Myelodysplastic syndromes in patients under 50 years old: a single institution experience

IPSS-M has greater survival predictive accuracy compared with IPSS-R in persons ≥ 60 years with myelodysplastic syndromes

There are considerable new data on mutation topography in persons with myelodysplastic syndromes (MDS). These data have been used to update conventional risk models such as the Revised International Prognostic Scoring System (IPSS-R). Whether the molecular IPSS (IPSS-M) which includes these data improves survival prediction accuracy is untested. To answer this question, we compared survival prediction accuracies of the IPSS-R and IPSS-M in 852 consecutive subjects with de novo MDS. Concordance statistics (C-statistics) of the IPSS-R and IPSS-M in the entire cohort were similar, 0.67 (95% Confidence Interval [CI] 0.64, 0.71) and 0.68 (0.64, 0.71). Average numbers of mutations and of IPSS-M related mutations were greater in persons ≥ 60 years (2.0 [Interquartile Range [IQR], 1, 3] vs. 1.6 [0, 2], P = 0.003; 1.6 [0, 2] vs. 1.3 [0, 2], P = 0.006). Subjects ≥ 60 years had a higher incidence of mutations in RUNX1, TP53, TET2, SRSF2, DNMT3A, STAG2, EZH2 and DDX41. In contrast, mutations in U2AF1 were more common in persons < 60 years. Next we tested survival prediction accuracy based on age < or ≥ 60 years. C-statistics of the IPSS-R and IPSS-M in subjects ≥ 60 years were 0.66 (0.61, 0.71) and 0.69 (0.64, 0.73) whereas in subjects < 60 years they were 0.67 (0.61, 0.72) and 0.65 (0.59, 0.71). These data indicate an advantage for the IPSS-M over the IPSS-R in subjects ≥ 60 years but not in those < 60 years probably because of a great frequency of mutations correlated with survival in those ≥ 60 years.

Pregnancy and myelodysplastic syndrome: an analysis of the clinical characteristics, maternal and fetal outcomes

OBJECTIVE

To investigate the clinical characteristics, management, maternal and fetal outcomes in pregnant patients with myelodysplastic syndrome (MDS).

METHODS

A retrospective analysis was conducted on 25 pregnant women with MDS between June 1998 and January 2013. The clinical data were summarized. These patients were divided into poor outcome group and control group, and regression analysis was conducted to find the risk factors for maternal and fetal outcomes.

RESULTS

Five patients developed premature birth, five patients developed postpartum hemorrhage, one patient developed postpartum acute cardiac failure and one patient developed postpartum cerebral infarction. Twenty out of the 25 patients underwent complete follow-up and 17 newborns were normal during follow-up. The regression analysis shows anemia and gestational hypertension are the primary risk factors for poor outcomes, whereas age, first onset of hematological disease, WBC count and platelet count are not significantly associated with the outcomes.

DISCUSSION

Anemia and gestational hypertension may be the primary risk factors for poor maternal and fetal outcomes in pregnant patients with MDS. To avoid maternal and neonatal complications, a minimum of hemoglobin level >70 g/L, platelet count >30 × 10(9)/L and WBC count >3 × 10(9)/L, are recommended. Close monitoring on blood routine, maternal complications and active supportive treatment are recommended.

Acquired myelodysplasia or myelodysplastic syndrome: clearing the fog

Myelodysplastic syndromes (MDS) are clonal myeloid disorders characterized by progressive peripheral blood cytopenias associated with ineffective myelopoiesis. They are typically considered neoplasms because of frequent genetic aberrations and patient-limited survival with progression to acute myeloid leukemia (AML) or death related to the consequences of bone marrow failure including infection, hemorrhage, and iron overload. A progression to AML has always been recognized among the myeloproliferative disorders (MPD) but occurs only rarely among those with essential thrombocythemia (ET). Yet, the World Health Organization (WHO) has chosen to apply the designation myeloproliferative neoplasms (MPN), for all MPD but has not similarly recommended that all MDS become the myelodysplastic neoplasms (MDN). This apparent dichotomy may reflect the extremely diverse nature of MDS. Moreover, the term MDS is occasionally inappropriately applied to hematologic disorders associated with acquired morphologic myelodysplastic features which may rather represent potentially reversible hematological responses to immune-mediated factors, nutritional deficiency states, and disordered myelopoietic responses to various pharmaceutical, herbal, or other potentially myelotoxic compounds. We emphasize the clinical settings, and the histopathologic features, of such AMD that should trigger a search for a reversible underlying condition that may be nonneoplastic and not MDS.

Engineering mouse models with myelodysplastic syndrome human candidate genes; how relevant are they?

Myelodysplastic syndromes represent particularly challenging hematologic malignancies that arise from a large spectrum of genetic events resulting in a disease characterized by a range of different presentations and outcomes. Despite efforts to classify and identify the key genetic events, little improvement has been made in therapies that will increase patient survival. Animal models represent powerful tools to model and study human diseases and are useful pre-clinical platforms. In addition to enforced expression of candidate oncogenes, gene inactivation has allowed the consequences of the genetic effects of human myelodysplastic syndrome to be studied in mice. This review aims to examine the animal models expressing myelodysplastic syndrome-associated genes that are currently available and to highlight the most appropriate model to phenocopy myelodysplastic syndrome disease and its risk of transformation to acute myelogenous leukemia.

Daily practice management of myelodysplastic syndromes in France: data from 907 patients in a one-week cross-sectional study by the Groupe Francophone des Myelodysplasies

BACKGROUND

There is little published information on the everyday clinical management of myelodysplastic syndromes in real world practice.

DESIGN AND METHODS

We conducted a cross-sectional study of all patients with myelodysplastic syndromes attending 74 French centers in a 1-week period for inpatient admission, day-hospital care or outpatient visits.

RESULTS

Nine hundred and seven patients were included; 67.3% had lower-risk myelodysplastic syndromes (International Prognostic Scoring System: low or intermediate-1). Karyotype had been analyzed in 82.5% of the cases and was more often of intermediate or poor risk in patients under 65 years old compared with those who were older. Red blood cell transfusions accounted for as many as 31.4% of the admissions. Endogenous erythropoietin level was less than 500 IU/L in 88% of the patients tested. Erythroid stimulating agents had been or were being used in 36.8% of the lower risk patients, iron chelation in 31% of lower risk patients requiring red blood cell transfusions and lenalidomide in 41% of lower risk patients with del 5q. High-dose chemotherapy, hypomethylating agents, low dose cytarabine and allogeneic stem cell transplantation had been or were being used in 14.8%, 31.1%, 8.8% and 5.1%, respectively, of higher-risk patients.

CONCLUSIONS

Karyotype is now assessed in most patients with myelodysplastic syndromes, and patients under 65 years old may have more aggressive disease. Apart from erythroid-stimulating agents and, in higher-risk myelodysplastic syndromes, hypomethylating agents, specific treatments are used in a minority of patients with myelodysplastic syndromes and red blood cell transfusions still represent the major reason for hospital admission.

Diagnostic tools in the indications for allogeneic stem cell transplantation in myelodysplastic syndromes

The rates of allogeneic stem cell transplantation (SCT) to treat the myelodysplastic syndromes (MDS) is continually increasing. However, given the growing arsenal of therapeutic options in parallel to deeper insight into the heterogeneity of this disorder, determining the indications for SCT in MDS remains a difficult task. The International Prognostic Scoring System (IPSS) serves as a guideline for therapeutic decisions, but many aspects (eg, interpretation of rare cytogenetic abnormalities, combinations of chromosomal alterations and/or molecular markers, variant clinical courses within distinct biological subgroups) remain the subject of continuous investigation. In an effort to achieve a more well-differentiated risk categorization, attempts have been made to perform a more detailed cytogenetic categorization, and the use of various fluorescein in situ hybridization (FISH) techniques has improved the description of aberrations. Multicenter initiatives have standardized multiparameter flow cytometry techniques for diagnosis of MDS. In advanced MDS, screening for molecular mutations can identify cases with a high transformation risk. Finally, the new World Health Organization classification system provides a more homogenous morphological categorization of MDS compared with the former French-American-British system. Consequently, in the near future, risk stratification in MDS might incorporate additional diagnostic tools and categorization systems aimed at improving the timing and indication for SCT in this complex disorder.

Benzene exposure and refractory sideroblastic erythropoiesis: is there an association?

The myelodysplastic syndromes (MDS) consist of a group of diverse hematological disorders that carry an increased risk of transforming into acute myeloid leukemia. They may appear de novo and without obvious cause (primary or de novo MDS) or be induced by certain mutagenic environmental or therapeutic toxins (secondary MDS). Excessive exposures to benzene are generally considered to be a potential environmental risk factor for both MDS and acute myeloid leukemia. However, such risk is unproven for each disease component within the MDS classification. A critical review of the refractory sideroblastic disorders strongly suggests that benzene exposure is not a potential cause of this distinct and still-evolving subset of MDS. The widely disparate nature of MDS suggests that epidemiologic studies can only provide meaningful data on associations and potential causation of its component syndromes by a disease-specific analysis, as is currently advocated for other hematological malignancies.

Differences in epidemiology of MDS between Western and Eastern countries: Ethnic differences or environmental influence?

Myelodysplastic syndromes show ethnic differences. Several investigators have reported a striking difference in age at diagnosis between Eastern and Western MDS patients. Referring to a letter bei Paydas speculating about toxic environmental influences as a possible cause for younger age in Asian MDS patients, we discuss our experience from a direct comparison of Japanese and German MDS, in particular refractory anemia patients.

The spectrum of myelodysplastic syndromes post-solid organ transplantation: A single institutional experience

An increased incidence of acute myeloid leukemia (AML) has recently been documented in patients post-solid organ transplantation but the incidence and types of myelodysplastic syndromes (MDS) occurring in this patient population are not known. We identified 5 patients (3M, 2F, age 48-64 years) who developed MDS ranging from 1.8 to 25 years (median 4.2 years) post-solid organ transplantation, only 2 patients had received azathioprine. The cumulative incidence of MDS in heart and lung transplant recipients at 15 years was 0.5% and 1.8%, respectively, which is markedly higher compared to the general population. Low-risk types of MDS predominated, 3 of 5 patients are alive (median 3.9 years) since diagnosis. Deletions of chromosome 20q, which have not been previously reported in post-transplant MDS/AML, were identified in 3 cases. Our findings expand the morphologic and cytogenetic spectrum of MDS occurring post-solid organ transplantation and suggest that mechanisms beside azathioprine toxicity might be important in disease pathogenesis.

Myelodysplastic Syndromes in Patients Younger Than Age 50

Purpose

Myelodysplastic syndromes (MDS) mainly occur in the elderly but can affect younger individuals too. The latter require special consideration to identify suitable candidates for allogeneic stem-cell transplantation, a potentially curative approach carrying a high risk of treatment-related complications.

Patients and Methods

We report the largest series of young MDS patients as yet, including 232 patients younger than 50 years. Their clinical characteristics and prognosis are compared with 2,496 patients older than 50 years.

Results

Survival was significantly longer in the younger versus older age group (40 v 23 months, respectively; P < .00005). The difference arose from patients belonging to the low- and intermediate-I–risk categories of the International Prognostic Scoring System (median survival not reached v 45 months, respectively; P < .00005). In contrast, survival was identical for both age groups (8 months for both younger and older patients; P = .81) in the intermediate-II–and high-risk categories. Established classification systems and risk scores were applicable to young patients with primary MDS. Interestingly, a particularly large difference in median survival time was seen between the intermediate-I–and intermediate-II–risk groups (176 v 8 months, respectively). For low-risk patients, the overall survival rate was more than 86% at 20 years.

Conclusion

According to these results, aggressive treatment approaches should rarely be recommended to younger MDS patients belonging to the low and intermediate-I risk groups.

Pregnancy-induced pancytopenia with cellular bone marrow: distinctive hematologic features

Three patients with pregnancy-induced pancytopenia also exhibited variable features of sideroblastic anemia and amegakaryocytic thrombocytopenia. Treatment with anti-thymocyte globulin proved highly effective in two cases and a spontaneous remission occurred in the third. This illness is distinct from the more commonly reported incidental association of pregnancy with classic aplastic anemia. Its differentiation from myelodysplasia is also emphasized.

The myelodysplastic syndromes: diagnosis and treatment

The myelodysplastic syndromes (MDSs) are common, acquired, clinically challenging hematologic conditions that are characterized by bone marrow failure and a risk of progression to acute leukemia. These disorders can arise de novo, especially in elderly patients or, less often, as a consequence of prior chemotherapy or radiotherapy for an unrelated disease. The MDS classification systems were revised recently and updated. These refined classification and prognostic schemes help stratify patients by their risk of leukemia progression and death; this knowledge can help clinicians select appropriate therapy. Although many treatments for MDS have been proposed and evaluated, at present, only hematopoietic stem cell transplantation offers any real hope for cure, and no available therapy beyond general supportive care offers benefit to more than a minority of patients. However, recent clinical trials enrolling patients with MDS have reported encouraging results with use of newer drugs, including lenalidomide, decitabine, and darbepoetin alfa. Other exciting treatment regimens are being tested. Here, we present a contemporary, practical clinical approach to the diagnosis and risk-stratified treatment of MDS. We review when to suspect MDS, detail how to evaluate patients who may have a form of the condition, explain key features of treatments that are currently available in the United States, and summarize a general, common-sense therapeutic approach to patients with MDS.