Risk Myelodysplastic Syndrome Patients Research Articles

Patterns of lower risk myelodysplastic syndrome progression: factors predicting progression to high-risk myelodysplastic syndrome and acute myeloid leukemia.

The patterns of low risk myelodysplastic syndrome (MDS) progression, and the clinical and molecular features of those patterns are not well described. We divided our low risk (LR) MDS patients (n=1914) into 4 cohorts: 1) Patients who remained LR-MDS (LR-LR; n=1300; 68%), 2) Patients who progressed from LR to HR MDS (LR-HR) without AML transformation (n=317; 16.5%), 3) Patients who progressed from LR to HR MDS and then AML (LR-HR-AML; n=124; 6.5%), 4) Patients who progressed from LR MDS to AML directly (LR-AML; n=173; 9%). Risk factors for progression included male gender, low absolute neutrophil count (ANC), low platelet count, high bone marrow (BM) blasts, ferritin >1000 mcg/L, albumin.

Efficacy of Luspatercept in Low-Risk Myelodysplastic Syndrome: A Systematic Review and Meta-Analysis

BACKGROUND Patients with anemia and lower-risk myelodysplastic syndromes (MDS) in whom erythropoiesis-stimulating agent therapy is not effective, inevitably become RBC-transfusion dependent, unless other lines of therapy are offered. Luspatercept, a recombinant fusion protein that binds transforming growth factor β superfamily ligands to reduce SMAD2 and SMAD3 signaling, has been FDA approved for use in MDS with ring sideroblasts (RS) and/or detection of an SF3B1 mutation. The efficacy of luspatercept in lower risk (LR) MDS (regardless of RS) patients has been evaluated in clinical and real-world (RWD) studies, suggesting conflicting data. OBJECTIVES This study aimed to conduct a systematic review and meta-analysis of clinical trials and RWD evidence to evaluate the efficacy of luspatercept among lower risk MDS patients. METHODS Prospective randomized controlled trials (RCTs) and phase II trials, retrospective cohort studies and case series of patients with MDS treated with single agent luspatercept were retrieved from PubMed, EMBASE and conference proceedings. References were screened until June 30 th 2023. Two reviewers appraised the quality of the studies and extracted data. Primary outcome was the rate of transfusion independence (for at least 8 weeks). Secondary outcomes included erythroid hematologic improvement (HI-e) rate and safety. Subgroup analysis was conducted for MDS-RS and SF3B1 mutation. Studies were critically appraised using Joanna-Briggs Institute checklists. All studies were included in the meta-analysis. RESULTS We screened 244 titles and eventually included 9 studies, conducted between 2013-2022, and including 839 MDS patients who were treated with luspatercept. Of them: 2 RCTs, one single arm phase 2, and 6 retrospective “real-world” (RWD) studies. Six were published in peer reviewed journals and three RWD studies published as abstracts. Median age of patients ranged between 68-75 years and 707/839 patients had MDS-RS. Three studies were of moderate-high quality (N= 389) and 6 were deemed moderate quality (N=450). Rates of transfusion independence for at least 8 weeks were highly variable ranged between 8-87% among all patients and between 42-87% among MDS-RS subgroup. The median duration of longest response ranged between 23.9-42 weeks. Rates of erythroid hematologic improvement (HI-e), ranged between 25-100%. Pooled estimate of achieving independence from red-cell transfusion for >= 8 weeks was 39.5% (95% CI 0.24, 0.55; I²=96.6%, p<0.001) by meta-analysis. Pooled estimate of HI-e was 54.4% (95% CI 0.44,0.65; I²=87.8%, p<0.001). The most common cause for drug discontinuation was lack or loss of response and disease progression. CONCLUSION The response rate to luspatercept is highly heterogenous among different studies. Overall, the response rate and duration in the RWD setting did not compare favorably with clinical trials. Of note, the vast majority of patients had MDS-RS and the role of luspatercept in the management of patients with MDS without RS is still unclear, even when data from several studies are pooled together. This study has many limitations arising from heterogeneity of patient characteristics and outcomes ascertainment. This highlights the need for standardized post-marketing studies of new drugs and the heterogeneity in RWD patient population.

Ultra-Low-Dose of Decitabine with Venetoclax As Induction and Consolidation Therapy for Elderly or Frail Newly Diagnosed Acute Myeloid Leukemia and High Risk Myelodysplastic Syndrome Patients

Background: Venetoclax with hypomethylating agents is a new standard of care for newly diagnosed (ND) patients with acute myeloid leukemia (AML) who are 75 years or older, or unfit for intensive chemotherapy. Pharmacodynamic studies have suggested superiority of the longer 10-day regimen of decitabine which has shown promising results in high-risk AML in phase 2 trials. We hypothesized that venetoclax with 10-day decitabine may be effective in ND and secondly AML/MDS, particularly for high-risk subgroups. Methods: We retrospectively analyzed 45 patients with ND AML, secondary AML (sAML), or high-risk MDS who was older than 60 years or unfit for intensive chemotherapy due to frail / due to the COVID-19 pandemic. Patients were required adequate end-organ function. Patients received decitabine (6mg/m2 IV for 10-days) with oral venetoclax (400mg daily for 3 weeks (D10+VEN)) for induction, followed by the same chemo-free regimen for consolidation if patients responsed to induction therapy. The primary efficacy endpoint was overall response rate (ORR). The second endpoint was overall survival (OS) and progress free survival (PFS). Findings: Between January, 2020 and July , 2023, 45 patients were treated with this regimen, 31 (68.9%) had ND AML, 8 patients (17.8%) had untreated sAML, 6 patients (13.3%) had untreated high-risk MDS. The median age was 65 years (IQR, 59-69) and 26(57.8%) patients had ECOG performance status of 3 or higher. The ORR among all patients was 82.2% and in disease subgroups were: ND AML, 87.1% (27/31) (95% CI 79, 94); untreated sAML, 75% (6/8); untreated high-risk MDS, 66.7%(4/6). According 2022 ELN risk classification by genetics, the ORR in favorable risk patients was 87.5%(7/8), intermediate risk patients was 100%(12/12), adverse risk patients was 72%(18/25). The most common treatment-emergent adverse events included infections with grade 3/4 neutropenia (n=36, 80%) and febrile neutropenia (n=7, 15.6%). There were 2 grade 5 adverse events including one infections with Enterobacter cloacae Bacteremias combined with heart failure because of the shortage of Blood product transfusion during the COVID-19 pandemic, and one case of intracranial hemorrhage related to prolonged grade 3/4 thrombocytopenia. The one year OS of all patients was 71.9%(23/32), and in favorable risk patients was 83.3% (5/6), intermediate risk patients was 72.7%(8/11), adverse risk patients was 73.3%(11/15). The two-year OS of all patients was 58.3%(7/12). Conclusion: Ultra-low-dose of ten-day decitabine with venetoclax as induction and consolidation chemo-free therapy in elderly or frail newly diagnosed acute myeloid leukemia and high risk myelodysplastic syndrome result in high overall response rate and high 1-year overall survivial.

Encouraging Efficacy Observed in Bexmab Study: A Phase 1/2 Study to Assess Safety and Efficacy of Bexmarilimab in Combination with Standard of Care in Myeloid Malignancies

Background Clever-1 (common lymphatic endothelial and vascular endothelial receptor-1) constitutes a novel macrophage checkpoint. The receptor contributes to immune tolerance by antigen clearing and T cell inhibition. In multiple models, tumor growth is significantly reduced when Clever-1 function is inhibited. Expression of Clever-1 on bone marrow (BM) cells is a prognostic factor for poor outcome in acute myeloid leukemia (AML) and suppression of Clever-1 signaling inhibits leukemia cell growth. Bexmarilimab (BEX), a humanized IgG4 monoclonal antibody, binds Clever-1 resulting in increased antigen presentation, secretion of proinflammatory cytokines and activation of T cells. Clever-1 is highly expressed on leukemic blasts and monocytes of AML and myelodysplastic syndrome (MDS) patients. Treatment of AML bone marrow cells with BEX alone or in combination with azacitidine/venetoclax results in enhanced antigen presentation capacity and increased activation markers on effector T cells with synergistic effect on cell death. Also, BEX treatment alone lowers blast metabolic fitness via interference with mitochondrial oxidation. The ongoing BEXMAB clinical study investigates safety and efficacy of BEX combined with standard of care (SoC) in patients with myeloid malignancies (NCT05428969). Method This is a Ph1/2 study, investigating BEX combined with azacitidine (doublet) in patients with higher risk MDS frontline or hypomethylating agent (HMA)-failed, and relapsed/refractory (r/r) AML patients. BEX is dosed Q1W in 28-day cycles until disease progression or intolerable toxicity. SoC azacitidine is administered as per label. During Ph1, BEX doses were escalated from 1.0 mg/kg to 6.0 mg/kg (Bayesian optimal interval [BOIN] design). BM was analyzed at the end of Cycle 1 and 3 followed by every three cycles. Ph2 will start with a dose optimization per malignancy followed by a dose expansion for efficacy evaluation (2-Stage design). Results Here we report data from the dose finding Ph1 of the doublet. As of 25 July 2023, 22 patients have been enrolled in the doublet (MDS n=5; MDS HMA failed n=5; r/r AML n=12). Baseline characteristics are shown in Table 1. 8/10 MDS/MDS HMA-failed patients were of high to very high risk based on rIPSS; of the r/r AML 7/12 patients had adverse risk based on ELN 2017. The median number of prior therapies for the MDS HMA-failed patients was 1 (range 1-2). The median number of prior therapies for the r/r AML patients was 2 (range 1-4) with all patients having failed prior HMA-containing therapies and 7/12 having received prior HMA plus venetoclax. The majority of observed adverse events (AE) were Grade 1-2 and no dose limiting toxicities have been reported. As of 25 July 2023, a total of 10 BEX related AEs have been reported (8% of all treatment emergent AEs) with four of these events of ≥ Grade 3, two being immune related (capillary leak syndrome and hemophagocytic lymphohistiocytosis). Sustained target engagement of soluble Clever-1 of up to 75% compared to baseline was seen at all tested dose levels in patient blood. Activity of BEX in patient BM was demonstrated using receptor binding assays with BEX treatment resulting in decreased blast Clever-1 expression at all dose levels of the doublet cohort. Increased immune activation as measured using HLA expression and T/NK cell numbers in patient BM was observed after BEX treatment across indications. Up to 2-3-fold increase of CD8 T and NK cells in the BM of BEX treated patients was observed. Preliminary efficacy shows objective responses in 8/15 evaluable patients across all tested BEX doses. Four were observed in patients with prior HMA-failure and four patients stayed on treatment > 6 months. Clinical activity for frontline MDS was seen as one complete remission (CR), marrow CR (mCR) and hematologic improvement for platelets (HI-P); for MDS with HMA failure as one CR, mCR and partial remission (PR); for r/r AML as two incomplete CRs (CRi). Based on accumulating data, responses are observed between end Cycle 1 and end Cycle 4 for all BEX doses. Conclusion Combining BEX plus azacitidine is well-tolerated and shows efficacy across indications. Additional clinical and pharmacodynamic data of the completed Ph1 of the study will be presented during the meeting. Ph2 of BEX plus azacitidine will open in the 2 nd half of 2023 in HMA-failed r/r AML and/or higher risk MDS patients.

MDS-462 Response to Erythropoiesis-Stimulating Agent Therapy in IPSS-R Lower Risk Myelodysplastic Syndrome Patients Restratified According to IPSS-M

MDS-462 Response to Erythropoiesis-Stimulating Agent Therapy in IPSS-R Lower Risk Myelodysplastic Syndrome Patients Restratified According to IPSS-M

POSTER: MDS-462 Response to Erythropoiesis-Stimulating Agent Therapy in IPSS-R Lower Risk Myelodysplastic Syndrome Patients Restratified According to IPSS-M

POSTER: MDS-462 Response to Erythropoiesis-Stimulating Agent Therapy in IPSS-R Lower Risk Myelodysplastic Syndrome Patients Restratified According to IPSS-M

Age and sex associate with outcome in older AML and high risk MDS patients treated with 10-day decitabine

Treatment choice according to the individual conditions remains challenging, particularly in older patients with acute myeloid leukemia (AML) and high risk myelodysplastic syndrome (MDS). The impact of performance status, comorbidities, and physical functioning on survival is not well defined for patients treated with hypomethylating agents. Here we describe the impact of performance status (14% ECOG performance status 2), comorbidity (40% HCT-comorbidity index ≥ 2), and physical functioning (41% short physical performance battery < 9 and 17% ADL index < 6) on overall survival (OS) in 115 older patients (age ≥ 66 years) treated on a clinical trial with a 10-day decitabine schedule. None of the patient-related variables showed a significant association with OS. Multivariable analysis revealed that age > 76 years was significantly associated with reduced OS (HR 1.58; p = 0.043) and female sex was associated with superior OS (HR 0.62; p = 0.06). We further compared the genetic profiles of these subgroups. This revealed comparable mutational profiles in patients younger and older than 76 years, but, interestingly, revealed significantly more prevalent mutated ASXL1, STAG2, and U2AF1 in male compared to female patients. In this cohort of older patients treated with decitabine age and sex, but not comorbidities, physical functioning or cytogenetic risk were associated with overall survival.

Efficacy of Azacitidine Post-Transplant Maintenance for FLT3-Negative Acute Myeloid Leukemia and Myelodysplastic Syndrome

Introduction: For patients with myeloid malignancies undergoing allogeneic hematopoietic transplantation (alloHCT), disease relapse remains the most common cause of transplant failure and mortality. Treatment of relapse after alloHCT remains extremely challenging. Post-transplant maintenance with fms-like tyrosine kinase 3 (FLT3) inhibitors has shown benefit in preventing relapse in the minority of patients with FLT3 mutated acute myeloid leukemia (AML). For the remaining patients, the efficacy of hypomethylating agents (HMA) as post-transplant maintenance yields conflicting results. There is a paucity of data regarding the role of HMA as post-transplant maintenance administered outside the context of a clinical trial. We aimed to evaluate the efficacy of azacitidine (AZA) as post-alloHCT maintenance in a real-world setting in patients with FLT3-negative AML or myelodysplastic syndrome (MDS). Methods: We conducted a single center retrospective matched-control comparative analysis. The study group (AZA group) included adults, aged ³18, with FLT3-negative AML or MDS who received their first alloHCT between 2013 and 2020; and were treated post-transplant with AZA maintenance therapy, initiated within 180 days after alloHCT. All patients in the AZA group initiated maintenance while in complete remission (CR) without minimal residual disease (MRD), assessed by multi-color flow cytometry. We compared the AZA group to a matched control group of contemporaneous patients with AML or MDS who did not receive any maintenance. We matched the control group according to disease type (AML or MDS), disease risk category (by ELN12 for AML and IPSS-R for MDS) and disease status at transplant. Matched controls were required to have count recovery (ANC>1000 X 106 cells/L and PLT>20K/µL) within ±7 days of initiation of AZA in their counterparts. We excluded controls if they had positive MRD, overt relapse or if they died prior to the initiation of AZA in their counterparts; grade 2-4 acute graft versus host disease (GVHD) within +/-7 days, or chronic GVHD within +/-15 days of initiation of AZA in their counterparts. The primary endpoint was disease progression, evaluated considering death before progression as a competing event. Results: We identified 93 consecutive patients who received AZA maintenance. A total of 357 unique matched controls were identified at a 2/1, 3/1, 4/1 matching ratio for 1 (1%), 13 (14%), and 79 (85%) of cases, respectively. The AZA and control groups had comparable patient and disease characteristics except for older age (median: 61 vs. 57 years, p=0.01) and lower hematopoietic comorbidity index (HCT-CI) (median: 2 vs. 3, p=0.04) in the AZA group (Table 1). Patients in the AZA group received a median of 8 (range 1-60) cycles of AZA. Outcomes were compared starting at the time of initiation of AZA in the case. Median follow-up among surviving patients was 35 and 44 months in the AZA and control groups, respectively. The 3-year cumulative incidence of disease progression was 29% and 33% (HR 0.7, 95% CI 0.4-1.1; p=0.09), respectively. Subset analyses showed that the protective effect of AZA on disease progression was limited to patients with high risk AML or MDS [HR 0.4, 95% CI 0.2-0.8, p=0.009] (Figure 1 B,D).There was no beneficial effect for AZA for patients with low or intermediate risk disease [HR 1.04, 0.6-1.8, p=0.9] (Figure 1 A,C). The use of AZA was also associated with a lower rate (4% vs. 22%, p=0.001) of non-relapse mortality independent of the disease risk category. These effects translated into a significantly superior overall (74% vs. 51%, p<0.001) and progression-free (67% vs. 46%, P<0.001) survival in the AZA group compared to the control group. Results were consistent when the analyses were repeated using a second independently selected matched control group (data not shown). Conclusion: Post-alloHCT AZA maintenance was associated with lower progression rate in patients with high-risk FLT3-negative AML or MDS. This effect is remarkable considering that matched controls had been in MRD-negative CR prior to initiation of AZA in their matched counterparts. Our results also indicate a low rate of non-relapse mortality associated with AZA maintenance which warrants evaluation in prospective studies. Collectively, our data suggest that AZA maintenance should be considered for post-alloHCT maintenance in high risk FLT3-negative AML and MDS patients. Figure 1View largeDownload PPTFigure 1View largeDownload PPT Close modal

A Phase 1b Study to Evaluate Safety and Efficacy of IBI188 in Combination with Azacitidine (AZA) As a First-Line Treatment in Subjects with Newly Diagnosed Higher Risk Myelodysplastic Syndrome

Background: IBI188 is a recombinant fully human IgG4 monoclonal antibody targeting CD47, an antiphagocytic ('don't eat me') signal present on cancer cells. Blockage of this innate immune checkpoint, IBI188 enhances tumor cell phagocytosis. The study reported updated results from a phase 1b study (NCT04485065) that evaluated safety and efficacy of IBI188 in combination with AZA as a first-line treatment in subjects with newly diagnosed higher-risk myelodysplastic syndrome (MDS). Methods: IBI188 plus AZA was given to untreated intermediate to very high risk (IPSS-R > 3.5) MDS patients. An IBI188 priming/intrapatient dose escalation regimen (0.1-30 mg/kg QW) was used. AZA was dosed 75mg/m2 days 1-7 Q4W. Patients received IBI188 until disease progression, unacceptable toxicity, or withdraw ICF. The primary endpoint was to evaluate the safety and tolerability of IBI188 in combination with AZA. Efficacy was assessed by IWG 2006 (MDS). Results: Ninety-three patients (pts) were enrolled (median age: 59.0 years, 58 [62.4%] males). 72% pts were high to very high risk by IPSS-R. With a median follow-up of 9.2 mos (range: 0.1-21.0 mos), the most common IBI188-related AEs (≥30%) were platelet count decreased (49.5%), anaemia (44.1%), blood bilirubin increased (36.6%), neutrophil count decreased (36.6%), white blood cell count decreased (36.6%), and haemolysis (34.4%). Nine pts (9.7%) discontinued treatment due to IBI188-related AE. For 45 evaluable pts with ≥ 6 mos follow-up, 37/45 (82.2%) pts had an objective response with 14 pts (31.1%) achieving a complete response (CR), 16 (35.6%) with marrow CR (9/16 also had hematologic improvement (HI)), and 7 (15.6%) with HI alone. The median duration of response was 12.0 months (95%CI, 6.5-NC). A randomized phase 3 MDS trial is planned. Additional patients/analyses will be updated. Conclusions: IBI188 in combination with azacitidine demonstrated promising efficacy, and a manageable safety profile as a first-line treatment in subjects with newly diagnosed higher risk myelodysplastic syndrome. Keywords: Myelodysplastic syndrome, Immune therapy, CD47, IBI188 Clinical trial information: NCT04485065

Sequential Use of Flamsa, FLAG, CLAG or TEC-Based Conditioning Regimen Followed By Allogeneic Hematopoietic Transplantation Results in Favorable Outcome for High Risk Acute Myeloid Leukemia, Myelodysplastic Syndrome and Myeloproliferative Neoplasia Patients: 15 Year Follow-up of the Multicenter Study in Singapore

Introduction: Allogeneic hematopoietic cell transplant (allo-HCT) is an effective consolidative treatment for patients with certain hematological malignancies and gives the best outcome when done in remission. However, patients with refractory acute myeloid leukemia (AML) or some myeloproliferative neoplasia (MPN) and myelodysplastic syndrome (MDS) deemed unable to achieve remission with standard induction are often excluded from allo-HCT with conventional conditioning regimen as pre-transplant remission could not be achieved. Recently, a sequential transplant approach, as developed by the Munich group, comprising of intensive cytoreductive chemotherapy FLAMSA (Fludarabine/Amsacrine/Cytarabine) to decrease leukemia cell burden shortly prior to conditioning regimen, has been successfully used for high-risk (HR) AML/MDS with promising results. Methods: We studied 72 patients (median age 51 years, range 17-68) with HR AML (n=57), as defined by refractory, relapsed disease, secondary leukemia, complete remission with adverse-risk cytogenetics according to ELN criteria, or high/very risk refined Disease Risk Index (DRI), MPN (n=3) and HR MDS (n=12) according to IPSS-R, undergoing allo-HCT using the sequential transplant approach in 2 transplant centers in Singapore between January 2009 and July 2022. The sequential transplant approach combined a cytoreductive chemotherapy, which consisted of either FLAMSA (n=21), FLAG [Fludarabine/Cytarabine/Granulocyte Colony Stimulating Factor (GCSF)] +/- Idarubicin (n=30), CLAG (Clofarabine +/- Cytarabine +/- GCSF) (n=18), or TEC (Thiotepa, Etoposide, Cyclophosphamide) (n=3) followed by reduced intensity (RIC) (n=61) or myeloablative (MAC) (n=11) conditioning regimen. All patients received peripheral blood stem cell from matched related donors (MRD) (n=36), mismatched related donors (MMRD) (n=7), matched unrelated donors (MUD) (n=21), or mismatched unrelated donors (MMURD) (n=8). Post-grafting immunosuppression consisted of calcineurin inhibitor and mycophenolate mofetil (MMF) in all patients. Thymoglobulin and post-transplant cyclophosphamide were added for GVHD prophylaxis for MUD/MMURD and MMRD transplant, respectively. One MMRD had selective ex vivo T-cell depleted transplant followed by MMF as GVHD prophylaxis. Results: The median time to neutrophil > 1000/μL was 11 days (range, 8-25). With a median follow-up duration of 51 months (range, 1-148), the Kaplan-Meier estimate of overall survival (OS) and leukemia-free survival (LFS) at 5 years were 42% (95% CI, 30-54) and 32% (95% CI 20-44), respectively. The cumulative incidence of relapse and non-relapse mortality (NRM) at 2 years were 47% (95% CI, 35-59) and 16% (95% CI, 9-26), respectively. Patients receiving FLAG, CLAG or TEC-based sequential regimen showed a trend towards lower NRM and relapse compared to FLAMSA-based regimen, although the difference was not statistically significant. This translated into a more favorable 5-year LFS (40% vs 13%, p=0.04), but no statistically significant difference in 5-year OS (42% vs 40%, p=0.56). Patients with refractory disease (n=49) were at higher risk of relapse compared to patients whom had achieved at least a partial remission prior to sequential allo-HCT (n=17) (2-year cumulative incidence of relapse: 59.0% vs 34.0%, p=0.02). This resulted in an inferior 5-year OS (31% vs 66%; p=0.02) and LFS (20% vs 75%, p<0.01). On multivariable analysis, only refined DRI showed significant impact on OS (p=0.01) and LFS (p=0.02) but had no significant impact on NRM and relapse. The 5-year OS for patients with intermediate/high risk and very high risk DRI were 51% and 21% (p<0.01), and the corresponding 5-year LFS were 42% and 10% (p<0.01), respectively (Figure 1 and Figure 2). Conclusions: Sequential transplant conditioning with FLAMSA, FLAG, CLAG or TEC-based cytoreductive regimen followed by allo-HCT is an effective strategy in overcoming the dismal prognosis of HR AML, MDS and MPN, including patients with high risk DRI, and enabling favorable long-term disease-free survival. More studies on effective strategies such as optimising the conditioning regimen intensity or post-transplant maintenance therapy with prophylactic donor lymphocyte infusion, are needed to further eliminate the risk of relapse, without increasing risk of treatment-related toxicity. Figure 1View largeDownload PPTFigure 1View largeDownload PPT Close modal

Iron Chelation Improves Ineffective Erythropoiesis and Iron Overload in a Mouse Model of Myelodysplastic Syndrome

Myelodysplastic syndrome (MDS) is a heterogeneous group of bone marrow stem cell disorders characterized by ineffective hematopoiesis and cytopenias, most commonly anemia. Patients are treated with periodic red cell (RBC) transfusions, resulting in iron overload. Iron overload in MDS patients correlates with decreased survival, yet despite the availability of effective, safe, and orally administered iron chelation therapy, the treatment of iron overload in MDS remains controversial. The TELESTO trial, using deferasirox in low risk MDS patients, revealed an increase in event-free survival without impacting overall survival, hemoglobin, or RBC transfusion requirements [Angelucci Ann Int Med 2020]. However, iron chelators have different affinities for iron relative to transferrin; deferiprone has the lowest affinity of available iron chelators [Sohn Blood 2008], consistent with its ability to increase hepcidin expression in mice [Schmidt Am J Hematol 2015; Casu haematol 2016]. We hypothesize that deferiprone (DFP) impacts systemic and cellular iron distribution to enhance erythropoiesis in MDS. To test this hypothesis, we employed a highly penetrant well-established mouse model of MDS, NUP98:HOXD13 fusion transgenic mice. These MDS mice exhibit hypercellular marrow, increased apoptosis in the bone marrow compartment, and impaired survival relative to control; a proportion of mice progress to acute leukemic transformation after 7 months of age [Lin Blood 2005]. Using MDS mice, we further characterize parameters of iron trafficking in erythroblasts, evaluate the effects of DFP on erythropoiesis and iron distribution, and provide correlatory evidence in stem and progenitor cells from MDS patients. MDS mice were treated at 5 months of age with 1.25 mg/mL DFP in the drinking water for 4 weeks and compared with untreated MDS mice. Our results characterize an iron overload phenotype with aberrant erythropoiesis in MDS mice, reversed in DFP-treated MDS mice (Figure 1). Specifically, DFP leads to a redistribution of iron from liver and spleen to increase serum iron concentration and transferrin saturation, increased hemoglobin and RBC concentration in circulation, and normalized hepcidin responsiveness to iron. While MDS mice exhibit relatively decreased WBC count, no changes in WBC count are observed in DFP-treated MDS mice. Importantly, serum erythropoietin (Epo) concentration, splenomegaly, expanded erythropoiesis and erythroblast differentiation in the bone marrow are normalized in DFP-treated MDS mice. As expected when erythropoiesis is reversed, erythroblast expression of Fam132b (erythroferrone) is suppressed but no changes in STAT5 or AKT signaling, pathways downstream of Epo, are evident in DFP-treated MDS mice. These findings suggest that the expected changes in signaling downstream of Epo are unaffected by DFP administration, implicating possible changes in erythroblast Epor expression in DFP-treated MDS mice. We used sorted bone marrow to evaluate Epor expression in progressive stages of terminal erythropoiesis and demonstrate decreased Epor expression in later stage bone marrow erythroblasts from MDS mice, normalized in DFP-treated MDS mice. These findings provide evidence that increased Epor expression is a potential mechanism by which DFP leads to enhanced Epo-responsiveness and enhanced erythroblast differentiation despite decreased serum Epo concentration in MDS mice. In addition, we demonstrate for the first time increased ferritin concentration and normalized Tfr1, Pcbp1 and Ncoa4 expression in late stage erythroblasts from DFP-treated MDS mice, evidence of aberrant iron trafficking in MDS erythroblasts and their normalization with DFP treatment (Figure 2). Importantly, this effect is not observed in DFP-treated WT mice. Our data also provides evidence that reversal of ineffective erythropoiesis in DFP-treated MDS mice occurs independently of effects on erythroblast apoptosis. Finally, we confirm increased expression of genes involved in Epo-mediation as well as iron uptake and trafficking-Epor, Fam132b, Tfr1, Pcbp1 and Ncoa4-in stem and progenitor cells from MDS patients. Taken together, our findings provide evidence that erythroblast-specific iron metabolism is a novel potential therapeutic target to reverse ineffective erythropoiesis in MDS and provide a rationale for exploring the effect of DFP in patients with low risk MDS. Figure 1View largeDownload PPTFigure 1View largeDownload PPT Close modal

Micrornas Analysis in Patients with Myelodysplastic Syndrome. Possible Implications in Risk Stratification

Background. MicroRNAs (miRNAs) are significant regulators of human hematopoietic stem cells (HSC), and their deregulation contributes to hematological malignancies. Systematic analysis of miRNA expression and function during hematopoiesis has revealed regulatory loops where miRNAs contribute to hematopoietic differentiation and function. Among the identified miRNAs, miR-155 can regulate myelopoiesis and erythropoiesis and its overexpression along with the overexpression of miR-125 and miR-181 has been suggested to have functional effects in the regulation of HSC homeostasis. Myelodysplastic syndromes (MDS) are characterized by dysfunctional HSC, ineffective blood cell production, progressive marrow failure, and exhibit a significant risk of progression to acute myeloid leukemia (AML). Although the pathogenesis of MDS has not been fully understood, various alterations of microRNAs (miRNAs) have been reported in MDS. There is recent evidence that the miRNAs mediated post-transcriptional control of gene expression is key component in the pathogenesis of MDS and AML. Several studies have reported that differentially expressed microRNAs are associated with the transformation of MDS to AML and clinical outcomes. Aim. In this study we examined the potential prognostic impact of six previously described miRNAS (miR-181a-2-3p, miR-124-3p, miR-550a-3p, miR-155-5p, miR-151a-3p, and miR-125b-5p) on the pathogenesis of MDS. Methods. Total RNA was extracted from diagnostic bone marrow samples of 41 MDS patients. Patients were stratified per the revised International Prognostic Scoring System (IPSS-R). After polyadenylation of 1 μg total RNA by poly(A) polymerase and subsequent reverse transcription with an oligo-dT adapter primer, miRNAs transcript levels were determined using a reverse transcription quantitative real-time PCR method, based on SYBR Green chemistry. U6 was used as reference gene. Relative microRNA transcript levels were calculated by the 2-ΔΔct method. The IBM SPSS statistics, version 26 (IBM Corporation, North Castle, NY, USA) was used for the statistical analysis of the results. Results. The basic characteristics of the patients are shown in Table 1. Of the microRNAs analyzed in this study, miR-125b-5p, miR-155-5p, miR-181a-2-3p transcript levels were significantly elevated in higher (intermediate, high, and very high) risk MDS than in lower (very low and low) risk MDS (p=0.012, p=0.010, and p=0.024 respectively). MiR-125b-5p, miR-151a-3p, miR-155-5p, miR-181a-2-3p, and miR-550a-3p presented a positive correlation with the percentage of bone marrow blasts [p(0.001-0.05)], while a negative correlation was observed between the expression levels of mir-151-a-3p, miR181a-2-3p, miR-550a-3p, and the neutrophil count (p=0.05, 0.013, 0.010, and 0.007 respectively). None of the remaining factors that were tested (MDS type per the 2016 WHO classification, gender, age at diagnosis, hemoglobin levels, platelet count, and cytopenias) were correlated with the miRNAs levels. Discussion. In this study we demonstrated the notable difference in the pattern of miRNA expression between lower and higher risk MDS patients. It has been shown that deregulation of miR-155-5p and miR-181a-2-3p may promote aberrant hematopoietic stem cell proliferation, differentiation, and progression to AML. Moreover, mice transplanted with miR-155-5p transfected stem cells developed a myeloproliferative disorder with abnormal granulocyte morphology analogous to MDS, suggesting a role in the higher risk MDS phenotype. Finally, it has been reported that miR-181a-3p was strongly expressed in the cytoplasm of high risk MDS cells, in contrast to low risk samples which displayed reduced levels. The identification of miRNAs that distinguish lower risk from higher risk MDS indicates that microRNA expression profile may be exploited to assist with making treatment decisions. Given that certain miRNAs can discriminate MDS subtypes and risk groups, it is not unlikely to think that an miRNA signature could be a useful tool for MDS risk stratification. Based on our current findings and other previously reported results, we continue the study in a larger cohort of patients. Targeting miRNAs may provide new treatment options for MDS Figure 1View largeDownload PPTFigure 1View largeDownload PPT Close modal

Bone marrow CD3+ CD56+ regulatory T lymphocytes (TR3 -56 cells) are inversely associated with activation and expansion of bone marrow cytotoxic T cells in IPSS-R very-low/low risk MDS patients.

BackgroundEmergence of dysplastic haematopoietic precursor/s, cytopenia and variable leukaemia risk characterise myelodysplastic syndromes (MDS). Impaired immune‐regulation, preferentially affecting cytotoxic T cells (CTL), has been largely observed in MDS. Recently, we described the TR3−56 T cell subset, characterised by the co‐expression of CD3 and CD56, as a novel immune‐regulatory population, able to modulate cytotoxic functions. Here, we address the involvement of TR3−56 cells in MDS pathogenesis/progression.ObjectivesTo analyse the relationship between TR3−56 and CTL activation/expansion in bone marrow (BM) of very‐low/low‐risk MDS subjects.MethodsPeripheral blood and BM specimens, obtained at disease onset in a cohort of 58 subjects, were analysed by immune‐fluorescence and flow cytometry, to preserve the complexity of the biological sample.ResultsWe observed that a trend‐increase of BM TR3−56 in high/very‐high MDS stage, as compared with very‐low/low group, associates with a decreased activation of BM resident CTL; significant correlation of TR3−56 with BM blasts has been also revealed. In addition, in very‐low/low‐risk subjects the TR3−56 amount in BM inversely correlates with the presence of activated BM CTL showing a skewed Vβ T‐cell repertoire.ConclusionsThese data add TR3−56 to the immune‐regulatory network involved in MDS pathogenesis/progression. Better knowledge of the immune‐mediated processes associated with the disease might improve MDS clinical management.

Characterization of myelodysplastic syndromes hematopoietic stem and progenitor cells using mass cytometry.

Myelodysplastic syndromes (MDS) at risk of transformation to acute myeloid leukemia (AML) are difficult to identify. The bone marrows of MDS patients harbor specific hematopoietic stem and progenitor cell (HSPC) abnormalities that may be associated with sub-types and risk-groups. Leukemia-associated characteristics of such cells may identify MDS patients at risk of progression to AML and provide insight in the pathobiology of MDS. Bone marrow samples from healthy donors (n =10), low risk (n =12) and high risk (n =13) MDS patients were collected, in addition, AML samples for 5 out of 6 MDS patients that progressed. Mass cytometry was applied to assess expression of stem cell subset and leukemia-associated immunophenotype markers. We analyzed the data using FlowSOM to cluster cells with similar expression of 10 commonly used stem cell markers. Metaclusters (n =20) of these clusters represented populations of cells with a related phenotype, largely resembling known stem cell subsets. Within specific subsets, intra-cellular expression levels of pCREB, IkBα, or pS6 differed significantly between healthy bone marrow (HBM) and MDS or consecutive secondary AML samples. CD34, CD44, and CD49f expression was significantly increased in high risk MDS and AML-associated metaclusters. We identified MDS/sAML cells with aberrant phenotypes when compared to HBM. Such cells were observed in clusters of both primary MDS and secondary AML samples. High-dimensional mass cytometry and computational data analyses enabled characterization of HSPC subsets in MDS and identification of leukemia stem cell populations based on their immunophenotype. Stem cells in MDS that display leukemia-associated features may predict the risk of developing AML.

Prognostic impact of immunophenotypic aberrancies of blasts in lower risk myelodysplastic syndrome

Objective/background: Low risk myelodysplastic syndrome (MDS) is a marrow failure state eventually leading to transfusion dependence. Flow cytometry has previously been demonstrated as prognostic tool in MDS, however not thoroughly studied in lower risk MDS. In this study, we assessed whether assessment for immunophenotypic blast aberrancies by flow in low risk MDS patients has a prognostic role in these patients.Methods: A total of 63 consecutive patients diagnosed with low/intermediate risk MDS were included. We recorded initial flow results, and collected time to transfusion dependence, and AML progression.Results: On multivariate cox regression analysis, increasing IPSS-R score, an increase in the number of blast aberrancies on flow cytometry, and aberrant expression of CD7 on myeloid blasts increased likelihood of transfusion dependence.Conclusion:Low risk MDS patients with increasingly aberrant blast phenotypes by flow may be at risk for earlier transfusion dependence.

Iron Chelation Therapy in Low- to Intermediate- Risk Myelodysplastic Syndrome Patients: A Systematic Review and Meta-Analysis

BackgroundTransfused patients with low- to intermediate-risk myelodysplastic syndromes (MDS) are known to suffer from iron overload. Iron chelation therapy (ICT) may improve outcomes, however, it remains to be thoroughly investigated.MethodsWe conducted a systematic review and meta-analysis to assess the benefit of ICT in patients with MDS. MEDLINE, EMBASE, and Cochrane CENTRAL were searched for studies on ICT for low- to intermediate-risk MDS that reported adjusted hazard ratios (aHR) or overall survival (OS). Two reviewers independently screened titles and abstracts and subsequent full texts for eligibility. Studies were extracted for general demographics, AML progression rate, incidence of cardiac injury, and median OS or aHR. aHR risk ratios were calculated using a random-effects model meta-analysis. Risk of bias was assessed using the Cochrane Risk of Bias tool for randomized controlled trials (RCTs) and Newcastle-Ottawa scale for non-randomized studies.ResultsThe initial search yielded 1177 citations, of which we included 11 observational studies (n = total patient number) and one RCT (n = total patient number) for analysis. The heterogeneity was moderate (I 2=57%; P=0.02). There was a significant reduction in risk of mortality in patients with iron overload and low- or intermediate-risk MDS treated with ICT (aHR 0.43; 95% CI 0.32-0.57; P < 0.00001) (figure 1). The median OS among patients receiving ICT and patients receiving no ICT was reported for nine studies. The median OS for patients receiving ICT was consistently longer than the median OS in the non-ICT group across all studies (figure 2).ConclusionIron chelation therapy (ICT) is associated with a lower risk of mortality in low- to intermediate- risk myelodysplastic syndrome patients. Given the limited number of RCTs, more high-quality studies are required before ICT becomes a standard of care for this group of patients [Display omitted] DisclosuresCrowther: Syneos Health: Honoraria; Precision Biologicals: Honoraria; Pfizer: Speakers Bureau; CSL Behring: Speakers Bureau; Bayer: Speakers Bureau; Hemostasis reference laboratories: Honoraria.

Assessing the Role of Venetoclax in Combination with Hypomethylating Agents in Higher Risk Myelodysplastic Syndromes

Assessing the Role of Venetoclax in Combination with Hypomethylating Agents in Higher Risk Myelodysplastic Syndromes

A Phase 2, Open-Label, Ascending Dose Study of Ker-050 for the Treatment of Anemia in Patients with Very Low, Low, or Intermediate Risk Myelodysplastic Syndromes

A Phase 2, Open-Label, Ascending Dose Study of Ker-050 for the Treatment of Anemia in Patients with Very Low, Low, or Intermediate Risk Myelodysplastic Syndromes

Impact of p53 Disruption on AML & HR-MDS Treatment out-Come. a Single Centre Experience

Introduction: Acute myeloid leukaemia (AML) is a heterogeneous disorder that arises from clonal expansion of malignant hematopoietic precursor cells. Somatic mutations of the p53 gene have been reported in 5-10% of AML, with a higher incidence therapy-related disease and elderly patients. Alteration or loss of p53 is one of the most powerful independent indicators of poor outcome.Methods: This is a retrospective analysis of AML & high risk-Myelodysplastic syndrome (HR-MDS) patients treated over the study period (2006-2020). Informed consent was obtained. Initial presentation, treatment response, and survival were analysed. Percentage of p53 expression (a surrogate marker for TP53 mutations) by immunohistochemistry (IHC) (>30% cut-off) on BM trephines was analysed and its impact on treatment outcome was evaluated.Results: We identified 114 patients (AML=104 & HR-MDS=10), the median age was 70 years (Range 36-85) with male predominance (M=73 vs. F=41). The AML group included, 57 patients (50%) with Denovo AML and 47 patients (41%) with Secondary AML (MDS=27, MPN=12 / JAKII mutation =7, t-AML=8). The median age was 70 years (Range 36-85) and the median blast count was 70% (Range 25-95%). Cytogenetic analysis reports were available on 78 patients (75%)(Poor risk=40 vs. Intermediate risk=38). NPM1 (22 patients) and FLT3 mutations analysis (33 patients )were available and reported as positive in 4(18%) and 5(15%) patients respectively.The HR-MDS is defined by patients who fall into higher-risk group categories in the original or revised IPSS (N=10), the median age was 74 years (Range 63-83) with male predominance (M=7 vs. F=3). The median blast count was 15% (Range 11-18%). Cytogenetic risk prognostic subgroup results were available on 6 patients (60%), 2 patients (2%) had intermediate-risk and 4 patients (4%) had poor-risk.Ninety-nine patients (87%) were eligible for treatment, 48 patients (42%) were treated with intensive induction chemotherapy, and 51 patients (45%) received less intensive therapy (HMA / LD-Ara C). Five patients (4%) consolidated with allogeneic stem cell transplant (Allo-SCT) post-induction therapy. The remaining (15 patients) were on supportive care. Forty-one AML patients (36%) relapsed post CR1, 3 patients had Allo-SCT in CR2. Table 1At the time of study analysis (31/01/2021), 25 patients (22%) are still alive including 23 patients (20%) with AML (Denovo AML=18 & Sec AML=5) and 2 patients (4%) with HR-MDS. The median age of the survival group was 69 years (Range 51-83). The whole study cohort median OS was 12 months. (Figure. 1) The median OS & PFS for AML patients were 15 & 13 months respectively. According to AML sub-type, t-AML associated with shortest median OS of 2.5 months (P.value 0.0190). (Figure. 2) The median OS was more favourable for intermediate-risk than the high-risk cytogenetic AML, 24 and 10 months respectively (P<00016).(Figure. 3) The HR-MDS group median OS was 22 months.One hundred and four patient's BM trephines (91%) were available and screened for p53 IHC expression (AML= 96 & HR-MDS =8). Eight samples (8%) showed p53 over-expression, all these samples with underlying AML diagnosis. The remaining 96 samples (92%) were negative for high p53 expression. The majority of p53 over-expressed AML harboured complex cytogenetics, 4 patients with Sec AML, 3 patients with Denovo AML, and 1 patient with t-AML. Most of the patients (5 patients) in this sub-set had a refractory disease to induction therapy, of whom 2 patients (25%) had Allo-SCT consolidation in CR2. Only one patient (12%) is still alive in this sub-group.The median OS & PFS in p53 wild-type AML cohort was 16 & 13 months respectively, which compared favourably to 12 & 8 months in those with p53 disruptions. The P. values were 0.134 & 0.193, respectively. The impact of the p53 alterations was more pronounced on the AML sub-group treated with intensive chemotherapy (42%), the median OS & PFS in wild-type p53 AML were 24 & 20 months, while in p53 disrupted cohort were 12 & 10 months respectively (P= 0.030)(95%CI of ratio 0.1755 to 1.425) & (P=0.049)( 95%CI of ratio 0.7015 to 5.702).(Figure.4)Conclusion: In this study we demonstrated the potential role for p53 expression by IHC, which is readily available in routine practice, in assessing AML prognosis. Our real-life data confirms the dismal prognosis of p53 alterations in this disease. Participation in clinical trials based on genetic risk stratification is warranted. [Display omitted] DisclosuresNo relevant conflicts of interest to declare.

Immunohistochemical Analysis of Inflammasome Signaling Component Expression Among Patients with Low Risk and High Risk Myelodysplastic Syndrome Using Tissue Microarray

Background: Myelodysplastic syndromes (MDS) are characterized by aberrant maturation, ineffective hematopoiesis, cytopenias, and progression to acute myeloid leukemia. MDS pathogenesis is multifactorial and potentially linked to constitutive innate immune stimulation converging upon the NLRP3 inflammasome to induce pyroptosis, a caspase-1 dependent cell death. Inflammasome assembly is initiated by both cell-extrinsic stimuli including S100A9, the TLR4 and CD33 ligand, and cell-intrinsic danger signals licensing caspase-1 which activates IL1b and beta-catenin resulting in cell death and increased cellular proliferation leading to maturation and differentiation blocks. Further, EYA2 has been suggested to be an inflammasome activator, whereas PLA2 has been suggested to be an inhibitor. Recent work demonstrates immunohistochemistry (IHC) may be utilized to assess expression of inflammasome components. The purpose of the present study is to compare inflammasome component expression among patients with low and high risk MDS and correlate these findings with clinical outcome data.Methods: An IRB protocol was approved prior to initiating this study. We retrospectively identified 87 patients with MDS including 40 (46%) low risk MDS and 47 (54%) high risk MDS patients. A tissue microarray (TMA) was constructed utilizing MDS bone marrow biopsy samples (2-3 representative cores per sample). IL-1, S100A9, EYA2, CPLA2, Beta Catenin, and TLR4 expression were assessed by IHC after validation of each antibody. IHC expression was scored independently by two hematopathologists by calculating scores (product of staining intensity x percent expression). IHC expression was compared using Spearman correlation estimate. Demographic and clinical data were collected and correlated with IHC expression using Kruskal-Wallis test, Spearman correlation, and Logrank test.Results: Patients were median 72 years of age, 69% men and included 29% MDS-EB2, 28% MDS-MLD, 17% MDS-RS, 15% MDS-EB1, 9% MDS-SLD, 1% MDS del5q and 1% MDS/MPN-U. Correlation matrix in Figure 1 illustrates correlation seen between expression of various inflammasome components. Increased expression of CPLA2 and TLR4 (median 0.6 and 1.71, respectively) were observed in high risk MDS compared to low risk MDS (median 0.12 and 0.02, respectively, p<0.0001), and decreased beta-catenin expression was seen in high risk MDS compared to low risk MDS (median 0.00 vs 0.14, p<0.0001). IL-1, S100A9, and EYA2 expression was similar between high risk MDS and low risk MDS samples (median score 1.55 vs 1.55, 0.56 vs 0.60, and 0.74 vs 0.60, respectively). Simple linear regression demonstrates relationship between R-IPSS and CPLA2 (r 2=0.175, p<0.001), beta-catenin (r 2=-0.182, p<0.001), and TLR4 (r 2=0.555, p<0.001). Progression free survival (112.5 months vs 19.8 months) and overall survival (107.6 months vs 24.5 months) were longer for low risk MDS compared to high risk MDS, respectively (p<0.0001). Overall survival was increased in patients with low CPLA2 expression compared to high CPLA2 expression (88.9 months vs 38.1 months, p =0.0018), high beta-catenin expression compared to low beta-catenin expression (130.0 months vs 36.8 months, p < 0.0001) and low TLR4 expression compared to high TLR4 expression (90.1 months vs 22.3 months, p < 0.001).Conclusions: IHC staining of inflammasome activators using TMA may allow better characterization of molecular pathways contributing the MDS pathogenesis. A correlation was seen between expression of antigens known to be increased downstream of NLRP3 inflammasome activation. Survival was increased in patients with low CPLA2 expression, high beta-catenin expression, and low TLR4 expression. Further characterization of inflammasome signaling may lead to novel therapeutic targets and prognostic tools in the management of MDS. [Display omitted] DisclosuresLancet: Millenium Pharma/Takeda: Consultancy; Celgene/BMS: Consultancy; ElevateBio Management: Consultancy; BerGenBio: Consultancy; AbbVie: Consultancy; Daiichi Sankyo: Consultancy; Agios: Consultancy; Astellas: Consultancy; Jazz: Consultancy. Komrokji: Jazz: Consultancy, Speakers Bureau; AbbVie: Consultancy; Acceleron: Consultancy; Geron: Consultancy; Taiho Oncology: Membership on an entity's Board of Directors or advisory committees; PharmaEssentia: Membership on an entity's Board of Directors or advisory committees; Novartis: Consultancy, Honoraria, Membership on an entity's Board of Directors or advisory committees; BMSCelgene: Consultancy, Membership on an entity's Board of Directors or advisory committees, Speakers Bureau.