Cytogenetic and molecular predictors of response in patients with myeloid malignancies without del[5q] treated with lenalidomide

<p>Abstract</p> <p>Background</p> <p>While lenalidomide (LEN) shows high efficacy in myelodysplastic syndromes (MDS) with del[5q], responses can be also seen in patients presenting without del[5q]. We hypothesized that improved detection of chromosomal abnormalities with new karyotyping tools may better predict response to LEN.</p> <p>Design and methods</p> <p>We have studied clinical, molecular and cytogenetic features of 42 patients with MDS, myeloproliferative neoplasms (MPN), MDS/MPN overlap syndromes and secondary acute myeloid leukemia (sAML) without del[5q] by metaphase cytogenetics (MC) who underwent therapy with LEN.</p> <p>Results</p> <p>Fluorescence in situ hybridization (FISH) or single nucleotide polymorphism array (SNP-A)-based karyotyping marginally increased the diagnostic yield over MC, detecting 2/42 (4.8%) additional cases with del[5q], one of whom were responded to LEN. Responses were more often observed in patients with a normal karyotype by MC (60% vs abnormal MC; 17%, <it>p </it>= .08) and those with gain of chromosome 8 material by either of all 3 karyotyping methods (83% vs all other chromosomal abnormalities; 44% <it>p </it>= .11). However, 5 out of those 6 patients received combined LEN/AZA therapy and it may also suggest those with gain of chromosome 8 material respond well to AZA. The addition of FISH or SNP-A did not improve the predictive value of normal cytogenetics by MC. Mutational analysis of <it>TET2, UTX, CBL, EZH2, ASXL1, TP53, RAS, IDH1/2</it>, and <it>DNMT-3A </it>was performed on 21 of 41 patients, and revealed 13 mutations in 11 patients, but did not show any molecular markers of responsiveness to LEN.</p> <p>Conclusions</p> <p>Normal karyotype and gain of chromosome 8 material was predictive of response to LEN in non-del[5q] patients with myeloid malignancies.</p

A case of mistaken identity: When lupus masquerades as primary myelofibrosis

Introduction: Autoimmune myelofibrosis is an uncommon hematologic disease characterized by anemia, bone marrow myelofibrosis, and an autoimmune feature. Myelofibrosis is often associated with other conditions, including infections, nutritional/endocrine dysfunction, toxin/drug exposure, and connective tissue diseases, including scleroderma and systemic lupus erythematosus. Absence of clonal markers ( JAK2 ) and heterogeneity of the symptoms often complicate the diagnosis. Case presentation: Here, we present two cases of systemic lupus erythematosus–induced autoimmune myelofibrosis. The first case is of a 36-year-old African American female with diagnosis of systemic lupus erythematosus at the age of 12 years. The second patient is a 44-year-old African American male with family history of systemic lupus erythematosus who developed anemia and constitutional symptoms later on. Both patients showed hypercellularity and fibrotic changes of the bone marrow. Moreover, mutational analysis showed that both patients were wild type for JAK2 (V617F and exon 12) and MPL (exon 10). Conclusions: These two cases illustrate that anemic patients with fibrotic changes in the bone marrow without other clinicopathologic features associated with primary myelofibrosis in the presence of clinical manifestations and history of an autoimmune disease should suggest an autoimmune myelofibrosis. These cases demonstrate that a good clinical history combined with molecular technologies and pathomorphologic criteria are helpful in distinguishing between primary myelofibrosis and a nonclonal myelofibrosis from an associated condition

SNP array–based karyotyping: differences and similarities between aplastic anemia and hypocellular myelodysplastic syndromes

In aplastic anemia (AA), contraction of the stem cell pool may result in oligoclonality, while in myelodysplastic syndromes (MDS) a single hematopoietic clone often characterized by chromosomal aberrations expands and outcompetes normal stem cells. We analyzed patients with AA (N = 93) and hypocellular MDS (hMDS, N = 24) using single nucleotide polymorphism arrays (SNP-A) complementing routine cytogenetics. We hypothesized that clinically important cryptic clonal aberrations may exist in some patients with BM failure. Combined metaphase and SNP-A karyotyping improved detection of chromosomal lesions: 19% and 54% of AA and hMDS cases harbored clonal abnormalities including copy-neutral loss of heterozygosity (UPD, 7%). Remarkably, lesions involving the HLA locus suggestive of clonal immune escape were found in 3 of 93 patients with AA. In hMDS, additional clonal lesions were detected in 5 (36%) of 14 patients with normal/noninformative routine cytogenetics. In a subset of AA patients studied at presentation, persistent chromosomal genomic lesions were found in 10 of 33, suggesting that the initial diagnosis may have been hMDS. Similarly, using SNP-A, earlier clonal evolution was found in 4 of 7 AA patients followed serially. In sum, our results indicate that SNP-A identify cryptic clonal genomic aberrations in AA and hMDS leading to improved distinction of these disease entities

Cytogenetic Predictors of Response to Lenalidomide In Myeloid Malignancies without Del(5q)

Abstract Abstract 4016 Lenalidomide (LEN) is effective in patients with myelodysplastic syndromes (MDS) and the del(5q) cytogenetic abnormality, and has activity in a proportion of patients without this chromosomal defect. To date, no clinically actionable biomarkers, other than the presence of del(5q) detected by metaphase cytogenetics, have been identified to predict response to LEN. The diagnostic yield of metaphase cytogenetics can be enhanced by application of fluorescence in situ hybridization (FISH) for targeted chromosomal lesions including del(5q), as this technique is more sensitive. Similarly, single nucleotide polymorphism array (SNP-A)-based karyotyping, due to its superb resolution, allows for detection of previously cryptic unbalanced chromosomal defects. Both techniques can be preformed on interphase cells and thereby do not require cell division. We hypothesized that application of these technologies may allow for better identification of putative responders to LEN in patients with MDS without del(5q); we stipulated that i) we may detect previously unrecognized cases of del(5q) and that ii) more precise analysis of the karyotypes may allow for recognition of other chromosomal markers of response or refractoriness to LEN. In patients with MDS (N=82), MDS/myeloproliferative neoplasm (MPN) (N=13), acute myeloid leukemia (AML) (N=23), and MPN (N=4), the detection rate of del(5q) increased only marginally with use of additional techniques, from 24% (metaphase cytogenetics (MC) + FISH), to 25% (MC + SNP-A), 25% (FISH + SNP-A) and 26% (all 3 methods). Within this cohort, we then analyzed by FISH and SNP-A karyotype a subset of 42 patients with myeloid malignancies without del(5q) by MC who received LEN. This cohort included 33 MDS (RA, N=5; RARS, N=12; RARS-T, N=1; RCMD, N=1; RAEB1, N=4; RAEB2, N=6; MDS-U, N=4), 6 MDS/MPN and MPN patients (CMML1, N=1; CMML2, N=3, IMF; N=2) and 3 secondary AML. By MC, 32 (76%) showed normal karyotype, 1 (2.4%) no growth and 9 (21%) abnormal karyotype other than del(5q). The overall response rate (ORR) (2006 International Working Group criteria) was 44%, including 3 CR, 3 PR and 8 HI. Previously cryptic del(5q) was detected in an additional 1/18 patient by both SNP-A and FISH (secondary AML with normal metaphase cytogenetics), but this case was refractory to LEN. Del(5q) was also revealed by FISH in 1 patient with unsuccessful MC, but, due to the small size of the clone (8%), SNP-A did not detect this lesion. This patient had a sustained PR with transfusion independence. In 28 patients who received LEN for more than 3 months, the ORR to LEN in patients with normal metaphase cytogenetics was 62%, and 17% for those with chromosomal aberrations (p=.08); the addition of SNP-A did not improve the predictive value of normal cytogenetics. We also analyzed 10 patients without del(5q) by MC who received combination therapy with azacitidine (AZA) and LEN, for whom the ORR was 80% (7 CR, 1 PR). By metaphase cytogenetics, 7/10 patients had a normal karyogram and a response of 86%, compared to 3 patients with chromosomal lesions, 1 of whom responded. Similar to the results in LEN alone, inclusion of defects detected by SNP-A or FISH did not allow for better separation of responders based on normal cytogenetics by MC. Six out of 38 LEN-treated patients had a gain of chromosome 8 material by FISH or SNP-A. 4 out of 6 patients had CR (all of them received combination therapy of AZA and LEN), 1 out of 6 had HI, and 1 with complex karyotype had NR (ORR was 83%), while ORR in patients with other chromosomal abnormalities by FISH or SNP-A was 18%. In conclusion, FISH and SNP-A, when added to routine metaphase cytogenetics, marginally increased the diagnostic yield leading to detection of only 2/42 additional cases with del(5q). In our cohort, the non-del(5q) patients with normal karyotype and those with trisomy 8 or microduplication on chromosome 8 were associated with a favorable response to LEN. Disclosures: Sekeres: Celgene: Consultancy, Honoraria, Research Funding. List:Celgene: Research Funding. Maciejewski:Celgene: Research Funding

A case of mistaken identity: When lupus masquerades as primary myelofibrosis

Introduction: Autoimmune myelofibrosis is an uncommon hematologic disease characterized by anemia, bone marrow myelofibrosis, and an autoimmune feature. Myelofibrosis is often associated with other conditions, including infections, nutritional/endocrine dysfunction, toxin/drug exposure, and connective tissue diseases, including scleroderma and systemic lupus erythematosus. Absence of clonal markers ( JAK2 ) and heterogeneity of the symptoms often complicate the diagnosis. Case presentation: Here, we present two cases of systemic lupus erythematosus–induced autoimmune myelofibrosis. The first case is of a 36-year-old African American female with diagnosis of systemic lupus erythematosus at the age of 12 years. The second patient is a 44-year-old African American male with family history of systemic lupus erythematosus who developed anemia and constitutional symptoms later on. Both patients showed hypercellularity and fibrotic changes of the bone marrow. Moreover, mutational analysis showed that both patients were wild type for JAK2 (V617F and exon 12) and MPL (exon 10). Conclusions: These two cases illustrate that anemic patients with fibrotic changes in the bone marrow without other clinicopathologic features associated with primary myelofibrosis in the presence of clinical manifestations and history of an autoimmune disease should suggest an autoimmune myelofibrosis. These cases demonstrate that a good clinical history combined with molecular technologies and pathomorphologic criteria are helpful in distinguishing between primary myelofibrosis and a nonclonal myelofibrosis from an associated condition

Phase I Combination Trial of Lenalidomide and Azacitidine in Patients With Higher-Risk Myelodysplastic Syndromes

Purpose Lenalidomide and azacitidine are active in patients with lower- and higher-risk myelodysplastic syndromes (MDS). These agents may complement each other by targeting both the bone marrow microenvironment and hypomethylating action on the malignant clone. Patients and Methods This phase I trial explored the safety of combination therapy in patients with higher-risk MDS. Response and characterization of molecular and methylation status of responders were secondary objectives. Patients were enrolled using a 3 + 3 dose escalation. Cycles lasted 28 days, and patients received a maximum of seven cycles. Results Of 18 patients enrolled, median age was 68 years (range, 52 to 78 years), interval from diagnosis was 5 weeks (range, 2 to 106 weeks), and follow-up was 7 months (range, 1 to 26 months). International Prognostic Scoring System categories were intermediate 1 (n = 2), intermediate 2 (n = 10), and high (n = 6). No dose-limiting toxicities occurred, and a maximum-tolerated dose was not reached. Grades 3 to 4 nonhematologic toxicities (> 1) included febrile neutropenia (n = 5), cardiac (n = 2), and CNS hemorrhage (n = 2). Median absolute neutrophil count decrease was 26%, and platelet decrease was 1% (mean, 24%). The overall response rate was 67%: eight patients (44%) had a complete response (CR); three patients (17%) had hematologic improvement; one patient (6%) had marrow CR. Patients achieving CR were more likely to have normal cytogenetics and lower methylation levels. Conclusion The combination of lenalidomide and azacitidine is well tolerated with encouraging clinical activity. The go-forward dose is azacitidine 75 mg/m 2 on days 1 through 5 and lenalidomide 10 mg on days 1 through 21