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Stone M, Lilley CM, Tang G, Loghavi S, Mirza KM. Phenotypic clues that predict underlying cytogenetic/genetic abnormalities in myeloid malignancies: A contemporary review. Cytopathology 2023; 34:530-541. [PMID: 37522274 DOI: 10.1111/cyt.13280] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2023] [Revised: 07/13/2023] [Accepted: 07/14/2023] [Indexed: 08/01/2023]
Abstract
Precise subclassification of myeloid malignancies per the World Health Organization (WHO) classification system and the International Consensus Classification of Myeloid Neoplasms and Acute Leukaemias (ICC) requires investigation and documentation of the presence of cytogenetic and/or molecular genetic changes. These ancillary studies not only help in diagnosis, but also the prognosis of disease; however, they take time to be completed. In contrast, morphological evaluation of material from the blood and bone marrow specimens of cases where myeloid malignancies are suspected is usually completed quickly. Cytomorphological assessment may predict genetic changes and can be helpful in triaging acuity. This is especially true in haematological emergencies such as acute promyelocytic leukaemia (APL), where prompt APL-specific therapy can be life changing. Similarly, some morphological clues may help identify core binding factor leukaemias where a diagnosis of acute myeloid leukaemia (AML) could be rendered without reaching the 20% blast cutoff with immediate treatment-decision implications, or even a subset of cases of AML with FLT3 ITD/NPM1 mutation(s) which show characteristic features. Even though FISH/cytogenetics and/or PCR are still required for establishing the final diagnosis, evaluation for the presence of specific cytomorphological features that help predict genetic changes can be a useful tool to help guide early therapy.
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Affiliation(s)
- Michael Stone
- Department of Pathology, University of Illinois at Chicago, Chicago, Illinois, USA
| | - Cullen M Lilley
- Department of Pathology and Laboratory Medicine, Loyola University Chicago Stritch School of Medicine, Maywood, Illinois, USA
| | - Guilin Tang
- Department of Hematopathology, MD Anderson Cancer Center, Houston, Texas, USA
| | - Sanam Loghavi
- Department of Hematopathology, MD Anderson Cancer Center, Houston, Texas, USA
| | - Kamran M Mirza
- Department of Pathology and Laboratory Medicine, Loyola University Chicago Stritch School of Medicine, Maywood, Illinois, USA
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Kwiecień I, Rutkowska E, Gawroński K, Kulik K, Dudzik A, Zakrzewska A, Raniszewska A, Sawicki W, Rzepecki P. Usefulness of New Neutrophil-Related Hematologic Parameters in Patients with Myelodysplastic Syndrome. Cancers (Basel) 2023; 15:cancers15092488. [PMID: 37173954 PMCID: PMC10177198 DOI: 10.3390/cancers15092488] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2023] [Revised: 04/20/2023] [Accepted: 04/25/2023] [Indexed: 05/15/2023] Open
Abstract
Myelodysplastic syndromes (MDS) are common malignant disorders with a poor prognosis. It is necessary to search for new rapid diagnostic methods to detect MDS patients with cytogenetic changes. The aim of the study was to assess new hematological neutrophil- and monocyte- related parameters I then bone marrow of MDS patient with and without cytogenetic changes. A total of 45 patients with MDS, including 17 patients with cytogenetic changes, were examined. The study was conducted using the Sysmex XN-Series hematological analyzer. New neutrophil and monocyte parameters, such as immature granulocytes (IG), neutrophil reactivity intensity (NEUT-RI), neutrophil granularity intensity (NEUT-GI), neutrophil size (NE-FSC) and neutrophil/monocyte data relating to granularity, activity and volume (NE-WX/MO-WX, NE-WY/MO-WY, NE-WZ/MO-WZ, MO-X, MO-Y, MO-Z) were evaluated. We observed higher median proportions of NE-WX, NE-WY, NE-WZ, and IG counts in MDS patients with cytogenetic changes than in patients without cytogenetic changes. The NE-FSC parameter was lower in MDS patients with cytogenetic changes than in patients without cytogenetic changes. The combination of new neutrophil parameters was found to be a new successful approach in distinguishing MDS patients with cytogenetic changes from patients without cytogenetic changes. It appears that there may be unique neutrophil parameter signatures associated with an underlying mutation.
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Affiliation(s)
- Iwona Kwiecień
- Laboratory of Hematology and Flow Cytometry, Department of Internal Medicine and Hematology, Military Institute of Medicine-National Research Institute, Szaserów 128 Street, 04-141 Warsaw, Poland
| | - Elżbieta Rutkowska
- Laboratory of Hematology and Flow Cytometry, Department of Internal Medicine and Hematology, Military Institute of Medicine-National Research Institute, Szaserów 128 Street, 04-141 Warsaw, Poland
| | - Krzysztof Gawroński
- Department of Internal Medicine and Hematology, Military Institute of Medicine-National Research Institute, Szaserów 128 Street, 04-141 Warsaw, Poland
| | - Katarzyna Kulik
- Laboratory of Hematology and Flow Cytometry, Department of Internal Medicine and Hematology, Military Institute of Medicine-National Research Institute, Szaserów 128 Street, 04-141 Warsaw, Poland
| | - Alicja Dudzik
- Laboratory of Hematology and Flow Cytometry, Department of Internal Medicine and Hematology, Military Institute of Medicine-National Research Institute, Szaserów 128 Street, 04-141 Warsaw, Poland
| | - Agata Zakrzewska
- Laboratory of Hematology and Flow Cytometry, Department of Internal Medicine and Hematology, Military Institute of Medicine-National Research Institute, Szaserów 128 Street, 04-141 Warsaw, Poland
| | - Agata Raniszewska
- Laboratory of Hematology and Flow Cytometry, Department of Internal Medicine and Hematology, Military Institute of Medicine-National Research Institute, Szaserów 128 Street, 04-141 Warsaw, Poland
| | - Waldemar Sawicki
- Department of Internal Medicine and Hematology, Military Institute of Medicine-National Research Institute, Szaserów 128 Street, 04-141 Warsaw, Poland
| | - Piotr Rzepecki
- Department of Internal Medicine and Hematology, Military Institute of Medicine-National Research Institute, Szaserów 128 Street, 04-141 Warsaw, Poland
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Kirito K. Myeloid neoplasm with isolated del(5q) and the MPLW515L mutation fulfills the WHO diagnostic criteria for ET. Int J Hematol 2020; 112:238-242. [PMID: 32246278 DOI: 10.1007/s12185-020-02872-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2020] [Revised: 03/26/2020] [Accepted: 03/26/2020] [Indexed: 11/24/2022]
Abstract
A 70-year-old male was referred to our hospital for marked thrombocytosis without anemia. The patient simultaneously presented with an MPL W515L mutation, one of the major driver mutations in essential thrombocythemia (ET), and deletion of 5q, a characteristic cytogenetic abnormality in myelodysplastic syndrome (MDS). Bone marrow examination showed a combination of both mature hyperlobulated megakaryocytes, as found in ET, and small hypolobulated megakaryocytes, typically found in MDS with del(5q). The present case is consistent with the recently proposed category of myeloid neoplasms with isolated del(5q) and an MPN driver mutation.
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Affiliation(s)
- Keita Kirito
- Department of Hematology and Oncology, University of Yamanashi, 1110, Shimokato, Chuo, Yamanashi-ken, 409-3898, Japan.
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Huang J, Wang Z, Huang L, Zheng M. CD41 immune staining of micromegakaryocytes improves the diagnosis of myelodysplastic syndrome and differentiation from pancytopenia. Leuk Res 2018; 66:15-19. [PMID: 29353154 DOI: 10.1016/j.leukres.2017.10.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2017] [Revised: 10/15/2017] [Accepted: 10/17/2017] [Indexed: 12/24/2022]
Abstract
A morphometric analysis was performed on aspirated clots of bone marrow to identify the presence of micromegakaryocytes after immune staining with a monoclonal antibody raised against CD41. Quantitative and qualitative abnormalities of micromegakaryocytes were assessed based on both standard staining and CD41 immune staining. Micromegakaryocytes were largely detected in bone marrow from patients with myelodysplastic syndrome (MDS), while almost no micromegakaryocytes were present in aplastic anemia. CD41 immune staining clearly improved the efficiency of micromegakaryocyte detection under any conditions, showing strong potential as a tool for the auxiliary diagnosis of MDS and differentiation of MDS from pancytopenia, particularly aplastic anemia(AA).
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Affiliation(s)
- Jinjin Huang
- Department of Hematology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Zhiqiong Wang
- Department of Hematology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Lifang Huang
- Department of Hematology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China.
| | - Miao Zheng
- Department of Hematology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China.
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Bürki S, Shumilov E, Bonadies N, Flach J, Legros M, Banz Y, Oppliger-Leibundgut E, Fiedler M, Angelillo-Scherrer A, Rovo A, Bacher U. Coincidence of 5q deletion and the JAK2V617F mutation: report of two patients with overlapping myelodysplastic and myeloproliferative features and review of the literature. Leuk Lymphoma 2018; 59:2233-2237. [PMID: 29295644 DOI: 10.1080/10428194.2017.1416367] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Affiliation(s)
- Susanne Bürki
- a Department of Haematology , Inselspital, Bern University Hospital, University of Bern , Bern , Switzerland
| | - Evgenii Shumilov
- b Department of Haematology and Clinical Oncology , University Medicine Göttingen (UMG) , Göttingen , Germany
| | - Nicolas Bonadies
- a Department of Haematology , Inselspital, Bern University Hospital, University of Bern , Bern , Switzerland
| | - Johanna Flach
- b Department of Haematology and Clinical Oncology , University Medicine Göttingen (UMG) , Göttingen , Germany.,c Institute of Molecular Oncology , University Medicine Göttingen (UMG) , Göttingen , Germany
| | - Myriam Legros
- a Department of Haematology , Inselspital, Bern University Hospital, University of Bern , Bern , Switzerland.,d Center of Laboratory Medicine (ZLM) , Inselspital, Bern University Hospital, University of Bern , Bern , Switzerland
| | - Yara Banz
- e Institute of Pathology , University of Bern , Bern , Switzerland
| | - Elisabeth Oppliger-Leibundgut
- a Department of Haematology , Inselspital, Bern University Hospital, University of Bern , Bern , Switzerland.,f Department of Clinical Research , University of Bern , Bern , Switzerland
| | - Martin Fiedler
- d Center of Laboratory Medicine (ZLM) , Inselspital, Bern University Hospital, University of Bern , Bern , Switzerland
| | - Anne Angelillo-Scherrer
- a Department of Haematology , Inselspital, Bern University Hospital, University of Bern , Bern , Switzerland
| | - Alicia Rovo
- a Department of Haematology , Inselspital, Bern University Hospital, University of Bern , Bern , Switzerland
| | - Ulrike Bacher
- a Department of Haematology , Inselspital, Bern University Hospital, University of Bern , Bern , Switzerland.,d Center of Laboratory Medicine (ZLM) , Inselspital, Bern University Hospital, University of Bern , Bern , Switzerland
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6
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Myelodysplastic syndrome with del (5q) and JAK2(V617F) mutation transformed to acute myeloid leukaemia with complex karyotype. Ann Hematol 2016; 95:525-7. [PMID: 26750119 DOI: 10.1007/s00277-015-2584-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2015] [Accepted: 12/23/2015] [Indexed: 10/22/2022]
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Abstract
OBJECTIVES Acute myeloid leukemia with myelodysplasia-related changes (AML-MRC) is a heterogeneous disorder defined by morphologic, genetic, or clinical features. Genetic abnormalities associated with AML-MRC are often associated with adverse prognostic features, and many cases are preceded by a myelodysplastic syndrome (MDS) or a myelodysplastic/myeloproliferative neoplasm. METHODS Although the criteria of 20% or more blasts in blood or bone marrow and multilineage dysplasia affecting 50% or more of cells in two or more of the myeloid lineages seem straightforward for AML-MRC, identification of morphologic dysplasia among observers is not always consistent, and there is morphologic overlap with other leukemic disorders such as acute erythroleukemia. RESULTS Session 3 of the workshop cases displayed heterogeneity as expected within AML-MRC, yet several cases suggested that recently recognized entities may exist within this category, such as familial MDS/AML predisposition syndromes and rare cases of high-risk AML associated with the cryptic t(5;11)(q35;p15);NUP98-NSD1 that may masquerade as a del(5q). However, most cases of AML-MRC were usually associated with adverse genetic abnormalities, particularly -5/del(5q), -7/del(7q), and/or complex karyotypes. CONCLUSIONS Whole-genome sequencing and array studies may identify genetic abnormalities, such as those affecting TP53, which may provide prognostic information.
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Arber DA, Hasserjian RP. Reclassifying myelodysplastic syndromes: what's where in the new WHO and why. HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2015; 2015:294-298. [PMID: 26637736 DOI: 10.1182/asheducation-2015.1.294] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
Abstract
A revision to the 4th edition of the WHO Classification of myelodysplastic syndromes (MDSs), originally published in 2008, is expected in mid-2016. Based on recommendations of a Clinical Advisory Committee, the revision will aim to incorporate new discoveries in MDS that impact existing disease categories. Although the basic diagnostic principles of the WHO classification remain unchanged, several changes to the classification are proposed. All revisions are considered preliminary until the actual publication of the monograph and online document. Proposals for change include abandoning the routine use of "refractory anemia/cytopenia" in the various disease names, including the prognostic significance of gene mutations in MDS, revising the diagnostic criteria for MDS entities with ring sideroblasts based on the detection of SF3B1 mutations, modifying the cytogenetic criteria for MDS with isolated del(5q), reclassifying most cases of the erythroid/myeloid type of acute erythroleukemia, and recognizing the familial link in some cases of MDS. This review will provide details of the major proposed changes as well as rationale for the revisions.
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Affiliation(s)
- Daniel A Arber
- Department of Pathology, Stanford University, Stanford, CA; and
| | - Robert P Hasserjian
- Department of Pathology, Massachusetts General Hospital and Harvard Medical School, Boston, MA
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Musto P, Simeon V, Guariglia R, Bianchino G, Grieco V, Nozza F, La Rocca F, Marziano G, Lalinga AV, Fabiani E, Voso MT, Scaravaglio P, Mecucci C, D'Arena G. Myelodysplastic disorders carrying both isolated del(5q) and JAK2(V617F) mutation: concise review, with focus on lenalidomide therapy. Onco Targets Ther 2014; 7:1043-50. [PMID: 24966686 PMCID: PMC4063862 DOI: 10.2147/ott.s59628] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
The concomitant presence of del(5q) and JAK2(V617F) mutation is an infrequent event which occurs in rare patients with peculiar cytogenetic, molecular, morphological and clinical features, resembling those of both myelodysplastic syndromes and myeloproliferative neoplasms. Lenalidomide may induce rapid, profound, and long-lasting responses in a subset of these patients. However, the mechanism(s) by which the drug acts in these conditions remain not completely elucidated. A new case report and a review of all cases published so far in this setting are provided. Furthermore, the possibility of categorizing - from a clinical, pathological, and biological point of view - for at least some of these patients as a potential distinct entity is discussed.
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Affiliation(s)
| | | | | | | | - Vitina Grieco
- Laboratory of Clinical Research and Advanced Diagnostics, Italy
| | - Filomena Nozza
- Laboratory of Clinical Research and Advanced Diagnostics, Italy
| | | | | | - Anna Vittoria Lalinga
- Pathology Unit, IRCCS, Centro di Riferimento Oncologico della Basilicata, Rionero in Vulture, Italy
| | - Emiliano Fabiani
- Department of Hematology, Universita Cattolica del Sacro Cuore, Rome, Italy
| | - Maria Teresa Voso
- Department of Hematology, Universita Cattolica del Sacro Cuore, Rome, Italy
| | - Patrizia Scaravaglio
- Laboratory of Internal Medicine and Hematology, S Luigi Gonzaga Hospital, Orbassano, Italy
| | - Cristina Mecucci
- Hematology and Bone Marrow Transplantation Unit, University of Perugia, Perugia, Italy
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Walenda T, Stiehl T, Braun H, Fröbel J, Ho AD, Schroeder T, Goecke TW, Rath B, Germing U, Marciniak-Czochra A, Wagner W. Feedback signals in myelodysplastic syndromes: increased self-renewal of the malignant clone suppresses normal hematopoiesis. PLoS Comput Biol 2014; 10:e1003599. [PMID: 24763223 PMCID: PMC3998886 DOI: 10.1371/journal.pcbi.1003599] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2013] [Accepted: 03/18/2014] [Indexed: 12/20/2022] Open
Abstract
Myelodysplastic syndromes (MDS) are triggered by an aberrant hematopoietic stem cell (HSC). It is, however, unclear how this clone interferes with physiologic blood formation. In this study, we followed the hypothesis that the MDS clone impinges on feedback signals for self-renewal and differentiation and thereby suppresses normal hematopoiesis. Based on the theory that the MDS clone affects feedback signals for self-renewal and differentiation and hence suppresses normal hematopoiesis, we have developed a mathematical model to simulate different modifications in MDS-initiating cells and systemic feedback signals during disease development. These simulations revealed that the disease initiating cells must have higher self-renewal rates than normal HSCs to outcompete normal hematopoiesis. We assumed that self-renewal is the default pathway of stem and progenitor cells which is down-regulated by an increasing number of primitive cells in the bone marrow niche – including the premature MDS cells. Furthermore, the proliferative signal is up-regulated by cytopenia. Overall, our model is compatible with clinically observed MDS development, even though a single mutation scenario is unlikely for real disease progression which is usually associated with complex clonal hierarchy. For experimental validation of systemic feedback signals, we analyzed the impact of MDS patient derived serum on hematopoietic progenitor cells in vitro: in fact, MDS serum slightly increased proliferation, whereas maintenance of primitive phenotype was reduced. However, MDS serum did not significantly affect colony forming unit (CFU) frequencies indicating that regulation of self-renewal may involve local signals from the niche. Taken together, we suggest that initial mutations in MDS particularly favor aberrant high self-renewal rates. Accumulation of primitive MDS cells in the bone marrow then interferes with feedback signals for normal hematopoiesis – which then results in cytopenia. Myelodysplastic syndromes are diseases which are characterized by ineffective blood formation. There is accumulating evidence that they are caused by an aberrant hematopoietic stem cell. However, it is yet unclear how this malignant clone suppresses normal hematopoiesis. To this end, we generated mathematical models under the assumption that feedback signals regulate self-renewal and proliferation of normal and diseased stem cells. The simulations demonstrate that the malignant cells must have particularly higher self-renewal rates than normal stem cells – rather than higher proliferation rates. On the other hand, down-regulation of self-renewal by the increasing number of malignant cells in the bone marrow niche can explain impairment of normal blood formation. In fact, we show that serum of patients with myelodysplastic syndrome, as compared to serum of healthy donors, stimulates proliferation and moderately impacts on maintenance of hematopoietic stem and progenitor cells in vitro. Thus, aberrant high self-renewal rates of the malignant clone seem to initiate disease development; suppression of normal blood formation is then caused by a rebound effect of feedback signals which down-regulate self-renewal of normal stem and progenitor cells as well.
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Affiliation(s)
- Thomas Walenda
- Helmholtz Institute for Biomedical Engineering, RWTH Aachen University Medical School, Aachen, Germany
| | - Thomas Stiehl
- Interdisciplinary Center of Scientific Computing (IWR), Institute of Applied Mathematics, University of Heidelberg, Heidelberg, Germany
| | - Hanna Braun
- Helmholtz Institute for Biomedical Engineering, RWTH Aachen University Medical School, Aachen, Germany
| | - Julia Fröbel
- Department of Hematology, Oncology and Clinical Immunology, Heinrich-Heine-University Düsseldorf, Düsseldorf, Germany
| | - Anthony D. Ho
- Department of Medicine V, Medical Center, University of Heidelberg, Heidelberg, Germany
| | - Thomas Schroeder
- Department of Hematology, Oncology and Clinical Immunology, Heinrich-Heine-University Düsseldorf, Düsseldorf, Germany
| | - Tamme W. Goecke
- Department of Obstetrics and Gynecology, RWTH Aachen University Medical School, Aachen, Germany
| | - Björn Rath
- Department for Orthopedics, RWTH Aachen University Medical School, Aachen, Germany
| | - Ulrich Germing
- Department of Hematology, Oncology and Clinical Immunology, Heinrich-Heine-University Düsseldorf, Düsseldorf, Germany
| | - Anna Marciniak-Czochra
- Interdisciplinary Center of Scientific Computing (IWR), Institute of Applied Mathematics, University of Heidelberg, Heidelberg, Germany
| | - Wolfgang Wagner
- Helmholtz Institute for Biomedical Engineering, RWTH Aachen University Medical School, Aachen, Germany
- * E-mail:
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Atypical chronic myeloid leukemia is clinically distinct from unclassifiable myelodysplastic/myeloproliferative neoplasms. Blood 2014; 123:2645-51. [PMID: 24627528 DOI: 10.1182/blood-2014-02-553800] [Citation(s) in RCA: 137] [Impact Index Per Article: 13.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023] Open
Abstract
Atypical chronic myeloid leukemia (aCML) is a rare subtype of myelodysplastic/myeloproliferative neoplasm (MDS/MPN) largely defined morphologically. It is, unclear, however, whether aCML-associated features are distinctive enough to allow its separation from unclassifiable MDS/MPN (MDS/MPN-U). To study these 2 rare entities, 134 patient archives were collected from 7 large medical centers, of which 65 (49%) cases were further classified as aCML and the remaining 69 (51%) as MDS/MPN-U. Distinctively, aCML was associated with many adverse features and an inferior overall survival (12.4 vs 21.8 months, P = .004) and AML-free survival (11.2 vs 18.9 months, P = .003). The aCML defining features of leukocytosis and circulating myeloid precursors, but not dysgranulopoiesis, were independent negative predictors. Other factors, such as lactate dehydrogenase, circulating myeloblasts, platelets, and cytogenetics could further stratify MDS/MPN-U but not aCML patient risks. aCML appeared to have more mutated RAS (7/20 [35%] vs 4/29 [14%]) and less JAK2p.V617F (3/42 [7%] vs 10/52 [19%]), but was not statistically significant. Somatic CSF3R T618I (0/54) and CALR (0/30) mutations were not detected either in aCML or MDS/MPN-U. In conclusion, within MDS/MPN, the World Health Organization 2008 criteria for aCML identify a subgroup of patients with features clearly distinct from MDS/MPN-U. The MDS/MPN-U category is heterogeneous, and patient risk can be further stratified by a number of clinicopathological parameters.
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