ALBERT

Description: Introduction An "ideal" marker to monitor MRD after allo-SCT should be informative in the majority of pts and facilitate the use of a method with high sensitivity and specificity in a standardized manner. In addition, to allow repeated monitoring in timely tight intervals but also ensuring patients' comfort such marker should ideally be measurable in peripheral blood (PB). Despite recent identification of several molecular aberrations AML and MDS, many of these do not fulfil the above-mentioned requirements, as they are present only in small patient groups, their potential instability during disease course, the absence of standardized assays and the need for BM as optimal sample source. A molecular marker which might provide these properties is the WT1 gene, as it is overexpressed in the majority of AML pts and in about 50% MDS pts and is measurable in PB by a standardized assay. To estimate its value after allo-SCT we compared serial WT1 measurement with other methods used to monitor MRD in a real-life situation. Patients and Methods For this retrospective analysis all AML and MDS pts who underwent allo-SCT at our center between 2012 and 2016 were screened for PB WT1 mRNA overexpression using the ELN certified Ipsogen® WT1 ProfileQuant® Kit. Pts with WT1 overexpression, as defined by an validated cut-off level of 50 copies/104 ABL copies, were routinely monitored after transplant. In addition, in all pts STR-based chimerism analysis was performed. In pts with chromosomal aberrations existing prior allo-SCT metaphase and FISH analysis was performed, while XY FISH was additionally conducted in pts with sex-mismatched donor-recipient constellation. Furthermore, pts with molecular markers were regularly monitored by NGS or qPCR. Results of WT1 monitoring were correlated with clinical course and compared with results obtained from the other methods. Results Of 104 screened pts 59 (57%) showed an WT1 overexpression at diagnosis and underwent an allo-SCT. This included 40 AML pts (WT1 overexpressed in 66%) and 19 MDS pts (WT1 overexpressed in 44%). Chimerism analysis was accessible in all 59 pts (100%), while 20 pts (34%) could also be monitored by XY-FISH. Additionally, in 40 pts (68%) cytogenetics and FISH were applicable, while 22 pts (37%) could be investigated by NGS or qPCR. Overall, in 5 pts MRD could be monitored by WT1 and chimerism only, while in 29 pts MRD could be monitored by 1, in 22 pts by 2 and in 3 pts by 3 additional methods. With a median follow up of 13 months (2 - 51) we analyzed a total of 472 WT1 samples reflecting a median of 8 samples per patient (2 - 19). One month after allo-SCT 57 pts (97%) showed complete remission and a rapid decrease of WT1 expression below threshold. Only 2 pts had persistant hematological disease with sustained WT1 overexpression. Twenty-four pts (41%) experienced hematologic (62%) or molecular (38%) relapse at a median of 126 d (28 - 938 ) after allo-SCT. In 20 (83%) of these at least one WT1 value wasabove the cut-off before relapse. Median time from first elevated WT1 to relapse was 2 weeks (0 - 27). Only 4 pts (17%) with molecular relapse showed WT1 expression below cut-off. In contrast, known molecular aberrations were found again in 63% and loss of complete donor-chimerism or a positive signal in XY-FISH analyses were only seen in 46% and 57% before relapse. Furthermore, cytogenetics or FISH detected known or new aberrations in 39% before relapse. From 35 pts remaining in CR for a median of 13 months, only 1 (3%) had a transient increase of WT1 expression above the cut-off, whereas WT1 levels of the other 34 pts persisted below. Three pts (9%) with ongoing remission showed a transient decrease of donor-chimerism, whereas even 31% of pts accessible for XY-FISH showed temporary conspicuous results. Conventional cytogenetics and FISH in pts with CR showed transient abnormalities in 18%, whereas in 14% with molecular aberrations these were temporary detectable. Conclusion Measurement of PB WT1 overexpression is an easy accessible method to monitor MRD after allo-SCT that can be employed by a standardized assay in the majority of AML and MDS pts independent from their individual leukemic genotype. Besides these advantages, the results from our real-life experience also suggest that WT1 overexpression allows sensitive detection of imminent relapse after allo-SCT. Taking into account the methodical restrictions of this retrospective analysis, our data requires confirmation in a prospective trial. Disclosures Gattermann: Celgene: Consultancy, Honoraria, Research Funding; Novartis: Consultancy, Honoraria, Other: travel, accomodation expenses, Research Funding. Kobbe:Jansen: Honoraria, Other: travel support; Celgene: Honoraria, Other: travel support, Research Funding.

Description: Abstract 1861 Introduction: Total or partial Monosomy 7 (-7/del(7q)) is one of the most frequent cytogenetic abnormalities in MDS, occurring in about 11% of abnormal cases in patients (pts) with primary MDS. The cytogenetic module of the IPSS defines any abnormality of chromosome 7 as unfavourable and classifies them, combined with complex abnormalities, into the poor risk cytogenetic subgroup. However, in previous publications from other groups, the prognosis of isolated -7/del(7q) was described as intermediate. The aim of the present study was to re-analyze the prognostic impact of -7/del(7q) as a single anomaly based on a large, international MDS database which was previously presented at the 2009 ASH-meeting (Schanz et al. abstract #2772). Materials and Method: Patients with -7/del(7q), derived from the international MDS database were examined. The large international data collection contains 2901 patients with MDS, originating from the German-Austrian (GA)-, the International MDS Risk Analysis Workshop (IMRAW)- and the Spanish Cytogenetic Working group (GCECGH) and the International Cytogenetics Working Group of the MDS Foundation (ICWG). Inclusion criteria for the study were defined as follows: Primary MDS, age 〉=16, and bone marrow blasts

Description: The WHO classification of myelodysplastic syndromes (MDS) is based on uni- or multi-lineage hematopoietic involvement, blast count and cytogenetic features. We recently confirmed the prognostic value of this classification and demonstrated that cytogenetics and transfusion requirement are the main prognostic factors affecting survival of WHO subgroups (JCO 2005, in the press). The aim of the present study was to define and validate a scoring system for evaluating prognosis in MDS classified according to WHO criteria. The patients comprised a learning cohort, in whom investigations were aimed at defining the set of variables to be included in the prognostic model and their weighted scores, and a validation cohort, in whom we evaluated whether the prognostic value of the scoring system was confirmed. The learning cohort was formed of 467 consecutive patients with a diagnosis of de novo MDS made at the IRCCS Policlinico S. Matteo, Italy, between 1992 and 2002, while the validation cohort consisted of 620 consecutive patients diagnosed at the Heinrich-Heine-University Hospital between 1982 and 2003. All cases were reclassified by independent cytologists according to the WHO criteria. Those patients who were treated with allogeneic stem cell transplantation or chemotherapy, were censored at the time of this therapeutic intervention. Uni- and multivariate analyses were performed by means of Cox proportional hazards regression. The actuarial probabilities of overall survival (OS) and leukemia-free survival (LFS) were estimated using the Kaplan-Meier product limit method. Based on the results of the uni- and multivariate analyses, the most significant variables selected for the prognostic model were WHO subgroups, cytogenetic abnormalities scored according to the IPSS and transfusion requirement. Risk scores for each variable were estimated based on coefficients from the proportional hazards regression (Table 1). Table 1 - WHO-Classification Based Prognostic Scoring System (WPSS) for MDS Prognostic variable Score value 0 1 2 3 WHO category RA, RARS, 5q- RCMD, RCMD-RS RAEB-1 RAEB-2 Karyotype Good Intermediate Poor - Transfusion requirement No Regular - - By summing the score values for the three variables, patients were stratified into five distinct risk groups [very low (score 0), low (1), intermediate (2), high (3–4), very high (5–6)], showing significantly different OS and probability of leukemia evolution (P

Description: In the IPSS the variables bone marrow blasts, cytogenetics and cytopenias were found to be most relevant for clinical outcome by multivariate analysis. Comparing cytogenetics and blasts scoring points were assigned as follows: 0 (good cytogenetics and less than 5% blasts), 0.5 points (intermediate cytogenetics, and 5–10% blasts), 1.0 points (poor cytogenetics), 1.5 points (11–20% blasts), 2.0 (21–30% blasts). In order to examine the correctness of weighting of cytogenetics in comparison to blast counts we compared the survival curves, median survival times (mst) and differences of mst (mst diff.) related to the mst of 37.5 months (mo) of our entire study population (on the basis of 2124 pts. with MDS from our German-Austrian database) between patient subgroups. The results in the subgroups were as follows: Blasts below 5% (n=609) (mst: 58 mo, mst diff.: +20.5 mo), good cytogenetics (n=768) (mst: 55.3 mo, mst diff.: +17.8 mo), blasts 5–10% (n=231) (mst: 28.0 mo, mst. diff.: −9.5 mo), intermediate cytogenetics (n=222) (mst: 28.0 mo, mst diff.: −9.5 mo), blasts: 11–20% (n=160) (mst: 16.5 mo, mst diff.: −21 mo), poor cytogenetics (n=212) (mst: 11.1 mo, mst diff.: −26.3 mo), blasts 21–30% (n=92) (mst: 11.7, mst diff.: −25.7 mo). Our results clearly show that within the IPSS poor cytogenetics are significantly underweighed. Referring to the survival data unfavorable cytogenetics resulted in a survival disadvantage at the same scale as compared to 21–30% blasts. Thus, in a revised IPSS this cytogenetic feature should get the same scoring points as compared to 21–30% blasts when using the FAB-classification. For a scoring system based on the WHO-classification unfavorable cytogenetics should get an even higher scoring value as compared to the maximum blast count of 19%. Further statistical analyses are on the way to substantiate our conclusions.

Description: Introduction: Several recent publications have advanced our knowledge of the prognostic significance of clonal cytogenetic abnormalities in MDS, yet the genetic risk assessment of the rare karyotypic aberrations in MDS patients (pts) remains unknown. Using the German-Austrian (G-A) Cytogenetics Database, we previously defined 24 cytogenetic prognostic subgroups; however, 12 subgroups characterized by non-complex (isolated or one additional abnormality only) karyotypes with del(9q), del(15q), t(15q), del(12p), −X, t(1q), t(7q), t(17q), −21, t(11q23), +19, t(5q) were observed infrequently (

Description: Introduction: The IPSS-Score, published by Greenberg et al., defines the gold standard in risk stratification of patients suffering from MDS. Nevertheless, the assessment of cytogenetic findings within the IPSS was discussed intensively since its implementation in 1997. Within the IPSS, patients with a high number of bone marrow blasts are rated with a higher risk as compared to those with unfavourable cytogenetics. In a further univariate anylysis, we were able to demonstrate that poor cytogenetics are associated with the same prognostic risk as blast counts 〉20%. The aim of our present study was to investigate the prognostic impact of poor cytogenetics and bone marrow blast count in a multivariate analysis of a large patient cohort. Patients and Methods: 3169 patients were extracted from our large database, including 3860 patients with MDS and secondary AML following MDS. This data pool was collected in the framework of a cooperative project merging data from the German-Austrian Cooperative MDS Study Group (GACMSG; 55% of pts.) and the MD Anderson Cancer Centre, Houston, USA (45% of pts.). Median age of all study patients was 65.9 years, the female-male ratio 1:1.53. Complex abnormalities occurred in 21.2% of all patients. Multivariate analysis was done using a Cox-regression hazard model with overall survival as primary endpoint. The following groups were established for analysis: Blasts 20%, normal karyotype, complex abnormalities including chromosomes 5 or 7, complex abnormalities not including abnormalities of chromosomes 5 or 7 and −7/7q- (as single abnormality). Results: Former Kaplan-Meier analysis (data presented last year) showed that median survival (ms) in patients with unfavourable cytogenetics (n=516, ms=7.9 months) is similar to those showing 〉20% bone marrow blasts (n=197; ms=8.9 months). In multivariate analysis, relative Hazard ratio (HR) was 1.50 in pts. with 5–10% blasts, 1.64 in 11–20% blasts and 1.81 in 〉20% blasts (baseline for relative HR:

Description: The 5q deletion syndrome is described as having a favourable outcome in MDS. However, little data is available concerning del(5q) and additional karyotype anomalies or taking into account bone marrow blast count. We screened the MDS registries of Düsseldorf, Germany and Lausanne, Switzerland in order to obtain data on patients with karyotype anomalies including del(5q). In both registries 1073 patients were karyotyped at diagnosis. 198 patients with del(5q) with or without other karyotype anomalies and 105 patients with complex karyotype anomalies without del(5q) were analysed. 106 patients showed del(5q) as single anomaly, 23 had 1 additional karyotype anomaly, 69 had 2 or more additional anomalies and were therefore classified as complex karyotype. In the group with del(5q) only, mean survival was 76 months as compared to 42 months in patients with a normal karyotype. In the group with 1 additional anomaly mean survival was 47 months (p=0.02), in the group with 2 or more additional anomalies 7 months (p=0.0005). Survival differed significantly in each subgroup when patients presenting less than 10% of bone marrow blasts where compared to patients with 10% or more. Patients with del(5q) only show a median survival of 12 months when presenting with more than 10% medullary blasts. Patients with a complex karyotype including del(5q) with less than 5% medullary blasts had a median survival of 12 months, but median survival was only 6 months in patients with elevated medullary blasts. By multivariate analyses, we found that additional karyotype anomalies, followed by an elevated medullary blast count above 10% are the most important independent prognostic parameters. Furthermore, we compared the subgroups with del(5q) and 2 or more additional karyotype anomalies (n=69) to patients with complex karyotype anomalies not including del(5q) (n=105). Median survival of the group with complex karyotype anomalies including del(5q) was 7 months as compared to 12 months in the group without del(5q) (p=0.02). 12 months after diagnosis, 30% of the group with del(5q) in a complex karyotype was alive as compared to 45% of the group with a complex karyotype without del(5q). Disease related death was noted in 77% of patients with a complex karyotype and del(5q) and 73% without del(5q). Therefore, our data show that the prognosis of survival in patients with del(5q) is highly dependent on the number of additional karyotype anomalies as well as medullary blast count. The prognosis of MDS patients with del(5q) is associated with an extremely poor prognosis when diagnosed within a complex karyotype. Although there are no substantial differences in clinical, haematological and morphological data between patients with or without del(5q), the median survival differs significantly. Figure Figure

Description: INTRODUCTION: Myelodysplastic syndromes are dynamic diseases affecting the stem cell compartment in bone marrow presenting with different clinical courses ranging from stable, indolent disease to rapid progression to acute myeloid leukemias. So far, only 3 studies on karyotype analysis in MDS with a minimum of 30 patients have been published. Most knowledge about genetic evolution in MDS is based on the description of parallely existing subclones within one single examination. Thus, little is known about the real frequency, the time spans and the clinical impact of karyotype evolution. MATERIALS AND METHODS: So far, data from 322 patients with MDS or secondary AML and at least two successfully performed classical cytogenetic analyses are available from four centres of the Competence Network Acute and Chronic Leukemias. As yet, we retrospectively examined 268 patients out of this data set. Karyotype evolution (KE) was defined as acquisition of additional aberrations, expansion of an aberrant clone (〉20%) or development of a completely aberrant karyotype after an initial mosaic karyotype. RESULTS: In 44 cases (16%) KE was observed. In the mean 2.8 (range 2–9) cytogenetic examinations have been performed. In 27 cases additional aberrations occurred and in 17 cases the abnormal clone expanded in a subsequent analysis. Compared to stable courses, patients with KE had a tendency towards a shorter survival (p=0.15). In the group of patients with expansion of the aberrant clone the most frequent karyotypes were −7/7q- (4x), complex (3x), 5q- (3x) and +8 (3x). The most frequent karyotypes in which during the course of the disease additional aberrations occurred were complex (4x) and karyotypes with two miscellaneous aberrations (4x). The most frequent additional aberrations were 5q- (3x) and −17/17p- (3x). CONCLUSIONS: In sequential cytogenetic examinations KE is a frequent event. Patients with KE tend to have a shortened survival. In our collective no long-term survivor could be observed in the group displaying KE regardless of the therapy strategies (excluding allogeneic transplantation). In this multicentric study which encompasses the largest data base on sequential analyses in MDS to date, frequency, evolution patterns and prognostic relevance of karyotype changes have been studied allowing a better insight into the genetic dynamics of MDS.

Description: Valproic acid (VPA) has been shown to inhibit histone deacetylase activity and to synergize with all-trans retinoic acid (ATRA) in the differentiation induction of acute myelogenous leukemia (AML) blasts in vitro. We treated 18 patients with myelodysplastic syndromes (MDS) and AML secondary to MDS (sAML/MDS) with VPA monotherapy (serum concentrations 346-693 μM [50-100 μg/mL]). Five patients received VPA and ATRA (80 mg/m2/d, days 1-7, every other week). Response according to international working group (IWG) criteria was observed in 8 patients (44%) on VPA monotherapy, including 1 partial remission. Median response duration was 4 months (range, 3-9 months). Four of 5 patients relapsing were treated with VPA + ATRA, 2 of them responding again. Among 5 patients receiving VPA + ATRA from the start, none responded according to IWG criteria, but 1 patient with sAML/MDS achieved a marked reduction in peripheral and marrow blasts. Thus, VPA is of therapeutic benefit for patients with MDS, and ATRA may be effective when added later.