Refractory Cytopenia With Multilineage Dysplasia Research Articles

Outcomes of Hematopoietic Cell Transplantation for Patients with Refractory Cytopenia with Multilineage Dysplasia: A Comparison Children with Adolescents and Young Adults

Background: The 2008 World Health Organization (WHO) classification proposed a new entity in childhood myelodysplastic syndrome (MDS), refractory cytopenia of childhood (RCC). The spectrum of patients with RCC is wide, ranging from patients with severe hypocellular bone marrow (BM) and mild dysplasia (hypocellular RCC) to those with normocellular BM and distinct dysplasia meeting the criteria for refractory cytopenia with multilineage dysplasia (RCMD) defined for adults with MDS. The term of RCMD was revised to MDS with multilineage dysplasia in the 2017 WHO classification. In Japan, children who meet the criteria for RCMD have been diagnosed as RCMD distinguished from hypocellular RCC. Although hematopoietic cell transplantation (HCT) is a curative treatment for RCMD in children, there have been few reports of the outcomes of HCT for children with RCMD. Patients and Methods: To clarify the outcomes of HCT for children with RCMD, we retrospectively analyzed the clinical data in children (<16 years) with RCMD who underwent the first HCT from 2010 to 2021 and registered in the Japan Society for Hematopoietic Cell Transplantation Registry, and compared with those in adolescents and young adults (AYA; ≥16, <40 years) with RCMD who underwent the first HCT during the same study period. During the study period, 195 patients with RCMD (children, 69; AYA, 126) underwent HCT. The stem cell source was BM in 138 (children, 58; AYA, 80), peripheral blood (PB) in 27 (children, 2; AYA, 25), and cord blood (CB) in 30 patients (children, 9; AYA, 21). Myeloablative conditioning (MAC) regimen was defined as the use of total body irradiation (TBI) ≥8 Gy (MAC-TBI) and the administration of busulfan (BU) >8 mg/kg (MAC-BU). All other regimens were included in reduced intensity conditioning (RIC) regimen. Results: We retrospectively analyzed 195 patients with RCMD (male, 105; female, 90). The median age at HCT was 8 years (range, 0-15) in children and 29 years (range, 16-39) in AYA. Of the 195 patients, 20 (29%) and 52 (41%) had abnormal karyotypes in children and AYA, respectively. Of the patients who underwent HCT, 68 were from related (children, 22; AYA, 46), and 127 from unrelated (children, 47; AYA, 80) donors. MAC-BU was used for 46 (children, 9; AYA, 37), MAC-TBI for 51 (children, 1; AYA, 50), and RIC for 98 (children, 59; AYA, 39) patients. Of the 195 patients, 8 (children, 3; AYA, 5) developed primary graft failure, 16 (children, 5; AYA, 11) secondary graft failure, 10 (children, 3; AYA, 7) disease relapse, and 11 (children, 2; AYA, 9) secondary tumor. Twenty-four (children, 5; AYA, 19) patients died of HCT-related complications and four AYA of disease relapse. The 5-year overall survival (OS) rate was significantly higher in children (93%) than in AYA (82%) (p = 0.04). The 5-year event-free survival (EFS) rate was 76% in children and 64% in AYA. The 1-month cumulative incidence (CI) of neutrophil engraftment was 93% in children and 94% in AYA. The 5-year CI of relapse was 6% in AYA and 2% in children. The 5-year CI of treatment-related mortality (TRM) was 16% in AYA and 7% in children. The 5-year CI of graft failure was 12% in children and 12% in AYA. The 3-year CI of chronic graft-versus-host disease (GVHD) was significantly higher in AYA (37%) than in children (21%) (p = 0.04), while there was no difference in the 3-month CI of acute GVHD (gradeⅡ-Ⅳ) between children (35%) and AYA (39%). In children, the 5-year OS and EFS rates were significantly lower in CB (67% and 42%) than in BM/PB (97% and 81%) (p < 0.01 and p < 0.01), respectively, while the 5-year OS and EFS rates were not different between CB (91% and 76%) and BM/PB (80% and 62%) in AYA, respectively. Of the 59 children who underwent HCT using RIC, 43 without abnormal karyotypes showed 95% and 16 with abnormal karyotypes showed 88% in the 5-year OS rate. Even in AYA, there was no difference in the 5-year OS rate between RIC and MAC in both groups with (RIC, n = 14, 76%; MAC, n =38, 72%) and without (RIC, n = 25, 81%; MAC, n = 49, 90%) abnormal karyotypes. Conclusions: HCT for children with RCMD showed better OS rate than that for AYA with RCMD. HCT using RIC regimen provided good outcomes for RCMD in children with or without abnormal karyotypes. Even in AYA, HCT using RIC regimen showed OS rate comparable to MAC regimen in both groups with and without abnormal karyotypes.

Finding the best haematopoietic stem cell transplant regimen for GATA2 haploinsufficiency: how close are we?

Finding the best haematopoietic stem cell transplant regimen for GATA2 haploinsufficiency: how close are we?

Clinical Outcomes of Decitabine Treatment for Patients with Lower-Risk Myelodysplastic Syndrome By the International Prognostic Scoring System

IntroductionDecitabine has shown clinical benefits in patients with International Prognostic Scoring System (IPSS) intermediate (INT)-2 or high risk myelodysplastic syndrome (MDS), but the benefits have not been well defined in patients with lower-risk disease group (IPSS low or INT-1). Recently, it was proposed that the prognosis for patients with lower-risk disease is heterogeneous, with a substantial fraction of these patients having poor survival. Therefore, we classified IPSS lower-risk MDS patients using the Lower-Risk Prognostic Scoring System (LR-PSS) and then identified clinical outcomes after decitabine treatment in each subgroup.MethodsTwo observational studies (DIVA [NCT01041846] and DRAMA [NCT01400633]) on the effectiveness of decitabine treatment in patients with IPSS INT-1, 2, or high risk MDS were previously conducted. This analysis included patients with IPSS INT-1 risk disease from these two studies, and the patients were classified into one of the LR-PSS categories (category 1, 2, or 3) classifying patients by clinical variables such as cytogenetic, age, hemoglobin, platelet levels, and bone marrow blast percentage, so that patients with higher scores would be classified into higher risk categories. Patients in each LR-PSS category were divided by response or non-response to decitabine treatment. Overall response rate (ORR) included complete response (CR), partial response, marrow CR with or without hematologic improvement (HI), and stable disease with HI by the modified IWG 2006 response criteria. The overall survival (OS) in each subgroup was calculated and we analyzed differences in survival by response in each category group.ResultsA total of 130 patients were included in this analysis: 12 patients (9.2%) in LR-PSS category 1, 65 (50.0%) in category 2, and 53 (40.8%) in category 3. Patients in LR-PSS category 3 were older, predominantly male, and had more comorbidities. Overall refractory cytopenia with multilineage dysplasia (RCMD) was the most common WHO subtype (53/130, 40.8%), but there was a trend toward more patients with refractory anemia with excess of blasts (RAEB-1) in LR-PSS category 3. Transfusion dependency at baseline was more common in LR-PSS category 3. ORR was observed in 74 patients (56.9%) after decitabine treatment: there was no significant difference in ORR between the LR-PSS groups (category 1, 58.3%; category 2, 56.9%; and category 3, 56.6%, P = 0.9940). Unlike patients in category 1 or 2, those in category 3 showed a significant difference in OS between responders and non-responders (P = 0.0015). A higher platelet count at baseline (≥50 x 109/L) was a favorable predictor of ORR (odds ratio, 2.24; 95% confidence interval [CI], 1.03 to 4.84) and a patient with lower percentage of bone marrow blasts at baseline (<4%) showed significantly lower ORR (odds ratio, 0.26; 95% CI, 0.12 to 0.56). The presence of comorbidities was the only variable significantly associated with OS in Cox proportional hazards regression model (hazard ratio, 0.35; 95% CI, 0.129 to 0.922).ConclusionsDecitabine treatment was effective in patients with lower-risk disease and showed a survival benefit in patients with lower-risk MDS classified as LR-PSS category 3 who responded to treatment. DisclosuresNo relevant conflicts of interest to declare.

Effect of Azacitidine on CD4+CD25+Foxp3+ Regulatory T Cell on Immunity in Myelodysplastic Syndrome Survivors

Background: Immune editing is recognized as important in various pathogenic processes. We previously showed that regulatory T cell (Treg) levels were elevated in MDS with a poor prognosis and that Treg levels decreased with Azacitidine (AZA) treatment and became equivalent to that in the untreated group. In this study, we examined changes in the number of circulating Tregs, T cells, and NK cells in the peripheral blood of patients with MDS treated with AZA, and we evaluated the clinical significance of these findings with survival.Patients and Methods: Patients with MDS and with acute myeloid leukemia with myelodysplasia-related changes (AML-MRC) according to the WHO 2008 classification who were initially treated between January 2015 and December 2016 and followed up for more than 6 months were enrolled in the study. AZA was given intravenously at a dose of 75 mg/m2 daily for either 5 or 7 consecutive days every 4 weeks. The response was assessed using the IWG response criteria for MDS. A total of 50 patients with AML-MRC (n=11), refractory anemia with excess blasts (RAEB) (n=8), refractory cytopenia with multilineage dysplasia (RCMD) (n=28), myelodysplastic/myeloproliferative neoplasms (MDS/MPN) (n=12), and refractory anemia with ring sideroblastis (RARS) (n=1) were included in the study. The IPSS was classified as low (n=15) intermediate-1 (n=13), intermediate-2 (n=10), and high (n=13). Twenty-six patients did not require treatment, including a transfusion (untreated group). Twenty-two patients were treated with AZA (AZA group). The remaining patients received conventional chemotherapy. After obtaining informed consent, blood was drawn from all of the patients at initial diagnosis. In the 22 patients treated with AZA, blood was also drawn after 6 completed treatment cycles. CD4+CD25+Foxp3+ Treg cells, CD3+CD4+ T cells, CD3+CD8+ T cells, and CD3-CD56+ NK cells were analyzed using flow cytometry, and the absolute numbers of these cells were calculated. Overall survival (OS) probabilities were estimated using the Kaplan-Meier method and compared by the log-rank test for univariate analysis.Results: The median age was 74 years (range: 44-93 years), and 35 of the patients were male. The median period of observation was 391 days. In the AZA group, 10 patients died (AZA-ineffective group), and 12 had either a CR, PR, or HI (AZA-effective group). The 2-year OS of the AZA group was 43.7%. The absolute number of Tregs and Treg% values before treatment were not significantly different between the AZA group and the untreated group. The Treg levels in peripheral blood before treatment in the AZA-effective (0.80±0.39%) tended to be lower than that in the AZA-ineffective (1.29±0.82%) group (p=0.076). The CD8+ T cell counts before treatment were moderately higher in the AZA-effective group compared to that in the AZA-ineffective group (385.5 ± 129.0 vs. 195.5 ± 70.0 /μL, p<0.01). Similarly, the CD3-CD56+ NK cell counts before treatment differed significantly between the AZA-effective group (197.4 ± 138.8 /μL) and the AZA-ineffective group (82.3 ± 36.7 /μL) (p=0.015). In a univariate analysis, the MDS patients with elevated NK cells survived longer than the group with reduced NK cells (p=0.013). In a multivariate analysis, the lower percentage of Treg cells and the higher percentage of CD8+T cells before treatment were independent factors for OS (HR, 4.80; p=0.085, HR, 4.13; p=0.040, respectively). In the AZA group, the percentage of CD8+T cells before treatment associated with OS (HR, 39.24; p=0.018). After treatment, the AZA group had an increase in the NK cell counts, which tended to associate with survival (HR 4.29; p=0.067).Conclusions: The number of Tregs in MDS cases requiring treatment was higher than that in MDS cases for which treatment was unnecessary. The prognosis of the patients with high CD8+ T cells counts was better. In contrast, there was an increase in the number of NK cells after AZA treatment, which was found to be associated with an improved prognosis. These results suggest that an immunological mechanism associated with the prognosis of MDS may be enhanced by treatment with AZA. Further examination of this mechanism and of the influence of AZA on the immunological effect are required. DisclosuresNo relevant conflicts of interest to declare.

Next Generation Sequencing and Microrna Assay in a Cohort of Patients Affected By Myelodysplastic Syndromes. an Analysis of Clinical and Genotypic Features

Introduction : The myelodysplastic syndromes (MDS) are a group of clonal haematopoietic stem cell disorders and they can be a consequence of genomic/chromosomal instability. The World Health Organization (WHO) 2008 classification divides the MDS in 4 types: refractory anaemia with excess of blast (RAEB), refractory anaemia (RA), refractory cytopenia with multilineage dysplasia (RCMD) and chronic myelomonocytic leukaemia (CMML). Various mechanisms contribute to the pathogenesis and prognosis of the disease and currently next generation sequencing (NGS) detects pathogenic gene mutations that can allocate patients to different risk classes. MicroRNAs (miRNAs) are small non-coding RNA molecules that regulate gene expression via post-transcriptional mechanisms and may have oncogenic properties or act as tumour suppressor and have an active role in the onset of myeloid disorders. A prospective study based on integration of NGS and miRNA quantification was launched at Policlinico San Martino in 2017. The aim of this paper is to report the results and the correlation with the clinical features. Patients and methods: 28 consecutive patients were enrolled in this study because they met our eligibility criteria: (i) availability of bone marrow sample at diagnosis, (ii) IPSS and (iii) clinical follow up. Specifically, 11 patients were affected by RAEB, 9 by RA, 5 by RCMD and 3 by CMML. Median age was 66 years old (48 - 85). Eight patients evolved into acute myeloid leukaemia. NGS analysis was performed with Myeloid Oncomine Panel Thermo fisher; miRNA expression was quantified with TaqMan Advanced miRNA Cards. In the context of a machine learning supervised analysis we evaluated if there were significant differences in the miRNAs expression among the patients classified based on the WHO 2008 classification. This analysis was conducted using l1l2-penalized regularization method within PALLADIO, a machine-learning framework that can provide robust variable selection in high-dimensional problems. The identified miRNA signature was characterized though a miRNA enrichment analysis using the webtoolkit WebGestalt. Results: each patient carried a distinctive miRNA signature composed by a median of 650 miRNA. The supervised analysis identified a signature of 24 miRNAs (table 1) able to discriminate the 4 WHO classes with a balanced accuracy of 0.616 (whose significance with respect to the balanced accuracy distribution of the permutation batch experiments has 2.206e-08 p-value). Among these miRNAs, 14 were selected because frequently up-regulated in most the patients of one or more WHO classes (figure 1). NGS identified mutations in 43% of patients affected by RAEB, RCMD and CMML in genes known to be pathogenic for MDS (figure 2). miRNA enrichment analysis allowed the identifications of genes involved in (i) pathways (some in common and some specific for a WHO class) likely involved in the onset of MDS, (ii) in diseases related to MDS and to disease evolution into acute myeloid leukaemia. Some of these genes were the same with the ones identified by NGS in our study population (i.e. TET2, ASLX1, RUNX1, IKZF1, SRSF2) but many others (e.g., GATA2, NfkB, BCL2, CD46, mTOR) were not detected by NGS but are likely to be involved in MDS pathogenesis and disease progression as described previously by other groups (figure 3). C onclusions : our study gives a further input toward the understanding of pathogenesis in MDS through the integration of miRNA analysis with NGS at the diagnosis of MDS. With the identification of specific miRNA signature for each patient it is possible to highlight multiple genes pathway that may contribute to the onset and progression of MDS. In a prospective trial we also aim to verify if a specific miRNA signature is linked to azacitidine resistance. Disclosures Mufti: Celgene: Consultancy, Research Funding.

Diagnostic and Correlative Analysis of Circrnas in Bone Marrow and Peripheral Blood of Patients with Refractory Cytopenia with Multilineage Dysplasia

This study was to detect expression levels of circular RNA (circRNA) in bone marrow (BM) and peripheral blood (PB) of patients with refractory cytopenia with multilineage dysplasia (RCMD). The objective was to identify circRNAs with potential diagnostic value and investigate the correlation between these circRNAs in BM and PB of RCMD patients.We first analyzed circRNAs in the BM of 5 RCMD patients and 4 control subjects using circRNA arrays. We found 369 circRNAs were differentially expressed between these two groups; 145 were upregulated and 224 were down regulated. Using a set of stringent criteria, we selected 10 circRNAs as potential biomarkers and verified their expression levels in 115 RCMD patients and 20 control subjects. 6 circRNAs were increased in RCMD patients while 3 were decreased and 1 showed no difference. ROC analysis using the same cohort confirmed 8 of these 9 circRNAs could be potential diagnostic biomarkers. We then tested the expression levels of these 10 circRNAs in PB samples from same 115 RCMD patients. There was no correlation between expression levels of these 10 circRNAs in BM and PB samples. This suggested that 10 circRNAs identified in BM samples could not be insteaded by circRNAs in PB samples. Funding: This work was supported in part by grants from the National Natural Science Foundation of China (#81500099) and Shanghai Municipal Science and Technology Commission (#16ZR1404400). Declaration of Interest: The authors declare no conflict of interest. Ethical Approval: The study was approved by the institutional review board at Huashan Hospital of Fudan University and informed consents were obtained from each study participant.

Gender disparity in the survival of patients with primary myelodysplastic syndrome.

Several prognostic scoring systems have been developed to assess prognosis in myelodysplastic syndrome (MDS). However, currently there are no systems that list gender as a prognostic factor. We queried a National Cancer Institute database to investigate the prognostic influence of gender on the survival of patients with MDS. We first identified 34,681 qualified patients diagnosed with MDS from 2001-2014 in the Surveillance, Epidemiology, and End Results (SEER) database, and then analyzed the characteristics of these patients using chi-squared tests. The Kaplan-Meier method and the multivariate Cox regression model were used to examine whether gender disparity in the survival of patients with MDS existed. We found that male patients had higher incidence rate of MDS (55.3% vs 44.7%, P<0.001) and a significant survival disadvantage (27.6% vs 33.6%, P<0.001) compared to female patients. Moreover, the less favorable survival rate of male MDS patients was associated with the age at diagnosis, race, marital status at diagnosis and the histological subtypes including refractory anemia (RA), refractory cytopenia with multilineage dysplasia (RCMD), myelodysplastic associated with isolated del 5q (MDS 5q-), myelodysplastic/myeloproliferative neoplasm (MDS/MPN) and not otherwise specified (NOS). In conclusion, gender can be considered as an independent prognostic factor for the overall survival of patients with MDS.

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

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

Expression of WT1 gene in bone marrow mononuclear cells of patients with myelodysplastic syndromes

Objective To analyze the relationship between the expression of WT1 gene in bone marrow mononuclear cells and the cytogenetic characteristics, curative effect and prognosis in patients with myelodysplastic syndromes (MDS). Methods The quantitative expression of WT1 gene was detected by real-time quantitative polymerase chain reaction (RQ-PCR) in bone marrow mononuclear cells of 115 MDS patients who were admitted to Taixing People's Hospital from August 2010 to March 2018, and the relationship between the expression of WT1 gene and the cytogenetic characteristics, curative effect and prognosis were evaluated. Results WT1 gene was highly expressed in 80 cases (69.6%), lowly expressed in 15 cases (13.0%), and unexpressed in 20 cases (17.4%). Of the 80 patients with high WT1 expression, 56 cases(70.0%) were refractory anemia with excess blasts (RAEB), and 22 cases (27.7%) were refractory cytopenia with multilineage dysplasia (RCMD). In 55 patients with very poor cytogenetic prognosis, 44 patients had high expression of WT1 gene, and in 28 patients with poor prognosis, 19 patients had high expression of WT1 gene. The complete remission rate of WT1 gene high expression group [12.5% (10/80)] was lower than that of low expression group [26.7% (4/15)] and unexpressed group [40.0% (8/20)], and the difference of complete remission rate between the three groups was statistically significant (χ2= 8.96, P < 0.05). Conclusion MDS patients with high expression of WT1 gene have low remission rate and poor prognosis. Key words: Myelodysplastic syndromes; WT1 gene; Cytogenetics; Prognosis; Treatment outcome

Increased cardiovascular comorbidities in patients with myelodysplastic syndromes and chronic myelomonocytic leukemia presenting with systemic inflammatory and autoimmune manifestations

Myelodysplastic syndromes (MDS) and associated diseases, like chronic myelomonocytic leukemias (CMML), are heterogeneous, clonal disorders affecting the hematopoietic stem cells. They are characterized by dysplasia and a propensity to evolve toward acute myeloid leukemia. Systemic inflammatory and autoimmune manifestations (SIAMs) occur with a prevalence of 10% to 20% in myeloid malignancies, but the underlying pathogenetic mechanisms remain obscure. In this study, we aimed to characterize patient- and disease-based differences in MDS and CMML patients with and without SIAMs and explore the impact of SIAMs on progression and survival. We performed a retrospective, single-centre, and case-control study in a cohort of 93 patients diagnosed with MDS and CMML between 01/2008 and 12/2015. Thirty patients (32%) were identified with SIAMs: musculoskeletal and connective tissue (26.8%), vascular (19.5%), systemic autoinflammation (17%), skin (12.2%), gastrointestinal (9.8%), and others (14.6%). SIAMs were treated with glucocorticoids (60%), methotrexate (16.7%), biologicals (13.3%), and cyclosporine (3.3%). No significant differences between the SIAM and non-SIAM patients were observed in age, gender, or previous exposure to cancer treatment. Cardiovascular comorbidities were significantly more frequent in patients with SIAMs (63.1% vs 90%; OR 5.5; P < .01), but no differences were observed for other comorbidities or IPSS and IPSS-R risk scores. CMML and refractory anemia with excess blasts 1/2 subtypes were by tendency more frequent in patients with and refractory cytopenia with multilineage dysplasia (RCMD) in those without SIAMs. Finally, time to progression, leukemia free survival and overall survival were similar for both groups. Despite patient heterogeneity and small cohort size, we were able to identify a significant association of SIAMs with cardiovascular comorbidities but without influence on progression or survival.

DNA repair gene expressions are related to bone marrow cellularity in myelodysplastic syndrome

ObjectiveTo evaluate the expression of genes related to nuclear excision (ERCC8, XPA and XPC), homologous recombination and non-homologous end-joining (ATM, BRCA1, BRCA2 and LIG4) repair mechanisms, using quantitative PCR methodologies,...

Clinicohematological and cytogenetic profile of myelodysplastic syndromes in Pakistan-compare and contrast

BackgroundMyelodysplastic syndromes (MDS) are clonal stem cell disorders exhibiting cytopenias, ineffective hematopoiesis and morphological dysplasia. Bone marrow cytogenetics, inspite of being incorporated as mandatory tool in diagnosis are done less frequently due to limited availability of this technique in Pakistan. The aim of the study was to study baseline clinicohematological and cytogenetic characteristics of patients presenting with de novo MDS.ResultsA retrospective cross sectional study was done at National Institute of Blood Diseases and Bone Marrow Transplantation, Karachi, Pakistan from 2010 to 2016. Total of 177 patients were included in the study having median age 51 years and male to female ratio of 3:1. Pancytopenia was observed in 80 (45%) patients and bicytopenia in 74 (42%). Mean Hb% was 7.8 ± 2.18 g/dl, total leukocyte count (TLC) 8.8 ± 13.6 × 109/l, platelet count was 82 ± 95.7 × 109/l. Of total 170 (96%) were transfusion dependent. Refractory cytopenias with multilineage dysplasia (RCMD) was the most common world health organization (WHO) category. Karyotype was done in 98 (55%) patients out of which 44 (45%) had abnormal karyotype, complex karyotype (CK) was most commonly observed in 12 (12.2%) followed by monosomy 7 in 7 (7.1%).ConclusionsWe found younger median age at diagnosis, higher mean TLC and no significant history of recurrent infections. CK and monosomy 7 carry bad prognostic implications and early disease transformation to acute myeloid leukemia (AML). Monosomy 7 being associated with bad overall survival, such patients must be identified early with close clinical follow up and offered stem cell transplant. This is the largest cohort of patients of MDS evaluated for baseline clinical and cytogenetic characteristics in our country.

P53 protein expression in patients with myelodysplasia treated with allogeneic bone marrow transplantation.

Tumor protein 53 mutations adversely affect the prognosis of myelodysplastic syndromes (MDS); however, few studies have reported on the prognostic significance of the expression of p53 protein in MDS. The current study investigated p53 immunoreactivity (p53-IR) in bone marrow biopsies (BMBs) obtained at diagnosis from 18 patients (6 females and 12 males; mean age, 50.5 years) with MDS that underwent bone marrow transplantation (BMT) to determine the associations between clinical and histopathological data and outcome. There were 5 refractory cytopenia with multilineage dysplasia (RCMD) and 13 refractory anemia with excess blasts, type 2 (RAEB-2) cases. p53-IR was assessed as the percentage of hematopoietic cells exhibiting intense nuclear staining. The cut off for positivity was 5% of stained cells. A positive p53-IR was detected in 7 patients (38.9%) and was associated with age (P=0.005) and pattern of BM fibrosis (P=0.03). A positive p53-IR was more frequent in females, in highly cellular BMBs and in RAEB-2 cases. Overall survival (OS) was associated with patients' age (P=0.01), hemoglobin level (P=0.04), type of MDS (P=0.05), degree of BM fibrosis (P=0.006) and number of BM blasts (P=0.05). The OS of patients with negative p53-IR tended to be longer compared with that of patients with positive p53-IR, although this difference was not statistically significant (P=0.1). Despite the limitation of the low number of cases, the present results indicate that a positive p53-IR at diagnosis is associated with clinically more aggressive MDS subtypes and adverse histological prognostic factors, such as BM fibrosis. Therefore, the evaluation of p53 expression of BMBs of patients with MDS may be introduced in the histopathological work-up of the disease.

191 - Lenalidomide Treatment in Lower Risk MDS – The Experience of One Czech Center (Positive Effect of Erythropoietin ± Prednisone Addition)

In 2008, the WHO combined the former categories RCMD (refractory cytopenia with multilineage dysplasia) and RCMD-RS (ring sideroblasts ≥15%). We studied the clinical impact and genetic background of RARS, RCMD, and RCMD-RS in 1082 patients. Good karyotypes (IPSS) were similarly frequent in RARS, RCMD, and RCMD-RS. 2-year overall survival (OS) rates were similar in RARS, RCMD, and RCMD-RS (85.9%/89.0%/91.7%; n.s.). The 2-year OS rate was better in good than intermediate or poor karyotypes (p < 0.001). These results support to combine RCMD and RCMD-RS as performed by WHO and emphasize the prognostic power of cytogenetic criteria for these MDS subtypes.

Enhanced plasma protein carbonylation in patients with myelodysplastic syndromes

Myelodysplastic syndromes (MDS) represent a heterogeneous group of pre-leukemic disorders, characterized by ineffective hematopoiesis and the abnormal blood cell development of one or more lineages. Oxidative stress, as an important factor in the carcinogenesis of onco-hematological diseases, is also one of the known factors involved in the pathogenesis of MDS. An increase of reactive oxygen species (ROS) may lead to the oxidation of DNA, lipids, and proteins, thereby causing cell damage. Protein carbonylation caused by ROS is defined as an irreversible post-translational oxidative modification of amino acid side chains, and could play an important role in signaling processes. The detection of protein carbonyl groups is a specific useful marker of oxidative stress.In this study, we examined 32 patients divided into three different subtypes of MDS according to the World Health Organization (WHO) classification criteria as refractory anemia with ringed sideroblasts (RARS), refractory cytopenia with multilineage dysplasia (RCMD), refractory anemia with excess blasts-1,2 (RAEB-1,2). We found significant differences in protein carbonylation between the group of all MDS patients and healthy controls (P=0.0078). Furthermore, carbonylated protein levels were significantly elevated in RARS patients compared to healthy donors (P=0.0013) and to RCMD patients (P=0.0277). We also found a significant difference in the total iron binding capacity (TIBC) between individual subgroups of MDS patients (P=0.0263). Moreover, TIBC was decreased in RARS patients compared to RCMD patients (P=0.0203). TIBC moderately negatively correlated with carbonyl levels (r=−0.5978, P=0.0054) in the MDS patients as a whole. Additionally we observed changes in the carbonylated proteins of RARS patients in comparison with healthy controls and their negative controls. Using tandem mass spectrometry (LC-MS/MS) we identified 27 uniquely carbonylated proteins of RARS patients, which were generated by ROS and could influence the pathophysiology of low-risk MDS.These data indicate that increased protein carbonylation is related with RARS as low-risk MDS subgroup. We suggest that this type of post-translational modification in MDS disease is not “only” a consequence of oxidative stress, but also plays an active role in the pathophysiology and iron metabolism within the RARS subgroup of MDS. Measurement of plasma carbonyl levels and the isolation of carbonylated plasma proteins, followed by their identification, could serve as a potential diagnostic and prognostic tool in MDS.

Comparison of Clinical Outcomes Between Pediatric Aplastic Anemia and Refractory Cytopenia of Childhood

In the diagnosis of childhood bone marrow failures (BMFs), differentiating aplastic anemia (AA) from hypoplastic myelodysplastic syndrome (MDS) is challenging. The 2008 World Health Organization (WHO) classification has proposed a provisional entity, "refractory cytopenia of childhood (RCC)". The spectrum of patients with RCC is wide, ranging from patients with severe hypocellular bone marrow (BM) and mild dysplasia to those with normocellular BM and distinct dysplasia meeting the criteria for refractory cytopenia with multilineage dysplasia (RCMD) defined for adults with MDS. Currently, it is recommended that children who meet the criteria for RCMD should be classified as RCC in the WHO classification until the number of lineages involved has been fully evaluated with regard to their relative importance as prognostic factors. Until now, few studies have addressed the question whether the current WHO classification reflects clinical outcomes of childhood BMFs.To determine the clinical differences among AA, RCC, and RCMD, we compared clinical outcomes for patients with AA, RCC, and RCMD in Japan. From February 2009 to December 2013, 252 patients were registered to the central morphology review system of the Japanese Society of Hematology and Oncology and were diagnosed with BMFs. Peripheral blood (PB) and BM smears were reviewed by two pediatric hematologists, and BM trephine biopsies were reviewed by a hematopathologist. RCC is defined as persistent cytopenia with <2% and <5% blasts in PB and BM, respectively. BM aspirate smears show dysplastic changes in >2 cell lineages or >10% within one cell lineage. On the other hand, the criteria of RCMD is defined as persistent cytopenia with <1% and <5% blasts in PB and BM, respectively. BM smears show >10% dysplastic changes in >2 cell lineages. Patients with inherited BMFs were excluded by family history and physical examination. Further, Fanconi anemia was excluded by chromosome fragility test and Dyskeratosis congenita was screened by measuring the telomere length of the peripheral lymphocytes by flowcytometry.Out of 252 patients, 63 were classified as AA, 131 as RCC, and 58 as RCMD. Median ages in AA, RCC, and RCMD groups were 10, 8, and 7 years, respectively (p=0.07). The median of leukocyte, neutrophil, reticulocyte, and platelet count, and mean corpuscular volume were significantly lower in AA than in RCC and RCMD groups (p<0.01). Chromosomal abnormalities were detected in 1 patient with AA (trisomy 8), 3 patients with RCC (trisomy 8, n=2; other, n=1), and 9 patients with RCMD (trisomy 8, n=5; monosomy 7, n=1; other, n=3) at the time of diagnosis (p<0.01). Out of 252 patients, 82 (AA, n=3; RCC, n=46; RCMD, n=33) were observed without any treatments (watch and wait, WW). 5-year overall survival (OS)/failure free survival (FFS) rates in WW group were 67%/67% in AA, 98%/54% in RCC, and 100%/69% in RCMD patients (p<0.01/p=0.97). Immunosuppressive therapy (IST) with rabbit antithymocyte globulin and cyclosporine was performed in 110 (AA, n=39; RCC, n=57; RCMD, n=14) patients. Six months after the IST, the response rates to the IST were not significantly different among AA (40%), RCC (63%), and RCMD (64%) (p=0.08). The development of additional chromosomal aberrations was found in 2 patients with RCC, and 1 with RCMD. The 5-year OS/FFS rates in IST group were 89%/36% in AA, 94%/38% in RCC, and 93%/23% in RCMD patients (p=0.64/p=0.86). Stem cell transplantation (SCT) as a first line therapy was performed in 19 patients with AA, 10 with RCC, and 5 with RCMD. The rejection was found in 2 patients with RCC and 3 with RCMD. Although 5-year OS rates in patients who underwent SCT were not different among 3 groups (p=0.26), FFS rate (30%) in patients with RCMD was significantly lower than in those with AA (100%) and RCC (78%) (p<0.01).In conclusion, we could not find any clinical relevance of separating RCC from AA because response rates to IST and the development of clonal evolution did not significantly differ between AA and RCC. The entity of RCMD should be adopted to childhood MDS classification because children with RCMD exhibited a distinct characteristic of morphology and a frequent chromosomal aberration at the time of diagnosis. The optimal treatment strategy including preconditioning regimen of SCT should be established for children with acquired BMFs based on the BM cellularity and morphological classification. DisclosuresKojima:SANOFI: Honoraria, Research Funding.

Alteration of the Hematopoietic Components, Mesenchymal Stromal Cells and Vascular Elements in the Bone Marrow Niche in Myelodysplastic Syndrome: Refractory Cytopenia with Multilineage Dysplasia

Introduction:The myelodysplastic syndromes (MDS) are clonal disorders characterized by cytopenias and abnormal hematopoiesis. Though there are reports of perturbations in the hematopoietic stem cells (HSC) and the mesenchymal stromal cells (MSC) as well as other elements of the bone marrow (BM) niche in an instructive or permissive manner leading to the genesis of ineffective hematopoiesis in this condition, most studies have evaluated single elements. Here we demonstrate altered HSC, MSC and the vascular niche elements in patients with MDS - Refractory cytopenia with multilineage dysplasia (RCMD).Methods and results: Bone marrow aspirates from patients with RCMD (n=12, mean age 54.33±14.51 years) were compared with those from age-matched controls (n=18, mean age 47.78±18.60 years) who had a ’normal’ marrow obtained for other diagnostic purposes. Cytogenetic analysis showed abnormal karyotypes in seven patients and normal karyotypes in five. The abnormalities seen were as follows: deletion 7q/monosomy 7 (four patients), deletion 5q (three patients), loss of Y (two patients), monosomy 5, deletion 20q (one each), complex karyotypes (four patients). Phenotypic enumeration of HSPCs revealed a marked decrease in the frequency of highly purified HSCs (Lin-CD34+CD38-CD90+CD45RA-) in RCMD (0.04135±0.01748%, n=11) when compared to controls (0.3168±0.05266%, n=13, p<0.0001) (Figure 1). Patients with RCMD also had increased common myeloid progenitors (CMP) (3.221 ± 0.7478%, n=8) compared to control (1.243±0.4463%, n=10, p<0.0302) and loss of granulocyte-macrophage progenitors (GMP) (0.4863±0.1638%, n=8) compared to controls (2.047±0.5422%, n=10, p<0.0242) (Figure 2).Assessment of the frequency of de novo MSCs (CD31-CD45/CD71- population) expressing CD271 and/or CD146, indicating the more primitive population, in total nucleated cells showed increased CD271+CD146-MSCs (0.632±0.2, n=5) compared to controls (0.2000±0.05158, n=6, p<0.0401) as also the CD271+CD146+ MSCs (0.2900±0.09803, n=5) in RCMD patients when compared to controls (0.02861±0.01354, n=6, p<0.0172) (Figure 3). We also evaluated in vitro cultured MSCs (P4) in these patients. CD271+CD146+ MSCs within total cultured MSCs were higher (0.1900±0.06429%, n=3) than in controls (0.0040±0.0040%, n=3, p<0.0447). RCMD MSCs had significantly lower proliferation index (32±3.7%, n=3) compared to controls (60±9.2%, n=3, p<0.0479). Cell cycle analysis of MSC showed significantly lower numbers in G0 in RCMD (0.1567 ± 0.07881 %, n=3) compared to control (0.6400 ± 0.1007 %, n=3; p<0.0194). Apoptosis was much higher in RCMD MSCs (2.700±0.8007%, n=3) compared to controls (0.03633±0.01802%, n=3, P<0.0292). No significant differences in expression profile of stem cell maintenance related cytokines and growth factors (CXCL12a, SCF, VEGF, ANGPT and LIF ) or components of Notch (Notch1, Notch3, Jagged-1, Delta like-1 and Hes1) and Wnt (Dkk1 and Dkk-2) pathways were found between RCMD and control MSCs within the limited numbers evaluated. Interestingly, unlike controls, immunofluorescence imaging of bone marrow trephine from MDS-RCMD revealed CD271+CD146+ MSCs co-localized with sinusoids and in direct contact with CD34+ (<5% blast) HSC/progenitor cells (HSPCs).Conclusion: Our data shows that in patients with MDS-RCMD, both qualitative and quantitative abnormalities exist in the HSC, HSPC and niche elements. We also show that the cytopenia could be related to decreased numbers of primitive HSCs and a differentiation arrest at the CMP stage. Primitive MSCs are reduced, and those that exist show poorer proliferative and survival features. Further studies are needed to understand the cause and effect relationship of these changes. [Display omitted] [Display omitted] DisclosuresNo relevant conflicts of interest to declare.

Expression of S100A9 in Bone Marrow Cells Differentiates Refractory Cytopenia with Multilineage Dysplasia (RCMD) from Refractory Anemia with Excess Blasts (RAEB) and Acute Myeloid Leukemia (AML)

Introduction: Myelodysplastic syndrome (MDS) is a heterogeneous group of bone marrow disorders with a yearly incidence of approximately 13,000 in the United States. It has been observed that both genetic mutations within stem and progenitor cells and a disordered immune microenvironment are present early in MDS. Abnormal levels of inflammatory cytokines as well increased numbers of suppressive cell types, such as regulatory T cells and myeloid derived suppressor cells (MDSC) have been noted in MDS bone marrow. MDSC are recently discovered subset of myeloid cells with specific immune regulatory functions, such as T cells suppression, seen in pathological conditions, such as cancer. Recent data suggest MDSC may play a critical role in MDS pathogenesis, and that S100A9, a danger-associated molecular pattern (DAMP) produced by some myeloid cells, including neutrophils, monocytes and MDSC, is a key signal for bone marrow immune dysregulation. Here, we report a systems immunology approach to cell type discovery within MDS bone marrow using high dimensional mass cytometry.Methods: Bone marrow aspirate samples with informed consent from MDS (n=19) and AML (n=4) patients were collected and cryopreserved following red blood cell lysis for storage by the Vanderbilt Hematology Tissue Repository, a tissue repository approved by the local Institutional Review Board (IRB). Samples were acquired for the study and stained with a 35-marker panel of metal tagged mass cytometry antibodies and analyzed with a mass cytometer (CyTOF). Cellular populations were then characterized using biaxial gating as well as viSNE, SPADE and hierarchical clustering as has been previously reported (Diggins et al. Methods 2015, Ferrell et al. PLoS One, 2016).Results: Unsupervised viSNE analysis of 35-markers per cell revealed distinct cellular subsets within each sample. Interestingly, one of the strongest marker signals was expression of S100A9, which was seen in multiple cells types including phenotypic MDSC. Further analysis revealed that as a percentage of bone marrow cells, S100A9 expression was significantly more common in RCMD vs. RAEB and AML (30.0% (n=10) vs. 10.9% (n=9) and 2.4% (n=4), respectively, p<0.05 for each comparison) (Figure 1A). Additionally, three paired RCMD/AML samples were available for analysis. Within these patients, the percentage of S100A9+ cells dropped from a mean of 41.7% in RCMD to a mean of 1.84% in AML bone marrow (Figure 1B&C).Conclusion: S100A9 is both a distinguishing feature of RCMD and of disease progression within MDS. Because of its important role inflammation and cellular recruitment, S100A9 may correlate with bone marrow cellular inflammation and could represent a viable target in treatment of the disordered immune microenvironment present in MDS, especially RCMD. [Display omitted] DisclosuresSavona:Celgene: Membership on an entity's Board of Directors or advisory committees; Sunesis: Research Funding; Incyte: Membership on an entity's Board of Directors or advisory committees, Research Funding; Ariad: Membership on an entity's Board of Directors or advisory committees; Amgen Inc.: Membership on an entity's Board of Directors or advisory committees; TG Therapeutics: Research Funding; Takeda: Research Funding; Gilead: Membership on an entity's Board of Directors or advisory committees. Irish:Incyte: Research Funding; Janssen: Research Funding; Cytobank, Inc.: Equity Ownership, Membership on an entity's Board of Directors or advisory committees.

Effect of Treatment with Azacitidine on CD4+CD25+Foxp3+ Regulatory T Cells in Myelodysplastic Syndrome Survivors

Background: Regulatory T cells (Treg) play an important role in immune surveillance of malignancies. Treg expansion occurs frequently in high-risk myelodysplastic syndrome (MDS) and in progression of this disease. Azacitidine (AZA) is increasingly used for treatment of MDS. In this study, we examined changes in the number of circulating Treg in peripheral blood of patients with MDS treated by AZA and we evaluated the clinical significance of these changes.Patients and Methods: Patients with MDS and acute myeloid leukemia with myelodysplasia-related changes (AML-MRC) according to the WHO 2008 classification who were initially treated between January 2015 and December 2015 and followed up for more than six months were enrolled in the study. AZA was given intravenously at a dose of 75 mg/m2 daily for 5 or 7 consecutive days every 4 weeks. The response was assessed using the IWG response criteria for MDS. A total of 29 patients with AML-MRC (n=5), refractory anemia with excess blasts (RAEB) (n=7), refractory cytopenia with multilineage dysplasia (RCMD) (n=16), and myelodysplastic/myeloproliferative neoplasms (MDS/MPN) (n=1) were included in the study. IPSS was intermediate-1 (n=15), intermediate-2 (n=6), and high (n=8). Eighteen patients did not need treatment, including transfusion (untreated group). Eleven patients were treated with AZA (AZA group). After obtaining informed consent, blood was drawn from all patients at initial diagnosis. In the 11 patients treated with AZA, blood was also drawn after 6 completed cycles. CD4+CD25+Foxp3+ Treg cells, CD3+CD8+ T cells, and CD3-CD56+ NK cells were analyzed using flow cytometry and the absolute numbers of these cells were calculated.Results: The median age was 74 years (range: 44-88) and 22 of the patients were male. The median period of observation was 283 days. In the AZA group, 3 patients died and one had recurrence (AZA-ineffective group), and 7 reached CR or PR (AZA-effective group). The absolute number of Treg was higher in AML/MRC + MDS/MPN than in RCMD (32.5 ± 19.6 vs. 16.4 ± 11.9 /μL, p=0.0234). Treg% values in peripheral blood before treatment in the AZA (1.17±0.80%), AZA-effective (1.15±0.54%), and AZA-ineffective (1.21±1.24%) groups were all significantly higher than that in the untreated group (0.49±0.26%, p=0.0022, p=0.0004, p=0.0241, respectively). Similarly, the absolute numbers of Treg were significantly higher in the AZA (31.9±17.0 /μL), AZA-effective (24.3±11.5 /μL), and AZA-ineffective (45.1±18.2 /μL) groups than in the untreated group (14.9±8.1 /μL, p=0.0011, p=0.0296, p=0.00003, respectively), and significantly higher in the AZA-ineffective group than in the AZA-effective group (p=0.0434). After 6 months of treatment in the AZA group, there were significant decreases in %Treg (1.17±0.80% to 0.65±0.48%, p=0.0373) and absolute number of Treg (31.9 ± 17.0 to 19.7 ± 13.6 /μL, p=0.0258). These changes were not significant in the AZA-effective group, but the absolute number of Treg significantly decreased in the AZA-ineffective group (45.1 ± 18.2 to 16.23 ± 9.54 /μL, p=0.0194). No Treg values after treatment differed significantly from those in the untreated group. The count of CD8+ T cells was unchanged by AZA treatment, but was moderately higher in the AZA group compared to the untreated group (378.6 ± 504.6 vs. 205.4 ± 140.2 /μL, p=0.0455). The counts of CD3-CD56+ NK cells did not differ significantly between the untreated group and the AZA group before treatment. However, after AZA treatment, this count became significantly higher than that in the untreated group (311.0 ± 263.5 vs. 159.2 ± 105.5 /μL, p = 0.0371). The count of NK cells did not reach a high level in the AZA-ineffective group, but was significantly higher (300.9 ± 183.5 /μL, p=0.0030) in the AZA-effective group.Conclusion: The number of Treg in MDS cases requiring treatment was higher than that in MDS cases for which treatment was unnecessary. In particular, Treg was high in MDS with a poor prognosis. Treg was decreased by treatment with AZA and became equivalent to that in the untreated group. In contrast, there was increase in the number of NK cells after AZA treatment, which was found to be particularly high in cases with a good prognosis. These results suggest that an immunological mechanism associated with the prognosis of MDS may be improved by treatment with AZA. Further examination of this mechanism and the influence of AZA on the immunological effect is required. DisclosuresNo relevant conflicts of interest to declare.

A Retrospective Analysis of Ultra Low-Dose Decitabine Combined with Gha Regimen in Patients with Middle and High Risk Myelodysplastic Syndrome

Background:Myelodysplastic syndrome (MDS) represents a heterogenous group of meyloid clonal disorders typically characterized by aberrant myeloid differentiation, dysplasticchanges, ineffective hematopoiesis and high potential to progress into acute meyloid leukemia. In the general population, the incidence of MDS is approximately 5/100000 and the mean age of onset of MDS is 68 years. Most of the patients in middle-2 and high risk were uneligible for intensive therapy.It have been confirmed that epigenetic play important roles in processes of tumorigenesis both in soild tumer and hematopoic malignacies. The aberrant changes of this key epigenetic process contribute significantly to the development of hematologic malignancies.Irregular DNA hypermethylation which lead to the silencing of tumor suppressor genes is a very commonamong MDS. The epigenetic therapy with hypomethylating agents has become a new strategy for the treatment ofpatients with MDS.The decitabine (DAC) is an inhibiter of DNA hypermethylationand act as an anti-tumor by reactivating the tumor suppressor genes. While the treatment dose and schedule of DAC haven't reach a consensus.The CAG chemotherapy regimen is widely used for the treatment of patients with relapsed AML since 1995. The regimen is composed of low-dose cytosine arabinoside (10 mg/m2/12 h, usually day 1~14), low-dose aclarubicin (10-14 mg/m2/day, day 1~4), and concurrent use of G-CSF (200 micrograms/m2/day).But the cardiotoxicity limit its application among elder patients. So we tried to modify the regimen by replacing the aclarubicin with homoharringtonine (HHT) which was reported have the function of arresting leukemic cell cycle, inducing apoptosis and it has been used in the treatment of AML in China for decades.The aim of this study was to provide a retrospective analysis of the safety and performance of ultra low-dose decitabine combined a modified protocol GHA to find an option for middle-2 and high risk MDS patients.Methods:Retrospective analysis of 40 MDS patients who were enrolled in the low-dose decitabine combined with GHA regimen. All the patients were classified in to RAEB1/2(Refractory anemia with excess blasts) or RCMD (Refractory cytopenia with multilineage dysplasia) by 2008 WHO classification of MDS. In IPSS (international prognostic scoring system), all the patients were categoried in intermediate-2 or high risk. The decitabine were used at the dose of 10 mg/d given intravenously over 1 h daily for 5 days (d1~5). The GHA regimen consisted of homoharringtonine 1mg/m2 daily by intravenous continuous infusion d 1~14), cytarabine 10mg/m212hr by subcutaneous injection (day 1~14), and G-CSF200 mg/m2/day by subcutaneousinjection one day prior to chemotherapy and continued until the end of chemotherapy or when the peripheral white blood cell (WBC) >20*109/L. The clinical efficiency and side effects were observed.Results:27 patients achieved CR and 5 patients achieved PR. The CR and PR rate were 67.5% and 12.5%, respectively. Total effective rate was 80%. In the induction therapy, a total of 10/40(25.0 %) patients experienced absolute neutrophol count (ANC) less than 0.5*109/L with a mean 8 days of agranulocytic period, and 28/40 (70%) patients experienced platelets less than 20*109/L with a mean 7 days of recovery over 20*109/L. The nonhematologic toxicities were mild and early death was zero. The median follow up time was 28 months; the median overall survival (OS) and disease free survival (DFS) were 25 and 12 months, respectively.Conclusion:The ultra low-dose decitabine combined with regimen is effective and well tolerated in induction therapy for intermediate-2 and high-risk MDS who were uneligible for intensive therapy and the results are better than the single regimen of decitabine or GHA. [Display omitted] [Display omitted] DisclosuresNo relevant conflicts of interest to declare.