Understanding iron homeostasis in MDS: the role of erythroferrone

Myelodysplastic neoplasms (MDS) are a heterogenous group of clonal stem cell disorders characterized by dysplasia and cytopenia in one or more cell lineages. Anemia is a very common symptom that is often treated with blood transfusions and/or erythropoiesis stimulating factors. Iron overload results from a combination of these factors together with the disease-associated ineffective erythropoiesis, that is seen especially in MDS cases with SF3B1 mutations. A growing body of research has shown that erythroferrone is an important regulator of hepcidin, the master regulator of systemic iron homeostasis. Consequently, it is of interest to understand how this molecule contributes to regulating the iron balance in MDS patients. This short review evaluates our current understanding of erythroferrone in general, but more specifically in MDS and seeks to place in context how the current knowledge could be utilized for prognostication and therapy.

Many faces of SF3B1-mutated myeloid neoplasms: concurrent mutational profiles contribute to the diverse clinical and morphologic features

Splicing factor SF3B1 mutation occurs in 20-30% of myelodysplastic syndrome (MDS) and myelodysplasia/myeloproliferative neoplasm (MDS/MPN), particularly those with ring sideroblasts (RS), and rarely in acute myeloid leukemia (AML). In this study, we performed a comprehensive evaluation of 77 SF3B1-mutated myeloid neoplasms (45 MDS, 18 MDS/MPN, 13 AML, and 1 MPN), including their clinical presentations, morphologic features, cytogenetic studies, and targeted next-generation sequencing. Our study demonstrated that concurrent gene mutations were very different in SF3B1-mutated MDS, MDS/MPN, and AML. MDS cases were frequently characterized by either sole SF3B1 mutation or in combination with TET2 mutation. Acquiring additional mutations in transcription factors, such as RUNX1 and GATA2, were associated with increased blasts and progression to AML in patients with MDS or MDS/MPN. Our study also demonstrated that SF3B1-mutated MDS/MPN was not only associated with thrombocytosis (5/18, 27.7%), defined by the current WHO classification as MDS/MPN-RS-T, but also associated with neutrophilia (6/18, 33.3%), monocytosis (6/18, 33.3%), and mastocytosis (1/18, 5.6%). Our results indicate that although SF3B1-mutated myeloid neoplasms in general have a good prognosis, evaluation of the concurrent gene mutational profile is important for risk stratification. In addition, our study, in combination with other published data, suggests that the category of MDS/MPN-RS-T in the current WHO classification could be expanded to include SF3B1-mutated MDS/MPN-RS with peripheral leukocytosis such as neutrophilia and monocytosis.

The clinical implications of BCOR mutations in a large cohort of acute myeloid leukemia patients: a 5-year single-center retrospective study

To elucidate the effect of BCOR mutation (BCORmut) on clinical outcomes, we included a total of 899 consecutive AML patients in a single-center during July 2016 to December 2021. Fifty cases (5.6%) had BCOR mutations, which co-occurred with mutations of RUNX1, DNMT3A, IDH2, BCORL1, STAG2, SF3B1 and U2AF1, but were exclusive with KIT and CEBPA mutations. BCORmut was also found to be exclusive with t(8;21)(q22;q22.1) AML in all patients and MLL rearrangements in the European Leukemia Net (ELN) adverse group. In those receiving intensive chemotherapy regimens, BCORmut was associated with lower complete remission (CR) rates and worse prognosis. Subgroup analysis showed that BCORmut mainly conferred a poor prognosis in the intermediate and adverse groups of the ELN2017 risk. These results suggest that BCOR mutation is an independent prognostic parameter in AML, implying BCOR mutation as a novel marker for chemorefractory disease and inferior prognosis.