Dr.

Fariha Saleem

 The myelodysplastic syndromes (MDS) are a group of

clonal stem cell diseases characterized by cytopenia(s),dysplasia in one or more of the major myeloid cell lines, ineffective haematopoiesis, and increased risk of development of acute myeloid leukaemia(AML).

 The thresholds for cytopenias as recommended in IPSS

for risk stratification in MDS are:

haemoglobin < 10 g/dL neutrophils < 1.8 10 9 /L platelets < 100 10 9 /L.

 Values above these thresholds are, however, not

exclusionary for a diagnosis of MDS if definitive morphologic and/or cytogenetic findings are present.
The dysplasia may be accompanied by an increase in

myeloblasts in the PB and BM but the no is < 20% , which is the requisite threshold recommended for the diagnosis of AML.

EPIDEMIOLOGY:
Affects older adults, with a median age of 70 years.
Annual incidence of MDS is : 3-5/100,000 persons. male predominance with a male to female ratio of 1.4:1

AETIOLOGY:
Primary or de novo MDS :
Possible etiologies for primary MDS include:

Benzene exposure
exposure to agricultural chemicals or solvents smoking

family history of haematopoietic neoplasm

Therapy related MDS: (15%)

Commonly implicating cytotoxic agents are: alkylating agents, such as cyclophosphamide the topoisomerase II inhibitors, such as etoposide, ionizing radiation antimetabolite drugs

The latency period ranges from 1 to 10 years and

beyond.

 By comparison with primary MDS, these cases of

therapy -related MDS are associated with a higher incidence of trilineage dysplasia, genetic abnormalities, evolution to AML and poor response to treatment.

FAB CLASSIFICATION:
SUBTYPE Refractory anaemia (RA) Refractory anaemia with ringed sideroblasts (RARS) Refractory anaemia with excess blasts (RAEB) Refractory anaemia with excess blasts in transformation (RAEBt) Chronic myelomonocytic leukaemia (CMML) BLOOD < 1% blasts < 1% blasts BONE MARROW Dysplasia < 5% blasts As for RA and > 15% ringed sideroblasts

< 5% blasts

Dysplasia 5 19% blasts Dysplasia 20 29% blasts or Auer rods Dysplasia < 30% blasts

< 5% blasts

> 1 10 9 /L monocytes

WHO CLASSIFICATION:
SUBTYPE Refractory cytopenias with unilineage dysplasia (RCUD) Refractory anaemia (RA) Refractory neutropenia (RN) Refractory thrombocytopenia (RT) Refractory anaemia with ring sideroblasts (RARS) Refractory cytopenia with multilineage dysplasia (RCMD) BLOOD Unicytopenia or bicytopenia BONE MARROW Dysplasia in > 10% of cells of one myeloid lineage only < 5% blasts < 15% ring sideroblasts

Anaemia

Erythroid dysplasia only > 15% ring sideroblasts Dysplasia in > 10% of cells in two or more myeloid lineages < 5% blasts < 15% ring sideroblasts

Cytopenia(s)

SUBTYPE

BLOOD

BONE MARROW

Refractory cytopenia with multilineage dysplasia and ring sideroblasts (RCMD- RS)

Cytopenia(s)

Dysplasia in > 10% of cells in two or more myeloid lineages < 5% blasts > 15% ring sideroblasts

Refractory anaemia with Cytopenia(s) excess blasts - 1 (RAEB - 1) < 5% blasts

Unilineage or multilineage dysplasia 5 9% blasts No Auer rods

Unilineage or multilineage dysplasia 10 19% blasts Auer rods

Refractory anaemia with Cytopenia(s) excess blasts - 2 (RAEB - 2) 5 19% blasts

SUBTYPE Myelodysplastic syndrome unclassified (MDS - U)

BLOOD Cytopenia(s) < 1% blasts

BONE MARROW Dysplasia in < 10% of cells in one or more myeloid lineage Cytogenetic abnormality supportive of diagnosis < 5% blasts

MDS associated with isolated del(5q)

Anaemia thrombocytosis < 1% blasts

Prominent megakaryocytes with hypolobated nuclei Isolated del(5q) cytogenetic abnormality < 5% blasts

RELATIVE FREQUENCY OFMDS SUBTYPES:

Subtype of MDS Approximate percentage of MDS cases
10 10 25 10 25 15 5

Cytogenetic abnormalities

Median survival (months)

66 72 33 33 18 10 116

RA RARS RCMD RCMD - RS RAEB- 1 RAEB- 2 Isolated del(5q)

25 < 10 50 50 30 40 40 50 100

PATHOGENESIS:
The cardinal features of MDS are : Increased marrow proliferation Failure of stem cells to differentiate Increased marrow apoptosis.
The disease is of clonal origin
Chromosomal abnormalities are detectable in 30-

70% of patients.

MDS: a stem cell disorder

MDS is a clonal disorder which commonly affects all

three myeloid lineages (i.e. megakaryocytic, erythroid and granulocytic/monocytic). the presence of trilineage dysplasia and cytogenetic abnormalities provides irrefutable evidence for a multipotent stem/progenitor cell origin. These cells must be capable of sufficient self renewal in order to perpetuate the disease.

 Bone marrow microenvironment, termed stem cell

niche also plays important role in the pathogenesis of MDS. Interfering with this niche by targeting the molecular interactions between the stem cell and its microenvironment represents a novel therapeutic strategy.

Immunological abnormalities in MDS

Particularly apparent in cases of hypoplastic MDS.
There is clonal expansion of T cells that are antigen

driven. MDS is characterized by a pathological immune response triggered by abnormal haemopoietic stem cells that results in the autoimmune destruction of normal stem cells and/or their niche.

 There is higher incidence of autoimmune diseases in

these patients, which also suggest role of immune system in the pathogenesis. T - cell - mediated inhibition of haemopoieis appears to be an important aspect of this mechanism, with oligoclonal CD8 + cytotoxic T cells being found in many patients. However, the antigens produced by the MDS cells that lead to these T - cell responses are largely unknown.

Apoptosis in MDS:
In cases of MDS that lack an excess of blasts, the

cytopenias are a reflection of the ineffective haemopoiesis.

This is due to increased apoptosis of haemopoietic

precursors in the marrow.

Apoptosis is more prominent in early MDS, such as RA

and RARS, than in advanced MDS with excess myeloblasts

 Blasts lost their G 2 /M checkpoint control that

appears to be a necessary requirement for progression to leukaemia. This progression is accompanied by a change in favour of pro apoptotic proteins such as c - Myc in CD34 positive precursors at diagnosis to anti - apoptotic proteins such as Bcl - 2 in leukaemic blasts at time of transformation. Patients with higher rates of apoptosis have a considerably better overall survival than patients with lower rates of apoptosis.

 Apoptosis can be initiated by various cytokines, ie

TNF - , Fas - ligand, and TNF related apoptosis inducing ligand (TRAIL) These cytokines are typically upregulated in the marrow. Apoptosis can also be triggered by cytotoxic T cells and by signals from marrow stromal cells, probably via activation of similar pathways. This balance of pro - apoptotic to anti - apoptotic signals swings in favour of the latter as the MDS evolves towards AML.

MOLECULAR BASIS OF MDS:

Cytogenetic abnormalities
Genetic abnormalities in MDS Epigenetic abnormalities

Cytogenetic abnormalities:
Clonal abnormalities are observed in approximately

50% of all primary MDS cases and 90% of cases of secondary therapy - related MDS.

 The common chromosomal abnormalities found in MDS

include: loss of Y, 5q or monosomy 5, 7q or monosomy 7, trisomy 8, 20q , abnormalities of 11q23, deletions of 17p, 12p, 13q and 11q None of these is specific for MDS as they can also occur in AML and myeloproliferative states.

 Cytogenetic analysis is required for calculating a risk

score according to established prognostic scoring systems. Good risk karyotypes: normal, Y, del(5q) del(20q) Poor - risk karyotypes: chromosome 7 anomalies, complex (more than three abnormalities) very complex (more than five abnormalities)

Cytogenetic abnormalities in MDS with approximate frequency.

Abnormality Complex karyotype del(5q)/monosomy 5 del(7q)/monosomy 7 Trisomy 8 Primary MDS (%) 15-20 15-20 10-15 10-15 Therapy - related MDS (%) 80-90 30-40 40-50 10-15

del(20q) del(17p)
del(13q) del(11q) del(12p)

5-10 <5
<5 <5 <5

Genetic abnormalities in MDS:

Recurrent abnormalities in a large number of genes

have been identified in MDS. These include genes coding for: cell surface molecules, signal transduction proteins, transcriptional factors, epigenetic modifiers, protein degradation pathways many genes of unknown function

 Mutations of the AML1 gene: Seen particularly in treatment - related or radiation

induced MDS. In contrast with the mutations of AML1 found in M0 AML that are often biallelic, those found in MDS are generally monoallelic and result in AML1 haploinsuffi ciency rather than a dominant negative protein. Mutations in MDS occur more frequently in the C terminus of the protein causing truncation and loss of its transactivating domain. Individuals who inherit one abnormal copy of the AML1 gene commonly exhibit congenital thrombocytopenia with a propensity to develop AML, suggesting the gene might be acting as a tumour suppressor gene.

Isolated del(20q):

typically involves erythroid and megakaryocytic

lineages.
Carries favourable prognosis

Activating mutations of RAS :

Found in up to 20% of cases of MDS, especially

CMML,
Often associated with AML1 point mutations

V617F mutation of the JAK2 gene: Demonstrated in up to 50% of patients with the

overlap condition of RARS with thrombocytosis (RARS - T) This mutation causes constitutive activation of the JAK2 protein and downstream signalling.
mutations of the MPL gene, which are described in

essential thrombocythaemia, have also been identified in patients with RARS- T.

TET2 gene mutations: TET2 gene is located within a region of UPD at 4q24 . It is a candidate tumour suppressor gene mutated in

19% of patients with MDS.

TET2 has also been shown to be defective in patients

with other myeloid malignancies, ie CMML (22%) secondary AML (24%) myeloproliferative disorders (12%).

 TET2 mutation appears to be an early genetic lesion

identifiable in haematopoietic stem cells that is generally acquired before other mutations, such as the JAK2 V617F mutation.
The CBL gene at 11q23.3 is another candidate tumour

suppressor gene recently implicated in MDS.

Recurrent mutated genes in MDS according to their major function:

Gene function
Cell surface receptor

Abnormal gene
KIT , FMS , PDGFRB , GCSFR , MPL , FLT3 NRAS , JAK2 A ML1 , G ATA - 1 , P U.1 , C EBPA , TP53 M LL , ATRX CBL TET2

Signal transduction Transcription factor

Epigenetic factor Protein degradation Unknown function

Epigenetic abnormalities:
Two important epigenetic modifications relevant to

MDS: DNA methylation Histone modification

 DNA methylation: Refers to the addition of a methyl group to cytosine, which

can occur wherever this is followed by a guanine within a CpG dinucleotide pair. In normal cells, these CpG islands are typically unmethylated, allowing genes to be expressed. However, if a CpG island is methylated, then transcriptional activity at the promoter is impeded and the gene becomes silenced. Aberrant promoter methylation leads to inactivation of the gene, thereby providing an alternative mechanism whereby tumour - suppressor genes can be functionally deleted. This is the rationale for using hypomethylating agents as a novel therapeutic strategy in MDS

 Histone modification: Histones form the chromatin scaffold and closely regulate

whether the DNA exists locally in a repressed or permissive state. Biochemical alterations to the tails of the histone molecules influence the degree of compaction of the nucleosomes and hence the level of transcriptional activity of nearby genes. There is a close and cooperative interplay between these two epigenetic control mechanisms that together can render a gene permanently silenced. The significance of this is that combination epigenetic therapies that comprise a hypomethylating agent with a histone deacetylase inhibitor may be more effective than single agents in reawakening silenced tumour - suppressor genes.

Diagnosis:
Depends on:

Clinical features Blood count Peripheral blood morphology Bone marrow morphology Bone marrow histology

Clinical features:
App. 20% of cases of MDS are detected incidently -

unexpected cytopenia or dysplasia. Remainder 80% patients presents with symptoms and signs of bone marrow failure,ie anaemia (80%) infections or bleeding ( 20%) Features of lymphadenopathy, splenomegaly and hepatomegaly are rarely found.

Blood count:
Anaemia (most common presentation) pancytopenia ( 30 50% cases)

Anemia with neutropenia or thrombocytopenia ( 20

30%). Isolated neutropenia or thrombocytopenia ( 5-10% ) Occasionally blood count may be normal.

Peripheral blood morphology:

marked anisocytosis/poikilocytosis.
macrocytosis and ovalocytes. In sideroblastic anaemia, the blood film is classically

dimorphic. Microcytosis is rare. Ocassionally dysplastic or megaloblastic erythroblasts are seen in PF.

 Neutropenia :( common ) neutrophils often exhibit reduced granulation and the

acquired Pelger Hut anomaly.

Monocytosis : ( in CMML )
monocytes are often morphologically abnormal.

Basophils and eosinophils :

Often reduced but might also be raised in the

proliferative overlap syndromes.

Circulating blasts:
May be found in all categories of MDS but if present

in significant numbers ,then indicates RAEB.

Myeloblasts with scant cytoplasm and few granules

are seen.
Auer rods are sometimes present.

platelets:
Often reduced platelets may show dysplasia , ie

hypogranulated or agranular forms giant forms. MDS patients have high incidence of autoimmune thrombocytopenia.

Bone marrow morphology:

The bone marrow is hypercellular in the majority of

patients but can be normocellular or, in 10 20% of cases, hypocellular.

Dysplastic features can be recognized in any number

of lineages.
Reticulin can be modestly increased.

Morphologic manifestations of dysplasia:

DYSERYTHROPOIESIS: Nuclear: Nuclear budding Internuclear bridging Karyorrhexis Multinuclearity Nuclear hyperlobation Megaloblastic changes Cytoplasmic: Ring sideroblasts Vacuolization PAS positivity

DYSGRANULOPOIESIS: Small or usually large size Nuclear hypolobation ( pseudo pelger-huet ) Irregular hypersegmentation Decreased granules or agranularity Pseudo chediak-higashi granules Auer rods

DYSMEGAKARYOCYTOPOIESIS:
Micromegakaryocytes Nuclear hypolobation multinucleation

Large mononuclear megakaryocyte.

Bone marrow histology:

Hypercellular or hypocellular.
Cytological evidence of dysplasia. Derangement of normal architecture.

Abnormal localization of immature precursors

(ALIP),ie groups of granulocytic precursors in the central parts of intertrabecular spaces and erythroid precursors and megakaryocytes in the para-trabecular regions.

 Megakaryocytes are usually increased in number and

clustering is often seen.

Increased numbers of apoptotic erythroid and

granulocytic precursors, reflecting ineffective haemopoiesis are seen.

Reticulin fibrosis ( CMML)

Cytochemistry:
Iron staining for iron stores, ring sideroblasts and

other abnormal sideroblasts.

MPO and SBB stains - myeloblasts and detection of

Auer rods.
Non - specific esterase stains - monoblasts and

promonocytes.
NSE and PAS stains abnormal megakaryocytes.

Immunophenotyping:
Reduced expression of normal myeloid markers, and

aberrant patterns of expression of other markers.

CD34 expression, and to a lesser degree CD117, often

correlates with the blast percentage.

Coexpression of CD7 is significant for conferring a

worse prognosis.

DIFFERETIAL DIAGNOSIS:
Exclude: Other causes of anaemia (haematinic deficiency,

haemolysis, blood loss, renal failure).

Other causes of neutropenia (drugs, viral infection).
Other causes of thrombocytopenia (drugs, ITP). Other causes of bi-/pancytopenia (drugs, infection,

aplastic anaemia).

DIFFERENTIAL DIAGNOSIS: (cont)

Other causes of monocytosis (infection, AML) or

neutrophilia (infection,CML).
Reactive causes of BM dysplasia: megaloblastic

anaemia, HIV infection,alcoholism, recent cytotoxic therapy, severe intercurrent illness.

Other causes of marrow hypoplasia in hypoplastic

MDS: aplastic anaemia, PNH.

Prognosis and predictive factors:

Two scoring systems:

IPSS WPSS

IPSS:
Score value Bone marrow blasts (%) 0 <5 0.5 5-10 1.0 1.5 11-20 2.0 21-30

Karyotype
Cytopenias

good
0/1

intermediat poor e
2/3 -

Prognostic outcomes of MDS patients according to IPSS risk score:

IPSS risk category Combined score Leukaemic death ( % ) Low 0 19 Intermediate -1 0.5-1.0 30 3.3 3.5 Intermediate -2 1.5-2.0 33 1.1 1.2 High 2.5 45 0.2 0.4

Median time 9.4 to AML (years) Median survival (years) 5.7

WPSS:
Score value WHO category 0 1 2 RAEB- 1 3 RAEB- 2 RA, RARS, 5q RCMD, RCMD- RS

Karotype
Transfusion requirement

good
no

Intermediate
Regular

poor
-

Median survival of MDS patients according to WPSS risk score:

WPSS risk category Combined score Very low low intermedia high te 2 3-4 Very high

5-6

Median survival (months)

136

63

44

19

MANAGEMENT OF MDS:

SUPPORTIVE CARE:
Supportive care includes:
blood products with deferoxamine.

haemopoietic growth factors .

Antibiotics. EPO (increases red blood cells in some patients). GM-CSF (limit infections).

IMMUNOSUPPRESSION:
Include polyclonal immunoglobulin preparations, ie
rabbit antithymocyte globulin (ATG) horse antilymphocyte globulin (ALG) Patients with Low IPSS score and marrow

hypocellularity has better outcome with immunosuppresive therapies.

 For young fit patients presenting with hypoplastic

MDS, a trial of immunosuppression with ATG should be considered first - line treatment before proceeding to allogeneic transplantation

CHEMOTHERAPY:
Treatment of MDS patients with intensive

chemotherapy regimens generally yields: low remission rates and high relapse rates.
The karyotype appears to be the major determinant

of response to intensive chemotherapy.

 Fludarabine appears to be better than daunorubicin

when combined with cytarabine.

The addition of G - CSF to this regimen in order to

sensitize the cells to these drugs has not been shown to confer any significant clinical benefit.

AUTOLOGOUS SCT:
Consolidation of remission by way of autologous SCT

is only applicable to a minority of patients due to the difficulty in harvesting CD34 - positive progenitors from patients with MDS. Despite achieving stable engraftment after myeloablative high - dose chemotherapy, the graft is likely to be contaminated with residual disease cells that inevitably compromise any clinical benefit.

ALLOGENEIC SCT:
The optimal timing of transplantation in MDS is

influenced by three factors: disease state cytogenetics Age

Patients should be transplanted in a state of remission,

after two or three cycles of intensive chemotherapy, since progressive or relapsed disease at time of SCT has a major adverse influence on outcome.

 Historically, busulfan and cyclophosphamide, with or

without total body irradiation, were used at high dose to condition the patient by way of total myeloablation allowing disease - free allogeneic stem cells to reconstitute the bone marrow.
But as Allogeneic SCT is associated with extremely high

transplant - related mortality (TRM) rate of 37 54% .

 This results in the use of reduced - intensity

conditioning (RIC) regimens for MDS.

RIC regimens are characterized by reduced

myelosuppression and aimed at decreasing toxicity and related mortality.

RIC protocols involves some combination of : fludarabine, melphalan or busulfan, and alemtuzumab

or ATG, occasionally with low - dose total body irradiation also.

 Poor prognostic factors for outcome following

allogeneic SCT includes:

older age poor - risk cytogenetics

high IPSS score

advanced disease therapy - related MDS

prolonged disease duration

marrow fibrosis.

HYPOMETHYLATING DRUGS:
MOA: Hypomethylating agents are incorporated into

the DNA where they covalently bind to the methyltransferase molecule, thereby inhibiting its function and leading to loss of methylation as DNA is replicated during mitosis. Currently, there are two hypomethylating agents that are approved for use in the treatment of MDS:

5 - azacytidine (azacitidine) 5 - aza - 2 - deoxycytidine (decitabine)

IMMUNOMODULATORY DRUGS:
Lenalidomide.
It have broad activity on the bone marrow

microenvironment, including anti angiogenic activity and cytokine suppression. It also causes enhancement of erythropoietin receptor signalling. Most marked responses are observed in those patients with del(5q) compared with normal karyotype or other cytogenetic abnormalities (83% vs. 57% vs. 12%, respectively).

CLINICAL VARIANTS OF MDS:

CMML:
classified as MDS/MPD in the WHO classification. clinical outcome relates to BM blast % rather than PB

monocyte count.
5q syndrome: clinically distinct form of MDS in WHO classification.

 Pure sideroblastic anaemia (PSA): defined as sideroblastic anaemia with dysplasia

confined to erythropoietic cells (RARS in WHO classification)

survival better (77% OS at 3yrs) than where dysplastic

features are also present in myeloid or megakaryocytic lineages (RCMD-RS in WHO classification; 56% OS at 3yrs) and very low risk of AML.

 Secondary MDS: Incidence increasing due to successful chemotherapy

and increased pollution. Multiple chromosomal abnormalities in almost all patients. Poorer prognosis than de novo MDS. Hypoplastic MDS: <15% of cases of MDS have hypocellular BM on biopsy. Dysplastic megakaryocytes, myeloid cells or excess blasts should be present. Difficult to distinguish from aplastic anaemia. May respond to immunosuppressive therapy.

 Fibrotic MDS: Up to 50% of cases have increased BM fibrosis but

<15% have marked fibrosis. More common in secondary MDS. PB shows pancytopenia and dysplastic features and sometimes leucoerythroblastic picture. BM hypercellular with myelofibrosis. Rapid deterioration usual.