A specific type of myelodysplastic syndrome (MDS) is associated with isolated deletion on the long arm of chromosome 5, i.e., 5q-syndrome (del(5q)). The treatment approaches for MDS del(5q) include ...the immunomodulating drug lenalidomide (LEN). Thirteen MDS del(5q) patients were included in this study. We found elevated activities of lactate dehydrogenase (LDH) and matrix metalloproteinase 9 (MMP-9) in the blood plasma of MDS del(5q) patients as compared with healthy controls. This was stabilized to control values after LEN treatment. Similar behavior we registered also for the thioredoxin and calnexin contents in BP. Peripheral blood mononuclear cells (PBMC) from patients with MDS del(5q) prior to and after treatment with LEN did not exhibit any detectable amount of P-glycoprotein (P-gp) gene transcript. However, we detected a measurable amount of multidrug resistance associated protein 1 (MRP1) mRNA in PBMCs from three patients prior to LEN treatment and in one patient during LEN treatment but it was not present prior to treatment. These data indicated on usefulness of applied protein markers estimation for monitoring of MDS del(5q) patient treatment effectiveness by LEN. Expression of MRP1 seems to be independent on LEN treatment and reflects probably the molecular variability in the ethiopathogenesis of MDS del(5q).
Objective The capacity of mononuclear blood cells to form autoreactive cytotoxic T lymphocytes was investigated in order to elucidate the mechanism of successful immunosuppressive therapy in some ...myelodysplastic syndrome (MDS) patients (autoreactivity studies). The failure in autoreactivity studies raised the question of alloreactive cytotoxic T lymphocyte formation in MDS (alloreactivity studies). Materials and Methods Sixteen MDS patients and relevant controls were examined. Autoreactive lymphocytes directed against autologous bone marrow mononuclear cells and alloreactive lymphocytes directed against unrelated third-party cells were tested using cytotoxicity assay. In addition, we used one-way mixed lymphocyte reaction, human androgen receptor test for clonality detection, and enzyme-linked immunosorbent assay kits for tumor necrosis factor and interferon- γ testing. Results We did not confirm the presence of autoreactive T cells in eight of nine MDS patients tested. The response to allogeneic cells was impaired in 11 of 16 MDS patients, more often in refractory anemia (RA; 80%) than in RA with ring sideroblasts (40%). Interestingly, the response to allogeneic cells in mixed lymphocyte reaction was normal in all MDS patients. T lymphocytes were polyclonal in all but one patient. Tumor necrosis factor and interferon- γ level in supernatants of mononuclear cells was significantly reduced in RA. Conclusion The presumed autoaggressive T cells were not confirmed in MDS in our experimental arrangement. Alloreactivity studies demonstrated the impairment of effector cytotoxic phase of cell-mediated immunological reaction in MDS, namely in RA. The significance of our finding of defective cytotoxicity for pathogenesis, clinical course, and even for therapy is discussed together with other immunological defects reported so far.
Interactions between genetic variants and risk factors in myelodysplastic syndromes are poorly understood. In this case-control study, we analyzed 1 421 single nucleotide polymorphisms in 408 genes ...involved in cancer-related pathways in 198 patients and 292 controls.
The Illumina SNP Cancer Panel was used for genotyping of samples. The chi-squared, p-values, odds ratios and upper and lower limits of the 95% confidence interval were calculated for all the SNPs that passed the quality control filtering.
Gene-based analysis showed nine candidate single nucleotide polymorphisms significantly associated with the disease susceptibility (q-value<0.05). Four of these polymorphisms were located in oxidative damage/DNA repair genes (LIG1, RAD52, MSH3 and GPX3), which may play important roles in the pathobiology of myelodysplastic syndromes. Two of nine candidate polymorphisms were located in transmembrane transporters (ABCB1 and SLC4A2), contributing to individual variability in drug responses and patient prognoses. Moreover, the variations in the ROS1 and STK6 genes were associated with the overall survival of patients.
Our association study identified genetic variants in Czech population that may serve as potential markers for myelodysplastic syndromes.
This international phase III, randomized, placebo-controlled, double-blind study assessed the efficacy and safety of lenalidomide in RBC transfusion-dependent patients with International Prognostic ...Scoring System lower-risk non-del(5q) myelodysplastic syndromes ineligible for or refractory to erythropoiesis-stimulating agents.
In total, 239 patients were randomly assigned (2:1) to treatment with lenalidomide (n = 160) or placebo (n = 79) once per day (on 28-day cycles). The primary end point was the rate of RBC transfusion independence (TI) ≥ 8 weeks. Secondary end points were RBC-TI ≥ 24 weeks, duration of RBC-TI, erythroid response, health-related quality of life (HRQoL), and safety.
RBC-TI ≥ 8 weeks was achieved in 26.9% and 2.5% of patients in the lenalidomide and placebo groups, respectively (P < .001). Ninety percent of patients achieving RBC-TI responded within 16 weeks of treatment. Median duration of RBC-TI with lenalidomide was 30.9 weeks (95% CI, 20.7 to 59.1). Transfusion reduction of ≥ 4 units packed RBCs, on the basis of a 112-day assessment, was 21.8% in the lenalidomide group and 0% in the placebo group. Higher response rates were observed in patients with lower baseline endogenous erythropoietin ≤ 500 mU/mL (34.0% v 15.5% for > 500 mU/mL). At week 12, mean changes in HRQoL scores from baseline did not differ significantly between treatment groups, which suggests that lenalidomide did not adversely affect HRQoL. Achievement of RBC-TI ≥ 8 weeks was associated with significant improvements in HRQoL (P < .01). The most common treatment-emergent adverse events were neutropenia and thrombocytopenia.
Lenalidomide yields sustained RBC-TI in 26.9% of RBC transfusion-dependent patients with lower-risk non-del(5q) myelodysplastic syndromes ineligible for or refractory to erythropoiesis-stimulating agents. Response to lenalidomide was associated with improved HRQoL. Treatment-emergent adverse event data were consistent with the known safety profile of lenalidomide.
Myelodysplastic syndrome (MDS) is a common hematological disease in patients over sixty. Despite intensive research, the therapy of this heterogeneous blood disease is complicated. In recent years, ...two new therapeutic approaches have been proposed: immunomodulation and demethylation therapy. Immunomodulation therapy with lenalidomide represents a meaningful advance in the treatment of anemic patients, specifically those with 5q- aberrations. As much as 60-70% of patients respond and achieve transfusion independence. We present the initial lenalidomide experience of the Czech MDS group. We analyze Czech MDS register data of 34 (31 female; 3 male; median age 69 years) chronically transfused low risk MDS patients with 5q- aberration treated by lenalidomide. Twenty-seven (79.4%) patients were diagnosed with 5q- syndrome, 5 patients with refractory anemia with multilineage dysplasia, 1 patient with refractory anemia with excess of blasts 1, and 1 patient with myelodysplastic/myeloproliferative unclassified. Response, as represented by achieving complete transfusion independence, was achieved in 91% of patients. A true 5q- syndrome diagnosis in most our patients may be responsible for such a high response rate. Complete cytogenetic response was reached in 15% of patients and partial cytogenetic response in 67%, within a median time of 12 months. TP53 mutation was detected in 15% (3 from 18 tested) and 2 of these patients progressed to higher grade MDS. The majority of patients tolerated lenalidomide very well. Based on this albeit small study, we present our findings of high lenalidomide efficacy as well as the basic principles and problems of lenalidomide therapy.
Myelodysplastic neoplasms (MDS) are hematopoietic stem cell (HSC) disorders characterized by ineffective hematopoiesis, peripheral cytopenia, and increased tendency to leukemic transformation. ...Somatic mutations in spliceosome machinery occur in approx. 50% of MDS patients. Among these, up to 30% of MDS patients carry a mutation in SF3B1. According to the 2022 classification system, MDS-SF3B1 is now considered as separate MDS subtype. Mutated SF3B1 perturbs mitochondrial function, resulting in apoptosis and ineffective erythropoiesis. The most common mutation of SF3B1, K700E, accounts for 50% of the variants, with additional codons (such as 666 and 662) acting as hotspot sites. Different mutations seem to be associated with distinct clinicopathological features. However, the prognostic implication of different SF3B1 mutations in MDS remains controversial and needs further clarification. This study investigated differences in clinical and molecular features of MDS-SF3B1 with different types of SF3B1 mutations. To investigate a direct impact of different point mutations in SF3B1, the study was based on four isogenic NALM6 cell lines, the wildtype (wt) and three cell lines, each with different SF3B1 mutation (CRISPR/Cas9-edited K700E, K666N, and H662Q). To understand phenotypic manifestations of the mutations in the disease, we also analyzed clinical and transcriptional characteristics of 146 lower-risk MDS patients. Using RNA-seq in the cell lines and CD34+ BM patient cells (17 patients with no mutation, 11 patients with K700E SF3B1 mutation, 5 patients with K666N/E SF3B1 mutation), we investigated effects of different SF3B1 mutations on RNA splicing events and gene expression levels. Initially, outcome analysis confirmed the previously described observation that patients with a SF3B1 mutation have favorable outcomes compared to those with other splicing factor mutations. Further, the analysis showed that specific mutations in SF3B1 tend to lead to different prognoses; patients with K700E had longer survival compared to those with other SF3B1 mutations (mean progression-free survival was 64.8 vs. 29.1 months). Analysis of RNA splicing in NALM6 showed that K666N and H662Q mutations share similar characteristics whereas K700E mutation is more similar to wt-cells. Most significant changes were found in retained introns (RI); increased RI inclusion levels were detected in K666N/H662Q cells compared to K700E/wt cells. In patients, RI events were also strongly increased in K666N/E compared to K700E samples (Fig. 1). A significant overlap was identified between cell line and patient data; out of 173 genes with higher RI inclusion level in K666N-NALM6 cells, 77 genes had higher RI inclusion also in patients. Interestingly, 12 out of these 77 genes were related to mitochondrial functions (e.g., CREBZF, DDX1, MRPL23, MUTYH, and RAF1). RNA-seq data further showed significant alternations in gene expression levels in the four isogenic cell lines and also in patient samples with different mutations. Surprisingly, a more pronounced difference was detected in gene expression between patients with different SF3B1 mutations than between patients with no mutation and with any SF3B1 mutation (irrespective of its type), suggesting that specific SF3B1 mutations result in different phenotypes. Pathway analyses showed that deregulated genes in samples with K700E vs. other hotspot mutations were significantly enriched in electron transport, cell cycle, proliferation, quiescence, and HSC differentiation. Importantly, expression of multiple mitochondria-related genes was altered between K700E and K666N/H662Q NALM6 cells (334 genes, FDR < 0.01; Fig. 2), indicating different metabolic characteristics of the cells with non-K700E mutations. For example, several subunits of mitochondrial respiratory complexes I and IV were upregulated in K700E cells, pointing to differences in energetic metabolism. Altogether, our data support the hypothesis that only K700E mutation of SF3B1 may have a positive prognostic value and that other SF3B1 mutations may influence cells differently, specifically affecting their mitochondrial functions. Based on our results, we conclude that prognostic implication of different SF3B1 mutations in MDS will need additional refinements in future. Supported by AZV CR (NU20-03-00412), GA CR (20-19162S), and MH CZ-DRO (00023736).
Idiopathic aplastic anemia (AA) and hypoplastic myelodysplastic neoplasms (MDS-h) are severe hematopoietic disorders characterized by pancytopenia and hypoplastic bone marrow. There is compelling ...evidence that these distinct clinical entities share a common pathophysiology based on the damage of hematopoietic stem and progenitor cells (HSPCs) by cytotoxic T cells. Expanded T cells overproduce proinflammatory cytokines, resulting in decreased proliferation and increased apoptosis of HSPCs. To uncover the molecular mechanisms underlying this abnormal immune response, we used RNA-Seq for the transcriptome analysis of T cells from patients with idiopathic AA and MDS-h. CD3+ cells were isolated from peripheral blood of 15 patients with AA or MDS-h at diagnosis and 6 healthy blood donors. The RNA-Seq library was constructed by NEB Next Ultra II Directional RNA Library Prep Kit and the data were analysed by R software 4.0.2. Functional annotation of differently expressed genes was performed using DAVID database and Gene Set Enrichment Analysis (GSEA). Principal component analysis-based clustering of RNA-Seq data defined the three major components for AA and MDS-h patients, and healthy individuals (Fig. 1A). As expected, the control samples formed a distinct group, meanwhile patient samples partially clustered together. The same results were obtained using unsupervised hierarchical clustering. The differential expression analysis (DEA) identified 256 significantly upregulated and 96 downregulated genes (ІlogFCІ>1, FDR<0.05) in patients compared to controls. Notably, the DEA detected many long noncoding RNAs (lncRNAs) including upregulated lncRNAs associated with immunological disturbances (e.g. CDC42-IT1 and NEAT1), and oncogenesis (e.g. ACAP2-IT1, and FAM238A). Particularly, NEAT1 positively regulates differentiation of CD4+ T cells into Th17 cells through STAT3 protein. Autoreactive T cells may be further stimulated by increased expression of S100A8/A9 detected in the patient cells. Gene Ontology (GO) analysis annotated the upregulated genes in AA/MDS-h to biological processes associated with oxygen transport, B cell receptor signaling pathway, innate immune response, positive regulation of inflammatory response, and apoptotic process, etc. (adjusted p<0.05) (Fig. 1B). The downregulated genes were significantly enriched in processes related to adaptive immune response, cell surface receptor signaling pathway, mitochondrial ATP synthesis coupled proton transport, etc. (adjusted p<0.05) (Fig.1B). B cell receptor signaling pathway was enriched by upregulated genes such as BANK1, MEF2C, and SYK whose deregulation is associated with autoimmune disorders. Herein, the activation of apoptosis is likely driven via AP-1 positive modulators that showed increased expressions in the patients. These modulators are essential for T cell activation and regulatory T cell differentiation. Pathway enrichment analysis determined the following signaling pathways (adjusted p<0.05): B cell receptor signaling pathway, osteoclast differentiation, oxidative phosphorylation, chemical carcinogenesis - reactive oxygen species, and cytokine-cytokine receptor interaction. The GSEA using the Hallmark gene sets showed that DNA Repair and Oxidative Phosphorylation were significantly negatively correlated with patient phenotype (Fig. 1C). Both GSEA and pathway analysis revealed that oxidative phosphorylation was supressed in patient-derived T cells. This is consistent with previous metabolic findings demonstrating that a transition from oxidative phosphorylation to glycolysis is a sign of T cell activation and it is critical for support of rapid cell growth. In conclusion, our study suggests the possible mechanisms of aberrant T cellular-immunity in idiopathic AA and MDS-h. Consistent with abnormal biological features of T cells, a large number of deregulated genes in the patients was involved in immune and inflammatory responses. Furthermore, our analyses revealed novel pathways, such as oxidative phosphorylation, as well as candidates ( TLR2, and CDC42-IT1) for functional studies. The deregulation of multiple lncRNAs in the patients indicates their implication in the molecular pathogenesis and thus their roles in bone marrow failure need to be explored. Supported by AZV (NU21-03-00565), and MH CZ-DRO (UHKT, 00023736).
Patients with myelodysplastic neoplasms (MDS) face the risk of transformation to acute myeloid leukemia (AML). Although prognostic scoring systems exist for risk stratification and treatment decision ...making in MDS patients (Garcia-Manero G. Am J Hematol. 2023;98(8):1307-1325), disease management remains challenging due to the heterogeneity of clinical courses and long-term outcomes. The natural history of patients with lower-risk MDS (LR-MDS) is very heterogeneous and some LR-MDS patients experience rapid progression despite a generally favorable prognosis. The aim of our study was to uncover the molecular mechanisms underlying accelerated progression in hematopoietic stem/progenitor cells of patients with LR-MDS regardless of driver mutations. We focused on the transcriptome of bone marrow (BM) CD34 + cells from diagnostic samples using RNA-seq and used various bioinformatic pipelines to examine differentially expressed protein-coding genes, and long non-coding RNAs (lncRNAs) as well as differential alternative splicing events. RNA-seq dataset of CD34 + ribodepleted RNA samples from 53 LR-MDS patients without accelerated progression (stMDS) and 8 who progressed within 20 months (prMDS) showed 845 differentially expressed genes (ІlogFCІ > 1, FDR < 0.01) between these groups. CD34 + cells of prMDS exhibited a transcriptional pattern of quiescent-like cell state with overall decreased metabolism signatures and significantly reduced lineage differentiation compared to stMDS CD34 + cells. Gene set enrichment analysis (GSEA) showed that cell cycle- and cell cycle checkpoint- associated genes and activation of ATR in response to replication stress were all significantly under-represented in prMDS CD34 + BM (Fig. 1A). Cellular pathways from GO Biological Processes associated with cellular responses to stress and DNA damage responses (DDR) were downregulated in prMDS compared to stMDS. The only GO terms that were significantly upregulated in prMDS were processes related to cell-matrix adhesion or cell-cell adhesion. Indeed, key transcription factor controlling changes in cell-cell adhesion, ZEB1, was significantly overexpressed in prMDS BM CD34 + cells, whereas E-cadherin expression ( CDH1) was decreased; the expression levels of CDH1 and ZEB1 showed a significant moderate negative correlation (Fig. 1B). Additionally, prMDS samples exhibited high levels of aberrant splicing and global lncRNA expression. Analysis of aberrant transcripts, deregulated lncRNAs and their targets suggested their contribution to the attenuation of DDR pathways in prMDS. Given that the downregulation of DDR gene expression was the major feature distinguishing the prMDS CD34 + cell transcriptome from that of stMDS in our cohort, we selected - from the transcriptional profile of the top 50 downregulated genes in GSEA - a prognostic DDR-associated gene signature consisting of 19 genes. Using regularized Cox regression analysis of the expression profile of 19 DDR-associated genes, the probability of a progression-free disease was calculated in our cohort. High DDR gene expressors had a significantly higher probability of progression-free disease (p < 0.001) compared to low DDR gene expressors (Fig. 2A). Among the top 50 upregulated genes in the prMDS vs. stMDS samples, ranked by GSEA, overexpression of previously identified markers of leukemic progression and/or poor MDS/AML survival ( SPNS2, MN1, DOCK1 and others) was demonstrated. Interestingly, overexpression of NEK3, a gene not previously associated with MDS/AML progression, showed a predictive power for accelerated progression in LR-MDS with the best significance of curve separation among the genes tested (Fig. 2B). Furthermore, NEK3 expression was an independent prognostic factor (p<0.001) for progression-free disease in a multivariate analysis of important clinical and genetic factors. To conclude, our data suggest that DDR gene expression signature and NEK3 expression appear to be a significant predictor of LR-MDS progression and may be applicable at the time of diagnosis for the prognostic stratification of patients with LR-MDS, regardless of their mutational status. Supported by AZV (NU21-03-00565) and (NU23-03-00401); MH CZ-DRO (UHKT, 00023736); Program EXCELES, ID Project No. LX22NPO5102, and UP Young Researcher Grant Competition, ID Project JG_2023_016.
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