Refractory Anemia With Excess Blasts Research Articles

Prognostic Significance of WT1 mRNA and Anti-WT1 Antibody Levels in Peripheral Blood in Patients with Myelodysplastic Syndromes.

Abstract 3821Poster Board III-757(INTRODUCTION) The Wilms tumor gene (WT1) message is overexpressed in tumor cells from various solid cancers as well as hematologic malignancies including myelodysplastic syndromes (MDS). We reported previously that WT1 mRNA expression in peripheral blood mononuclear cells (PBMCs) as well as bone marrow (BM) cells increased with the aggressiveness of MDS disease subtype as defined by the French-American-British (FAB) classification and that a humoral immune response, IgG- or IgM-type anti-WT1 antibody (Ab) expression, was detected in sera from most MDS patients. In this study, we investigated whether WT1 mRNA expression and anti-WT1 Ab titers in PB were associated with prognosis in MDS patients by examining their long-term follow-up data. (METHODS AND RESULTS) (1) WT1 mRNA expression in PBMCs was examined in 80 patients: 35 with refractory anemia (RA); 5 with RA with ringed sideroblasts (RARS); 24 with RA with excess blasts (RAEB); 5 with RAEB in transformation (RAEB-t); and 11 with acute myeloid leukemia transformed from MDS (AML-MDS). Levels of WT1 mRNA expression were assessed using the real-time quantitative polymerase chain reaction [Tamaki H, et al, Leukemia 1999]. WT1 mRNA levels increased with the aggressiveness of disease subtype (mean: RA, 220.9; RARS, 129.4; RAEB, 5,554.3; RAEB-t, 14,284.0; AML-MDS, 56,272.7 copies/μg) and with the aggressiveness of the International Prognostic Scoring System (IPSS) category (mean: low, 114.5; intermediate-1, 360.8; intermediate-2, 12,041.6; high, 7,357.9 copies/μg) in these patients. (2) IgG- and IgM-type anti-WT1 Ab titers were determined using the dot-blot assay [Elisseeva OA, Blood 2002] in sera from 45 of the 80 patients: 15 RA; 3 RARS; 18 RAEB; 3 RAEB-t; and 6 AML-MDS. IgM and IgG WT1 Abs were detected in 31 (79.5%) and 34 (87.2%) MDS patients, and 5 (83.3%) and 6 (100%) AML-MDS patients, respectively. WT1 Abs levels were not correlated with FAB subtype, IPSS, or WT1 mRNA expression in PBMCs. (3) When patients were divided into three groups based on the WT1 mRNA level (fewer than 100 copies/μg, 100 to 10,000 copies/μg, and more than 10,000 copies/μg), their survival rates differed significantly (P = 0.0186): survival was worse in those with increased WT1 mRNA levels. Specifically, a high WT1 mRNA level was a strong predictor of rapid AML transformation even if adjusted by the IPSS (P = 0.0005). Furthermore, patients with high levels of either IgM or IgG WT1 Abs had significantly better survival compared with those whose IgM and IgG WT1 Abs values were both low (P = 0.0007) even when adjusted by the IPSS (P = 0.0019). (CONCLUSIONS) This study showed for the first time that high WT1 mRNA expression and high WT1 Ab titers in PB affected the prognosis of MDS patients negatively and positively, respectively, suggesting that an optimal immune response against WT1 may beneficial. Recently, clinical trials of WT1 peptide-based immunotherapy have been conducted for various malignancies including MDS. Our data presented here may provide a rationale for anti-WT1 immunotherapy in MDS. Disclosures:No relevant conflicts of interest to declare.

Interferon-γ and Tumor Necrosis Factor-α Induce An Immunoinhibitory Molecule, B7-H1, Via NfκB Activation in Blasts of Myelodysplastic Syndromes.

Abstract 2766Poster Board II-742 (Introduction)B7-H1 (CD274) is a costimulatory/coinhibitory molecule that plays a crucial role in T cell regulation in various immune responses. B7-H1 expression is detected not only on professional antigen-presenting cells but also on some tumor cells. It has been reported that B7-H1 molecules on tumor cells inhibit the proliferation of tumor-specific cytotoxic T-lymphocytes and are associated with poor prognosis in patients with some tumors such as renal and breast cancers. In this study, we investigated whether functional B7-H1 molecules are expressed on blasts from myelodysplastic syndromes (MDS) and, if so, are associated with pathophysiology in specific immune evasion in MDS. (Materials and methods)(1) First, we analyzed the expression of B7-H1 mRNA and protein in MDS cell lines (OIH-1, SKM-1, and F36P) using reverse transcription-PCR and flow cytometry (FCM), respectively. Although F36P cells alone expressed B7-H1 molecules at mRNA and protein levels, interferon (IFN)-γ and more efficiently a combination of IFN-γ and tumor necrosis factor (TNF)-α enhanced or induced B7-H1 expression in all of these cell lines. Notably, the combination of IFN-γ and TNF-α induced nuclear factor (NF) γB activation of MDS cell lines, and the blocking of NFκB activation by pyrrolidine dithiocarbamate (PDTC) or NFκB inhibitor peptide turned off the B7-H1 induction. (2) To investigate whether B7-H1+ MDS blasts have a proliferative advantage, we compared the cell cycle and colony formation between B7-H1+ and B7-H1– cell fractions in F36P cells. B7-H1+ cells had fewer G0/G1-phase cells and more G2/M-phase cells compared with B7-H1– cells. Furthermore, purified B7-H1+ cells formed more colonies than B7-H1– cells in the colony-forming assay using the methylcellulose. (3) We investigated the immunomodulatory effects of B7-H1+ blasts on T cells. When normal CD3+ T cells were cultured with or without irradiated B7-H1+ F36P cells, the B7-H1+ F36P cells had markedly increased percentages of T cells showing apoptosis. The blocking antibody for B7-H1 or PD-1 inhibited the T-cell apoptosis induced by B7-H1+ cells, decreased the percentage of caspase-3+ cells in T cells, and increased T-cell proliferation. (4) We then examined B7-H1 expression on blasts from 41 MDS patients, 20 patients with acute myeloid leukemia transformed from MDS (AML-MDS), and 10 hematologically normal individuals using FCM. B7-H1+ cases, in whom more than 5% of blasts expressed B7-H1 molecules, were observed in 6 of 14 (43%) patients with refractory anemia with excess blasts (RAEB), 6 of 12 (50%) with RAEB in transformation (RAEB-t), and 4 of 20 (20%) AML-MDS patients, but in none of 15 RA patients and normal individuals. Similar to the data obtained using MDS cell lines, B7-H1 expression on blasts purified from MDS patients was induced by stimulation with IFN-γ or TNF-α, and more strikingly by their combination. PDTC inhibited the induction of B7-H1 expression. The percentages of G0/G1-phase cells were lower and those of G2/M-phase cells higher in B7-H1+ blasts than in B7-H1– blasts from patients. Furthermore, in allogeneic coculture, in which B7-H1+ blasts from an MDS patient and CD3+ T cells from healthy volunteers were cultured, T-cell proliferation was significantly augmented by blocking B7-H1 molecules. (5) Finally, we investigated the expression of PD-1, a counterreceptor of B7-H1, on circulating T cells in 34 MDS patients. PD-1 expression on CD3+, CD4+, and CD8+ T cells in MDS patients was significantly higher than that in healthy volunteers. (CONCLUSIONS)Taking the results together, in MDS: 1) B7-H1 expression on blasts occurs more often in the advanced disease stages; 2) B7-H1 expression on blasts may be induced by cytokines derived from the bone marrow environment via NFκB activation; 3) cell cycle and proliferation were more active in B7-H1+ blasts than in B7-H1– blasts; and 4) B7-H1 molecules on blasts suppress T-cell immunity. These findings indicate that B7-H1 molecules on blasts may be involved in the pathophysiology of MDS. Disclosures:No relevant conflicts of interest to declare.

Alpha-Catenin, ARHGAP21 and β-Catenin Are Abnormally Expressed in Bone Marrow Cells From Patients with Myelodysplatic Syndromes and Are a Possible Target for Decitabine Treatment.

Abstract 1778Poster Board I-804 IntroductionMyelodysplastic syndrome (MDS) encloses a group of clonal hematopoietic disorders clinically and morphologically characterized by ineffective hematopoiesis. The gene encoding alpha-catenin (CTNNA1) is expressed at a much lower level in leukemia-initiating stem cells from individuals with MDS del(5q). Thus, loss of alpha-catenin tumor suppressor expression in hematopoietic cells may provide a growth advantage that collaborates MDS pathogenesis. ARHGAP21, a negative regulator of RhoGTPase signaling pathways, is a partner of alpha-catenin that controls its recruitment to the adherens junctions. ARHGAP21 is upregulated during myeloid differentiation, and could be involved in the malignant process of hematopoietic cells. In addition, alpha-catenin is a target for decitabine (DAC) treatment, a demethylating agent with potent antitumorigenic properties against MDS. The aim of this work was to evaluate the expression of alpha-catenin, ARHGAP21 and beta-catenin (gene CTNNB1) in bone marrow cells from MDS patients with or without del(5q) and to analyze CTNNA1, ARHGAP21 and CTNNB1 expression after DAC treatment. PATIENTS AND METHODScells were isolated from bone marrow of 6 MDS patients, including 5 refractory anemia (RA), being two with del(5q), and 1 refractory anemia with excess blasts (RAEB), based on the French-American-British classification, and 4 control subjects (normal hematopoietic tissues were obtained from healthy donors). The study was approved by the National Ethical Committee Board and bone marrow samples were collected at the Hematology and Hemotherapy Center, University of Campinas, after all participants provided informed written consent. Alpha-catenin, ARHGAP21 and beta-catenin localization in CD34+ cells was obtained using confocal microscopic analysis. ARHGAP21 localization was also analyzed in HS-5 stromal cells that were submitted to a CTNNA1 RNA interference (RNAi) approach. Leukemia cells lines (HL-60 and P-39) and bone marrow mononuclear cells obtained from 7 MDS patients, 5 RA and 2 refractory anemia with ringed sideroblasts (RARS), were treated with DAC for 72 hours; then mRNA expression of CTNNA1, ARHGAP21 and CTNNB1 was analyzed by Real-time PCR (normalized by GAPDH and beta-actin). RESULTSalpha-catenin, ARHGAP21 and beta-catenin are preferentially localized in the nucleus of CD34+ cells from MDS patients in contrast to the preferential cytoplasm and membrane localization in healthy donors and in MDS patients with del(5q). In del(5q) patients and healthy donors, ARHGAP21 and alpha-catenin co-localizated in the cell membrane. ARHGAP21 was abnormally expressed in cells with decreased CTNNA1 expression: in HS-5 stromal cells, ARHGAP21 was localized at the cytoplasm (mainly in the perinuclear region) and at the nucleus, in contrast, ARHGAP21 was poorly detectable in the nucleus of CTNNA1-RNAi treated cells. DAC treatment of MDS cells and leukemia cell lines induced CTNNA1, ARHGAP21, and CTNNB1 expression in a dose-dependent way. In HL60 and P39 cells, ARHGAP21 relocate to the cell membrane after DAC treatment. CONCLUSIONThe abnormal localization of alpha-catenin, ARHGAP21 and beta-catenin in MDS may compromise the reorganization of actin dynamics at sites of cell–cell contact that stabilizes cadherin-mediated cell–cell adhesion; moreover, these results also suggest a deficient recruitment of alpha-catenin to the cell membrane and an aberrant signaling in the Wnt pathway. In addition, ARHGAP21, alpha-catenin and beta-catenin are a target for DAC treatment in MDS. Supported by: FAPESP.Keywords: alpha-catenin, ARHGAP21, beta-catenin, myelodysplastic syndrome, Rho-GAP, decitabine DisclosuresNo relevant conflicts of interest to declare.

Quantitative Assessment of Myeloid Nuclear Differentiation Antigen Distinguishes Myelodysplastic Syndrome From Normal Bone Marrow.

Abstract 1754▪▪This icon denotes an abstract that is clinically relevant.Poster Board I-780 IntroductionDefinitive diagnosis and classification of MDS are often difficult because of variable presence of diagnostic criteria and imprecision and ambiguities of interpretation of both morphologic and ancillary data. An objective criterion that reliably distinguishes MDS from normal marrow would greatly facilitate diagnosis, and might contribute to subclassification of MDS. Gene expression profiling has identified marked (7 fold) down-regulation of myeloid nuclear differentiation antigen (MNDA) message in cases of MDS (Hofmann WK, et al, Blood 2002;100:3553-60), and we have previously shown down-regulation of MNDA protein expression in random MDS cases using immunohistochemistry and flow cytometry (Briggs RC, et al. Cancer Research 2006;66:4645-51). To continue our previous analyses, we evaluated MNDA expression in myeloid progenitors using quantitative flow cytometric analysis in MDS and normal control marrow samples. Patients and MethodsThe study included 20 MDS patients receiving only supportive care undergoing bone marrow sampling for clinical purposes, and 19 frequency age-matched normal controls undergoing orthopedic surgery with no antecedent primary hematologic abnormalities. MDS diagnosis was based on 2008 WHO criteria. Quantitative flow cytometric analysis was performed with an FC500 flow cytometer (Beckman Coulter, Fullerton, CA). Cells were treated with CD45-PE and CD34-ECD (Beckman Coulter), washed in PBS with 2% FCS, and permeabilized with PermiFlow. MNDA-Alexa-488 was added at a granulocyte-monocyte specific concentration, with analysis using Winlist 5.0 software (Verity Software, Topsham, ME) with DDE links to ModFitLT 3.0 using modifications of published methods. Differentiating myeloid progenitors were identified as high side scatter/intermediate CD45/CD34-negative cells, with lymphocytes (low side scatter/high CD45/CD34-negative cells) serving as an internal dim MNDA control in each sample. ResultsMDS cases consisted of 12 patients with refractory cytopenia with multilineage dysplasia (RCMD), 3 with refractory anemia with excess blasts-1(RAEB-1), 4 with RAEB-2, and 1 with therapy-related MDS. In myeloid progenitors in MDS patients, the median percent of MNDA-dim cells was 67.4% (range 0.7-97.5%, interquartile range 44.9-82.7%). The analogous median percent of MNDA-dim cells in control patients was 1.2% (range 0.2-13.7%, interquartile range 0.6-2.7%). The area under the ROC curve was 0.96 (p = 9×10-7), indicating almost complete discrimination between cases and controls. 19 of 20 MDS patients demonstrated bimodal distribution of MNDA expression comprising a distinct MNDA-dim population and a separate MNDA-normal population, suggesting an admixture of MDS and normal cells. 18 of 19 control patients demonstrated a single population of MNDA-normal cells without evidence of a bimodal distribution. The single MDS patient with normal MNDA expression had prior clinical and laboratory features suggestive of refractory anemia with ringed sideroblasts. The single pediatric MDS patient had reduced MNDA expression similar to other high grade MDS samples. Patients showed trends for MDS subtype (p = 0.21) and IPSS score (p = 0.07) versus percent MNDA-dim myeloid progenitors. These data demonstrate remarkable sensitivity and specificity for use of MNDA expression to detect MDS. ConclusionsQuantitative flow cytometric analysis of MNDA expression in marrow myeloid progenitors is a promising objective test for diagnosis of MDS, demonstrating a striking difference of MNDA expression in myeloid progenitors in MDS versus control patients. Our results require elaboration with analysis of low grade cases. A single possible low grade MDS case in this series demonstrated MNDA expression identical to normal control samples. Our results also require elaboration in cases constituting the differential diagnosis of MDS to evaluate the clinical utility of MNDA evaluation. The biological significance of down-regulation of MNDA in MDS is uncertain, although MNDA has been implicated in regulation of programmed cell death. Our results suggest a mix of normal and abnormal myelopoiesis in MDS patients, as predicted by cytogenetics in many cases of MDS. In summary, testing of MNDA expression in myeloid progenitors shows great promise as an objective test for diagnosis of MDS in marrow samples. DisclosuresNo relevant conflicts of interest to declare.

Clinical and Biological EFFECTS of 5-Azacitidine FIVE Days/Monthly Schedule IN Symptomatic LOW-RISK (IPSS: 0-1) Myelodisplastic Patient.

Abstract 4851 BackgroundNucleoside 5-Azacitidine (5-Aza) administered at a dose of 75mg/mq/day subcutaneously for 7 days, every 28 days, induces high hematologic response rates, reduces progression to acute myeloid leukaemia (AML) and increases overall survival in the high risk MDS patients. AimThe use of 5-Aza in the earlier phases of MDS could reduce the proliferative advantage of MDS clone and favours the regrowth of normal hematopoiesis. In the setting of low-risk MDS patients lower doses of 5-Aza could be enough to induce hematologic responses. We attempted to use an alternative schedule, 75 mg/mq subcutaneous daily for 5 consecutive days every 28 days, for a total of 8 courses, to evaluate its efficacy and tolerability in low risk MDS patients. Pharmacogenomic studies (gene expression profile and single nucleotide polymorphism analysis), cytokine network and phosphatidylinositol-phospholipase C – β1 (PI-PLC - β1) expression, before and after 5-Aza treatment, were planned to identify new biological markers to predict the response. MethodsFrom September 2008 to August 2009, 25 patients were enrolled into the study. According to WHO criteria 12 patients had refractory anemia (RA), 5 patients refractory cytopenia with multilineage dysplasia (RCMD), 7 patients refractory anemia with excess blasts-1 (RAEB-1) and 1 patient refractory anemia with ringed sideroblasts (RARS). All patients were classified as Low Risk (IPSS score 0-1). Age at diagnosis ranged between 56 and 84 years. All patients failed previously EPO therapy and were in chronic red blood cell (RBC) supportive care with a median transfusions requirement of 4 units/monthly. The response treatment criteria was according to IWG 2006. Results9/25 (36%) patients completed at least 4 courses of therapy and only 6/25 (24%) patients finished the treatment plan (8 courses). Five patients obtained an hematologic improvement (3 erythroid response and 2 neutrophil response) whereas 4 patients maintained a stable disease. The others 16 patients are ongoing. The drug was very well tolerated. WHO grade III hematologic toxicity consisted in neutropenia (1 case) and thrombocytopenia (1 case) was observed in only two patients, but it was transitory and no delay of treatment was necessary. ConclusionOur preliminary results show that the 5-Aza five days/monthly schedule is very well tolerated and it appears to induce hematologic improvements as well as the seven days/monthly schedule, at least in the low-risk MDS setting. Biological studies will be useful to elucidate the genetic bases of sensititvity or resistance to 5-AZA and to optimise the therapy.Acknowledgments: this work was supported by MIUR 2008. DisclosuresNo relevant conflicts of interest to declare.

Unrelated Donor Umbilical Cord Blood Transplantation in Pediatric Myelodysplastic Syndrome: A Single-Center Experience

Myelodysplastic syndromes (MDS) respond poorly to chemotherapy. Between 1995 and 2006, 23 pediatric patients with MDS were transplanted with unrelated donor umbilical cord blood (UUCB) at our center. The median age was 11.1 years (range: 1.1-19.7), median weight was 38.6 kg (range: 9.6-62.6), 61% of patients were male, and median time from diagnosis to transplant was 6.6 months (range: 2.0-61.4). Patients were followed for a median of 5.3 years (range: 1.6-12.4 years) posttransplant. MDS stage was refractory anemia (RA) in 12, refractory anemia with excess blasts (RAEB) in 8, and refractory anemia with excess blasts in transformation (RAEB-T) in 3 patients; 18 (78%) patients had primary MDS. Monosomy 7 was present in 17(74%) patients. Patients with acute myelogenous leukemia (AML) were excluded. Preparative regimen was total body irradiation (TBI) based in 18 (78%) patients. Graft-versus-host-disease (GVHD) prophylaxis was cyclosporine (CsA)/steroids (19 patients) or CsA/mycophenolate mofetil (MMF; 4 patients). Grafts were HLA matched at Class I (A and B) at low resolution and Class II (DRB1) at the allelic level, resulting in 16 (70%) 4/6 and 7 (30%) 5/6 matched transplants. The grafts contained a median of 4.0 × 10 7 (range: 1.7-12.6) total nucleated cells (TNC)/kg precryopreservation; 3.6 × 10 7 (range: 1.0-12.0) TNC/kg and 1.7 × 10 5 (range: 0.2-28.5) CD34 + cells/kg were infused. Cumulative incidence of neutrophil engraftment (absolute neutrophil count [ANC] >500/ μL) at day 42 and day 100 was 73.9% (95% confidence interval [CI] 55.1%-92.7%) and 91.3% (95% CI 71.3%-100.0%) respectively, and that of platelet engraftment (50 K) at 180 days was 69.6% (95% CI 49.8%-89.4%). Three patients had graft failure whereas 3 patients (13%) engrafted slowly (after day 42). Three patients developed acute GVHD (aGVHD) grades II-IV with a cumulative incidence at 100 days of 13% (95% CI 0.0%-27.1.0%). Four patients relapsed with a cumulative incidence of relapse at 3 years of 13.0% (95% CI 0.0%-27.1%). Cumulative incidence of nonrelapse mortality (NRM) at 1 year was 27% (95% CI 8.0%-46.0%). Ten patients died: 3 graft failure, 4 relapse, 2 infections (1 adenovirus, 1 toxoplasmosis), and 1 Epstein-Barr virus (EBV) lymphoproliferative disorder. Probabilities of event-free survival (EFS) at 1 and 3 years were 69.6% (95% CI 46.6%-84.2%) and 60.9% (95% CI 38.3%-77.4%), respectively. Factors associated with better EFS were age ≤11 years ( P = .05) and weight ≤38 kg ( P = .03). These results, especially in younger patients with monosomy 7 positive MDS, are equivalent to published matched allogeneic bone marrow data. UUCB should be actively considered for pediatric MDS patients lacking matched related or unrelated adult donors.

Reporting Confidence Intervals for Myelodysplasia Blast Counts

It is good to see discussions of statistics related to matters of pathology. I welcome the discussion by Dr Vollmer in the February 2009 issue of the Journal .1 What Dr Vollmer has demonstrated is that by statistical considerations, any blast count corresponds to a diagnosis of one of the subsets of myelodysplasia. For example, a cell count of 5% blasts could be a result from any of the following subsets: no excess blasts group, refractory anemia with excess blasts (RAEB)1, RAEB2, or acute leukemia. However, the further the observed blast count is from the diagnostic count value for a subset, the less likely it is that the subset diagnosis is responsible for the observed count. This is generally intuitively understood by pathologists and clinicians. Dr Vollmer has provided some quantitative and theoretical background to this practical understanding. What I think would improve the pathology report for clinicians is a measure of the precision of the blast count. This could be the confidence interval. Pathologists and clinicians are familiar with confidence …

Interstitial pneumonia associated with progression of myelodysplastic syndrome

Pulmonary complications are common in patients with myelodysplastic syndrome (MDS) and may be caused by infections, heart failure, hemorrhage, chemotherapy and rarely by leukemic infiltration of the parenchyma of the lungs [1]. Besides these conditions, MDS is rarely complicated by interstitial lung diseases, such as interstitial pneumonia [2, 3], bronchiolitis obliterans with organizing pneumonia (BOOP) [1, 4], and lung involvement associated with Sweet’s disease [1, 5, 6]. Here, we describe a case of steroid-responsive interstitial pneumonia, which developed in parallel with the progression of MDS. A 76-year-old Japanese woman who had been diagnosed with refractory anemia (RA) with normal karyotype 6 years previously was admitted to our hospital because of a 2-week history of fever, productive coughs and respiratory distress. On admission, physical examination disclosed a temperature of 37.5 C and coarse crackles over the lower fields of both lungs. Hematologic examination demonstrated a WBC count of 5.1 9 10/L with 2% blasts; a hemoglobin concentration of 8.7 g/dL and a platelet count of 378 9 10/L. She also had high levels of serum lactate dehydrogenase (528 IU/L) and C-reactive protein levels (7.24 mg/dL). Arterial blood gas analysis on room air showed an oxygen partial pressure of 54.4 mmHg, carbon dioxide partial pressure of 41.5 mmHg and pH of 7.47. Serology for autoimmune diseases and fungal antigen tests were negative. Blood and sputum cultures were negative for pathogens. Bone marrow aspirate and biopsy demonstrated hypercellular marrow with 15% blasts, and trilineage dysplasia without myelofibrosis. Cytogenetic analysis demonstrated an abnormal complex karyotype: 47,XX, der (5;17) (p10; q10), ?8, del (13) (q12q14) in the bone marrow cells. Thus, disease progression of RA to refractory anemia with excess blasts (RAEB)-2 was confirmed. Chest roentgenogram showed patchy infiltrates in the lower lobes of both lungs. A computed tomography (CT) scan of the chest demonstrated multiple patchy consolidation and ground-grass opacities in both lungs (Fig. 1a). Despite empirical treatment with broad-spectrum antibacterial and antifungal agents, oxygenation progressively deteriorated and fever persisted over the following weeks. Subsequent CT scan of the chest showed that the infiltrates had expanded and migrated along the bronchovascular bundles, suggesting BOOP. She had high levels of serum sialylated carbohydrate antigen KL-6 (1160 U/mL; normal range 0.0–500.0 U/mL) and surfactant protein D (419.1 ng/mL; normal range 0.0–110.0 ng/mL). Thereafter, fiberoptic bronchoscopy was performed, which did not show any endobronchial abnormalities. Bronchoalveolar lavage (BAL) fluid analysis demonstrated increased total cell count (5.3 9 10/mL), which was predominantly composed of lymphocytes with an elevated CD4/8 ratio of 2.53. Neither pathogenic microorganisms nor malignant cells were observed in the BAL fluid. Fluorescence in situ hybridization analysis detected an increase of cells showing trisomy 8 (6%), which should represent the MDS clone, in BAL fluid. Although radiographic and BAL findings suggested BOOP, histological examination of the specimen obtained by transbronchial lung biopsy demonstrated alveolitis with lymphocyte infiltration, which is compatible K. Kataoka M. Ichikawa A. Hangaishi T. Takahashi Y. Imai M. Kurokawa (&) Department of Hematology and Oncology, Graduate School of Medicine, University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo 113-8655, Japan e-mail: kurokawa-tky@umin.ac.jp

Primary Myelodysplastic Syndrome in Jordan: A Single-Centre Experience

Objective: Study of the disease patterns and clinical evaluation of myelodysplastic syndrome (MDS). Subjects and Methods: A retrospective analysis was carried out on 85 patients, with MDS who were followed up over a period of 23 years at Jordan University Hospital, Amman, Jordan. Cases were analyzed according to the French, American and British Classification. Results: Of the 85 patients, 42 (49.4%) were females and 43 (50%) males; mean age was 59 ± 19 years (range 18–88). Most subtypes found in patients were refractory anemia (RA) in 27 (31.8%) and RA with excess blasts (RAEB) in 28 (32.9%). Adverse prognostic indicators were RAEB subtype and requirement for blood transfusion. Conclusion: Our findings showed that MDSs appeared at a younger age and tended to be of the aggressive subtype. Chronic myelomonocytic leukemia subtype seemed to appear dominantly in men.

Expression of WT-1 mRNA in Peripheral Blood from Myelodysplastic Syndromes

(INTRODUCTION) The Wilms' tumor gene WT-1 is overexpressed in various types of solid tumor as well as in hematologic malignancies, i.e., acute myeloid leukemia (AML), acute lymphocytic leukemia, chronic myeloid leukemia, and myelodysplastic syndromes (MDS). It was reported that WT-1 overexpression in peripheral blood (PB) and bone marrow (BM) is useful for the monitoring of minimal residual disease and early detection of relapse in AML. MDS are clonal hematologic stem cell disorders characterized by cytopenias and a risk of progression to acute leukemia. It is important for decisions on treatment strategy to assess disease progression and predict the prognosis in MDS. The aim of this study was to investigate the clinical significance of WT-1 mRNA expression in PB obtained from patients with MDS.(METHODS AND RESULTS) PB was obtained from 92 patients with MDS or leukemia transformed from MDS (AL-MDS): 40 refractory anemia (RA), 5 RA with ringed sideroblasts (RARS), 27 RA with excess blasts (RAEB), 5 RAEB in transformation (RAEB-t), and 15 AL-MDS cases in the FAB classification (RA 27, RARS 5, refractory cytopenia with multilineage dysplasia 12, RAEB-1 13, RAEB-2 14, 5q- 1, and AL-MDS 20 cases in the WHO classification). RNA was isolated from PB mononuclear cells (PBMCs) and converted into cDNA. The levels of WT-1 mRNA expression were assessed using the real-time quantitative polymerase chain reaction. We analyzed whether the level of WT-1 mRNA expression in PBMCs was associated with MDS subtype in the FAB classification, clinical characteristics (hemoglobin value, white blood cell counts, neutrophil counts, lymphocyte counts, chromosomal abnormality, number of cytopenias, blast percentages in BM, lactate dehydrogenase values, C-reactive protein values), International Prognostic Scoring System (IPSS) score, survival, and time to leukemia transformation. High expression of WT-1 mRNA, which was defined as more than 50 copies/μg mRNA according to the results of normals, was observed in 42.5%, 40.0%, 85.2%, 80.0%, and 100% of RA, RARS, RAEB, RAEB-t, and AL-MDS patients, respectively. The WT-1 mRNA levels increased with the aggressiveness of disease subtype and IPSS. FAB subtypes included RARS (mean ± SD, 129 ± 111 copies/μg), RA (220 ± 134), RAEB (5554 ± 2593), RAEB-t (14284 ± 9056), and AL-MDS (51591 ± 30309). IPSS score were divided into low/intermediate-1 risk (316 ± 136) and intermediate-2/high risk (7901 ± 3035) (P < 0.05 for RA vs RAEB, RAEB-t or AL-MDS; RAEB vs AL-MDS; and low/intermediate-1 vs intermediate-2/high risk). Furthermore, the WT-1 mRNA level was inversely correlated with the neutrophil percentage in PB and positively correlated with the blast percentage in both PB and BM. Among RA patients, those with favorable cytogenetics had lower WT-1 mRNA values compared with other patients (P < 0.05). When patients were divided into three groups based on the log value of WT-1 mRNA (<2, 2–4, and >=4), the survival times of those groups were 73.1, 55.6, and 15.3 months, respectively (P < 0.005).(CONCLUSIONS) Higher quantitative expression of WT-1 mRNA in PBMCs is associated with aggressive disease behavior in MDS patients. This may justify anti-WT-1 immunotherapy under investigation for MDS treatment (PNAS 2004; 101:13885–13890).

Clinical Efficacy of Decitabine in Patients with Myelodysplastic Syndrome (MDS)

Decitabine (DACOGEN, Janssen Pharmaceutica N.V. and Eisai Inc.) is an efficient hypomethylating agent approved for the treatment of MDS in the United States and other countries. Previous studies from North America reported the efficacy and safety of decitabine 15 mg/m2 every 8 hours for 3 days every 6 weeks (3-d schedule; Kantarjian, Cancer 2006; 106:1794) and 20 mg/m2 once daily for 5 days every 4 weeks (5-d schedule; Kantarjian Blood 2007; 109:52 and Steensma, ASH 2007; 110:1450) in MDS patients. The aim of the study reported here was to assess the clinical efficacy and safety of the 3-d schedule of decitabine in MDS patients in Russia. A total of 15 patients with MDS were enrolled: 9 male and 6 female; average age 62 years. Diagnoses included refractory anemia with ringed sideroblasts (RARS) in 3 patients, refractory anemia with excess blasts (RAEB) in 9 patients, refractory anemia with excess blasts in transformation (RAEB-T) in 2 patients, and chronic myelomonocytic leukemia (CMML) in 1 patient. Cytogenetic abnormalities included: -Y in 2 patients, del(5q) in 2 patients, and del(5q)+t(11;17) in 1 patient. At the time of this analysis, decitabine treatment had been administered for 1–2 cycles in 7 patients and for 3 cycles in 8 patients. The most frequent grade ≥3 adverse events were neutropenia (n=8, including 5 with neutropenic fever) and thrombocytopenia (n=4). Two patients with RAEB-T had severe neutropenia with infection: a necrotic lesion of hemorrhoids (n=1) and lower limb cellulitis (n=1). No other grade ≥3 adverse events were observed. Among the 8 patients who had received 3 cycles of decitabine, transfusion dependence was 100% before treatment and 38% (3/8) after decitabine treatment, with prolongation of transfusion independence periods in all 8 patients. Average hemoglobin level was 6.8 g/dL before treatment and 8.4 g/dL after 3 cycles of decitabine treatment. Overall response rate was 50% after 3 cycles of decitabine, including complete response (CR) in 1 (13%) patient and partial response (PR) in 3 (38%) patients. The other 4 patients who had received 3 cycles of decitabine had stable disease. The median time to first treatment response was 2 cycles. In this study of MDS patients in Russia, toxicity was consistent with previous studies and patients responded well to decitabine treatment on a 3-day dosing schedule.

Phase I Trial of Vorinostat (SAHA) in Combination with Alvocidib (Flavopiridol) in Patients with Relapsed, Refractory or (Selected) Poor Prognosis Acute Leukemia or Refractory Anemia with Excess Blasts-2 (RAEB-2)

Based on preclinical findings demonstrating marked antileukemic synergism between the HDAC inhibitor vorinostat and the CDK inhibitor flavopiridol (Almenara et al., Leukemia 16:1331–43, 2002), a Phase I trial of these agents has been initiated in patients with refractory AML/MDS. Eligible patients (pts) have acute leukemia (AL) refractory to standard therapy or de novo AL with poor risk factors (age >60 or antecedent myelodysplastic syndrome), imatinib-refractory chronic myeloid leukemia in blast crisis, or RAEB-2. Pts are excluded for prior auto- or allogeneic marrow or stem cell transplantation, significant comorbidities or organ dysfunction, and QTc interval >0.470 seconds. All pts receive oral vorinostat (V) 200 mg 3 times daily. In the initial stages of the trial, pts also received flavopiridol (F) by 1-hour bolus infusion on days 1–5 out of a 21-day cycle. Initial F dose levels were (mg/m2): 10, 20, 30, 40. Subsequently, a “hybrid” F infusion schedule (30 minute load followed by 4 hour infusion) was adopted based on recent evidence of activity of this schedule in CLL. With the hybrid schedule, F is given on a combination of days (d) 1, 3, 8 and 11. Targeted F dose levels are, in mg/m2 (Fload/Finfusion): 20/20 on d1 and 8; 30/20 on d1 and 8; 30/30 on d1 and 8; 30/50 on d1 and 8; 30/50 on d1, 3 and 8; 30/50 on d 1,3, 8 and 11. Dose limiting toxicity (DLT) is defined as NCI CTCAE grade 4 non-hematologic (heme) toxicity (except that related to cytopenias, infection or hyperbilirubinemia), grade 3 non-heme toxicity which lasts >7 days, or grade 4 ANC/platelet toxicity that persists for > 6 weeks in absence of leukemia. 28 pts have been enrolled. With the bolus schedule 14 pts were treated at 4 dose levels without identification of an MTD, after which development of the hybrid schedule was begun. Since initiation of the hybrid schedule, 8 pts have been treated at 3 dose levels. One DLT (infectious colitis with sepsis) was seen on level 4 of the bolus schedule and one DLT (gr 3 atrial fibrillation) was seen at the 3rd hybrid dose level. The MTD of the hybrid schedule has not been reached. Non-DLT toxicities include diarrhea, anorexia, nausea, weight loss, fatigue, electrolyte abnormalities, hyperbilirubinemia, dyspnea, confusion, febrile neutropenia and infectious complications (including atypical infections). Of 22 pts treated, 20 are evaluable for response. Thus far, there have been no complete remissions in this heavily pretreated population. However, 10 pts experienced some clinical benefit despite meeting criteria for “remission induction failure” – of those, 3 were treated with ≥ 5 cycles. 10 pts had a best response of progressive disease. One heavily pre-treated pt with refractory AML, who progressed after FLAG x2 followed by gemtuzumab ozogamycin, remains in treatment following 7 cycles with improved PS and QOL, a marked improvement in peripheral WBC, and a normocellular marrow with 6% blasts. To date, hyperacute tumor lysis has not been seen with the hybrid schedule, but aggressive prophylaxis and monitoring remain integral to the treatment plan. QTc evaluation and monitoring has been implemented because of V interactions with concurrent medications commonly used in this population (azole antifungals, among others). Correlative laboratory studies reveal a regular increase in acetylated tubulin but heterogeneous post-treatment effects on p21CIP1, Mcl-1, and other proteins in leukemic blasts. Collectively, these findings indicate that a regimen combining vorinostat and flavopiridol is well tolerated in patients with refractory or high-risk AML, and may have some activity in patients highly resistant to standard therapy. Pending identification of the MTD and RPTD (recommended phase II dose), Phase II evaluation of this therapeutic strategy should define its activity more definitively.

Treatment of Anemia with Darbepoetin Alfa in Patients with Low and Intermediate-1 Risk Myelodysplastic Syndromes. Results from the ARAMYS Study

Anemia is the main symptom in patients (pts) with myelodysplastic syndromes (MDS) which usually makes subjects with this pathology dependent on transfusions, resulting in a very limited quality of life. Darbepoetin alfa (DA) is a highly glycosylated erythropoiesis-stimulating agent (ESA) with a pharmacokinetic profile that includes a longer serum half-life and allows it to be administered less frequently than rHuEPO, thereby increasing patient convenience. This single-arm, open-label, multi-center, phase 2 study evaluated the efficacy and safety of DA in pts with low risk MDS. Eligible pts had low or intermediate-1 risk MDS [International Prognostic Scoring System (IPSS) criteria], anemia [Hemoglobin (Hb) 10 g/dL], FAB (French–American–British) classification of refractory anemia (RA), refractory anemia with ringed sideroblasts (RARS), or refractory anemia with excess blasts (RAEB) (with marrow blasts ≤ 10%), serum erythropoietin levels < 500 IU/L and transfusion requirements < 2 packed red blood cells cells/month over the preceding 2 months. Pts were evaluated for erythroid response after 8 weeks (wks) and 16 wks of treatment. Major erythroid response (MaR) was defined as an increase in Hb values ≥2 g/dl on baseline values and/or suppression of transfusion requirements. A minor erythroid response (MiR) was defined as a > 1 g/dL increase in Hb values but < 2 g/dl on baseline values or a reduction in transfusion requirements of at least 50%. DA treatment was initiated at a fixed dose of 300 mcg weekly (QW). For pts achieving a MaR at wk 8, DA could be administered at the same dose every two wks (Q2W). For pts who did not achieve a MaR by 8 weeks, filgrastim 300 mcg QW was added for an additional 8 wks. If at any time during the treatment period Hb values of > 12g/dL were obtained, DA was discontinued until Hb falls to values of < 11 g/dL. At this time, DA treatment was reintroduced with half of the previous dose (150 mcg). A number of 44 evaluable pts were included in the study. Median age 75, 8 years (range 41, 3–92, 4), 53, 5% male and 90,7% with ECOG Performance Status (0–1). FAB diagnoses were 30,2% RA, 62,8% RARS and 7% RAEB; divided into IPSS low (76,7%) and intermediate-1 (23,3%). Baseline mean (SD) Hb was 9,2 g/dL (0.8) and serum erythropoietin 122,1 IU/L (124,7).72,7% of the pts were transfusion independent. An erythroid response was achieved by 31 of 44 pts (70,5%) at wk 8 (43,2% MaR, 27,3% MiR, 29,5% no response) and by 30 of 43 pts (69,8%) at week 16 (51,2% MaR, 18,6% MiR, 30,2% no response). A total of 19 pts received filgrastim between wk 8 and 16. Erythroid response at wks 8 and 16 depending on the transfusion dependence were 68,8% (59,1% MaR and 40,9% MiR) and 71.0% (68,2% MaR and 31,8% MiR) in the transfusion independent group and 75.0% (66,7% MaR and 33,7% MiR) and 66,70% (87,5% MaR and 12,5% MiR) in the transfusion dependent group. Baseline serum erythropoietin levels were the only predictive factor of response found in the study population. DA was generally well tolerated. Three mild adverse events were considered related to DA (iron deficiency, flu syndrome and headache), one severe (iron deficiency) and one fatal (thromboembolic event). Results from this study indicate that a fixed dose of 300 mcg DA QW (+/− filgrastim) is an effective and well-tolerated treatment of anemic patients with low- and intermediate-1 risk MDS.

Evaluation of Apoptotic Molecular Markers in Myelodysplastic Syndrome Patients

The aetiology and pathogenesis of Myelodysplastic Syndrome (MDS) remain poorly characterized. One mechanism invoked to explain the apparent discrepancy between cellular marrow and peripheral blood cytopenias in patients with MDS is programmed cell death (apoptosis), which occurs with increased frequency in MDS marrow. Higher rates of apoptosis have been observed in Refractory Anaemia (RA) and Refractory Anaemia with Excess Blasts (RAEB) compared with transforming MDS or acute leukaemia while others have found increased rates in late stages of disease. Cell death may be triggered by activated T cells (in an attempt to eliminate the armful clone), secretion of death proteins/inhibitory cytokines (TNFα, Fas/Fas-L) and interleukin-6, expression of the pro-apoptotic proteins of Bcl-2 family, and/or through a relative deficiency in hematopoietic growth factors (stromal defects). Increased expression and release of TNF-related apoptosis inducing ligand (TRAIL), also known as Apo2 ligand (Apo2L) at the bone marrow level is likely to impair erythropoiesis and to contribute to the degree of anaemia, the major clinical feature of MDS. The exact mechanism by which TRAIL eliminates tumour cells preferentially or selectively is not known. One possibility is differential expression of agonistic receptors 1 and 2 (TRAIL-R1 and -R2), also known as death receptors, DR4 and DR5, and antagonistic or modulatory receptors, TRAIL-R3 and R4, also known as decoy receptors, DcR1 and DcR2. An alternative mechanism would be differential expression of, or functional defects in, cytoplasmatic inhibitors of apoptosis such as FADD-like converting enzyme (ICE)–inhibitory protein (FLIP) or other inhibitory IL -1 apoptotic proteins (IAP) likely survivin. Although increased programmed cell death in MDS may occur as an early rescue or compensatory response to deregulated clonal proliferation, it may also represent a pathophysiologic consequence of the epigenetic changes associated with the disease biology of MDS as we have already referred (EHA 2008). However the MDS remain an inadequately characterized disorder and novel strategies for studying disease pathogenesis and progression continue to shape our understanding and approach to diagnosing and treating. With this study we hope to contribute to the identification of molecular markers involved in apoptotic signalling pathways that could be related with MDS and that could interfere with the prognosis, namely the evolution to acute leukaemia, and with the therapeutic approach. For this purpose we have examined the expression of proteins involved in apoptotic pathways (membranar and mitochondrial) namely Bax, Bcl-2, p53, Fas/FasL, TRAIL/TRAIL-Rs and survivin, in CD34 bone marrow cells populations collected at diagnosis from 23 patients with de novo MDS and in 6 ITP (non-malignant controls). The expression of the proteins was evaluated by flow cytometry using monoclonal antibodies. The median age was 77 years (33–84), M/F=12/11, WHO subtypes: RCMD (n=12), RA (n=2), RCMD-RS (n=1), CMML (n=2), RAEB-2 (n=5), 5q- syndrome (n=1) and IPSS: low (n=6), intermediate-1 (n=6) and intermediate-2 (n=2), in patients with cytogenetic results. Two of the patients (both RAEB-2) evolve to acute leukemia, with a median follow-up of 24 months (12–65). Our results show that CD34 MDS patients cells have an higher Bax/Bcl-2 ratio, Bax, survivin, cit c, TRAIL-R3 and TRAIL-R4 levels and lower levels of Bcl-2, TRAIL, TRAIL-R1, Fas and Fas-L compared with non-malignant controls. However RA patients have the higher Bax, Fas, Fas-L, TRAIL-R3 and survivin levels while RAEB-2 patients have the lowest. This subtype of patients (RAEB-2) also show a decrease in Bax/Bcl-2 ratio, lower levels of TRAIL-R2 and higher levels of Bcl-2. This study suggest that apoptosis deregulation may be implicated in MDS. However, in RA an increase in apoptosis predominates while in RAEB the resistance to apoptosis may contribute to a less favourable prognosis and may influence the transition to acute myeloid leukaemia. Furthermore, we hope that the identification of all that molecular markers may contribute to identify new risk patients groups and molecular therapeutic targets.

Gain of 1q as a Potential Adverse Prognostic Marker in Myelodysplastic Syndrome: Comparison with International Prognostic Scoring System Variables

The gain of the 1q region, which is a recurrent chromosomal aberration in B lymphoproliferative disorder, has been reported one of the most common anomalies in Korean myelodysplastic patients. Recently, risk based application of hypomethylating agents or tailored therapy in MDS rely on the prognostic variables of International Prognostic Scoring System (IPSS). To investigate the possibility of 1q gain as a new prognostic marker, we evaluated the prognostic impact of 1q gain, along with comparison with IPSS variables. A total of 117 patients with newly diagnosed MDS between 1997 and 2007 at the Seoul National University Hospital were investigated. Fluorescence in situ hybridization (FISH) studies with 5 specific probe(EGR1 for 5q31 deletion, D7S522 for 7q31 deletion, CEP8, D20S108 for 20q12 deletion, LSI 1p36/1q25 for 1q gain) and conventional G-banding karyotyping were performed on bone marrow aspirates. Other laboratory findings, such as hemoglobin(Hb), absolute neutrophil count(ANC), platelet count, bone marrow blast percent and IPSS score, and clinical data were collected through the individual medical records. The median age was 54 years and the male-to-female ratio was 1.4. Using WHO classification, refractory anemia(RA) was 27.4% and the other subgroups as follows: RA with ringed sideroblast(RARS), 3.4%; refractory cytopenia with multilineage dysplasia(RCMD), 8.5%; RCMD with ringed sideroblasts(RCMD-RS), 0.9%; RA with excess blasts-1(RAEB-1), 26.5%; RAEB-2, 31.6%; and 5q- syndrome, 1.7%. Cytogenetic abnormalities by FISH and G-banding were detected in 58 patients (49.6%). Most frequent anomaly was trisomy 8 occuring in 28 patients(23.9% of the 117 patients, 48.3% of the 58 patients with clonal cytogenetic abnormalities). Gain of 1q was the second common anomalies seen in 18 patients (15.4%) and other anomalies were −7/del7q (13.7%), −5/del5q (13.7%), and del20q (2.6%). G-banding showed gain of 1q in 7 cases, additional 11 patients with gain of 1q were revealed by FISH only. Patients with 1q gain showed a poor survival (median survival 23 months; n=18) compared to patients without 1q gain (median survival 60 months; p=0.02). EGR1 and D7S522 deletion by FISH also had a shorter median survival (8 months vs. 60 months p=0.0001, 16 months vs. 60 months p=0.005). The initial platelet count and blast count were found to affect overall survival, whereas CEP8 FISH, D20S108 FISH, Hb and ANC did not. Our results show that gain of 1q is associated with an adverse clinical outcome and can be considered as a poor cytogenetic risk factor of IPSS. In the Western study, the prevalence of 1q gain was low because most studies report G-banding result only. But it may be increased up to 2.5 fold higher by using FISH analysis in combination with G-banding. A gain of 1q could be a candidate as an adverse prognostic marker in clinical practice, which could help for risk-adapted therapies. [Display omitted]

Red Blood Cell Transfusion Dependence and Outcome after Allogeneic Peripheral Blood Stem Cell Transplantation in Patients with de Novo Myelodysplastic Syndrome (MDS)

The prognosis of patients with de novo myelodysplastic syndrome (MDS) who are red blood cell transfusion-dependent (TD) and receive supportive care is inferior to that of patients who do not require transfusions. Whether TD also affects outcome after allogeneic transplantation is unknown. Consequently, in 172 de novo MDS patients (median age, 51 years), we analyzed the impact of TD on outcome after high-dose conditioning and allogeneic peripheral blood stem cell transplantation (PBSCT). With a median follow-up of 37 months, the probability of 3-year overall survival (OS) did not differ significantly between patients who were TD and those who were not TD before PBSCT (P=.1); however, transfusion burden, as reflected by ferritin levels, was correlated with a greater probability of severe acute graft-versus-host disease (aGVHD; P=.03) and a higher comorbidity index (P=.01), and OS was inferior in those patients with a ferritin level>1000 microg/L before PBSCT (P=.03). In multivariate analysis, only marrow myeloblast count (P=.01) and comorbidity index (P=.001) had a significant impact on OS. Our data do not identify TD as an independent negative prognostic factor for outcome after allogeneic PBSCT' however, iron overload (presumably transfusion-related) may contribute to poor transplantation success by adding to the overall comorbidities. Whether clinical intervention in the form of iron chelation can improve the outcome of allogeneic PBSCT in TD patients with MDS remains to be determined.

A Case of Myelodysplastic Syndrome in a Liver Transplant Patient

Purpose: There is a known increased incidence of myelodysplastic syndrome (MDS) after heart and lung transplant. There is, however, only one reported case of MDS in a liver transplant (LT) patient. This abstract presents the second known case of MDS in a LT patient and discusses the role of immunosuppression in development of MDS after LT. Methods: PubMed search using keywords “myelodysplastic syndrome” and “liver transplant” was done to identify any previous reported case of MDS in LT. Patient data was gathered from the patient and the medical record. Results: A 54-year-old white man underwent LT in 2003 for hepatitis C (HCV) related cirrhosis and hepatocellular carcinoma and in 2004 for recurrence of his HCV. He developed pancytopenia in 2006 which was attributed to his pegylated interferon treatment for HCV. The peg-interferon dose was intitally decreased, later stopped entirely and erythropoietin was initiated. In January 2007, the patient presented to his hepatologist complaining of weakness, malaise, and shortness of breath. WBC was 3.47 × 1000/μl, hemoglobin 10.6 gm/dL, Hct 33.8%, platelets 21 × 1000/μl, and neutrophils were 1.61 × 1000/μl. A liver biopsy revealed bridging fibrosis and recurrent hepatitis C. A bone marrow biopsy revealed myelodysplastic syndrome, type refractory anemia with excess blasts (RAEB)-1. He underwent 4 cycles of azacitidine from February to May 2007 with no improvement on repeat bone marrow biopsy in May 2007. Prograf dose was lowered and the patient underwent 3 cycles of decitabine. His last bone marrow biopsy done in November 2007 continued to show MDS, RAEB-1 with hypocellular marrow. The patient underwent 1 more cycle of decitabine without significant improvement in his laboratory testing. Conclusion: This is only the second reported case of MDS occurring in a post-LT patient. Our patient developed MDS almost 2 years after his second LT, as compared to the previous report in which the patient developed MDS 3 months after LT with subsequent progression to acute myelogenous leukemia within 2 months of the MDS diagnosis. Our patient's MDS type carries a very poor prognosis and high likelihood of conversion to acute myelogenous leukemia. He was treated with chemotherapy and reduction in immunosuppression without a clinical response. Given the rarity of MDS after LT, further study is needed to optimize the medical management of these patients. Although rare, MDS should be considered in the evaluation of pancytopenia after LT.

Combination of 5‐azacytidine and thalidomide for the treatment of myelodysplastic syndromes and acute myeloid leukemia

The treatment of myelodysplastic syndromes (MDS) remains a challenge to the clinician despite recent advances. Many patients will either not respond or will have only limited and/or brief responses to single-agent therapy. Eventually, 30% of patients with MDS will progress and develop acute myeloid leukemia (AML). New strategies are needed for these patients. 5-Azacytidine (AZA) and thalidomide were administered to 40 patients with MDS or AML. AZA was given at a dose of 75 mg/m2 subcutaneously for 5 of 28 days together with thalidomide starting at a dose of 50 mg per day and increasing to 100 mg per. Six patients had refractory anemia (RA), 2 patients had RA with ringed sideroblasts, 10 patients had RA with excess blasts (RAEB), 1 patient had RAEB in transformation, 4 patients had chronic myelomonocytic leukemia, 1 patient had chronic idiopathic myelofibrosis, and 16 patients had AML. Thirty-six patients were evaluable for outcome. A hematologic improvement (HI) was observed in 15 of 36 patients (42%), stable disease was observed in 5 of 36 patients (14%), and 10 of 36 patients (28%) had disease progression. Six patients experienced complete remission (CR), 2 patients experienced an erythroid HI (HI-E), 1 patient experience an absolute neutrophil count HI (HI-ANC), 5 patients experienced a platelet HI (HI-P), and 7 patients had bilineage HI (HI-P and HI-ANC or an HI-E and HI-ANC). It was noteworthy that 9 of 14 patients with AML had a history of prior MDS, 2 of 9 patients achieved a CR, 4 of 9 patients had HI (HI-E and bilineage HI), and 1 patient had stable disease and was continuing treatment. DNA microarray analysis of 8 responders and 4 nonresponders revealed that the genes associated with cellular proliferation had higher expression levels in nonresponders. The current findings indicated that a combination of low-dose AZA and thalidomide was well tolerated and was effective therapy for the treatment of patients with MDS and AML arising from prior MDS.

Improved Survival in Patients with Myelodysplastic Syndrome Receiving Iron Chelation Therapy

PurposePatients with myelodysplastic syndrome (MDS) and iron overload (IOL) often receive iron chelation therapy (ICT); however, data on clinical outcomes are limited. We reviewed 178 patients with MDS to determine the effect of ICT on survival. Patients and MethodsData were collected by chart review and survival analysis performed. A subgroup analysis compared control patients with clinical features similar to patients who received ICT. ResultsFrench-American-British MDS subtypes for patients were as follows: refractory anemia (RA), n = 36; RA with ringed sideroblasts, n = 42; RA with excess blasts (RAEB), n = 28; RAEB in transformation or acute myeloid leukemia (AML), n = 16; chronic myelomonocytic leukemia, n = 25; other, n = 31. International Prognostic Scoring System (IPSS) scores were as follows: low risk, n = 44; intermediate-1 risk, n = 55; intermediate-2 risk, n = 17; high risk, n = 17. Eighteen patients received ICT; median duration was 21.6 months (range, 1.3-151 months). In univariate analysis (UVA), factors significant for overall survival (OS) were IPSS score; MDS subtype; number of red blood cell (RBC) units transfused; MDS treatment; elevated ferritin; clinical IOL; receiving ICT (P < .05 for all); and age (P = .01). In multivariate analysis (MVA), significant factors included IPSS score (P = .008; hazard ratio [HR], 2.2 [95% CI, 1.3-3.7]) receiving ICT (P = .02; HR, 0.2 [95% CI, 0.01-1.0]). For low/intermediate-1 risk IPSS score, 4-year OS was 64% for patients receiving ICT and 43% for patients not receiving ICT (P = .003). An MVA was performed, including number of cytopenias; blast count; karyotype; AML transformation; ≥ 1 serious infection (P < .05 in UVA for all) with MDS treatment; number of RBC units transfused; and clinical IO; receipt of iron chelation therapy determined that factors significant for OS were infection (P = .05; HR, 3.2 [95% CI, 0.97-10.4]) and ICT (P = .02). Improved OS was maintained in the subgroup analysis (P = .01; HR, 0.29 [95% CI, 0.1-0.79]). ConclusionPatients with MDS and IOL receiving ICT had improved survival compared with patients not receiving ICT, suggesting a possible beneficial effect on clinical outcome. Prospective studies of ICT in MDS are warranted.

WHO classification and WPSS predict posttransplantation outcome in patients with myelodysplastic syndrome: a study from the Gruppo Italiano Trapianto di Midollo Osseo (GITMO)

AbstractWe evaluated the impact of World Health Organization (WHO) classification and WHO classification–based Prognostic Scoring System (WPSS) on the outcome of patients with myelodysplastic syndrome (MDS) who underwent allogeneic stem cell transplantation (allo-SCT) between 1990 and 2006. Five-year overall survival (OS) was 80% in refractory anemias, 57% in refractory cytopenias, 51% in refractory anemia with excess blasts 1 (RAEB-1), 28% in RAEB-2, and 25% in acute leukemia from MDS (P = .001). Five-year probability of relapse was 9%, 22%, 24%, 56%, and 53%, respectively (P < .001). Five-year transplant-related mortality (TRM) was 14%, 39%, 38%, 34%, and 44%, respectively (P = .24). In multivariate analysis, WHO classification showed a significant effect on OS (P = .017) and probability of relapse (P = .01); transfusion dependency was associated with a reduced OS (P = .01) and increased TRM (P = .037), whereas WPSS showed a prognostic significance on both OS (P = .001) and probability of relapse (P < .001). In patients without excess blasts, multilineage dysplasia and transfusion dependency affected OS (P = .001 and P = .009, respectively), and were associated with an increased TRM (P = .013 and P = .031, respectively). In these patients, WPSS identified 2 groups with different OS and TRM. These data suggest that WHO classification and WPSS have a relevant prognostic value in posttransplantation outcome of MDS patients.