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Paroxysmal Nocturnal Hemoglobinuria (PNH) Screening in Patients with Myelodysplastic Syndrome (MDS) in Clinical Practice: Frequency and Indications
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Poster Presentations – 14th International Symposium on Myelodysplastic Syndromes / Leukemia Research 55 S1 (2017) S45–S167
BCORL1 (66%), CDKN2A (80%, n = 5), and EZH2 (75%, n = 4). On the contrary, mutations with increasing abundance on AZA were observed in genes encoding IDH2 (75%, n = 4) and RUNX1 (62%, n = 8), the latter often related to the progression. There were also de novo mutations that developed on AZA involving seven genes: TP53, BCORL1, STAG2, DNMT3A, ASXL1, SMC3, PTPN11; again, last three related to progression. We conclude that dynamic changes observed in the mutational pattern often reflect the disease course with a decrease/elimination of allelic burden during remission. Mutation reappearance was observable upon progression or relapse while stable pattern was seen in cases of stable disease. Furthermore, in 5 patients (13%) we noted the progression-preceding mutations in ASXL1, RUNX1, SRSF2, STAG2, SF3B1 with markedly increasing allele frequency at morphological remission which was within 2–6 months exchanged into progression. We conclude that tracking of somatic mutations helps to monitor the genetic development of the mutant clone/s and to predict forthcoming disease progression. Acknowledgement: Grant support: AZV16-27790A, GAČ R1605649S, UNCE204021, LH15170, Progres Q26/Q28, NPU2 LQ1604 & RVO-VFN64165.
Results: 152 MDS pts were diagnosed in 2009 or later. Lactate dehydrogenase (LDH), bilirubin (BILI) and reticulocyte count (RETICS) were measured (elevated) in 96 (23), 109 (10) and 142 (14) pts, respectively, and haptoglobin (HAPTO) decreased in 2 of 7 measured. The direct antiglobulin test (DAT) was negative in 9 of 13 pts and serum ferritin level <100 ng/mL in 14 of 116. No pts had hemoglobinuria. 79 (52%) pts were RBC TD, with a median TR of 4 (1–8) units/8 weeks. PNH testing was positive in 1 of 11 pts tested. Reasons for PNH testing were: anemia, n = 3 (with abdominal symptoms in 1); new MDS dx, n = 2; hypoplastic MDS, n = 2; decreased HAPTO; increased TR; and iron deficiency, n = 1 each; see Figure. At a median follow up of 21.1 (0.7–69.9) months for all patients, 113 were alive and the median OS was not reached. Conclusions: PNH was tested for infrequently in MDS patients in clinical practice. Only 11 (7%) of MDS pts since 2009 had PNH testing done despite potential indicators of hemolysis in 27%. Clinical rather than laboratory indicators prompted PNH testing in 6 of 11 pts. Complement mediated hemolysis could exacerbate anemia in MDS. As there is now an effective treatment available, screening for PNH in MDS should be considered.
89 PAROXYSMAL NOCTURNAL HEMOGLOBINURIA (PNH) SCREENING IN PATIENTS WITH MYELODYSPLASTIC SYNDROME (MDS) IN CLINICAL PRACTICE: FREQUENCY AND INDICATIONS S. Wong1, B. Dalal2, H.A. Leitch3 1 Medicine, The Royal College of Surgeons in Ireland, Dublin, Ireland; 2 Division of Laboratory Hematology, Vancouver General Hospital, Vancouver- British Columbia, Canada; 3Hematology, St. Paul’s Hospital and the University of British Columbia, Vancouver, Canada
90 CYTOGENETIC CLONAL EVOLUTION IN MYELODYSPLASTIC SYNDROMES (MDS) WITH ISOLATED DEL(5Q) Z. Zemanova1, K. Michalova1, J. Brezinova2, K. Svobodova1, H. Lhotska1, I. Sarova2, L. Lizcova1, S. Izakova1, S. Ransdorfova2, L. Pavlistova1, A. Berkova1, K. Skipalova1, M. Belickova3, M. Siskova4, R. Neuwirtova4, J. Cermak5, T. Stopka4, A. Jonasova4 1 General University Hospital and First Faculty of Medicine- Charles University in Prague, Center of Oncocytogenetics- Institute of Medical Biochemistry and Laboratory Diagnostics, Prague 2, Czech Republic; 2 Cytogenetic Department, Institute of Hematology and Blood Transfusion, Prague 2, Czech Republic; 3Department of Genomics, Institute of Hematology and Blood Transfusion, Prague 2, Czech Republic; 4General University Hospital and First Faculty of MedicineCharles University in Prague, 1st Medical Department, Prague 2, Czech Republic; 5Clinical Department, Institute of Hematology and Blood Transfusion, Prague 2, Czech Republic
Background: MDS is characterized by ineffective hematopoiesis and peripheral blood cytopenias including anemia which may lead to red blood cell (RBC) transfusion dependence (TD). In paroxysmal nocturnal hemoglobinuria (PNH), complement-mediated lysis occurs. PNH clones are detected in up to 50% of MDS pts might confound the reason for RBC TD. The first specific treatment for PNH was approved in Canada in 2009. Eculizumab reduces hemolysis and RBC transfusion requirements (TR) and has other benefits. We wanted to determine whether PNH as a contributor to anemia is considered in MDS pts in the Eculizumab era. Methods: Pts with a bone marrow biopsy confirmed MDS diagnosis (dx) since 2009 were reviewed. Data extracted included baseline clinical and laboratory features, clinical course, treatment, outcome and indicators of hemolysis. High resolution PNH testing was done by flow cytometry for expression of FLAER, CD24, CD14, and CD59 on neutrophils, monocytes and RBC.
The interstitial deletion of the long arm of chromosome 5 – del (5q) – is the most common cytogenetic finding in patients with MDS (∼30% of abnormal karyotypes). According to IPSS-R, MDS with isolated del(5q) are associated with a favorable clinical course. However in some cases, acquisition of additional genetic aberrations may occur during the course of the disease. The aim of the study was: to evaluate the frequency of cytogenetic clonal evolution (CCE) in MDS patients with isolated del(5q); to analyze the pattern of acquired cytogenetic abnormalities; and to assess the impact of CCE on transformation to AML and/or overall survival. A detailed genome-wide analysis of fixed bone-marrow cells of 184 adults with del(5q), identified with G-banding at the diagnosis of MDS, was performed during the follow-up using FISH (Vysis DNA probes, Abbott), mFISH/mBAND (MetaSystems) and array CGH/SNP (CytoChip Cancer SNP 180K, BlueGnome or SurePrint G3 Cancer CGH+SNP 4 × 180K, Agilent). Amplicon deep sequencing of TP53 mutations (exons 4–11) was performed on a 454 GS Junior system (Roche). CCE was observed in 25/184 patients with isolated del(5q). The clinical progression occurred in 24 of them. One woman lives 56 months after CCE with no signs of disease progression. CCE was detected between 2 and 145 months after first cytogenetic evaluation (median 26 months). Median survival from the first emergence of CCE was 11 months (range 1–56 months; 22 patients died, 3 patients live). In 20/25 cases (80%), clones with del(5q)
Poster Presentations – 14th International Symposium on Myelodysplastic Syndromes / Leukemia Research 55 S1 (2017) S45–S167
BCORL1 (66%), CDKN2A (80%, n = 5), and EZH2 (75%, n = 4). On the contrary, mutations with increasing abundance on AZA were observed in genes encoding IDH2 (75%, n = 4) and RUNX1 (62%, n = 8), the latter often related to the progression. There were also de novo mutations that developed on AZA involving seven genes: TP53, BCORL1, STAG2, DNMT3A, ASXL1, SMC3, PTPN11; again, last three related to progression. We conclude that dynamic changes observed in the mutational pattern often reflect the disease course with a decrease/elimination of allelic burden during remission. Mutation reappearance was observable upon progression or relapse while stable pattern was seen in cases of stable disease. Furthermore, in 5 patients (13%) we noted the progression-preceding mutations in ASXL1, RUNX1, SRSF2, STAG2, SF3B1 with markedly increasing allele frequency at morphological remission which was within 2–6 months exchanged into progression. We conclude that tracking of somatic mutations helps to monitor the genetic development of the mutant clone/s and to predict forthcoming disease progression. Acknowledgement: Grant support: AZV16-27790A, GAČ R1605649S, UNCE204021, LH15170, Progres Q26/Q28, NPU2 LQ1604 & RVO-VFN64165.
Results: 152 MDS pts were diagnosed in 2009 or later. Lactate dehydrogenase (LDH), bilirubin (BILI) and reticulocyte count (RETICS) were measured (elevated) in 96 (23), 109 (10) and 142 (14) pts, respectively, and haptoglobin (HAPTO) decreased in 2 of 7 measured. The direct antiglobulin test (DAT) was negative in 9 of 13 pts and serum ferritin level <100 ng/mL in 14 of 116. No pts had hemoglobinuria. 79 (52%) pts were RBC TD, with a median TR of 4 (1–8) units/8 weeks. PNH testing was positive in 1 of 11 pts tested. Reasons for PNH testing were: anemia, n = 3 (with abdominal symptoms in 1); new MDS dx, n = 2; hypoplastic MDS, n = 2; decreased HAPTO; increased TR; and iron deficiency, n = 1 each; see Figure. At a median follow up of 21.1 (0.7–69.9) months for all patients, 113 were alive and the median OS was not reached. Conclusions: PNH was tested for infrequently in MDS patients in clinical practice. Only 11 (7%) of MDS pts since 2009 had PNH testing done despite potential indicators of hemolysis in 27%. Clinical rather than laboratory indicators prompted PNH testing in 6 of 11 pts. Complement mediated hemolysis could exacerbate anemia in MDS. As there is now an effective treatment available, screening for PNH in MDS should be considered.
89 PAROXYSMAL NOCTURNAL HEMOGLOBINURIA (PNH) SCREENING IN PATIENTS WITH MYELODYSPLASTIC SYNDROME (MDS) IN CLINICAL PRACTICE: FREQUENCY AND INDICATIONS S. Wong1, B. Dalal2, H.A. Leitch3 1 Medicine, The Royal College of Surgeons in Ireland, Dublin, Ireland; 2 Division of Laboratory Hematology, Vancouver General Hospital, Vancouver- British Columbia, Canada; 3Hematology, St. Paul’s Hospital and the University of British Columbia, Vancouver, Canada
90 CYTOGENETIC CLONAL EVOLUTION IN MYELODYSPLASTIC SYNDROMES (MDS) WITH ISOLATED DEL(5Q) Z. Zemanova1, K. Michalova1, J. Brezinova2, K. Svobodova1, H. Lhotska1, I. Sarova2, L. Lizcova1, S. Izakova1, S. Ransdorfova2, L. Pavlistova1, A. Berkova1, K. Skipalova1, M. Belickova3, M. Siskova4, R. Neuwirtova4, J. Cermak5, T. Stopka4, A. Jonasova4 1 General University Hospital and First Faculty of Medicine- Charles University in Prague, Center of Oncocytogenetics- Institute of Medical Biochemistry and Laboratory Diagnostics, Prague 2, Czech Republic; 2 Cytogenetic Department, Institute of Hematology and Blood Transfusion, Prague 2, Czech Republic; 3Department of Genomics, Institute of Hematology and Blood Transfusion, Prague 2, Czech Republic; 4General University Hospital and First Faculty of MedicineCharles University in Prague, 1st Medical Department, Prague 2, Czech Republic; 5Clinical Department, Institute of Hematology and Blood Transfusion, Prague 2, Czech Republic
Background: MDS is characterized by ineffective hematopoiesis and peripheral blood cytopenias including anemia which may lead to red blood cell (RBC) transfusion dependence (TD). In paroxysmal nocturnal hemoglobinuria (PNH), complement-mediated lysis occurs. PNH clones are detected in up to 50% of MDS pts might confound the reason for RBC TD. The first specific treatment for PNH was approved in Canada in 2009. Eculizumab reduces hemolysis and RBC transfusion requirements (TR) and has other benefits. We wanted to determine whether PNH as a contributor to anemia is considered in MDS pts in the Eculizumab era. Methods: Pts with a bone marrow biopsy confirmed MDS diagnosis (dx) since 2009 were reviewed. Data extracted included baseline clinical and laboratory features, clinical course, treatment, outcome and indicators of hemolysis. High resolution PNH testing was done by flow cytometry for expression of FLAER, CD24, CD14, and CD59 on neutrophils, monocytes and RBC.
The interstitial deletion of the long arm of chromosome 5 – del (5q) – is the most common cytogenetic finding in patients with MDS (∼30% of abnormal karyotypes). According to IPSS-R, MDS with isolated del(5q) are associated with a favorable clinical course. However in some cases, acquisition of additional genetic aberrations may occur during the course of the disease. The aim of the study was: to evaluate the frequency of cytogenetic clonal evolution (CCE) in MDS patients with isolated del(5q); to analyze the pattern of acquired cytogenetic abnormalities; and to assess the impact of CCE on transformation to AML and/or overall survival. A detailed genome-wide analysis of fixed bone-marrow cells of 184 adults with del(5q), identified with G-banding at the diagnosis of MDS, was performed during the follow-up using FISH (Vysis DNA probes, Abbott), mFISH/mBAND (MetaSystems) and array CGH/SNP (CytoChip Cancer SNP 180K, BlueGnome or SurePrint G3 Cancer CGH+SNP 4 × 180K, Agilent). Amplicon deep sequencing of TP53 mutations (exons 4–11) was performed on a 454 GS Junior system (Roche). CCE was observed in 25/184 patients with isolated del(5q). The clinical progression occurred in 24 of them. One woman lives 56 months after CCE with no signs of disease progression. CCE was detected between 2 and 145 months after first cytogenetic evaluation (median 26 months). Median survival from the first emergence of CCE was 11 months (range 1–56 months; 22 patients died, 3 patients live). In 20/25 cases (80%), clones with del(5q)