Deeg, H. Joachim

ABSTRACT The epidemiology of myelodysplastic syndromes/neoplasms (MDS) is challenging to define due to inconsistent reporting, complex diagnostic procedures, and evolving diagnostic criteria. Using the National MDS Natural History Study—a prospective cohort with centrally adjudicated histopathology and genetic variant review—we characterized the landscape of MDS across the United States and identified differences across demographics. Among 2115 participants, 64% (1346) had an MDS spectrum condition, including MDS (24%), MDS/myeloproliferative neoplasm (5%) and precursor conditions—clonal cytopenia of undetermined significance (22%) and idiopathic cytopenia/dysplasia of undetermined significance (13%). The median age was 74 years, and participants were predominantly male (66%), White (91%), and Non‐Hispanic (92%). Myeloid‐associated variants were detected in 68% of participants, most commonly in TET2, DNMT3A, ASXL1, SF3B1, and SRSF2 . Black, compared to White, participants were younger at diagnosis (69 vs. 74 years, p = 0.01), had equal or increased prevalence of higher‐risk MDS, lower hemoglobin, and higher peripheral blood blasts, yet were less likely to receive MDS‐directed therapy (14% vs. 42%, p = 0.008). Black and Hispanic participants had fewer detectable gene mutations than White participants. Females had lower variant allele frequencies and fewer RNA splicing gene mutations than males. After multivariable adjustment, TP53 mutations, MDS diagnosis, and higher‐risk disease were associated with worse progression‐free and overall survival; age was also associated with overall survival. Black race trended toward improved progression‐free survival. These findings highlight the need for enhanced understanding of MDS pathogenesis across patient groups and refined prognostic tools to improve personalized management of MDS spectrum conditions. Trial Registration: ClinicalTrials.gov identifier: NCT02775383

Abstract Patients at risk for progression from myeloid precursor states (idiopathic cytopenia of undetermined significance [ICUS] and clonal cytopenia of undetermined significance [CCUS]) to myelodysplastic syndrome (MDS) are not well defined. Epidemiologic risk factors, clonal changes for MDS development, and evolution from one MDS state to another were available in the MDS Natural History Study (NHS), a prospective cohort enrolled at diverse US sites. Extensive clinical data and biospecimens were collected at baseline and follow-up. A total of 1177 (56%) individuals with MDS or MDS-related precursor conditions (ICUS/idiopathic dysplasia of undetermined significance [IDUS], CCUS, and MDS/myeloproliferative neoplasm overlap) were enrolled and diagnosed in the MDS NHS. The median age was 74 years, with 89% aged ≥60 years, and most were male patients. Median follow-up time was 1.6 years and was similar among ICUS/IDUS, CCUS, and MDS. During follow-up period, 68% of participants terminated the study, 35% died, and 38% had disease progression. Using a refined clinical definition of progression, the greatest proportion of progression was observed among higher-risk-MDS (116 [73%]), followed by lower-risk-MDS (170 [52%]); fewer progression events were observed among participants with CCUS (65 [22%]) and ICUS/IDUS (46 [17%]). Predictors of progression are delineated, including female sex, higher quantity of mutations, the presence of TP53 mutation, and poor/very poor cytogenetic score. Based on these prospective data, guidelines for clinical management including monitoring and surveillance are outlined. The MDS NHS provides real-world data to illustrate how clinical and genotypic differences inform the classification, disease course, and approach to therapy, with informed monitoring guidelines for patients. This trial was registered at www.ClinicalTrials.gov as NCT02775383.

Introduction Knowledge of epidemiologic risk factors, clonal changes associated with MDS development from precursor states, and evolution from one MDS state to another (lower- (LR) or higher-risk (HR) disease or leukemia (AML)) are largely limited to retrospective studies, which may not reflect the true MDS spectrum. The MDS NHS is an established prospective cohort of patients (pts) with suspected MDS enrolled at diverse US sites. Extensive clinical data and biospecimens are collected at baseline and throughout follow-up (F/U), in real time, as pts are followed for life. Here, we assess rates and potential predictors of progression providing a foundation for precise stratification across the MDS spectrum, which may ultimately guide intervention. Methods At baseline, all MDS NHS pts have central pathology review and those assigned to MDS, MDS/MPN overlap, AML<30% blasts, or at-risk of MDS (AR-MDS: CCUS and other at-risk) are followed prospectively. We compared AR-MDS with LR-MDS (MDS and MDS/MPN overlap with IPSS-R ≤ 3.5) and HR-MDS (MDS and MDS/MPN overlap with IPSS-R > 3.5). We defined disease progression as any F/U diagnosis of worsening disease or documented disease-related death. Rates of disease progression were compared between groups using survival analysis methods for cumulative incidence incorporating non-disease death as a competing risk. Associations between progression and predictor variables were explored using univariate tests of association and multivariable survival (Cox regression) models for time-to-progression and logistic models for probability of progression (yes/no). Results The MDS NHS enrolled 2051 pts during June 2016-February 2024, with 54% (1111, above categories) followed prospectively. Median F/U is 1.7 yrs (IQR: 0.8-3.1 yrs, max: 7.9 yrs). For the current analysis, 582 MDS and 505 AR-MDS pts were included. Compared to AR-MDS, MDS patients were more often male (70% v 61%, p<0.01), older (median age: 75 v 72 years, p<0.01), and had lower baseline hemoglobin (median: 10.1 v 11.9 g/dL, p<0.001), platelets (median: 124 x109 v 146 x109 cells/L, p<0.001), and absolute neutrophil counts (median: 1.9 x109 vs 2.8 x109 cells/L, p<0.001). F/U time was similar among AR-MDS and MDS (median: 1.9 vs 1.6 yrs), with both groups having a 75th percentile of 3 yrs and maximum of 7 yrs. A total of 331 deaths were observed (30%), with 145 (44%) of these due to causes related to MDS (myeloid disease and/or cardiovascular disease). Overall, 18.5% had disease progression, with annual rates of 8% (MDS) and 2% (AR-MDS) (p<0.01). Among HR-MDS, progression rates were greatest in the 1st year following diagnosis (33%) and declined thereafter, whereas progression rates remained between 5-8% for LR-MDS and 1-3% for AR-MDS over 5 yrs of F/U. AR-MDS had similar rates of progression within the first 3 yrs from diagnosis as MDS with the lowest IPSS-R category. Among AR-MDS, low hemoglobin (hazard ratio, HR [95% CI]=3.2 [1.4-7.3], p<0.01) was significantly associated with progression. Among MDS, low hemoglobin (HR=4.0 [2.2-7.0], p<0.001), low platelet count (HR=3.1 [1.7-5.6], p<0.001) and higher numbers of mutations (HR=1.13 [1.0-1.2], p<0.01) were significantly associated with progression. Due to the low rate of progression in AR-MDS, meaningful comparisons of mutations could not be completed. In MDS, univariate analyses showed that somatic mutation prevalence in gene pathways for transcription, cell cycle and RAS signaling, and in genes TP53, BCOR, SF3B1, DDX41, PTPN11, SETBP1, and JAK2 were significantly associated with the probability of progression (p<0.05 in all). In multivariable models, adjusting for patient age, sex, and MDS risk level, the probability of progression (PP) was significantly higher among those with vs without somatic mutations in BCOR (PP=63% vs 29%, p=0.004), PTPN11 (PP=67% vs 29%, p=0.009), SETBP1 (PP=61% vs 30%, p=0.02), JAK2 (PP=59% vs 30%, p=0.02), DDX41 (PP=56% vs 30%, p=0.03) and TP53 (PP=43% vs 29%, p=0.04). Conclusions In this large prospective cohort of MDS and pts at risk for MDS, the annual rate of any disease progression was 8% among MDS and 2% among AR-MDS, lower than some retrospective series. Specific cytopenias and genetic factors associated with progression were identified. The MDS NHS provides an incomparable opportunity to address the critical clinical challenges of management and prevention of MDS progression across its spectrum.

Introduction: Myelodysplastic syndromes (MDS) occur due to the acquisition of mutational events over time. Tobacco smoking is a risk factor for MDS and has been associated with distinct genetic mutations in solid cancers. We investigated the association between smoking intensity and duration and the number and types of genetic mutations in MDS using a large prospective cohort. Methods: The prospective NHLBI/NCI National MDS Natural History Study includes individuals with suspected or recently diagnosed MDS enrolled between June 2016-August 2023. Patient (Pt) bone marrow samples underwent central pathology review, resulting in diagnoses including MDS, MDS/myeloproliferative neoplasm overlap (MDS/MPN), or precursor conditions, such as clonal cytopenia of undetermined significance (CCUS). Self-reported smoking data were collected at enrollment. Smoking intensity (i.e., light, medium, and heavy) was defined per CDC definitions. Included mutations were those manually annotated to be pathogenic for MDS. Mutation frequency and prevalence, as well as associations with smoking history and other key covariates, were assessed using univariate tests of association and multivariable regression models for counts and proportions. Rates of disease progression were compared between groups using survival analysis methods for cumulative incidence incorporating non-disease death as a competing risk. Results: Of 1898 evaluable pts, 52% (N=979) had a history of cigarette smoking [MDS: 58% (252/436), MDS/MPN: 57% (52/91), CCUS: 57% (230/405)], and 18% still smoked at diagnosis. The mean ± SD cigarettes per day was 15.8 ± 12.5 and the mean ± SD smoking years was 29.8 ± 16.9 years. Compared to non-smokers, smokers were more often males (68% v 54%, p<0.001) in the 70-79 year age group (45% v 34%, p<0.001). Similar proportions of those with and without a smoking history had MDS (41% v 37%, respectively). Within MDS, there was no association between smoking and MDS prognostic risk per revised international prognostic scoring system. Compared to light smokers [1-10 pack-years (PY)], heavy smokers (30+ PY) were more often male (81% v 62%, p<0.001) and had higher rates of cardiovascular disease (38% v 20%, p<0.001). In univariate analyses, smokers and non-smokers had similar numbers of mutations (mean ± SD: 2.0 ± 2.7 in both groups). Pts with CCUS had the least number of mutations (1.5 ± 1.2), followed by MDS (2.3 ± 1.8), and MDS/MPN overlap (3.3 ± 1.8). Within disease groups, smokers and non-smokers had similar numbers of mutations. Mutation prevalence was higher among smokers v non-smokers in gene pathways for chromatin modification (15% v 11%, p<0.01) and RNA splicing (26% v 19%, p<0.001) and for individual genes ASXL1 (12% v 8%, p<0.01), SF3B1 (9% v 6%, p<0.05), U2AF1 (6% v 3%, p<0.05) and ZRSR2 (2% v 1%, p<0.05). In multivariable regression models, after adjustment for sex, age and disease group, smokers had significantly more mutations on average than non-smokers (2.0 v. 1.4, p=0.04). Moreover, the number of mutations increased significantly with PY smoked (p=0.006), and those at the 75th and 90th percentiles of PY had 1.8 and 3.5 times the number of mutations, respectively, compared to non-smokers, indicating a dose-response relationship. After adjustment, mutation prevalence increased with PY smoked in the gene pathways for chromatin modification and RNA splicing (p<0.03 for both) and for the genes ASXL1 and ETNK1 (p<0.05 in both cases). The five-year cumulative incidence of disease progression was significantly higher among long-term smokers compared to non-smokers/those with shorter smoking history (mean [95% CI] proportion progressed, 20+ years vs <20 years smoking: 27% [19%-36%] vs 18% [13%-24%], p < 0.05). Overall survival was significantly lower for smokers compared to non-smokers for CCUS pts [HR 1.91, 95% CI (1.03-3.55), p=0.04] but not for MDS [HR 1.21, 95% CI (0.53-1.30), p=0.41]. Conclusions: In this prospective, national cohort, tobacco smoking was associated with distinct genetic mutations related to MDS, suggesting smoking potentially contributes to its multi-step molecular pathogenesis. A dose-response relationship was also demonstrated, as was an association with progression and survival. Our data suggest that pts with a new MDS diagnosis who are also smokers should be counseled to stop smoking, as it appears to contribute to the acquisition of new genetic mutations that can lead to progression.

Abstract Clonal cytopenia of undetermined significance (CCUS) represents a distinct disease entity characterized by myeloid-related somatic mutations with a variant allele fraction of ≥2% in individuals with unexplained cytopenia(s) but without a myeloid neoplasm (MN). Notably, CCUS carries a risk of progressing to MN, particularly in cases featuring high-risk mutations. Understanding CCUS requires dedicated studies to elucidate its risk factors and natural history. Our analysis of 357 patients with CCUS investigated the interplay between clonality, cytopenia, and prognosis. Multivariate analysis identified 3 key adverse prognostic factors: the presence of splicing mutation(s) (score = 2 points), platelet count of <100 × 109/L (score = 2.5), and ≥2 mutations (score = 3). Variable scores were based on the coefficients from the Cox proportional hazards model. This led to the development of the clonal cytopenia risk score (CCRS), which stratified patients into low- (score of <2.5 points), intermediate- (score of 2.5 to <5), and high-risk (score of ≥5) groups. The CCRS effectively predicted 2-year cumulative incidence of MN for low- (6.4%), intermediate- (14.1%), and high-risk (37.2%) groups, respectively, by the Gray test (P < .0001). We further validated the CCRS by applying it to an independent CCUS cohort of 104 patients, demonstrating a c-index of 0.64 (P = .005) in stratifying the cumulative incidence of MN. Our study underscores the importance of integrating clinical and molecular data to assess the risk of CCUS progression, making the CCRS a valuable tool that is practical and easily calculable. These findings are clinically relevant, shaping the management strategies for CCUS and informing future clinical trial designs.

Introduction: Myelofibrosis (MF) is a clonal hematologic malignancy characterized by constitutive JAK-STAT activation and aberrant cytokine signaling. Allogeneic hematopoietic stem cell transplantation (allo-HCT) remains the only potentially curative therapy in MF. The contribution of disease-, patient- and donor-related factors to allo-HCT outcomes remains to be fully elucidated, as well as the presence of somatic mutations in genes such as ASXL1, EZH2, SRSF2, U2AF1 and IDH1/2 which are associated with worse prognosis in MF patients (pts). In this large multi- center retrospective analysis, we aimed to study the impact of clinical and molecular mutations on transplant outcomes. Methods: This analysis including 498 pts from 11 centers in North America and Canada. Univariate proportional-hazard Cox regression analysis stratified by center was used to assess the association of patient, transplant, and disease characteristics on overall survival (OS). Baseline patient demographic data and disease characteristics were selected as covariates in the multivariate analysis. Results: Pts transplanted between 2002-2021 were included in this analysis. Baseline and transplant characteristics are summarized in table 1. The 1- and 2-year OS was 77% (95% CI; 73-81) and 70% (95% CI; 66-74) and non-relapse mortality (NRM) 19% (95% CI: 17-21) and 23% (95% CI: 19-27), respectively. The cumulative incidence (CMI) of relapse at 1- and 2-years was 12% (95% CI; 10-14) and 16% (95% CI; 12-20). The CMI of acute graft versus host disease (aGVHD) grade II-IV was 31% (95% CI; 27-35) at 3 months and 42% (95% CI; 38-46) at 1-year post-transplant and grade was III-IV 13% (95% CI; 11-15) and 18% (95% CI; 14-22), respectively. The CMI of neutrophil engraftment at 1 and 3 months was 90% (95% CI: 87-93) and 97% (95% CI: 95-95) and for platelets 55% (95% CI: 50-59) and 80% (95% CI: 76-83). Univariate analysis included pts (age and gender), transplant (donor type and conditioning regimen intensity) and disease characteristics (DIPSS, mutations, cytogenetics (CG), blood counts, and spleen size). Hemoglobin > 10 g/dL (HR .5, 95% CI .34 -.73 p=3 x 10 -4) and platelets >50× 10 9/L (HR .59, 95% CI .42-.81, p=.0013) prior to transplant were associated with improved OS. High risk DIPSS was associated with decreased OS (p=0.0002). Mutations in ASXL1, EZH2, IDH1/2, U2AF1 and SRSF2 were not associated with decreased OS in this analysis (Figure 1). However, mutations in ZRSR2 were associated with inferior OS (HR 2.07, 95% CI 1.08-3.95, p=.0252). Lastly, JAK2 which had the most frequent mutations was not associated with OS (HR .0.93, 95% CI .65-1.31). There was no association between the CG risk groups and OS. Splenomegaly, measured radiographically, had no impact on OS but was strongly associated with engraftment (better engraftment defined as HR>1). For platelets, spleen size of 15.6-18.9 cm HR of 0.69 (95% CI .47-1, p=.0489) and size >18.9-22.5 cm HR of 0.48 ( 95% CI .33-.7, p=1x10^-4). For neutrophils, spleen size >19.9-22.5 cm had a HR of 0.68, (95% CI .48-.96, p=.0268) and size>22.5 cm had a HR of 0.65 (95% CI .46-.91, p=.0114). Mismatched unrelated (MMURD) and haplo identical donors had no impact on survival but were associated with delayed platelet engraftment; MMURD (HR .67, 95% CI .47-.96, p=.0298) and haploidentical donors (HR .56, 95% CI .39-.8, p=.0017). In a multivariate analysis adjusted for age, gender, highest DIPSS, donor type and conditioning regimen, platelets > 50× 10 9/L (HR .61, 95% CI .44-.87, p=.0053) hemoglobin >10 g/dL (HR .6, 95% CI .4-.9, p=.0244) and lower DIPSS at the time of transplant were associated with improved OS. Conclusions: In this large multicenter analysis only clinical variables; hemoglobin and platelets, were found to be associated with OS after allo-HCT in MF patients. Somatic mutations associated with poor prognosis were not associated with OS suggesting that transplant can overcome their negative impact. Splenomegaly was associated with delayed engraftment but not OS. Interestingly, using alternative donors (MMURD and haplo identical) didn't have a negative effect on OS, possibly reflecting the use of post-transplant cyclophosphamide for GVHD prophylaxis in recent years. These results highlight the importance of biologic factors in the prognostication of outcomes in MF pts undergoing allo-HCT independent of somatic mutations. Supported by the American Society of Hematology (ASH) and MPN Research Foundation

Background: Oral decitabine/cedazuridine (ASTX727) is a fixed dose combination of decitabine (35 mg) and the cytidine deaminase inhibitor cedazuridine (100 mg) given once daily X 5 days on a 28-day cycle producing pharmacokinetic (PK) exposure equivalent to the standard intravenous (IV) decitabine regimen of 20 mg/m 2 daily X 5 days on a 28-day cycle. This was demonstrated in the pivotal ASCERTAIN study (Garcia-Manero, et al, ASH 2019) as it provided a PK bridge to existing decitabine data and demonstrated median OS was 31.7 mo. (Savona,et al. Intl. MDSF International Congress on MDS, 2021). Subjects were initially classified by the International Prognosis Scoring System (IPSS) for historical reasons, however IPSS-R and IPSS-M are enhancements to IPSS that provide dynamic risk assessment for predicting clinical outcomes in MDS. Here, the objective was to re-classify the MDS subjects enrolled on the ASCERTAIN study by IPSS-R and IPSS-M and measure the impact of informing patient outcomes based on re-calculated risk assessment. Methods: One hundred thirty-three subjects with MDS/CMML (chronic myelomonocytic leukemia) were enrolled in ASCERTAIN and were randomly assigned either IV decitabine for cycle 1 and oral decitabine/cedazuridine for cycle 2 or the opposite treatment sequence. All subjects continuing beyond cycle 2 received oral decitabine/cedazuridine for all subsequent cycles until treatment discontinuation for disease progression, toxicity, patient's decision, or HSCT. Whole blood collected prior to treatment was used for DNA isolation and molecular abnormalities identified using next-generation sequencing (NGS) hematologic malignancy panel of 179 genes including all genes commonly mutated in MDS. In the initial analysis of clinical outcomes, subjects were classified by IPSS with response assessment by IWG 2006 IPSS low and Int-1 risk levels were categorized as lower-risk MDS (LR-MDS), whereas IPSS Int-2 and high-risk categories were categorized as higher-risk MDS (HR-MDS). Subjects with sufficient data based on (e.g., available heme parameters, cytogenetics, NGS etc.) were reclassified by IPSS-R and IPSS-M. Subjects with IPSS-R score of ≤3.5 or IPSS-M of either very low, low, or moderate low were categorized as LR-MDS. Similarly subjects with IPSS-R score of >3.5 or an IPSS-M categorization of either moderate high, high, or very high were categorized as HR-MDS. Reclassified subjects were reassessed for CR (Complete Response), OS, and LFS and Harrell's concordance index (c-index) was used to describe the level of agreement between each scale and outcomes. Results: Based on the available data, the number of MDS subjects in the different risk classifications were the following: IPSS: 117, IPSS-R: 104, and IPSS-M: 105. Thirteen and 12 subjects on the IPSS could not be reclassified in the IPSS-R and IPSS-M, respectively, including 5 Int-1 and 2 low-risk MDS cases. CMML subjects were excluded from these analyses. Re-classification generally resulted in the upgrade of the subjects from LR-MDS to HR-MDS (Fig. 1). Thirty-one (26.5%) subjects from IPSS were reallocated in the IPSS-R to different risk categories; 3 (9.7%) were downgraded and 28 (90.3%) were upgraded. Similarly on reclassification with IPSS-M 34 (32.4%) of the patients reclassified; 5 (14.8%) were downgraded and 29 (85.3%) were upgraded. For IPSS LR-MDS, 23.2% of patients achieved CR, and 22.9% in the IPSS HR-MDS. Similarly, 21.6% patients achieved CR in the IPSS-R LR-MDS, and 23.9% in the IPSS-R HR-MDS; 26.3% patients achieved CR in the IPSS-M LR-MDS, and 20.9% in the IPSS-M HR-MDS. The c-index for the IPSS was .64 (OS) and .67 (LFS), IPSS-R was .70 (OS) and .71 (LFS), and .75 (OS) and .78 (LFS) for the IPSS-M (Table1). Conclusion: Reclassification from IPSS to IPSS-R or IPSS-M upgraded multiple subjects from a LR to a HR category, describing the ASCERTAIN patient population as a majority higher risk population with worse prognosis than previously assumed based on the IPSS. The efficacy as measured by the CR rates did not change when the LR and HR categories were defined by the different risk stratification systems. In contrast, the c-index improves with migration from IPSS to IPSS-R to IPSS-M, indicating an increased discriminatory ability of IPSS-M score in comparison to IPSS and IPSS-R, to predict patient outcomes.