Secondary Myelodysplastic Syndrome Research Articles

Impact of Early Cytomegalovirus Reactivation After Allogeneic Hematopoietic Stem Cell Transplantation on Relapse in Patients With Myelodysplastic Syndrome: A Nationwide Retrospective Study From Adult Myelodysplastic Syndrome Working Group of the JSTCT

Cytomegalovirus (CMV) reactivation is a prominent complication associated with adverse outcomes in allogeneic hematopoietic stem cell transplantation (HSCT). However, CMV reactivation after allogeneic HSCT may be associated with a lower incidence of relapse in some hematological malignancies. This study analyzed the Japanese registry data from 1082 patients with myelodysplastic syndrome (MDS) who underwent their first allogeneic HSCT and survived for 100 days after transplantation without graft failure or disease relapse to investigate this association. Patients who received cord blood transplants, demonstrated in vivo T cell depletion, underwent prophylactic anti-CMV treatment, or diagnosed with secondary MDS were excluded. CMV reactivation measured by pp65 antigenemia within 100 days after allogeneic HSCT was observed in 57.5% of patients, with a median time of 46 days from transplant. The 5-yr overall survival and cumulative incidence of relapse (CIR) in the cohort were 60.5% and 15.6%, respectively. The 5-yr CIR showed no significant difference between patients with and without CMV reactivation (14.4% versus 17.2%; P = .185). Interestingly, CMV reactivation within 100 days was significantly associated with a lower 5-yr CIR (7.6% versus 16.4%; P = .002) in patients with <5% myeloblasts in the bone marrow (BM) just before HSCT. Furthermore, this relevancy confirmed even when excluding patients with Grade II to IV acute GVHD (Hazard ratio: 0.38; 95% confidential intervals: 0.18–0.801; P = .011). Our findings indicate a correlation between early CMV reactivation and MDS relapse, based on the proportion of myeloblasts in the BM. These results may contribute to the development of effective CMV prophylaxis post-HSCT.

Clinical Features of Clonal Cytogenetic Abnormalities in Philadelphia-negative Cells Developed During Tyrosine Kinase Inhibitor Treatment.

Most clonal cytogenetic abnormalities of Philadelphia-negative cells (CCA/Ph-) occurring during tyrosine kinase inhibitor (TKI) treatment are transient, and the development of secondary myelodysplastic syndrome (MDS)/acute myeloid leukemia (AML) is rare, but the frequency and clinical significance in Japanese patients are still unknown. We herein report four patients who developed CCA/Ph- during TKI therapy and were diagnosed with secondary MDS/AML. The duration from TKI therapy initiation to MDS/AML onset ranged from 3 to 48 months, and the survival ranged from 5 to 84 months. The occurrence of CCA/Ph- with MDS/AML may be associated with a poor prognosis, and careful follow-up is recommended for patients who receive TKI therapy.

Communication That Enables Shared Decision-Making in Myelodysplastic Syndrome Is Suboptimal: Early Results from the Cancer Experience Registry

Background: Myelodysplastic Syndromes (MDS) are a heterogeneous group of marrow failure diseases whose prognosis and treatments are guided by marrow morphology, degrees of cytopenias, and genetic changes. Due to the complexity of the disorder, combined with the advanced age and frailty of most patients, conveying crucial information for shared decision-making poses challenges. Despite efforts designed to enhance communication, there is limited understanding of these initiatives' effectiveness. Methods: The Cancer Experience Registry® is an ongoing online research study conducted by the Cancer Support Community that seeks to uncover the emotional, physical, practical, and financial impact of cancer from the patient's perspective. In association with the MDS Foundation, this observational, cross-sectional study enrolls patients with MDS who provide socio-economic and clinical history, supplemented with information related to their MDS diagnosis. Frequencies and descriptive statistics are presented. Results: Between December 2021 and February 2023, 140 MDS patients joined the registry. By self-report, the study population was 51% female and 91% non-Hispanic white with a median age 61 (range 34-93). Like other cancer disease cohorts in the online registry, the MDS population was highly educated (81% attending college and 31% obtaining advanced degrees). 18% reported gross annual incomes less than $40,000 but 29% reported incomes above $80,000 (with 25% not responding). 70% were retired, 15% were still employed and 11% considered themselves unemployed due to disability. 41% of the patients were newly diagnosed (disease duration less than 1 year) and an additional 19% had MDS for less than 2 years. Interestingly, 24% carried a diagnosis of MDS for more than 6 years (including 11% reporting &amp;gt;10 years duration). 51% were in active treatment, 18% were between therapies, and 26% had never received any MDS-directed therapy. 76% self-reported a primary MDS diagnosis and 7% secondary MDS, with the remainder unsure. 33% of the respondents did not know their WHO morphologic subtype with 13% stating that they were never informed and 16% unsure if they were told this information. Similarly, although the IPSS-R is a critical determinant of prognosis and informs treatment decisions, 23% could not recall this score with 11% stating that they were not told their IPSS-R and 9% not sure if they were informed. Among 118 respondents, only 18% could remember their genetic testing results. 120 participants answered questions regarding whether they received additional assistance with MDS-related information and when this was provided. By patient recall, general information about MDS was provided to 78% at the time of diagnosis and an additional 5% after starting treatment. Help in understanding the WHO subtype and IPSS-R was remembered by 41% and 52%, respectively, at the time of diagnosis, and 8% and 9% after starting treatment. A third could not recall being informed about genetic mutational testing. Information about the possibility of MDS transforming into AML was not recalled by 21%. Information about transfusion support was remembered by 46% at the time of diagnosis and 17% after starting treatment (with 29% stating that they had not received information about transfusions and 8% unable to recall). A discussion about transplant options was remembered by 67%. Although a quarter of patients have never received therapy, 32% stated that they had never had a discussion of treatment options and an additional 6% were unsure if a discussion had occurred. A discussion about specific MDS medications was remembered by 51% at the time of diagnosis and 19% only after the start of therapy, with 30% not recalling any assistance in understanding medication options. Conclusions: Based on the early results of the Cancer Experience Registry® derived from a cohort of highly educated and motivated MDS patients, it appears that effective communication about MDS and treatment options is suboptimal. A significant proportion of respondents were unable to recall information about their diagnosis critical to informed shared decision-making. Given the complexities of an MDS diagnosis, additional efforts to educate patients are necessary. Patient support organizations, such as the Cancer Support Community and the MDS Foundation, can serve as valuable educational resources.

Phase 2 Trial of Mini-Hyper-CVD Plus Inotuzumab Ozogamicin, with or without Blinatumomab, in Older Patients with Newly Diagnosed Philadelphia Chromosome-Negative B-Cell Acute Lymphoblastic Leukemia

Background The introduction of inotuzumab ozogamicin (InO) and blinatumomab (blina) has drastically improved the overall survival (OS) of patients with relapsed/refractory B-cell acute lymphoblastic leukemia (B-ALL). Older patients with B-ALL have worse outcomes compared with younger patients due to the poor-risk biology of their disease and their inability to tolerate intensive chemotherapy. We aim to study the incorporation of InO and blina with low intensity chemotherapy in older patients with newly diagnosed (ND) B-ALL. Methods Adults ≥60 years with ND Philadelphia chromosome (Ph)-negative B-ALL who were untreated or had received up to two cycles of previous therapy were eligible. Other inclusion criteria included an Eastern Cooperative Oncology Group (ECOG) performance status of ≤3 and adequate organ function. Patients with central nervous system (CNS) disease were eligible. Patients received mini-Hyper-CVD (mHCVD, cyclophosphamide 150mg/m 2 q12h D1-3, dexamethasone 20mg daily D1-4, 11-14, and vincristine 2mg D1, 8 alternating with methotrexate (MTX) 250mg/m 2 D1 &amp; cytarabine 500mg/m 2 q12h D2, 3) for up to 8 cycles. Eight doses of intrathecal (IT) MTX /cytarabine were given for CNS prophylaxis; patients with CNS disease had IT hydrocortisone, MTX, and cytarabine twice weekly till CNS clearance, then weekly x4. Eight doses of rituximab 375mg/m 2 were given on D1, 8 of C1-4 if CD20 was ≥20% by flow cytometry. Initially, InO was given at 1.3-1.8mg/m 2 on D3 of C1 and 1.0-1.3mg/m 2 on D3 in C2-4. The protocol was amended from patient 50 such that InO was given in fractionated doses with a maximum cumulative dose of 2.7mg/m 2 (0.6 mg/m 2 on D2 of C1, 0.3 mg/m 2 on D8 of C1, then 0.3 mg/m 2 on D2 and D8 of C2-4). Ursodeoxycholic acid was given to all patients. Four cycles of blina 28µg/day replaced C5-8 of mHCVD + InO. Maintenance was initially with vincristine 2mg D1, prednisolone 50mg daily D1-5, 6-mercaptopurine 50mg BID &amp; MTX 10mg/m 2 weekly (POMP) for three years. After the protocol amendment, this was reduced to 12 cycles of POMP, with one cycle of blina given after every three POMP cycles (total four blina cycles). Results 83 patients with a median age of 68y (range, 60 - 87; ≥70y, 34%) were enrolled (Table 1). Several patients had high-risk features: 25 (39%) harbored TP53 mutations, 9 (18%) had a Ph-like signature, and 19 (23%) had high-risk cytogenetics (12 low hypodiploidy/near triploidy, 3 tetraploidy, 3 complex and 1 t(4;11)). 77 patients were not in CR at enrollment and evaluable for response. 76 (99%) responded, with 69 (90%) attaining CR. Among responders, 60 (79%) and 71 (94%) patients had no detectable minimal residual disease (MRD) by flow cytometry after C1 and overall, respectively. No early deaths were observed. After a median follow-up of 88 months (IQR, 41-120), the median overall survival (OS) was 56 months (95%CI, 28-85), and the median progression-free survival (PFS) was 47 months (95% CI, 21-72). The 5-year continuous remission duration (CRD) and OS rates were 78% and 49%, respectively. The 5-year OS for patients aged 60-69 without adverse cytogenetics (n=40), age 60-69 with adverse cytogenetics (n=15), age ≥70 without adverse cytogenetics (n=24) and age ≥70 with adverse cytogenetics (n=4) were 73%, 27%, 39% and 0%, respectively. Five (6%) patients underwent allogeneic stem cell transplantation (ASCT) in first CR, 12 (15%) relapsed, 33 (40%) remain in ongoing continuous remission without ASCT, and 33 (40%) died in remission. Of the 12 relapsing patients, 5 had extramedullary disease, all with CNS involvement. 12 (14%) patients died due to progressive disease at a median of 23 (range 2 - 78) months; these patients had a median age of 64 (range 60 - 79) years. Of the 33 who died in remission, nine were due to secondary myelodysplastic syndrome (MDS) or acute myeloid leukemia (AML). The median age of these patients was 71 years (range, 64 - 87), with a median time to MDS/AML of 34 months (range, 7 - 75). Fourteen deaths in CR were due to treatment-related complications (9 sepsis, 3 veno-occlusive disease (VOD), 2 ASCT). Six (7%) patients developed veno-occlusive disease, 4/49 (8%) in the pre-amendment group and 2/34 (6%) in the post-amendment group. Conclusion Older patients with ND Ph-negative ALL treated with mHCVD plus InO, with or without blina had excellent response rates and deep remissions. However, further adjustment of the regimen is needed, especially in patients ≥70 years.

A Phase 2 Study of Nivolumab for Relapsed/Refractory Multiple Myeloma or Non-Hodgkin Lymphoma Following CAR-T Therapy

Background: Treatment options are limited for patients with relapsed multiple myeloma (MM) or non-Hodgkin lymphoma (NHL) after CAR-T failure. While checkpoint inhibition may theoretically improve T-cell effector activity following CAR-T, a prospective trial of pembrolizumab (a monoclonal antibody targeting PD-1 on T-cells) following CD19 CAR-T in NHL showed an ORR of only 25% (Chong Blood 2022). In a recent multicenter NHL cohort (Major Blood Advances 2023), responses were similarly low with both pembrolizumab and nivolumab (nivo). However, nivo has not been studied prospectively in this setting, and the efficacy of checkpoint inhibition after CAR-T failure in MM has not been characterized. Methods: We conducted a single-center phase 2 trial (NCT04205409) of nivo for MM or NHL pts with relapse following any CAR-T product (including investigational products) as their last line of therapy. Nivo monotherapy was dosed 480mg IV every 4 weeks until PD or toxicity. The primary endpoint was overall response rate (ORR) by IMWG or Lugano criteria. Secondary endpoints included safety data for AEs and immune-related AEs (irAEs) using CTCAE v5.0 as well as post-nivo CRS/ICANS using ASTCT criteria. Other endpoints included duration of response (DoR), PFS, CAR-T expansion following first nivo dose, and PD-L1/PD-1 IHC expression on tumor biopsies. Results: We enrolled 20 pts (11 MM, 9 NHL) as detailed in Table 1. Prior to nivo, the best response to CAR-T had been CR in 64% of MM pts and 44% of NHL pts, while 1 MM pt and 1 NHL pt had experienced PD as best response. Median time between CAR-T infusion &amp; C1D1 nivo was 624 days (range 59-1211) in MM and 149 days (range 34-506) in NHL. The ORR was 15% overall: 18% (2/11) for MM and 11% (1/9) for NHL. Characteristics of the 3 responders are detailed in Table 2. Both responders with MM had previously received fully human CAR-T therapies; in NHL, the sole response was in a patient who had received commercial axi-cel. In all 3 cases, clinical benefit was evident following a single nivo dose. Both MM patients achieved a VGPR by light chains (&amp;gt;95% reduction) within 4 weeks; in one patient, PET-CT showed complete resolution of a plasmacytoma that had measured 8.6cm one week before C1D1 nivo. DoR was 687 days for this patient and ≥198 days (ongoing) in the other responder with MM. In NHL, the responding patient - who had had a DS4 response at Day +30 then a DS5 response at Day +60 following axi-cel before starting nivo one month later - achieved a complete response (DS3) including resolution of hepatic and splenic lymphomatous lesions. Conversely, in all non-responders, PD was uniformly evident within a month of nivo as well. The most common Grade 3+ AEs were neutropenia (25%), anemia (15%), and sepsis (15%). One MM patient developed secondary MDS. Two irAEs (one Gr2 pneumonitis, one Gr2 rash) occurred, both in non-responders, and both resolved with brief courses of prednisone. CRS or ICANS did not occur following nivo in any pt. There were 3 deaths within 100 days of nivo initiation, all unrelated to treatment and, all in non-responders: two clearly due to PD and one due to hypotensive cardiac arrest (no evidence of myocarditis). The results of ongoing correlative analyses will be presented at the meeting, including post-nivo CAR T-cell expansion data, nivolumab binding assays on T-cells, and PD-L1 tissue expression on tumor biopsies. Conclusions: We found that responses to PD-1 blockade following CAR-T failure are uncommon, confirming prior studies in NHL which demonstrate poor activity in this setting. Our 18% ORR with post-CAR-T nivo in R/R MM (2/11 pts) is notably higher than the 4% ORR (1/27 pts) reported with nivo monotherapy in R/R MM (Lesokhin JCO 2016), although conclusions are difficult to draw with small n. Day +28 responses following a single dose of nivo 480mg were uniformly predictive of long-term efficacy. irAEs were relatively uncommon and manageable with steroids, while CRS and ICANS did not occur. To our knowledge, this is the first prospective evaluation of nivo following CAR-T failure. Given the non-curative nature of BCMA CAR-T, there may be certain pts with MM for whom checkpoint inhibition leads to a meaningful clinical benefit without unacceptable risks. Better tools to identify such patients are needed, and novel correlative data to help identify pre-nivolumab features of responders - particularly in MM - will be presented at the meeting.

Retrospective Evaluation of Patients Who Underwent Allogeneic Stem Cell Transplantation for Bone Marrow Failure

Background: Bone marrow failure is a disease that develops due to different etiologies. Aplastic anaemia (AA) and hypocellular myelodysplastic syndrome (HMDS) are the most common bone marrow failure disorders. Treatment options include supportive therapy, immunosuppressive therapy, and allogeneic hematopoietic stem cell transplantation (allo-HCT). Allo-HCT is the only curative treatment option. This study aimed to retrospectively evaluate the demographic characteristics, treatment, and transplantation results of patients who underwent Allo-HCT for bone marrow failure.&#x0D; Material and Methods: This single-centre retrospective study enrolled 11 patients (9 with severe AA and 2 with HMDS) who underwent allo-HCT for bone marrow failure. The patients' records until 17.08.2023 were analysed. Age, gender, diagnosis, donor age and gender, type of transplantation, pre-transplant ferritin levels, time to transplantation, volume of infused product, number of CD34+ cells in the infused product, post-transplant engraftment times, discharge time, transplant-related complications, post-transplant follow-up and overall survival times were obtained.&#x0D; Results: Eleven patients underwent 12 allo-HCTs for bone marrow failure. Seven patients were male, and four were female. The median age was 40, and seven patients were ≥40 years old at the time of transplantation. Eleven transplants were performed from HLA fully matched siblings and one from a 9/10 matched sibling donor. Bone marrow was used as a stem cell source in 8 transplants and peripheral blood in 4 transplants. The conditioning regimen was fludarabine/cyclophosphamide/anti-thymocyte globulin in all patients. The median time from diagnosis to transplantation was five months. The median time for neutrophil engraftment was 23 days. The median platelet &gt;20.000/mm3 engraftment time was 16 days. A statistically significant positive correlation was found between ferritin levels and platelet &gt;20.000/mm3 engraftment (days) (r=0.653, p=0.040) and platelet &gt;50.000/mm3 engraftment (days) (r=0.720, p=0.029). There was a statistically significant negative correlation between the number of infused CD34 positive cells (10⁶/kg) and platelet &gt;50.000/mm3 engraftment (days) (r=-0.670, p=0.024). Patients were discharged in a median of 23 days. Acute graft versus host disease (GvHD) was observed in one patient, while chronic GvHD was not observed in any patient. The median overall survival time was 48 months, and the median post-transplant follow-up was 37 months. Secondary malignancy and MDS were not detected in any patient during the follow-up period. All 11 patients who underwent Allo-HCT from a matched sibling donor are alive and continue to have a complete hematological response. There was no increase in mortality and morbidity in patients aged 40 years and older.&#x0D; Conclusions: In patients with severe AA and high-risk HMDS without comorbidities between the ages of 40 and 50, allo-HCT should be considered as first-line treatment in the presence of an HLA-matched sibling donor.

Small myeloid subclones are present at diagnosis of multiple myeloma in patients who develop secondary myelodysplastic syndromes.

Not available.

MicroRNA profiling in aplastic anemia reveals similarities between secondary myelodysplastic syndromes arising from clonal progression and de novo MDS

MicroRNA profiling in aplastic anemia reveals similarities between secondary myelodysplastic syndromes arising from clonal progression and de novo MDS

Vemurafenib combined with cladribine and cytarabine results in durable remission of pediatric BRAF V600E-positive LCH.

Langerhans cell histiocytosis (LCH) is a disorder with a variety of clinical signs. The most severe forms affect risk organs (RO). The established role of the BRAF V600E mutation in LCH led to a targeted approach. However, targeted therapy cannot cure the disease, and cessation leads to quick relapses. Here, we combined cytosine-arabinoside (Ara-C) and 2'-chlorodeoxyadenosine (2-CdA) with targeted therapy to achieve stable remission. Nineteen children were enrolled in the study: 13 were RO-positive (RO+) and 6 RO-negative (RO-). Five patients received the therapy upfront, whereas the other 14 received it as a second or third line. The protocol starts with 28days of vemurafenib (20mg/kg), which is followed by 3 courses of Ara-C and 2-CdA (100mg/m2 every 12 h, 6mg/m2 per day, days 1-5) with concomitant vemurafenib therapy. After that, vemurafenib therapy was stopped, and 3 courses of mono 2-CdA followed. All patients rapidly responded to vemurafenib: the median disease activity score decreased from 13 to 2 points in the RO+ group and from 4.5 to 0 points in the RO- group on day 28. All patients except 1 received complete protocol treatment, and 15 of them did not have disease progression. The 2-year reactivation/progression-free survival (RFS) for RO+ was 76.9% with a median follow-up of 21months and 83.3% with a median follow-up of 29months for RO-. Overall survival is 100%. Importantly, 1 patient experienced secondary myelodysplastic syndrome after 14months from vemurafenib cessation. Our study demonstrates that combined vemurafenib plus 2-CdA and Ara-C is effective in a cohort of children with LCH, and the toxicity is manageable. This trial is registered at www.clinicaltrials.gov as NCT03585686.

A CASE OF MYELODYSPLASTIC SYNDROME WITH RARE TRANSLOCATION (2-11) (Q31 P15) SECONDARY TO CHEMOTHERAPY TREATMENT

Chromosomal translocations are common genetic alterations in myeloid neoplasia, and certain translocations have been specifically associated with secondary myeloid neoplasms following treatment with Topoisomerase II inhibitors. The most frequently observed translocations involve chromosomes 11q23 (MLL) and 21q22 (Runx1), and they typically occur early after chemotherapy. Here, we present a rare case of secondary myelodysplastic syndrome that occurred 14 years after chemotherapy, which included both alkylating agents and Topoisomerase II inhibitors. The patient presented with a translocation t (211) (q31 p15), which resulted in a rearrangement of the Nup98 gene with the HOXD13 gene. To our knowledge, this is the first reported case of this specific translocation in the literature. This case underscores the importance of continued vigilance for the development of secondary myeloid neoplasms in patients who have received chemotherapy and suggests the need for further research to better understand the genetic mechanisms underlying these rare translocations.

151 - A Retrospective Validation Study Comparing the IPSS-M and IPSS-R Risk Stratification Scores in Primary and Secondary Myelodysplastic Syndrome (MDS)

151 - A Retrospective Validation Study Comparing the IPSS-M and IPSS-R Risk Stratification Scores in Primary and Secondary Myelodysplastic Syndrome (MDS)

A rare case of familial hemophagocytic lymphohistiocytosis with secondary myelodysplastic syndrome in a pediatric patient

A rare case of familial hemophagocytic lymphohistiocytosis with secondary myelodysplastic syndrome in a pediatric patient

Миелодиспластический синдром, возникший после полихимиотерапии лейкоза. Последствие химиотерапии или проявление генетической нестабильности?

Great progress has been achieved in the treatment of oncological diseases; however, the problem of the occurrence of secondary malignant neoplasms remains actual, among which hematologic malignancies are common. The development of secondary tumors is of particular interest, because the individual predisposition of the body to malignant transformation of cells and the carcinogenic effect of antitumor therapy of primary cancer are possible etiological factors. The article presents a review of literature devoted to the cases of secondary malignant neoplasms that emerged after antitumor treatment. A clinical case of a secondary myelodysplastic syndrome developed after chemotherapy in the treatment of primary acute lymphoblastic leukemia is described.

[Clinical significance of clonal hematopoiesis and disease boundaries in bone marrow failure diseases].

Aplastic anemia (AA) is a non-neoplastic bone marrow failure syndrome caused by the destruction of hematopoietic stem and progenitor cells by the immune system. However, in some cases of AA, a small number of specific clones with gene mutations are observed without clinical manifestations. Cases with mutated PIG-A, BCOR/BCORL1, or HLA class I allele clones respond better to immunosuppressive therapies (ISTs). Cases with MDS-related clones, such as DNMT3A or ASXL1 mutations, are at a higher risk for secondary MDS. In this review, I will focus on the clonal hematopoiesis (CH) in AA and discuss its clinical significance, including its impact on disease boundaries and transition. I will also discuss the pathophysiology and diagnosis of hypoplastic MDS, a type of MDS that responds to ISTs.

Second Malignancy after Childhood AML Treatment - a Retrospective Analysis of the AML-BFM Stud

In the past decades the outcome in ped AML patients improved continuously. However, secondary malignancies seem to be a severe side-effect, affecting the quality of life in survivors. This retrospective data analysis in patients treated according to AML-BFM protocols, is focused the occurrence of secondary malignancies after AML treatment and evaluates the consequences thereof. Between 1993 - 2019 (total n=2797) 51 patients were documented with a secondary malignancy (SM) after AML treatment. 5 pat (10%) were excluded due to a lack of data concerning the SMs exact diagnosis or a clear differentiation from AMLs relapse. Patients were included if the de novo AML occurred before <18yrs. 46 pat (f=20; m=26) remained in the analysis. All pat were treated acc to the current AML-BFM protocol version at the time of their AML diagnosis and for their SM acc. to local standard of care. For AML treatment the cumulative dose of i.v.-cytarabine ranged from 41,380 to 51,380 mg/m2(median 47,380 mg/m2), i.th. cytarabine from 140 to 370 mg age and weight-depended (median 330 mg), etoposide was given constantly with 950 mg/m2 and from 2004 to 2017 anthracyclines with cumulative doses of 500 mg/m² were applied (idarubicin/mitoxantrone calculated with equivalence dosage of 1:5). Since 2004 the i.th. therapy was added with a max. dose of 70 mg prednisolone and 84 mg MTX, both depending on age and weight. The median age on initial AML was 7.3 yrs, ranged from 0.1-17.5 yrs while the median age at date of SM diagnosis was 14.4 yrs, ranged from 0.86-30.2 yrs. The median percentage of BM blasts was 61% (0 - 100%), the median WBC of 7,200/ μl (670 - 214,000/μl) and hemoglobin was 8.7 g/dl (4.6-14.2 g/dl). Acc. to the FAB classification, FAB M4/M5 (43%) was the largest group, followed by FAB M0/M1/ M2 (35%), FAB M6/M7 (6%), M3 (6%) and others (6%). In 63% of the cohort a normal karyotype was detected. Beside a single patient (2%) all others received CR during AML treatment. The median time between AML and SM was 3.6 yrs (0.6 to 19.7 years). Interestingly the median time differs between AML followed by blood cancers with 3.2 yrs (0.8- 15.2 yrs) to 8.1 yrs (0.6-19.7 yrs) for AML followed by a solid tumor. Leukemia (n=13, 28%), such as ALL (n=10) or CML (n=3), was the most frequent SM, however also secondary myelodysplastic syndromes (n=8, 17%; including RAEB and RAEB in transformation), lymphoma (n=7, 15%), head and neck tumors (n=6, 13%), skin cancer (n=3, 7%), CNS tumors (n=3, 7%) and other diagnoses (n=6, 13%) were reported. None of the patients was reported with known genetic disorders explaining the SM, but in 9 cases (20%) pre-existing diseases (malignant and non-malignant) was documented, often as multi-morbidity (e.g., heart, lung, neurological diseases). According to a median follow-up-period of 11.7 yrs (0.6-22.3 yrs) after AML diagnosis, the 5-yr-overall survival (OS) rate of the cohort was 97±2% after AML and decreases to 78±6% from the date of SM. The OS of 97±2% resulted from a single patient, which was diagnosed with the SM and died at the same day. The 5-yr-event-free-survival (EFS), defined as death by any cause, relapse (independently of AML or SM) and third malignancy, was 87±5% vs. 71±7%. Patients suffering from blood cancers as SM (n=29, 63%) had a slightly poorer outcome in comparison to solid tumor patients (n=17, 37%) with a 5-yr-OS of 79±8% vs. 88±2% (p 0.223) and 5-yr-EFS of 65±9% vs. 82±9% (p 0.097). With a cumulative incidence of 2%, SM are extremely rare after ped AML. In contrast, in the same period three times more t-AML cases were reported, therefor AML itself is the most frequent treatment-related malignancy in ped patients as previously published. The results showed a shorter period between AML followed by blood cancers than solid tumors, which suggesting either that AML and the SM are pathophysiologically related whereas solid tumors may be therapy-induced only or that hematopoiesis is more sensitive for toxic effects or shows a higher proliferation rate. Due to the very limited case numbers and lack of further genetic results to exclude e.g. predisposition syndromes, these hypotheses are speculative and cannot be proven. Based on the frequency of SM after ped AML and the outcome thereof, a further therapy intensification to improve especially the AMLs EFS is justifiable. Caused on the results and the revealed median intervals, a long-term follow up for ped AML patients into their adult life is highly recommendable to learn more about these rare events.

A Retrospective Validation Study Comparing the IPSS-M and IPSS-R Risk Stratification Scores in Primary and Secondary Myelodysplastic Syndrome (MDS)

Introduction: Myelodysplastic syndrome (MDS) is a stem cell disorder characterized by bone marrow stem cell dysfunction, cytopenia(s), and increased risk of acute myeloid leukemia (AML) transformation. Treatment of MDS varies based on a patient's estimated risk of transformation to AML and the presence of molecular and cytogenetic changes known to confer poor clinical outcomes. Significant effort over the last few decades has been undertaken to develop prognostic models to risk stratify patients, resulting in the international prognostic scoring system (IPSS), revised version (IPSS-R), and WHO classification-based prognostic scoring system (WPSS). Recently, the molecular international prognostic scoring system (IPSS-M) was proposed to consider clinical indices, laboratory and pathology parameters, cytogenetics, and mutational data in the progression of MDS. Currently, this model has only been validated within a Japanese database, wherein 42% of patients were re-stratified by IPSS-M in comparison to IPSS-R. To date, these results have yet to be validated in a cohort of patients in the U.S. Methods: We conducted a single-center retrospective validation cohort study of adults with a known diagnosis of MDS referred to Oregon Health & Science University from 2019 through 2021. The study was approved by the Institutional Review Board prior to initiation (OHSU IRB number- STUDY00023980). Patients were identified using relevant diagnostic codes for MDS and those who were <18 years of age, did not have a biopsy-confirmed diagnosis of MDS, did not have next-generation sequencing performed on diagnostic tissue, or were lost to follow-up shortly after diagnosis were excluded. Patients with treatment-related MDS were included. The primary outcomes, measured from MDS diagnosis and determined through May 2022, were overall survival (OS) and leukemia-free survival (LFS). Predictors of interest were IPSS-R, age-adjusted IPSS-R, WPSS, and IPSS-M, each with categories of "very low", "low", "intermediate" (called "moderate" for IPSS-M), "high", and "very high" risk. OS and LFS in specific prognostic risk categories/groups were estimated by the Kaplan-Meier method and compared using the log-rank test. Median follow-up was estimated by the reverse Kaplan-Meier method. Cox regression models of OS and LFS were fit to estimate the relative risk of AML transformation or death with hazard ratios (HRs) and the prognostic accuracy with concordance indices (C-index). Results: One hundred and forty-nine patients, diagnosed between 2011 and 2021, met inclusion criteria and were analyzed: 136 diagnosed with primary MDS and 13 with secondary/treatment-related MDS (Table 1). After IPSS-M re-stratification, 32% of patients were up-staged (with 24 moving into the "very high" group) and 12% down-staged (with 3 patients exiting the "very high" group) from their IPSS-R risk category. Median follow-up time was 2.8 years and 54 patients died (36%) during the study period. Among the 32 patients (21%) whose disease transformed to AML, median time from MDS diagnosis to transformation was 7 months. When considering death as a competing risk, estimated cumulative incidence of AML transformation was 14% at 1 year and 19% at 3 years post-diagnosis. IPSS-R groups were significantly segregated by LFS (log-rank p=6.3e-05; "very high" vs. "low" HR=4.08, p=3.3e-04; Figure 1, Table 1) and by OS (log-rank p=4.9e-06; "very high" vs. "low" HR=5.38, p=1.0e-04; Fig 1, Table 1). IPSS-M was also highly significantly associated with LFS (log-rank p=1.2e-07; "very high" vs. "low" HR=5.64, p=4.4e-06; Fig 1, Table 1) and OS (log-rank p=4.6e-08; "very high" vs. "low" HR=7.30, p=6.1e-06; Fig 1, Table 1). IPSS-M had better discrimination than IPSS-R for LFS (C-index 0.72 [95% CI: 0.67 - 0.78] vs. 0.68 [95% CI: 0.62 - 0.75]) and for OS (C-index 0.74 [95% CI: 0.68 - 0.81] vs. 0.70 [95% CI: 0.63 - 0.78]). This discrimination advantage was also observed for LFS (0.73 vs. 0.70) and OS (0.76 vs. 0.73) when taking into account a patient's transfusion dependence at MDS diagnosis. Discussion & Conclusion: This single-center study is the first U.S. cohort validation of the IPSS-M, finding that this mutation-incorporating prognostic index has greater discriminative potential than IPSS-R in predicting AML transformation and any-cause mortality. Further multicenter prospective studies are needed to confirm the utility of the IPSS-M model. Figure 1View largeDownload PPTFigure 1View largeDownload PPT Close modal

Phase 2 Study of Oral Decitabine/Cedazuridine in Combination with Magrolimab for Previously Untreated Subjects with Intermediate to Very High-Risk Myelodysplastic Syndromes (MDS)

Rationale Hypomethylating agents (HMAs) are approved for higher risk MDS (azacitidine, decitabine, oral decitabine/cedazuridine US package insert). Parenteral therapy (subcutaneous or intravenous) is required 5-7 days each month, often resulting in hospital or clinic visits on a chronic basis and represents a substantial burden for this primarily elderly population and their caregivers. Not surprisingly, patients with higher risk MDS are often not started and/or have low compliance with parenteral HMAs, with patients preferring oral medications (Zeidan et al., CLML 2022). Magrolimab has demonstrated encouraging preliminary data in the higher-risk MDS population in combination with azacitidine and is currently being evaluated in a randomized Phase 3 study (ENHANCE, NCT04313881), comparing the efficacy and safety of magrolimab plus azacitidine with that of azacitidine plus placebo in previously untreated patients with higher-risk MDS. This phase 2 study examines the possibility of using an oral HMA (oral decitabine/cedazuridine) in combination with magrolimab which may provide the benefits without the burden of significant parenteral therapy (4-6 additional clinic days each month). Study Design ASTX727-10 is a phase 2, international, single-arm, open-label study investigating the safety and efficacy of combination oral decitabine/cedazuridine and magrolimab treatment in intermediate to very high-risk MDS, based on the MDS International Prognostic Scoring System - Revised (IPSS-R). Secondary objectives include evaluating the pharmacokinetic profiles of oral decitabine/cedazuridine and magrolimab, other clinical efficacy of the combination, and safety and efficacy in prespecified subgroups (e.g. IPSS-Molecular, p53 mutant status). To be eligible, subjects with ECOG Performance Status ≤2 must have previously untreated MDS per WHO 2016 classification with < 20% bone marrow blasts and be willing to undergo red blood cell transfusions to achieve a hemoglobin >9 gm/dl at the start of study treatment. Subjects must also be willing to undergo blood transfusions as per the parameters of the protocol and as clinically necessary. Key exclusion criteria include significant medical issues (including uncontrolled diabetes and New York Heart Association Class III-IV heart failure), creatinine clearance < 50 ml/min, immediate eligibility for hematopoietic stem cell transplant, secondary MDS, or MDS / (myeloproliferative neoplasm) overlap syndromes. As part of the study, tolerability of the combination regimen will be confirmed in the first 6-18 subjects. Dose and/or dosing decreases identified during this dose limiting toxicity assessment will be applied to the entire study. Approximately 100 subjects will be enrolled. Anticipated study opening is November 2022.

Impact of Allelic State on Overall Survival in TP53-mutant Acute Myeloid Leukemia (AML) and Higher Risk Myelodysplastic Syndromes (HR-MDS)

Introduction: Mutations in TP53 confer an adverse prognosis in patients (pts) with AML and HR-MDS. There are conflicting results regarding the prognostic impact of mono-allelic vs bi-allelic and mono-hit vs multi-hit TP53 mutation status on prognosis in AML and HR-MDS. Additionally, assessment of loss-of-heterozygosity (LOH) status is not routinely available in many settings limiting the clinical implementation of TP53 mutational status. Methods: We took advantage of a large, randomized study with extensive clinical and molecular annotation to analyze 61 patients (pts) with TP53-mutated (TP53-mut) disease and to compare them to 144 TP53 wild-type pts. All pts received azacitidine and half were randomized to receive the anti-PDL1 antibody durvalumab, which did not improve clinical outcomes (Zeidan et al. Blood Advances 2022). A 38 gene-targeted myeloid mutation analysis from screening bone marrow was performed at Munich Leukemia Laboratory. Only pathogenic TP53 variants with variant allele frequency (VAF) ≥2% were included. Pts with a common SNP or VUS in the TP53 gene were classified as TP53-WT in the analysis. Multi-hit TP53 mutations were defined as previously published by the International Consensus Conference (ICC; Arber et al. Blood 2022) as ≥2 distinct TP53 mutations (VAF ≥10%) or a single TP53 mutation associated with either: 1) cytogenetic deletion involving chromosome 17p (e.g., del(17p) or monosomy 17); 2) a VAF of >50%; or 3) with any complex karyotype. We also defined multi-hit TP53 mutations as proposed by Grob et al. (Blood 2022) as (I) ≥2 TP53 gene variants irrespective of VAF, (II) ≥1 TP53 gene variant co-occurred with a cytogenetic deletion involving chromosome 17p, or (III) TP53 mutations with VAF >55%. Based on multiple prior studies (Grob et al. Blood 2022, Weinberg et al. Blood Advances 2022) patients with AML and HR-MDS with TP53 mutations were analyzed as one disease entity. Results: 37 had TP53-mut AML, 89 were TP53-WT AML, 24 had TP53-mut HR-MDS, and 55 were TP53-WT HR-MDS pts. The average VAF for TP53 mutations was 37%, and 90% had ≥10% VAF. 93% of TP53 mutations occurred in the p53 DNA-binding domain. TP53-mut pts had fewer co-occurring mutations compared with TP53-WT pts (mean number of mutations: 1.8 [SD: 0.77] for TP53-mut pts (including TP53) vs 2.9 [SD: 1.4] for TP53-WT pts; Wilcoxon P <0.001) with distinct patterns in the distribution of co-occurring mutations. In terms of TP53 allelic status, 22 (11.0%) were mono-hit and 41 (20.5%) pts were multi-hit as defined by Grob et al, while 7 (3.4%) and 56 (28.0%) pts were classified as mono-hit and multi-hit per ICC definition, respectively. In the AML cohort, TP53-mut pts were more likely to have poor-risk cytogenetics (59.5% vs 11.2%; p<0.001), therapy-related myeloid neoplasm (10.8% vs 1.1%; p=0.042), and lower bone marrow blast percentage (27.5% vs 35.5%; p=0.001) compared to TP53-WT. Among MDS pts, TP53-mut pts were more likely to have secondary MDS (20.8% vs 1.8%; p=0.013), very poor risk cytogenetics by IPSS-R (75% vs 14.6%; p<0.001), and very high risk IPSS-R score (62.5% vs 34.6%; p=0.039). There were no statistically significant differences in terms of baseline demographics and other clinical characteristics. There was no difference in overall response rate (ORR) between TP53-mut and TP53-WT pts (AML: ORR: 35.1% [95% CI: 20.7% - 52.6%] vs. 33.7% [95% CI: 24.2% - 44.6%]; p=1.000; MDS: ORR: 41.7% [95% CI: 22.8% - 63.1%] vs. 60.0% [95% CI: 45.9% - 72.7%]; p=0.208). TP53 allelic status did not influence OS using either definition (Grob et al: mono-hit: median OS 7.6 months [95% CI:5.4-10.6 months]; multi-hit 10.6 months [95% CI: 9.1-13.0 months] (Figure A); ICC definition: 8.0 months (95% CI: 6.1-20+ months) and 9.5 months [95% CI: 7.7-10.9 months], (Figure B)) and was inferior to TP53-WT (median OS: 18.9 months; 95% CI: 15.5-22.9 months). Conclusion: Outcomes of AML and MDS pts with TP53 mutations are worse compared to TP53-WT without differences between mono-hit vs multi-hit status as defined by the ICC and Grob et al. This suggests that either the negative prognostic impact of a multi-hit TP53 allelic status can be overcome by treatment with azacitidine or that a distinction by TP53 allelic status in newly diagnosed AML/HR-MDS pts treated with azacitidine does not provide additional prognostic information. Whether incorporating TP53 LOH status is necessary to further refine risk assessment warrants additional studies. Figure 1View largeDownload PPTFigure 1View largeDownload PPT Close modal

Spatial Organization of Hematopoietic Clones in the Bone Marrow of a Patient with Polycythemia Vera

All humans become genetic mosaics over time as our stem cells acquire somatic mutations throughout life. In the hematopoietic compartment, this phenomenon is termed clonal hematopoiesis (Steensma et al. 2015). Clonal hematopoiesis (CH) increases in prevalence with age and is associated with an increased risk for hematologic malignancy (Genovese et al. 2014; Jaiswal et al. 2014; Xie et al. 2014). CH harboring JAK2 mutations are frequently observed in healthy individuals; and yet JAK2 mutations are also the most frequent drivers of myeloproliferative neoplasms (MPNs) such as polycythemia vera (PV). MPNs are clonal diseases marked by dysregulated hematopoiesis and can progress to a secondary myelodysplastic syndrome or acute leukemia. There is increasing evidence that the clonal mutations driving MPNs arise early in life-potentially in utero-often years before the development of symptoms (Williams et al. 2022). While the intrinsic factors driving clonal expansion are increasingly known (Watson et al. 2020), the extrinsic factors driving the expansion of clones harboring these MPN driver mutations are not well characterized. Prior work has shown that clonal mutations are geographically constrained in solid organs such as skin, colon and esophagus (Lee-Six et al. 2018; Martincorena et al. 2015, 2018). Strikingly, in the esophagus non-malignant NOTCH1 mutant clones can even outcompete nascent malignant clones (Colom et al. 2021). In the hematopoietic compartment, the spatial organization of clones harboring these mutations and their interaction with the niche and each other is largely unknown. We hypothesized that clonal mutations are geographically constrained in the bone marrow niche as is seen in solid organs. To answer these questions, we developed methods for spatially-aware clonal mutation detection. As proof of principle, we characterized the hematopoietic clonal organization within a femur head explant from a 50 year-old man with PV undergoing hip arthroplasty. Briefly, the femur head was sectioned into 2mm slices, which were then further partitioned into approximately 300 bone marrow fragments (2mm3). Approximately 20% of the fragments were snap frozen and pulverized for DNA extraction. The remainder were formalin fixed and decalcified for correlative imaging. Targeted error-corrected sequencing was performed using a myeloid-specific panel (Duncavage et al. 2018) on 24 bone marrow fragments, and bulk peripheral blood and bone marrow aspirate. In the peripheral blood, JAK2 V617F (0.24 VAF) and TET2 L1081* (0.02 VAF) mutations were identified. In the bone marrow aspirate, the same JAK2 (0.62 VAF) and TET2 (0.05 VAF) mutations were identified in addition to a DNMT3A R882C mutation (0.02 VAF). Interestingly, peripheral blood sequencing two years prior identified the JAK2 and DNMT3A mutations, but not the TET2 mutation, suggesting recent clonal expansion of TET2 mutant clone. From the 24 sequenced bone marrow fragments, the geographical organization of clonal mutations in the bone marrow was determined (Figure 1). The JAK2 V617F clone was identified in all bone marrow fragments sequenced (0.12-0.69 VAF). The TET2 L1081* clone was identified in 11/24 bone marrow fragments with some regional constraint (0.03-0.05 VAF). The DNMT3A R882C mutation was detected in only a single bone marrow fragment (0.02 VAF) and co-localized with the JAK2 V617F and TET2 L1081* mutations. A previously undetected clonal SETBP1 E616V mutation was identified in two adjacent bone marrow fragments from sequential slices of the femur head (0.05 VAF and 0.10 VAF). Together this provides the first characterization of spatial organization of clonal mutations in the bone marrow niche for an MPN patient. Currently, we are utilizing digital droplet PCR targeting these detected mutations in ~60 additional bone marrow fragments to accurately quantify clone size across the tissue. We plan to employ multiplex fluorescent imaging of bone marrow fragments adjacent to detected clusters of mutations to identify the surrounding bone marrow niche elements in those regions. These findings suggest that bone marrow biopsy from a small section of bone marrow may not accurately describe disease state and clonal mutation burden in myeloid neoplasms. Future applications of these tools will help describe the extrinsic factors and local microenvironment that drive clonal evolution over time in the bone marrow. Figure 1View largeDownload PPTFigure 1View largeDownload PPT Close modal

Characterizing the Development of Secondary Myelodysplastic Syndrome (MDS) with Antecedent or Concurrent Chronic Lymphocytic Leukemia (CLL) in the Era of Small Molecule Inhibitors for the Treatment of CLL

Introduction Secondary MDS (sMDS) is defined by MDS arising from another bone marrow disorder or related to previous therapy [chemotherapy (CT), radiation, or immunosuppression], and comprises about 10% of MDS cases. The rate of sMDS following CLL (including treatment-naïve CLL) has been reported as high as 3.5%. Developing in elderly populations, both CLL and MDS are associated with clonal hematopoiesis (CH), and chemoimmunotherapy (CIT) treatment for CLL likely contributes to the occurrence of MDS. There is little published data on the characteristics of patients (pts) who develop sMDS with antecedent/concurrent CLL, particularly in the era where kinase inhibitor therapy has displaced CIT. Therefore, we sought to characterize a cohort of CLL pts who develop sMDS in the era of modern treatments. Methods We performed a retrospective chart review at The Ohio State University between 01/01/2016 and 02/10/2021 of pts with a diagnosis of CLL who subsequently or concurrently were diagnosed with MDS. Clinical, next generation sequencing (NGS), and outcome data were collected. NGS test refers to a 50 gene hematologic neoplasm mutation panel. Overall survival (OS) was calculated from MDS diagnosis and estimated using Kaplan-Meier method. Results We identified 27 sMDS pts with antecedent/concurrent CLL. At CLL diagnosis, median age was 58 years (range 40-86). 5 pts (18.5%) had a TP53 mutation and/or del(17p) noted during their CLL disease course prior to sMDS diagnosis. Median number of therapies for CLL prior to sMDS was 1 (range 0-10), with 4 pts diagnosed with CLL at the same time as MDS. CLL treatments, as any line of therapy, included CT/CIT in 21 pts (77.8%) and ibrutinib in 10 pts (37.0%). Of the pts that received CLL therapy, only 1 pt did not receive CT/CIT. 5 pts (18.5%) were not treated for CLL. A median of 6.9 years (range 0-31.8) elapsed between the diagnosis of CLL and sMDS. At sMDS diagnosis median age was 70 years (range 50-86), 17 pts (65.4%) were MDS IPSS-R category high/very high. 5 pts transformed to AML after a median of 9.2 months (mos) from MDS diagnosis (range 4.1-21.3). After a median follow-up of 6.3 mos (range 0.8-109.2), the median OS from MDS diagnosis was 18.8 mos (95% CI, 10.2-not reached). (Table 1) In pts who received CT/CIT for CLL (n=21) and those who did not (n=6), a TP53 mutation developed following CLL or MDS diagnosis in 10 pts (47.6%) and 1 pt, respectively. All but 1 pt who developed TP53 mutations (n=11) received prior CT. 15 pts (71.4%) who received CT/CIT for CLL therapy had MDS with complex karyotype; this was seen in 2 pts who never received CT/CIT. Twenty-six (96.3%) pts had NGS testing. 5 pts (18.5%) had 1 or more tests completed for CLL prior to sMDS: 4 pts had TP53 mutations, 2 pts each had DNMT3A and SF3B1 mutations, and 1 pt each had an ASXL1, KMT2A, BTK, or PLCG2 mutation. Of these 5 pts, 1 pt had 5 NGS tests performed on serial B-cell selected samples (as opposed to total leukocytes): mutations included 2 TP53, 1 SF3B1 and 1 BTK mutation. 25 (92.6%) pts had 1 or more tests completed at or after sMDS diagnosis (all assessed total leukocytes): 8 pts (36.4%) had TP53, 6 pts (27.3%) had DNMT3A, 5 pts (22.7%) had RUNX1, and 3 pts (13.6%) each had ASXL1, SF3B1, and TET2 mutations. Finally, 4 pts (14.8%) had NGS testing done both pre and post sMDS diagnosis (all assessed total leukocytes). Two pts had the same mutation present pre and post sMDS diagnosis: 1 ASXL1, 1 DNMT3A. A third pt had 3 identical mutations pre and post sMDS diagnosis: 1 TP53 p.G244D, 1 TP53 p.N235_Y236del, and 1 SF3B1. (Table 2) Conclusions Here we have characterized a cohort of CLL pts who developed sMDS in the modern era, where small molecule inhibitors are commonly used for CLL, and NGS is widely available for both CLL and MDS. While the majority of pts with CLL received CT, 5 pts were treatment-naive, and 1 pt only received a BTK inhibitor and an anti-CD20 antibody. The OS of this cohort following MDS diagnosis is similar to historical data of pts with comparable IPSS-R scores, despite the fact that this is a sMDS population; this may be due to lead time bias as pts likely received frequent blood work for CLL. Prior to sMDS diagnosis, complex karyotype and TP53, SF3B1 and CH-associated mutations DNMT3A and ASXL1 were prevalent. TP53, SF3B1, and CH-associated mutations DNMT3A, ASXL1, and TET2 mutations were prevalent at the time of or following a sMDS diagnosis. Further investigation into the interplay between CLL and CH in MDS development in the modern therapy era is needed. Figure 1View largeDownload PPTFigure 1View largeDownload PPT Close modal