Christina Ganster

CPX-351 is approved for myelodysplasia related changes (MRC)-type AML which can be classified by MDS-defining cytogenetic changes (MDCC). According to WHO 2022 this entity is renamed AML-MR (myelodysplasia-related) and molecular features are considered too. In a prospective study we aimed to prove that a rapid identification of AML-MRC/MR cases with MDCC is practicable and reliable using a streamlined 6-probes FISH-panel. We assessed feasibility, success rate, sensitivity to detect cytogenetic aberrations, especially MDCC, turnaround times (TAT), and reliability of peripheral blood (pb) vs. bone marrow (bm) analysis in 131 patients with suspected AML. All 6 probes could be evaluated in 94.7%. In 45.8%, we identified cytogenetic abnormalities by FISH. In 19.1%, complex changes and distinct aberrations such as -5/5q- (20.6%), -7/7q- (19.1%), +11/+11q (12.2%), 12p- (10.7%) and ‑17/17p- (10.7%) and others were found. We also traced International Consensus Classification (ICC)-defined MDCC trisomy 8 (16.9%) and 20q- (4.4%) with additional probes. MDCC were detected in 34.4% (WHO 2022) and in 35.1% (ICC) of cases. Aberration rate with chromosome banding analysis (CBA) (n=115) was 48.7%. Statistical comparison of FISH vs. CBA demonstrated non-inferiority of FISH for the detection of chromosomal changes including MDCC as well as for the use of pb vs. bm. The mean TAT for the FISH panel analysis was 7 hours 48 minutes only. Our six-probes-FISH panel represents a reliable, rapid, cost-effective, and robust method for identifying MDCC in suspected AML, including when only pb samples are available. It can complement - or in time-critical cases potentially replace - CBA.

Purpose: Serum ferritin is an independent prognostic marker in myelodysplastic neoplasms (MDS) and serves as a surrogate parameter for iron overload. Oxidative stress derived from iron overload may induce genomic damage, thereby promoting genetic instability and disease progression in MDS. We aimed to evaluate a possible association between iron overload via serum ferritin and various parameters for genetic instability in MDS. Methods: Fifty-one patients with confirmed MDS were analyzed and divided into three groups based on ferritin levels: non-elevated (≤ 275 µg/L), moderately elevated (> 275 and < 1000 µg/L), and highly elevated (≥ 1000 µg/L). Genetic instability was assessed by cytogenetic analysis and somatic mutation profiling. DNA double-strand breaks were quantified by γH2AX-foci in CD34+ peripheral blood cells, and telomere length was measured by flow-FISH. Results: Elevated serum ferritin was associated with increased cytogenetic abnormalities and somatic mutations at genomic regions commonly involved in MDS, higher levels of double-strand breaks, and shortened telomeres in granulocytes but not in lymphocytes. Markers of early-stage genetic instability, such as double-strand breaks and telomere shortening in granulocytes, were detectable at moderately elevated ferritin > 275 µg/L, whereas markers for advanced-stage genetic aberrations, including somatic mutations and cytogenetic aberrations, were more prominent at ferritin levels ≥ 1000 µg/L. Conclusion: These findings support the hypothesis that iron overload, reflected by elevated ferritin as surrogate parameter, may contribute to and/or increase genetic instability in MDS patients with ineffective hematopoiesis. Notably, correlations were observed at ferritin levels below current thresholds for initiating iron chelation therapy, indicating clinical relevance early in the disease course.

Myelodysplastic neoplasia (MDS) comprises heterogeneous clonal hematologic disorders characterized by peripheral cytopenia, bone marrow dysplasia, and a risk of leukemic transformation. A hypoplastic variant (MDS‐h) shares features with aplastic anemia and responds to immunosuppressive therapy (IST). We report three low‐risk MDS‐h cases treated with IST and monitored over 9–17 years using serial cytogenetic and molecular analyses. All patients achieved transfusion independence after IST, and two experienced durable, long‐term remissions. One patient developed late clonal evolution culminating in secondary acute myeloid leukemia. Molecular follow‐up revealed diverse mutational dynamics, including stable and fluctuating clones and delayed mutational emergence, detectable in peripheral blood. These findings suggest that in MDS‐h, disease activity is largely driven by immune dysregulation rather than early molecular changes, and that repeated IST can yield sustained remissions. However, accumulating mutations may eventually predict malignant transformation, underscoring the importance of long‐term molecular monitoring.

Treatment of high-risk Myelodysplastic Neoplasms (hr-MDS) and (secondary) Acute Myeloid Leukemia (AML) remains a clinical challenge. The combination of azacitidine and venetoclax (aza/ven) may improve treatment outcomes, but still fails in a significant fraction of patients. We established a single-center collection of longitudinal samples from patients with MDS and AML/sAML and performed comprehensive genetic, proteomic and functional apoptosis profiling to identify biomarkers and targetable escape mechanisms to aza/ven. Baseline genetic characterization ( n = 55) identified high-risk genetic alterations, while longitudinal analyses ( n = 268, mean 8.7 [3–20] timepoints) revealed distinct genetic profiles of clonal evolution. Functional BH3-profiling at treatment initiation identified heterogeneous dependencies on BCL-2 family members. Notably, high BCL-2 dependence correlated with genetic response to aza/ven and improved overall survival, whereas increased BCL-xL dependence was associated with resistance. We further identified patterns of acquired resistance, with loss of apoptotic priming and shifts in anti-apoptotic dependencies contributing to treatment failure. BH3 profiling revealed functional shifts toward MCL-1 and/or BCL-xL in individual cases, suggesting potential therapeutic targets to overcome resistance. In vitro, BCL-xL inhibition effectively counteracted resistance in increased BCL-xL dependence cases. In summary, we characterized treatment-associated clonal evolution in MDS and AML, providing insights into clinical response, disease progression and potential individualized therapeutic strategies.

Myelodysplastic syndromes (MDS) are clonal hematologic disorders characterized by morphologic abnormalities of myeloid cells and peripheral cytopenias. Although genetic abnormalities underlie the pathogenesis of these disorders and their heterogeneity, current classifications of MDS rely predominantly on morphology. We performed genomic profiling of 3233 patients with MDS or related disorders to delineate molecular subtypes and define their clinical implications. Gene mutations, copy-number alterations, and copy-neutral loss of heterozygosity were derived from targeted sequencing of a 152-gene panel, with abnormalities identified in 91%, 43%, and 11% of patients, respectively. We characterized 16 molecular groups, encompassing 86% of patients, using information from 21 genes, 6 cytogenetic events, and loss of heterozygosity at the TP53 and TET2 loci. Two residual groups defined by negative findings (molecularly not otherwise specified, absence of recurrent drivers) comprised 14% of patients. The groups varied in size from 0.5% to 14% of patients and were associated with distinct clinical phenotypes and outcomes. The median bone marrow (BM) blast percentage across groups ranged from 1.5% to 10%, and the median overall survival ranged from 0.9 to 8.2 years. We validated 5 well-characterized entities, added further evidence to support 3 previously reported subsets, and described 8 novel groups. The prognostic influence of BM blasts depended on the genetic subtypes. Within genetic subgroups, therapy-related MDS and myelodysplastic/myeloproliferative neoplasms had comparable clinical and outcome profiles to primary MDS. In conclusion, genetically-derived subgroups of MDS are clinically relevant and might inform future classification schemas and translational therapeutic research.

The acquisition of subsequent genetic lesions (clonal evolution, CE) and/or the expansion of existing clones (CEXP) contributes to clonal dynamics (CD) in myelodysplastic syndromes (MDS). Although CD plays an important role in high‐risk patients in disease progression and transformation into acute myeloid leukemia (AML), knowledge about CD in lower‐risk MDS (LR‐MDS) patients is limited due to lack of robust longitudinal data considering the long clinically stable courses of the disease. In this retrospective analysis, we delineate the frequency and the prognostic impact of CD in an unselected real‐world cohort of LR‐MDS patients. We screened 68 patients with a median follow‐up of 40.5 months and a median of 7.5 (range: 2–22) timepoints for CE and CEXP detected by chromosomal banding analysis, fluorescence in situ hybridization, sequencing, and molecular karyotyping. In 30/68 patients, 47 CE events and a CD rate of 1 event per 4 years were documented. Of note, patients with at least 1 CE event had an increased probability for subsequent treatment. Unexpectedly, CE did not correlate with inferior outcomes, which could be reasonably explained by CD detection triggering the subsequent start of a disease‐modifying therapy.

Mutations in UBA1, which are disease-defining for VEXAS (vacuoles, E1 enzyme, X-linked, autoinflammatory, somatic) syndrome, have been reported in patients diagnosed with myelodysplastic syndromes (MDS). Here, we define the prevalence and clinical associations of UBA1 mutations in a representative cohort of patients with MDS. Digital droplet polymerase chain reaction profiling of a selected cohort of 375 male patients lacking MDS disease-defining mutations or established World Health Organization (WHO) disease classification identified 28 patients (7%) with UBA1 p.M41T/V/L mutations. Using targeted sequencing of UBA1 in a representative MDS cohort (n = 2027), we identified an additional 27 variants in 26 patients (1%), which we classified as likely/pathogenic (n = 12) and of unknown significance (n = 15). Among the total 40 patients with likely/pathogenic variants (2%), all were male and 63% were classified by WHO 2016 criteria as MDS with multilineage dysplasia or MDS with single-lineage dysplasia. Patients had a median of 1 additional myeloid gene mutation, often in TET2 (n = 12), DNMT3A (n = 10), ASXL1 (n = 3), or SF3B1 (n = 3). Retrospective clinical review, where possible, showed that 82% (28/34) UBA1-mutant cases had VEXAS syndrome–associated diagnoses or inflammatory clinical presentation. The prevalence of UBA1 mutations in patients with MDS argues for systematic screening for UBA1 in the management of MDS.

Lenalidomide (LEN) can induce red blood cell-transfusion independence (RBC-TI) in 60–70% of del(5q) myelodysplastic neoplasm (MDS) patients. Current recommendation is to continue LEN in responding patients until failure or progression, with likelihood of toxicity and a high cost for healthcare systems. This HARMONY Alliance study investigated the outcome of MDS del(5q) patients who discontinued LEN while RBC-transfusion independent. We enrolled 118 patients with IPSS-R low-intermediate risk. Seventy patients (59%) discontinued LEN for intolerance, 38 (32%) per their physician decision, nine (8%) per their own decision and one (1%) for unknown reasons. After a median follow-up of 49 months from discontinuation, 50/118 patients lost RBC-TI and 22/30 who underwent cytogenetic re-evaluation lost complete cytogenetic response. The median RBC-TI duration was 56 months. In multivariate analysis, RBC-TI duration after LEN discontinuation correlated with low transfusion burden before LEN therapy, treatment ≥ 12 LEN cycles, younger age and higher Hb level at LEN withdrawal. Forty-eight patients were re-treated with LEN for loss of response and 28 achieved again RBC-TI. These data show that stopping LEN therapy in MDS del(5q) patients who reached RBC-TI allows prolonged maintenance of TI in a large subset of patients.

Lenalidomide (LEN) can induce RBC transfusion independence (RBC-TI) in 60–70% of del(5q) myelodysplastic syndrome (MDS) patients. Current recommendation is to continue LEN in responding patients until failure or progression, with likelihood of toxicity and a high cost for healthcare systems. This HARMONY Alliance study investigated the outcome of MDS del(5q) patients who discontinued LEN in RBC-TI. We enrolled 118 patients with an IPSS-R low-intermediate risk. Seventy patients (59%) discontinued LEN for intolerance, 38 (32%) per their physician decision, nine (8%) per their own decision and one (1%) for unknown reasons. After a median follow-up of 49 months from discontinuation, 50/118 patients lost RBC-TI and 22/30 who underwent cytogenetic re-evaluation lost complete cytogenetic response. The median RBC-TI duration was 56 months. In multivariate analysis RBC-TI duration after LEN discontinuation correlated with low transfusion burden before LEN therapy, treatment ≥ 12 LEN cycles, younger age and higher Hb level at LEN withdrawal. Forty-eight patients were re-treated with LEN for loss of response and 28 achieved RBC-TI. These data show that stopping LEN therapy in MDS del(5q) patients in RBC-TI allows prolonged maintenance of TI in a large subset of patients.