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Abstract Introduction L-asparaginase therapy results in systemic depletion of antithrombin (AT) and fibrinogen (FG), resulting in thrombotic (TE) and hemorrhagic events (HE). Prophylactic correction of coagulation disturbances have been inconclusive with regard to cost effectiveness, and specifically cost effectiveness of antithrombin concentrate (ATC) replacement has not been evaluated. (Abbott et al, 2009, Mitchell et al, 2003). Currently, AT repletion is recommended for levels less than 60%. (Stock et al, 2012) Several treatment protocols with distinctly different L-asparaginase (LAS) or pegaspargase (PEG) doses complicate the frequency and intensity of ATC replacement. We carried out this study to evaluate the cost effectiveness of ATC replacement, based on our institutional practice. Methods This single center, retrospective, observational study was approved by the Institutional Review Board and conducted at Mayo Clinic, Rochester, MN. Consecutive adult patients with a confirmed diagnosis of ALL receiving LAS or PEG between January 2000 and October 2012 were evaluated. Patients with hereditary or acquired thrombophilias or pre-existing TE or HE, were excluded. Per institutional guidelines, ATC was administered if levels were less than 70%. The Centers for Medicare & Medicaid (CMS) single drug historical pricing guide was utilized for 2000-2004. ATC cost beginning January 1, 2005, was derived from the CMS average sales price, reported quarterly. To adjust for price differences due to regimen utilization trends, each dose was also calculated at the final 2012 cost of 3.05/unit. ATC repletion practices and estimated expenditures were compared between regimens. Results Fifty four patients were treated with LAS or PEG containing regimens. Of these, 47 (87%) received ATC. Twenty-eight patients received LASP, 22 received PEGASP and 4 received both. Distribution across protocols was; CALGB 9111 (n=20, Larson et al, 1998), E2993 (n=13, Goldstone et al, 2008), C10403 (n=9, NLM: NCT00558519), CCG 1941 (n=7, Gaynon et al, 2006) and Augmented HyperCVAD (n=5, Faderl et al, 2005). PEG and LAS dosing schemes are outlined in table 1 . LAS doses were converted to PEG upon specific protocol revision or at discontinuation of LAS availability in 2012. Regimens specified a dose cap with the exception of C10403. A total of 399 LAS and PEG doses resulted in 378 instances of ATC repletion. The reimbursement price of ATC in 2000 was estimated at 1.50/unit U.S. dollars (USD) and 3.04/unit USD by the fourth quarter of 2012. The total estimated average sales price was 2,471,745 USD over the study period. C10403 resulted in the highest median number of PEG doses per patient (n = 5) and a median of 17 ATC doses per dose of PEG. This resulted in C10403 being the most expensive regimen with the median expense for ATC replacement being 118,064 USD (chart 1). This conclusion was also seen after comparing different regimens using the most recent 2012 cost estimates. The overall incidence of TE or HE was 17% and equally distributed between regimens (please see accompanying abstract). Conclusions Repletion of ATC in patients receiving asparaginase containing chemotherapy regimens is very expensive and continues to add to costs at many centers, without clear benefit, especially with regards to TE and HE. A prospective, randomized, multicenter clinical trial looking to answer this question is the need of the hour. Disclosures: No relevant conflicts of interest to declare.

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 Background It is widely recognized that advanced age and prior thrombosis predict recurrent thrombosis in essential thrombocythemia (ET) and are used to risk-stratify patients. However, the paucity of large sample size and long-term follow-up has limited the development of similar prognostic models for survival and leukemic transformation (LT). Methods Data was abstracted from the medical records of a consecutive cohort of patients with WHO-defined ET seen at the Mayo Clinic. Cox proportional hazards was used to determine the impact of clinical and laboratory variables on survival and LT. Overall survival and leukemia-free survival was estimated by Kaplan-Meier plots. Results i. Patient characteristics and outcome The study cohort included 605 patients of which 399 (66%) were females (median age, 57 years; range 5–91). Median follow-up was 84 months (range; 0–424). During this period, 155 patients (26%) have died and LT was documented in 20 patients (3.3%) occurring at a median of 138 months (range; 23–422) from ET diagnosis. ii. Prognostic variables for overall survival Univariate analysis of parameters at diagnosis identified age ≥ 60 years, hemoglobin less than normal (defined as < 12 g/dL in females and < 13.5 g/dL in males), leukocyte count ≥ 15 x 109/L, tobacco use, diabetes mellitus, thrombosis, male sex, and the absence of microvascular symptoms as independent predictors of inferior survival. All of the above except the last two (i.e. male sex and the absence of microvascular symptoms) sustained their prognostic significance on multivariate analysis. Based on the first three prognostic variables: age, hemoglobin level, and leukocyte count, we constructed a prognostic model for survival: low-risk (none of the risk factors), intermediate-risk (1of 3 risk factors), and high-risk (≥ 2 risk factors). The respective median survivals were 278, 200, and 111 months (p<0.0001; Figure 1) iii. Prognostic variables for leukemic transformation On univariate analysis of parameters at ET diagnosis, LT was significantly associated with platelet count ≥ 1000 x 109/L, hemoglobin less than normal, and exposure to P-32. However, on multivariate analysis, only hemoglobin less than normal and platelet count ≥ 1000 x 109/L maintained independent prognostic value. Accordingly, we utilized these two variables, to construct a prognostic model for LT: low-risk (none of the risk factors), intermediate-risk (1 risk factor), and high-risk (both risk factors). Only 1 of the 239 patients (0.4%) in the low-risk group vs. 14 of the 289 (4.8%) in the intermediate-risk and 5 of the 77 (6.5%) in the high-risk group underwent LT (p=0.0009; Figure 2). Conclusion The current study provides clinician-friendly prognostic models for both survival and LT in ET. Figure 1 Figure 1. Figure 2 Figure 2.

Abstract Background : Celiac disease (gluten sensitive enteropathy) is a systemic disease with hematological manifestations including; iron deficiency anemia, vitamin B12 and folate deficiency, leukopenia/neutropenia, hyposplenism, venous thromboembolism, and the enteropathy associated T cell lymphoma (E-TCL). Leukopenia/neutropenia is rare, and can result from folate or copper deficiency, but in many cases remains idiopathic. The consequences of neutropenia and neutrophil responses to a gluten free diet are not well described. We carried out this study to assess the incidence and outcomes of neutropenia in patients with celiac disease. Methods : The Mayo clinic celiac disease database (n=1729) was retrospectively analyzed for all patients with a confirmed diagnosis of celiac disease that had leukopenia (<3.5 x10(9)/L) and/or neutropenia (<1.5 x 10(9)/L). The diagnosis of celiac disease was established by positive tissue transglutaminase antibodies (TTG) and confirmatory small bowel biopsy findings. Additional causes of neutropenia such as copper and folate deficiency, drugs, benign ethnic and cyclic neutropenia, chemotherapy, hematological malignancies, combined variable immunodeficiency (CVID), and autoimmune diseases were meticulously excluded. Data abstracted included demographics, temporal association with diagnosis, nadir counts, associated hematological findings, relationship with infections, the use and effect of G-CSF, response to gluten free diet and survival outcomes. Results: 21(1.2%) of 1729 cases screened had idiopathic-celiac related neutropenia; 17 (81%) Caucasian, 15 (48%) females. In 12(57%) patients the neutropenia preceded or occurred near the time of the diagnosis of celiac disease, while in 7 (33.3%) it occurred subsequently. In 2 cases the temporal association could not be established. The median age at diagnosis of celiac disease was 46 years (10-67) and the median follow up for this group was 41.7 months (0-207.3). At last follow up 1 (4.8%) death has been documented; 0 from infectious complications, with no cases of E-TCL. The median laboratory values at diagnosis of celiac disease were available in 11 (52%) patients and included; hemoglobin 12.9 g/dL (10.5-16.8), MCV 91.5 fl (79.6-102.8), WBC 3.2 x109/L (2.3-5.2), ANC 1.29x109/L (0.33-3.24), ALC 1.34x109/L (0.75-2.17), AMC 0.39x109/L (0.15-0.71), and platelet counts 225x109/L (168-711). Anti-granulocyte antibodies were assessed in 7 patients and were negative in all cases. None of these patients had coexistent hyposplenism and three cases of neutropenia that occurred in the setting of celiac disease and CVID were excluded. In 15 (71%) patients the neutropenia was incidentally detected during routine laboratory work and in 4 (19%) it came to light secondary to infections. Ten (48%) patients had recurrent infections (≥1) as documented by their providers, including 7 with sinopulmonary infections, 1 with urinary tract infections, and 1 with skin and soft tissue infections. Additional immunological assessments were not available in these patients. Three (14%) patients had an ANC <500 (significant neutropenia); of which 2 had recurrent sinopulmonary infections. The third patient remained largely asymptomatic. Two of the 3 patients received G-CSF support during infections and responded adequately (ANC improvement > 1 x 10(9)/L). The ANC in patients in this cohort did not correlate with severity of infections. Five (23%) of 21 patients had improvement in neutrophil counts after adopting a gluten free diet, while there was no response in 10 and data was unavailable in 6. The median time to ANC response was 14.5 months (10-15.3) and the median increment in ANC was 0.67 x 10(9)/L (0.48-0.98). Conclusions: Celiac disease associated neutropenia, especially significant neutropenia (ANC <500) is a rare occurrence (~1%). It can often pre-date the diagnosis of celiac disease or occur subsequently. It is potentially associated with an increased incidence of infections, with-out good correlation with the severity of neutropenia. Less than half the patients do seem to respond to a gluten free diet. G-CSF responses seem to be adequate and G-CSF can be used in the setting of severe infections. 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 Background: Current drugs in myelofibrosis (MF), including JAK inhibitors, do not induce complete or partial remissions. Imetelstat is a 13-mer lipid-conjugated oligonucleotide that targets the RNA template of human telomerase reverse transcriptase. A phase-2 study in essential thrombocythemia showed platelet-lowering activity of imetelstat accompanied by reduction in JAK2V617F allele burden, thus providing the main rationale for conducting the current study. Methods: The current study (NCT01731951) is investigator-driven and IRB approved. Drug and research funding were provided by Geron Corporation (Menlo Park, CA, USA). The objective was to obtain preliminary information on therapeutic activity and safety of imetelstat in DIPSS-plus high or intermediate-2 risk MF. Adverse events (AEs) were monitored by Common Terminology Criteria for Adverse Events (Version 4.03) and responses by the International Working Group criteria (Blood2013). Laboratory correlative studies included measurement of plasma cytokines and analysis of mutations. Results : 33 patients were accrued and met eligibility criteria (median age 67 years; 67% males); type of MF was primary 55% and post-PV/ET 45%; risk distribution was high 48% and intermediate-2 52%. Karyotype was abnormal in 16 (48.5%) patients. 79% of patients had received prior therapy including JAK inhibitors in 33%. Protocol treatment : Imetelstat was administered by a 2-hour intravenous infusion (9.4 mg/kg) every three weeks (cohort A; n=19) or weekly x 3 followed by every three weeks (cohort B; n=16). As of 7/24/2014, 11 (33.3%) patients remain on active treatment (median number of cycles completed for all patients = 7; range 1-21). Three patients have died post-registration: intracranial hemorrhage (related), upper gastrointestinal hemorrhage (unrelated) and disease progression. Median follow-up for living patients was 11.0 months (range, 3.6 – 18.4). 22 (66%) patients have discontinued treatment, mainly because of suboptimal response (n=15) or disease progression (n=3). Toxicity : Treatment-related grade 4 neutropenia was seen in 6 (18%) patients and grade 4 thrombocytopenia in 7 (21%). Grade 3 anemia was seen in 9 (27%) patients. Two patients experienced grade 4+ non-hematologic AE: grade 5 intracranial hemorrhage (related), grade 5 upper gastrointestinal hemorrhage (not related); other grade 3+ non-hematologic AEs were seen in only one patient. Regardless of attribution, treatment-emergent grade 1 or 2 liver function test abnormalities affected bilirubin 46%, ALP 52%, AST 55% and ALT 24%. There were 3 instances of grade 3 ALP and one of bilirubin elevations. Efficacy : There were 7 (21.2%) complete (CR; n=4) or partial (PR; n=3) remissions, occurring at a median of 5 cycles of treatment (range 1-9). All 4 CR patients experienced reversal of BM fibrosis and 3 of them a complete molecular response. Six of the 7 CR/PR patients remain in remission (median 9.9 months, range 4.8-14.7). Other responses included anemia response in 4 (31%) of 13 transfusion-dependent patients, >50% reduction in palpable spleen size in 9 (39%) of 23 evaluable patients, ≥50% reduction in leukocyte count in 8 (80%) of 10 patients with marked leukocytosis (WBC >25 x 10(9)/L), resolution of leukoerythroblastosis in the majority of patients, and normalization of platelet count in 9 (75%) of 12 patients with thrombocytosis. Laboratory correlative studies : Mutational frequencies were 79% for JAK2, 18% for CALR, 3% for MPL, 33% for ASXL1, 9% for IDH1/2 and 33% for spliceosome component mutations. CR/PR rates were 27% in JAK2-mutated vs 0% unmutated (p=0.3) and 32% in ASXL1-unmutated vs 0% mutated (p=0.07). CR rate was 38% in SF3B1/U2AF1-mutated vs 4% unmutated (p=0.036). Grade 3+ neutropenia or thrombocytopenia was more likely to occur in JAK2-unmutated (p=0.02) and ASXL1-mutated cases (p=0.049). Multi-cytokine panel screening showed significant differences between baseline and post-treatment samples involving several cytokines, including IL-1b, IL-5, IL-7, IL-17, VEGF, IL-8 and TNF-α (p<0.001 for all). CR/PR did not correlate with baseline cytokine levels. Conclusions : The current study identifies imetelstat as an active drug in patients with MF, but also reveals its potential to cause significant myelosuppression. The association between CR/PR and specific mutations suggests potential targeted activity that might be exploited for patient and disease selection. Disclosures No relevant conflicts of interest to declare.

Abstract Introduction Acute panmyelosis with myelofibrosis (APMF) is classified under acute myeloid leukemia not otherwise specified by World Health organization (WHO). The clinical course of this entity is rapidly progressive and fatal, therefore, it is essential to make the accurate diagnosis and distinguish it from its mimickers, particularly acute megakaryoblastic leukemia; AML-M7 (AMKL). The main objective of this study is to identify clinical and pathologic features which could help distinguish APMF from AMKL. Methods We evaluated all patients treated at our institution between 1994 and 2013, with APMF and AMKL. We retrospectively reviewed their clinical data, laboratory results, and initial bone marrow morphologic evaluation. The lineage of blasts was evaluated using immunohistochemical staining with antibodies to CD34, anti-megakaryocyte antibodies CD41, CD61, and polyclonal factor VIII. Flow cytometry and cytogenetic studies were reviewed. Results i) Clinical characteristics 28 patients were studied which included 8 with APMF (median age 63 years) and 20 with AMKL (median age 65 years). Splenomegaly was commonly seen in AMKL (40%) as opposed to APMF (12.5%) (P=0.21). None of the APMF patients had an antecedent hematologic malignancy, compared to 50% of AMKL patients (p=0.02). Accordingly, APMF patients had a lower incidence of the JAK2V617F mutation compared to AMKL (14% vs. 78%, p=0.04). ii) Pathological features Patients with APMF had a hypercellular marrow with increased erythropoiesis (87% vs. 10%, p<0.01) and granulopoiesis (100% vs. 25%, p<0.01), with lower bone marrow blast percentage (14% vs. 33%, p<0.01), with all blasts staining positive for CD34 (p=0.23) compared with AMKL. In AMKL, the majority of blasts stain positive for anti-megakaryocytic antibodies CD61 (100% vs. 30%, p=0.02), CD41 (75% vs. 20%, p=0.10), and factor VIII (50% vs. 20%, p=0.02). On flow cytometry, all cases of APMF demonstrated multilineage proliferation with subsets of blasts positive for CD61, CD117, and MPO. In comparison, all cases of AMKL expressed megakaryocytic marker CD61. iii) Treatment Half of our patients received intensive induction chemotherapy in each group. Median survival was similar in APMF and AMKL of 8.6 and 7.6 months respectively (P=0.82). Of the 8 APMF patients, two are alive, with follow-up duration of 14 and 20 months, respectively. In the AMKL group, only one patient is alive, with follow-up duration of 55 months. All three patients have undergone allogeneic bone marrow transplant. Conclusion In summary, our study illustrated important clinical and pathologic differences between APMF and AMKL, two similar but distinct conditions. Allogenic stem cell transplant has shown promise in limited number of cases. Future trials evaluating the efficacy of novel therapies are warranted.Table 1Clinical and Laboratory features including treatment details of patients with APMF and AMKLAPMFN=8AMKLN=20P-valueAge in years (median)63650.11Gender, M:F5:310:100.69Splenomegaly at diagnosis, n (%)1 (12.5)8 (40)0.21Antecedent hematological malignancy08- myeloproliferative neoplasm 2- myelodysplastic syndromes0.02Hgb [median] g/dl9.68.70.73WBC [median] x 109/L1.14.40.15Platelets [median ] X 109/L28360.29Blast % [median]2130.47LDH [median]4227090.12JAK2V617F mutation, n (%)1/7 (14)7/9 (78)0.04Bone marrow Cellularity, n (%): - Hypercellular - Normocellular - Hypocellular8 (100) 13 (65) 4 (20) 3 (15)0.07 0.29 0.54↑erythropoiesis, n (%)7 (87)2 (10)<0.01Left shift, n (%)5 (62)6 (30)0.20↑granulopoiesis, n (%)8 (100)5 (25)<0.01Left shift, n (%)8 (100)9 (55)0.01↑megakaryopoiesis, n (%)7 (87)16 (80)1.00Micromegakaryocytes, n (%)7 (87)18 (90)1.00↓megakaryocyte nuclear lobulation, n(%)7 (87)12 (60)0.21Clustering of megakaryocytes, n (%)5 (62)13 (65)1.00BM blast % [median]3314<0.01% of blasts CD34 + [median]100300.23% of blasts + for megakaryocyte markers [median] - CD61+ - CD41+ - Factor VIII+30 20 20100 75 500.020.10 0.01Reticulin fibrosis ≥ 3+, n (%)5 (62)9 (45)0.67Complex karyotype, n (%)4(50)10(50)1.00Treatment, n (%) - Induction chemotherapy - Hypomethylating agent - Clinical trial - Supportive care4 (50) 0 0 4(50)10(50) 2(10) 2 (10) 6(30)Allogeneic bone marrow transplant, n (%)3 (38)3 (15)Overall survival in months (median)8.677.610.82 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.

Abstract Background Increased bone marrow (BM) reticulin fibrosis in polycythemia vera (PV) has been reported in 20% (Ann Hematol. 1999;78:495) to 51% (Eur J Haematol. 2011;86:148) of patients at diagnosis. In a previous report by the international working group for myeloproliferative neoplasms (MPN) research and treatment (IWG-MRT), the presence of BM fibrosis (≥ grade 1) at diagnosis was associated with a lower incidence of thrombosis during the clinical course and a higher risk of fibrotic progression while it did not affect overall (OS) or leukemia-free (LFS) survival (Blood. 2012;119:2239). The objectives for the current single center study of 262 PV patients were to validate the observations from the IWG-MRT and also identify other risk factors for myelofibrosis-free survival (MFFS) in PV. Methods Study patients were selected from our institutional database of MPN and fulfilled the 2016 World Health Organization (WHO) criteria for the diagnosis of PV (Blood. 2016;127:2391). Cytogenetic analysis and reporting was done according to the International System for Human Cytogenetic Nomenclature (Cytogenetic and Genome Research 2013;141:1-6). The degree of BM reticulin fibrosis was based on "real life" BM reports from Mayo Clinic hematopathologists and often in accordance with the European consensus scoring system (Haematologica 2005;90:1128). Statistical analyses considered clinical and laboratory parameters obtained at time of diagnosis. Results Patient characteristics: Analysis was conducted on 262 patients (median age 62 years; 50% males) who met 2016 WHO criteria for diagnosis of PV. Median (range) values were: hemoglobin 18 g/dl (14.8-24), leukocyte count 11.7 x109/L (4.3-59.3) and platelet count 454 x109/L (44-2747). Among informative cases, palpable splenomegaly was present in 27%, pruritus in 33% and erythromelalgia in 6%. Thrombosis history at diagnosis was documented in 28% of the patients and 23% experienced thrombotic events after diagnosis. Information on cytogenetics was available in 142 patients and karyotype was abnormal in 19%. BM reticulin fibrosis was reported to be absent in 135 patients (MF-0, 52%), grade 1 (MF-1) in 101 (39%), grade 2 (MF-2) in 22 (8%) and grade 3 (MF-3) in 4 (2%) patients. After a median follow up of 85 months, 107(41%) deaths, 30 (11%) fibrotic progression and 5 (2%) leukemic transformations were documented. Comparison of patients with and without bone marrow fibrosis A number of clinical and laboratory parameters were evaluated for possible association with the presence of ≥ grade 1 BM reticulin fibrosis and none, including age, sex, complete blood count, palpable splenomegaly, pruritus or erythromelalgia displayed a significant association. In univariate analysis, the presence of BM fibrosis (MF-0 versus MF-1 or greater) did not affect OS (p=0.5), LFS (p=0.2) or thrombosis-free survival (p=0.97) whereas a significant association was noted for MFFS (p=0.009; HR 2.9, 95% CI 1.3-6.7). Others risk factors for MFFS, in a univariate analysis, were leukocytosis ≥15 x 109/L (p=0.02; HR 2.7, 95% CI 1.17-6.48), presence of splenomegaly (p=0.02; HR 2.6, 95% CI 1.16-6) and abnormal karyotype (p=0.0005; HR 4.6, 95% CI 1.9-11). During multivariable analysis, not including karyotype, leukocytosis ≥15 x 109/L (p=0.04), presence of splenomegaly (p=0.04) and presence of BM reticulin fibrosis (p=0.01) remained significant; however, this significance for leukocytosis ≥15 x 109/L, presence of splenomegaly and BM reticulin fibrosis was lost when abnormal karyotype was added as covariate to each risk factor individually (p=0.4, p=0.1 and p=0.9, respectively). Conclusion We report a not infrequent (48% incidence) occurrence of ≥ grade 1 BM reticulin fibrosis at time of initial diagnosis of PV. In the current study, we did not find a prognostic impact for the presence of BM reticulin fibrosis, in terms of OS, LFS or thrombosis-free survival; however, a significant association was confirmed for MFFS that was independent of other non-genetic risk factors. The preliminary observation on the adverse prognostic impact of abnormal karyotype on MFFS requires additional studies. Disclosures No relevant conflicts of interest to declare.

Abstract Background : The 2016 revision to the World Health Organization (WHO) classification of myeloid neoplasms has recommended distinction between "proliferative" (WBC ≥ 13 x 10(9)/L) and "dysplastic" (WBC < 13 X 10(9)/L) subtypes of chronic myelomonocytic leukemia (CMML). In the current study of 261 molecularly-annotated cases, we sought to clarify the prognostic relevance of distinguishing proliferative from dysplastic CMML and also describe differences in the distribution of disease-associated mutations. Methods : 261 patients with WHO-defined CMML were included in the study. All patients had bone marrow (BM) biopsies and cytogenetics performed at diagnosis. Targeted capture assays were carried out on BM DNA specimens obtained at diagnosis for the following genes; TET2, DNMT3A, IDH1, IDH2, ASXL1, EZH2, SUZ12, SRSF2, SF3B1, ZRSR2, U2AF1, PTPN11, Tp53, SH2B3, RUNX1, CBL, NRAS, KRAS, JAK2, CSF3R, FLT3, KIT, CALR, MPL, NPM1, CEBPA, IKZF, and SETBP. The 2016 WHO criteria were used to sub-classify CMML into proliferative and dysplastic subtypes. Results :Among the 261 study patients, 65% were males and median age was 70 years. 154 (59%), 64 (25%) and 43 (16%) patients were classified as CMML-0, 1 and 2, respectively. At a median follow-up of 23 months, 174 (67%) deaths and 37 (14%) leukemic transformations were documented. Mutational frequencies were; TET2 45%, ASXL1 45%, SRSF2 40%, NRAS 14%, SETBP1 13%, CBL 10%, JAK2 7%, RUNX1 6%, U2AF1 6%, DNMT3A 6%, SF3B1 5%, ZRSR2 4%, Tp53 4%, IDH2 4%, KRAS 3%, PTPN11 2%, SH2B3 1%, CSF3R 1%, IDH1 1%, EZH2 1%, SUZ12 1%, KIT 1%, FLT3 1%, and CALR 1%. Risk stratification was based on the Mayo Molecular Model: 31% high, 30% intermediate-1, 28% intermediate-2 and 11 % low risk. i) Dysplastic versus proliferative CMML: phenotypic and molecular differences 139 (53%) patients had proliferative and 122 (47%) dysplastic subtypes. There was no difference between the CMML subtypes in terms of age and gender distribution, hemoglobin level, platelet count or BM blast content. Patients with proliferative CMML had higher absolute monocyte counts (AMC) (p<0.0001), circulating immature myeloid cells (IMC, p<0.001), circulating blasts (p<0.001) and serum LDH levels (p=0.01). The following gene mutations were more common in proliferative vs dysplastic CMML: ASXL1 (54% vs 37%, p=0.009), JAK2 (11% vs 3%, p=0.01) and CBL (11% vs 8%, p=0.047); SF3B1 mutations were more common in dysplastic CMML (8% vs 1%, p=0.02). There was no difference in the incidence of TET2, DNMT3A and SRSF2 mutations whereas there was a trend towards a higher prevalence of NRAS (p=0.06) and CSF3R (p=0.06) mutations in proliferative CMML. Cytogenetic abnormalities (p=0.03), including higher risk categories by the Spanish (p=0.03) and the Mayo-French (p=0.01) systems were more common in proliferative CMML. ii) Impact on overall and leukemia-free survival: Median survival for the entire cohort (n=261) was 24 months. In univariate analysis, survival was shorter in patients with proliferative (median 20 months) versus dysplastic (median 29 months) CMML (p=0.008; HR1.5, 95% CI 1.1-2.1; Figure 1A). Other variables of significance, in univariate analysis, included hemoglobin (p=0.001), leukocyte count (p=0.001), AMC (p=0.003), PB blast % (p=0.003), IMC (p=0.01), BM blast % (p=0.045), abnormal karyotype (p=0.02), ASXL1 (p=0.01) and DNMT3A (p=0.0003) mutations. In multivariable analysis, the difference in survival between proliferative and dysplastic subtypes remained significant with the addition of hemoglobin level (p=0.01), PB blast % (p=0.02), IMC (p=0.04), BM blast % (p=0.01) or DNMT3A mutations (p=0.01). This was, however, not the case with addition of leukocyte count (p=0.32), AMC (p=0.18) or ASXL1 mutational status (p=0.14); whereas the adverse impact on survival from the latter three parameters remained significant. The prognostic impact of ASXL1 mutations was most apparent in dysplastic CMML (Figure 1B). There was no difference in leukemic transformation rates (p=0.4). Conclusions: In the context of current prognostic models, sub-classification of CMML into proliferative and dysplastic subtypes might not provide additional prognostic value. The apparent difference in survival between the two subtypes of CMML is probably accounted for by the higher prevalence of leukocytosis/monocytosis and of ASXL1 mutations in proliferative CMML. Disclosures No relevant conflicts of interest to declare.