Unexplained blood cytopenias, in particular anemia, are often found in older persons. The relationship between these cytopenias and myeloid neoplasms like myelodysplastic syndromes is currently ...poorly defined. We studied a prospective cohort of patients with unexplained cytopenia with the aim to estimate the predictive value of somatic mutations for identifying subjects with, or at risk of, developing a myeloid neoplasm. The study included a learning cohort of 683 consecutive patients investigated for unexplained cytopenia, and a validation cohort of 190 patients referred for suspected myeloid neoplasm. Using granulocyte DNA, we looked for somatic mutations in 40 genes that are recurrently mutated in myeloid malignancies. Overall, 435/683 patients carried a somatic mutation in at least 1 of these genes. Carrying a somatic mutation with a variant allele frequency ≥0.10, or carrying 2 or more mutations, had a positive predictive value for diagnosis of myeloid neoplasm equal to 0.86 and 0.88, respectively. Spliceosome gene mutations and comutation patterns involving TET2, DNMT3A, or ASXL1 had positive predictive values for myeloid neoplasm ranging from 0.86 to 1.0. Within subjects with inconclusive diagnostic findings, carrying 1 or more somatic mutations was associated with a high probability of developing a myeloid neoplasm during follow-up (hazard ratio = 13.9, P < .001). The predictive values of mutation analysis were confirmed in the independent validation cohort. The findings of this study indicate that mutation analysis on peripheral blood granulocytes may significantly improve the current diagnostic approach to unexplained cytopenia and more generally the diagnostic accuracy of myeloid neoplasms.
•Mutation profiling has a high predictive value for identifying individuals with, or at high risk of developing, a myeloid neoplasm.•Patients with clonal cytopenia have a significantly higher risk of developing a myeloid neoplasm than those with no evidence of clonality.
Diagnostic criteria for hypoplastic myelodysplasic syndrome (h-MDS) have not been clearly established, making the differential diagnosis from other bone marrow failure syndromes (BMF) challenging. In ...this study, we aimed to delineate clinical, histopathological, and molecular features of h-MDS, based on a large and well-annotated cohort of patients with bone marrow (BM) hypocellularity. The study included 534 consecutive adult patients with hypocellular BM (278 h-MDS and 136 aplastic anemia), and 727 with normo- or hypercellular MDS (n-MDS). Comparison of clinical features of patients with h-MDS as defined by BM cellularity ≤25% (n = 204) or reduced age-adjusted cellularity (n = 74) did not reveal significant differences. We developed a diagnostic score to discriminate h-MDS from non-malignant BMF based on histological and cytological variables with the highest specificity for MDS (h-score). The information from chromosomal abnormalities and somatic mutation patterns was then integrated into a cyto-histological/genetic score (hg-score). This score was able to segregate two groups of h-MDS with a significantly different risk of blast progression (P < 0.001). The integration of cyto-histological and genetic features in adult patients with hypocellular BM facilitated segregation into two distinct groups, one with clinical and genetic features highly consistent with myeloid neoplasm, and one with features more consistent with non-malignant BMF.
Although post-transplant cyclophosphamide (PT-Cy) is effective for graft-versus-host disease (GVHD) prophylaxis, it is associated with toxicities, which might be dose-dependent. We compared the ...outcomes with PT-Cy at 80 mg/kg to those with PT-Cy at 100 mg/kg in elderly patients undergoing haploidentical hematopoietic cell transplantation (HCT). Inclusion criteria included peripheral blood stem cells, hematological malignancy, and age>65 years (or age>60 years if cardiac event history). Thirty-eight patients received PT-Cy at 80 mg/kg and 55 100 mg/kg, divided in two doses. The cumulative incidences (CI) of acute grade II-IV, acute grade III-IV, and moderate/severe chronic GVHD were 32%, 16%, and 13% with PT-Cy at 80 mg/kg compared to 33%, 13%, and 16% with 100 mg/kg, respectively. In multivariable analysis, reducing PT-Cy dose had no significant impact on GVHD. Neutrophil and platelet engraftments were significantly improved, and CI of BK virus-associated hemorrhagic cystitis was reduced with 80 mg/kg of PT-Cy compared to 100 mg/kg. At 2 years, non-relapse mortality was 16% and 31%, progression-free survival 65% and 49%, overall survival 70% and 56%, and GVHD-free, relapse-free survival 52% and 36% with 80 mg/kg and 100 mg/kg, respectively. Reducing PT-Cy dose to 80 mg/kg is safe and associated with improved hematological recovery and lower CI of hemorrhagic cystitis in elderly patients undergoing haploidentical HCT.
Patients undergoing allogeneic stem cell transplant (HSCT) have a higher risk of developing malnutrition. The aetiology is multifactorial and complex: the conditioning regimen causes damages to the ...gastrointestinal tract that can contribute to trigger graft-versus-host disease and/or infectious complications that adversely affect food intake and the gut absorption of nutrients in transplant recipients.
Consequently, patients might develop weight loss and muscle wasting. There is mounting evidence that insufficient muscle mass increases the risk of toxicity to many chemotherapy drugs. Furthermore, the screening for malnutrition, assessment and intervention can vary among HSCT centers. Hereby, we report the main nutritional clinical issues in the field of HSCT and the main nutritional tools used in this setting. Future clinical trials investigating nutritional tools and dose-escalating studies based on pre-treatment body composition assessment may help having the potential to alter cancer treatment paradigms.
Background: Pre- and post-transplant pulmonary function tests (PFT) have been previously analyzed in patients who underwent allogeneic hematopoietic stem cell transplantation (HSCT). A deterioration ...in pulmonary function could be observed in this setting and accounts for higher morbidity and mortality. Haploidentical allogeneic stem cell transplantation (HAPLO) with post-transplant cyclophosphamide (PTCY) is increasingly used. Limited data exists on evaluation of PFT after HAPLO and the number of patients who underwent HAPLO in previously published studies is negligible. We report the evolution of PFT as well as pre-transplant characteristics and outcomes after HAPLO in the adult setting.
Methods: We retrospectively analyzed 80 HAPLO performed in a single center between 2013 and 2019. All patients with available pre- and post-transplant PFT results were included in the study. The Friedman test was used for comparing PFT at baseline, 100 days and 1 year after HAPLO.
Results: The median follow up was 32 (range: 12-74) months. CMV serology was positive in 45% and 65% of patients were male. The median age was 58 (range: 16-73) years. The proportion of surviving patients with available PFT at 3 months and 1 year were 86% and 68%, respectively. Diagnosis was acute myeloid leukemia in 51% and disease risk index was intermediate-low in 75% of the cases. Disease status before HAPLO was complete remission in 61%. Graft source was peripheral blood stem cells in 91% of the cases. Conditioning regimen was reduced intensity in 40% and the most frequent chemotherapy regimen was thiotepa, busulfan and fludarabine. Graft-versus- host disease (GvHD) prophylaxis consisted of Cyclosporine A (CsA) and mycophenolate mofetil in all but one patient who received methotrexate and CsA. All patients received PTCY, 64 (80%) at days 3 and 5 after HAPLO, 7 (9%) at days 3 and 4, and 9 (11%) at day 3 only. Seventy-three (91%) patients received anti-thymocyte globulin.
In total, 24% of the patients had previously smoked, 8% had type 2 diabetes, and 23% suffered from hypertension. Three patients had a lung infection at baseline, of which one was bacterial and two were possibly aspergillosis. At screening for HAPLO, five (6%) patients had restrictive lung disease, nine (11%) met the criteria for obstructive lung disease, and diffusing capacity for carbon monoxide (DLCO) corrected for hemoglobin was impaired in 74% of the patients. The median forced expiratory volume in the first second (FEV1) was 100 (range: 58-146) before HAPLO, 93 (range: 42-10) at 100 days after HAPLO and 99 (range: 32-144) at 1 year. The median forced vital capacity (FVC) was 106 (range: 57-153), 98 (range: 44-148) and 106 (range: 31-153) at pre HSCT, 100 days and 1 year after HAPLO, respectively. FEV1 and FVC were significantly different over time during the 1 year follow up (p=0.01 and p=0.001, respectively). The median FEV1/FVC was 80 (range 51-105) before HAPLO, 77 (range: 54-103) after 3 months, and 75 (range: 43-100) after 1 year. FEV1/FVC, residual volume, and total lung capacity (TLC) remained stable from baseline to 1 year (p=0.27, p=0.84 and p=0.21, respectively). In contrast, DLCO remained impaired during the follow-up period (p<0.001). The median DLCO was 72 (range: 39-105), 64 (range: 16-105) and 66 (range: 26-104) at baseline, 3 months and 1 year after HAPLO.
Twenty-nine patients had an infectious respiratory complication during the follow-up period. Of these, 19 were bacterial, three were viral, two were fungal and five had no microbial documentation. During the 1-year follow-up period, four patients met the criteria for bronchiolitis obliterans syndrome and two for interstitial lung disease. Of these, only one had died at last follow-up.
The cumulative incidence of grade II-IV acute GvHD was 21% (95% CI 14-33%). At 1 year, the cumulative incidence of chronic GvHD was 26% (95% CI 18-39%). Non-relapse mortality was 9% (95% CI 4-18%) at 100 days and 14% (95% CI 8-24%) at 1 year. Relapse incidence was 3% (95% CI 1-10%) and 14% (95% CI 8-24%) at 100 days and 1 year, respectively. Overall survival was 73% (95% CI 62-82%). In all, 22 patients died. Cause of death was relapse of hematological disease in 7 (35%), infection in 7 (35%), GvHD in 2 (9%), multi organ failure in 4 (20%) and other causes in 2.
Conclusion: We observed a significantly impaired DLCO at baseline, which remained impaired at 3 months and 1 year after HAPLO, but with a substantial stable pulmonary function at 1 year.
Malard:Theralos/Mallinckrodt: Honoraria; Sanofi: Honoraria; Keocyt: Honoraria; Astellas: Honoraria; JAZZ pharmaceutical: Honoraria; Biocodex: Honoraria; Janssen: Honoraria.
Prior studies have reported pulmonary function tests (PFT) before and after related and unrelated allogeneic hematopoietic stem cell transplantation (HSCT). However, limited data exist on the ...evaluation of lung function after haploidentical stem cell transplantation (HAPLO) with post-transplant cyclophosphamide (PTCY). We retrospectively reported the evaluation of PFTs at screening before HAPLO in 80 patients at 100 days and 1 year of follow-up. The proportion of surviving patients with available PFTs at 100 days and 1 year were 86% and 68%, respectively. During the follow-up period, four patients met the criteria for bronchiolitis obliterans syndrome and two for interstitial lung disease. Overall survival was 73% (95% CI 62-82%) at 2 years. We observed a significant reduction in diffusing capacity of the lungs for carbon monoxide (DLCO) corrected for the most recent hemoglobin concentration (DLCOc) at 100 days after HAPLO. However, an overall substantial stable pulmonary function was observed at 1 year.
Celotno besedilo
Dostopno za:
DOBA, IJS, IZUM, KILJ, NUK, PILJ, PNG, SAZU, UILJ, UKNU, UL, UM, UPUK
We assessed the outcomes associated with thiotepa, busulfan and fludarabine (TBF) conditioning regimen in a cohort of 29 consecutive patients allografted for myelofibrosis (MF). The median age was 56 ...(range 42-70) years. According to the refined Dynamic International Prognostic Scoring System (DIPSS-plus), 15 (52%) patients were classified as high risk. Graft source was peripheral blood stem cells in 27 patients. Donor type was HLA-matched related (n = 5), matched unrelated (n = 16), mismatched unrelated (n = 1), and haploidentical (n = 7). All but 2 patients engrafted. The cumulative incidence (CI) of grade II-IV acute graft-versus-host disease (GVHD) was 21% (95% CI, 10-42) at day 100. The CI of chronic GVHD was 39% (95% CI, 23-65) at 3 years. The median follow-up period was 39 (range 14-60) months. Overall survival was 69% (95% CI, 50-83) at 3 years. No relapse was observed. TBF is a valid conditioning strategy in patients with MF.
Celotno besedilo
Dostopno za:
DOBA, IJS, IZUM, KILJ, NUK, PILJ, PNG, SAZU, UILJ, UKNU, UL, UM, UPUK
The prevalence of anemia in the general population rises sharply after the age of 50, reaching 20% or more in individuals aged 85 years or older. In up to one third of cases, the origin of anemia ...remains unexplained, i.e. not attributable to causes detectable with conventional tests or to any concomitant diseases, and several potential mechanisms have been proposed, including myelodysplasia (MDS) (PMID 15238427). Recent studies showed that somatic mutations are commonly acquired in hematopoietic cells during aging, and are associated with increased risk of hematologic malignancies (PMID 25426837; 25426838). In a recent analysis in patients with unexplained cytopenia undergoing a comprehensive diagnostic workup, we found that mutation profiling was highly predictive of myeloid neoplasm (PMID 28424163).
In this study, we performed a mutation analysis in a cohort of elderly individuals with unexplained anemia and in sex- and age-matched control subjects both selected from a population-based study, as well as in a matched group of patients with MDS, with the aim to investigate the relationship between clonal hematopoiesis, mutation profile and unexplained anemia in community-dwelling elderly subjects.
Seventy individuals aged 60 years or older having anemia according to WHO criteria, not explained by nutritional deficiency, renal failure or inflammation, and 105 sex- and age-matched control subjects (ratio 1:1.5) were selected from the “Val Borbera” Study, a population-based study recruiting a total of 1803 people. In addition, 105 matched control patients with newly diagnosed MDS without excess blasts was analyzed. Median age was 78 years (range 62-102), 133 individuals were males, 147 females. A panel of 54 genes was analyzed on peripheral blood cells, using a HiSeq 2500 platform (Illumina, San Diego, CA) (median depth 1550, range 845-2057).
Among community-dwelling individuals, a significant effect of age was observed on mutation prevalence (P=.023); however, this effect was limited to controls. A significantly higher mutation rate was observed in cases compared with controls (42.9% vs 24.8%, P=.014). This rate was even higher when restricting the analysis to individuals with hemoglobin <12.5 g/dL in males and <11.5 g/dL in females and/or MCV>105 fL (63% vs 24.8%, P<.001). A significantly higher Variant Allele Frequency (VAF) was found in cases compared with controls (median value 0.21, range 0.02-0.51 vs 0.07, 0.02-0.38; P=.035). A significantly higher number of individuals with two somatic mutations was found among cases compared with non-anemic controls (14.3% vs 1.9%, P=.003). Subjects with two somatic mutations showed a significantly higher VAF compared with those having an isolated mutation (median value 0.31, range 0.03-0.50 vs 0.06, 0.06-0.51; P=.008). In a multivariable regression analysis, number of mutations per subject and VAF were independent predictors of anemia (OR=7.55, P=.03, and OR=1.67, P=.037, respectively). A significantly higher prevalence of splicing factor mutations was found in cases compared with controls (11.1% vs 0%, P=.008). In most individuals with multiple mutated genes, mutation pattern included a DNA methylation gene mutation associated with a subclonal mutation.
When comparing community dwelling individuals with unexplained anemia with a matched group of patients with MDS, a significantly higher number of subjects with two or more mutations was found in MDS compared with unexplained anemia (47.6% vs 14.3%, P<.001). MDS patients showed a significantly higher VAF compared with individuals with unexplained anemia (median value 0.41, range 0.02-0.93 vs 0.21, 0.02-0.51; P<.001). Finally, a significantly higher prevalence of splicing factor mutations was observed in MDS compared with unexplained anemia (55.2% vs 11.1%, P<.001).
In conclusion, this study provides evidence of a high rate of clonal hematopoiesis in community-dwelling elderly individuals with unexplained anemia compared with matched controls with normal hemoglobin values, mainly sustained by an enrichment in subjects with accumulation of mutations proven highly predictive of myeloid neoplasm with myelodysplasia. Mutation analysis on peripheral blood cells may complement current diagnostic approach to unexplained anemia in the frail population of elderly individuals, increasing compliance to diagnostic tests and overall the diagnostic accuracy of myeloid neoplasms.
Rizzo:enGenome srl: Employment. Camaschella:Vifor Pharma: Membership on an entity's Board of Directors or advisory committees.
Introduction and Aims
Hypoplastic Myelodysplasic Syndrome (h-MDS) has distinct features compared to normo- or hypercellular MDS, with a higher response rate to immunosuppressive therapy and more ...favorable prognosis. However, to date, reproducible diagnostic criteria for h-MDS have not been clearly defined, making differential diagnosis from other bone marrow failure (BMF) syndromes challenging. Based on a large and well-annotated consecutive cohort of patients with BM hypocellularity from two tertiary centres, we aimed to delineate the clinical, histopathological and molecular features of h-MDS.
Methods
Of 1262 consecutive adult patients analyzed at King's College Hospital, London, UK and IRCCS Policlinico San Matteo & University of Pavia, Italy: 533 patients had a hypocellular BM, including 205 MDS patients with BM cellularity ≤25%, 77 MDS with reduced age-adjusted BM cellularity, 139 with Aplastic Anemia (AA), 97 with a diagnosis of Idiopathic Cytopenia of Undetermined Significance (ICUS) and 15 with congenital BMF (c-BMF) and 729 with normo- or hypercellular MDS (n-MDS).
Results
Comparison of clinical features and outcome of patients with h-MDS as defined by a BM cellularity ≤25% (n=205) and those with a reduced age-adjusted cellularity (n=77) did not detect any significant differences. Therefore, a reduced age-adjusted BM cellularity was adopted as a criterion to define h-MDS (n=282). Compared with patients with n-MDS, those with h-MDS were significantly younger, displayed higher levels of hemoglobin (p=.01), lower neutrophil and platelet counts and lower percentage of BM blasts, ring sideroblasts (RS) and CD34+cells as determined by immunohistochemistry (all p<.001). No significant difference was observed in the distribution of chromosomal abnormalities. A significantly higher prevalence of PNH clones was observed in h-MDS (24% vs 2%, p<.001). Those patients with h-MDS showed a significantly lower risk of leukemic evolution compared with n-MDS (4-year cumulative incidence 14% vs 26%, p=.003). Comparing h-MDS with AA, h-MDS showed a significantly higher percentage of RS (p=.004), BM blasts, dysmegakaryopoiesis and dysgranulopoiesis (p<.001), BM fibrosis (p=.002), clusters of CD34+ cells and chromosomal abnormalities (p<.001). H-MDS patients showed a significantly higher risk of leukemic evolution compared with AA (4-year cumulative incidence 14% vs 0%, p<.001).
Targeted sequencing of 24 commonly mutated myeloid genes was performed on 358 patients (73 h-MDS, 45 AA and 240 n-MDS). Twenty-five patients with h-MDS (34%) showed one or more somatic mutation (median 1; range 1-4). Comparing h-MDS to n-MDS revealed a significantly lower number of mutations per subject and variant allele frequency (VAF) (p<.001). Moreover, a significantly lower number of mutations per patient and VAF were observed in AA compared to h-MDS (p=.031 and p=.003, respectively). Thirty-seven patients with a hypocellular BM had a peripheral blood telomere length (TL) ≤1st percentile and/or a germline mutation consistent with a diagnosis of c-BMF, leading to an estimated prevalence of unidentified c-BMF of 13% in cases without robust morphological evidence of MDS.
Based on these findings, we defined a diagnostic score (h-score), including variables with the highest specificity for MDS: dysmegakaryopoiesis, dysgranulopoiesis, BM fibrosis, clusters of CD34+ cells, RS 2-14%, BM blasts 2-4% (score 1); RS≥15% and BM blasts ≥5% (score 2). By applying ROC analysis, a cut off value of 2 was associated with the highest specificity for MDS (0.98). Notably, 71% of patients with a hypoplastic BM and low h-score (0-1) had no evidence of clonal disease by cytogenetic or mutation analyses or had a mutation pattern consistent with age-related clonal hematopoiesis. These patients showed a significantly better OS and lower risk of leukemic evolution (P<.001).
Conclusions
Integration of cyto-histological and genetic features in patients with a hypocellular BM identifies two distinct groups, one with clinical and genetic features highly consistent with a clonal disease with high risk of leukemic evolution, and one with features more consistent with a non-malignant bone marrow failure. Furthermore, we identified relevant enrichment of patients with previously undiagnosed c-BMF.
Kulasekararaj:Akari Therapeutics Plc: Consultancy, Honoraria; Alexion Pharmaceuticals: Consultancy, Honoraria; Ra Pharmaceuticals: Consultancy, Honoraria; Achillion pharmaceuticals: Consultancy, Honoraria.
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The diagnostic approach to unexplained cytopenia is hampered by the poor specificity of dysplastic changes that may complicate the distinction between myeloid neoplasms (MN) and non-malignant ...cytopenias. In the last years, several somatic mutations were identified in MN; however, the diagnostic value of mutation analysis needs to be defined. In this study, we performed a mutation screening in a prospective cohort of patients with unexplained cytopenia undergoing a comprehensive diagnostic work-up, with the aim to estimate the predictive value of somatic mutations.
This study included two cohorts: a learning cohort that consisted of 683 consecutive patients investigated for unexplained cytopenia at the Policlinico San Matteo & University of Pavia, Italy, between 2003 and 2015; and a validation cohort, including 190 patients referred as second opinion for suspected MDS. A set of 42 genes was analyzed on DNA from peripheral blood granulocytes using Illumina HiSeq (Illumina Inc., CA, USA). The diagnosis of patients in the learning cohort was MN in 409 cases (233 MDS, 86 MDS/MPN, 35 MPN; 55 AML), other cytopenia in 120 cases, whereas in 154 patients a provisional diagnosis of Idiopathic Cytopenia of Undetermined Significance (ICUS) was adopted. After a median follow-up of 22 months (range 3-136), 38 patients in this category developed a MN (ICUS-MN).
The most frequently mutated genes were TET2 (171/683, 25%), ASXL1 (15%), SRSF2 (14%), SF3B1 (11%), DNMT3A (10%), RUNX1 (9%). Significantly higher number of mutations per subject and variant allele frequency (VAF) were observed in MN (n=2, range 0-9; VAF=0.39, 0.03-0.57) compared with ICUS (n=0, 0-7; VAF=0.31, 0.03-0.51) or other cytopenia (n=0, 0-2; VAF=0.06, 0.03-0.44) (P<0.001). Fifty-seven of 409 (14%) MN patients did not carry any mutation in the set of analyzed genes. Among these, 6 had MDS del(5q), while 18 received a diagnosis of MDS based on mild dysplasia with normal karyotype, and showed a 5-year probability of progression of 0%, suggesting that a diagnosis of MDS might have been not appropriate despite WHO criteria. When accounting for these cases, an unmutated status had a negative predictive value for MN of 0.83. Conversely, having two or more mutations had a positive predictive value (PPV) for MN of 0.94. We then performed ROC analyses to explore the cut-off value of VAF with the highest predictive value for MN, and found that a VAF equal or higher than 0.10 had a PPV for having or developing MN of 0.92.
Next, we calculated the predictive value for diagnosis of MN of the most frequently mutated genes. In multivariable logistic regression, having two or more mutations (OR=4.07, P<0.001) or carrying SF3B1 mutation (OR=3.56, P=0.016) were independent predictors for MDS or other MN. SF3B1 mutation showed a specificity for myelodysplasia of 0.99, suggesting that this lesion may provide presumptive evidence of MDS even in the absence of definitive morphological features. RNA splicing genes (SF3B1, SRSF2, U2AF1) and RUNX1 had the highest predictive value for MN irrespective of co-occurring mutations, PPVs ranging from 0.88 to 0.93. PPVs increased to 0.97-0.99 when accounting for ICUS-MN as true positive cases. Conversely, PPVs of mutations in genes of DNA methylation (TET2, DNMT3A) and chromatin (ASXL1) as isolated lesions ranged from 0.39 to 0.69, while having one or more co-mutated genes significantly increased PPVs to 0.88-0.96.
Among patients with a diagnosis of ICUS, 57 of 154 (37%) carried one or more mutations (Clonal Cytopenia of Undetermined Significance, CCUS). Patients with CCUS showed a significantly higher probability of developing MDS compared with those without evidence of clonality (HR=7.48, 10-year cumulative probabilities of progression: 96% vs 15% respectively, P<.001).
Finally, the predictive values of mutation analysis were tested in the independent validation cohort of patients referred to our institution for suspected MDS, and were fully confirmed.
In conclusion, selected mutated genes or co-mutation patterns may identify patients with high likelihood of having MDS or other MN. The definition of a category of CCUS allows to recognize with high sensitivity patients who do not fulfill diagnostic criteria but are at high risk of developing MDS. Taken together, these data suggest that mutation analysis on peripheral blood cells may significantly improve current diagnostic approach to patients with unexplained cytopenia.
Ogawa:Sumitomo Dainippon Pharma: Research Funding; Takeda Pharmaceuticals: Consultancy, Research Funding; Kan research institute: Consultancy, Research Funding.
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