Serial Assessment of Patients with Suspected Myelodysplastic Syndromes: Significance of Flow Cytometric Findings As Validated by Cytomorphology, Cytogenetics, and Molecular Genetics

Blood ◽  
2011 ◽  
Vol 118 (21) ◽  
pp. 2787-2787
Author(s):  
Wolfgang Kern ◽  
Claudia Haferlach ◽  
Susanne Schnittger ◽  
Tamara Alpermann ◽  
Torsten Haferlach
Keyword(s):  
Myelodysplastic Syndromes ◽  
Molecular Genetic ◽  
Antigen Expression ◽  
Initial Assessment ◽  
Multiparameter Flow Cytometry ◽  
Trisomy 8 ◽  
Employment Equity ◽  
Number Of Patients ◽  
Equity Ownership

Abstract Abstract 2787 Background: Multiparameter flow cytometry (MFC) is capable of detecting aberrant antigen expression related to myelodysplastic syndromes (MDS) and is increasingly applied as a diagnostic tool in patients with cytopenias and suspected MDS. While in the majority of cases concordant diagnostic results between MFC and cytomorphology (CM) are found, the significance of MFC indicating MDS in the absence of a diagnosis of MDS by CM remains to be clarified. Aim: To assess the course of disease in serially analyzed patients with suspected MDS in whom the first evaluation revealed MDS by MFC but not by CM. Patients and Methods: A total of 142 patients were analyzed in parallel by MFC, CM and cytogenetics (CG) for suspected MDS on at least two separate occasions. The median number of assessments amounted to 2 (range 2–6). The median interval between first and last assessment amounted to 9 months (range 1–53). In a subset of the assessments molecular genetic (MG) analyses were performed for the detection of RUNX1 mutations and FLT3-ITD. Results: At the first assessment MFC results indicated MDS in 64/142 (45.1%) patients and revealed no sign of MDS in 33/142 (23.2%) patients. In the remaining 45/142 (31.7%) patients only minor aberrancies of antigen expression were observed by MFC not sufficient to indicate MDS (“possible MDS by MFC”). In 9/142 (6.3%) patients CG revealed an aberrant karyotype and thereby confirmed MDS at the initial assessment. This applied to 1/33 (3.0%) patient with no MDS by MFC, 3/45 (6.7%) patients with possible MDS by MFC, and 5/64 (7.8%) with MDS by MFC (n.s.). Karyotype abnormalities included complex karyotype (n=3), trisomy 8 (n=1), trisomy 21 (n=1), and others (n=4). These proven MDS patients were excluded from further analyses which were thus based on n=133 patients. During follow-up assessments MDS was confirmed by CM, CG or MG in 30/59 (63.8%) patients with MDS by MFC at initial assessment, in 10/42 (21.3%) with “possible MDS” by MFC at initial assessment, and in 7/32 (14.9%) with no MDS by MFC at initial assessment (p=0.004). The respective median intervals between initial assessment and confirmation of MDS by a non-MFC method amounted to 10.8 months (range, 1.7–53.1), 10.3 months (range, 2.4–36.9), and 15.6 months (range, 7.9–44.4). Thus, in a total of 47 patients follow-up assessments revealed MDS by non-MFC methods as follows: n=38 by CM (36 MDS, 2 AML), n=8 by CG (one case each with del(5q), del(11q), del(20q), trisomy 8, and trisomy 4 and three cases other abnormalities) and n=4 by MG (2 RUNX1 mutations, 1 RUNX1 mutation and FLT3-ITD, 1 FLT3-ITD). Notably, in the 7 patients with no MDS by MFC at the initial assessment, in whom follow-up assessments revealed MDS by non-MFC methods, changes in MFC results at follow-up assessments to “possible MDS” (n=4) and MDS (n=2) were observed. The respective figure for the 10 patients with “possible MDS” by MFC at initial assessment, who were confirmed MDS by non-MFC methods during follow-up assessments, is “possible MDS” in 5 patients and MDS in 4 patients during follow-up MFC assessment. Conclusions: This data indicates that diagnostic findings by MFC revealing MDS in the absence of diagnostic findings of MDS by CM are confirmed in the majority of cases during follow-up. Furthermore, the confirmation of MDS during follow-up even in cases with minor aberrancies of antigen expression is higher as compared to cases with no MDS by MFC. There remains, however, a significant number of patients (36.2%) with MDS by MFC which is not confirmed by other methods during follow-up; further clinical evaluation is needed to validate the significance of MFC findings in these cases. Overall, this data argues in favour of a combined approach to diagnose MDS including MFC besides CM, CG and MG, and suggests a closer monitoring of patients with suspected MDS in whom aberrancies are detected by MFC. Disclosures: Kern: MLL Munich Leukemia Laboratory: Employment, Equity Ownership. Haferlach:MLL Munich Leukemia Laboratory: Employment, Equity Ownership. Schnittger:MLL Munich Leukemia Laboratory: Employment, Equity Ownership. Alpermann:MLL Munich Leukemia Laboratory: Employment. Haferlach:MLL Munich Leukemia Laboratory: Employment, Equity Ownership.

In Myelodysplastic/Myeloproliferative Neoplasms Aberrant Antigen Expression As Assessed by Multiparameter Flow Cytometry Is Related to Molecular Genetic Mutations

Blood ◽  
2011 ◽  
Vol 118 (21) ◽  
pp. 5152-5152
Author(s):  
Wolfgang Kern ◽  
Susanne Schnittger ◽  
Tamara Alpermann ◽  
Claudia Haferlach ◽  
Torsten Haferlach
Keyword(s):  
Myeloproliferative Neoplasms ◽  
Molecular Genetic ◽  
Antigen Expression ◽  
Multiparameter Flow Cytometry ◽  
Employment Equity ◽  
Aberrant Expression ◽  
Equity Ownership ◽  
Diagnostic Work ◽  
Work Up ◽  
Diagnostic Work Up

Abstract Abstract 5152 Background: Immunophenotyping by multiparameter flow cytometry (MFC) is increasingly used in the diagnostic work-up of patients with cytopenias and suspected myelodysplastic syndromes (MDS). Myelodysplastic/myeloproliferative neoplasms (MDS/MPN) comprise a group of diseases with some features of MDS and is separately classified in the current WHO system. While the immunophenotype of chronic myelomonocytic leukemia has been described in detail, data is scarce on the use of MFC in myelodysplastic/myeloproliferative neoplasms, unclassifiable (MDS/MPNu) as well as on refractory anemia with ring sideroblasts and thrombocytosis (RARS-T), which is a provisional entity in the current WHO classification. Aim: To assess patients with MDS/MPNu and RARS-T for MDS-related aberrant immunophenotypes in the context of a comprehensive diagnostic work-up including cytomorphology, cytogenetics, and molecular genetics. Patients and Methods: A total of 91 patients were analyzed in parallel by cytomorphology, cytogenetics, and MFC applying an antibody panel designed to diagnose MDS. MFC was used to detect expression of mature antigens in myeloid progenitors; abnormal CD13-CD16- and CD11b-CD16-expression patterns, aberrant expression of myeloid markers and reduced side scatter signal in granulocytes; reduced expression of myelomonocytic markers in monocytes; aberrant expression of CD71 in erythroid cells; as well as expression of lymphoid markers in all myeloid cell lines. In 77/91 patients molecular genetic markers were investigated. The median age of the patients was 75.1 years (range, 35.3–87.4). The male/female ratio was 60/31. Six patients had RARS-T and 85 had MDS/MPNu. Results: In 54/91 (59.3%) patients MFC identified an MDS-immunophenotype. This was true in 4/6 (66.7%) RARS-T and in 50/85 (58.8%) MDS/MPNu (n.s.). Cases with MDS-immunophenotype displayed aberrancies significantly more frequently than those without as follows: in myeloid progenitor cells (number of aberrantly expressed antigens, mean±SD: 0.5±0.6 vs. 0.2±0.4, p=0.002), granulocytes (2.7±1.3 vs. 1.2±1.1, p<0.001), and monocytes (1.7±1.2 vs. 0.5±0.7, p<0.001). Accordingly, there was a significant difference in the total number of aberrantly expressed antigens (4.9±2.4 vs. 2.0±1.4, p<0.001). The presence of an aberrant karyotype was not related to an MDS-immunophenotype which was observed in 11/18 (61.1%) cases with aberrant karyotype and in 43/73 (58.9%) with normal karyotype (n.s.). Mutations in RUNX1 and TET2 as well as FLT3-ITD were predominantly present in cases with an MDS-immunophenotype (10/33, 30.3%) and occurred less frequently in cases without (1/7, 9.1%, n.s.). In detail, RUNX1 mutations were present in 4/26 (10.3%) vs. 0/2, TET2 mutations were present in 4/6 (66.7%) vs. 1/2 (50%), and FLT3-ITD was present in 3/29 (10.3%) vs. 0/5. Accordingly, in cases with RUNX1 or TET2 mutations or with FLT3-ITD a significantly higher number of aberrantly expressed antigens was observed as compared to cases with none of these mutations (mean±SD, 6.4±2.0 vs. 4.4±2.5, p=0.024). In contrast, JAK2V617F mutations occurred at identical frequencies in patients with and without MDS-immunophenotype (11/38, 28.9% vs. 9/31, 29.0%). Regarding prognosis, the presence of an MDS-immunophenotype had no impact on overall survival. Conclusions: These data demonstrates that MDS-related aberrant antigen expression is present in the majority of patients with RARS-T and MDS/MPNu. While there is no association between the presence of an MDS-immunophenotype and the detection of JAK2 mutations cases with an MDS-immunophenotype tended to more frequently carry mutations in RUNX1 and TET2 as well as FLT3-ITDs. These data therefore suggests that MDS/MPNu may be subdivided based on molecular genetics and on the immunophenotype into cases with MDS-related features and those without. Further analyses are needed to validate these findings and their potential significance in RARS-T. Disclosures: Kern: MLL Munich Leukemia Laboratory: Employment, Equity Ownership. Schnittger:MLL Munich Leukemia Laboratory: Employment, Equity Ownership. Alpermann:MLL Munich Leukemia Laboratory: Employment. Haferlach:MLL Munich Leukemia Laboratory: Employment, Equity Ownership. Haferlach:MLL Munich Leukemia Laboratory: Employment, Equity Ownership.

Use Of Flow Cytometry To Identify Myelodysplasia In Peripheral Blood

Blood ◽  
2013 ◽  
Vol 122 (21) ◽  
pp. 2774-2774
Author(s):  
Wolfgang Kern ◽  
Richard Schabath ◽  
Tamara Alpermann ◽  
Claudia Haferlach ◽  
Susanne Schnittger ◽  
...  
Keyword(s):  
Flow Cytometry ◽  
Peripheral Blood ◽  
Antigen Expression ◽  
Employment Equity ◽  
Aberrant Expression ◽  
Equity Ownership ◽  
Diagnostic Work ◽  
Work Up ◽  
Diagnostic Work Up

Abstract Background Flow cytometry (FC) is increasingly used in diagnostic work-up of bone marrow (BM) from patients with suspected or proven myelodysplastic syndrome (MDS). Data on FC in peripheral blood (PB) is scarce. Aims Evaluate the use of FC for PB in suspected or proven MDS by comparison to BM analyzed during follow-up. Methods PB of 157 patients (pts) with suspected MDS was analyzed by FC applying ELN criteria defined recently for diagnosis of MDS in BM (Westers et al., Leukemia 2012). For all pts during follow-up at least one BM sample was evaluable by morphology, cytogenetics, and FC in parallel to confirm or exclude MDS (according to WHO 2008 criteria). Pts were then grouped according to results obtained from BM analysis during follow-up time points into 1) proven MDS (n=96), 2) no MDS (n=32), and 3) MPN, MDS/MPN, or “MDS possible” (presence of dysplastic features by morphology but not sufficient to diagnose MDS) (n=29) (median time to MDS confirmation, 0.9 months, range, 0.1-53.0; median time to last BM assessment without confirmation of MDS; 0.8 months, range, 0.2-23.0). Results First, results of FC on PB were compared between pts with finally proven MDS (n=96) by BM vs. those with no MDS by BM as diagnosed during follow-up. All 34 pts with myeloid progenitor cells (MPC) by FC in PB had finally proven MDS. However, in addition 62/94 (66.0%) of those without MPC (p<0.0001) also had proven MDS. Thus, the presence of MPC in PB was at least strongly indicative of MDS while there were also cases with MDS without MPC in PB. Moreover, besides the presence of MPC in PB, 17 of these 34 cases in addition displayed an aberrant antigen expression on MPC. Focusing on granulocytes we first analyzed side-scatter (SSC) signals in granulocytes as ratio of mean SSC signals granulocytes/lymphocytes (G/L). While for BM samples a reduced SSC ratio G/L had been described which reflects hypogranulation, we indeed found similar data for PB with a significantly lower SSC ratio G/L in pts with proven MDS as compared to those without (mean±SD 5.7±1.1 vs. 6.3±1.0, p=0.015). More strict, a mean SSC ratio G/L of 3.9 was found to most specifically identify pts with MDS: all 6 cases with a ratio <3.9 had MDS. Regarding aberrant antigen expression in granulocytes, MDS was more frequently diagnosed among cases with vs. without the following features: aberrant CD11b/CD16 expression pattern (43/46 investigated, 93.5% vs. 53/82, 64.6%; p=0.0002), lack of CD10 expression (37/43, 86.0% vs. 59/85, 69.4%; p=0.052), CD56 expression (19/21, 90.5% vs. 77/107, 72.0%; p=0.098). Cumulating this data, ≥2 aberrantly expressed antigens on granulocytes were found indicative of MDS: 42/45 (93.3%) of pts with aberrant expression of ≥2 antigens had MDS while only 54/83 (65.1%) of those with 0 or 1 aberrantly expressed antigen had finally proven MDS (p=0.0003). Regarding aberrant antigen expression in monocytes, pts with the following features more frequently had MDS as compared to those without: reduced expression of HLA-DR, CD13, CD11b, or CD15, aberrant expression of CD2 or CD34 (as single makers all n.s.). However, cumulating this data also resulted in a significant relation to a diagnosis of MDS during follow-up: 31/36 (86.1%) of pts with aberrant expression of ≥2 antigens on monocytes were diagnosed MDS vs. 65/92 (70.7%) of those without (p=0.052). Integrating the data for the different cell compartments, pts were separated according to the presence of the following 4 criteria: 1) presence of MPC in PB by FC, 2) aberrant expression of ≥1 antigen in MPC in PB, 3) aberrant expression of ≥2 antigens in granulocytes in PB, and 4) aberrant expression of ≥2 antigens in monocytes in PB: 68/76 (89.5%) of pts with ≥1 of these criteria had MDS, which was the case in 28/52 (53.8%) of cases fulfilling none of these criteria (p<0.0001). Strengthening the selection to presence of ≥2 of the criteria, all such 36 cases had MDS which was true for 60/92 (65.2%) of those with ≤1 criterion (p<0.0001). Applying these criteria to the set of remaining 29 pts with MPN, MDS/MPN, or possible MDS, 17 (58.6%) of them fulfilled ≥1 criterion which was true for 8/32 (25.0%) of pts not diagnosed MDS (p=0.010). Conclusions FC reveals MDS-related findings in PB samples using a specific panel targeting 10 antigens and may be used to identify pts with a high probability of MDS. Further studies with direct comparison of PB and BM should clarify the role of PB analysis by FC in the diagnostic work-up of pts with suspected MDS. Disclosures: Kern: MLL Munich Leukemia Laboratory: Employment, Equity Ownership. Schabath:MLL Munich Leukemia Laboratory: Employment. Alpermann:MLL Munich Leukemia Laboratory: Employment. Haferlach:MLL Munich Leukemia Laboratory: Employment, Equity Ownership. Schnittger:MLL Munich Leukemia Laboratory: Employment, Equity Ownership. Haferlach:MLL Munich Leukemia Laboratory: Employment, Equity Ownership.

Multiparameter Flow Cytometry in Patients with Suspected Myelodysplastic Syndromes Adds Significant Prognostic Information: A Study on 1,013 Patients

Blood ◽  
2011 ◽  
Vol 118 (21) ◽  
pp. 1722-1722
Author(s):  
Wolfgang Kern ◽  
Claudia Haferlach ◽  
Tamara Alpermann ◽  
Susanne Schnittger ◽  
Torsten Haferlach
Keyword(s):  
Flow Cytometry ◽  
Myelodysplastic Syndromes ◽  
Continuous Variable ◽  
The Other ◽  
Multiparameter Flow Cytometry ◽  
Prognostic Information ◽  
Employment Equity ◽  
Aberrant Expression ◽  
Equity Ownership ◽  
Cox Analysis

Abstract Abstract 1722 Backgroundn: Multiparameter flow cytometry (MFC) has been demonstrated capable of identifying aberrant antigen expression related to myelodysplastic syndromes (MDS). The exact role and place of MFC in the diagnostic work-up of patients with suspected MDS, however, remains to be defined. Aim: Evaluation of the diagnostic impact of MFC in relation to cytomorphology (CM) and cytogenetic (CG) by determining the association of MFC results to overall survival (OS). Patients and Methods: In 1,013 patients with suspected MDS bone marrow samples had been analyzed in parallel by MFC, CM, and CG. CM confirmed MDS in 511 patients, excluded MDS in 277 patients, and showed dysplastic features but not sufficient to unequivocally diagnose MDS by CM in 225. The MFC diagnostic result was in agreement with MDS (“MDS by MFC”) in 446 patients including 382/511 patients with MDS proven by CM. CG revealed an aberrant karyotype in 245/1,013 patients. The median follow-up time amounted to 14.8 months, a total of 156 deaths was recorded. Results: The first set of analyses was performed on the cohort of 511 patients with MDS confirmed by CM. The median total number of aberrantly expressed antigens amounted to 3 (range, 0–11) and included expression of mature antigens in myeloid progenitors; abnormal CD13-CD16- and CD11b-CD16-expression patterns, aberrant expression of myeloid markers and reduced side scatter signal (SSC) in granulocytes; reduced expression of myelomonocytic markers in monocytes; aberrant expression of CD71 in erythroid cells; as well as expression of lymphoid markers in all myeloid cell lines. A higher total number of aberrantly expressed antigens as a continuous variable correlated with a shorter OS (Cox analysis, p=0.008). Next, patients were categorized based on the three parameters i) at least 3 aberrantly expressed antigens, ii) significantly reduced SSC in granulocytes, and iii) >5% myeloid progenitor cells in MFC. Patients with at least one of these criteria had a significantly shorter OS than those without (median 48.5 months vs. not reached (n.r.), p<0.001). Overall, the global diagnostic rating of “MDS by MFC” was the strongest MFC parameter: Patients with “MDS by MFC” had a shorter OS as compared to patients without (median 56.8 months vs. n.r., p=0.001). Non-MFC parameters related to OS in univariable Cox analysis included WBC count, thrombocyte count, CG (grouped according to IPSS), % blasts by CM (p<0.001 each), Hb level (p=0.001), and age (p=0.002). In order to determine the clinical relevance of “MDS by MFC” a multivariable analysis for OS was performed on this parameter together with non-MFC parameters (blood counts excluded due to incomplete data sets). It revealed an independent relation between “MDS by MFC” and OS (p=0.045). This was also true for relation of OS to the other parameters (CG, p<0.001; age, p=0.001, % blasts by CM p=0.014). Given this strong prognostic value of “MDS by MFC” in cases with MDS proven by CM a second set of analyses on the relation between MFC findings and OS were performed for the complete cohort of 1,013 patients, i.e. additionally including all cases with a diagnostic result by CM of “no MDS” or “dysplastic features not sufficient to diagnose MDS”. Again, significant relations to OS was found for the total number of aberrantly expressed antigens as a continuous variable (Cox analysis, p<0.001), for at least one of the above mentioned criteria i), ii) or iii) (median 75.6 months vs. n.r., p<0.001), as well as for “MDS by MFC” (median 60.5 months vs. n.r., p<0.001). Again, “MDS by MFC” proved to be the most relevant MFC parameter. Multivariable Cox analysis for OS including “MDS by MFC” and non-MFC parameters revealed a trend only for “MDS by MFC” (p=0.135) and significance for the other parameters (age, p<0.001; CG, p<0.001; blasts by CM, p=0.045). Conclusions: 1) The present data indicates the diagnostic use of MFC for MDS results in independent prognostic information for cases with MDS as proven by CM. 2) Furthermore, the diagnosis of MDS by MFC has a strong prognostic impact even without prove of MDS by CM which strengthens the diagnostic value of MFC even more. 3) This analysis therefore argues in favour of diagnosing MDS not only based on a combination of CM and CG but of adding also MFC for better classification and even prognostication in the future. Disclosures: Kern: MLL Munich Leukemia Laboratory: Employment, Equity Ownership. Haferlach:MLL Munich Leukemia Laboratory: Employment, Equity Ownership. Alpermann:MLL Munich Leukemia Laboratory: Employment. Schnittger:MLL Munich Leukemia Laboratory: Employment, Equity Ownership. Haferlach:MLL Munich Leukemia Laboratory: Employment, Equity Ownership.

Cytogenetic and Molecular Genetic Clonal Evolution in CLL Is Associated with an Unmutated IGHV Status and Frequently Leads to a Combination of Loss of 17p and TP53 mutation

Blood ◽  
2016 ◽  
Vol 128 (22) ◽  
pp. 3213-3213
Author(s):  
Claudia Haferlach ◽  
Sabine Jeromin ◽  
Niroshan Nadarajah ◽  
Melanie Zenger ◽  
Wolfgang Kern ◽  
...  
Keyword(s):  
Median Time ◽  
Tp53 Mutation ◽  
Clonal Evolution ◽  
Molecular Genetic ◽  
Normal Karyotype ◽  
Employment Equity ◽  
Mutation Status ◽  
Equity Ownership ◽  
Mutation Analyses

Abstract Background: The clinical course in CLL is very heterogeneous ranging from stable disease to a rather rapid progression requiring treatment. The acquisition of genetic abnormalities termed clonal evolution (CE) is likely to correlate with clinical progression and might be used to guide treatment strategies. Aim: The aim of this study was to evaluate the frequency of CE on the cytogenetic (CCE) and molecular genetic (MCE) levels and its association with the IGHV mutation status and clinical outcome. Methods: 179 CLL cases were selected on the basis that chromosome banding analysis (CBA) and mutation analyses in TP53 and SF3B1 all having been performed at least at two time points. The median age at first evaluation was 72 years (range: 46-95). The first time point of analysis was at primary diagnosis (n=131) or during course of disease but prior to any treatment (n=48). In all patients interphase FISH was performed with probes for 17p13 (TP53), 13q14 (D13S25, D13S319, DLEU), 11q22 (ATM), and the centromeric region of chromosome 12 and the IGHV mutation status was evaluated. A total of 465 CBA, 417 TP53 and 424 SF3B1 mutation analyses were evaluated. The median number of samples per patient was 2 (range: 2-9). The time between samples ranged from 1 month to 9.8 years (median 21 months). For all patients clinical follow-up data was available with a median follow-up of 7.4 years and 5-year overall survival (OS) of 88%. Results: At first investigation CBA revealed a normal karyotype in 31 (17%) patients. In cases with an aberrant karyotype the pattern of abnormalities was typical for CLL: del(13q); 51% (homozygous: 15%), +12: 18%, del(11q): 16%, and del(17p): 5%. A complex karyotype (≥3 abnormalities) was present in 18%. The IGHV status was unmutated (IGHV-U) in 56% of cases and TP53 and SF3B1 mutations were detected in 10% and 15%, respectively. CCE was observed in 63/179 patients (35%). The median time to CCE was 46 months (range 3-111). The most frequent abnormalities gained during CCE were loss of 17p (14/63; 22%), 13q (11/63; 18%), and 11q (10/63; 16%). Acquired loss of 17p was more frequent in SF3B1mutated CLL (19% vs 6%, p=0.04). MCE was observed in 29/179 cases (16%). TP53 and SF3B1 mutations were acquired during the course of the disease in 23 (14%) and 7 (5%) cases, respectively. The median time to MCE was 61 months (range 1.5-109). Of note, in 2 cases with TP53 deletion a TP53 mutation was acquired and in 2 cases with TP53 mutation a TP53 deletion was acquired. In 12 CLL both a TP53 deletion and a TP53 mutation were acquired (table). CCE and MCE were significantly associated with IGHV-U (p=0.003; p<0.001) and with each other (p<0.001). In more detail, in 71% of cases with CCE and 90% of cases with MCE an IGHV-U was present. Thus, CCE and MCE were less frequent in IGHVmut CLL (23% and 4%). In 30% of CLL with CCE also MCE occurred. In addition CCE was associated with an aberrant karyotype at first investigation (p<0.001). CCE occurred in only 3% of CLL with a normal karyotype but in 42% of CLL with an aberrant karyotype. Time to treatment was significantly shorter in patients with CCE, MCE and both compared to the respective patients without (2.1 vs 5.5 yrs, p=0.004; 1.8 vs 4.8 yrs, p=0.07; 2.2 vs 5.3 yrs; p=0.04). While no impact of CCE on OS was observed in patients with a mutated IGHV status, in patients with an unmutated IGHV status a tendency to shorter OS was observed in cases with CCE compared to those without (7 year OS: 67% vs 83%; p=0.2). No impact on OS was observed for MCE. This may be due to rather short follow up after CE. However, if CCE and MCE resulted in CLL harboring both TP53 deletion and TP53 mutation 5 year OS was significantly shorter than in CLL with neither TP53 deletion nor TP53 mutation (75% vs 91%, p=0.03). Conclusions: 1) We observed CCE in 35% and MCE in 16% of CLL. 2) The pattern of cytogenetic abnormalities acquired during the course of the disease is similar to the pattern observed in CLL at diagnosis, however the frequency varies with del(17p) being the most frequently gained in CE. 3) CCE and MCE were highly correlated to IGHV-U. 4) In 25% of CLL with CCE and MCE CE resulted in the co-occurrence of TP53 deletion and TP53 mutation, which was associated with a significantly shorter OS emphasizing the necessity to reevaluate the TP53 status during the course of the disease to guide treatment. 5) The frequency and impact of CE needs to be further studied in unselected patient cohorts in which CBA and mutational analysis is performed on a regular basis. Table Table. Disclosures Haferlach: MLL Munich Leukemia Laboratory: Employment, Equity Ownership. Jeromin:MLL Munich Leukemia Laboratory: Employment. Nadarajah:MLL Munich Leukemia Laboratory: Employment. Zenger:MLL Munich Leukemia Laboratory: Employment. Kern:MLL Munich Leukemia Laboratory: Employment, Equity Ownership. Haferlach:MLL Munich Leukemia Laboratory: Employment, Equity Ownership.

scholarly journals Distinct, Ethnic, Clinical, and Genetic Characteristics of Myelodysplastic Syndromes with Der(1;7)

Blood ◽  
2019 ◽  
Vol 134 (Supplement_1) ◽  
pp. 5392-5392 ◽  
Author(s):  
Rurika Okuda ◽  
Hideki Makishima ◽  
Yasuhito Nannya ◽  
Yotaro Ochi ◽  
Tetsuichi Yoshizato ◽  
...  
Keyword(s):  
Myelodysplastic Syndromes ◽  
High Frequency ◽  
Copy Number ◽  
Research Funding ◽  
Trisomy 8 ◽  
Employment Equity ◽  
Monosomy 7 ◽  
Asian Populations ◽  
Myeloid Neoplasms ◽  
Equity Ownership

der(1;7)(q10;p10) is a recurrent chromosomal abnormality found in a wide variety of myeloid neoplasms observed in as high as 6% of myelodysplastic syndromes (MDS) in Asian populations, while rarely observed in Caucasian populations. It is thought to be generated by a recombination between two highly homologous centromere alphoid sequences which lead to an unbalanced abnormality of monosomy of 7q and trisomy of 1q. However, despite the presence of -7q, der(1;7) has been associated with a better prognosis compared to monosomy 7 or other del(7q) (-7/del(7q)). In addition to its association with +8 and del(20q), frequent RUNX1 mutations and a paucity of mutated TP53 have been reported in der(1;7) tumors, but otherwise, the molecular features of this abnormality have been poorly characterized in the literature. This is most likely because it is very rare in Caucasians, even though it represents one of the most prevalent lesions among Asian populations. The purpose of our study is to clarify the frequency and mutational landscape of der(1;7) in myeloid neoplasms on the basis of targeted-capture sequencing. A total of 1,707 MDS cases, including 944 German and 763 Japanese cases, were enrolled, from which we identified 73 (4.0%) cases with der(1;7). The prevalence was >20 times higher in Japanese (9.0%) than German (0.43%) cohorts (p<0.0001). We also identified a strong male predominance in der(1;7)-positive cases (90.4%) compared to negative cases. Also including an additional 22 cases, somatic mutations and copy number abnormalities in der(1;7) were interrogated in a total of 95 cases, which included 84 (88.4%) with MDS, 9 (9.5%) with AML, and 2 (2.1%) with MPN. Among MDS patients, 29 were low-risk, 47 were high-risk, and the rest were not specified. In mutation analysis, at least one mutation was detected in 98% of der(1;7) cases, most frequently affecting RUNX1 (42%), followed by EZH2 (26%), and ETNK1 (25%). Copy number analysis showed a high frequency of del(20q) and trisomy 8 in der(1;7) cases: 27.4% and 18.9% respectively. On the basis of mutant cell fractions, most of these mutations were present in subclones acquired within the major population harboring der(1;7). In particular, most of the EZH2 (7q35-q36) mutations were thought to be secondary events in der(1;7)-positive cases, while representing initial events acquired before UPD(7q) or -7/del(7q) in der(1;7)-negative cases. Of interest, der(1;7) was associated with a low frequency of TP53 mutations, which were seen only in 3% of cases with der(1;7), whereas highly prevalent in non-der(1;7) cases with -7/del(7q) (52%), which is concordant with a better clinical outcome was observed in der(1;7) cases compared with non-der(1;7) cases with monosomy 7 or other del(7q). Another unique feature of der(1;7) positive MDS was an extremely high frequency of RUNX1 mutations. However, the most prominent finding with secondary mutations in der(1;7) cases is the frequent hot spot mutation in ETNK1, which were originally reported in 8.8% of myeloid neoplasms with MPN features, like SETBP1 mutations. ENTK1 mutations were found in as many as 25% (23/95) of der(1;7) cases, while rarely seen in -7/del(7q) (1/89) (p<0.0001) or amp(1q) (2/68) (p=0.0001). Despite the high frequency of trisomy 8 observed in der(1;7) cases, none were associated with ETNK1 mutations. In addition, all of the RAS pathway mutations (positive in 16 cases) were observed in der(1;7) cases with wild-type ETNK1, while none were in ETNK1-mutant cases. Morphologically, these ETNK1-mutated der(1;7) cases presented with an increased eosinophil count in peripheral blood (760.9/ul vs. 78.1/ul) (p<0.001), compared to those without EKNK1 mutations, suggesting that ENTK1-mutated der(1;7) cases represent a novel disease entity within der(1;7), characterized by unique genetic features and increased eosinophils. In conclusion, der(1;7) is a genetically and clinically distinct subset of myeloid neoplasms, which showed unique features that are distinct from MDS cases in -7 and other del(7q). Especially, ETNK1 mutations subdivided cases with der(1;7) into two groups of genetically distinct subsets as shown in Figure 1. In the future, inhibition of the kinase activity in ETNK1 could be a novel therapeutic strategy in such a previously unrecognized subset as characterized by der(1;7) and eosinophilia. Figure 1 Disclosures Kern: MLL Munich Leukemia Laboratory: Employment, Equity Ownership. Baer:MLL Munich Leukemia Laboratory: Employment. Nadarajah:MLL Munich Leukemia Laboratory: Employment. Haferlach:MLL Munich Leukemia Laboratory: Employment, Equity Ownership. Atsuta:Janssen Paharmaceutical K.K.: Honoraria; Mochida Pharmaceutical Co. Ltd: Honoraria; Kyowa Kirin Co., Ltd: Honoraria; Chugai Pharmaceutical Co., Ltd.: Honoraria. Handa:Ono: Research Funding. Haferlach:MLL Munich Leukemia Laboratory: Employment, Equity Ownership. Ogawa:Qiagen Corporation: Patents & Royalties; Kan Research Laboratory, Inc.: Consultancy; ChordiaTherapeutics, Inc.: Consultancy, Equity Ownership; Dainippon-Sumitomo Pharmaceutical, Inc.: Research Funding; Asahi Genomics: Equity Ownership; RegCell Corporation: Equity Ownership.

scholarly journals The Evolution of Genetic Aberrations in CML Patients Harboring a Ph-Negative Clone: A 6-Year Follow-up Study of 52 Patients

Blood ◽  
2018 ◽  
Vol 132 (Supplement 1) ◽  
pp. 3002-3002
Author(s):  
Constance Baer ◽  
Wolfgang Kern ◽  
Torsten Haferlach ◽  
Claudia Haferlach
Keyword(s):  
Molecular Genetic ◽  
Clinical Impact ◽  
Employment Equity ◽  
Genetic Aberrations ◽  
Myeloid Malignancy ◽  
Mutation Pattern ◽  
Equity Ownership ◽  
Reference Cohort ◽  
Ph Detection

Abstract Background: Clonal chromosome aberrations in Philadelphia chromosome-negative metaphases (CCA/Ph-) occur in a subset of chronic myeloid leukemia (CML) patients. A shorter survival was reported for "non -Y" CCA/Ph- cases (Issa et al. Blood 2017). Besides -Y, the most frequent CCA/Ph- is +8, but a broad spectrum of other abnormalities can be found, including 7q-/-7, which is a typical aberration of myelodysplastic syndromes (MDS). In previous analyses we had shown an increased number of molecular genetic aberrations in CCA/Ph- compared to non-CCA/Ph- patients (Schnittger et al. ASH 2013, 2014). However, the clinical impact and the evolution of the mutation pattern is largely unknown. Here we extended follow-up and genetic characterization of the initial CCA/Ph- cohort. Aim: To determine the pattern of molecular mutations and their evolution To determine if mutations are part of the Ph+ or Ph- clone Patients and Methods: We included 52 CCA/Ph- patients (female: 25; male 27), with a median age of 58 [33-81] years, and a median BCR-ABL1/ABL1 ratio of 4.322% [0-58.088%] (N.A. for 4 pts.) at the time of initial CCA/Ph- detection. The following CCA/Ph- were present: trisomy 8 (n=26), other trisomies (n=4), -Y (n=7), del(7q)/-7 (n=4), others (n=7), two CCA/Ph- (n=4). We performed sequencing of myeloid gene panels on follow-up samples (1 to 3 per patient) on Illumina's MiSeq and NextSeq instruments (library preparation: 29-gene panel Thunderstorm RainDance [Lexington, MA] or 28-gene panel TruSeq [Illumina, San Diego, CA]). Data was analyzed with SeqNext (JSI Medical Systems, Kippenheim, Germany). Detected mutations were monitored on additional time points to determine variant allele frequency (VAF: mutated/all reads) development. A reference cohort of 47 patients with no sign of CCA/Ph- after MMR achievement was presented as part of our initial study (Schnittger et al. ASH 2014). Results: Cytogenetic monitoring was available over a median period of 31 [0-126] months for the CCA/Ph- and 26 [12-85] months for the reference cohort. Of the CCA/Ph- patients, 5/52 (10%) acquired additional typical aberrations as CCA/Ph- clone (incl. one -7), while in the reference cohort only one of 47 (2%) patients developed a -Y clone (n.s.). On the molecular level, we conducted a median follow-up of 72 [9-150] months for the CCA/Ph- cohort (mutations and BCR-ABL1/ABL1 ratio). Following the CCA/Ph- detection, somatic mutations were found in 30/52 (58%) patients (up to 4 per patient): ASXL1 (n=13), DNMT3A (n=10), TET2 (n=6), NRAS (n=3), RUNX1 (n=3), non-recurrent (n=8). The VAF of 7 mutations was strongly correlated to the BCR-ABL1 ratio and thus most likely present in the Ph+ clone. Mutations in ASXL1 were present in the Ph+ clone in five patients, of whom four never reached MMR, while 6/8 patients with ASXL1 mutations in Ph-independent clones achieved MMR under first- or second-line TKI therapy. Molecular genetic aberrations in Ph- cells were found in 23/52 (42%) CCA/Ph- patients, but only in 2 of 47 (4%) cases of the non-CCA/Ph- cohort (p<0.001). Importantly, in the reference cohort only TET2 and DNMT3A mutations were identified, which is the typical pattern in age related clonal hematopoiesis (ARCH) and also found in older individuals without a hematological malignancy. In the CCA/Ph- cohort, eight of 23 (35%) showed only TET2 or DNMT3A mutations. However, a highly predictive mutation signature for development of a myeloid malignancy (according to Malcovati et al. Blood 2017) was found in 8/23 (35%). In addition, of three NRAS positive CCA/Ph- cases, one was diagnosed with MDS/MPN overlap (also CALR positive) and two developed s-AML during the follow-up period and the NRAS VAF had increased to ≥35% at our last monitoring time point. Conclusions: ASXL1 mutations can occur in the Ph- as well as in the Ph+ clone and are associated with a poor TKI response, if present in the Ph+ clone. Molecular mutations are significantly more frequent in CCA/Ph- than in non-CCA/Ph-. While the mutation pattern in non-CCA/Ph- resembles ARCH, the spectrum in CCA/Ph- includes a higher risk pattern for development of a myeloid malignancy. Further prospective studies are required to evaluate the clinical impact of mutations acquired during the course of CML in order to determine which mutation pattern is related to a higher incidence of secondary myeloid malignancies. Disclosures Baer: MLL Munich Leukemia Laboratory: Employment. Kern:MLL Munich Leukemia Laboratory: Employment, Equity Ownership. Haferlach:MLL Munich Leukemia Laboratory: Employment, Equity Ownership. Haferlach:MLL Munich Leukemia Laboratory: Employment, Equity Ownership.

Degree of Aberrant Antigen Expression in Myelodysplastic Syndromes Correlates with the Number of Molecular Mutations

Blood ◽  
2015 ◽  
Vol 126 (23) ◽  
pp. 2856-2856
Author(s):  
Wolfgang Kern ◽  
Manja Meggendorfer ◽  
Seishi Ogawa ◽  
Claudia Haferlach ◽  
Susanne Schnittger ◽  
...  
Keyword(s):  
Flow Cytometry ◽  
Molecular Genetics ◽  
Myelodysplastic Syndromes ◽  
Antigen Expression ◽  
Erythroid Cells ◽  
Employment Equity ◽  
Cell Compartment ◽  
Flow Cytometric ◽  
Equity Ownership ◽  
Myeloid Progenitors

Abstract Introduction: The diagnostic approach for suspected myelodysplastic syndromes (MDS) is evolving and flow cytometry and molecular genetics are increasingly considered to be applied in addition to cytomorphology and cytogenetics. While reports on comparisons of flow cytometric findings with results of cytomorphology and cytogenetics are available, data on comparisons between results obtained by flow cytometry and molecular genetics, however, have not yet been presented in detail. Aims: 1) To assess the correlation between flow cytometric findings on MDS-specific aberrant antigen expression and the presence of molecular mutations in patients with cytomorphologically proven MDS. 2) To determine the respective impact of flow cytometric findings and of molecular mutations on survival in patients with MDS. Patients and methods: In 256 patients (male/female, 161/95; median age 72 years, range 24-90) with proven MDS (137 low-risk MDS, 119 RAEB1/2) we compared data on aberrantly expressed antigens (AEA) determined according to ELN guidelines (Westers, Leukemia 2012) to the previously published mutational status of 104 genes (Haferlach, Leukemia 2014). Results: Median numbers (ranges) of AEA were 0 (0-3) in myeloid progenitors, 2 (0-4) in granulocytes, 1 (0-5) in monocytes and 0 (0-1) in erythroid cells. Median number of mutation was 2 (0-7). The number of AEA in myeloid progenitors, granulocytes and monocytes increased with increasing number of mutations (r=0.257, p<0.001). Accordingly, in cases with ≥3 mutations the number of AEA in myeloid progenitors, granulocytes and monocytes was higher than in cases with ≤2 mutations (mean±SD, 3.9±1.9 vs. 3.0±2.0, p=0.001). This correlation was significant also when considering granulocytes as a single cell compartment (r=0.308, p<0.001) but non-significant trends only for myeloid progenitors and monocytes. No such correlation was observed for erythroid cells. Specifically, mutations in each of the genes TET2, ASXL1, SRSF2, STAG2, ZRSR2 or NF1 were associated with significantly higher numbers of AEA in ≥1 cell compartment. Cases with mutations in ≥1 of these genes (n=145), as compared to those without these 6 mutations (n=111), had higher numbers of AEA in myeloid progenitors (0.4±0.7 vs. 0.2±0.5, p=0.037), granulocytes (2.0±1.1 vs. 1.4±1.1, p<0.001) and monocytes (1.5±1.3 vs. 1.0±1.0, p=0.002). Consequently, the difference in the total of AEA was even larger (3.9±2.0 vs. 2.7±1.9, p<0.001). Regarding scoring points according to IPSS-R, there was a significant correlation with the number of AEA in granulocytes (r=0.189, p=0.004) as well as with the number of AEA in monocytes (r=0.159, p=0.017). Consequently, there was also a significant correlation between the IPSS-R scoring points and the number of AEA in myeloid progenitors, granulocytes and monocytes (r=0.227, p=0.001). Overall survival was impacted by the presence of mutations in ≥1 of the genes TP53, EZH2, ETV6, RUNX1 and ASXL1 (p<0.001, HR 2.9) published by Bejar (NEJM 2011) as well as by the presence of ≥3 AEA in myeloid progenitors, granulocytes and monocytes (p=0.015, HR 1.7) and by IPSS-R (p<0.001, HR 1.4). Multivariate analysis considering mutations and AEA revealed an independent significance for both of them (mutations, p<0.001, HR 2.9; AEA, p=0.017, HR 1.7). However, inclusion of also IPSS-R as a covariate resulted in a trend only for AEA (p=0.16, HR 1.4) and independent significance for mutations (p<0.001, HR 2.3) and IPSS-R (p<0.001, HR 1.3). Conclusions: This data demonstrates that the degree of flow cytometric findings on MDS-related aberrant antigen expression correlates with the number of molecular mutations as well as with the IPSS-R. The present result therefore further support the consideration of both flow cytometry and molecular genetics for the diagnostic work-up of MDS in an integrated approach in combination with cytomorphology and cytogenetics. Disclosures Kern: MLL Munich Leukemia Laboratory: Employment, Equity Ownership. Meggendorfer:MLL Munich Leukemia Laboratory: Employment. Haferlach:MLL Munich Leukemia Laboratory: Employment, Equity Ownership. Schnittger:MLL Munich Leukemia Laboratory: Employment, Equity Ownership. Haferlach:MLL Munich Leukemia Laboratory: Employment, Equity Ownership.

Down Syndrome AML Is Unique in Phenotype Both at Diagnosis and in Post Chemotherapy Regeneration

Blood ◽  
2016 ◽  
Vol 128 (22) ◽  
pp. 1687-1687
Author(s):  
Elisabeth R Wilson ◽  
Lisa Eidenschink Brodersen ◽  
Barbara Katharina Zehentner ◽  
Andrew J. Menssen ◽  
Andrew P. Voigt ◽  
...  
Keyword(s):  
Down Syndrome ◽  
Cell Sorting ◽  
Residual Disease ◽  
Antigen Expression ◽  
Oncology Group ◽  
Employment Equity ◽  
Hla Dr ◽  
Equity Ownership ◽  
Antibody Panel

Abstract Background: Down syndrome (DS) acute myeloid leukemia (DS-AML) is predominantly found in young children (under the age of 4) and responds well to chemotherapy. The difference in clinical features suggests that despite the predominance of megakaryoblastic disease, DS-AML blasts are different from non-DS AML blasts with megakaryoblastic morphology (AMKL). The immunophenotypes of DS-AML blasts at diagnosis were compared to those of non-DS AML patients using unsupervised hierarchical clustering analysis (HCA) and assessed for their immunophenotypic overlap with known morphologic subgroups. In addition, residual disease monitoring of non-DS AML patients using "Difference from Normal" flow cytometry has been applied to DS-AML with unexpected results. Methods: A standardized antibody panel was used to define quantitative gene product (antigen) expression in bone marrow (BM) specimens from patients with AML at diagnosis and following chemotherapy. The quantitative phenotypic expression of multiple cell surface markers and physical characteristics defined a position in 15 dimensional data space for each patient. HCA was performed to mathematically cluster DS-AML patients enrolled on Children's Oncology Group study AAML1531 with non-DS patients from study AAML0531 based on 15 dimensional profiles. Five patients with DS who were older than 4 years of age and therefore treated on AAML0531 were also included. Data regarding morphology were appended to the data set. The same antibody panel was used to assess measurable residual disease (MRD) in 147 follow up BM aspirates from 50 DS patients ages 1 to 21 undergoing treatment for either AML or B-ALL (n=46, n=4 respectively) who were not included in the clinical studies. When possible, cell sorting was performed for FISH or SNP/CGH microarray studies. Results: Diagnostic Clustering: HCA of 17 DS-AML diagnostic phenotypes with 769 non-DS AML patients revealed a tight immunophenotypic correlation between 12 (71%) DS-AML patients (Figure 1). Further analysis of this diagnostic subset showed a consistent mean antigen expression profile that was distinct from non-DS AML diagnostic phenotypes. Similarly, the DS-AML patients clustered separately from the 5 older DS patients (>4 years of age) with AML, who were treated on AAML0531 and exhibited consistently different identifying diagnostic markers despite the shared constitutional trisomy 21. Additionally, the phenotype associated with the DS-AML cluster does not match that of patients with AMKL morphology. The largest immunophenotypic cluster of non-DS patients with AMKL morphology were classified with the RAM phenotype[1], which segregate into a mathematically unique branch of the dendogram distinct from the DS-cluster. Observation of a consistent DS-specific non-leukemic myeloid regenerative phenotype: Of the 147 post chemotherapy specimens submitted for MRD analysis off clinical study, 141 (96%) had a clearly identifiable CD34+/CD56+ population present between 0.06-6.0% total non-erythroid composition. A second abnormal population expressing CD34+ but not HLA-DR was also observed in these patients but at a lower level (0.02-2.66%) compared to the CD34+/CD56+ cell population. Two patients had a reproducible absence of 56+, DR- progenitors across all follow up specimens (6/147) and may represent unique clinical cases with disease features beyond our knowledge. In four DS patients undergoing treatment for B-ALL, the same immunophenotypic features (CD34+/CD56+ and negative HLA-DR) were observed. Genetic data: In 4 cases, cell sorting of CD34+/CD56+ post treatment progenitors revealed a lack of cytogenetic markers present in the clone of leukemic blasts at diagnosis. Conclusions: The blasts of patient with typical DS-AML (i.e under the age of 4 years at diagnosis) are immunophenotypically distinct from those of non-DS-AML patients and exhibit consistent immunophenotypic features that differ from DS patients with AML who are older than 4 years of age. The normal myeloid progenitors in DS patients who have undergone chemotherapy for AML or ALL express an immunophenotype that is different from normal BM of non-DS patients recovering from chemotherapy. [1] Brodersen, Lisa Eidenschink, et al. "A Recurrent Immunophenotype at Diagnosis Independently Identifies High Risk Pediatric AML: A Report from the Children's Oncology Group Trial AAML0531." Disclosures Wilson: Hematologics: Employment. Brodersen:Hematologics: Employment. Zehentner:Hematologics: Employment, Equity Ownership. Pardo:Hematologics, Inc: Employment. Wells:Hematologics: Employment, Equity Ownership. Loken:Hematologics: Employment, Equity Ownership.

Significance of Flow Cytometric and Mutational Findings in Patients with Cytopenias and Limited or No Signs of Myelodysplasia By Cytomorphology

Blood ◽  
2015 ◽  
Vol 126 (23) ◽  
pp. 1671-1671
Author(s):  
Wolfgang Kern ◽  
Manja Meggendorfer ◽  
Claudia Haferlach ◽  
Susanne Schnittger ◽  
Torsten Haferlach
Keyword(s):  
Flow Cytometry ◽  
Normal Karyotype ◽  
Initial Assessment ◽  
Employment Equity ◽  
Initial Flow ◽  
Flow Cytometric ◽  
Equity Ownership ◽  
Diagnostic Work ◽  
Work Up

Abstract Introduction: The diagnosis of myelodysplastic syndromes (MDS) has been clearly defined by the WHO classification but remains a challenge in a significant number of cases with cytomorphologically borderline findings and normal karyotype. Furthermore, flow cytometry is capable of identifying MDS-specific aberrant antigen expression yet its value in these borderline cases as well as in those even without cytomorphologic findings of myelodysplasia remains to be clarified. Follow-up analyses as well as extension of diagnostic work-up to screening for molecular mutations may give further insight. Aims: Assess the significance of cytomorphologically borderline dysplastic changes and of flow cytometric MDS-related findings in the absence of a clear-cut diagnosis of MDS by screening for molecular mutations and by diagnostic reassessment during follow-up. Patients and methods: Bone marrow samples of 322 patients were assessed for suspected MDS by cytomorphology, flow cytometry and cytogenetics in parallel from 08/2005 to 11/2014 which 1) did not reveal a definite diagnosis of MDS by cytomorphology, 2) had a normal karyotype and 3) had at least one follow-up bone marrow assessment. By cytomorphology, 159 (49%) cases had borderline dysplastic findings while 163 (51%) had no sign of MDS. By flow cytometry, 138 (43%) cases had findings in agreement with MDS according to ELN criteria (Westers et al., Leukemia 2012; at least three aberrantly expressed antigens), 141 (44%) had borderline findings (one or two aberrantly expressed antigens) and 43 (13%) had no signs of MDS. A total of 699 follow-up samples were analyzed (median 2/patient). The median follow-up amounted to 3.0 years. In 147/322 patients (46%) screening for molecular mutations was performed on the initial samples, respectively, targeting a total of 20 genes (median 4 genes/patient, range 1-20). Analyzed genes were ASXL1, TET2, RUNX1, SRSF2, BCOR, DNMT3A, IDH2, NPM1, SF3B1, TP53, ZRSR2, CBL, CSF3R, ETV6, KDM6A, KRAS, MLL, SETBP1, SMC3 and U2AF1. Results: A total of 145 patients (45%) were diagnosed with MDS by cytomorphology during follow-up. The median duration until diagnosis amounted to 3.4 years. Regarding initial cytomorphology, more cases with borderline dysplastic findings were diagnosed MDS at follow-up than those without any dysplastic findings (82/159 (52%) vs 63/163 (39%), p=0.025). However, the duration until diagnosis of MDS did not differ significantly between the two groups (median 2.6 vs 3.4 years). Regarding initial flow cytometry, more cases with findings in agreement with MDS were diagnosed MDS by cytomorphology at follow-up than those without (80/138 (58%) vs 65/184 (35%), p<0.001) while there was no difference between cases with one or two aberrantly expressed antigens at initial assessment vs those with none (51/141 (36%) vs 14/43 (33%), n.s.). The duration until diagnosis of MDS significantly differed between the groups as defined by flow cytometry and was shortest in cases in agreement with MDS at initial assessment and longest in those without any aberrantly expressed antigen (median 1.9 vs 4.1 vs 5.6 years, p<0.001). Overall survival (OS) for all cases was 80% at 5 years. While initial cytomorphologic results revealed no impact on OS, patients with an initial flow cytometric result in agreement with MDS tended to have a shorter OS (5 year OS 70% vs 88%, p=0.12). Molecular screening revealed mutations in 21/147 patients (14%) at initial assessment. Mutated genes included ASXL1 (mutated in 6 patients), TET2 (6), RUNX1 (3), SRSF2 (3), as well as 2 cases each for BCOR, DNMT3A, IDH2, NPM1, SF3B1, TP53 and ZRSR2 and 1 case each for CBL, CSF3R, ETV6, KDM6A, KRAS, MLL, SETBP1, SMC3 and U2AF1. The percentage of patients with at least one mutation did not differ between cases with borderline dysplastic findings by cytomorphology as compared to those without any dysplastic findings. In contrast, significantly more cases with findings in agreement with MDS by flow cytometry had at least one mutation as compared to those with one or two aberrantly expressed antigens as well as to those with none (15/71 (21%) vs 6/58 (10%) vs 0/18, p=0.012). Conclusions: This data strongly supports the need to define the role of flow cytometry in the diagnostic work-up in suspected MDS and argues for an integrated approach with cytomorphology and cytogenetics. Implementation also of molecular data on mutations may further improve the validity of MDS diagnostics. Disclosures Kern: MLL Munich Leukemia Laboratory: Employment, Equity Ownership. Meggendorfer:MLL Munich Leukemia Laboratory: Employment. Haferlach:MLL Munich Leukemia Laboratory: Employment, Equity Ownership. Schnittger:MLL Munich Leukemia Laboratory: Employment, Equity Ownership. Haferlach:MLL Munich Leukemia Laboratory: Employment, Equity Ownership.

Rationale for Therapy Discontinuation in Patients with Lower-Risk Transfusion-Dependent Myelodysplastic Syndromes (MDS)

Blood ◽  
2016 ◽  
Vol 128 (22) ◽  
pp. 3541-3541
Author(s):  
Aaron T. Gerds ◽  
Shaloo Gupta ◽  
Gary Binder ◽  
Mikkael A. Sekeres ◽  
Aziz Nazha ◽  
...  
Keyword(s):  
Disease Progression ◽  
Board Of Directors ◽  
Lower Risk ◽  
Research Funding ◽  
Treatment Discontinuation ◽  
Employment Equity ◽  
Advisory Committees ◽  
Number Of Patients ◽  
Equity Ownership

Abstract Introduction: Approximately 50% of patients with MDS are anemic at initial diagnosis, with many becoming transfusion dependent (TD), necessitating the introduction of therapy with a goal of achieving transfusion independence (TI). In addition to transfusions, treatments to improve hemoglobin levels have historically been limited to erythropoiesis-stimulating agents (ESAs), whereas patients with more advanced disease may require treatment with a hypomethylating agent (HMA) (azacitidine [AZA] or decitabine [DAC]) or lenalidomide (LEN). As there is no predetermined treatment course, these therapies are continued until unacceptable toxicity, lack/loss of response, or disease progression. We examined treatment patterns, clinical outcome(s) of patients with MDS, and the physician's report of reason for treatment discontinuation (previously shown to vary from patients' perspectives) in patients who became TD at or after MDS diagnosis (Gerds et al. Blood 2014;124:abstract 2642). Methods:Data were derived from disease-specific physician surveys and patient charts, which provided information on demographic, treatment, and outcome data on lower-risk TD MDS patients. Patient inclusion criteria were: age ≥ 18 years, diagnosis of Low/Intermediate-risk MDS (International Prognostic Scoring System defined) 2-6 years prior to study entry, and becoming TD at least once during the minimum follow-up of 24 months. TD was defined as having received ≥ 2 transfusions within 8 weeks during the follow-up period. Patients who progressed to higher-risk disease or acute myeloid leukemia prior to becoming TD, had an additional malignancy, or were in an MDS clinical trial were excluded. Demographics, disease history, treatment history, TI, and reasons for treatment discontinuation were collected and reported descriptively. Results: A total of 239 physicians provided information on 1,221 lower-risk TD MDS patients. The median age of patients was 65 years (range 27-95 years), 56.3% were male, and median time since diagnosis was 3.2 years (range 2-6 years). Along with packed red blood cell transfusions, 354 patients (29%) were prescribed LEN [of whom 12.7% had del(5q)], 348 patients (28.5%) were prescribed ESAs, and 32 patients (2.6%) were prescribed HMAs. During the follow-up period, 31.3% of ESA patients discontinued therapy (at a median of 12 months; range 3-47 months), 32% of HMA patients discontinued therapy (at a median of 10 months; range 3-52 months), and 26% of LEN patients discontinued therapy (at a median of 13 months; range 2-30 months). In the LEN-treated group, only 9.8% of patients who discontinued therapy had del(5q). The main reason cited for treatment discontinuation across therapy groups reported by physicians was "patients completing the scheduled course of treatment" (28.2%), which occurred in 32.6%, 20.2%, and 22.6% of the LEN, ESA, and HMA groups, respectively. Other reported reasons for discontinuation included "insufficient initial response" (20.0%), "patients no longer responding to therapy" (19.0%), "disease progression" (18.0%), "death" (13.3%), and "worsening hemoglobin levels" (12.8%). Across therapy groups, "patient preference to stop therapy" was reported less frequently (9.7%), occurring in 7.6%, 8.3%, and 12.9% of the LEN, ESA, and HMA groups, respectively. Conclusions:Over 30% of TD lower-risk MDS patients receiving LEN, ESAs, AZA, or DAC discontinued therapy. Per physician reports, the most frequent reason for discontinuation of therapy was completion of scheduled treatment course, which is in stark contrast to recommendations in consensus guidelines, as MDS is a chronic disease in which treatment should be continued ad infinitum. The significant number of patients who stop therapy for alternative reasons suggests opportunities for further investigation. Education on the expected duration of therapy is essential to help support physicians and inform patients about optimal treatment decisions in the care of all MDS patients. Disclosures Gupta: Kantar Health: Employment; Celgene Corporation: Consultancy, Research Funding. Binder:Celgene Corporation: Employment, Equity Ownership. Carraway:Incyte: Membership on an entity's Board of Directors or advisory committees; Novartis: Membership on an entity's Board of Directors or advisory committees; Celgene Corporation: Research Funding, Speakers Bureau; Baxalta: Speakers Bureau; Amgen: Membership on an entity's Board of Directors or advisory committees. Hawthorne:Kantar Health: Employment; Celgene Corporation: Consultancy, Research Funding. King-Concialdi:Kantar Health: Employment; Celgene Corporation: Consultancy, Research Funding. McGuire:Celgene Corporation: Employment, Equity Ownership.

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