Michelina Santopietro

Evaluation of comorbidities at diagnosis predicts outcome in myelodysplastic syndrome patients

Recent data suggest that proper assessment of comorbidities is useful to predict the outcome of MDS patients receiving allogeneic stem cell transplantation. However, the results obtained in this highly selected subset of patients cannot be applied to the whole MDS population. We evaluated the impact of comorbidities in 418 consecutive MDS patients diagnosed at our institute from 1992 to 2005. All patients were classified according to WHO criteria and all received only conservative and supportive treatment. One or more comorbidities were detected in 390 patients (93%) at the time of diagnosis, with a higher incidence in older patients. Cardiac diseases were the most frequent comorbidities (30%) while diabetes and correlated adverse events were the second cause of comorbidity (20%). We applied 3 comorbidity prognostic scores (CCI, HCT-CI and a MDS-CI score proposed by Della Porta et al.). According to CCI score, 253 patients had a score 0, 111 patients had a score 1 and 54 patients had a score >2. According to HCT-CI, 209 patients had a score 0, 105 patients had a score 1 and 106 patients had a score >2. With MDS-CI score, 288 patients had a score 0 and 129 patients had a score >1. We found a significant correlation between survival and stratification according to CCI and MDS-CI scores (p=0.01 and 0.02, respectively), but not according to HCT-CI score. The number of comorbidities as evaluated according to CCI was directly correlated to the development of RBC transfusion-dependency and was associated to a significantly higher risk of death not related to leukemic evolution (HR = 2.12, p ≤ 0.001). Conversely, higher risk of non-leukemic death did not correlate with higher transfusional requirement according to HCT-CI and MDS-CI scores (p = 0.3 and 0.43, respectively). As suggested by Della Porta et al., also in our experience the presence of cardiac, liver, renal, pulmonary diseases and solid tumours was found to independently affect the risk of death in a multivariable Cox regression analysis (p values from <0.01 to 0.004). In conclusion, assessment of comorbidities at diagnosis in MDS patients may improve the ability of therapeutic decisions.

Differences in hematological and non-hematological toxicity during treatment with imatinib in patients with early and late chronic phase chronic myeloid leukemia

Imatinib is a relatively specific inhibitor of the BCR/ABL tyrosine kinase, effective in chronic myeloid leukemia (CML). The aim of our study was to analyse the frequency and type of hematological and non-hematological adverse events in our series of late and early chronic phase patients with CML treated with imatinib and correlate the grade of hematological toxicity with the response obtained. Hematological events were seen in 59 out of 150 (39%) late chronic phase (CP) patients: of these, 24% experienced toxicity Grade 3–4. Of the 100 early CP patients, 26 (26%) had hematological adverse event: 7% experienced toxicity Grade 3–4 (p = 0.0001). We found that only in early CP patients, the occurrence of hematological side effects of any grade within 6 months of therapy had a negative influence on cytogenetic response. We compared the incidence of non-hematological adverse events occurring in late and in early CP patients and found that in these latter, some side effects were more frequent, such as weight gain, periorbital edema, muscle cramps, skin rashes, diarrhea, weeping. On the contrary, we found that bone pain and hemorrhagic events were more common in late CP patients. Grade 3–4 adverse events were recorded at rates below 4% and decreased over time: in late CP patients hemorrhages and muscle cramps were the most common side effects of Grade 3–4, whereas in early CP patients, the most frequent events were nausea, weight gain and cutaneous rash. We have observed that hematological and non-hematological side effects during imatinib therapy are different among late and early CP patients and that severe hematological toxicity may influence cytogenetic response only in early CP patients.

Refractory cytopenia with unilineage dysplasia: analysis of prognostic factors and survival in 126 patients

According to the revised WHO classification of 2008, dysplasia in ≥10% of one bone marrow lineage and one cytopenia constitutes the low-risk category of unilineage cytopenia and unilineage dysplasia (UCUD). We retrospectively reclassified, according to WHO, low-risk MDS from our database and found 126 subjects with these features at diagnosis: 79 patients were categorized as refractory anemia (RA), 23 patients as refractory neutropenia (RN), and 24 as refractory thrombocytopenia (RT). We did not find differences between the three subgroups as regards sex, median age, and cytogenetic aberrations. Lower PMN count (0.8 × 109/L) was observed in the RN category, as well as lower platelet count in the RT category (51 × 109/L). Moreover, we found a lower rate of patients requiring RBC transfusions, during the disease course, in the RT category (45.8%) as compared to RA (62%) and RN (69%) groups (p = 0.05); a lower incidence of infections at diagnosis in the RT category (20.8%) compared to RA (32%) and RN (43%) categories (p = 0.03); and a higher incidence of hemorrhagic symptoms at diagnosis in the RT category (41.6%) and RN category (26%) as compared to the RA group (5%) (p = 0.001). Application of different scoring systems (Bournemouth and Spanish scores, WPSS) revealed a low OS in high-risk patients within the RT category, compared to RA and RN categories, although unlikely to reflect the consequences of low OS found in the former category. Statistically significant differences were also evidenced in the incidence of acute myeloid leukemia (AML) evolution and overall survival: 7/79 (8%) patients with the RA category evolved to AML in a median time of 89 months, whereas 4/23 (17%) of the RN category and 1/24 (4%) of the RT category experienced disease progression, in a median time of 33.8 and 12.8 months, respectively (p = 0.03). The RT category had a lower overall survival (15.9 months) as compared to RA (48.2 months) and RN (35.9 months) categories (p < 0.001). In conclusion, in our study, application of the revised 2008 WHO classification confirmed the importance of separating patients with unilineage dysplasia for prognostic disease assessment; from our results it seems that the RT category has a worse outcome.

Suboptimal response to imatinib according to 2006–2009 European LeukaemiaNet criteria: a ‘grey zone’ at 3, 6 and 12 months identifies chronic myeloid leukaemia patients who need early intervention

Barker, J.N., Weisdorf, D.J., DeFor, T.E., Blazar, B.R., McGlave, P.B., Miller, J.S., Verfaillie, C.M. & Wagner, J.E. (2005) Transplantation of 2 partially HLA-matched umbilical cord blood units to enhance engraftment in adults with hematologic malignancy. Blood, 105, 1343–1347. Barker, J.N., Scaradavou, A. & Stevens, C.E. (2010) Combined effect of total nucleated cell dose and HLA match on transplantation outcome in 1061 cord blood recipients with hematologic malignancies. Blood, 115, 1843–1849. Blume, K.G., Forman, S.J., O’Donnell, M.R., Doroshow, J.H., Krance, R.A., Nademanee, A.P., Snyder, D.S., Schmidt, G.M., Fahey, J.L., Metter, G.E., Hill, L.R., Findley, D.O. & Sniecinski, I.J. (1987) Total body irradiation and high-dose etoposide: a new preparatory regimen for bone marrow transplantation in patients with advanced hematologic malignancies. Blood, 69, 1015–1020. Brunstein, C.G., Barker, J.N., Weisdorf, D.J., DeFor, T.E., Miller, J.S., Blazar, B.R., McGlave, P.B. & Wagner, J.E. (2007) Umbilical cord blood transplantation after nonmyeloablative conditioning: impact on transplantation outcomes in 110 adults with hematologic disease. Blood, 110, 3064–3070. Delaney, C., Gutman, J.A. & Appelbaum, F.R. (2009) Cord blood transplantation for haematological malignancies: conditioning regimens, double cord transplant and infectious complications. British Journal of Haematology, 147, 207–216. Kurtzberg, J., Laughlin, M., Graham, M.L., Smith, C., Olson, J.F., Halperin, E.C., Ciocci, G., Carrier, C., Stevens, C.E. & Rubinstein, P. (1996) Placental blood as a source of hematopoietic stem cells for transplantation into unrelated recipients. New England Journal of Medicine, 335, 157–166. Laughlin, M.J., Barker, J., Bambach, B., Koc, O.N., Rizzieri, D.A., Wagner, J.E., Gerson, S.L., Lazarus, H.M., Cairo, M., Stevens, C.E., Rubinstein, P. & Kurtzberg, J. (2001) Hematopoietic engraftment and survival in adult recipients of umbilical-cord blood from unrelated donors. New England Journal of Medicine, 344, 1815–1822. MacMillan, M.L., Weisdorf, D.J., Brunstein, C.G., Cao, Q., DeFor, T.E., Verneris, M.R., Blazar, B.R. & Wagner, J.E. (2009) Acute graftversus-host disease after unrelated donor umbilical cord blood transplantation: analysis of risk factors. Blood, 113, 2410–2415. Rocha, V. & Broxmeyer, H.E. (2010) New approaches for improving engraftment after cord blood transplantation. Biology of Blood and Marrow Transplantation: Journal of the American Society for Blood and Marrow Transplantation, 16, S126–132. Wagner, J.E., Barker, J.N., DeFor, T.E., Baker, K.S., Blazar, B.R., Eide, C., Goldman, A., Kersey, J., Krivit, W., MacMillan, M.L., Orchard, P.J., Peters, C., Weisdorf, D.J., Ramsay, N.K. & Davies, S.M. (2002) Transplantation of unrelated donor umbilical cord blood in 102 patients with malignant and nonmalignant diseases: influence of CD34 cell dose and HLA disparity on treatment-related mortality and survival. Blood, 100, 1611–1618.

Cytogenetic and molecular responses in chronic phase chronic myeloid leukaemia patients receiving low dose of imatinib for intolerance to standard dose.

Imatinib mesylate is the gold standard treatment of chronic myeloid leukaemia (CML) and 400 mg/day is considered the standard dose. Although it is generally well tolerated, some patients require temporary drug discontinuation and permanent dose reduction because of haematological or non‐haematological toxicities. Whether or not reduced doses are effective as the standard dose in inducing and/or maintaining complete cytogenetic and molecular response is not clear. We report the outcome of 45 CML patients in early (17) and late (28) chronic phase (CP) in whom, within a series of 250 patients treated with imatinib, reduced the dose of the drug after experiencing adverse events. Median time interval between the start of therapy and dose reduction was 58 days, whereas median administered dose was 300 mg/day. At 6 months from reduction, major cytogenetic responses (MCRs) were observed in 67% of patients, with 58% being complete cytogenetic remission (CCR), and complete molecular response (CMR) were obtained in 18% of patients. At 12 months, all patients who had obtained MCR reached CCR: this was significantly higher in low risk patients (87%) versus non‐low risk patients (66 and 46%), and in early phase (82%) versus late phase (53.5%). CMR and major molecular response (MMR) were detected in 20 and 22% of patients, respectively. Low dose imatinib appears effective in patients with intolerance to standard dose, even though long‐term effects remain to be established. Copyright

Prognostic features of patients with myelodysplastic syndromes aged < 50 years: update of a single-institution experience

Abstract Fewer than 10% of patients with myelodysplastic syndromes (MDS) are younger than 50 years. A series of 91 younger patients (median age 44 years with female prevalence) are reported and compared with elderly patients. Frequent karyotypic changes were trisomy 8 (9.8%) and monosomy 7 (5%). Twenty-three patients had occupational exposure to potential mutagens (benzene and solvents), with a male predominance, higher frequency of refractory cytopenia with multilineage dysplasia (RCMD) (52%) and higher frequency of monosomy 7 (21.7%). At a median follow-up of 72 months, 22 patients (24%) evolved to acute leukemia, with higher frequency being observed among the exposed cohort (39% vs. 19% non-exposed). Unfavorable factors for overall survival were: age > 40 years, > 5% of blasts, trilinear bone marrow involvement and intermediate–high World Health Organization Prognostic Scoring System (WPSS) risk. The present results suggest that younger MDS could be identified as a distinct subset. For patients belonging to the low/intermediate-I risk group, due to a low transformation rate, aggressive approaches should rarely be recommended.

Isolated central nervous system relapse after nine years of complete molecular remission in a lymphoid blast crisis of chronic myeloid leukemia treated with imatinib

Extramedullary blast crisis (BC) of chronic myeloid leukemia CML) has been observed in 7–10% of patients, with or withut other manifestation of disease progression [1]. Cerebrospinal nvolvement as a site of extramedullary BC is rare, but since the dvent of imatinib as first-line treatment for CML, there have een several reports describing patients with isolated central nerous system (CNS) involvement [1–5], because the drug poorly enetrates the blood-brain barrier. Here we report a case of a ymphoid BC, developed under IFN therapy, which reached comlete molecular remission with imatinib and presented an isolated elapse of the same disease in CNS after nine years of imatinib herapy. A 71-year-old female was diagnosed with Philadelphia+ CML in anuary 2001 and was initially treated with interferon (IFN ) at he maximum tolerated dose of 5 MU/day. After 6 months of treatent, she developed a sudden leucocytosis (WBC 52 × 109 /l). At hat time bone marrow examination showed a total infiltration by 0% blast cells: immunophenotypic analysis revealed a blastic poplation, which was positive for the following superficial antigens: D34, CD79-a, CD19 and CD38, CD13, CD33, CD66-C, TdT+, and egative for CD10, CD20, leading to a diagnosis of lymphoid BC. ytogenetic analysis at the time of acute transformation showed uplication of Ph+ chromosome in 20 analysed metaphases. Cererospinal fluid (CSF) analysis at that time did not reveal evidence of isease. The patient was started on imatinib at the dose of 600 mg aily and achieved a complete haematological response after 1onth and a complete cytogenetic response (CCR) after 3 months. complete molecular response (CMR) was reached after 3 years f treatment (ratio BCR-ABL1/ABL1 < 0.001IS), with imatinib being ontinued at 400 mg/day for the following nine years, without any ign of toxicity. In September 2010, the patient suddenly develped left hypoacusia, left lower limb weakness and right visual loss. MRI showed a solid tissue around the left facial nerve. Optical xamination revealed bilateral papilloedema. Bone marrow examnation confirmed CCR and RQ-PCR showed a residual disease with BCR-ABL1/ABL1 ratio of 0.2%IS. CSF analysis demonstrated high cell ount (1,300 cells/mm3): cytological examination revealed lymhoblast infiltration. Immunophenotypic analysis performed on SF showed the same phenotype detected at diagnosis (positivty for CD34, CD79-a, CD19 and CD38, CD13, CD33, CD66-C, TdT, egativity for CD10, CD20) and FISH analysis detected duplicaion of Ph+ chromosome. RQ-PCR performed on CSF showed a CR-ABL1/ABL1 ratio of 120% IS. A diagnosis of extramedullary BC

Very short-term lenalidomide treatment associated with durable resolution of anemia in a patient with myelodysplastic syndrome with chromosome 5q deletion.

Dear Editor, Dose–response relationship and the precise mechanism of action of lenalidomide in myelodysplastic syndromes (MDS) are still unclear, despite the remarkable response rates in patients with chromosome 5q deletion (del 5q) [1, 2]. A selective effect of lenalidomide on the hematopoietic del5q clone has been described, with inhibition of proteins critical for cell survival or stimulation of tumor suppressor genes on that region [3]. In this context, a critical role of the ribosomal protein RPS14, located in the common deleted region of del5q, has been recently reported [4]. During lenalidomide treatment, most patients usually require transient dose interruption followed by dose reduction due to early adverse events (mainly neutropenia and/or thrombocytopenia) [2]. Few case reports have shown sustained long-term RBC-transfusion independency even after short-term treatment [5–7]. Here, we report a durable response achieved in a patient with del5q MDS after only 17 days of lenalidomide treatment. A 77-year-old female was referred to our hospital in September 2006 because of progressive anemia. Our laboratory tests revealed severe macrocytic anemia (hemoglobin, Hb, 7.0 g/dL; MCV, 122 fl), moderate neutropenia (WBC, 2.42×10 L; absolute neutrophil count, ANC, 1.0× 10 L) and mild thrombocytosis (platelet count, PLT, 475×10 L). A BM examination showed trilinear severe dysplasia, 12% blasts, and del5q in all analyzed metaphases [46, XX, del(5) (q13q31)] [5, 8]. The patient was thus diagnosed with RAEB-2, intermediate-2 International Prognostic Scoring System (IPSS). Treatment with recombinant human erythropoietin (EPO-α, 80.000 IU weekly) was started in October 2006. Erythroid response was achieved in January 2007, lasting until December 2007, when a relapse of anemia with transfusional requirement occurred. In October 2008, lenalidomide 10 mg daily was started. Baseline peripheral blood evaluation revealed Hb, 9.1 g/dL; ANC, 1.5×10 L; and PLT, 658×10 L. BM smear showed persistent trilineage dysplasia, 8% blasts, and isolated del5q (RAEB-1 with intermediate-1 IPSS). After 17 days of treatment, lenalidomide was halted due to severe neutropenia (ANC, 0.39×10 L) with increased transfusion requirement, severe asthenia, nausea, gastrointestinal pain, and a skin infection requiring oral antibiotics. After 2 weeks of lenalidomide deferral, neutrophil count rapidly recovered, but the patient was hospitalized because of paroxysmal atrial fibrillation and thyrotoxic crisis. In November 2008, the patient achieved a complete hematological response (Hb, 12.3 g/dL; WBC, 4.19×10 L; ANC, 2.0×10 L; PLT, 353×10 L) without therapy, and lenalidomide was definitely discontinued at the patients request. At 3 and 6 months after lenalidomide treatment, BM examination showed persistence of moderate trilinear dysplasia without blasts. Partial cytogenetic response was documented in May 2009 (46, XX, del(5) (q13q31) [7]/ 46,XX [13]) and L. Cannella : R. Latagliata (*) :M. Breccia : I. Carmosino : G. Loglisci : P. Volpicelli :A. Ferretti :M. Santopietro : F. Vozella :C. Girmenia :G. Alimena Department of Cellular Biotechnology and Hematology, Sapienza University of Rome, Via Benevento, 6, 00161 Roma, Italy e-mail: rob.lati@libero.it

Analysis of prognostic factors in patients with refractory anemia with excess of blasts (RAEB) reclassified according to WHO proposal

The WHO classification subdivides the FAB RAEB category into RAEB-1 (bone marrow (BM) blasts <10%, peripheral blasts <5%) and RAEB-2 (bone marrow blasts >10% and peripheral blasts >5%). We reclassified according to WHO criteria 228 RAEB patients and analysed them in terms of haematological, karyotypic and prognostic features. We used the database of 680 MDS patients referred to our Institution from 1990 to 2000. Clinical features at presentation, such as sex, age, leukocyte count, polymorphonuclear cell count (PMN), platelet count, haemoglobin level, presence of one or more lineage dysplasia were tested in univariate and multivariate analysis in the two groups of RAEB-1 and RAEB-2 reclassified patients. In multivariate analysis we identified prognostic significant factors in the two patient groups, which consisted of age >70 years and platelet count <100 x 10(9)l(-1) for RAEB-1 category, while for RAEB-2 group parameters negatively influencing survival and risk of progression were haemoglobin <10g/dl, platelet count <100 x 10(9)l(-1), bone marrow blastosis >15% and complex karyotype. We also found differences in cytogenetic data (more balanced translocations and complex karyotypes in RAEB-2 group, p=0.02), and in survival (23.3 months in RAEB-1 vs. 16.1 months in RAEB-2 group, p=0.001). WHO classification provides valuable prognostic information for RAEB patient population, and can identify those subjects with more unfavourable prognosis who should be offered alternative therapeutic strategies.

Isodicentric duplication of Philadelphia chromosome as a mechanism of resistance to dasatinib in a patient with chronic myeloid leukemia after resistance to imatinib

Imatinib mesylate, the first selective inhibitor of BCR–ABL1 tyrosine kinase protein, has shown clinical efficacy in the treatment of chronic myeloid leukemia (CML) by inducing a high rate of complete remission and decreased mortality of patients with CML. Despite the beneficial effects of imatinib, some patients may develop primary or acquired resistance [1]. The IRIS study (International Randomized Study of Interferon vs. STI571) at 8-year follow-up provided an indication of imatinib resistance: 31% of patients discontinued imatinib, with an estimated resistance of 16% [1]. Several mechanisms may contribute to this phenomenon, including increased expression of BCR–ABL1 kinase through gene amplification or duplication, decreased intracellular drug concentration caused by altered drug efflux/influx proteins (OCT1 or P-glycoprotein; Pgp), clonal evolution, or overexpression of Src kinases (Lyn, Hck) involved in BCR–ABL1 independent activation of alternative pathways. However, 40% of resistance in chronic phase (CP) is attributed to the emergence of clones expressing mutant forms of BCR–ABL1 [2]. Alternative treatments for resistant patients have been indicated by the recently updated European LeukemiaNet recommendations [3]: in a case of failure or suboptimal response to imatinib, dasatinib or nilotinib has been proposed as a valid therapeutic strategy. Development of mutations in the ABL1 kinase domain has been reported as a cause of resistance to second-generation tyrosine kinase inhibitors (TKIs), but to date no case of Philadelphia chromosome positive (Phþ) duplication has been reported as a possible mechanism of resistance to dasatinib. In the present study, we determined through G-banding and fluorescence in situ hybridization (FISH) analysis the presence of an acquired isodicentric Ph chromosome occurring in a dasatinib-resistant patient. The impact of this chromosome anomaly on genomic instability and TKI resistance is discussed. A 69-year-old female was referred to our center in June 1998 for the finding of leukocytosis during routine analysis. A peripheral blood complete cell count revealed white blood cells (WBC) 158 6 10/ L with the presence of intermediate forms, hemoglobin 8.3 g/dL, and platelets 450 6 10/L. Physical examination revealed mild hepatosplenomegaly. Bone marrow analysis showed hypercellular marrow with a granuloblastic hyperplastic population in the absence of undifferentiated cells, which was compatible with a chronic myeloproliferative disorder. Conventional cytogenetic analysis revealed a standard t(9;22)(q34;q11.2) translocation in 100% of analyzed metaphases. Conventional cytogenetic analysis was performed on bone marrow cells according to standard methods. Chromosomes were G-banded with trypsin-Giemsa stain (GTG-band), and karyotype was described according to International System for Human Cytogenetic Nomenclature (ISCN 2009) recommendations [4]. The patient