myelodysplastic syndrome - cme...

Ryotaro Nakamura, MD

Associated Professor

Hematology and Hematopoietic Cell Transplantation

Myelodysplastic

Syndrome

CONFLICTS OF INTEREST

Advisory Board meeting: Seattle Genetics Inc.

Translation for lay people

• Myelo (=bone marrow)

• dysplastic (=looks funny)

• Syndrome (=we don’t really know what

it is, but just pretending to know it)

Patients: limited understanding, lack of insight

An Internet-based survey of 348 MDS patients

80% reported that their MDS was first described as a

“bone marrow disorder,”

6% to 7% indicated their MDS was first described as

either “cancer” or “leukemia.”

42% did not know their blast percentage.

A separate Internet-based survey of 349 MDS patients

33% did not know their MDS subtype.

Oncologist 2011;16(6):904-911

Leuk Res 2008;32(5):691-698

Ineffective hematopoiesis with cytopenia

Clonal disease of hematopoietic stem cell

Dysplastic morphology

Tendency to evolve to acute leukemia

Characteristics of this “syndrome”

WHO 2008

WHO 2008 - MDS/MPD

Blood, Vol 89, No 6 (March 15), 1997: pp 2079-2088

IPSS

Prognosis - IPSS

IPSS-R

Nature Reviews Cancer 12, 849-859

Cytogenetic Abnormalities

Somatic Mutations

Bejar and Steensma, Blood. 2014;124(18):2793

Landscape of genetic lesions

Leukemia (2014) 28, 241–247

N=944

N Engl J Med 2011;364:2496-506.

- Genomic approaches: next-generation sequencing

and mass spectrometry–based genotyping,

- Bone marrow aspirate from 439 patients wit MDS.

- Association with clinical variables

Mutations of genes involved in tyrosinesignaling pathways (JAK2, CBL, and NRAS–

KRAS– BRAF) were largely mutually exclusive (Fig. 1). TET2 mutations, in contrast,

overlapped with lesions in nearly every other mutated gene, suggesting that TET2

mutations have a pathogenic role that is at least partially independent of other

abnormalities. N Engl J Med 2011;364:2496-506.

N Engl J Med 2011;364:2496-506.

Diagnostic Challenges

Overlap “bone marrow failure” syndrome

Aplastic anemia

“Hypoplastic MDS”

Large granular lymphocyte disease (CD3/CD8/CD57,

TCR gene rearrangement)

PNH clone

Idiopathic cytopenias of undetermined significance (ICUS)

Clonal hematopoiesis of indeterminate potential (CHIP).

Metabolic (B12, copper deficiency, liver disease)

“Idiopathic” thrombocytopenic purpura

45yo female with hypocellular BM, 45,X in 15/20 metaphases

-> slowly responded to ATG/CSA (turned to be mosaic Turner)

62yo male with common variable immune deficiency, later dx’d with

thymoma, then severe anemia with dysplastic BM

-> likely immune mediated. TCR gene rearrangement negative,

but responded to CSA

50yo female, thrombicytopenia, trisomy 8, morphologic dysplasia in BM,

Plt-assoc Ab positive

-> responded to prednisone/eltrombopag

Diagnostic Challenges - Examples


51yo male: thrombocytopenia (~50k/ul), mild anemia, no PNH, hypocellular

marrow, no clear dysplasia

Cytogenetics: Clone 1: 46,XY,+1,der(1;7)(q10;p10)[4]

Clone 2: 46,XY,+1,der(1;12)(q10;q10)[5]


50 yo female presented with pancytopenia

WBC 2,300/uL, Hb 7g/dL, plts 15,000/uL.

Bone Marrow: variable cellularity, mild dysplasia

No clonal T or B cell population

Sucrose test negative (in 1996)

Cytogenetics: trisomy 8 in 2~5/20 metaphases

Treated with ATG and CSA, achieved transfusion

independence, but remains dependent on GCSF and

Epo for anemia. Later evolved into hemolytic PNH,

currently on eculizumab (age 69)

Somatic Mutations and Clonal Hematopoiesis

in Aplastic Anemia

N Engl J Med 2015;373:35-47.

Somatic Mutations and Clonal Hematopoiesis

in Aplastic Anemia

N Engl J Med 2015;373:35-47.

- “unfavorable” mutations: DNMT3A, ASXL1, TP53,

RUNX1, JAK2, JAK3, or CSMD1

- “favorable” mutations: PIGA or BCOR and BCORL1

Young NS. Ann Int Med 2002

Possible relationship among bone

marrow failure syndromes

Management Approaches

Supportive care

- Transfusions

- Growth factors (EPO if EPO level <500mu/ml, G/E for

RARS)

- IV access, iron chelation

MDS-directed therapy

- 5-azacitidine, decitabine, revlimid

- Immunosuppressive therapy (selected cases)

Potentially curative therapy

- Allogeneic HCT

Conventional chemotherapy

- 7+3, FLAG, MEC, cloforabine, low-dose cytarabine,etc.

Goals of Therapy

Cure

Improve the natural history

- prolong life

- delay transformation

Symptomatic support

Weigh against side effects/risks

Can’t get wrong by referring to clinical trials.

RBC transfusions, EPO

- RBC transfusion parameter: to be individualized (7-

9g/dl)

- Lower parameters might not always reduce

transfusions…

- EPO: if <500iu/l

- EPO plus GCSF: to be considered for RARS

- Survival benefit? Benefit in hematopoiesis by reducing free

radicals? in retrospective studies (no prospective randomized

trial data)

- Currently approved agents are inconvenient (deferroxamine) or

costly and not well-tolerated by many patients (deferasirox).

- TELESTO trial: multicenter, randomized, double-blind,

placebo-controlled trial of deferasirox on low-risk MDS patients

with iron overload (NCT00940602)

- New formulation of deferasirox: Jadenu

Iron Chelation

NCCN guideline: IPSS low, int-1, Target ferritin: 1000 ng/ml

- >20 transfusions, or

- Anticipated ongoing RBC transfusions, or

- Serum ferritin >2500 ng/ml

- Potential risk to augment myeloblast proliferation

- The rate of progression to AML was not increased with

romiplostim therapy in lower-risk MDS,

- Platelet transfusion needs and clinically significant

bleeding events were reduced with active therapy.

- Decreased frequency of dose reductions or delays in

patients receiving lenalidomide therapy

TPO Receptor Agonists Romiplostim (Nplate) and Eltrombopag (Promacta)

Sekeres MA, Kantarjian H, Fenaux P, et al. Subcutaneous or intravenous administration of romiplostim in thrombocytopenic patients with lower risk myelodysplastic syndromes.

Cancer. 2011;117(5):992-1000.

Kantarjian H, Fenaux P, Sekeres MA, Becker PS, Boruchov A, Bowen D, Hellstrom-Lindberg E, Larson RA, Lyons RM, Muus P, Shammo J, Siegel R, Hu K, Franklin J, Berger DP.

Safety and efficacy of romiplostim in patients with lower-risk myelodysplastic syndrome and thrombocytopenia. J Clin Oncol. 2010 Jan 20;28(3):437-44

Kantarjian HM, Giles FJ, Greenberg PL, Paquette RL, Wang ES, Gabrilove JL, Garcia-Manero G, Hu K, Franklin JL, Berger DP. Phase 2 study of romiplostim in patients with low- or

intermediate-risk myelodysplastic syndrome receiving azacitidine therapy. Blood. 2010 Oct 28;116(17):3163-70.

Giagounidis A, Mufti GJ, Fenaux P, et al. Results of a randomized, double-blind study of romiplostim versus placebo in patients with low/intermediate-1-risk myelodysplastic syndrome

and thrombocytopenia. Cancer. 2014;120(12):1838-1846.

Wang ES1, Lyons RM, Larson RA, Gandhi S, Liu D, Matei C, Scott B, Hu K, Yang AS. A randomized, double-blind, placebo-controlled phase 2 study evaluating the efficacy and safety

of romiplostim treatment of patients with low or intermediate-1 risk myelodysplastic syndrome receiving lenalidomide. J Hematol Oncol. 2012 Nov 29;5:71.

TPO Receptor Agonists

Median platelet counts over time.

Kantarjian et al. JCO 2010;28:437-444

Lenalidomide

Erythroid Response rate:

5q31.1: 83%

normal karyotype: 57%

other karyotypic abnormalities: 12%

N Engl J Med 2005;352:549-57.

Phase II, N=148, 10mg/d continuous or 21d

- 112 had a reduced (>50%) need for transfusions (76%)

- 99 patients (67%): TI regardless of the karyotype complexity.

- Median time to response, 4.6 weeks; range, 1 to 49

- Sustained response: the median duration of TI had not been

reached after a median of 104 weeks of follow-up.

- Cytogenetic response:

- 62 of 85 had cytogenetic improvement (38: complete

cytogenetic remission).

Lenalidomide in the Myelodysplastic

Syndrome with Chromosome 5q Deletion

N Engl J Med 2006;355:1456-65.

Phase 2 study of lenalidomide in transfusion-dependent, low-

and int1–risk MDS with karyotypes other than deletion 5q

Blood. 2008;111:86-93

J Clin Oncol 20:2429-2440

Hypomethylating Agents

J Clin Oncol 20:2429-2440

Lancet Oncol 2009; 10: 223–32

J Clin Oncol 29:1987-1996.

• 233 patients (median age:70 years, range: 60-90)

• 53% had poor-risk cytogenetics,

• The median MDS duration at random assignment: 3 months.

• Primary end point: overall survival (OS).

• Decitabine (15 mg/m2) intravenously over 4 hours 3x/day for 3 days in

6-week cycles.

No cross over

J Clin Oncol 29:1987-1996.

Long-term outcome of higher-risk MDS patients treated with

azacitidine: an update of the GFM compassionate program cohort

Design/Therapy

Total

N Overall Survival

Cohort: Outcome after AZA-failure(1) 435 15% (2 year)

Cohort: Prognostic Factors in Compassionate

Use AZA(2) 282 ~20% (3 year by survival curve)

Cohort: Compassionate Use AZA(3) 282 17.5% (3 year)

Ph III: Low-Dose Decitabine vs. BSC(4) 233 19% (2 year)

Ph III: European AZA-001: AZA vs. BSC(5) 358 50.8% (2 year), ~30% (3 year by survival curve)

Ph III: Decitabine vs. BSC(6) 170 Not available

Ph III: CALGB AZA vs. BSC(7) 191

~45% (2 year), ~25% at (3 year by survival

curves)

Retrospective: HCT in 60-70 yo vs. No Donor +

AZA(8) 178 23% (2 year)

Decision Analysis (<60yo)(9) 184

<5% for high, ~20% for Int 2 (3 year by survival

curve)

Survival Outcomes from HMA trials

Prebet et al. J Clin Oncol 29:3322

Poor outcome after azacitidine

treatment failure

Poor outcome after azacitidine

treatment failure

Combination Therapy

A phase II trial of azacitidine (75 mg/m2/d x 5 days) in combination with

lenalidomide (10 mg/d x 21 days (28-day cycle) for higher-risk MDS.

-overall response rate of 72% (CR: 44%)

- median CR duration of 17+ months (range, 3-39+)

- median overall survival of 37+ months (range, 7-55+) for CR patients,

13.6 months for the entire cohort (range, 3-55).

Phase I study evaluated the combination of azacitidine and vorinostat

in MDS and AML patients. There were no serious non-hematologic

toxicities, and responses were seen in up to 86% of patients.

Randomized Phase II Study of Azacitidine Combined with

Lenalidomide or with Vorinostat Vs. Azacitidine Monotherapy

in Higher-Risk Myelodysplastic Syndromes (MDS) and

Chronic Myelomonocytic Leukemia (CMML): North American

Intergroup Study SWOG S1117

(Sekeres at al. ASH 2014 Late Breaking Abstract 5)

Higher-risk MDS (IPSS Int-2 or High and/or bone marrow

blasts ≥5%) and CMML patients (pts) with <20% blasts

- AZA (75 mg/m2/d on d1-7 of a 28d cycle)

- AZA + LEN (10 mg/d on d1-21), or

- AZA + VOR (300 mg BID on d3-9).

Combination Therapy

≥Grade 3 AE (AZA:AZA+LEN:AZA+VOR)

- febrile neutropenia (10:13:13)

- gastrointestinal disorders (4:11:23)

- infections (2:3:3)

- rash (2:12:1).

ORR (N=290): 33%

CR: 19%, PR: 1%, HI: 13%

RFS (median): 7 months.

ORR in study arms:

AZA: 36%

AZA+LEN: 37% (p=1.0),

AZA+VOR: 22% (p=.07)

CR/PR/HI rates:

AZA: 23%/0%/13%

AZA+LEN: 18%/1%/17% (CR p=.47)

AZA+VOR 14%/1%/7% (CR p=.18)

Allogeneic HCT

• The only potentially curative treatment

• Eliminates malignant hematopoietic clones

through conditioning chemo-radiotherapy and

graft-versus-leukemia (GVL) effects

• Restores hematopoiesis with donor-derived

progenitor cells

• Associated with significant risks of transplant-

related mortality/morbidity (GVHD, infection,

organ toxicity, graft failure)

Transplant is not a gamble….

CIBMTR data

City of Hope RIC HCT experience for MDS

Initial disease control:

Focusing on patients with persistent MDS

(n=27) or persistent AML (n=7) at the time

of transplant, an early post transplant bone

marrow examination was available in

27 (MDS: 21, AML: 6). Of these, 24

patients (89%) showed no evidence of

MDS or AML around day 30.

TRM: 35%, grade II-IV GVHD: 62%

• Fludarabine (125mg/m2+Melphalan 140mg/m2)

• GVHD prophylaxis: CSA+MMF +/-miniMTX

Nakamura et al. BMT 2007

N=43

Leukemia Res 2012

City of Hope Experience with RIC-HCT

(Flu/Mel, Tacro/Siro)

• Who and when?

Age, co-morbidities?

Subtypes/IPSS risk categories?

• How?

Conditioning

Donor source (MRD, MUD, Cord, Haplo)

GVHD prophylaxis

Pre- and post-HCT therapy to reduce relapse

pre-HCT cytoreduction (HM agents, high-

intensity induction)

post-HCT HM agents/MRD monitoring

Challenges in HCT for MDS

A decision analysis of allogeneic BMT for MDS: delayed

transplantation for low-risk MDS is associated with improved outcome

Cutler et al. Blood. 2004;104:579-585

Markov decision model

BMT cohort: BM graft

ablative conditioning,

sibling donor, tacro-MTX

Coverage with Evidence Development

• CMS issued a decision memo in Aug 2010 allowing

“coverage with evidence development (CED)”

Suggests insufficient evidence

“..evidence does not demonstrate that the use of

HCT improves health outcomes in Medicare

beneficiaries with MDS.”

“paucity of evidence regarding the use of HCT in

patients with MDS who are 65 years or older”

Will cover costs of HCT if patients enrolled in a study

that will provide CMS with data (“evidence”) to

determine the value of the procedure in the

Medicare population

Biol Blood Marrow Transplant. 2014 Oct; 20(10): 1566–1572.

Role of RIC-HCT in Older Patients

With De Novo MDS: An

International Collaborative Decision Analysis

RIC, 60-70yo, MUD/MRD

Blue area: superior QALE

Koreth et al J Clin Oncol 2013; 31:2662-2670

IPSS Low/Int-1

IPSS Int-2/High

Platzbecker et al. Biol Blood Marrow Transplant 18:1415-1421, 2012

Allo-HCT in Patients Age 60-70 Years with De Novo High-Risk

MDS/2ndary AML: Comparison with Patients Lacking Donors Who

Received Azacitidine

Platzbecker et al. Biol Blood Marrow Transplant 18:1415-1421, 2012

HLA-matched allogeneic HCT improves

outcome of higher risk MDS: SFGM-TC and GFM

Robin et al. Leukemia (2015) 29, 1496–150

162 patients with MDS (50: no donor, 112: donor)

Median age: 60 years (range: 50–70).

IPSS no donor donor

Int-1 5 (10%) 8 (7%)

Int-2 28 (56%) 75 (67%)

High 12 (24%) 22 (20%)

Corey Cutler, MD MPH

Ryotaro Nakamura, MD

• 3-yr overall survival benefit (Primary Objective)

• 3-yr LFS (Secondary Objective)

• QOL benefit (Secondary Objective)

• Cost Effectiveness (Ancillary study)

Key questions

BMT CTN 1102: A Multi-Center Biologic Assignment Trial

Comparing Reduced Intensity Allogeneic Hematopoietic

Cell Transplant to Hypomethylating Therapy or Best

Supportive Care in Patients Aged 50-75 with Intermediate-2

and High Risk Myelodysplastic Syndrome

Accrual: ~50% complete (target 340-400)

Summary….

Bejar and Steensma, Blood. 2014;124(18):2793

myelodysplastic syndrome - cme...

Documents