M.P. Chaury

Azacitidine in untreated acute myeloid leukemia: a report on 149 patients.

Limited data are available on azacitidine (AZA) treatment and its prognostic factors in acute myeloid leukemia (AML). One hundred and forty‐nine previously untreated AML patients considered ineligible for intensive chemotherapy received AZA in a compassionate patient‐named program. AML diagnosis was de novo, post‐myelodysplastic syndromes (MDS), post‐MPN, and therapy‐related AML in 51, 55, 13, and 30 patients, respectively. Median age was 74 years, median white blood cell count (WBC) was 3.2 × 109/L and 58% of the patients had ≥30% marrow blasts. Cytogenetics was adverse in 60 patients. Patients received AZA for a median of five cycles (range 1–31). Response rate (including complete remission/CR with incomplete recovery/partial remission) was 27.5% after a median of three cycles (initial response), and 33% at any time (best response). Only adverse cytogenetics predicted poorer response. Median overall survival (OS) was 9.4 months. Two‐year OS was 51% in responders and 10% in non‐responders (P<0.0001). Adverse cytogenetics, WBC >15 × 109/L and ECOG‐PS ≥2 predicted poorer OS, while age and marrow blast percentage had no impact. Using MDS IWG 2006 response criteria, among patients with stable disease, those with hematological improvement had no significant survival benefit in a 7 months landmark analysis. Outcomes observed in this high‐risk AML population treated with AZA deserve comparison with those of patients treated intensively in prospective studies. Am. J. Hematol. 89:410–416, 2014.

Early introduction of ESA in low risk MDS patients may delay the need for RBC transfusion: A retrospective analysis on 112 patients

ESAs are increasingly used to treat anemia of lower risk MDS, even before RBC transfusion requirement. From a previously published patient cohort treated with ESAs, we selected 112 patients with de novo low or int-1 IPSS MDS with Hb<10 g/dl, serum EPO<500 UI/l and who had never been transfused. Erythroid response rate at 12 weeks was 63.1% (IWG 2006). In multivariate analysis, an interval between diagnosis and ESA onset<6 months, Hb level>9 g/dl, and serum EPO<100 UI/l predicted better response to ESA while shorter interval between diagnosis and ESA onset (p=0.01), lower serum EPO (p=0.04) and WHO diagnosis of RCMD-RS (p=0.03) were associated with longer response. Median interval from diagnosis to transfusion dependency was 80 months and 35 months, respectively, in patients with onset of ESA < 6 months and ≥ 6 months from diagnosis (p=0.007). Those results support early onset of ESA in lower risk MDS, to better avoid the consequences of anemia. Early introduction of ESA may also delay the need for RBC transfusions, hypothetically by slowing the disease course, but prospective studies are required to further assess this point.

Bortezomib combined with low-dose cytarabine in Intermediate-2 and high risk myelodysplastic syndromes. A phase I/II Study by the GFM.

Marrow cells from patients with higher‐risk myelodysplastic syndrome (MDS) exhibit constitutive nuclear factor (NF)‐κB activation. The proteasome inhibitor, bortezomib, has limited efficacy as a single agent in acute myeloid leukaemia. Its activity on leukaemic cell lines is potentiated by chemotherapy. We treated 43 higher‐risk MDS patients with bortezomib (1·5 mg/m2, days 1, 4, 8 and 11) and low dose cytarabine arabinoside (LDAC; 10 mg/m2, then 20 mg/m2 from days 1–14), every 28 d for four cycles. Median follow‐up was 29·7 months. Responses were seen in 12 of the 43 patients (28%), including complete response (CR, n = 1), marrow‐CR (n = 3), partial response (PR, n = 5) and haematological improvement (HI, n = 3). Responses were seen in 12 (36%) of the 33 previously untreated patients (11% CR, 13% PR, 2·5% HI), compared to none in the 12 previously treated patients (P < 0·01). Responders had better overall survival (median 18·2 vs. 10 months). One CR and 3 marrow‐CRs were seen in patients with complex karyotypes. Main toxicity was haematological, responsible for infection in six patients and bleeding in 3. Three patients with Grade 1–2 pre‐treatment haematotoxicity developed Grade 3–4 toxicity. Neuropathy was seen in 12% of patients. The addition of bortezomib to LDAC in higher‐risk MDS may improve results obtained with LDAC alone, especially in patients with unfavourable karyotypes.

O-010 Prognostic factors of response to azacitidine (AZA) in low-risk MDS resistant to erythroid stimulating agents (ESA). The GFM Azaepo 08 study

Conclusions: Our data demonstrate that HSCs are disease-initiating cells in MDS. While MDS HSCs exhibit relatively few functional differences from their normal counterparts, committed myeloid progenitors in low-risk MDS exhibit numerous alterations including loss of GMPs, upregulation of CRT, and increased phagocytosis by macrophages, with increased expression of CD47 and decreased phagocytosis associated with disease progression. These findings are consistent with a model in which committed progenitors in MDS undergo molecular alterations that promote programmed cell removal, thereby resulting in the cytopenias that characterize MDS, but this mechanism does not appear to be critical for disease maintenance by HSCs.