Immunophenotyping myelodysplastic neoplasms: the role of flow cytometry in the molecular classification era

The unique heterogenous landscape of myelodysplastic syndromes/neoplasms (MDS) has resulted in continuous redefinition of disease sub-entities, in view of the novel translational research data that have clarified several areas of the pathogenesis and the progression of the disease. The new international classifications (WHO 2022, ICC 2022) have incorporated genomic data defining phenotypical alterations, that guide clinical management of specific patient subgroups. On the other hand, for over a decade, multiparameter flow cytometry (MFC) has proven its value as a complementary diagnostic tool for these diseases and although it has never been established as a mandatory test for the baseline evaluation of MDS patients in international guidelines, it is almost universally adopted in everyday clinical practice for the assessment of suspected cytopenias through simplified scoring systems or elaborate analytical strategies for the detection of immunophenotypical dysplastic features in every hematopoietic cell lineage in the bone marrow (BM). In this review, we explore the clinically meaningful interplay of MFC data and genetic profiles of MDS patients, to reveal the currently existing and the potential future role of each methodology for routine clinical practice, and the benefit of the patients. We reviewed the existing knowledge and recent advances in the field and discuss how an integrated approach could lead to patient re-stratification and guide personalized management

Integrating advanced analytical methods to assess epigenetic marks affecting response to hypomethylating agents in higher risk myelodysplastic syndrome

Background: Patients with higher-risk (HR) myelodysplastic syndrome (MDS), ineligible for allogeneic hematopoietic stem cell transplantation (alloHSCT), require prompt therapeutic interventions, such as treatment with hypomethylating agents (HMAs) to restore normal DNA methylation patterns, mainly of oncosuppressor genes, and consequently to delay disease progression and increase overall survival (OS). However, response assessment to HMA treatment relies on conventional methods with limited capacity to uncover a wide spectrum of underlying molecular events. Methods: We implemented liquid chromatography-tandem mass spectrometry (LC-MS/MS) to assess 5’ methyl-2’ deoxycytidine (5mdC), 5’ hydroxy-methyl-2’-deoxycytidine (5hmdC) levels and global adenosine/thymidine ([dA]/[T]) ratio in bone marrow aspirates from twenty-one HR MDS patients, pre- and post-HMA treatment. Additionally, targeted methylation analysis was performed by interpretation of NGS-methylation (MeD-seq) data obtained from the same patient cohort. Results: LC/MS-MS analysis revealed a significant hypomethylation status in responders (Rs), already established at baseline and a trend for further DNA methylation reduction post-HMA treatment. Non-responders (NRs) reached statistical significance for DNA hypomethylation only post-HMA treatment. The 5hmdC epigenetic mark was approximately detected at 37.5–40% among NRs and Rs, implying the impairment of the natural active demethylation pathway, mediated by the ten-eleven (TET) 5mdC dioxygenases. R and NR subgroups displayed a [dA]/[T] ratio &lt; 1 (0.727 − 0.633), supporting high frequences of 5mdC transition to thymidine. Response to treatment, according to whole genome MeD-seq data analysis, was associated with specific, scattered hypomethylated DMRs, rather than presenting a global effect across genome. MeD-seq analysis identified divergent epigenetic effects along chromosomes 7, 9, 12, 16, 18, 21, 22, X and Y. Within statistically significant selected chromosomal bins, genes encoding for proteins and non-coding RNAs with reversed methylation profiles between Rs and NRs, were highlighted. Conclusions: Implementation of powerful analytical tools to identify the dynamic DNA methylation changes in HR MDS patients undergoing HMA therapy demonstrated that LC-MS/MS exerts high efficiency as a broad-based but rapid and cost-effective methodology (compared to MeD-seq) to decode different perspectives of the epigenetic background of HR MDS patients and possess discriminative efficacy of the response phenotype to HMA treatment.</p

Fetal hemoglobin induction in azacytidine responders enlightens methylation patterns related to blast clearance in higher-risk MDS and CMML

Background: As new treatment options for patients with higher-risk myelodysplastic syndromes are emerging, identification of prognostic markers for hypomethylating agent (HMA) treatment and understanding mechanisms of their delayed and short-term responses are essential. Early fetal hemoglobin (HbF) induction has been suggested as a prognostic indicator for decitabine-treated patients. Although epigenetic mechanisms are assumed, responding patients’ epigenomes have not been thoroughly examined. We aimed to clarify HbF kinetics and prognostic value for azacytidine treated patients, as well as the epigenetic landscape that might influence HbF re-expression and its clinical relevance. Results: Serial HbF measurements by high-performance liquid chromatography (n = 20) showed induction of HbF only among responders (p = 0.030). Moreover, HbF increase immediately after the first azacytidine cycle demonstrated prognostic value for progression-free survival (PFS) (p = 0.032, HR = 0.19, CI 0.24–1.63). Changes in methylation patterns were revealed with methylated DNA genome-wide sequencing analysis (n = 7) for FOG-1, RCOR-1, ZBTB7A and genes of the NuRD-complex components. Targeted pyrosequencing methodology (n = 28) revealed a strong inverse correlation between the degree of γ-globin gene (HBG2) promoter methylation and baseline HbF levels (p = 0.003, rs = − 0.663). A potential epigenetic mechanism of HbF re-expression in azacytidine responders was enlightened by targeted methylation analysis, through hypomethylation of site -53 of HBG2 promoter (p = 0.039, rs = − 0.504), which corresponds to MBD2-NuRD binding site, and to hypermethylation of the CpG326 island of ZBTB7A (p = 0.05, rs = 0.482), a known HbF repressor. These changes were associated to blast cell clearance (pHBG2 = 0.011, rs = 0.480/pZBTB7A = 0.026, rs = 0.427) and showed prognostic value for PFS (pZBTB7A = 0.037, HR = 1.14, CI 0.34–3.8). Conclusions: Early HbF induction is featured as an accessible prognostic indicator for HMA treatment and the proposed potential epigenetic mechanism of HbF re-expression in azacytidine responders includes hypomethylation of the γ-globin gene promoter region and hypermethylation of the CpG326 island of ZBTB7A. The association of these methylation patterns with blast clearance and their prognostic value for PFS paves the way to discuss in-depth azacytidine epigenetic mechanism of action. Graphical abstract: (Figure presented.)</p

Investigation of the epigenetic mechanism of fetal Hemoglobin (HbF) re-expression in patients with myelodysplastic syndrome (MDS) following treatment with hypomethylating agents and investigation of the prognostic significance of this re-expression for patient response to treatment

Background : myelodysplastic syndromes (MDS) are characterized by epigenetic modification and dysregulation, and hypomethylating agents (HMAs), decitabine (DAC) and azacytidine (AZA), remain the primary therapeutic options to prevent the progression of high-risk MDS (HR-MDS) patients, to acute myeloid leukemia (AML). Although the mechanism of action of HMAs has been extensively studied, it remains yet incompletely understood. As new treatment options emerge for patients with HR-MDS, the identification of accessible prognostic markers for the response to HMA therapy and the understanding of mechanisms, underlying their delayed and short-term responses are essential. Despite their known action against DNMT1 and DNMT3A methyltransferases, uncertainty persists regarding the prognostic value of induced hypomethylation. Data from studies on peripheral blood cells suggest that after initial hypomethylation, DNA methylation levels are restored by the end of the 28-day treatment cycle with HMAs. However, data on DNA methylation analysis from bone marrow aspirates of MDS patients using high-resolution advanced techniques are scarce in the literature. Since it is epigenetically silenced, fetal hemoglobin (HbF) induction has been proposed as a prognostic marker for patients receiving DAC. Furthermore, although epigenetic mechanisms are assumed, the methylomes of patients have not been thoroughly examined to elucidate the precise mechanism of HbF re-expression. Our aim was to clarify the kinetics and prognostic value of HbF in patients undergoing AZA treatment. Additionally, we investigated the changes in the epigenetic landscape of patients treated with HMAs at the genome-wide/chromosomal level, as well as the alterations in the methylation of HbF expression regulators following AZA treatment and their clinical significance. Results: In the cohort of patients treated with HMAs and analyzed using genome-wide methylated DNA sequencing (MeD-seq) with the restriction enzyme LpnPI (n=13), an overall increase in average chromosomal methylation was observed, along with a concurrent relative decrease in specific regions, primarily involving non-coding RNAs, among responders (n=6) at the end of six or more HMA treatment cycles. In contrast, non-responders (n=7) exhibited hypomethylation across most chromosomes, which did not lead to an improvement in their clinical phenotype but might instead, have promoted disease progression, as seen in other cancer types. However, chromosomes 21, X, and Y were notably hypermethylated. Serial HbF measurements using high-performance liquid chromatography (n=20) showed HbF induction only among AZA responders (p=0.030). Furthermore, HbF increase immediately after the first AZA treatment cycle demonstrated prognostic value for progression-free survival (PFS) (p=0.032, HR=0.19, CI:0.24-1.63). In AZA-treated patients, changes in methylation patterns were revealed through MeD-seq analysis (n=7) for the genes FOG-1, RCOR-1, ZBTB7A, and genes encoding subunits of the NuRD complex. Targeted pyrosequencing methodology (n=28) revealed a strong inverse correlation between the methylation status of the γ-globin gene (HBG2) promoter and baseline HbF levels (p=0.003, rs=-0.663). A potential epigenetic mechanism of HbF re-expression in AZA responders was highlighted by targeted methylation analysis, showing hypomethylation of the -53 site of the HBG2 promoter (p=0.039, rs=-0.504), which corresponds to the MBD2-NuRD binding site, as well as hypermethylation of the CpG326 island of ZBTB7A (p=0.05, rs=0.482); a known HbF repressor. These changes were associated with blast cell clearance in the bone marrow (pHBG2=0.011, rs=0.480 / pZBTB7A=0.026, rs=0.427) and demonstrated prognostic value for PFS (pZBTB7A=0.037, HR=1.14, CI:0.34-3.8). Reduction of ZBTB7A expression in leukemic cell lines (TF1, MV4-11) showed a tendency to decrease their proliferation, although without a reduction in clonogenicity or sensitivity to AZA. Treatment with low-dose AZA in differentiating to erythroid TF1 cells did indeed show an increase in HBG2 expression along with a simultaneous decrease in ZBTB7A. Conclusions: Response to HMAs appears to be associated with patterns of average hypermethylation at the chromosomal level after at least six treatment cycles, with their demethylating effect targeting specific genomic regions, including non-coding RNAs. In contrast, overall hypomethylation is observed in non-responding patients across most chromosomes, except for chromosomes 21, X, and Y, which are strongly hypermethylated. Early HbF induction emerges as an accessible prognostic marker for HMA therapy, and the proposed epigenetic mechanism of HbF re-expression in AZA responders involves hypomethylation of the γ-globin gene promoter and hypermethylation of the CpG326 regulatory island of ZBTB7A. The correlation of these methylation patterns with blast cell clearance and their prognostic value for PFS, along with the chromosomal-level methylation changes based on treatment response, pave the way for a deeper exploration of the epigenetic mechanism of action of HMAs.Εισαγωγή : τα μυελοδυσπλαστικά σύνδρομα (ΜΔΣ) χαρακτηρίζονται από επιγενετική απορρύθμιση και οι απομεθυλιωτικοί παράγοντες (HMAs), δεσιταμπίνη (DAC) και αζακυτιδίνη (AZA), είναι έως και σήμερα η κύρια θεραπευτική επιλογή για την αναχαίτηση της εξέλιξης των υψηλού κινδύνου ΜΔΣ (HR-MDS) σε οξεία μυελογενή λευχαιμία (ΟΜΛ). Αν και ο ακριβής τρόπος δράσης των HMA έχει μελετηθεί συστηματικά και σε βάθος, ωστόσο δεν είναι απόλυτα σαφής έως και σήμερα. Καθώς αναδύονται νέες θεραπευτικές επιλογές για τους ασθενείς με HR-MDS, η αναγνώριση εύκολα αποκτώμενων προγνωστικών δεικτών για την ανταπόκριση στη θεραπεία με HMA και η κατανόηση των μηχανισμών των καθυστερημένων και βραχυπρόθεσμων ανταποκρίσεών τους είναι απαραίτητη. Παρά την γνωστή δράση τους έναντι των μεθυλτρανσφερασών DNMT1 και DNMT3A, παραμένει αβεβαιότητα σχετικά με την προγνωστική αξία της επαγωγής υπομεθυλίωσης στο γονιδίωμα. Στοιχεία από τις έως τώρα μελέτες σε κύτταρα περιφερικού αίματος έχουν δείξει επαναφορά των επιπέδων μεθυλίωσης του DNA στο τέλος του κύκλου των 28 ημερών θεραπείας με HMA, μετά την αρχική υπομεθυλίωση, ενώ δεδομένα ανάλυσης της μεθυλίωσης του DNA από μυελικά αναρροφήματα ασθενών με ΜΔΣ με υψηλής ευκρίνειας νεότερες τεχνικές είναι πενιχρά στην βιβλιογραφία. Λόγω της επιγενετικής τροποποίησης και αποσιώπησης της έκφρασης των γ-γονιδίων της αιμοσφαιρίνης, η επαγωγή της εμβρυϊκής αιμοσφαιρίνης (HbF) έχει προταθεί ως προγνωστικός δείκτης για ασθενείς που λαμβάνουν θεραπεία με DAC. Επιπλέον, αν και υπήρχε σοβαρή υποψία ότι επιγενετικοί μηχανισμοί εμπλέκονται, τα μεθυλιώματα των ασθενών με ΜΔΣ δεν έχουν εξεταστεί διεξοδικά για να προσεγγίσουν τον μηχανισμό της επανέκφρασής της. Στόχος μας αυτής της διατριβής ήταν να διευκρινιστεί η κινητική της HbF και η προγνωστική της αξία σε ασθενείς που λαμβάνουν θεραπεία με AZA. Επιπλέον, διερευνήθηκαν οι μεταβολές του επιγενετικού τοπίου των ασθενών που λαμβάνουν HMA σε επίπεδο ολικού γονιδιώματος/χρωμοσωμάτων, αλλά και οι αλλαγές στην μεθυλίωση ρυθμιστών έκφρασης της HbF μετά από θεραπεία με AZA, καθώς και η κλινική τους σημασία. Αποτελέσματα: Στο σύνολο των ασθενών που έλαβαν HMA και αναλύθηκαν με αλληλούχιση DNA επόμενης γενιάς για την ανίσχνευση μεθυλίωσης σε επίπεδο γονιδιώματος (MeD-seq), χρησιμοποιώντας το περιοριστικό ένζυμο LpnPI (n=13), φάνηκε η συνολική αύξηση της μέσης μεθυλίωσης σε επίπεδο χρωμοσωμάτων με ταυτόχρονη σχετική μείωση της σε συγκεκριμένες περιοχές, που αφορούν κυρίως μη-κωδικά RNA, στους ανταποκριθέντες ασθενείς (n=6), στο τέλος έξι ή περισσότερων κύκλων HMA. Αντίθετα, στους μη ανταποκριθέντες ασθενείς (n=7) καταγράφηκε υπομεθυλίωση στα περισσότερα χρωμοσώματα, η οποία όμως δεν οδήγησε σε βελτίωση του κλινικού τους φαινοτύπου, αλλά πιθανώς να προήγαγε την εξέλιξη της νόσου, όπως παρατηρείται και σε άλλους τύπους νεοπλασμάτων, με εξαίρεση τα χρωμοσώματα 21, Χ, και Y τα οποία ήταν έντονα υπερμεθυλιωμένα. Οι διαδοχικές μετρήσεις της HbF με χρήση υγρής χρωματογραφίας υψηλής απόδοσης (n=20) έδειξαν επαγωγή της HbF μόνο μεταξύ των ασθενών που ανταποκρίθηκαν στην AZA (p=0.030). Επιπλέον, η αύξηση των επιπέδων της HbF, αμέσως μετά τον πρώτο κύκλο θεραπείας με ΑΖΑ διαπιστώθηκε να έχει προγνωστική αξία για την επιβίωση χωρίς εξέλιξη της νόσου (PFS) (p=0.032, HR=0.19, CI:0.24-1.63). Επιπλέον, σε ασθενείς που έλαβαν ΑΖΑ, με ανάλυση MeD-seq (n=7) αποκαλύφθηκαν αλλαγές στα πρότυπα μεθυλίωσης για τα γονίδια FOG-1, RCOR-1, ZBTB7A καθώς και για γονίδια των υπομονάδων του συμπλόκου NuRD. Η στοχευμένη μέθοδος πυροαλληλούχισης (pyrosequencing) (n=28) αποκάλυψε ισχυρή ανάστροφη συσχέτιση μεταξύ του βαθμού μεθυλίωσης του υποκινητή του γονιδίου της γ-αλυσίδας (HBG2) και των αρχικών επιπέδων της HbF (p=0.003, rs=-0.663). Με την ίδια μέθοδο αναδείχθηκε ένας πιθανός επιγενετικός μηχανισμός επανέκφρασης της HbF στους ασθενείς που ανταποκρίθηκαν στην AZA, μέσω υπομεθυλίωσης της θέσης -53 του υποκινητή του HBG2 (p=0.039, rs=-0.504), η οποία αντιστοιχεί στη θέση σύνδεσης MBD2-NuRD, καθώς και υπερμεθυλίωσης της νησίδας CpG326 του ZBTB7A (p=0.05, rs=0.482), ενός γνωστού καταστολέα της HbF. Αξιοσημείωτο είναι ότι αυτές οι μεταβολές συσχετίστηκαν με την κάθαρση των βλαστικών κυττάρων (pHBG2=0.011, rs=0.480 / pZBTB7A=0.026, rs=0.427) και έδειξαν προγνωστική αξία για την επιβίωση χωρίς εξέλιξη της νόσου (pZBTB7A=0.037, HR=1.14, CI:0.34-3.8). Η μείωση της έκφρασης του ZBTB7A σε λευχαιμικές κυτταρικές σειρές (TF1, MV4-11) έδειξε τάση μείωσης του πολλαπλασιασμού τους, χωρίς ωστόσο μείωση της κλωνογονικότητας ή της ευαισθησίας τους στην AZA. Η θεραπεία με μικρή δόση AZA σε ωριμάζοντα προς ερυθροκύτταρα, κύτταρα της σειράς TF1 έδειξε πράγματι την αύξηση της έκφρασης του HBG2, με ταυτόχρονη μείωση της έκφρασης του ZBTB7A. Συμπεράσματα: Η ανταπόκριση στους HMA φαίνεται να σχετίζεται με μοτίβα μέσης υπερμεθυλίωσης σε επίπεδο χρωμοσωμάτων στο τέλος τουλάχιστον 6 κύκλων θεραπείας και η υπομεθυλιωτική δράση τους αφορά συγκεκριμένες γονιδιωματικές περιοχές, που συμπεριλαμβάνουν μη-κωδικά RNA. Αντίθετα, συνολική υπομεθυλίωση παρατηρείται σε μη ανταποκριθέντες ασθενείς στα περισσότερα χρωμοσώματα, με εξαίρεση τα χρωμοσώματα 21, Χ, και Y που υπερμεθυλιώνονται έντονα. Η πρώιμη επαγωγή της HbF αναδεικνύεται ως ένας εύκολα προσβάσιμος προγνωστικός δείκτης για τη θεραπεία με HMA, και ο προτεινόμενος επιγενετικός μηχανισμός επανέκφρασης της HbF σε ασθενείς που ανταποκρίνονται στην AZA περιλαμβάνει την υπομεθυλίωση του υποικινητή του γονιδίου της γ-αλυσίδας και την υπερμεθυλίωση της ρυθμιστικής νησίδας CpG326 του ZBTB7A. Η συσχέτιση αυτών των προτύπων μεθυλίωσης με την κάθαρση των βλαστικών κυττάρων στο μυελό και η προγνωστική τους αξία για το PFS, καθώς και τα μοτίβα μεταβολής της μεθυλίωσης σε επίπεδο χρωμοσωμάτων ανάλογα με την ανταπόκριση στην θεραπεία, ανοίγουν τον δρόμο για μια βαθύτερη συζήτηση σχετικά με τον επιγενετικό μηχανισμό δράσης των HMA

Unraveling Venetoclax Resistance: Navigating the Future of HMA/Venetoclax-Refractory AML in the Molecular Era

Acute myeloid leukemia (AML) has traditionally been linked to a poor prognosis, particularly in older patients who are ineligible for intensive chemotherapy. The advent of Venetoclax, a powerful oral BH3 mimetic targeting anti-apoptotic protein BCL2, has significantly advanced AML treatment. Its combination with the hypomethylating agent azacitidine (AZA/VEN) has become a standard treatment for this group of AML patients, demonstrating a 65% overall response rate and a median overall survival of 14.7 months, compared to 22% and 8 months with azacitidine monotherapy, respectively. However, resistance and relapses remain common, representing a significant clinical challenge. Recent studies have identified molecular alterations, such as mutations in FLT3-ITD, NRAS/KRAS, TP53, and BAX, as major drivers of resistance. Additionally, other factors, including metabolic changes, anti-apoptotic protein expression, and monocytic or erythroid/megakaryocytic differentiation status, contribute to treatment failure. Clinical trials are exploring strategies to overcome venetoclax resistance, including doublet or triplet therapies targeting IDH and FLT3 mutations; novel epigenetic approaches; menin, XPO1, and MDM2 inhibitors; along with immunotherapies like monoclonal antibodies and antibody&ndash;drug conjugates. A deeper understanding of the molecular mechanisms of resistance through single-cell analysis will be crucial for developing future therapeutic strategies

Contingent Synergistic Interactions between Non-Coding RNAs and DNA-Modifying Enzymes in Myelodysplastic Syndromes

Myelodysplastic syndromes (MDS) are a heterogeneous group of clonal hematopoietic stem cell disorders with maturation and differentiation defects exhibiting morphological dysplasia in one or more hematopoietic cell lineages. They are associated with peripheral blood cytopenias and by increased risk for progression into acute myelogenous leukemia. Among their multifactorial pathogenesis, age-related epigenetic instability and the error-rate DNA methylation maintenance have been recognized as critical factors for both the initial steps of their pathogenesis and for disease progression. Although lower-risk MDS is associated with an inflammatory bone marrow microenvironment, higher-risk disease is delineated by immunosuppression and clonal expansion. &ldquo;Epigenetics&rdquo; is a multidimensional level of gene regulation that determines the specific gene networks expressed in tissues under physiological conditions and guides appropriate chromatin rearrangements upon influence of environmental stimulation. Regulation of this level consists of biochemical modifications in amino acid residues of the histone proteins&rsquo; N-terminal tails and their concomitant effects on chromatin structure, DNA methylation patterns in CpG dinucleotides and the tissue-specific non-coding RNAs repertoire, which are directed against various gene targets. The role of epigenetic modifications is widely recognized as pivotal both in gene expression control and differential molecular response to drug therapies in humans. Insights to the potential of synergistic cooperations of epigenetic mechanisms provide new avenues for treatment development to comfort human diseases with a known epigenetic shift, such as MDS. Hypomethylating agents (HMAs), such as epigenetic modulating drugs, have been widely used in the past years as first line treatment for elderly higher-risk MDS patients; however, just half of them respond to therapy and are benefited. Rational outcome predictors following epigenetic therapy in MDS and biomarkers associated with disease relapse are of high importance to improve our efforts in developing patient-tailored clinical approaches

Acute Erythroid Leukemia: From Molecular Biology to Clinical Outcomes

Acute Erythroid Leukemia (AEL) is a rare and aggressive subtype of Acute Myeloid Leukemia (AML). In 2022, the World Health Organization (WHO) defined AEL as a biopsy with &ge;30% proerythroblasts and erythroid precursors that account for &ge;80% of cellularity. The International Consensus Classification refers to this neoplasm as &ldquo;AML with mutated TP53&rdquo;. Classification entails &ge;20% blasts in blood or bone marrow biopsy and a somatic TP53 mutation (VAF &gt; 10%). This type of leukemia is typically associated with biallelic TP53 mutations and a complex karyotype, specifically 5q and 7q deletions. Transgenic mouse models have implicated several molecules in the pathogenesis of AEL, including transcriptional master regulator GATA1 (involved in erythroid differentiation), master oncogenes, and CDX4. Recent studies have also characterized AEL by epigenetic regulator mutations and transcriptome subgroups. AEL patients have overall poor clinical outcomes, mostly related to their poor response to the standard therapies, which include hypomethylating agents and intensive chemotherapy. Allogeneic bone marrow transplantation (AlloBMT) is the only potentially curative approach but requires deep remission, which is very challenging for these patients. Age, AlloBMT, and a history of antecedent myeloid neoplasms further affect the outcomes of these patients. In this review, we will summarize the diagnostic criteria of AEL, review the current insights into the biology of AEL, and describe the treatment options and outcomes of patients with this disease

Real-Life Multicenter Experience of Venetoclax in Combination with Hypomethylating Agents in Previously Untreated Adult Patients with Acute Myeloid Leukemia in Greece

Background: The landscape of first-line treatment for acute myeloid leukemia (AML) patients ineligible for intensive chemotherapy has changed remarkably after venetoclax approval. Accumulating real-world data further apprises us with more knowledgeable use. To assess the efficacy and safety challenges in the real-life setting of the combination of hypomethylated agent (HMA) and venetoclax, we conducted a multi-center retrospective study. Methods: Forty adult AML patients treated with the combination of HMA and venetoclax as a first-line treatment after full approval (2020) were included. To confirm VIALE-A results, this group was compared to a historical cohort of 17 chemotherapy-ineligible AML patients treated with HMA monotherapy before 2020. Results: The combination of HMA-venetoclax achieved a composite complete response rate of 86.8% (p &lt; 0.001), median overall survival, and event-free survival of 33.8 and 19.7 months, respectively, in a median follow-up of 17.8 months (pos &lt; 0.001, HR = 0.276, CI: 0.132&ndash;0.575, pEFS = 0.004, HR = 0.367, CI: 0.174&ndash;0.773). High rates of neutropenia (90%) and consequent infection rates (57.5%) were noted. Only 55% of our patients received antifungal prophylaxis, as its use remains controversial, and invasive fungal infections were presented in 7.5%. Conclusions: Evidently, venetoclax-HMA yields high response rates and profound survival benefits in real life and has changed our approach to alternative chemotherapy options

Real-Life Multicenter Experience of Venetoclax in Combination with Hypomethylating Agents in Previously Untreated Adult Patients with Acute Myeloid Leukemia in Greece

Background: The landscape of first-line treatment for acute myeloid leukemia (AML) patients ineligible for intensive chemotherapy has changed remarkably after venetoclax approval. Accumulating real-world data further apprises us with more knowledgeable use. To assess the efficacy and safety challenges in the real-life setting of the combination of hypomethylated agent (HMA) and venetoclax, we conducted a multi-center retrospective study. Methods: Forty adult AML patients treated with the combination of HMA and venetoclax as a first-line treatment after full approval (2020) were included. To confirm VIALE-A results, this group was compared to a historical cohort of 17 chemotherapy-ineligible AML patients treated with HMA monotherapy before 2020. Results: The combination of HMA-venetoclax achieved a composite complete response rate of 86.8% (p &lt; 0.001), median overall survival, and event-free survival of 33.8 and 19.7 months, respectively, in a median follow-up of 17.8 months (pos &lt; 0.001, HR = 0.276, CI: 0.132–0.575, pEFS = 0.004, HR = 0.367, CI: 0.174–0.773). High rates of neutropenia (90%) and consequent infection rates (57.5%) were noted. Only 55% of our patients received antifungal prophylaxis, as its use remains controversial, and invasive fungal infections were presented in 7.5%. Conclusions: Evidently, venetoclax-HMA yields high response rates and profound survival benefits in real life and has changed our approach to alternative chemotherapy options. © 2024 by the authors