Mengistu, Biruk

Abstract Background In routine myelodysplastic syndromes (MDS) practice, physicians do not submit bone marrow (BM) slides for central review. Instead, they rely on available BM reports to assess prognosis and make therapeutic decisions. Such practice is likely to introduce inaccuracies, especially in the diagnosis of MDS-unclassifiable (MDS-U). The objectives of the current study were to describe the natural history of MDS-U that is diagnosed based on routine BM and peripheral blood (PB) smear reports and compare its prognosis to refractory anemia (RA) or refractory cytopenia with multi-lineage dysplasia (RCMD), which were diagnosed in the same manner. Methods Mayo Clinic databases were reviewed to identify consecutive patients who meet current WHO criteria for MDS-U, RA and RCMD (Swerdlow et al. WHO classification of Tumors, Lyon 2008). No central review was required and diagnosis was based on routine Mayo Clinic pathology reports. Included in the current WHO-defined MDS-U are patients with findings of i) refractory cytopenia with unlineage dysplasia (RCUD) or RCMD with 1% blasts in the PB, 2) MDS with unilineage dysplasia and pancytopenia and 3) persistent cytopenia with ≤1% PB blasts, <5% BM blasts, <10% BM myeloid cell dysplasia and cytogenetic abnormalities considered presumptive evidence of MDS. Patients who had exposure to chemotherapy and/or radiotherapy were excluded. Results A total of 382 patients met WHO diagnostic criteria for MDS-U (n=146; 38%), RA (n=26; 7%), and RCMD (n=210; 55%). Presenting clinical characteristics for patients belonging to each one of these three categories are listed and compared in table 1. There was no difference between the three subgroups in age or gender distribution. Similarly, with the exception of thrombocytopenia that was more prevalent in RCMD, complete blood count and transfusion need at diagnosis were not significantly different between the groups. Risk distribution using conventional prognostic models for survival did not reveal significant differences between MDS-U, RCMD and RA. At the time of this analysis, 265 deaths and 25 leukemic transformations were documented. Overall and leukemia-free survival was similar between the three groups (Figure 1). IPSS and IPSS-R karyotypes (Figure 2&3), however delineate patients into distinct category (P=0.001 and P= 0.01) Conclusions Distinguishing between MDS-U, RCMD and RA, in daily practice, has limited clinical relevance. It might be simpler and more practical to consider MDS without excess blasts under one common morphologic category and utilize instead cytogenetic and molecular information for further prognostic stratification and identify patient subgroups with specific therapeutic needs. Myelodysplastic syndrome-unclassifiable (MDS-U) (n=146) compared with refractory anemia (RA) (n=26) and refractory cytopenia with multilineage dysplasia (RCMD) (n=210) Disclosures: No relevant conflicts of interest to declare.

Abstract Abstract 2831 Background and Aims: Primary myelofibrosis (PMF) is characterized by ineffective erythropoiesis, an underlying inflammatory state and potentially, iron overload in the setting of red cell transfusions. The potential interaction between these clinical variables and assessment of their independent prognostic contribution, if any, is of interest within the context of well established prognostic parameters including the DIPSS-plus model and increased circulating levels of inflammatory cytokines (J Clin Oncol. 2011 Apr 1;29(10):1356–63). Consequently, we studied the relationship between circulating levels of hepcidin (a surrogate for inflammation, iron stores and ineffective erythropoiesis), ferritin (iron stores and inflammation), red cell transfusion need (ineffective erythropoiesis) and soluble inflammatory cytokine levels in PMF patients. Methods: The diagnosis of PMF was according to WHO criteria. Inclusion in this study required availability of archived plasma, bone marrow biopsy, and cytogenetic information at the time of first referral. Plasma total hepcidin levels were measured by ELISA (USCN Life Sciences, Wuhan, China). Serum ferritin was measured as part of routine clinical assessment (normal range: males: 24–336 mcg/L; females: 11–307 mcg/L). Concentrations of plasma cytokines were analyzed in duplicate by using Multiplex Bead-Based Luminex technology (Invitrogen, Carlsbad, CA). Results: Two hundred and three PMF patients met the above stipulated criteria; 136 (67%) were males and the median age at referral was 63 years (range 17–83). Their dynamic international prognostic scoring system (DIPSS)-plus risk categorization was: low-risk 22 (11%), intermediate-1 26 (13%), intermediate-2 85 (42%) and high-risk 70 (34%). Hepcidin levels (median 156279 pg/mL; range 8082–2088002) were strongly correlated with serum ferritin (n=146; median 207 mcg/L; range 14–5367) (r2=0.43, p <0.0001). Both were directly correlated with red cell transfusion need and age, and inversely with hemoglobin level (all p <0.05); however, there was no correlation with increased levels of inflammatory cytokines (>3 standard deviation above mean of normal controls for IL-2 and/ or IL-8) (p>0.05). At a median follow up of 35 months, 104 (51%) deaths and 18 (9%) leukemic transformations were recorded. In univariate analysis, increased levels of hepcidin (HR=2.0; p=0.0006) and ferritin (HR=2.7; p<0.0001) were predictive of inferior overall survival and this significance was sustained during multivariable analysis that included either increased inflammatory cytokine levels (HR=3.2 and 2.7, respectively) or transfusion need (HR=1.7 and 2.2, respectively) as covariates. When all 4 variables (i.e. increased levels of hepcidin, ferritin, inflammatory cytokines and transfusion need) were considered together in the Cox model, only increased inflammatory cytokine levels retained their prognostic significance (HR=2.7; p=0.0046). Furthermore, neither increased ferritin nor increased hepcidin levels were prognostically significant for overall survival when tested either individually or together against the DIPSS-plus model (p>0.05). In univariate analysis, increased hepcidin level, but not increased ferritin or transfusion need, was predictive for inferior leukemia-free survival (HR=2.8; p=0.04) and this significance was sustained in multivariable analysis that included either cytogenetic risk categories (very-high risk versus high-risk versus other) (HR=2.7; p=0.046) or thrombocytopenia (platelet count <100 × 109/L) (HR=2.7; p=0.047) as covariates. Conclusions: Circulating levels of hepcidin and ferritin are highly correlated variables in PMF and appear to provide redundant prognostic information for overall survival in this setting. The lack of correlation with inflammatory cytokines suggests that ineffective erythropoiesis may be the common link for their apparent prognostic value noted during univariate analysis. In contrast to inflammatory cytokines, neither hepcidin or ferritin levels were useful as a complement to the DIPSS-plus prognostic model in the current analysis. The relationship between hepcidin and leukemia-free survival is intriguing however the pathogenetic mechanism remains obscure and needs confirmation in additional patients. Disclosures: No relevant conflicts of interest to declare.

Abstract Abstract 1742 Background Karyotype is one of the most potent and reproducible risk factors for both overall (OS) and leukemia-free (LFS) survival in primary myelofibrosis (PMF) (Blood 2011;118:4595). It is currently not clear if the number of metaphases studied or the abnormal metaphase percentage alters this prognostic impact. Methods: An updated Mayo Clinic database of karyotypically- and DIPSS-plus-annotated patients with PMF was used to identify a consecutive series of patients and their cytogenetic information obtained at time of referral was centrally re-reviewed. Cytogenetic results were interpreted and reported according to the International System for Human Cytogenetic Nomenclature; abnormal karyotype was defined by the presence of at least 2 metaphases with structural abnormalities or monosomy or 3 metaphases with polysomy, regardless of number of metaphases examined. For this particular study, the presence of less than 20 evaluable metaphases did not disqualify patients. “Very high risk” karyotype included monosomal karyotype, inv(3) or i(17q) abnormalities (Blood 2011;118:4595). “unfavorable” karyotype included complex or any sole or two abnormalities that included +8, −7/7q-, -5/5q-, inv(3), i(17q), 12p-, or 11q23 rearrangement (Blood 2011;118:4595). All other cytogenetic abnormalities were considered “favorable” Results: A total of 590 patients (median age 65 years; range 19–89 years) including 424 (72%) males. The DIPSS-plus (JCO 2011;29:392) risk distribution was 40% high, 39% intermediate-2, 12% intermediate-1 and 9% low. Cytogenetic findings included 17 (3%) very high risk, 69 (12%) unfavorable, 165 (28%) favorable and 339 (57%) normal karyotypes. The number of bone marrow metaphases studied to report these cytogenetic findings were ≥20 in 468 (79%) patients, 11 to 19 in 71 (12%) patients and ≤10 in 51 (9%) patients; the proportion of cases studied with ≥20 metaphases were 53% for very high risk, 74% for unfavorable, 83% for favorable and 80% for normal karyotype (p=0.006). Among patients with abnormal karyotype, the abnormal metaphase percentage was ≥75% in 148 (59%) patients, 50 to 74% in 36 (15%) patients, 26 to 49% in 27 (11%) patients and ≤25% in 38 (15%) patients; the proportion of patients with ≥75% was 59% for very high risk, 67% for unfavorable and 56% for favorable karyotypes (p=0.70). As expected, OS was significantly different among very high risk, unfavorable, favorable and normal karyotype patients with respective median survivals of 8, 23, 41 and 57 months (p<0.0001). The number of metaphases studied (p=0.62) or the abnormal metaphase percentage (p=0.12), by themselves, did not affect survival. Similarly, the survival difference among the aforementioned cytogenetic risk groups was equally apparent when patients with ≥20 metaphases studied (n=468; P<0.0001) and those with <20 metaphases studied (n=122; p<0.0001) were separately analyzed. Analysis of patients with very high risk or unfavorable karyotype (n=86) revealed no significant effect of abnormal metaphase percentage on survival (Figure; p=0.80). A similar scenario was demonstrated for patients with favorable karyotype (Figure; p=0.24). Conclusions: Neither the number of metaphases examined nor the abnormal metaphase percentage appear to influence the currently recognized cytogenetic risk stratification in PMF. The current study has implications for both clinical practice and clinical research involving cytogenetic prognostication in hematological malignancies. Disclosures: No relevant conflicts of interest to declare.

Abstract Abstract 2851 Background: It is widely appreciated that total cholesterol (TC) and triglyceride (TG) levels are decreased in patients with primary myelofibrosis (PMF). However, a systematic study looking into the serum lipid profile in PMF and its phenotypic and prognostic relevance is lacking. Methods: An updated Mayo Clinic database of 1008 karyotypically- and DIPSS-plus-annotated patients with PMF was used to identify study patients in whom serum lipid and lipoprotein levels were available at time of referral. Overall (OS) and leukemia-free (LFS) survivals were calculated from the time of referral, which was also the time of serum lipid analysis. Results: A total of 207 patients met the above stipulated criteria and had measurement of TC (n=207), TG (n=204), HDL cholesterol (HDL-C) (n=187), LDL cholesterol (LDL-C) (n=176) and non-HDL cholesterol (N-HDL-C) (n=184). The corresponding median (range) values (mg/dL) were 132 (57–296), 147 (42–742), 31 (8–96), 67 (11–186) and 104 (7–249). TC was significantly (P<0.05) lower in the presence of male sex, older age, red cell transfusion need, hemoglobin <10 g/dL, marked splenomegaly, circulating blasts, constitutional symptoms, JAK2 V617F, and ASXL1 mutations. TG was significantly (p<0.05) lower in the presence of JAK2 V617F, red cell transfusion need, hemoglobin <10 g/dL and thrombocytosis. DIPSS-plus risk categories showed significant differences in their TC (p<0.0001), HDL-C (p=0.004), LDL-C (p=0.004), and N-HDL-C (p=0.009) profiles with higher levels seen in lower risk patients; there were no correlations with TG levels. In univariate analysis, lower levels of TC, HDL-C, LDL-C and N-HDL-C were all associated with shortened survival (P<0.01 for each association) whereas survival was not affected by TG level (p=0.42). Multivariable analysis in the context of DIPSS-plus confirmed the independent prognostic relevance of both TC (p=0.05) and HDL-C (p=0.02) for OS. A similar analysis disclosed no correlation with LFS. Exclusion of patients receiving statin or other anti-lipid treatment did not affect the overall results. Patients in the lower quartiles for either TC (approximately <100 mg/dL) or HDL-C (approximately <25 mg/L) compared to those with higher levels displayed significantly shorter survival (Figure; RR 2.4, 95% CI 1.6–3.7; p<0.0001) that was not accounted for by DIPSS-plus (RR 1.6, 95% CI 1.1–2.5; p=0.03). Conclusions: Decreased levels of total or HDL cholesterol in PMF cluster with adverse disease features and carry a DIPSS-plus independent adverse prognostic value. Measurement of TC and HDL-C in PMF might be useful in monitoring disease progression and treatment response. Disclosures: No relevant conflicts of interest to declare.