Germline predisposition traits in allogeneic hematopoietic stem-cell transplantation for myelodysplastic syndromes: a survey-based study and position paper on behalf of the Chronic Malignancies Working Party of the EBMT

Genetic predisposition to myelodysplastic syndrome: Genetic counseling and transplant implications

The development of myelodysplastic syndromes (MDS) is influenced by various genetic predispositions. Several important genes contribute to disease susceptibility. This paper explores common genetic predisposition genes in MDS, including DDX41, CEBPA, and SAMD9/SAMD9L, which are linked to hereditary conditions presenting diagnostic and clinical challenges. It delves into hereditary conditions that affect platelet production and count, such as RUNX1, ETV6, and ANKRD26, detailing their clinical features and how they contribute to an increased risk of MDS. The discussion extends to additional genetic syndromes like GATA2 deficiency, telomere biology disorders, Fanconi anemia, and Li-Fraumeni syndrome, along with new findings on genes like ERG that offer new insights into disease etiology. The importance of genetic counseling in MDS is underscored, outlining its goals, methods for evaluating family history, risk assessment, and the ethical considerations involved. Furthermore, the role of hematopoietic cell transplantation in managing MDS, particularly in patients with germline syndromes, is reviewed, emphasizing the need for optimal donor selection and personalized treatment approaches. This comprehensive overview illustrates the critical role of genetic factors in MDS and highlights the need for continued research and tailored clinical practices to improve patient outcomes.

Update on Genetic Counselor Practice and Recommendations for Pediatric Cancer Predisposition Evaluation and Surveillance

In July 2023, the American Association for Cancer Research held the second Childhood Cancer Predisposition Workshop, at which international experts in pediatric cancer predisposition met to update the previously published 2017 consensus statements on pediatric cancer predisposition syndromes. Since 2017, advances in tumor and germline genetic testing and increased understanding of cancer predisposition in patients with pediatric cancer have led to significant changes in clinical care. Here, we provide an updated genetic counseling framework for pediatric oncology professionals. The framework includes referral indications and timing, somatic and germline genetic testing options, testing for adult-onset cancer predisposition syndromes in children with and without cancer, evolving genetic counseling models to meet the increased demand for genetic testing, barriers to cancer genetic testing and surveillance in children, and psychosocial and equity considerations regarding cancer genetic testing and surveillance in children. Adaptable genetic counseling services are needed to provide support to pediatric oncology provider teams and diverse patients with pediatric cancer, cancer predisposition, and their families.

Applying Implementation Science in the Field of Transplant and Cellular Therapy

Implementation science (IS) is a systematic way to approach the broader adoption of evidence-based practices and has as its goal to understand and address the gap between research and practice, ensuring that research findings are effectively translated into practice and policy to improve health outcomes and service. We describe the various facets of IS and their relevance to the field of hematopoietic cell transplantation and cellular therapy (HCT/CT) with an emphasis on health equity, community engagement, and systems approach. We also review the similarities and differences among clinical research, quality improvement, and IS. Additionally, we describe how the Center for International Blood and Marrow Transplant Research applies IS across various phases: dissemination, analyzing current practices, and developing implementation intervention strategies. This includes designing studies and evaluations, scaling up operations, and ensuring sustainability. Lastly, we discuss further applications of IS in HCT/CT including the application to prospective research studies, collaboration across the field, and standardization and adoption of best practices. The application of IS in HCT/CT is pivotal to bringing research benefits directly to all patients. Through partnership, open-mindedness, and a commitment to evidence-based practice, we can collectively ensure the greatest impact of research on improving patient outcomes following HCT/CT.

The impact of next-generation sequencing for diagnosis and disease understanding of myeloid malignancies

INTRODUCTION

Defining the chromosomal and molecular changes associated with myeloid neoplasms (MNs) optimizes clinical care through improved diagnosis, prognosis, treatment planning, and patient monitoring. This review will concisely describe the techniques used to profile MNs clinically today, with descriptions of challenges and emerging approaches that may soon become standard-of-care.

AREAS COVERED

In this review, the authors discuss molecular assessment of MNs using non-sequencing techniques, including conventional cytogenetic analysis, fluorescence in situ hybridization, chromosomal genomic microarray testing; as well as DNA- or RNA-based next-generation sequencing (NGS) assays; and sequential monitoring via digital PCR or measurable residual disease assays. The authors explain why distinguishing somatic from germline alleles is critical for optimal management. Finally, they introduce emerging technologies, such as long-read, whole exome/genome, and single-cell sequencing, which are reserved for research purposes currently but will become clinical tests soon.

EXPERT OPINION

The authors describe challenges to the adoption of comprehensive genomic tests for those in resource-constrained environments and for inclusion into clinical trials. In the future, all aspects of patient care will likely be influenced by the adaptation of artificial intelligence and mathematical modeling, fueled by rapid advances in telecommunications.

Latest Insights and Therapeutic Advances in Myelodysplastic Neoplasms

Myelodysplastic syndromes/neoplasms (MDSs) encompass a range of hematopoietic malignancies, commonly affecting elderly individuals. Molecular alterations in the hematopoietic stem cell compartment drive disease pathogenesis. Recent advancements in genomic profiling have provided valuable insights into the biological underpinnings of MDSs and have expanded therapeutic options, particularly for specific molecularly defined subgroups. This review highlights the diagnostic principles, classification updates, prognostic stratification systems, and novel treatments, which could inform future clinical trials and enhance the management of adult MDS patients, particularly for specific molecularly defined subgroups.

How I reduce and treat posttransplant relapse of MDS

ABSTRACT

Allogeneic hematopoietic stem cell transplantation (HSCT) is the only potentially curative option for patients with high-risk myelodysplastic syndromes (MDS). Advances in conditioning regimens and supportive measures have reduced treatment-related mortality and increased the role of transplantation, leading to more patients undergoing HSCT. However, posttransplant relapse of MDS remains a leading cause of morbidity and mortality for this procedure, necessitating expert management and ongoing results analysis. In this article, we review treatment options and our institutional approaches to managing MDS relapse after HSCT, using illustrative clinical cases that exemplify different clinical manifestations and management of relapse. We address areas of controversy relating to conditioning regimen intensity, chemotherapeutic bridging, and donor selection. In addition, we discuss future directions for advancing the field, including (1) the need for prospective clinical trials separating MDS from acute myeloid leukemia and focusing on posttransplant relapse, as well as (2) the validation of measurable residual disease methodologies to guide timely interventions.

Post-transplant Inflammatory Bowel Disease Associated with Donor-Derived TIM-3 Deficiency

Inflammatory bowel disease (IBD) occurring following allogeneic stem cell transplantation (aSCT) is a very rare condition. The underlying pathogenesis needs to be better defined. There is currently no systematic effort to exclude loss- or gain-of-function mutations in immune-related genes in stem cell donors. This is despite the fact that more than 100 inborn errors of immunity may cause or contribute to IBD. We have molecularly characterized a patient who developed fulminant inflammatory bowel disease following aSCT with stable 100% donor-derived hematopoiesis. A pathogenic c.A291G; p.I97M HAVCR2 mutation encoding the immune checkpoint protein TIM-3 was identified in the patient's blood-derived DNA, while being absent in DNA derived from the skin. TIM-3 expression was much decreased in the patient's serum, and in vitro-activated patient-derived T cells expressed reduced TIM-3 levels. In contrast, T cell-intrinsic CD25 expression and production of inflammatory cytokines were preserved. TIM-3 expression was barely detectable in the immune cells of the patient's intestinal mucosa, while being detected unambiguously in the inflamed and non-inflamed colon from unrelated individuals. In conclusion, we report the first case of acquired, "transplanted" insufficiency of the regulatory TIM-3 checkpoint linked to post-aSCT IBD.