Myelodysplastic Syndromes Subgroups Research Articles

Analyzing the characteristics and prognostic outcomes for patients with myelodysplastic syndrome with Q-gene deletion.

e18526 Background: Myelodysplastic syndromes (MDS) are a group of hemopoietic disorders in which the bone marrow is deficient in producing healthy mature blood cells. MDS associated with a deletion in the long arm of chromosome 5Q is a rare occurrence, but considered a good prognosis in comparison to other subgroups of MDS. There has been limited focus directed towards this variant of the disease, especially concerning outcomes among different demographics. Methods: The National Cancer Institute’s Surveillance, Epidemiology, and End-Result (SEER) registry research database 17 (2000 -2020) was used to assess & compare the outcomes for this variant of MDS in adult & AYA pts. Univariate & multivariate analyses was performed and cox proportional hazards regression was used to assess prognostic outcomes. A two-sided pvalue ≤0.05 was considered significant. Results: Analysing (table) 2,323 pts identified, 98.92% (n= 2298) were adults ≥40yrs, and 1.08% (n= 25) were AYAs. AYAs comprised 32% Hispanic, 4% Non-Hispanic Asian or Pacific Islander (NHAPI), 16% Non-Hispanic Black (NHB), and 48% Non-Hispanic White (NHW). Compared to adults, AYAs had higher proportions of Hispanics and NHBs but fewer NHWs. AYAs showed longer average survival (57.7 vs 33 months) than older adults. Females generally had longer survival periods than males in both AYA (64.4 vs 49.1 months) & adult (37.2 vs 26.4 months) groups. Among adult racial groups, Non-Hispanic Black females had the poorest prognosis (29.6 months), while Hispanic males had the worst prognosis overall (21 months). Among AYAs, Hispanic females had the worst prognosis (4 months), followed by Hispanic males (24.2 months). Conclusions: Our study shows AYAs are less likely to die from MDS compared to adults ≥40. Hispanic females appear to have a worse outcome than males in both age groups & is independent of other analysed prognostic factors. More research is needed to examine other prognostic factors with the aim of improving survival outcomes. [Table: see text]

The Epidemiology of Cardiovascular Disease in African American Patients with Myeloid Neoplasms: A SEER Data Analysis

Introduction: Cardiovascular disease (CVD) mortality rates are higher in cancer survivors compared to the general population. Numerous studies have reported racial disparities in CVD mortality among cancer survivors. However, there is a lack of research exploring CVD mortality specifically in African American (AA) patients (pts) with myelodysplastic syndromes (MDS) and myeloproliferative neoplasms (MPN). To address this gap, we conducted a comprehensive population-based study to analyze cardiovascular mortality in the AA population with MDS and MPN. Methods and Statistical analysis: In Surveillance, Epidemiology, and End Results (SEER) database using the 17 registries, we identified cases of essential thrombocythemia (ET), Polycythemia Vera (PV), Primary Myelofibrosis (PMF), and Myelodysplastic syndromes (MDS) in AA population diagnosed between 2001-2020, with the diagnosis age >=20. CVD deaths included deaths from heart diseases, hypertension without heart disease, cerebrovascular diseases, atherosclerosis, and diabetes mellitus, based on the SEER Causes of Death Register and International Classification of Diseases (10th Revision, ICD10). Death rates were calculated by dividing the number of deaths over person-years of follow-up. We also estimated the standardized mortality ratios (SMR by dividing the observed cardiovascular deaths rates in our sample over expected CVD death rates of general population with no cancer, matched to age, gender and ethnicity. All analyses were performed by SEER*Stat 8.4.1.2 and R 4.2.2. Results: The study included 8135 patients, with following diagnoses: ET (n= 2317), PV (n= 1231), PMF (n= 377) and MDS (n= 4210). Overall, 2640 of the total study population (32.45%) died, of which 39.5% were CVD deaths. The mean follow up for PV, ET, PMF and MDS cohorts was 6.44, 5.95, 3.67 and 3.82 years, respectively (Table 1). The CVD mortality rate per 1,000 person-years in PV, ET and PMF subgroups were 17.9, 14.95, and 29.6, respectively. Notably, the rate was highest in the MDS subgroup, 40.37 compared to other subgroups (P<0.01). Comparing the CVD mortality of each risk group to the general US AA population, we observed significantly increased CVD SMRs. These were highest in PMF and MDS (SMR, 3.07; 95% CI, 2.2-4.16 and 2.25; 95% CI, 2.08-2.43, respectively), followed by PV (SMR, 1.75; 95% CI, 1.47-2.06) and ET (SMR, 1.67; 95% CI, 1.45-1.92).When comparing CVD mortality to the general CVD mortality rate in the AA population, we found higher rates across all age groups, including SMR, 13.16; 95% CI, 4.27- 30.72 in 20-29 yrs, SMR, 5.4; 95% CI, 2.95- 9.06 in 30-39 yrs, (SMR, 2.20; 95% CI, 1.92- 2.52) in 60-69 yrs, (SMR, 1.87; 95% CI, 1.67- 2.1) in 70-79 yrs (Figure 1). Conclusion: Our analysis highlights the magnitude of CVD-related deaths in the AA population with MDS and MPN. Among studied subgroups, the impact was highest in patients with MDS. This could be explained by a shared mechanism of CVD pathogenesis with MDS and clonal hematopoiesis of indeterminate potential (CHIP). In addition, we report a higher risk of CVD mortality at younger ages in AA pts relative to older age group. Because CVD-related mortality is high in AA with MDS and MPN, introduction of preventative cardiology services after diagnosis might be warranted to improve survival.

Development of MDS in Pediatric Patients with GATA2 Deficiency: Increased Histone Trimethylation and Deregulated Apoptosis as Potential Drivers of Transformation

GATA2 deficiency is a heterogeneous, multisystem disorder associated with a high risk of developing myelodysplastic syndrome (MDS) and the progression to acute myeloid leukemia. The mechanisms underlying malignant transformation in GATA2 deficiency remain poorly understood, necessitating predictive markers to assess an individual’s risk of progression and guide therapeutic decisions. In this study, we performed a systematic analysis of bone marrow biopsies from 57 pediatric MDS patients. Focusing on hematopoiesis and the hematopoietic niche, including its microenvironment, we used multiplex immunofluorescence combined with multispectral imaging, gene expression profiling, and multiplex RNA in situ hybridization. Patients with a GATA2 deficiency exhibited a dysregulated GATA2 transcriptional network. Disease progression (GATA2-EB, n = 6) was associated with increased GATA2 mRNA levels, restored expression of the GATA2 target EZH2, and increased H3K27me3. GATA2-EB was further characterized by the high expression of the anti-apoptotic protein BCL2, a feature absent in children with a GATA2 deficiency and refractory cytopenia of childhood (GATA2-RCC, n = 24) or other pediatric MDS subgroups (RCC, n = 17; MDS-EB, n = 10). The multispectral imaging analysis of additional BCL2 family members revealed significantly elevated Mediators of Apoptosis Combinatorial (MAC) scores in GATA2-EB patients. Taken together, our findings highlight the potential drivers of disease progression in GATA2 deficiency, particularly increased histone trimethylation and dysregulated apoptosis. Furthermore, upregulated BCL2 and EZH2 and increased MAC scores provide a strong rationale for the use of venetoclax and azacitidine in therapeutic regimens for GATA2-EB.

Enhancing Cytogenetic Diagnostics: Incorporating Optical Genome Mapping in the Laboratory Routine

Key findings Introduction Optical Genome Mapping (OGM) is a is a novel high-throughput diagnostic technique that overcomes the limitations of conventional cytogenetic methods. The objective of this study was to evaluate the application of OGM in the daily workflow of the cytogenetics laboratory and compare it with standard techniques. Methods A total of 180 adult or pediatric patients referred to the Cytogenetics Laboratory at Hospital La Fe during disease onset or relapse were included. The patients had the following diagnoses: aplastic anemia (AA) n = 6, B-cell acute lymphoblastic leukemia (B-ALL) n = 39, T-cell acute lymphoblastic leukemia (T-ALL) n = 9, acute myeloid leukemia (AML) n = 51, myelofibrosis (MF) n = 36, polycythemia vera (PV) n = 3, essential thrombocythemia (ET) n = 2, multiple myeloma (MM) n = 11, and myelodysplastic syndromes (MDS) n = 22. Chromosome banding analysis (CBA) was performed on bone marrow samples, and in selected cases, fluorescence in situ hybridization (FISH) was carried out using specific probes following diagnostic recommendations. For OGM analysis, high molecular weight DNA was extracted and labeled from peripheral blood (PB, n = 62) or bone marrow (BM, n = 118) following the manufacturer's protocol (Bionano, San Diego, CA, USA). Results CBA was performed on all patients except MM, where an initial FISH panel targeting IGH rearrangement, TP53 deletion, and 1q amplification was applied. Among the CBA, 61/169 (36%) patients showed a CBA without alterations, 62/169 (37%) were abnormal and 46/169 (27%) were unsuccessful. OGM successfully detected cryptic alterations in 60% (37/61) of cases previously classified as normal with CBA. Additionally, OGM identified further alterations in 56% (35/62) of cases with abnormal CBA findings. Notably, OGM demonstrated a remarkable 93% success rate in resolving previously uninformative CBA results. AA OGM did not detect clinically significant alterations or copy neutral loss of heterozygozity (CN-LOH) on chromosome 6 in this subgroup of patients. B-ALL: OGM detected alterations in all patients with a normal or uninformative karyotype. Regarding cases with a previous abnormal CBA, OGM discovered 2 cases with masked hypodiploidy. Copy Number Alterations (CNA) affecting IKZF1, PAX5, ETV6, RB1, BTG1, EBF1, CDKN2A, CDKN2B, PAR1 region, and ERG were detected in 27/39 (69%) patients, 3 of whom harbored the IKZF1plus Moreover, several cryptic rearrangements were uncovered, such as MEF2D::BCL9, RUFY1::ETV6, PDGFRB::EBF1, and PAX5::PML. T-ALL: All patients showed an uninformative or normal CBA. However, OGM discovered rearrangements in 7/9 (78%) patients, including PICALM::MLLT10, GATA3::RUNX1, or STIL::TAL1. AML OGM enabled the detection of 4 cases with cryptic NUP98::NSD1 rearrangements and 2 cases with tandem duplication of KMT2A. Additionally, OGM successfully identified the partner involved in a previously uncharacterized KMT2A rearrangement ( KMT2A::ELL). MPN (MF, PV and ET) = The main utility of OGM was observed in MF, as it resolved all cases with uninformative CBA. MM Primary limitations in these cases were low plasma cell infiltration and difficulty in DNA extraction from total nucleated cells. Only one case showed an infiltration rate higher than 15%, as determined by flow cytometry. Consequently, 7 cases obtained a normal OGM result despite alterations detected by FISH. However, OGM successfully identified a cryptic rearrangement involving MYC and provided a detailed characterization of CNA in the remaining cases. MDS OGM resolved uninformative karyotypes in the subgroup of MDS with fibrosis. Additionally, the resolution of OGM allowed the detection of a t(3;8)(q26.2;q24.21) with a variant allele frequency of 6%, involving MECOM rearrangement, in a patient who later progressed to AML. In total, 8 cases were uninformative with OGM, mainly because of poor sample quality or low cellularity. Conclusion This study demonstrates the utility of integrating emerging technologies like OGM into the daily routine of the laboratory. DNA extraction should be performed through selected CD138 cells in multiple myeloma

Beta-2 Microglobulin As a Seric Marker for Diagnosis of Hematologic Neoplasms in First Contact Consultation with the Hematologist

Introduction Beta-2 microglobulin is a protein component of the Major histocompatibility complex I. Its concentration in blood has been long used as prognostic marker in some hematologic neoplasms, and even used as a tool for surveillance of relapse in other neoplasms. It is frequently elevated in non-Hodgkin lymphoma (NHL), Myelodysplastic syndrome (MDS), myeloma multiple (MM), chronic lymphocytic leukemia (CLL) and other Lymphoproliferative disorders. Although its utility as a diagnostic tool has been poorly described. Aim Describe the blood levels of Beta-2 Microglobulin in patients who are sent without established diagnosis to be evaluated by hematology department and its association with the different definitive diagnosis. Methods We captured information from outpatients who were evaluated in the first consultation at hematology department because of any citopenia or clinical suspicion of any hematologic neoplasm from September 2022 to July 2023. If the patient consented, we recorded it in database and measured blood levels of beta-2 microglobulin on first consultation, and then followed until definitive diagnosis was established. Analysis of data was made with IBM SPSS Statistics for Windows, Version 27.0. Armonk, NY: IBM Corp; we used Mann Whitney U Test for quantitative variable comparison, and Fisher exact test to determine differences between groups. Statistical significances were calculates using p<0.05. Results We captured a total of 87 patients, but 11 had to be excluded because of lack of information. Of the 76 patients included for analysis, 34 were male (44.7%) and 42 were female (55.3%). The medium age was 45.1 years (Range: 15-95 years). After the first consultation, 30 patients (39.5%) were suspected to have a neoplasm, and in follow-up, 35 (46.05%) ended up with a definitive diagnosis of hematologic neoplasm. Only one patient with initial suspected neoplasm ended up with benign disease, but 6 patients in which a bening condition was suspected ended up with a neoplasm diagnosis. There was a total of 35 (46.05%) patients with definitive neoplastic diagnostic, being the most frequent: NHL (n=15, 19.7%), Myeloproliferative neoplasm (MPNs) (n=6, 7.8%), and MM (4, 5.2%). In the no neoplastic pathology, the most frequent diagnosis was iron-deficit anemia (n=17; 22.36%), followed by megaloblastic anemia (n=4, 5.26%) and infectious disease (n=4, 26%). Beta-2 microglobulin was higher in the group with definitive neoplastic diagnosis (5.4mg/L vs 2.4mg/L, x 2=0.053), and was also, significatively higher in the NHL (4.94mg/L, x 2=0.005), MM (13.43mg/L, x 2=0.008), CLL (6.3mg/L, x 2=0.02) and MDS (8.05mg/L, x 2=0.034) subgroups. The sensibility for any hematologic neoplasm was 48.5% and specificity was 82.93%, with a positive LR of 2.84 and a Negative LR of 0.62. The subgroups with higher sensibility were MM (75%), CLL (66.6%), MPNs (66.6%) and MDS (100%), being the Positive LR of 4.3 for MM, 3.9 for CLL, 3.9 for MPNs and 5.86 for MDS. Groups with the lowest correlation were Hodgkin lymphoma (HL) with sensibility of 33.3%, and isolated plasmacytoma (PC) with sensibility of 0%. In the group with benign diagnosis, only 6 (7.89%) presented levels above upper normal limit of blood Beta-2 microglobulin, 4 (5.26%) with iron-deficit anemia, 1 (1.31%) with liver disease, 1 (1.31%) with Pulmonary tuberculosis and 1 (1.31%) with systemic lupus erythematosus; being the highest levels in pulmonary tuberculosis (14.9mg/L). Conclusions The blood levels of beta-2 microglobulin in our work were in concordance with other previous described papers, in which is frequently elevated in NHL, MM, and CCL. But in our case, it showed a marked elevation in MPNs, and MDS (higher correlation). It should be noted, no tumor burden was recorded in our study, which could directly affect beta-2 microglobulin levels. In conclusion, although not a strong correlation as an expert hematologist clinical evaluation, beta-2microglobulin could be of use to strengthen clinical suspicion of those hematologic neoplasms or reassess cases in which MDS/MPNs are a possible differential diagnosis.

Treosulfan-Based Conditioning Prior to Allogeneic Hematopoietic Stem Cell Transplantation (alloHSCT) for Patients with Myelodysplastic Syndrome (MDS): Comparative Analysis of a Randomized Controlled Trial and Real-World Data

Introduction MDS is a clonal myeloid disorder manifested by diverse genotypes and phenotypes, characterized by ineffective hematopoiesis. AlloHSCT is the only potential curative therapy for MDS. Myeloablative conditioning regimens are integral part of alloHSCT that allow engraftment and provide a therapeutic effect. Treosulfan has myeloablative and immunosuppressive properties and provides less transplantation related mortality than some of the traditionally used myeloablative conditioning regimens like busulfan-based treatments. In our analysis, we compared the results from the MDS subgroup of the randomized controlled trial (RCT) MC-FludT.14/L (NCT00822393) with real-world data (RWD) of patients treated at the University Hospital Münster and the University Hospital Dresden. Methods MDS patients conditioned with treosulfan (30 g/m²) and fludarabine in the RCT (June 2013 to January 2018) and the data obtained from 2 hospitals (RWD) (August 2017 to February 2023) were compared. Baseline characteristics, overall survival, relapse-free survival, relapse (or progression), non-relapse mortality, time to engraftment, and safety profiles between the RCT and RWD were compared. A sensitivity analysis was conducted using propensity score matching (PSM). Additionally, subgroup analyses evaluated the clinical effectiveness of treosulfan by baseline morphologic blast count and the revised International Prognostic Scoring System (IPSS-R). Results Overall, 195 MDS patients (RCT 84, RWD 111) with at least 12 months follow-up were analyzed. Median age was 62 years (range 39-76 years). Baseline characteristics only differed between the RCT and RWD with respect to age, IPSS-R categories, Hematopoietic Cell Transplantation Co-Morbidity Index total score (HCT-CI), and neutrophil count, indicating some heterogeneity between the RCT and RWD patients. In the PSM analysis, 106 (RCT 53, RWD 53) patients were matched to address the heterogeneity. The Kaplan-Meier estimates for overall survival (OS) at 2 years were 73% (95% CI 62-81%) and 72% (95% CI 62-81%) for the RCT and RWD (Figure 1), and for relapse-free survival (RFS) at 2 years were 68% (95% CI 57-77%) and 67% (95% CI 56-76%), respectively. Cumulative incidence of relapse at 2 years was 11% (95% CI 4-18%) and 15% (95% CI 7-23%), and for non-relapse mortality (NRM) was 21% (95% CI 12-30%) and 18% (95% CI 10-26%) for the RCT and RWD, respectively. In addition, cumulative incidence of neutrophil engraftment at 28 days was 93% (95% CI 87-98%) and 94% (95% CI 89-98%) for the RCT and RWD, while the median engraftment time was later in the RCT (19 days vs 15 days). Cumulative incidence of platelet engraftment at 28 days was 89% (95% CI 83-96%) and 93% (95% CI 88-98%) for the RCT and RWD, with the same median time 14 days. Further, the PSM sensitivity analysis showed comparable efficacy between the RCT and RWD. Interestingly, bone marrow blast count prior to conditioning and IPSS-R subgroups only had minor, statistically not significant impact on survival endpoints (Table 1). The number of deaths were 27 (32%) and 28 (25%) in the RCT and RWD, respectively. The most frequent cause of death was transplantation related (20% vs 14%). One patient experienced primary graft failure in the RCT and none in the RWD. More patients had acute GVHD with at least grade 2 in the RCT (27%) than in RWD (18%). Conclusions The efficacy and safety of treosulfan-based conditioning therapy prior to alloHSCT in post-authorization real world setting was comparable with the results obtained from the RCT. Our data suggest that bone marrow blast count is no strong predictor for survival after alloHSCT. Therefore, we conclude that the approved treosulfan-based conditioning therapy for patients with MDS, including those with increased blasts, has promising outcomes after alloHSCT.

Linking aberrant glycosylation of plasma glycoproteins with progression of myelodysplastic syndromes: a study based on plasmonic biosensor and lectin array

Aberrant glycosylation of glycoproteins has been linked with various pathologies. Therefore, understanding the relationship between aberrant glycosylation patterns and the onset and progression of the disease is an important research goal that may provide insights into cancer diagnosis and new therapy development. In this study, we use a surface plasmon resonance imaging biosensor and a lectin array to investigate aberrant glycosylation patterns associated with oncohematological disease—myelodysplastic syndromes (MDS). In particular, we detected the interaction between the lectins and glycoproteins present in the blood plasma of patients (three MDS subgroups with different risks of progression to acute myeloid leukemia (AML) and AML patients) and healthy controls. The interaction with lectins from Aleuria aurantia (AAL) and Erythrina cristagalli was more pronounced for plasma samples of the MDS and AML patients, and there was a significant difference between the sensor response to the interaction of AAL with blood plasma from low and medium-risk MDS patients and healthy controls. Our data also suggest that progression from MDS to AML is accompanied by sialylation of glycoproteins and increased levels of truncated O-glycans and that the number of lectins that allow discriminating different stages of disease increases as the disease progresses.

Novel THPO variant in hereditary thrombocytopenia: A potential candidate variant for predisposition to myeloid neoplasm.

Hereditary thrombocytopenia is a heterogeneous group of congenital disorders with a wide range of symptoms depending on the severity of platelet dysfunction or thrombocytopenia. Because of its clinical phenotypes and the bone marrow morphology associated with this condition, hereditary thrombocytopenia can be misdiagnosed as primary immune thrombocytopenia and myelodysplastic syndrome. Therefore, genetic evidence is necessary for the accurate diagnosis of hereditary thrombocytopenia. Refractory cytopenia of childhood is a subgroup of myelodysplastic syndrome that was added to the World Health Organization classification in 2008. To investigate the germline and somatic variants associated with refractory cytopenia of childhood, we performed targeted multigene sequencing in three patients with refractory cytopenia of childhood. Of the three patients, one progressed from megakaryocytic hypoplasia with thrombocytopenia, and targeted multigene sequencing revealed THPO variants in this patient and his sister. We propose that the monoallelic deletion of THPO is a potential candidate for germline predisposition to myeloid malignancy.

Characteristics and Distribution of Erythroid Progenitors and Precursors Correlate with Erythropoiesis Stimulating Agents (ESAs) Response in Lower Risk Myelodysplastic Syndromes

Myelodysplastic syndromes (MDS) are an heterogenous group of clonal myeloid disorders characterized by dysplastic ineffective hematopoiesis, peripheral blood cytopenias and a variable risk of progression to acute myeloid leukemia (AML) evaluated by IPSS-R score. Early stage erythropoiesis is dependent on growth factors like EPO, whereas late erythroid differentiation is iron-dependent. The entire process requires a fine regulation between apoptosis and cell survival. Anemia is the most common cytopenia in IPSS-R lower risk MDS (LR-MDS) and the mechanism underlying dyserythropoiesis is multifactorial, leading to apoptosis of erythroid progenitors and precursors. LR-MDS anemia is mainly treated with ESAs (e.g., Erythropoietin or EPO), but response is not optimal and eventually patients will suffer from chronic anemia and transfusion dependence. Moreover, the only strong predictor of ESAs treatment is the endogenous concentration of serum EPO (sEPO). The primary aim of this study was to detect quantitative and qualitative flow cytometry (FC) alterations of erythroid populations in the bone marrow (BM) of LR-MDS patients associated with resistance or response to ESAs and compared them with age-matched non cytopenic BM controls (CTRLs, 6). Secondly, we wanted to investigate if different WHO diagnostic MDS subgroups displayed specific pattern of erythroid maturation and/or FC abnormalities. We selected 97 LR-MDS anemic patients treated with ESAs at MDS Unit, Hematology dpt. AOU Careggi (Florence) and divided them according to type of ESAs response (e.g., primary refractory, PR; long responders, LR, with DOR longer than 24 months and secondary refractory, SR, with DOR shorter than 24 months). Baseline BM FC analysis was performed using an erythroid panel containing antibodies for CD33, CD34, CD36, HLA-DR, CD45, CD71, CD105, CD117. We also measured the coefficient of variance (CV) of CD71 and CD36 to assess qualitative FC abnormalities within the erythroid populations. We then identified all stages of erythroid maturation from A) CD34+ committed erythroid cells (CD34+, CD45dim, CD117+, CD71+, CD33+, HLA-DR +), or erythroid progenitors (COM-E), expressed both as fraction of all CD34+ cells and all 117+ progenitor cells, to B) CD34- erythroid precursors (from proerythroblasts, PROE, to orthochromatic erythroblasts). CV CD71 was increased in PR patients compared to CTRLs (p=0,009) and to responders (p=0,008). COM-E/tot.CD34+ cells were increased in all response categories, but there was a significant trend of higher values in LR vs. PR (p=0,055). Finally, (COM-E + PROE)/tot.117+ progenitors were only enriched in LR compared to CTRLs (p=0,009). Regarding WHO subgroups, MDS 5q- displayed a decrease in COM-E/CD34+ cells and in (COM-E + PROE)/tot.117+ cells compared to MDS-RS (p=0,00094 and p=0,009 respectively) and to CTRLs for the latter population (p=0,03). Moreover, total erythroid precursors were significantly reduced compared to MDS-SLD, -MLD and -RS. MDS-RS showed a marked erythroid hyperplasia and elevation of CV CD71 compared to CTRLs (p=0,0079 and p=0,024 respectively). Taken together, these results show that in LR-MDS, the increase of CV CD71 in erythroid cells is associated with resistance to ESAs, whereas response to ESAs is present in cases with enriched EPO sensitive COM-E and PROE populations compared to CTRLs, especially for LR vs PR (p=0,055). Finally, MDS-5q- and MDS-RS were the WHO subgroups with the highest rate of PR in our cohort (46% and 59% respectively), irrespective of sEPO. These 2 subgroups of MDS exhibited different repartition of erythroid subpopulations with characteristics associated with ESAs resistance. In 5q- COM-E and PROE were depauperate and, consequently, erythroid precursors reduced, while MDS-RS displayed an expansion of erythroid precursors and higher CV of CD71 compared to CTRLs. Finally, these FC parameters, easily and rapidly assessed at baseline BM evaluation in MDS patients, correlate with response to ESAs and with different WHO subgroups. FC erythroid abnormalities could partly explain the complex pathobiology underlying dyserythropoiesis and its treatment. The different repartition of erythroid progenitors observed could lead to molecular and transcriptome analyses focused on these altered subpopulations in order to investigate the exact mechanism of anemia in LR-MDS(s). Figure 1View largeDownload PPTFigure 1View largeDownload PPT Close modal

Transfusion Patterns during Early Follow-up Predict Overall Survival Independently of IPSS-M in Patients with Myelodysplastic Syndromes

Background: The cumulative red blood cells (RBC) transfusion burden is known to impact outcomes in myelodysplastic syndromes (MDS) but doesn't accurately predict prognosis during the early disease phase. Here we aimed to assess the prognostic value of early changes in transfusion patterns in addition to the recent IPSS-M scoring system. Methods: We gathered diagnostic biobank samples from adult patients (pts) with MDS and registered in the Karolinska Institute's biobank (KI) and the National Swedish MDS Biobank (NB) between 2003-2017 and 2013-2017, respectively. DNA targeted sequencing (152 genes) was performed (Bernard et al., NEJM Evid, 2022). Clinical data was retrieved through pts’ charts (KI) and the Swedish cancer registry (NB). Pts were treated according to Nordic/EU guidelines and most common therapies for lower-risk MDS and higher-risk MDS were erythropoietin and azacytidine, respectively. Transfusion data was obtained from the SCANDAT registry. Pts were followed with regards to RBC transfusion until censored due to death, transformation to acute myeloid leukemia (AML-t), allogenic stem cell transplantation (allo-SCT), or end of follow-up on the 31st of August 2018, whichever occurred first. As per the IWG hematological response criteria for MDS (Platzbecker et al., Blood 2019), transfusion states (TS) were categorized every 4 months (m) as transfusion dependent (TD) or transfusion free (TF) during the past 4 m period. Lower-risk MDS (LR) was defined as IPSS-M very low, low and moderate low, and higher-risk MDS (HR) as IPSS-M very high, high and moderate high at diagnosis (Bernard et al., NEJM Evid, 2022). Landmark analyses of overall survival (OS) were performed with the Kaplan-Meier method for estimating probabilities of OS over time. Multivariable analyses were conducted using Cox proportional hazards model. Results: We gathered a cohort of 688 pts with MDS from KI (n=424) and 33 other clinics in Sweden (NB, n=264). Median age at diagnosis was 74 years (y) old (range 19-93). The male:female ratio in the cohort was 1.4. At diagnosis, 63% of the pts were TF. Out of 646 pts evaluable by the IPSS-M score at diagnosis 54% had LR. Most frequently mutated genes in the cohort were TET2, SF3B1, ASXL1, DNMT3A, RUNX1, TET2, TP53 (66% TP53 multihit), U2AF1, STAG2, ZRSR2. Changes between TS (transitions) preferentially occurred within a year after diagnosis (panel A) with a median time for occurrence of transfusion-related transitions of 1.0 y (range 0.33-8.37). Based on this finding, we assessed whether TS at 8 m landmark impacted prognosis. We observed that there was a significant difference in OS since landmark between TF pts compared with TD pts at landmark 8 m and across IPSS-M categories (panel B). LR pts who were TD at 8 m, had a median OS of 3.2 y (95% CI: 2.2-4.0) versus 6.9 y (95% CI: 5.6-8.9) for LR pts who were TF (P<0.0001). Similarly, median OS was 0.8 y (95% CI: 0.6-1.1) in HR and TD pts while it was 2.4 y (95% CI: 2.1-3.1) in HR and TF pts at landmark 8 m (P<0.0001). Interestingly, OS for LR pts who were TD didn't significantly differ from HR pts who were TF at 8 m. Overall, pts TD at 8 m had more gene mutations compared to TF pts (median 5 [1;13] and 4 [1;16], respectively, P=0.0084). Moreover, studying specific genetic subgroups of MDS, TS at 8 m distinguished subsets of pts with adverse or favorable outcomes within SF3B1-mutated LR pts. In this population, the median OS in pts TF at 8 m was 8.4 y (95% CI: 6.5-13.1) compared to 3.2 y (95% CI: 1.7-4.1) for TD pts (P<0.0001). Next, in multivariable analysis, we found that TD at 8 m significantly impacted OS (HR=2.4 [95% CI: 1.9-3.1]), independently of diagnostic IPSS-M score, age, gender and type of MDS (de novo or therapy-related). Conclusion: TS at landmark 8 m, usually after outcome of first-line treatment was evaluated, appears to be a strong and independent predictor of OS in MDS. These findings are of particular importance for the LR group in which it could discriminate subsets with favorable outcomes from those with adverse prognosis. In addition to the IPSS-M calculation at diagnosis, transfusion dependency could be easily used for prognostic reassessment during follow-up. More generally, these results highlight the need of dynamic outcomes prediction tools and/or validation of current prognostic scores in dynamic settings. Finally, multistate modeling of the dataset is being completed and aims to assess how changes of transfusion patterns over time impact prognosis. Figure 1View largeDownload PPTFigure 1View largeDownload PPT Close modal

Comparison of Cytomorphology and Histopathology in Myelodysplastic Syndromes (MDS)

Introduction: Bone marrow cytomorphology, cytogenetics and molecular analyses are essential tools for diagnosing a myelodysplastic syndrome. MDS are characterized by dysplastic features of hematopoietic cells and may also show an increased blast cell count. Histopathology can provide additional information on bone marrow fibrosis and cellularity. We analysed correlations and differences between cytomorphological and histopathological findings at diagnosis. Patients and methods: In the Duesseldorf MDS registry, we identified 127 patients with detailed information available on bone marrow cytomorphology, blast count, blood cell counts and clinical features, who also had a bone marrow core biopsy taken at the time of diagnosis. From their formalin-fixed, paraffin-embedded histopathology specimens new sections and stains were made and evaluated by one reviewing pathologist (SB) who assessed a predefined set of features. The pathologist had no knowledge of the cytomorphological findings, except for the information that the specimen was from a "patient with myelodysplastic syndrome". Statistical analyses were performed by SPSS. Procedures were in accordance with the current version of the Helsinki Declaration. Informed consent was obtained from all patients included in the study. Results: The estimation of the percentage of CD34-positive cells by histopathology differed significantly from the cytomorphologically assessed medullary blast count, with a trend towards histopathological underestimation of blast cells (figure 1). Assessment of dysmegakaryopoiesis by histopathology identified 44 cases with dysplastic features, which were deemed inconspicious by cytomorphology. Histopathology yielded a significant positive correlation (p=0.002) between cellularity and degree of dysmegakaryopoiesis, and these two features were also correlated with higher-risk WHO subtypes. Fibrosis and dysmegakaryopoiesis were negatively correlated. Bone marrow cellularity seemed to be overestimated by cytomorphology compared with histopathology. The percentage of erythropoietic cells did not correlate well between cytomorphological and histopathological review. Neither WHO subtype nor medullary blast count showed an association with the proportion of erythropoiesis, regardless of the mode of evaluation. All patients with expanded erythropoiesis also showed signs of dysmegakaryopoiesis. There was no case of cytomorphologically diagnosed MDS that was not confirmed by histopathology, and 48% of MDS diagnoses were identical as to their WHO subtype. However, in 66 cases (52%), the WHO type diagnosed by histopathology differed from the WHO type diagnosed by cytomorphology. The discrepancy was mainly due to differing estimates of medullary blast counts. In our cohort, the degree of fibrosis positively correlated with bone marrow cellularity, a finding that appeared counterintuitive to clinical experience. Increased cellularity also correlated with higher-risk MDS subgroups. Prognosis in terms of overall survival was influenced by the following parameters: Cytomorphologically assessed medullary blast count, bone marrow cellularity, fibrosis, and percentage of erythropoiesis, the latter assessed by histopathology. Patients with of grade 2 or 3 fibrosis had an inferior outcome (figure 2). Conclusions: In our study, histopathology was fully congruent with bone marrow cytology as far as making a diagnosis of MDS is concerned. Histopathology, though, often underestimated the blast count and showed difficulty in identifying the correct MDS type according to the WHO classification. Histopathology is also at a disadvantage regarding evaluation of single cell morphology, with the exception of assessing certain aspects of dysmegakaryopoiesis. A clear advantage of histopathology is its exclusive capability of gauging bone marrow fibrosis and cellularity, both of which are relevant for the diagnosis and prognosis of MDS. We conclude that cytomorphology and histopathology should both be harnessed to optimize the characterization of a patient's myelodysplastic syndrome. Figure 1View largeDownload PPTFigure 1View largeDownload PPT Close modal

MDS-454 and Mutations Might Play a Role in Poor Prognosis and AML Progression in Patients With Isolated del(5q) MDS

Myelodysplastic syndromes (MDS) with isolated del(5q) represent a subtype defined by WHO with good prognosis. However, several studies have shown that the presence of somatic mutation, such as TP53, might have an impact on prognosis. In addition, recent publications suggest a role for SF3B1 in the poor outcome of some del(5q) MDS patients. Our aim was to validate the poor prognosis of SF3B1 mutations, present in patients with del(5q) MDS and to identify mutational profiles that could promote AML progression of patients del(5q) MDS. We performed a retrospective study including MDS patients with both isolated del(5q) and del(5q) with another alteration different from chromosome 7. We included 50 patients and a control group of 123 low-risk MDS patients with normal karyotype. Next-generation sequencing (NGS) data from bone marrow samples were analyzed using an in-house custom panel (>100 myeloid genes). Median age at diagnosis was similar in del(5q) MDS and control group (72.9 and 71.8 years, respectively, p>0.05). The number of mutations per patient was significantly higher in the control group than in del(5q) (a mean of 3.16 against 1.7 for del(5q), p<0.0001). Despite a higher prevalence of somatic mutations in the control group, no differences were found in median overall survival (OS) (64.5 and 60.1 months for del(5q) MDS and control group respectively, p=0.413). However, when analyzing del(5q) patients individually, OS was significantly lower in those patients with either TP53 or SF3B1 mutation (64.5 vs. 28 months median) (p=0.031). Regarding progression to AML, patients with TP53 and/or DNMT3A mutations (n=14) had a shorter time to progression compared to patients without mutations in these genes, with a median of 13.6 months vs. 26.97 months (p=0.004). Median follow-up for these patients was 14.93 (0-170.30) months. MDS patients with del(5q) have a good prognosis and a higher time to progression to AML compared to other MDS subgroups. However, the mutational profile may modify this evolution. In our study, mutations in SF3B1 and DNMT3A may be involved in OS and transformation to AML (respectively), but a larger cohort of patients is needed to confirm that.

Reduced Plasmacytoid Dendritic Cell Output Is Associated With High Risk in Low-grade Myelodysplastic Syndrome.

Reduced Plasmacytoid Dendritic Cell Output Is Associated With High Risk in Low-grade Myelodysplastic Syndrome.

What Are the Prospects for Treating TP53 Mutated Myelodysplastic Syndromes and Acute Myeloid Leukemia?

TP53 is a key tumor suppressor gene involved in fundamental biological processes of genomic stability and is recurrently mutated in a subgroup of myelodysplastic syndromes and acute myeloid leukemia. These patients have unique clinical and molecular features resulting in dismal outcomes despite standard cytotoxic chemotherapy, and long-term survival is seldom achieved with allogeneic stem cell transplant. Upfront use of hypomethylating agents with or without venetoclax has resulted in a favorable initial response over intensive cytotoxic chemotherapy, albeit responses are nondurable, and the median overall survival is typically less than 6 to 8 months. In this review, we examine the evidence of conventional treatments and focus on the emerging novel therapeutic options, including targeted molecular and immunotherapies for this challenging molecular subgroup. Together, there are still significant unmet needs to improve outcomes of patients with TP53 mutated myelodysplastic syndromes and acute myeloid leukemia, and enrollment in clinical trials should be highly favored whenever they are available.

Allogeneic Hematopoietic Stem Cell Transplantation (allo HSCT) in Patients with IPSS Low or Intermediate-1 Myelodysplastic Syndrome (MDS): A Prospective Multicenter Phase II Study Based on Donor Availability By the GFM & SFGM-TC “MDS-ALLO-Risk”

Allogeneic Hematopoietic Stem Cell Transplantation (allo HSCT) in Patients with IPSS Low or Intermediate-1 Myelodysplastic Syndrome (MDS): A Prospective Multicenter Phase II Study Based on Donor Availability By the GFM & SFGM-TC “MDS-ALLO-Risk”

Prevalence and Risk Factors of Antibodies to Class I and II Human Leukocyte Antigens in Haploidentical Allograft Candidates: A Prospective Study on 3805 Subjects

The aim of this study is to investigate the prevalence and risk factors of anti-human leukocyte antigen (HLA) antibodies in haploidentical candidates.This study was completed at Peking University People's Hospital, Beijing China. We performed a prospective analysis of patients with hematological diseases concerning the prevalence and risk factors of anti-HLA antibodies. Patients were enrolled between July 2015 - December 2019. Serum was collected for PRAs test within 1 month before haploidentical transplantation. The risk factors, such as age, sex, total transfusion, red blood cell (RBC) transfusion, platelet (PLT) transfusion, pregnancy, disease duration and diagnosis were collected. Univariate and multivariate logistic regression analyses were performed to evaluate the risk factors of anti-HLA antibodies.Six hundred and eighty (17.9%) patients were positive for panel reactive antibodies (PRA)-class I, 360 (9.5%) for class II, 768 (20.2%) class I or II, and 272 (7.1%) positive for class I and II both. Multivariate analysis indicated that female was related to higher risk of having PRAs for class I (P = 0.011), class I or II (P = 0.009), anti-HLA-A (P = 0.015), anti-HLA-DP (P = 0.048) and also for having higher mean fluorescence intensity (MFI) (2000 or more) of PRAs in class I (P = 0.020) and class I or II (P = 0.005). Compared to patients with myelodysplastic syndrome (MDS), patients with acute myeloid leukemia (AML), acute lymphoblastic leukemia (ALL), aplastic anemia (AA) had a lower incidence for PRAs in class I, class II, class I or II, class I and II, anti-HLA-A. anti-HLA-B, anti-HLA-C, anti-HLA-DQ, anti-HLA-DR, anti-HLA-DP (Table 1). Prior pregnancy was a risk factor for PRAs (P < 0.001), and no previous pregnancy group having lower MFI of PRAs in class I (P = 0.001) and class I or II (P = 0.004). PLT transfusion (more than 4 times) rleted with a higher prevalence of PRAs (P < 0.001), and also had a higher MFI of PRAs in class II (P < 0.001), class I and II (P < 0.001). Patients with RBC transfusion (more than 3 times) had a higher prevalence of PRAs in class I (P = 0.001), class II (P = 0.029), class I or II (P < 0.001), anti-HLA-A (P = 0.001), anti-HLA-B (P < 0.001), anti-HLA-C (P = 0.007), anti-HLA-DQ (P < 0.001) and anti-HLA-DR (P = 0.011). In addition, diseases duration (8 months or more) was also associated with higher MFI of PRAs in class I (P = 0.023) and class I or II (P = 0.004).Subgroup analysis showed that 11.7% of pediatric patients were positive for PRAs in class I; 19.2% of adults, 17.9% of elder patients; 12.4% of males; 26.1% of females; 21.0% of patients with AML; 10.5% of patients with acute lymphoblastic leukemia (ALL); 18.9% of patients with AA; 30.3% of patients with MDS; 16.6% of patients with other hematological diseases. The positive rate of class II PRAs in children was 4.3%; 11.1% for adults; 9.5% for elder patients; 5.5% for males; 15.4% for females; 11.4% for patients with AML; 5.2% for patients with ALL; 10.3% for patients with AA; 17.2% for patients with MDS; 6.6% of patients with other hematological diseases. Multivariate analysis showed that, in children, PLT transfusion and diagnosis were the two main risk factors of PRAs in class I and class II (P < 0.001, P = 0.017). In adults, diagnosis (P = 0.003), transfusion (P < 0.001) and pregnancy (P < 0.001) were the three main factors associated with PRAs in class I and transfusion (P < 0.001) and pregnancy (P < 0.001) were the two main factors associated with PRAs in class II. In males, PLT transfusion (P < 0.001) and diagnosis (P < 0.001) were the two main factors associated with PRAs in class I and class II. In ALL subgroup, gender (P = 0.026, P = 0.048), pregnancy (P < 0.001) and transfusion (P < 0.001) were the three main factors associated with PRAs in class I and II. In AA subgroup, gender (P = 0.004) and PLT transfusion (P < 0.001) were risk factors for class I PRAs, pregnancy (P = 0.008) and PLT transfusion (P = 0.003) were risk factors for class II PRAs. In elder patients, females, AML, MDS and other diseases subgroup, transfusion and pregnancy were the two main factors associated with PRAs in class I and class II.Our results indicated that female sex, diagnosis, pregnancy, transfusion, disease duration were independent risk factors of anti-HLA antibodies in haploidentical allograft candidates, which provided evidence for best haploidentical donor selection. The risk factors of anti-HLA antibodies were different among total patients and those of cases in different subgroups. [Display omitted] DisclosuresNo relevant conflicts of interest to declare.

TP53 Combined Phenotype Score Is Associated with the Clinical Outcome of TP53-Mutated Myelodysplastic Syndromes.

Simple SummaryTP53 is the most frequently mutated genes in cancer, and mutations of TP53 are observed in 5–10% of patients in myelodysplastic syndrome (MDS). In patients with MDS, TP53 mutations are associated with adverse outcomes; however, there is still significant heterogeneity in these disease courses. We performed retrospective review of 107 patients with untreated TP53-mutated MDS, and identified that the functional impact of TP53 mutations, represented by phenotypic annotation of TP53 mutations (PHANTM) combined phenotype score is associated with prognosis. In patients with TP53-mutated MDS, we found that a higher PHANTM combined phenotype score is associated with poorer clinical outcome, and this has independent influence on prognosis accounting for IPSS-R and other risk variables. Our findings suggest that TP53-mutated MDS is heterogeneous and not all TP53 mutations harbor the same impact on prognosis. The PHANTM combined score adds to prognostic precision in MDS beyond previously reported TP53 allelic state.Mutations of TP53 are observed in 5–10% of patients in myelodysplastic syndrome (MDS) and are associated with adverse outcomes. Previous studies indicate that the TP53 allelic state and variant allele frequency of TP53 mutation impact patient outcomes, but there is significant heterogeneity within this MDS subgroup. We performed retrospective review of clinicopathologic and genomic information of 107 patients with TP53-mutated MDS. We assessed each mutation according to the phenotypic annotation of TP53 mutations (PHANTM) and analyzed the associations between predicted TP53 mutant function, represented by the PHANTM combined phenotype score, and overall survival (OS) using the log rank test and Cox regression. Our results indicated that patients with PHANTM combined phenotype score above the median (>1) had significantly shorter OS compared to those with scores below the median (median OS: 10.59 and 16.51 months, respectively, p = 0.025). This relationship remained significant in multivariable analysis (HR (95%CI): 1.62 (1.01–2.58), p = 0.044) and identified to have an independent prognostic influence, accounting for known risk such as IPSS-R and other standard risk variables. Our results suggest that the functional information of TP53 mutations, represented by PHANTM combined phenotype score, are associated with the clinical outcome of patients with TP53-mutated MDS.

Therapy-related myeloid neoplasm after peptide receptor radionuclide therapy (PRRT) in 1631 patients from our 20years of experiences: prognostic parameters and overall survival.

To determine prognostic factors and overall survival (OS) in therapy-related myeloid neoplasm (t-MN) of patients after receiving peptide receptor radionuclide therapy (PRRT). All patients treated from February 1999 until September 2019 at our center who had bone marrow biopsy-proven t-MN after PRRT were included. Patient characteristics, laboratory results, and all tumor-directed therapies before t-MN diagnosis were collected. Cox regression analysis was performed to identify parameters associated with OS. Receiver operating characteristic (ROC) curve analysis was used to define cutoff values as well as sensitivity and specificity of the parameters. Out of 1631 patients treated with PRRT, 30 patients developed t-MN comprising myelodysplastic syndrome (MDS) in 23 patients (77%) and acute myeloid leukemia (AML) in 7 patients (23%). The median OS of t-MN patients was 13months (range 9.1-16.9months): 6months for AML and 15months for the MDS subgroup, respectively. Higher platelet level was a significant prognostic parameter for longer OS (hazard ratio (HR): 0.99, P < 0.05). Using ROC analysis, the best cutoff value for thrombocyte count was 183.5Gpt/L, resulting in a sensitivity of 92.3% and a specificity of 50%. Other factors, such as hemoglobin level, did not show a significant correlation with OS. Even rarely occurred, the OS is gravely compromised in t-MN patients after PRRT, and even less in the AML subgroup (6months). Higher platelet value was a significant prognostic parameter for longer OS in t-MN patients.

Analysis of the impact of adherence to guidelines and expert advice in patients with myelodysplastic syndromes

The European Leukemia Net (ELN) guidelines for treatment of myelodysplastic syndromes (MDS) connect heterogeneous MDS subgroups with a number of therapeutic options ranging from best supportive care to allogeneic stem cell transplantation (alloSCT). However, it is currently unknown whether adherence to guideline recommendations translates into improved survival. The sizeable database of the Duesseldorf MDS Registry allowed us to address this question. We first performed a retrospective analysis including 1698 patients (cohort 1) to whom we retrospectively applied the ELN guidelines. We compared patients treated according to the guidelines with patients who deviated from it, either because they received a certain treatment though it was not recommended or because they did not receive that treatment despite being eligible. We also performed a prospective study with 381 patients (cohort 2) who were seen in our department and received guideline-based expert advice. Again, we compared the impact of subsequent guideline-adherent versus non-adherent treatment. For the majority of treatment options (best supportive care, lenalidomide, hypomethylating agents, low-dose chemotherapy, and intensive chemotherapy), we found that adherence to the ELN guidelines did not improve survival in cohort 1. The same was true when patient management was prospectively enhanced through guideline-based treatment advice given by MDS experts (cohort 2). The only exceptions were alloSCT and iron chelation (ICT). Patients receiving ICT and alloSCT as recommended fared significantly better than those who were eligible but received other treatment. Our analysis underscores the limited survival impact of most MDS therapies and suggests to pursue alloSCT in all suitable candidates.Graphical abstract

Prediction of Relapse after Allogeneic Stem Cell Transplantation Using Individualized Minimal Residual Markers; The Prospective Nordic Study NMDSG14B

Introduction One third of patients with myelodysplastic syndrome (MDS) will relapse after allogeneic stem cell transplantation (SCT), with a dismal prognosis. Early detection of relapse enables pre-emptive treatment and may potentially reduce relapse risk, but is limited by the lack of sensitive markers for minimal residual disease (MRD). We developed a pipeline where patient-specific mutations, as determined by a myeloid next generation sequencing (NGS) panel are tracked using sensitive digital droplet PCR (ddPCR). Method We designed a prospective Nordic study (NMDSG14B; NCT02872662) enrolling all patients with MDS, mixed MDS / MPN or AML with myelodysplasia related disease and &amp;lt; 30% marrow blasts undergoing SCT in the Nordic region. We hypothesized that personalized MRD detection by ddPCR can predict clinical relapse earlier than conventional methods. Patients were included before SCT and serial bone marrow samples were collected before, and 1 and 3 months post SCT, and thereafter every third month for 2 years or until relapse or death. Blood samples were collected monthly. The MRD results were not available for the treating physicians. MRD positivity was defined based on the background noise of the specific ddPCR-assays and varied between 0.05-0.1% VAF. Results Three-hundred and sixteen patients were screened between 2016 and 2020, of which 19 were excluded due to lack of mutation or disease progression preventing SCT. We here present data of 254 patients followed ≥ 6 months after SCT. Median age was 64 (18-78) years and 59% were male. Most WHO subgroups of MDS (n=166), MDS/MPN (n=39), AML (n=8) and therapy-related disease (n=41), were represented. Risk profile according to IPSS-R was very low (n=13), low (n=32), intermediate (n=46), high (n=60) and very high (n=32). The majority of patients received pre-SCT treatment consisting of HMA (n=159) and / or intensive chemotherapy (n=59) while 60 patients did not receive disease-modifying treatment prior to SCT. The most common mutations were ASXL1 (n=69), TET2 (n=58), SRSF2 (n=57) and TP53 (n=44). No mutation was identified in 10 pts, and NGS data is still pending for 11 patients. After a median follow-up of 436 days, estimated 2 years overall survival and relapse free survival were 72% and 63%, respectively. Cumulative incidence of NRM and relapse at 2 years was 16% and 20%, respectively. Forty-six patients relapsed after a median of 170 (53-733) days, and the estimated median survival following relapse was 197 days. The most common pre-SCT mutations in the relapsed cohort were TP53 (n=19), DNMT3A (n=11) and RUNX1 (n=9). Thirty-seven patients died due to non-relapse mortality (NRM) after a median of 83 (4-754) days. To date, MRD results are available for 64 patients. Relapse was preceded by positive MRD in 14 out of 15 patients a median of 79 (21-173) days before clinical relapse. The 15th patient had an extra-medullary relapse only. Borderline positive MRD samples &amp;lt; 0.2% VAF within 100 days after SCT followed by negative samples were seen in 11 non-relapse patients. Twenty-four of 37 patients in continuous complete remission (CCR) were consistently MRD neg. Six CCR patients had positive MRD after 100 days; two with transient borderline peaks (&amp;lt;0.1%) at 6 months; two with transient peaks &amp;gt; 0.1%, which turned negative when the patients developed GVHD; one patient with slowly decreasing MRD which turned negative first after 1 y, and finally one patient with prevailing KIT mutation (&amp;gt;700 days post-SCT) despite negative BCOR and STAG2. Two MRD+ patients died from NRM without showing signs of clinical relapse. Discussion In summary, we show that our pipeline of personalized MRD-assessment, based on patient-specific mutations is feasible with a high sensitivity to predict relapse. An update of study progression will be presented at the meeting. Figure 1 Disclosures Illman: Sanofi-Genzyme: Other: Travel Support; Celgene: Other: Travel Support. Mielke:DNA Prime: Honoraria, Other: received via my institution , Speakers Bureau; KIADIS Pharma: Honoraria, Other: received via my institution , Speakers Bureau; Miltenyi: Honoraria, Membership on an entity's Board of Directors or advisory committees, Other: received via my institution , Speakers Bureau; Kite/Gilead: Honoraria, Other: received via my institution , Speakers Bureau; Bellicum: Honoraria, Other: received via my institution, Speakers Bureau; Novartis: Honoraria, Other: received via my institution, Speakers Bureau; Celgene/BMS: Honoraria, Other: received via my institution , Speakers Bureau. Ebeling:Accord Healthcare: Other: Travel Support; Amgen: Other: Travel Support; Celgene: Consultancy, Membership on an entity's Board of Directors or advisory committees, Other: Travel Support; Otsuka Pharma Scandanavia AB: Consultancy, Membership on an entity's Board of Directors or advisory committees.