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Additional file 1: Table S1. All treatment emergent adverse events categorised and graded according to CTCAE version 4.03. Table S2. HR23B score data for all treated patients. Figure S1. Progression-free Survival on CXD101.

The detection and grading of fibrosis in myeloproliferative neoplasms (MPN) is an important component of disease classification, prognostication and disease monitoring. However, current fibrosis grading systems are only semi-quantitative and fail to capture sample heterogeneity. To improve the detection, quantitation and representation of reticulin fibrosis, we developed a machine learning (ML) approach using bone marrow trephine (BMT) samples (n = 107) from patients diagnosed with MPN or a reactive / nonneoplastic marrow. The resulting Continuous Indexing of Fibrosis (CIF) enhances the detection and monitoring of fibrosis within BMTs, and aids the discrimination of MPN subtypes. When combined with megakaryocyte feature analysis, CIF discriminates between the frequently challenging differential diagnosis of essential thrombocythemia (ET) and pre-fibrotic myelofibrosis (pre-PMF) with high predictive accuracy [area under the curve = 0.94]. CIF also shows significant promise in the identification of MPN patients at risk of disease progression; analysis of samples from 35 patients diagnosed with ET and enrolled in the Primary Thrombocythemia-1 (PT-1) trial identified features predictive of post-ET myelofibrosis (area under the curve = 0.77). In addition to these clinical applications, automated analysis of fibrosis has clear potential to further refine disease classification boundaries and inform future studies of the micro-environmental factors driving disease initiation and progression in MPN and other stem cell disorders. The image analysis methods used to generate CIF can be readily integrated with those of other key morphological features in MPNs, including megakaryocyte morphology, that lie beyond the scope of conventional histological assessment.Key PointsMachine learning enables an objective and quantitative description of reticulin fibrosis within the bone marrow of patients with myeloproliferative neoplasms (MPN),Automated analysis and Continuous Indexing of Fibrosis (CIF) captures heterogeneity within MPN samples and has utility in refined classification and disease monitoringQuantitative fibrosis assessment combined with topological data analysis may help to predict patients at increased risk of progression to post-ET myelofibrosis, and assist in the discrimination of ET and pre-fibrotic PMF (pre-PMF)