBP1 mutations during follow‐ups. The SETBP1 mutation is associated with poor prognosis in MDS. The mutation can be acquired during the clinical course suggesting it may play a role in disease progression. Am. J. Hematol. 89:181–186, 2014. © 2013 Wiley Periodicals, Inc.