Response In Myelodysplastic Syndromes Research Articles

Biosimulation Using the Cellworks Computational Omics Biology Model (CBM) Identifies Immune Modulation As a Key Pathway for Predicting Azacitidine (AZA) Response in Myelodysplastic Syndromes (MDS)

Background: DNA methyltransferase inhibition (DNMTi) with the hypomethylating agents (HMA) azacitidine (AZA) or decitabine, remains the mainstay of therapy for the majority of high-risk Myelodysplastic Syndromes (MDS) patients. Nevertheless, only 40-50% of MDS patients achieve clinical improvement with DNMTi. There is a need for a predictive clinical approach that can stratify MDS patients according to their chance of benefit from current therapies and that can identify and predict responses to new treatment options. Ideally, patients predicted to be non-responders (NR) could be offered alternative strategies while being spared protracted treatment with HMA alone that has a low likelihood of efficacy. Recently, an intriguing discovery of immune modulation by HMA has emerged. In addition to the benefits of unsilencing differentiation genes and tumor suppressor genes, HMA's reactivate human endogenous retroviral (HERV) genes leading to viral mimicry and upregulation of the immune response as a major mechanism of HMA efficacy. Although the PD-L1/PD1 blockade plus HMA has been recognized as a beneficial combination, there are no established markers to guide decision-making. We report here the utility of immunomic profiling of chromosome 9 copy number status as a significant mechanism of immune evasion and HMA resistance.Methods: 119 patients with known clinical responses to AZA were selected for this study. Publicly available data largely from TCGA and PubMed was utilized for this study. The aberration and copy number variations from individual cases served as input into the Cellworks Computation Omics Biology Model (CBM), a computational biology multi-omic software model, created using artificial intelligence heuristics and literature sourced from PubMed, to generate a patient-specific protein network map. Disease-biomarkers unique to each patient were identified within protein network maps. The Cellworks Biosimulation Platform has the capacity to biosimulate disease phenotypic behavior and was used to create a disease model and then conduct biosimulations to measure the effect of AZA on a cell growth score comprised of a composite of cell proliferation, viability, apoptosis, metastasis, and other cancer hallmarks. Biosimulation of drug response was conducted to identify and predict therapeutic efficacy.Results: Although AZA treatment increased tumor associated antigens and interferon signaling, it also increased PD-L1 expression to inactivate cytotoxic CD8(+) T cells. Copy number alterations of the chromosome 9p region were found to significantly drive PD-L1 expression with multiple genes such as CD274, IFNA1, IFNA2, JAK2, PDCD1LG and KDM4C playing a role in PD-L1 regulation further increasing immune suppression (Figure 1). Among 6 cases of chromosome 9p aberration in this dataset, 9p amp (n=2) were clinical non-responders (NR) while 9p del (n=4) were responders (R) to AZA. In principle, checkpoint immunotherapy could improve outcomes for patients with 9p abnormalities. Additionally, copy number variation loss of key genes located on chromosome 16 involved in antigen processing and presentation such as CIITA, CTCF, IRF8, PSMB10, NLRC5, and SOCS1 were found to negatively impact AZA sensitivity (NR=4; R=0); these patients would also be unlikely to respond to checkpoint immunotherapy. Also, aberrations in melanoma antigen gene (MAGE) family proteins (NR=2; R=O), and STT3A (NR=1; R=5) were found to impact AZA efficacy by decreasing antigen processing on tumor cells.Conclusion: Based on the results from the Cellworks Biosimulation Platform applied to the CBM, copy number variants of chromosome 9p and 16 can be converted into CBM-derived biomarkers for response to checkpoint immunotherapy in combination with HMA. Our results support a future prospective evaluation in larger cohorts of MDS patients. [Display omitted] DisclosuresHoward: Servier: Consultancy; Cellworks Group Inc.: Consultancy; Sanofi: Consultancy, Other: Speaker fees. Kumar: Cellworks Group Inc.: Current Employment. Castro: Bugworks: Consultancy; Exact sciences Inc.: Consultancy; Guardant Health Inc.: Speakers Bureau; Cellworks Group Inc.: Current Employment; Caris Life Sciences Inc.: Consultancy; Omicure Inc: Consultancy. Grover: Cellworks Group Inc.: Current Employment. Mohapatra: Cellworks Group Inc.: Current Employment. Kapoor: Cellworks Group Inc.: Current Employment. Tyagi: Cellworks Group Inc.: Current Employment. Nair: Cellworks Group Inc.: Current Employment. Suseela: Cellworks Group Inc.: Current Employment. Pampana: Cellworks Group Inc.: Current Employment. Lala: Cellworks Group Inc.: Current Employment. Singh: Cellworks Group Inc.: Current Employment. Shyamasundar: Cellworks Group Inc.: Current Employment. Kulkarni: Cellworks Group Inc.: Current Employment. Narvekar: Cellworks Group Inc.: Current Employment. Sahni: Cellworks Group Inc.: Current Employment. Raman: Cellworks Group Inc.: Current Employment. Balakrishnan: Cellworks Group Inc.: Current Employment. Patil: Cellworks Group Inc.: Current Employment. Palaniyeppa: Cellworks Group Inc.: Current Employment. Balla: Cellworks Group Inc.: Current Employment. Patel: Cellworks Group Inc.: Current Employment. Mundkur: Cellworks Group Inc: Current Employment. Christie: Cellworks Group Inc.: Current Employment. Macpherson: Cellworks Group Inc.: Current Employment. Marcucci: Abbvie: Other: Speaker and advisory scientific board meetings; Novartis: Other: Speaker and advisory scientific board meetings; Agios: Other: Speaker and advisory scientific board meetings.

Towards CD177 As a Predictive Biomarker for Hypomethylating Agent Response in Myelodysplastic Syndrome

BackgroundMyelodysplastic syndrome (MDS) represents a heterogenous spectrum of pre-leukemic conditions with a wide range of outcomes. Higher risk MDS as classified by the revised international prognostic scoring system (IPSS-R) score is associated with poor overall survival and up to 30% of patients progressing to acute myeloid leukemia. Hypomethylating agents (HMA) such as azacitadine can improve cytopenias and delay progression to leukemia in about 30% of patients, but these agents may take months to promote response and initially exacerbate cytopenias. Thus treatment related biomarkers that help predict eventual hematologic response are of interest.CD177 is expressed in neutrophils and plays a role in cellular adhesion. In healthy cells, it exhibits bimodal expression by flow cytometry that is stable over time within an individual. The percentage of CD177 positive neutrophils is often decreased in hematopoietic malignancies and myelodysplastic syndromes. Our group has demonstrated that CD177 has diagnostic utility in the identification of myelodysplastic syndromes. As transcription of CD177 is regulated by CpG methylation of its promotor, we hypothesized that treatment with HMAs may improve CD177 expression in clinical responders and potentially guide continuation of HMA therapy.MethodsTo interrogate the above, we performed a retrospective review of patients with a diagnosed with MDS or MDS/MPN overlap syndromes who received disease modifying therapy with HMA at our institution from 2015 to 2018. Inclusion criteria required documentation of serial bone marrow biopsies with aspirate flow cytometry analysis. CD177 positivity was determined by increase in mean florescence intensity compared to isotype controls. Data was analyzed with using cox multivariate and univariate analysis correlating to treatment response.ResultsOf the 237 patients, 27 patients met the above criteria. Their average age was 62 (21 to 77) at time of diagnosis with 20 men and 7 women. They exhibited a range of R-IPSS risk stratification with four very high risk, eight high risk, six intermediate risk, and four low risk. Five cases were MDS/MPN overlap. Patients received on average 10 months of HMA treatment with a wide range from 1 month to 42 months of treatment. Median baseline CD177 positivity was 16, 31, 28.5, and 72 percent respectively amongst R-IPSS groups.Of the 27 patients analyzed with repeat bone marrow biopsies, eight patients exhibited 20% or greater increase in CD177(+) neutrophils, ten exhibited a decrease in CD177(+) neutrophils of 20% or greater, and nine exhibited less than a 20% change in CD177(+) neutrophils. with similar distribution of R-IPSS risk stratification amongst groups. (CD177-decreased: 1 very high, 3 high, 1 intermediate, 2 low risk, CD177-stable 1 very high, 2 high, 2 intermediate, and 1 low, Improved-CD177 1 very high, 4 high, 2 intermediate and 1 low). Cox proportional hazard analysis suggests that patients exhibiting a decrease or stable CD177 were less likely to exhibit a treatment response with results trending to significance (OR= 0.13 p=0.099).ConclusionOur initial data suggests that change in CD177 may help predict HMA treatment response. More uniform prospective analysis is indicated to compared CD177 changes over initial treatment. Furthermore, CD177 in peripheral blood and bone marrow samples correlate excellently (R 2=0.95). Prospective studies are underway to correlate CD177 change and initial treatment response utilizing flow analysis of pre-treatment CBCs. DisclosuresNo relevant conflicts of interest to declare.

Ex Vivo Drug Sensitivity Assay Correlates with Clinical Response and Identifies Panobinostat and Bortezomib As a Potential Novel Drug Combination for Pediatric AML

BackgroundPediatric acute myeloid leukemia (AML) is a rare disease with roughly 600 cases diagnosed in the United States each year with minimal improvement in clinical outcomes over the last few decades. We previously demonstrated that an ex vivo drug sensitivity assay (DSA) can predict clinical response in myelodysplastic syndrome (Spinner et al. Blood Adv 2020). Here we investigated whether the DSA performed on pre-induction pediatric AML samples correlates with clinical response and can identify potent novel drug combinations.MethodsPre-induction blood or bone marrow samples were assayed from 20 de novo pediatric AML patients diagnosed at Texas Children's between 5/2015 and 10/2020. All patients consented to research (82% enrolled in clinical trial identifier NCT03568994) and received ADE (Cytarabine, Daunorubicin, and Etoposide), and next-generation sequencing was done as part of clinical care. Risk stratification was per AAML1831 guidelines. Drug sensitivity data was analyzed from 13/20 samples that passed quality control with matched treatment conditions: 9/13 (69%) patients had M1/M2 histology, 3/13 (23%) were M4/M5 and 1/13 (8%) was M7 with a median age of 12.3 years. For the ex vivo DSA, samples were incubated in conditioned media and treated with a single dose of up to 25 unique compounds and up to 149 drug combinations. After 72 hours, changes in tumor blast populations were assessed by flow cytometry using an 11-marker panel to identify blasts. For each treatment condition, drug sensitivity was calculated based on the number of blasts remaining after treatment compared to DMSO control. Clinical response data, including minimal residual disease (MRD) percentage by flow cytometry, and 1-year relapse-free survival (RFS), were correlated with drug sensitivity results. Log odds ratios (OR) were calculated with the Haldane-Anscombe correction. ORs were used to quantitatively measure the association between clinical attributes and the DSA to the clinical response data. For evaluation of ORs, a normalized blast score of 70% viability was used to maximize the separation between high and low drug sensitivity.ResultsEx vivo drug sensitivity correlated with both MRD (r=0.63) and 1-year RFS (r=0.59) in the de novo patient subset (Fig A). Three patients with an MRD >1% exhibited low ex vivo sensitivity to ADE, and among these 3 patients, 2 did not achieve 1-year RFS. Results from the DSA predicted increased odds of having an MRD >1% compared to demographic and mutational clinical attributes that showed weaker associations with MRD (Fig B).Of the 77 treatment conditions that were tested in 13 patient samples, Bortezomib in combination with Panobinostat (B/P) was the most efficacious treatment in the DSA, where drug sensitivity ranged from low (>100% blast viability) to high (0% blast viability). Separation of patient samples into two distinct low and high DSA response groups was observed with B/P, whereas ADE and single agents showed a graded distribution (Fig C). Within these response groups, pAML3 showed low sensitivity to ADE in the ex vivo DSA and the patient did not respond to ADE. In contrast, pAML8 showed high sensitivity to ADE ex vivo and the patient responded to ADE treatment. While pAML3 and pAML8 showed similar ex vivo sensitivity to B/P as for ADE (Fig D), pAML4 showed preferential sensitivity to ADE and not B/P, and conversely pAML6 showed sensitivity to B/P and not ADE.ConclusionEx vivo drug sensitivity to ADE correlates with both MRD and 1-year RFS in a cohort of 13 de novo pediatric AML patients. These results suggest that clinical response in pediatric AML may be assessed prior to treatment using an ex vivo drug sensitivity assay. Compared to demographic and mutational clinical characteristics queried, ex vivo drug sensitivity to ADE has the potential to be a more predictive measure compared to clinical attributes alone. Combining genomics with functional ex vivo drug sensitivity data could further enhance precision medicine and biomarker discovery in pediatric AML. The DSA also highlights Bortezomib/Panobinostat as a potential novel drug combination for pediatric AML, and the ability to identify a patient sample that is insensitive to ADE and sensitive to Bortezomib/Panobinostat ex vivo supports the use of the DSA to not only predict clinical response but also to possibly inform treatment decisions for pediatric AML patients. [Display omitted] DisclosuresStrachan: Notable Labs: Current Employment, Current holder of stock options in a privately-held company. Gu: Notable Labs: Current Employment, Current holder of stock options in a privately-held company. Kita: Notable Labs: Current Employment, Current holder of stock options in a privately-held company. Richardson: Notable Labs: Current holder of stock options in a privately-held company, Ended employment in the past 24 months. Anderson: Notable Labs: Current holder of individual stocks in a privately-held company, Ended employment in the past 24 months. Santaguida: Notable Labs: Consultancy, Current holder of individual stocks in a privately-held company, Ended employment in the past 24 months, Patents & Royalties.

Correlation of ex vivo drug sensitivity with clinical response in pediatric AML.

10032 Background: Pediatric acute myeloid leukemia (AML) is a rare disease with roughly 500 cases diagnosed in the United States each year and has had minimal improvement in clinical outcomes over recent decades. Novel treatment development to improve outcomes may be enhanced with an accompanying test for predicting treatment response. We previously demonstrated that an ex vivo drug sensitivity assay (DSA) can predict clinical response in myelodysplastic syndrome. Here we investigated the use of the DSA in pediatric AML patients, including a subset participating in a clinical trial of atovaquone. Atovaquone is an FDA-approved anti-parasitic drug that was associated with lower relapse rates in adult AML patients. Adding atovaquone and other standard of care combination treatments into the DSA, we investigated whether the assay, performed on pre-induction samples, correlated with measures of clinical response. Methods: We assayed pre-induction blood or bone marrow samples from 22 de novo pediatric AML patients diagnosed at Texas Children’s between 5/2015 and 10/2020 who consented to research (82% enrolled in clinical trial identifier NCT03568994). We subsetted this analysis to patients who received ADE (Cytarabine, Daunorubicin, Etoposide) (n = 20) induction, with the majority additionally receiving atovaquone (n = 16). For the DSA, samples were incubated with up to 25 compounds, including the treatment drug combinations and each of the compounds individually. After incubation, changes in tumor blast populations were assessed by flow cytometry. For each drug condition, drug sensitivity was calculated based on the number of blasts remaining after treatment. After quality control, downstream analyses were limited to 13 samples. Clinical response data, including minimal residual disease (MRD) percentage by flow cytometry and one year relapse-free survival, were correlated with the drug sensitivity results. Results: For the de novo subset analysis, we observed correlations between ex vivo drug sensitivity with both MRD percentage (r = 0.63) and one year relapse-free survival (RFS1, AUC = 0.92). The 3 patients with lowest ex vivo sensitivity had the highest MRD percentages (mean 21%). 2 of the 3 patients who did not achieve one year relapse-free survival had the lowest ex vivo sensitivity. Drug combination sensitivity correlated more with MRD and RFS1 than the single agents alone (single agent mean MRD r = 0.39). Conclusions: In our cohort, ex vivo DSA for ADE and atovaquone in pediatric AML cases correlated with both MRD and one year relapse-free survival. This suggests that clinical response in pediatric AML may be assessed prior to treatment using a DSA. This study also suggests that the DSA can be used to test drug combinations, and thus may be used for investigating novel treatment combinations. Further development of the DSA may benefit treatment decisions and prioritization of drug development.

Severe Inflammatory Response in Myelodysplastic Syndrome and Trisomy 8 Following 23-valent Polysaccharide Pneumococcal Vaccine Administration.

Severe Inflammatory Response in Myelodysplastic Syndrome and Trisomy 8 Following 23-valent Polysaccharide Pneumococcal Vaccine Administration.

Multicenter Validation of a Personalized Model to Predict Hypomethylating Agent Response in Myelodysplastic Syndromes (MDS)

Background While hypomethylating agents (HMAs) can improve cytopenias and even survival for MDS patients (pts), only 30-40% of pts respond to HMAs. Predicting response or resistance to therapy can improve pt outcomes, decrease cost and toxicities, and suggest alternative therapies when response is unlikely. No clinical or molecular model can reliability predict response or resistance to HMAs. We developed and validated a model to provide personalized predictions of response or resistance to HMAs during 12 weeks of treatment by monitoring changes in blood counts during therapy. Methods MDS pts treated with HMAs (azacitidine or decitabine) at Cleveland Clinic (314 pts) and the Moffit Cancer Center (100) and had their CBCs with differential monitored every 1-2 weeks in the first 12 weeks of therapy compromised the training cohort. The final model was externally validated in 80 MDS pts treated with HMAs at Sunnybrook hospital. Responses were defined per 2006 IWG criteria and pts with complete response (CR), marrow CR, partial response (PR), or hematologic improvement (HI) were considered responders. Time series analysis (analysis of serial changes in blood count parameters) using machine learning technology was used to develop the model, analogous to voice recognition algorithms such as Apple's Siri and Alexa, in which the sequence of words allows these algorithms to understand sentences. Changes in blood counts and monitoring the patterns of these changes during HMA therapy similarly can predict response/resistance to treatment. The area under the curve (AUC) was used to evaluate the performance of the final model. A feature importance algorithm was used to define the variables that most impacted the algorithm's decision for a given pt. Results For 494 included pts from all cohorts, the median age was 72 years (range: 40-94), 145 (29%) were female. Pts' IPSS-R scores at the time of treatment were: very low 4%; low 21%; intermediate 24%; high 21%; and very high 22%. Responses included: 56 (11%) complete remission (CR), 17 (3%) marrow CR, 6 (3%) partial remission (PR), and 143 (29%) hematologic improvement (HI). When trained exclusively on serial CBC values (adding other clinical or molecular values did not improve the model's performance), the model achieved an AUC of 0.82 in a cross-validated train/test schema and a similar AUC of 0.78 when it was applied to the Sunnybrook cohort. Feature importance algorithms identified improvements in hemoglobin from baseline between days 21-30 of therapy, improvement in platelets between days 51 and 60, changes in monocyte % between days 41 and 50, and changes in MCV and RDW between days 31 and 60 as predictors of response, Figure 1a. The model also can provide a personalized heatmap that summarizes the variables that impacted the response or resistance to HMAs and are specific for a given pt, Figure 1b, 1c. Conclusions We developed and externally validated a personalized prediction model that uses changes in blood counts during the initial 3 cycles of HMA therapy and can predict response or resistance to treatment with high accuracy. The model can provide personalized explanations of the variables that inform a given outcome. It can be used to develop novel clinical trial designs in which pts who are predicted not to respond within 3 cycles of HMA therapy can receive an investigational agent in addition to continuing HMA or change treatment entirely, whereas patients who are predicted to respond continue to receive HMA monotherapy. Disclosures Sallman: Agios, Bristol Myers Squibb, Celyad Oncology, Incyte, Intellia Therapeutics, Kite Pharma, Novartis, Syndax: Consultancy; Celgene, Jazz Pharma: Research Funding. Buckstein:Celgene: Research Funding; Takeda: Research Funding; Celgene: Honoraria; Astex: Honoraria; Novartis: Honoraria. Brunner:Forty Seven, Inc: Consultancy; Biogen: Consultancy; Acceleron Pharma Inc.: Consultancy; Jazz Pharma: Consultancy; Novartis: Consultancy, Research Funding; Takeda: Consultancy, Research Funding; Xcenda: Consultancy; GSK: Research Funding; Janssen: Research Funding; Astra Zeneca: Research Funding; Celgene/BMS: Consultancy, Research Funding. Mukherjee:Celgene/Acceleron: Membership on an entity's Board of Directors or advisory committees; Aplastic Anemia and MDS International Foundation: Honoraria; Celgene: Consultancy, Honoraria, Research Funding; Bristol Myers Squib: Honoraria; Partnership for Health Analytic Research, LLC (PHAR, LLC): Honoraria; Novartis: Consultancy, Membership on an entity's Board of Directors or advisory committees, Research Funding; EUSA Pharma: Consultancy. Komrokji:Abbvie: Honoraria; Agios: Speakers Bureau; BMS: Honoraria, Speakers Bureau; Jazz: Honoraria, Speakers Bureau; Incyte: Honoraria; Acceleron: Honoraria; Geron: Honoraria; Novartis: Honoraria. Maciejewski:Novartis, Roche: Consultancy, Honoraria; Alexion, BMS: Speakers Bureau. Sekeres:BMS: Consultancy; Pfizer: Consultancy; Takeda/Millenium: Consultancy. Nazha:Jazz: Research Funding; Incyte: Speakers Bureau; Novartis: Speakers Bureau; MEI: Other: Data monitoring Committee.

Mutations and karyotype predict treatment response in myelodysplastic syndromes.

We examined the influence of mutations and karyotype on conventional treatment response, specifically hematological improvement in anemia, in primary myelodysplastic syndromes (MDS). Cytogenetic and next generation sequencing (NGS)-derived mutation information was available in 357 patients (median age 74 years; 70% males); the revised international prognostic scoring system risk distribution was very high in 11%, high 15%, intermediate 17%, low 40% and very low 16%. At least one mutation was detected in 81% of patients; most frequent were SF3B1 (32%), ASXL1 (27%), TET2 (24%) and U2AF1 (15%). At median follow-up of 24 months, treatment with hypomethylating agents (HMAs) was documented in 121 (34%) patients, lenalidomide (LEN) in 55 (15%), and erythropoiesis stimulating agents (ESAs) in 136 (38%). ASXL1 mutations adversely affected response to HMAs (27% vs 48%; P = 0.02) and LEN (9% vs 43%; P = 0.04), but not ESAs (P = 0.6). LEN response was also adversely affected by U2AF1 mutations (0% vs 42%; P = 0.02) and high risk karyotype (0% vs 41% in intermediate vs 47% in low risk; P = 0.01). Patients with SF3B1 mutations were more likely to respond to LEN (56% vs 27%; P = 0.04). Contrary to previous reports, we found no association between TET2 mutations and HMA treatment response (40% vs 41%; P = 0.9), even in the absence of ASXL1 mutations (P = 0.4).We conclude that ASXL1 mutations in MDS predict inferior response to treatment with both HMAs and LEN; response to LEN was also compromised by U2AF1 mutations and high risk karyotype; SF3B1 mutations identified patients likely to respond to LEN.

188 - Are Correlated the Interleukin-8 and Nuclear Factor Kappa-B in the Inflammatory Response in Myelodysplastic Syndrome

188 - Are Correlated the Interleukin-8 and Nuclear Factor Kappa-B in the Inflammatory Response in Myelodysplastic Syndrome

Increase of DNA damage and alteration of the DNA damage response in myelodysplastic syndromes and acute myeloid leukemias

Increased DNA damage and alteration of the DNA damage response (DDR) are critical features of genetic instability presumably implicated in pathogenesis of myelodysplastic syndromes (MDS) and acute myeloid leukemias (AML). We used immunofluorescence staining of γH2AX and 53BP1 for analyzing DNA double-strand breaks (DSB) in MDS and AML cell lines, in CD34+ selected cells of normal and MDS bone marrow (including three cases of chronic myelomonocytic leukemias) and in blasts of AML bone marrow. In addition, we screened for activation of the DDR by immunoblotting of p-ATM, p-ATR, p-CHK1, p-CHK2 and p-TP53. As compared to γH2AX foci levels in normal bone marrow samples (0.2 focus per CD34+ cell±0.0; mean±standard error of mean), increased levels of γH2AX foci were detected in 16/16 MDS bone marrow samples (2.8 foci per CD34+ cell±0.5), 18/18 AML bone marrow samples (5.5 foci per blast±0.5), 1/1 MDS cell line (6.4 foci per cell) and 6/6 AML cell lines (12.0 foci per cell±0.6). γH2AX and 53BP1 co-localized in all tested samples forming diffuse, clustered and marginal patterns. Further, DDR proteins were expressed heterogeneously suggesting impairment of the DDR. In summary, our results provide evidence for a continuous increase of DSB across the spectrum from MDS to AML in conjunction with an impaired DDR. Co-localization of γH2AX and 53BP1 indicates promotion of (in)effective nonhomologous end-joining repair mechanisms at sites of DSB. Moreover, γH2AX/53BP1 foci distribution presumably reveals a non-random spatial organization of the genome in MDS and AML.

Karyotype and DNA-Methylation Responses in Myelodysplastic Syndromes following Treatment with Traditional Chinese Formula Containing Arsenic

We have previously shown that arsenic-containing Chinese herbal formula, Qing-Huang powder capsule (containing tetraarsenic tetrasulfide, As4S4), is effective in the treatment of myelodysplastic syndrome (MDS); yet the underlined mechanisms remain unclear. In this study, using standard cytogenetic analysis (G-banded) and global DNA methylation method (ChIP-on-chip assays), we aimed to determine the effect of arsenic-containing Chinese herbal formula on karyotype status and the genomic methylation level in primarily diagnosed MDS patients. Correlation of aberrant DNA methylation and chromosome aberrations in MDS was also investigated. We found that the number of genes with aberrant DNA methylation was highest in MDS patients with normal karyotype, followed by trisomy 8 karyotype, and relatively low in patients with cytogenetic abnormalities other than trisomy 8. Treatment with arsenic-containing Chinese herbal formula had no effects on karyotype status, but resulted in a significant genome-wide demethylation. Our research uncovered a DNA demethylating activity of arsenic-containing Chinese herbal formula in the treatment of MDS.

Platelet doubling after the first azacitidine cycle is a promising predictor for response in myelodysplastic syndromes (MDS), chronic myelomonocytic leukaemia (CMML) and acute myeloid leukaemia (AML) patients in the Dutch azacitidine compassionate named patient programme

The efficacy of azacitidine in the treatment of high-risk myelodysplastic syndromes (MDS), chronic myelomonocytic leukaemia (CMML) and acute myeloid leukaemia (AML) (20-30% blasts) has been demonstrated. To investigate the efficacy of azacitidine in daily clinical practice and to identify predictors for response, we analysed a cohort of 90 MDS, CMML and AML patients who have been treated in a Dutch compassionate named patient programme. Patients received azacitidine for a median of five cycles (range 1-19). The overall response rate (complete/partial/haematological improvement) was 57% in low risk MDS, 53% in high risk MDS, 50% in CMML, and 39% in AML patients. Median overall survival (OS) was 13·0 (9·8-16·2) months. Multivariate analysis confirmed circulating blasts [Hazard Ratio (HR) 0·48, 95% confidence interval (CI) 0·24-0·99; P = 0·05] and poor risk cytogenetics (HR 0·45, 95% CI 0·22-0·91; P = 0·03) as independent predictors for OS. Interestingly, this analysis also identified platelet doubling after the first cycle of azacitidine as a simple and independent positive predictor for OS (HR 5·4, 95% CI 0·73-39·9; P = 0·10). In conclusion, routine administration of azacitidine to patients with variable risk groups of MDS, CMML and AML is feasible, and subgroups with distinct efficacy of azacitidine treatment can be identified.

Hematologic Responses In Myelodysplastic Syndromes (MDS) Patients Treated with Deferasirox: An EPIC Post-Hoc Analysis Using International Working Group (IWG) 2006 Criteria

AbstractAbstract 2912 Background:Improvements in hematologic parameters and/or reductions in transfusion requirements have been associated with iron chelation therapy in transfusion-dependent patients with MDS; however, data has been limited to case reports/small studies (Jensen P et al. Br J Hematol 1996; Messa E et al. Acta Haematol 2008; Okabe H et al. Rinsho Ketsueki 2009; Oliva E et al. Transfusion 2010; n=1–11). The 1-year prospective EPIC study (Cappellini MD et al. Haematologica 2010) enrolled 341 transfusion-dependent MDS patients with iron overload. Patients were chelated with deferasirox leading to reductions in serum ferritin, an indicator of body iron burden (Gattermann N et al. Leuk Res 2010). During the EPIC study, transfusions were recorded and pretransfusion blood counts were assessed. Here we report a post-hoc analysis evaluating hematologic responses in a large cohort of MDS patients enrolled in EPIC using the IWG 2006 criteria (Cheson B et al. Blood 2006). Methods:Full study design and inclusion/exclusion criteria for EPIC have previously been described (Cappellini MD et al. Haematologica 2010; Gattermann N et al. Leuk Res 2010). Patients with a life expectancy of <1 year were excluded. Deferasirox dose was initiated at 20 mg/kg/day with adjustments of 5–10 mg/kg/day up to 40 mg/kg/day. MDS patients with pretreatment hemoglobin (Hb) levels <11 g/dL or red blood cell (RBC) transfusion requirements >4 units every 8 weeks and not receiving erythropoietin were eligible for erythroid response analysis. Patients with pretreatment platelet counts of <100 × 109/L or platelet-transfusion dependence, and absolute neutrophil counts of <1.0 × 109/L and not receiving GCSF were selected to assess platelet and neutrophil responses, respectively. Erythroid response: Hb increase '1.5 g/dL or reduction of ≥4 RBC transfusions/8 weeks compared with previous 8 weeks before treatment start. Platelet response: increase ≥30 × 109/L for patients with >20 × 109/L platelets, increase from <20 × 109/L to >20 × 109/L and by at least 100%. Neutrophil response: ≥100% increase and an absolute increase >0.5 × 109/L. All responses to last ≥8 weeks (IWG 2006). Results:Of the 341 iron-overloaded MDS patients enrolled in the EPIC study, 279, 121 and 56 patients were included in erythroid, platelet and neutrophil response analyses, respectively. Mean deferasirox dose for erythroid, platelet and neutrophil analysis groups were 19.2, 19.4 and 18.4 mg/kg/day, respectively; no significant difference in dose was observed between responders and non-responders. During deferasirox treatment, erythroid responses were observed in 22.6% (63/279) of patients. Median time to response was 113.0 days. Of these erythroid responses, a transfusion reduction-only response with maintenance of Hb level was observed in 10.8% (n=30) of patients, Hb improvement-only response in 10% (n=28) of patients and both transfusion and Hb response observed in 1.8% (n=5) of patients. Platelet and neutrophil responses were observed in 14.0% (n=17) of patients after a median of 169.0 days and 19.6% (n=11) of patients after a median of 226 days, respectively. Conclusions:This is the first large study to show that, alongside reducing iron overload, deferasirox may affect hematologic parameters in MDS patients. Overall erythroid response was 22.6% with deferasirox; although cross-trial comparisons should be interpreted with caution, a study in patients with low- and intermediate-1-risk MDS (IPSS) treated with valproic acid for a median of 4 months showed a major hematological response (IWG 2000 criteria) of 29% (Kuendgen A et al. Ann Hematol 2005). A limitation of the current analyses is the lack of a control arm comparing to best supportive care. The exact mechanism by which deferasirox can lead to improved hematological response in MDS remains to be determined. The effect may be attributed to reduction in iron overload, a specific pharmacological effect of the drug on hematopoiesis such as the ability to inhibit nuclear factor κB (Messa E et al. Haematologica 2010; Epub), or both. Other implicated mechanisms include the ability to sequester iron in a particular target or to affect the neoplastic clone or bone marrow microenvironment (Messa E et al. Acta Haematol 2008). Confirmation of these results and greater insights into mechanisms will require larger prospective trials specifically investigating hematologic responses in deferasirox-treated patients. Disclosures:Gattermann:Novartis: Honoraria, Research Funding. Finelli:Celgene: Consultancy. Fenaux:CELGENE: Honoraria, Research Funding; JANSSEN CILAG: Honoraria, Research Funding; AMGEN: Honoraria, Research Funding; ROCHE: Honoraria, Research Funding; GSK: Honoraria, Research Funding; NOVARTIS: Honoraria, Research Funding; MERCK: Honoraria, Research Funding; CEPHALON: Honoraria, Research Funding. Guerci-Bresler:Novartis: Honoraria, Membership on an entity's Board of Directors or advisory committees. Habr:Novartis: Employment. Marcellari:Novartis: Employment. Roubert:Novartis: Employment.

Long‐term Erythropoietin Therapy Improves Response in Myelodysplastic Syndrome

We report on a 53-year-old Japanese female on hemodialysis with myelodysplastic syndrome whose condition improved with recombinant human erythropoietin (epoetin) therapy. In 1992, based on a diagnosis of folic acid deficiency anemia, folate derivatives were administered. However, the anemia did not improve, and red blood cells had to be transfused subsequently. The transfusion volume was gradually increased afterward, as renal failure progressed, probably due to nephropathy by phenacetin. In 1998, when hemodialysis started, epoetin therapy was started with a dose of 3000 units three times per week. In July 2001, myelodysplastic syndrome (MDS) of a refractory anemia type was diagnosed through bone marrow aspiration. Myelodysplastic syndrome might cause an epoetin-resistant renal anemia. Afterwards the transfusion volume was gradually reduced, and transfusions were not performed after March 2002. Improvements of histological findings of MDS as well as anemia were confirmed by bone marrow aspiration in July 2003. This is an unusual case of a patient with a previously existing MDS, who subsequently develops end stage renal disease, and has an amelioration of her underlying MDS with the administration of epoetin over a long-term period, while being treated with chronic hemodialysis, even when not effective for a short-term.