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Myelodysplastic syndromes (MDSs) represent a heterogeneous group of hematological stem cell disorders with an increasing burden on health care systems. Evidence-based MDS guidelines and recommendations (G/Rs) are published but do not necessarily translate into better quality of care if adherence is not maintained in daily clinical practice. Guideline-based indicators (GBIs) are measurable elements for the standardized assessment of quality of care and, thus far, have not been developed for adult MDS patients. To this end, we screened relevant G/Rs published between 1999 and 2018 and aggregated all available information as candidate GBIs into a formalized handbook as the basis for the subsequent consensus rating procedure. An international multidisciplinary expert panel group (EPG) of acknowledged MDS experts (n = 17), health professionals (n = 7), and patient advocates (n = 5) was appointed. The EPG feedback rates for the first and second round were 82% (23 of 28) and 96% (26 of 27), respectively. A final set of 29 GBIs for the 3 domains of diagnosis (n = 14), therapy (n = 8), and provider/infrastructural characteristics (n = 7) achieved the predefined agreement score for selection (>70%). We identified shortcomings in standardization of patient-reported outcomes, toxicity, and geriatric assessments that need to be optimized in the future. Our GBIs represent the first comprehensive consensus on measurable elements addressing best practice performance, outcomes, and structural resources. They can be used as a standardized instrument with the goal of assessing, comparing, and fostering good quality of care within clinical development cycles in the daily care of adult MDS patients.

'MDS with isolated del(5q)' is a subtype of Myelodysplastic Syndrome (MDS) with characteristic morphological and genomic features. Clinically, MDS with isolated del(5q) is uniquely responsive to immunomodulatory agents, with lenalidomide (LEN) approved for treating anemia in this indication. Erythropoiesis Stimulating Agents (ESA) and red cell transfusion (RBCT) are other options for anemia management. The EUMDS Registry is an international prospective registry of newly diagnosed patients (within 100 days of diagnosis) with IPSS Low/Int-1-risk MDS (plus higher-risk MDS from 2017) recruiting since 1 st April 2008, currently at 146 sites in 17 countries. We describe the largest prospective Registry series of 'MDS with del(5q)' patients, with data from diagnosis. Methods Comparative analyses of baseline characteristics for categorical variables compared different groups by chi 2 test, and for continuous variables by Kruskal-Wallis test. p values are given with Bonferonni correction applied. Results Baseline characteristics Of 2469 EUMDS patients, 197 (8%) met the WHO 2016 classification criteria for 'MDS with isolated del5q'. Median follow up is 4.3 yrs. 77% were female (34% for all EUMDS patients), and median age was 73y. In comparison to EUMDS patients lacking del(5q), patients with MDS with isolated del(5q) were lower risk at diagnosis (IPSS and IPSS-R, p Interventional management To date, 168/197 patients received active intervention and the following sequence of interventions was observed, in order of frequency of initial intervention, RBCT>ESA>LEN: RBCT (n=96), - then ESA (42) then LEN (21) - then LEN (32) then ESA (5) ESA (n=55), - then RBCT (30) then LEN (13) - then LEN (9) then RBCT (6) LEN (n=17), - then ESA (3) then RBCT (2) - then RBCT (2) then ESA (2) Ninety-two patients have received LEN. In comparison with those not (yet) treated with LEN, LEN treated patients were younger (mean 70y vs 75y, p Adverse events were considered but proved too difficult to evaluate from the Registry data. For example, anticoagulant treatment data was collected, but not the specific indication. Outcome No difference in outcome (OS or PFS) was noted for patients treated with LEN vs. not (Figure, OS - adjusted Hazard Ratio, age and sex, 95% Confidence Interval: 0.67 [95% CI:0.35-1.29], lenalidomide treatment as a time-dependent variable). Conclusion EUMDS is uniquely placed to describe 'real-world' management of patients with 'MDS with isolated del(5q)' from diagnosis. To date, the largest (retrospective) case series reported had a median age 5 years younger than EUMDS, most likely representing referral bias(1). EUMDS demonstrates that most patients with MDS with isolated del(5q) require interventional therapy, and that more than half of transfusion dependent patients have received LEN. Further analysis of interventions and response will be presented. 1. Germing U, Lauseker M, Hildebrandt B, Symeonidis A, Cermak J, Fenaux P, et al. Survival, prognostic factors and rates of leukemic transformation in 381 untreated patients with MDS and del(5q): A multicenter study. Leukemia 2012;26(6):1286-92. Figure 1 Figure 1. Disclosures Fenaux: Takeda: Honoraria, Research Funding; Abbvie: Honoraria, Research Funding; JAZZ: Honoraria, Research Funding; Celgene/BMS: Honoraria, Research Funding; Novartis: Honoraria, Research Funding; Janssen: Honoraria, Research Funding; Syros Pharmaceuticals: Honoraria. Symeonidis: Janssen: Consultancy, Honoraria, Membership on an entity's Board of Directors or advisory committees, Research Funding; GSK: Research Funding; Roche: Consultancy, Honoraria, Membership on an entity's Board of Directors or advisory committees, Research Funding; Pfizer: Consultancy, Honoraria, Membership on an entity's Board of Directors or advisory committees, Research Funding; MSD: Consultancy, Research Funding; BMS: Consultancy, Honoraria, Membership on an entity's Board of Directors or advisory committees, Research Funding; Amgen: Consultancy, Honoraria, Membership on an entity's Board of Directors or advisory committees, Research Funding; Sanofi: Consultancy, Honoraria, Membership on an entity's Board of Directors or advisory committees; Demo: Research Funding; WinMedica: Research Funding; Astellas: Consultancy, Research Funding; Sanofi/Genzyme: Consultancy, Honoraria, Membership on an entity's Board of Directors or advisory committees, Research Funding; Novartis: Consultancy, Honoraria, Membership on an entity's Board of Directors or advisory committees, Research Funding; Takeda: Consultancy, Honoraria, Membership on an entity's Board of Directors or advisory committees, Research Funding; Gilead: Consultancy, Honoraria, Membership on an entity's Board of Directors or advisory committees, Research Funding; GenesisPharma: Consultancy, Honoraria, Membership on an entity's Board of Directors or advisory committees, Research Funding; AbbVie: Consultancy, Honoraria, Membership on an entity's Board of Directors or advisory committees, Research Funding. Kotsianidis: Novartis Hellas: Consultancy, Other: NONE, Research Funding, Speakers Bureau; Abbvie: Consultancy, Other: NONE, Research Funding, Speakers Bureau; Bristol Hellas: Consultancy, Other: NONE, Research Funding, Speakers Bureau; Janssen Hellas: Consultancy, Other: NONE, Speakers Bureau; Genesis: Consultancy, Other: NONE; Astellas: Other: NONE, Research Funding, Speakers Bureau. Mittelman: Janssen · Roche · Novartis · Takeda · Medison / Amgen · Neopharm / Celgene / BMS · Abbvie · Gilead: Research Funding; Novartis · Takeda · Fibrogen · Celgene / BMS · Onconova · Geron: Other: Clini; Onconova · Novartis · Takeda · Silence: Membership on an entity's Board of Directors or advisory committees; MDS HUB: Consultancy; Celgene / BMS · Novartis: Speakers Bureau. Sanz: Helsinn Healthcare: Consultancy, Membership on an entity's Board of Directors or advisory committees; Janssen: Consultancy, Membership on an entity's Board of Directors or advisory committees; Roche: Consultancy, Membership on an entity's Board of Directors or advisory committees, Other: Travel, accommodations, and expenses; Amgen: Consultancy, Membership on an entity's Board of Directors or advisory committees; Boehringer Ingelheim: Consultancy, Membership on an entity's Board of Directors or advisory committees; Novartis: Consultancy, Membership on an entity's Board of Directors or advisory committees, Speakers Bureau; Takeda: Consultancy, Membership on an entity's Board of Directors or advisory committees, Other: Travel, accommodations, and expenses, Speakers Bureau; Gilead Sciences: Other: Travel, accommodations, and expenses; Abbvie: Consultancy, Membership on an entity's Board of Directors or advisory committees; Celgene: Consultancy, Honoraria, Membership on an entity's Board of Directors or advisory committees, Other: Travel, accommodations, and expenses, Research Funding. Stauder: Celgene/BMS: Honoraria, Membership on an entity's Board of Directors or advisory committees, Other: Travel support; Novartis: Honoraria, Membership on an entity's Board of Directors or advisory committees. Germing: Janssen: Honoraria; Celgene: Honoraria; Novartis: Honoraria, Research Funding; Bristol-Myers Squibb: Honoraria, Other: advisory activity, Research Funding; Jazz Pharmaceuticals: Honoraria. van Marrewijk: EUMDS Registry: Current Employment; Novartis: Other: Educational Grants; BV Oncology Europe: Other: Educational Grants; Amgen Limited: Other: Educational Grants; Celgene International: Other: educational grants; Janssen Pharmaceuticals: Other: educational grants; Takeda Pharmaceuticals: Other: educational grants; MDS-RIGHT: Other: project budgets. de Witte: Amgen: Research Funding; Celgene: Research Funding; Takeda: Research Funding; Novartis: Research Funding; Janssen: Research Funding.

Background The assessment of health-related quality of life (HRQoL) in patients with myelodysplastic syndromes (MDS) is critical to organize more robustly patient-centered care. Therefore, availability of well-validated disease-specific HRQoL measures in this area is important. Objectives We investigate the validity of the Quality of Life in Myelodysplasia Scale (QUALMS), to assess HRQoL in MDS patients reported to the European MDS (EUMDS) Registry. A prior validation effort has been reported (Abel G, et al. Haematologica, 2016 June; 781-88), but this was largely a North American cohort and subscales suggested by the original principal components analysis had not been validated. Patients and Methods The QUALMS questionnaire was included in the EUMDS Registry (de Swart L, et al. Br J Haematol. 2015 Aug;170:372-83), a large international initiative including several European countries and Israel. We used proportions, median and interquartile range (IQR) to summarize patients' characteristics at baseline. We also assessed internal consistency and test-retest reliability by Cronbach's alpha (threshold for acceptability Cronbach's alpha ≥0.70). Confirmatory factor analysis (CFA) was used to examine the model fit for the underlying scale structure. The model performance was evaluated by Comparative Fit Index (CFI), the Tucker-Lewis Index (TLI), and the Root Mean Squared Error of Approximation (RMSEA), where acceptable values were >0.90 for CFI and TLI and RMSEA Results Overall, 270 MDS patients completed the QUALMS questionnaire, from 17 centers across four countries: Austria (N = 61), Israel (N = 67), The Netherlands (N = 37) and United Kingdom (N = 105). The majority of patients were male (67.4%) with a median age at diagnosis of 74 years (IQR =68.0-80.0) and a low MDS-CI score (n=158). CFA indicated acceptable model fit, respectively CFI=0.93, TLI=0.93 and RMSEA=0.07. For all analyses, the scales QUALMS-physical burden (P), QUALMS-emotional burden (E) and the total score showed satisfactory results, while the scale QUALMS-benefit finding (BF) showed worse results. Internal consistency and test-retest reliability were acceptable for the total score (TS) and all scales but BF (see figure). Pairwise correlations between QUALMS-P, QUALMS-E, TS and all the scales from EQ-5D-3L (including VAS) showed satisfactory concurrent validity (range from -0.67 to 0.60). Only the QUALMS-BF did not correlate with any of the EQ-5D-3L scales (range from -0.07 with EQ-VAS to 0.14 with EQ-5D Anxiety/ Depression). As per discriminant validity, all known-group comparisons were statistically significant and consistent with the underlying clinical construct for all scales apart for the QUALMS-BF. For example, the QUALMS-P mean scores were 75.8 vs 54.6 (p< 0.001) for patients with a higher vs lower KPS, while the corresponding QUALMS-BF mean scores were 49.4 vs 50.9 (p=0.829). The same profile resulted for responsiveness to change, where all scales reflected significant changes in Hb levels and in EQ-VAS score in the expected direction, while QUALMS-BF did not. For example, those patients who experienced a clinically meaningful deterioration in the VAS score also had also a worsening in QUALMS-P (Δ=-6, p=0.003), QUALMS-E (Δ=-1.8, p=0.075) and TS (Δ=-3, p=0.003). Conclusions Current findings provide novel evidence-based data that support the validity of the QUALMS for its use in European and Israeli patients with MDS. Implementation of the QUALMS in MDS research may further raise PRO standards in this area. Figure 1 Figure 1. Disclosures Efficace: Takeda: Consultancy; Janssen: Consultancy; Abbvie: Consultancy, Other: Grants (to Institution); Amgen: Consultancy, Other: Grants (to Institution). Mittelman: Janssen · Roche · Novartis · Takeda · Medison / Amgen · Neopharm / Celgene / BMS · Abbvie · Gilead: Research Funding; Novartis · Takeda · Fibrogen · Celgene / BMS · Onconova · Geron: Other: Clinical Trial Support; Onconova · Novartis · Takeda · Silence: Membership on an entity's Board of Directors or advisory committees; MDS HUB: Consultancy; Celgene / BMS · Novartis: Speakers Bureau. Van Marrewijk: Novartis Pharmacy B.V. Oncology Europe: Other: project manager of the EUMDS Registry, is funded from the EUMDS (educational grants from Novartis Pharmacy B.V. Oncology Europe); Amgen Limited: Other: project manager of the EUMDS Registry, is funded from the EUMDS (educational grants from Amgen Limited); Celgene International: Other: project manager of the EUMDS Registry, is funded from the EUMDS (educational grants from Celgene International); Janssen Pharmaceutical: Other: project manager of the EUMDS Registry, is funded from the EUMDS (educational grants from Janssen Pharmaceutical); Takeda Pharmaceuticals International: Other: project manager of the EUMDS Registry, is funded from the EUMDS (educational grants from Takeda Pharmaceuticals International); EU's Horizon 2020 program: Other: MDS-RIGHT (grant from EU's Horizon 2020 program) project budgets. de Witte: Takeda: Research Funding; Novartis: Research Funding; Janssen: Research Funding; Celgene: Research Funding; Amgen: Research Funding. Stauder: Celgene/BMS: Honoraria, Membership on an entity's Board of Directors or advisory committees, Other: Travel support; Novartis: Honoraria, Membership on an entity's Board of Directors or advisory committees.

Background Red blood cell (RBC) transfusion dependence (TD) and anemia are associated with inferior quality of life (QOL) and survival in myelodysplastic syndromes (MDS). As part of a research programme to identify the optimal transfusion hemoglobin (Hb) threshold that translates into significantly improved QOL, we conducted a pilot randomized study of two transfusion algorithms (liberal versus restrictive) to determine the feasibility of a larger study. This trial was aligned with the REDDS study (ISRCTN26088319, Stanworth et al., BJH 2019) and followed the same pre-defined statistical analysis plan. Methods The study was undertaken at 3 cancer centers (NCT02099669). We included patients with MDS, CMML, low blast AML (20-30%) or myeloproliferative neoplasms who were TD (> 1 RBC/8 weeks x 16 weeks). Patients on disease modifying therapy for > 6 months were permitted only if they had remained stably RBC-TD with a life expectancy of > 3 months. Central randomization was to one of two RBC transfusion strategies over a 12-week period: Restrictive strategy to maintain Hb between 85 and 105g/L. To achieve this, 2 RBC units were transfused when Hb < 85 g/LLiberal strategy to maintain Hb between 110 and 120 g/L. To achieve this, 2 RBC units were transfused when Hb < 105 g/L and 1 unit for Hb 105-110 g/L. The first 4 weeks were considered a run-in period to achieve the target Hb. The primary outcomes of this feasibility study were The percentage compliance of Hb being within or above the target range of the assigned transfusion threshold (after the 4 week run-in). Feasibility was set at 70%.Achievement of at least a 15 g/L difference between the mean pre-transfusion Hb of the liberal and restrictive strategy groups. Secondary outcomes included changes and differences in QOL scores, rates of transfusion reactions and alloimmunizations, overall blood utilization and visit numbers and impact on serum ferritin. The primary analysis was intention to treat. The study was closed early due to COVID-19, with 28 patients randomized of planned 30. Results 30 patients were enrolled over 5 years and 28 patients randomized (n=15, liberal; n=13 restrictive). Median age was 74 (range 58-84), 26/28 had MDS or CMML and there were no significant imbalances in baseline disease and patient characteristics although patients in the restrictive group tended to have lower risk disease (IPSS-R very low + low 69% versus 53% liberal). Compared with the restrictive arm, liberal arm patients had more complete blood counts, were transfused more RBC units (only during the 4-week run-in) and were transfused at shorter intervals (Table 1). There were no differences in adverse events. Over the 12 weeks, the mean Hb value was 90 ± 4 g/L (restrictive) versus 101 ± 4 g/L (liberal), (p Adherence with QOL completion (minimum of 4 serial) was 93%. While sample sizes are small and comparisons exploratory, the area under the curve for several serial quality of life scores was numerically higher and the curve more stable for the liberal arm (EQ5D (figure 2), EORTC cognitive and emotional functioning). Similarly, a higher % of patients in the liberal arm achieved pre-defined clinically meaningful increases in several symptom and function domains (emotional, social, fatigue, dyspnea, financial problems). Discussion Whilst our study results did not meet our feasibility endpoints, this small randomized trial in MDS patients demonstrated clinically important differences in mean Hb achievable with different transfusion thresholds. Poor rates of compliance with Hb targets were clearly identified for patients in the liberal arm, suggesting a need to understand the barriers to protocol adherence in this arm prior to embarking on larger trials. Compared with the REDDS trial, we did not document a significant excess of RBC transfusions needed (post run-in period) to maintain the higher Hb threshold. Similar to REDDS, we did observe some signals of improved QOL with a liberal transfusion strategy. A formal analysis of pooled results with REDDS study patients is planned. (Funding, CCSRI grant QOLL-14 and MOSPI Fund 2014). Disclosures Buckstein: Novartis: Honoraria; Astex: Honoraria; Celgene: Honoraria; Celgene: Research Funding; Takeda: Research Funding. Prica:seattle genetics: Honoraria; Gilead: Honoraria; astra zeneca: Honoraria. Leber:Amgen: Honoraria, Membership on an entity's Board of Directors or advisory committees, Speakers Bureau; BMS/Celgene: Honoraria, Membership on an entity's Board of Directors or advisory committees; Abbvie: Consultancy, Honoraria, Membership on an entity's Board of Directors or advisory committees, Speakers Bureau; Pfizer: Consultancy, Honoraria, Membership on an entity's Board of Directors or advisory committees, Speakers Bureau; Novartis: Consultancy, Honoraria, Membership on an entity's Board of Directors or advisory committees, Speakers Bureau; Otsuka Pharmaceutical: Honoraria, Membership on an entity's Board of Directors or advisory committees; Janssen: Honoraria, Membership on an entity's Board of Directors or advisory committees; Lundbeck: Honoraria, Membership on an entity's Board of Directors or advisory committees, Speakers Bureau; Alexion: Honoraria, Membership on an entity's Board of Directors or advisory committees, Speakers Bureau; Takeda/Palladin: Honoraria, Membership on an entity's Board of Directors or advisory committees; Treadwell: Honoraria, Membership on an entity's Board of Directors or advisory committees. Chodirker:Hoffman Laroche: Honoraria. Lin:Novartis: Research Funding; Pfizer: Honoraria. Callum:Octapharma: Research Funding; Canadian Blood Services: Research Funding.

Background Treatments for 'accelerated phase' MPNs (MPN-AP, 10-19% blasts)/post-MPN AML (MPN-BP, ≥20% blasts) are limited. Most patients are precluded from potentially curative haematopoietic stem cell transplantation (HSCT). For HSCT ineligible patients, azacitidine (AZA) is licensed to treat high-risk MDS or AML. Whilst dose and toxicity profile of AZA is well understood, the response of MPNs and post-MPN AML to monotherapy is limited. AZA-based doublet chemotherapy may however result in improved clinical responses. The phase Ib single-arm PHAZAR trial was established to determine maximum tolerated dose (MTD), safety profile and clinical activity of the selective JAK1/2 inhibitor ruxolitinib (RUX) used in combination with AZA to treat MPN-AP and MPN-BP patients. Methods A modified two-stage continual reassessment method with an expansion cohort at the MTD, was used to establish the MTD of RUX in combination with AZA. Successive flexible cohorts of 3-5 patients were enrolled at a fixed AZA dose of 75 mg/m2 s/c for 7 days (excluding weekends, on a 5-2-2 schedule) of a 28-day cycle with continuous administration of an allocated oral RUX dose (dose levels 0, 1, 2 and 3 = 10, 15, 20 and 25 mg BD respectively), and a formal response assessment recorded after 6 cycles. Toxicities were prospectively recorded as per CTCAE v4.0 with dose limiting toxicity (DLT) defined as a grade 3 or 4 non-haematological toxicity during treatment cycle 1. Clinical activity was evaluated over 12 months through assessment of bone marrow response after 3 and 6 treatment cycles, progression free survival (PFS), leukaemia free survival (LFS) and overall survival (OS). Results Thirty four advanced phase MPN patients were recruited from 12 Trials Acceleration Programme sites (19 MPN-AP; 15 MPN-BP). Baseline characteristics are summarized in Table 1. Driver mutation status was available for 25/34(74%) patients. 17/25(68%) carried canonical mutations in JAK2, 4/25 (16%) in CALR, and 4/25(16%) were triple negative. Three patients each received 10 and 15 mg of RUX BD, 4 patients received 20 mg RUX BD, 21 patients received 25 mg RUX BD and 3 did not begin treatment. Median number of cycles received was 3 RUX and 4 AZA. The MTD of RUX in combination with AZA was determined at 25 mg BD, with no DLTs reported during phase 1 of the study. During the expansion phase, 1 DLT at dose level 3 was reported as grade 3 febrile neutropenia; with this patient's RUX dose reduced from 25 to 20 mg BD. Overall, 601 adverse events were reported of which 16.3% were grade 3 and 3.5% grade 4, with anaemia and febrile neutropenia the most common grade 3 and 4 events. There were 77 serious adverse events reported with 50.6% believed trial treatment related; febrile neutropenia, sepsis and, infections and infestations were the most common affecting 29.4%, 14.7% and 14.7% of patients respectively. In total, 20 of 34 patients were evaluable for disease response. IWG MDS criteria were used for blasts Conclusions The combination of RUX and AZA is well tolerated in MPN-AP and MPN-BP patients with toxicities comparable to the individual agents. Of evaluable patients 10 of 20 achieved a PR or CR. The OS compares favourably with historical cohorts and clinically meaningful responses were achieved for transfusion independence. In 1 patient the regimen permitted successful bridge to transplant. Such combinations should be further explored, potentially with higher dose RUX. An expanded molecular analysis including responses is presented as a separate abstract. Disclosures Drummond: Novartis: Consultancy, Honoraria, Membership on an entity's Board of Directors or advisory committees, Research Funding, Speakers Bureau; Gilead: Membership on an entity's Board of Directors or advisory committees; Takeda: Membership on an entity's Board of Directors or advisory committees; Blueprint Medicine Corporation: Research Funding; Jazz: Membership on an entity's Board of Directors or advisory committees, Speakers Bureau; Bristol Myers Squibb: Honoraria, Membership on an entity's Board of Directors or advisory committees, Speakers Bureau; Astellas: Membership on an entity's Board of Directors or advisory committees; Pfizer: Consultancy, Membership on an entity's Board of Directors or advisory committees. Harrison:Shire: Honoraria, Speakers Bureau; Gilead Sciences: Honoraria, Speakers Bureau; Incyte Corporation: Speakers Bureau; Promedior: Honoraria; AOP Orphan Pharmaceuticals: Honoraria; CTI Biopharma Corp: Honoraria, Speakers Bureau; Novartis: Honoraria, Research Funding, Speakers Bureau; Celgene: Honoraria, Research Funding, Speakers Bureau; Sierra Oncology: Honoraria; Roche: Honoraria; Janssen: Speakers Bureau. Mead:Celgene/BMS: Consultancy, Honoraria, Other: travel, accommodations, expenses, Research Funding; Novartis: Consultancy, Honoraria, Other: travel, accommodations, expenses, Research Funding, Speakers Bureau; Gilead: Consultancy; CTI: Consultancy; Abbvie: Consultancy. Yap:Bristol-Myers Squibb: Honoraria, Speakers Bureau; Faron Pharmaceuticals: Consultancy. Narayanan:Takeda: Other: Educational support to attend conferences; Alexion: Speakers Bureau; MSD: Speakers Bureau; Celgene: Other: Educational support to attend conferences; Novartis: Other: Educational support to attend conferences. Somervaille:Novartis: Consultancy, Honoraria; Imago Bioscience: Research Funding. Gudgin:Jazz Pharmaceuticals: Membership on an entity's Board of Directors or advisory committees. Milojkovic:Incyte: Consultancy, Honoraria; Pfizer: Consultancy, Honoraria; Novartis: Consultancy, Honoraria; Bristol-Myers Squibb: Consultancy, Honoraria. Knapper:Novartis: Honoraria, Membership on an entity's Board of Directors or advisory committees, Research Funding. OffLabel Disclosure: 5-azacitidine is licensed and approved for treatment of adult patients who are not eligible for HSCT with high risk myelodyplastic syndromes. Ruxolitinib is licensed and approved for use in Myelofibrosis and for Polycythaemia Vera resistant/intolerant to hydroxyurea

The heterogeneity of myelodysplastic syndromes (MDSs) has made evaluating patient response to treatment challenging. In 2006, the International Working Group (IWG) proposed a revision to previously published standardized response criteria (IWG 2000) for uniformly evaluating clinical responses in MDSs. These IWG 2006 criteria have been used prospectively in many clinical trials in MDSs, but proved challenging in several of them, especially for the evaluation of erythroid response. In this report, we provide rationale for modifications (IWG 2018) of these recommendations, mainly for “hematological improvement” criteria used for lower-risk MDSs, based on recent practical and reported experience in clinical trials. Most suggestions relate to erythroid response assessment, which are refined in an overall more stringent manner. Two major proposed changes are the differentiation between “procedures” and “criteria” for hematologic improvement–erythroid assessment and a new categorization of transfusion-burden subgroups.

Background: Azacitidine (AZA) based therapy is a standard of care in IPSS INT-2/High MDS/low blast count AML and CMML-2. Thrombocytopenia is an adverse prognostic factor in MDS; increased severity correlates with haemorrhagic complications and shorter AML progression time, and early platelet recovery after AZA is linked to better outcomes. Accumulation of AZA doses is important to patient response, but initial treatment with AZA can aggravate thrombocytopenia and impact outcome. Eltrombopag (ELT) is a thrombopoietin receptor (TpoR) agonist approved for adult chronic immune thrombocytopenic purpura. ELT has shown efficacy in low risk MDS and reduces thrombocytopenic events in advanced MDS and AML. The ELASTIC trial (ISRCTN05858391) is a single-arm phase 1b dose-finding study examining the safety and tolerability of ELT/AZA in patients with MDS/AML with expansion cohort (n=10) at MTD. We investigated if ELT/AZA would lead to earlier platelet recovery and improve AZA efficacy. Although a Phase 3 study testing ELT/AZA (SUPPORT) was terminated due to futility during the ELASTIC trial, we reasoned that drug sequencing may affect outcome. As ELASTIC patients received an ELT pre-phase, ELASTIC was run to completion. Methods: Patients with IPSS INT-2 or High MDS/CMML-2/AML The primary outcome was safety and tolerability (including establishing the MTD) of ELT in combination with AZA. Key secondary outcomes were the effect of ELT on platelet counts, platelet transfusions and marrow blast percentage. Full blood count was measured weekly over the first 13 weeks and monthly thereafter; bone marrow was taken on day 8 of ELT and at the end of cycles 3 and 6. Results: Thirty-one patients were recruited from November 2014 to August 2018. Thirty (median age 74, range: 62-86) were evaluable for analysis in the safety population (AML=5, IPSS INT-2 MDS=12, IPSS High MDS=12, CMML-2=1); 1 patient was ineligible post registration. 11/30 (37%) were IPSS good risk, 3/30 (10%) intermediate risk and 14/30 (47%) high risk (2 unknown). ELT was well tolerated up to 300mg (25mg=5, 50mg=3, 100mg=4, 200mg=4, 300mg=14) and was safely combined with AZA. There were no DLTs in the DLT evaluable patients (n=15). The MTD was established as 300mg (n=14). There were 3 SUSARs, 19 SAEs, 28 SARs and 87 episodes of grade 3/4 AEs. There were 16 episodes of grade 3/4 neutropenia and 11 episodes of grade 3/4 anaemia. Five patients discontinued treatment due to toxicity (25mg=2, 300mg=3), 6 due to death (pneumonia=2, disease-related=4, ischaemic heart disease=1) and 1 withdrew. Platelet responses were seen at ELT 50mg and higher. At the MTD, median platelet count at baseline was 37 (IQR: 25-52), rising to 77 (IQR 50-108.5) and 74 (IQR: 32-430) at cycle 2 and 3 respectively. The median platelet nadir was 20.5 (IQR: 11-25) and 42 (IQR 18.5-51.5) after cycle 1 and 2 dropping to 20 (IQR: 9-160) after cycle 3 when ELT was stopped. Mean platelet transfusions did not change with ELT dose. There was no increase in delays to AZA dosing across the ELT dose cohorts. There was no change in bleeding incidents when patients received ELT. Overall, there was no increase in bone marrow blast percentage from baseline. The cycle 3 marrow aspirate was reached by 27/30 (90%) and 11/30 (37%) reached the cycle 6 marrow aspirate. At the end of 3 cycles there were 21 non-responders and 10 responders (CR=3, marrow CR=4, PR=3, SD=9). At the end of 6 cycles there were 22 non-responders and 9 responders (CR=3, marrow CR=4, PR=2, SD=5). 6/14 (43%) treated at the MTD responded while 3/16 (19%) treated at below the MTD responded. Conclusions: The combination of ELT with AZA is safe and tolerable. Clinically meaningful responses in platelets were seen in patients receiving 50mg or more ELT. At the MTD, there was a noticeable drop in platelet nadir in cycle 3 when patients were not receiving ELT. No change in platelet transfusion was identified across cohorts. The results suggest that an ELT pre-phase may improve platelet responsiveness in patients treated with AZA and warrants further exploration. Disclosures Sternberg: Celgene/BMS: Honoraria, Research Funding; GSK/Novartis: Honoraria, Research Funding. Raghavan:Celgene UK: Speakers Bureau. Culligan:Celgene: Consultancy, Honoraria, Speakers Bureau; Jazz: Consultancy, Honoraria; Abbvie: Consultancy, Honoraria, Speakers Bureau; Diiachi-Sankyo: Consultancy, Honoraria; Pfizer: Consultancy; Novartis: Consultancy, Honoraria. Cargo:Novartis: Honoraria. Vyas:Celgene: Research Funding, Speakers Bureau; Novartis: Research Funding, Speakers Bureau; Forty Seven: Research Funding; Pfizer: Speakers Bureau; Daiichi Sankyo: Speakers Bureau; Astellas: Speakers Bureau; AbbVie: Speakers Bureau. OffLabel Disclosure: Eltrombopag is a second generation thrombopoietin receptor (TpoR) agonist approved for adult chronic immune thrombocytopenic purpura.

Background. The severity of hematopoietic impairment and the kinetics of disease progression in lower risk myelodysplastic syndromes (LR-MDS) are extremely variable. Genomic profiling has the potential to inform the clinical management of these disorders, including improved classification, risk assessment and therapeutic choice. In the present study, based on a comprehensive mutation analysis in a large and clinically well-characterized cohort of LR-MDS patients, either recruited into the European MDS Registry or referred to European excellence centers involved in the MDS-RIGHT project, we adopted unsupervised hierarchical clustering analyses to identify relevant genetically defined disease subtypes within early stage MDS. Methods. The dataset comprised 856 cases identified as LR-MDS based on IPSS risk low or intermediate-1. Median age was 73 years (range 36-98); IPSS-R risk was very low in 30.1% of patients, low in 50.4%, intermediate in 19.5%. We investigated possible sub-structure amongst patients according to their mutational profiles, and correlated this sub-structure with relevant endpoints. For this analysis, unsupervised clustering was used, based on a mixture model of multivariate Bernoulli distributions. The optimal number of clusters was chosen using the Bayes Information Criterion (BIC), with secondary structure identified with the Akaike Information Criterion (AIC). Results. This analysis identified three distinct clusters within LR-MDS. Cluster 1 comprised exclusively patients with SF3B1 mutation, either isolated or associated with other mutations (SF3B1-mutant cluster) (37% of patients). Cluster 2 was characterized by excess mutations associated with higher risk disease (high-risk (HR) cluster) (27% of patients), including a significantly higher prevalence of ASXL1, IDH1/IDH2, SRSF2, RUNX1, CBL and EZH2 mutations (P The three recognized clusters showed distinct clinical features and outcome measures. Patients within HR cluster were significantly older (P=.008) and showed significant enrichment in WHO categories with multi-lineage dysplasia and excess blasts (P HR-cluster showed significantly lower overall survival (OS) compared to CHIP-like and SF3B1-mutant clusters (median 2.6 vs 6.8 or 6.4 years; P Conclusion. Mutation profiling identifies meaningful clusters of lower risk MDS with distinct molecular pathways, clinical features and endpoints. These results represent a robust basis to inform genetic ontogeny-based classification and individual risk assessment, as well as to inspire biology-driven clinical trials in lower risk MDS. Disclosures Symeonidis: Bristol-Myers Squibb: Honoraria, Membership on an entity's Board of Directors or advisory committees, Research Funding; Merck Sharp & Dohme: Honoraria, Membership on an entity's Board of Directors or advisory committees, Research Funding; Janssen: Honoraria, Membership on an entity's Board of Directors or advisory committees, Research Funding; Novartis: Honoraria, Membership on an entity's Board of Directors or advisory committees, Research Funding; Pfizer: Honoraria, Membership on an entity's Board of Directors or advisory committees, Research Funding; Roche: Honoraria, Membership on an entity's Board of Directors or advisory committees, Research Funding; Sanofi/Genzyme: Honoraria, Membership on an entity's Board of Directors or advisory committees, Research Funding; Takeda: Honoraria, Membership on an entity's Board of Directors or advisory committees, Research Funding; Amgen: Honoraria, Membership on an entity's Board of Directors or advisory committees, Research Funding; WinMedica: Research Funding; Celgene: Honoraria, Research Funding; Astellas: Research Funding; Abbvie: Honoraria, Membership on an entity's Board of Directors or advisory committees, Research Funding; Gilead: Honoraria, Membership on an entity's Board of Directors or advisory committees, Research Funding; GenesisPharma: Honoraria, Membership on an entity's Board of Directors or advisory committees, Research Funding. Stauder:Celgene: Honoraria, Membership on an entity's Board of Directors or advisory committees; Novartis: Honoraria, Membership on an entity's Board of Directors or advisory committees; Teva: Research Funding. Fenaux:Novartis: Honoraria, Research Funding; Abbvie: Honoraria, Research Funding; Jazz: Honoraria, Research Funding; BMS: Honoraria, Research Funding. Van Marrewijk:EUMDS and MDS-RIGHT (Providing the right care to the right patient with MyeloDysplastic Syndrome at the right time) project: Other: Project manager of the EUMDS Registry.

Prognosis of lower-risk (International Prognostic Scoring System [IPSS] low/intermediate-1) myelodysplastic syndrome (MDS) is heterogeneous and relies on steady-state assessment of cytopenias. We analyzed relative drops in neutrophil and platelet counts during the first 6 months of follow-up of lower-risk MDS patients. We performed a landmark analysis of overall survival (OS) of lower-risk MDS patients prospectively included in the European LeukaemiaNet MDS registry having a visit at 6 +/- 1 month from inclusion to assess the prognostic relevance of relative drops in neutrophils and platelets, defined as (count at landmark - count at inclusion)/count at inclusion. Of 2102 patients, 807 were eligible for the stringent 6-month landmark analysis. Median age was 73 years. Revised IPSS was very low, low, and intermediate/higher in 26%, 43%, and 31% of patients, respectively. A relative drop in platelets >25% at landmark predicted shorter OS (5-year OS, 21.9% vs 48.6% with platelet drop 25% had no significant impact on OS. We built a classifier based on red blood cell transfusion dependence (RBC-TD) and relative platelet drop >25% at landmark. Patients with none (62%), either (27%), or both criteria (11%) had 5-year OS of 53.3%, 32.7%, and 9.0%, respectively (P < 10(-4)). This classifier was validated in an independent cohort of 335 patients. Combining relative platelet drop >25% and RBC-TD at 6 months from diagnosis provides an inexpensive and noninvasive way to predict outcome in lower-risk MDS. This study was registered at www.clinicaltrials.gov as #NCT00600860.

An international expert panel, active within the European Society for Blood and Marrow Transplantation, European LeukemiaNet, Blood and Marrow Transplant Clinical Trial Group, and the International Myelodysplastic Syndromes Foundation developed recommendations for allogeneic hematopoietic stem cell transplantation (HSCT) in myelodysplastic syndromes (MDS) and chronic myelomonocytic leukemia (CMML). Disease risks scored according to the revised International Prognostic Scoring System (IPSS-R) and presence of comorbidity graded according to the HCT Comorbidity Index (HCT-CI) were recognized as relevant clinical variables for HSCT eligibility. Fit patients with higher-risk IPSS-R and those with lower-risk IPSS-R with poor-risk genetic features, profound cytopenias, and high transfusion burden are candidates for HSCT. Patients with a very high MDS transplantation risk score, based on combination of advanced age, high HCT-CI, very poor-risk cytogenetic and molecular features, and high IPSS-R score have a low chance of cure with standard HSCT and consideration should be given to treating these patients in investigational studies. Cytoreductive therapy prior to HSCT is advised for patients with ≥10% bone marrow myeloblasts. Evidence from prospective randomized clinical trials does not provide support for specific recommendations on the optimal high intensity conditioning regimen. For patients with contraindications to high-intensity preparative regimens, reduced intensity conditioning should be considered. Optimal timing of HSCT requires careful evaluation of the available effective nontransplant strategies. Prophylactic donor lymphocyte infusion (DLI) strategies are recommended in patients at high risk of relapse after HSCT. Immune modulation by DLI strategies or second HSCT is advised if relapse occurs beyond 6 months after HSCT.

ObjectiveA subset analysis of the randomised, phase 3, MDS-004 study to evaluate outcomes in patients with International Prognostic Scoring System (IPSS)-defined Low-/Intermediate (Int)-1-risk myelodysplastic syndromes (MDS) with isolated del(5q). MethodsPatients received lenalidomide 10mg/d (days 1-21; n=47) or 5mg/d (days 1-28; n=43) on 28-d cycles or placebo (n=45). From the placebo and lenalidomide 5mg groups, 84% and 58% of patients, respectively, crossed over to lenalidomide 5 or 10mg at 16wk, respectively. ResultsRates of red blood cell-transfusion independence (RBC-TI) 182d were higher in the lenalidomide 10mg (57.4%; P

Contains fulltext : 137293.pdf (Publisher’s version ) (Open Access) Del(5q) myelodysplastic syndromes defined by the International Prognostic Scoring System as low- or intermediate-1-risk (lower-risk) are considered to have an indolent course; however, recent data have identified a subgroup of these patients with more aggressive disease and poorer outcomes. Using deep sequencing technology, we previously demonstrated that 18% of patients with lower-risk del(5q) myelodysplastic syndromes carry TP53 mutated subclones rendering them at higher risk of progression. In this study, bone marrow biopsies from 85 patients treated with lenalidomide in the MDS-004 clinical trial were retrospectively assessed for p53 expression by immunohistochemistry in association with outcome. Strong p53 expression in >/= 1% of bone marrow progenitor cells, observed in 35% (30 of 85) of patients, was significantly associated with higher acute myeloid leukemia risk (P=0.0006), shorter overall survival (P=0.0175), and a lower cytogenetic response rate (P=0.009), but not with achievement or duration of 26-week transfusion independence response. In a multivariate analysis, p53-positive immunohistochemistry was the strongest independent predictor of transformation to acute myeloid leukemia (P=0.0035). Pyrosequencing analysis of laser-microdissected cells with strong p53 expression confirmed the TP53 mutation, whereas cells with moderate expression predominantly had wild-type p53. This study validates p53 immunohistochemistry as a strong and clinically useful predictive tool in patients with lower-risk del(5q) myelodysplastic syndromes. This study was based on data from the MDS 004 trial (clinicaltrials.gov identifier: NCT00179621).

Introduction: The incidence and prevalence of patients with Myelodysplastic Syndromes (MDS) are continuously rising due to population ageing and diagnostic advances. Consequently, the appropriate use of health care resources and assessment of their impact on relevant outcomes are of growing interest. Several evidence-based guidelines and recommendations (G&Rs) have been published for adult MDS patients. However, publishing G&Rs does not necessarily translate into better quality of care. Several studies have shown that MDS patients are not always treated according to published G&Rs, but systematic investigations have not been done so far. To this aim, we initiated the I-CARE for MDS study with the objectives to i) define relevant guideline-based indicators (GBIs) as measurable elements of practice performance for appropriate care, ii) assess the level of adherence and reasons for non-adherence to GBIs and iii) investigate the impact of adherence/non-adherence to GBIs on MDS relevant outcomes. Here we present results of the development of GBIs for appropriate care in adult MDS patients. Methods: We systematically screened G&Rs from cooperative MDS groups as well as cancer care accreditation/certification programs (table 1). All relevant information was extracted by a structured procedure and summarized as candidate GBIs in a handbook (table 2). We applied a RAND technique with a two-step DELPHI rating procedure to find an expert consensus for the clinically most relevant GBIs (Coulter J et al, J Health Serv Res Policy, 2018). The expert panel group (EPGs) members consisted of 17 internationally acknowledged MDS experts, 7 additional health-professionals (3 nurses, 1 pharmacologist, 1 physiotherapist, 1 psychologist and 1 epidemiologist) and 3 patient advocates. Candidate GBIs were rated using a 9-point Likert-like scale for Relevance, Understandability, Measurability, Behaviorability, Attainability (RUMBA-criteria) and ranked according to the agreement score, defined as % of all EPG members scoring all RUMBA-criteria in the first tertile (9, 8, or 7). Results: We extracted 61 candidate GBIs from G&Rs for the three domains Diagnostics (n=23), Treatment (n=21) and Provider characteristics (n=17). 18 and 16 candidate GBIs were excluded after the first and second round, respectively, remaining with a set of 27 GBIs (figures 1-3). Twelve GBIs were selected for Diagnostics (figure 1). Patient reported outcomes (PROs), Toxicity assessment (TAs) and Geriatric assessment were excluded as there was no agreement among experts on appropriate measurement instruments and concerns for practicability in daily routine. Eight GBIs were selected for Treatment (figure 2). Iron-chelation and Immunosuppressive treatment, even though mentioned in most G&Rs, were excluded, as there were concerns with regard to controversial indications, side effects and benefit for only a minority of patients. Seven GBIs were selected for Provider characteristics (figure 3), which will be generally fulfilled by accreditation or certification of institutions. Agreement scores were generally higher in this domain and required a more stringent threshold for selection of GBIs. Conclusions: Here we report on the development of relevant GBIs for the management of adult MDS patients covering the domains of Diagnostics, Treatment and Provider characteristics. Our preliminary set GBIs represents the most comprehensive integration of current practice based G&Rs and were developed by a structured consensus process involving internationally acknowledged experts. We identified important shortcomings in standardisation, measurability and practicability, especially for PROs and TAs, which asks for improvements in the future. Even though PROs and TAs are generally acknowledged endpoints for efficacy and safety, respectively, they are yet not standardised outside clinical trials or validated to inform routine MDS care. Our preliminary set of GBIs will be tested for applicability/operability as well as validated for their potential impact on relevant outcomes in MDS cohorts. They will eventually enable to systematically monitor, compare and optimize appropriateness of health care provided to MDS patients in everyday clinical practice. As such, GBIs will be important for the realization of a common standard for value-based medicine in economically driven health care systems with limiting resources. Disclosures Fenaux: Celgene Corporation: Honoraria, Research Funding; Jazz: Honoraria, Research Funding; Aprea: Research Funding; Astex: Honoraria, Research Funding. Germing:Novartis: Honoraria, Research Funding; Jazz Pharmaceuticals: Honoraria; Amgen: Honoraria; Celgene: Honoraria, Research Funding. Pfeilstocker:Janssen-Cilag: Honoraria; Novartis: Consultancy, Honoraria; Celgene: Consultancy, Honoraria. Platzbecker:Celgene: Consultancy, Honoraria; Abbvie: Consultancy, Honoraria; Novartis: Consultancy, Honoraria. Medina De Almeida:Celgene: Speakers Bureau; Novartis: Speakers Bureau. Mittelman:Novartis: Honoraria, Research Funding, Speakers Bureau. Steensma:H3 Biosciences: Other: Research funding to institution, not investigator.; Stemline: Consultancy; Arrowhead: Equity Ownership; Aprea: Research Funding; Pfizer: Consultancy; Onconova: Consultancy; Astex: Consultancy; Summer Road: Consultancy. Santini:Menarini: Membership on an entity's Board of Directors or advisory committees; Amgen: Membership on an entity's Board of Directors or advisory committees; Acceleron: Membership on an entity's Board of Directors or advisory committees; Johnson & Johnson: Honoraria; Novartis: Honoraria, Membership on an entity's Board of Directors or advisory committees; Celgene Corporation: Honoraria, Membership on an entity's Board of Directors or advisory committees. Stauder:Novartis: Honoraria, Membership on an entity's Board of Directors or advisory committees; Teva (Ratiopharm): Honoraria, Research Funding; Celgene: Consultancy, Honoraria, Membership on an entity's Board of Directors or advisory committees, Other: Advisory board, Research Funding. Symeonidis:MSD: Membership on an entity's Board of Directors or advisory committees, Research Funding; Gilead: Membership on an entity's Board of Directors or advisory committees, Research Funding; Sanofi: Research Funding; Tekeda: Membership on an entity's Board of Directors or advisory committees, Research Funding; Celgene: Honoraria, Membership on an entity's Board of Directors or advisory committees, Research Funding; Janssen: Membership on an entity's Board of Directors or advisory committees, Research Funding; Novartis: Membership on an entity's Board of Directors or advisory committees, Research Funding; Pfizer: Research Funding; Roche: Membership on an entity's Board of Directors or advisory committees, Research Funding. de Witte:Novartis: Research Funding; celgene: Research Funding; Amgen: Research Funding. Bonadies:Novartis: Other: financial support for travel, Research Funding; Celgene: Other: financial support for travel, Research Funding; Janssen: Other: financial support for travel; Roche: ; Amgen: Other: financial support for travel.

Within the myelodysplastic syndrome (MDS) work package of the European LeukemiaNet, an Expert Panel was selected according to the framework elements of the National Institutes of Health Consensus Development Program. A systematic review of the literature was performed that included indexed original papers, indexed reviews and educational papers, and abstracts of conference proceedings. Guidelines were developed on the basis of a list of patient- and therapy-oriented questions, and recommendations were formulated and ranked according to the supporting level of evidence. MDSs should be classified according to the 2008 World Health Organization criteria. An accurate risk assessment requires the evaluation of not only disease-related factors but also of those related to extrahematologic comorbidity. The assessment of individual risk enables the identification of fit patients with a poor prognosis who are candidates for up-front intensive treatments, primarily allogeneic stem cell transplantation. A high proportion of MDS patients are not eligible for potentially curative treatment because of advanced age and/or clinically relevant comorbidities and poor performance status. In these patients, the therapeutic intervention is aimed at preventing cytopenia-related morbidity and preserving quality of life. A number of new agents are being developed for which the available evidence is not sufficient to recommend routine use. The inclusion of patients into prospective clinical trials is strongly recommended.

Abstract LBA-5 Myelodysplastic syndromes (MDS) are a diverse group of chronic hematological malignancies characterised by dysplasia, ineffective hematopoiesis and a variable risk of progression to acute myeloid leukemia (AML). Recent screens of MDS genomes have identified a diverse range of mutations in genes implicated in RNA splicing, DNA modification, chromatin regulation and cell signalling. Whilst these findings improve our understanding in the molecular aetiology of this disease a detailed understanding of the specific genetic contributions, genotype-phenotype relationships and prognostic value of this heterogeneous genomic landscape is warranted. To evaluate the genomic architecture of MDS in more detail, targeted sequencing analysis was performed for 111 genes implicated in myeloid malignancy across 738 MDS patients. Sequencing data were assessed for the presence of oncogenic mutations and detection of regional copy number changes. High-confidence oncogenic mutations (n = 1155) were identified in 41 genes. Of these 41 genes, only 4 (SF3B1, TET2, SRSF2, ASXL1) were mutated in >10% of patients with 15 genes mutated between 10% and 1% of patients and 22 in < 1%. Overall, oncogenic lesions are identified in 78% of MDS patients with 43% of the patients displaying two or three oncogenic events and approximately 10% of patients harbouring four or more oncogenic mutations. Amongst the less characterised genes, we confirm inactivating mutations in CUX1 and IRF1 in 2% and 0.5% of the patients respectively and provide strong evidence that these two genes are bona-fide rare tumour suppressors in MDS. We observe complex patterns of pairwise association between genes, including co-mutation and mutual-exclusivity. Of 325 possible pairwise associations, 47 driver gene mutations pairs were significant (FDR < 10%). Mutations in components of the U2-spliceosome machinery are characteristic of 51% of patients with MDS and whilst mutually exclusive with one another, spliceosome mutations show a strong tendency to co-occur with genes implicated in DNA methylation. Of 24 genes mutated in >5 patients, 8 genes were associated with significantly worse leukemia-free survival if mutated and one gene (SF3B1) with a better leukemia-free survival replicating findings from previous studies. For the new MDS genes described, loss of function truncating mutations in CUX1 are associated with a poor prognosis (p=0.02). Additionally, clinical outcome analysis identifies functional non-canonical mutations within well-characterised driver genes. We find that there is an inverse correlation of leukemia-free survival with the total number of oncogenic lesions observed (p The present study provides an unprecedented characterisation of the genomic lesions implicated in MDS pathogenesis, refines the classification of oncogenic driver mutations and reveals a diverse molecular landscape of mostly rare mutations with valuable insights on the operating biological networks. The absence of known oncogenic mutations in 22% of MDS indicates that additional yet uncharacterised genomic events are likely to be operating in MDS pathogenesis. Most importantly our data highlight the potential of well-defined gene mutations as reproducible diagnostic and predictive biomarkers to support MDS patient management and clinical decision-making in the future. Disclosures: No relevant conflicts of interest to declare.

Myelodysplastic syndromes (MDS) are a heterogeneous group of chronic hematological malignancies characterized by dysplasia, ineffective hematopoiesis and a variable risk of progression to acute myeloid leukemia. Sequencing of MDS genomes has identified mutations in genes implicated in RNA splicing, DNA modification, chromatin regulation, and cell signaling. We sequenced 111 genes across 738 patients with MDS or closely related neoplasms (including chronic myelomonocytic leukemia and MDS-myeloproliferative neoplasms) to explore the role of acquired mutations in MDS biology and clinical phenotype. Seventy-eight percent of patients had 1 or more oncogenic mutations. We identify complex patterns of pairwise association between genes, indicative of epistatic interactions involving components of the spliceosome machinery and epigenetic modifiers. Coupled with inferences on subclonal mutations, these data suggest a hypothesis of genetic "predestination," in which early driver mutations, typically affecting genes involved in RNA splicing, dictate future trajectories of disease evolution with distinct clinical phenotypes. Driver mutations had equivalent prognostic significance, whether clonal or subclonal, and leukemia-free survival deteriorated steadily as numbers of driver mutations increased. Thus, analysis of oncogenic mutations in large, well-characterized cohorts of patients illustrates the interconnections between the cancer genome and disease biology, with considerable potential for clinical application.

Background: Patient-reported outcomes (PROs) play a crucial role in providing patient-centered health care. Inclusion of patients' symptoms, disease perception and quality of life (QoL) provides valuable input for the individual treatment guidance and response evaluation of patients with myelodysplastic syndromes (MDS). Aims: (1) To provide an overview of QoL measurement instruments (QoL-MI) as a multidimensional source of PROs for patients with MDS. (2) To identify core PROs for MDS from the perspective of patients and physicians and to compare the two groups. Methods: (1) To identify studies applying QoL-MI in MDS, we performed a comprehensive systematic literature search (PubMed, Cochrane Library, Scopus, Web of Science). We excluded studies measuring solely one health domain or studies without an English version of the QoL-MI. Studies were screened by two independent reviewers and the observed QoL-MI were summarized in an evidence table. The domains and items within each of the observed QoL-MI were extracted and categorized into potential PROs by six experienced researchers and clinical experts. (2) The selection process included a two-round Delphi survey among MDS patients from France and physicians from 17 different countries as part of the MDS-RIGHT project. Each outcome was scored for importance, using a scale from 1 to 9. Following recommended criteria, highly important outcomes were defined as those scored 7-9 by at least 70% of participants and scored 1-3 by not more than 15%. Outcomes were excluded if scored 1-3 by at least 70% of the participants and 7-9 by not more than 15%. New outcomes were included in the next round if at least two participants suggested them. In the second round, all outcomes were presented together with the ratings of the first round. We used Spearman's rank correlation coefficient to determine the correlation between mean PRO scored by physicians (2nd round) and patients (1st round). Results: (1) Literature search resulted in 2863 studies; 81 studies were included. Overall, we identified twelve generic, six cancer-specific and two MDS-specific QoL-MI. The most commonly used instruments were EORTC QLQ-C30 (26 studies), FACIT-An (17), SF-36 (16), QoL-E (10), and FACIT-BMT (7). These five instruments composed 68% of the total 112 QoL-MI implementations, whereas the MDS-specific QoL-MIs composed only 10%. Based on the QoL-MI review we categorized 40 potential core PROs, which were used in the two-round Delphi survey. (2) In the physicians' Delphi survey, we obtained 38 responses in the first round and 32 responses in the second round. More than 80% of the survey participants had more than ten years of work experience with MDS patients. Three PROs fulfilled the strict inclusion criteria: transfusion dependence, general QoL and ability to work/activities of daily living. After the first round of the patients' survey, 40 answers were analyzed. Confidence in health care, disease knowledge, weakness, general QoL, relationship with friends/relatives, medication use, fatigue, general health, need to rest and shortness of breath were the ten highest ranked PROs. Based on these interim data, most outcomes did not yet fulfill the inclusion criteria and three additional outcomes were suggested: difficulty concentrating, dental problems and fear of falling. The reported low absolute scoring for speaking difficulties, headache, tremor, loss of independence, urinary incontinence and financial difficulties is remarkable. The Spearman coefficients (ρ) showed statistically significant moderate correlation between mean physician and patient scores (ρ=0.51; p-value= 0.0007). Absolute scores differed: patients assigned more often extreme categories (i.e., 1-3 or 7-9) and overall assigned lower importance than physicians. Conclusion: This systematic review demonstrates that the application of QoL scores in MDS patients and the use of MDS-specific QoL-MI are limited so far. Relative PRO-scoring was similar in physicians and patients, but was in general lower in absolute ranking in patients as compared with physicians. However, distinct PROs namely disease knowledge and confidence in health care were identified, which were scored higher by patients than by physicians. These results may form the basis for patient-centered outcome definition. The second patient survey is ongoing and will provide the basis for definition of core PROs in MDS. Disclosures Stojkov: MDS-RIGHT (Providing the right care to the right patient with MyeloDysplastic Syndrome at the right time) project: Research Funding; Erasmus Mundus-Western Balkans (ERAWEB) programme: Other: Doctoral scholarship. Conrads-Frank:MDS-RIGHT (Providing the right care to the right patient with MyeloDysplastic Syndrome at the right time) project: Research Funding. Rochau:MDS-RIGHT (Providing the right care to the right patient with MyeloDysplastic Syndrome at the right time) project: Research Funding. Arvandi:MDS-RIGHT (Providing the right care to the right patient with MyeloDysplastic Syndrome at the right time) project: Research Funding. Fenaux:Otsuka: Honoraria, Research Funding; Jazz: Honoraria, Research Funding; Janssen: Honoraria, Research Funding; Celgene: Honoraria, Research Funding. Efficace:TEVA: Research Funding; Seattle Genetics: Consultancy; Bristol Meyers Squibb: Consultancy; AMGEN: Research Funding; Orsenix: Consultancy; Incyte: Consultancy; TEVA: Consultancy; Amgen: Consultancy; Lundbeck: Research Funding. Siebert:MDS-RIGHT (Providing the right care to the right patient with MyeloDysplastic Syndrome at the right time) project: Research Funding. Stauder:Teva: Research Funding; Celgene: Honoraria, Membership on an entity's Board of Directors or advisory committees; Novartis: Honoraria, Membership on an entity's Board of Directors or advisory committees.

Early, low-risk International Prognostic Scoring System (IPSS) myelodysplastic syndrome (MDS) is a heterogeneous disorder where the molecular and cellular hematopoietic defects are poorly understood. To gain insight into this condition, we analyzed gene expression profiles of marrow CD34+ progenitor cells from normal-karyotype, low-blast-count MDS patients, age-matched controls, and patients with non-MDS anemia. Given the heterogeneity of early MDS, a surprisingly consistent finding was decreased expression of B-cell lineage-affiliated genes in MDS patients compared with healthy controls and 3 of 5 samples with non-MDS anemia. Both patients with non-MDS anemia with reduced B-cell gene expression were on chemotherapy. In 25 of 27 of the original samples and 9 further MDS samples, Taqman real-time polymerase chain reaction (PCR) confirmed these data. Flow cytometry on unfractionated marrow from independent samples also demonstrated reduced B-cell progenitors in MDS patients compared with healthy controls. These novel findings suggest a common perturbation in early MDS hematopoiesis. They also provide the rationale for a larger study to evaluate the diagnostic utility of reduced B-cell progenitor number as a diagnostic biomarker of early low-risk MDS, which can pose a diagnostic challenge.

An autoimmune mechanism in the pathogenesis of myelodysplastic syndrome (MDS) is suggested by response to immunosuppression, with CD8+ T-lymphocytes implicated in the haematopoietic suppression. We therefore sought evidence for human leucocyte antigen (HLA) restriction and variant frequency differences in selected polymorphisms at the loci for the immunomodulatory cytokines, tumour necrosis factor alpha (TNF-alpha), lymphotoxin-alpha (LT-alpha) and interleukin 10 (IL-10) in patients with MDS and acute myeloid leukaemia (AML) compared with normal controls. DNA from 150 MDS/AML patients [24 AML, 53 refractory anaemia (RA), 25 RA with excess blasts (RAEB), four RAEB in transformation (RAEBt), 21 sideroblastic leukaemia, 22 chronic myelomonocytic leukaemia] was screened. Control data was from Scottish blood donors (HLA class I/II), healthy General Practitioner-based subjects (TNF-alpha/LT-alpha) and published values (IL-10). HLA class I/II haplotypes were determined using sequence-specific primers. Polymorphisms were assayed at TNF-alpha -308, LT-alpha +252 and IL10 -824, -597 and -1082 loci. Variant frequencies of common haplotypes at HLA class I and II, high-/low-producer TNF-alpha/LT-alpha and IL-10 loci were not different between patients and controls or within the French-American-British, International Prognostic Scoring System or cytogenetic subgroups and were not associated with altered survival for MDS/AML patients. TNF2 allele frequency was greater in the MDS/AML cohort (chi2 = 6.593, P < 0.05) but the biological significance was uncertain in the absence of an increased high-producer TNF-alpha/LT-alpha haplotype frequency. We can find no genetic influence for these polymorphisms in HLA class I/II, TNF-alpha/LT-alpha and IL-10 loci on either predisposition or disease progression in MDS/AML.

Summary The primary objective of this study was to investigate factors associated with fatigue severity in newly diagnosed patients with higher-risk myelodysplastic syndromes (MDS). The secondary objectives were to assess symptom prevalence and to examine the relationships between fatigue, quality of life (QoL) and overall symptom burden in these patients. The analyses were conducted in 280 higher-risk MDS patients. Pre-treatment patient-reported fatigue was evaluated with the Functional Assessment of Chronic Illness Therapy (FACIT)-Fatigue scale and QoL was assessed with the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire-Core 30 (EORTC QLQ-C30). Female gender (P = 0·018), poor performance status (i.e., ECOG of 2–4) (P

BackgroundIron overload/toxicity due to red blood cell transfusions (RBCT) is associated with morbidity and mortality in various patient groups, including patients with lower-risk myelodysplastic syndrome (LR-MDS). Many studies suggested improved overall survival (OS) after iron chelation therapy (ICT), but most studies suffer from methodological problems. In daily practice, many transfused LR-MDS patients receive ICT according to (inter)national guidelines to counteract the effects of RBCT. The value of ICT in LR-MDS remains unproven. The aim of this study is to assess the effect of ICT on OS in LR-MDS patients. MethodsThe EUMDS registry, prospectively collects observational data on LR-MDS patients from 142 centers in 16 countries in Europe and Israel. Three iron chelators are available in Europe for treatment of secondary iron overload, but availability varies between countries. We first assessed the impact of treatment of the three iron chelators on OS. Secondly, we compared the chelated patients with a contemporary control group within the EUMDS registry. The control group consisted of patients who met the eligibility criteria for using ICT (≥15 RBC units, RBCT intensity of ≥1 RBC unit/month during a six-month period between visits, or serum ferritin ≥1000 µg/L), but who did not receive ICT. A Cox proportional hazards model was used, treating receipt of ICT as an time-varying variable. Finally, all transfused chelated and non-chelated patients were compared with a propensity-score matched model (3:1 nearest matching with replacement) in which more confounding factors could be added to Cox model in order to deal with confounding as adequately as possible. ResultsThe EUMDS registry included 2205 patients as of July 2017. At this point, 205 patients received ICT. Table 1 shows the follow-up duration for all patients. Of the chelated patients, 154 received deferasirox as initial chelator, 39 deferoxamine, and 12 deferiprone. Nineteen patients switched from one chelator to another, but usually the treatment period of the 2nd chelator was short compared to the 1st chelator (data not shown). The median time on chelation for all 205 patients was 13 months (range 3-42). Patients receiving ICT were on average younger, had better performance scores and less comorbidities compared to the control group (table 2). Comparison of three iron chelators The OS from the start of ICT for 154 patients treated with deferasirox is not significantly different compared to deferoxamine (n=39; p=0.058). The Hazard Ratio (HR) and 95% confidence intervals (CI) for OS (deferasirox as reference group) adjusted for age, sex, comorbidity, performance status, and cumulative number of RBCT for deferoxamine was 1.95 (0.85-4.50) and for deferiprone 0.38 (0.04-4.06) (Table 2). Comparison with non-chelated control group The control group consisted of 657 non-chelated patients (table 2). The crude HR and 95% CI for OS for all chelated patients was 0.66 (0.52-0.85) (non-chelated group as reference). After adjusting for age, sex, comorbidity, performance status, RBCT intensity, cumulative number of RBCT, and IPSS-R, the HR was 0.75 (0.50-1.15). When the analysis was restricted to the patients treated with deferasirox, the crude HR was 0.61 (0.46-0.81) and the adjusted HR was 0.79 (0.51-1.22). Propensity-matched model The chelated and non-chelated patients were matched for age, RBCT intensity, ferritin level, comorbidity, and performance status. 128 chelated patients and 223 controls could be matched, the overlap of propensity scores in both groups was good (data not shown). The crude HR and 95% CI for OS for the chelated group (non-chelated group as reference) was 0.77 (0.55-1.07). When correcting for age, sex, comorbidity, performance status, RBCT intensity, cumulative RBCT number, and IPSS-R, the HR was 0.62 (0.39-0.98). When we again restricted the analysis to deferasirox, the crude HR was 0.71 (0.48-1.06) and the adjusted HR was 0.58 (0.33-1.01). Conclusion OS of LR-MDS patients treated with ICT, was better compared to a large, control group and significantly better in a propensity-score matched model. In the absence of randomized, controlled trials proving the survival advantage of ICT, our large, prospective, observational study of clinical practice in Europe and Israel provides sound evidence of a beneficial effect of ICT on OS. Disclosures Fenaux: Novartis: Honoraria, Research Funding; Amgen: Honoraria, Research Funding; Janssen: Honoraria, Research Funding; Amgen: Honoraria, Research Funding; Celgene: Honoraria, Research Funding; Astex: Honoraria, Research Funding; Celgene: Honoraria, Research Funding; Astex: Honoraria, Research Funding; Janssen: Honoraria, Research Funding; Novartis: Honoraria, Research Funding. Sanz: Gamida Cell: Research Funding. skov-Holm: Celgene: Research Funding. Almeida: Alexion: Honoraria; Bristol Meyer Squibb: Honoraria; Servier: Consultancy; Celgene: Consultancy; Novartis: Consultancy. Germing: Novartis: Honoraria, Research Funding; Janssen: Honoraria; Celgene: Honoraria, Research Funding. Itzykson: Janssen: Research Funding; Novartis: Research Funding. Guerci-Bresler: BMS: Speakers Bureau; Incyte: Speakers Bureau; Pfizer: Speakers Bureau; Novartis: Speakers Bureau.

Background: The EUMDS registry, collecting prospective observational data on lower-risk MDS (LR-MDS) patients from 142 centers in 17 countries, is performing a study on the hypothesized negative impact of red blood cell transfusions (RBCT) on outcome in LR-MDS. The aim of this study istoevaluate in transfusion dependent (TD) patients temporal changes in iron metabolism and presence of potentially toxic forms of iron, measured as labile plasma iron (LPI) and their impact on oxidative stress, using malondialdehyde (MDA), and their impact on survival. Methods: We analyzed serum samples from 100 LR-MDS patients at 6-month intervals fortransferrin saturation (TSAT), non-transferrin bound iron (NTBI) and LPI.Cox proportional hazards regression models and Kaplan-Meier (KM) survival curves were used in time-to-event analyses to assess the impact of LPI, NTBI and TSAT by transfusion status. All variables were treated as time-varying covariates in the model by assessing the levels of the parameters: LPI, NTBI ( Results: Themedian age was 73 years.IPSS-R risk groups of this cohort of LR-MDS, defined as IPSS low & intermediate-1 risk, were: very low 32%, low 41%, intermediate 8%, high 3% and unknown 16%. Patients were subdivided in ring sideroblastic MDS (RS-MDS) (34%) and non-RS-MDS (64%). Both groups were subdivided in TD and TI patients.Elevated LPI in combination with high TSAT (>80%) occurred almost exclusively in patients with TI RS-MDS and in all TD MDS patients.Time-dependent, multivariate analysis (MVA), adjusting for age and IPSS-R risk group, of elevated LPIconcentrations for overall survival (OS) resulted in a Hazard Ratio (HR) of 2.3 with 95%CI (0.9-5.8). Elevated NTBI was associated with HR of 0.7 and 95%CI: 0.3-1.8 and TSAT >80% with HR of 0.9 and 95%CI: 0.3-2.6.MVA of OS by LPI and transfusion status as time varying variable showed a significant impact of elevated LPI in the TD group only(HR=4.0, 95%CI: 1.02-15.9) (p = 0.05). MDA concentrations were measured in 28 patients with RS-MDS and 28 non-RS-MDS patients. 21 and 29 patients were TD at time of 1st and 2nd MDA measurement respectively. The overall median MDA concentrations in the 1st sample were elevated compared to controls: 0.9 (0.3 - 4.1) (range controls: 0.16 to 0.64 mM) and remained elevated in the 2nd sample. Median MDA increased from 0.8 to 0.9 mM in the MDS-RS group (p = 0.008 paired one-sided T-test). Significantly higher MDA concentrations were observed in TD patients at time of the 2nd measurement: a median MDA level of 0.7 mM (0.3 - 3.6) in TI and 1.3 (0.3 - 6.8) in TD patients resp. (p = 0.01). MDA levels did not increase in time in TI MDS, but showed a trend to higher MDA in 9 patients who became TD between 2 MDA measurements (p=0.11) and in the 21 patients TD before the 1st measurement (p = 0.12). Median MDA did not change in time in the majority of patients with LPI levels below the detection line (LLOD vs Interpretation :Iron toxicity and increased oxidative stress occurred in all types of TD MDS patients and in TI RS-MDS patients. This study illustrates LPIas a clinically relevant assay for identification of the toxic fraction of iron overload and its negative impact on overall survival. In contrast, high TSAT (>80%) and elevated NTBI concentrations did not predict survival.Oxidative stress, using MDA as a measurement of lipid peroxidation, is increased in the majority of lower-risk MDS patients, usually early after diagnosis. The highest MDA levels are measured in patients receiving RBCT, but the LPI and MDA were not correlated, which can be explained by the slower clearance of MDA after RBCT compared to the more rapid clearance of LPI. Disclosures Symeonidis: Takeda: Consultancy, Honoraria; Amgen: Honoraria; Roche: Honoraria; Genesis: Honoraria. Smith:Jansen Cilag: Research Funding; Novartis: Research Funding; Amgen: Research Funding; Celgene: Research Funding. de Witte:Incyte: Consultancy; Celgene: Consultancy; Novartis: Honoraria, Research Funding.

Abstract 675 Background: Activation of the p53 pathway by inhibition of its negative regulator MDM2 has been proposed as a novel strategy for cancer therapy. We report the final results of the Phase 1 leukemia trial of RG7112, a small molecule antagonist of MDM2 which activates p53 by disrupting the p53-MDM2 interaction. Methods: The trial was designed as a multi-center, open-label Phase 1 MAD study of patients with relapsed/refractory leukemia treated with escalating doses of single agent RG7112 in two strata: A:AML, ALL, CML-BC; and B:CLL and S-CLL. RG7112 was administered orally daily for 10 days followed by 18 days of rest. Primary objectives were to determine MTD and DLT; secondary objectives to assess PK, PD and clinical responses. Enrollment is complete. 4 patients remain on study, and final data is being compiled. Peripheral blood was collected for PK and biomarkers pre-treatment, at multiple time points during the first 48 hours, and on d10. Bone marrow was collected pre-treatment, d10 and d28. Blood and marrow were purified by MACS sorting (CD19, 33 or 34 Ab). AmpliChip analysis of p53 mutational status (single nucleotide alterations exons 2–11) was performed. MIC-1 (macrophage inhibitory cytokine-1), a p53 transcriptional target, was analyzed in serum by ELISA as a pharmacodynamic marker of p53 activation. Baseline MDM2 mRNA levels, and changes from baseline, as a marker of p53 activation and feedback on MDM2, were measured by RT-PCR. A panel of 24 genes was assessed serially by TLDA (q-PCR). Results: 116 patients (84 AML,10 ALL, 2 CML, 20 CLL/sCLL) were treated with RG7112 doses ranging from 20 – 2430 (1215 BID) mg/m2/day × 10 days. The dose-exposure relationship (Cmax, AUC, and Ctrough) was approximately linear with a median half-life of 1–1.5 days. 43 patients with acute leukemia were dosed at the MTD of 1500 mg BID (flat dose) × 10 days. Major adverse events(> 20%) were nausea, diarrhea and vomiting. Other major (>10%) AEs were complications of leukemia (e.g. neutropenic fever). Clinical activity was noted during dose escalation (ASH 2011), including apoptosis in AML and CLL, CR in an AML patient (360mg/m2) stable for 6 cycles (10 months) and one patient with CLL/Richter's transformation with stable disease (40 mg/m2) for >25 cycles. New data focuses on AML patients treated at MTD. This cohort received a median of 3 prior treatments, 16 were refractory to last treatment. 17 (40%) had evidence of hematologic improvement (greater than 50% drop in peripheral and/or BM blasts by d28). Of the 31 patients who completed cycle 1 dosing, 5 patients (16%) had a CR (2 CR, 2 CRi. 1 CR without recovery). Two CR patients have proceeded to allotransplant. All CR patients' blasts were p53wt. Of the 12 additional patients with single-agent hematologic activity, 3 had biochemical evidence of tumor lysis syndrome, 10 had p53status evaluable, and mutations were detected in 3: (exon 7 missense, exon 9 frameshift, intron 7 splice). p53 activation by RG7112 was demonstrated by MIC-1 induction in serum. MIC-1 levels were elevated at RG7112 plasma concentrations >2 μg/mL or AUC24h >50 μg · h/mL and were highly correlated (0.5629) with exposure to RG7112 (AUC24h) at steady state following a sigmoidal Emax model. Preliminary data review suggests a positive correlation between exposure to RG7112 and changes in MDM2 gene expression at day 2. In addition, q-PCR analysis demonstrated exposure-dependent induction of key p53 transcriptional targets including MDM2, p21, and PUMA. p53 protein increase by WB was demonstrated at the MTD in selected patients. These findings are consistent with the proposed mechanism of action of RG7112. Conclusions: We report evidence of single agent clinical activity in patients with leukemia treated with RG7112, including 6 AML patients with CR, 5 of 31 (16%) at the MTD, and additional patients with significant decreases in blasts. Concentration-related pharmacodynamic biomarker activity of the p53 pathway was demonstrated by increases in MIC-1 levels, and induction of p53 target genes including mdm2, p21 and PUMA. 4 patients remain on treatment and final results will be reported. We provide proof of mechanism and evidence for single-agent clinical activity of MDM2 antagonism in leukemia by demonstrating complete remission, lysis of leukemic blasts and activation of p53 pathway targets in leukemic cells from patients treated with RG7112. Clinical studies of RG7112 in combination are underway. Disclosures: Andreeff: Hoffmann-La Roche: Research Funding; Karyopharm Therapeutics: Unrestricted gift, Unrestricted gift Other. Yee:Roche: Membership on an entity's Board of Directors or advisory committees. Assouline:Roche: travel funding Other. Martinelli:Novartis: Consultancy, Honoraria; BMS: Consultancy, Honoraria; Pfizer: Consultancy; Ariad: Consultancy. Drummond:Novartis: Membership on an entity's Board of Directors or advisory committees, Speakers Bureau; BMS: Membership on an entity's Board of Directors or advisory committees, Speakers Bureau; Celgene: Membership on an entity's Board of Directors or advisory committees, Speakers Bureau. Geho:Roche: Employment. Blotner:Roche: Employment. Cheng:Roche: Employment. Vassilev:Roche: Employment. Ding:Roche: Employment. Zhi:Roche: Employment. Middleton:Roche: Employment. Nichols:Roche: Employment.

This phase 3, randomized, double-blind study assessed the efficacy and safety of lenalidomide in 205 red blood cell (RBC) transfusion-dependent patients with International Prognostic Scoring System Low-/Intermediate-1-risk del5q31 myelodysplastic syndromes. Patients received lenalidomide 10 mg/day on days 1-21 (n = 69) or 5 mg/day on days 1-28 (n = 69) of 28-day cycles; or placebo (n = 67). Crossover to lenalidomide or higher dose was allowed after 16 weeks. More patients in the lenalidomide 10- and 5-mg groups achieved RBC-transfusion independence (TI) for ≥ 26 weeks (primary endpoint) versus placebo (56.1% and 42.6% vs 5.9%; both P < .001). Median duration of RBC-TI was not reached (median follow-up, 1.55 years), with 60% to 67% of responses ongoing in patients without progression to acute myeloid leukemia (AML). Cytogenetic response rates were 50.0% (10 mg) versus 25.0% (5 mg; P = .066). For the lenalidomide groups combined, 3-year overall survival and AML risk were 56.5% and 25.1%, respectively. RBC-TI for ≥ 8 weeks was associated with 47% and 42% reductions in the relative risks of death and AML progression or death, respectively (P = .021 and .048). The safety profile was consistent with previous reports. Lenalidomide is beneficial and has an acceptable safety profile in transfusion-dependent patients with Low-/Intermediate-1-risk del5q myelodysplastic syndrome. This trial was registered at www.clinicaltrials.gov as #NCT00179621.

Azacitidine is currently the only drug to have shown a significant survival benefit over conventional care regimens in patients with International Prognostic Scoring System (IPSS) intermediate-2 (Int-2) and high-risk myelodysplastic syndromes (MDS), establishing it as an important new treatment for these individuals. However, several aspects of the practical use of azacitidine remain uncertain. This manuscript outlines recommendations discussed by a panel of experts, providing a practical guide for physicians to ensure optimal management of Int-2 and high-risk patients receiving azacitidine.

Recombinant adeno-associated virus (rAAV) vectors are considered promising for human gene replacement because they facilitate stable expression of therapeutic proteins in transduced tissues. Whether the success of gene therapy will be influenced by cellular immune responses targeting transgene-encoded proteins that are potentially immunogenic is unknown. Here we characterized CD8+ T-cell activity against β-galactosidase and enhanced green fluorescent protein, model antigens containing major histocompatibility complex (MHC) class I epitopes that are constitutively produced in murine skeletal muscle after rAAV vector transduction. Antigen-specific CD8+ T cells were detected in the spleen and liver of mice within 7 days of muscle transduction. CD8+ T-cell frequencies in these organs were stable, and effector functions were intact for months despite ongoing antigen production in muscle. CD8+ T cells also infiltrated transduced muscle, where frequencies were at least 5-fold higher than in untransduced spleen and liver. Significantly, the majority of antigen-specific CD8+ T cells in vector-transduced muscle were not functional. Loss of function in the muscle was associated with programmed death of the effector cells. Stable gene expression therefore depended on selective death of CD8+ T cells at the site of antigen production, an effective mechanism for subverting immunity that is also potentially reversible.

Background Somatic mutations identified in patients with myelodysplastic syndromes (MDS) are associated with disease features and carry prognostic information independent of the International Prognostic Scoring System (IPSS) and the revised IPSS (IPSS-R). Risk models that include mutation information have been proposed, but not widely adopted. In practice, there is no consensus on how to best combine clinical information with tumor sequencing data to predict prognosis. To accomplish this, we must define the relevant genes to consider and accurately measure their prognostic impact. Here we examine the relationship between mutations in MDS-associated genes and clinically relevant measures, including overall survival, in a large, multi-center analysis of MDS patient cohorts collected around the globe. Methods Data on 3392 MDS patients gathered by members of the International Working Group for Prognosis in MDS-Molecular Committee were combined under the aegis of the MDS Foundation. Patients gave informed consent for collection of their data and tumor samples at their respective institutions in accordance with the Declaration of Helsinki. Samples were examined for somatic mutations primarily by next generation sequencing. Categorical variables were compared using a chi-squared test, while continuous variables were compared using a Wilcoxon rank-sum test. Overall survival (OS) was calculated from the date of the sequenced sample to the date of death and was censored at transplant or the last known follow-up time. P-values are two-sided and considered significant at the Results Survival data were available for 3200 patients with a median follow up of 3.7 years and included 1671 deaths. Median survival of the cohort was 2.88 years. The 27 genes sequenced in at least half of the cohort and mutated in > 1.5% of samples were included for analysis (Figure 1). Mutations in 12 genes were strongly associated with shorter OS in univariate analyses (p IPSS-R risk groups could be determined for 2173 patients and were strongly associated with OS. Adjusting the hazard ratio of death for IPSS-R risk groups identified several mutated genes with independent prognostic significance: TP53 (HR 2.37, CI 1.94-2.90), CBL (HR 1.57, CI 1.22-2.03), EZH2 (HR 1.55, CI 1.22-2.03), and RUNX1 (HR 1.50, CI 1.24-1.83). Mutations of U2AF1 (HR 1.29, CI 1.06-1.58) and ASXL1 (HR 1.21, CI 1.04-1.41) retained a more modest association with shorter OS. Adjustment for IPSS-R risk groups also moderated the favorable risk associated with mutations of SF3B1 (HR 0.83, CI 0.70-0.99). Patients without mutations in any of the 6 adverse genes above represented 58% of the fully sequenced cohort and had a longer median survival than patients with adverse mutations (4.8 years vs. 1.6 years respectively, p < 0.0001; Figure 2) even after correction for IPSS-R risk groups (adjusted HR 0.59, CI 0.51-0.67). Multivariable analysis of this dataset will examine the combined contribution of mutated genes to prognosis. A mutation score based on survival risk will be proposed and internally validated. The impact of somatic mutation in patients traditionally considered lower risk will be explored. Conclusions This large study definitively validates the prognostic value of mutations in several MDS-associated genes while clarifying the significance of other, less frequently mutated ones. Mutations in several genes retain their prognostic significance after adjustment for IPSS-R risk groups, indicating that these select abnormalities could refine the prediction of prognosis when incorporated into a clinical scoring system such as the IPSS-RM. The results of this analysis will serve as the template with which to build an integrated molecular risk model for MDS. Disclosures Bejar: Alexion: Other: ad hoc advisory board; Celgene: Consultancy, Honoraria; Genoptix Medical Laboratory: Consultancy, Honoraria, Patents & Royalties: MDS prognostic gene signature. Haferlach:MLL Munich Leukemia Laboratory: Employment, Equity Ownership. Sekeres:Celgene Corporation: Membership on an entity's Board of Directors or advisory committees; TetraLogic: Membership on an entity's Board of Directors or advisory committees; Amgen: Membership on an entity's Board of Directors or advisory committees. Fenaux:Celgene Corporation: Honoraria, Research Funding; Amgen: Honoraria, Research Funding; Janssen: Honoraria, Research Funding; Novartis: Honoraria, Research Funding. Kern:MLL Munich Leukemia Laboratory: Employment, Equity Ownership. Shih:Novartis: Research Funding. Komrokji:Celgene: Consultancy, Research Funding; Incyte: Consultancy; Novartis: Research Funding, Speakers Bureau; Pharmacylics: Speakers Bureau. List:Celgene Corporation: Honoraria, Research Funding. Santini:celgene, Janssen, Novartis, Onconova: Honoraria, Research Funding. Campbell:14M genomics: Other: Co-founder and consultant. Ebert:Celgene: Consultancy; Genoptix: Consultancy, Patents & Royalties; H3 Biomedicine: Consultancy.

Background The outcome of lower-risk MDS patients with red blood cell transfusions (RBCT) dependency is inferior to that of RBCT independent patients, but whether the intensity of RBCT is important for prognosis is unknown. The EUMDS Registry is a non-interventional, observational longitudinal study enrolling patients with lower-risk MDS from 142 sites in 17 countries as described elsewhere (1). The EUMDS registry has accrued 1,902 patients as of July 21, 2015. We hypothesized that RBCT intensity is an independent prognostic factor for survival. Methods We first assessed the impact of RBCT intensity in the first year post-diagnosis (1yrPD) on progression-free survival among the 1034 patients who survived at least 1yrPD and had potential for a further year of follow-up. Secondly, we developed a longitudinal model of platelet counts throughout follow-up for 1660 patients in the registry with potential for at least one year follow-up. Results Among the 1034 patients, 323 patients had died: 67 after progression to higher-risk MDS/AML and 256 without progression. A further 41 surviving patients had progressed to AML. The overall 5-year survival was 52%. In a proportional hazards regression model (Table), the risk of death or progression increased in a non-linear fashion with age at diagnosis (p In the 1660 patients no significant decline in platelet counts was observed (0.16x109 platelets/l average monthly decline, p=0.16) among patients who were not RBC transfused at any time during follow-up. However platelet counts of patients receiving RBCT declined more quickly (p Conclusion These multivariate regression models including age, sex, country, IPSS and WHO classification showed that more intensive RBCT treatment is associated with poor prognosis and a more rapid decline of platelets. This indicates that the intensity of RBCT should be incorporated in the regular prognostic scoring systems and the choice of therapeutic interventions. (1): De Swart L et al. Br J Haematol 2015; 170: 372-83. Disclosures Fenaux: NOVARTIS: Honoraria, Research Funding; CELGENE: Honoraria, Research Funding; JANSSEN: Honoraria, Research Funding; AMGEN: Honoraria, Research Funding. Hellström-Lindberg:Celgene Corporation: Research Funding. Sanz:JANSSEN CILAG: Honoraria, Research Funding, Speakers Bureau. Mittelman:Roche: Research Funding; Novartis Pharmaceuticals Corporation: Research Funding; GlaxoSmithKline: Research Funding; Johnson & Johnson: Research Funding, Speakers Bureau; Celgene: Research Funding, Speakers Bureau; Amgen: Research Funding. Almeida:Bristol Meyer Squibb: Speakers Bureau; Shire: Speakers Bureau; Celgene: Consultancy; Novartis: Consultancy. Park:Hospira: Research Funding; Novartis: Membership on an entity's Board of Directors or advisory committees, Research Funding; Celgene: Research Funding. Itzykson:Oncoethix: Research Funding. de Witte:Novartis: Research Funding.

Background: Patients myelodysplastic syndromes (MDS) diagnosed with higher-risk disease have poor prognosis thus making improvements in health-related quality of life (HRQOL) a major goal of therapy. Understanding HRQOL profile of untreated patients is important to help clinicians to better target subpopulations in need of special attention from the very beginning of therapy. Aims: The primary objective of this study is to investigate whether HRQOL differences exist by age and gender in untreated patients with higher-risk MDS. A secondary objective is to provide age and gender pretreatment HRQOL profiles to be used as reference baseline data for comparing HRQOL of MDS patients under treatments. Methods: This analysis is based on 280 adult patients diagnosed with IPSS risk score of intermediate-2 (74%) and high-risk (26%), enrolled in an international prospective observational study. Median age of patients was 71 years (range 32-89), 176 were men (63%) and 104 (37%) women. HRQOL was assessed at study entry and before treatment for higher-risk disease (except for transfusions), with the EORTC QLQ-C30, the most widely used HRQOL outcome measure in MDS research. Thus, our data are likely to further ease interpretation of outcomes in many studies using this questionnaire. One hundred seventy-five patients had received at least one red blood cell transfusion at the time of baseline HRQOL assessment. HRQoL data of MDS patients were age-gender matched with those general population norms. Wilcoxon-Mann-Whitney and Wilcoxon signed ranks tests were used for unmatched and matched comparisons, respectively (α=0.05). Effect sizes were also computed. Results: No statistically significant differences existed in any of the HRQOL domain by IPSS category (intermediate-2 versus high-risk). However, HRQOL profiles differed by age and gender and results are reported in Table 1. Women generally reported lower HRQOL scores than men, with statistically significant impairments in the global quality of life (P=0.008), role (P=0.014), emotional (P=0.024) and social functioning (P=0.028). When compared to their peers in the general population, HRQOL was found to be impaired in all age group categories (Figure 1, A and B). However, the magnitude of impairments across HRQOL domains was markedly larger in younger patients (aged 30-59 years) compared to older age groups (≥60 years). The top three largest impairments in this younger group were found for: fatigue (ES=2.47, P Conclusion: Pretreatment HROQL of higher-risk MDS patients vary by age and gender and current reference data will help making more accurate comparisons with HRQOL of patients under treatment. Clinicians should also pay special attention to younger patients, as these are those most in need of HRQOL improvements. Figure 1. Adjusted mean differences between MDS patients and their respective control groups by age categories (30-59 years, 60-69 years, 70-79 years and over 80) in functional aspects and global quality of life. A score below 0 line means worse outcomes for MDS patients. *= Statistically significant (P Disclosures Gaidano: MorphoSys; Roche; Novartis; GlaxoSmithKline; Amgen; Janssen; Karyopharm: Honoraria, Other: Advisory boards; Celgene: Research Funding. Santini:celgene, Janssen, Novartis, Onconova: Honoraria, Research Funding. Platzbecker:Celgene: Honoraria; GlaxoSmithKline: Honoraria, Research Funding; Novartis: Honoraria; Amgen, Inc.: Honoraria. Di Renzo:Celgene: Research Funding.

an increased risk to develop acute myeloid leukemia (AML). While de novo MDS is predominantly found in elderly patients, childhood MDS is rather rare and often associated with genetic disorders and inherited bone marrow failure syndromes. Introduction: Recently, germline mutations in the hematopoietic transcription factor GATA2 were identified in familial cases of MDS. Epigenetic alterations represent a major pathogenetic mechanism in MDS and have been extensively researched in adults, while genomewide studies on deregulated epigenetic processes in childhood MDS are still lacking. Purpose: The goal of the presented study was to analyze aberrant DNAmethylation in familiar childhoodMDSby genome-widemethylation profiling. Materials and Methods: Therefore we obtained DNA methylation profiles across the genome in a cohort of childhood MDS samples as well as monocytes from healthy donors (control) using methylCpG-immunoprecipitation combined with next-generation sequencing. The MDS cohort consisted of 10 patients (5 female, 5 male; median age at diagnosis: 13.7 years; range 6.1-19) carrying different mutations in GATA2 (except for two siblings with an identitical mutation). Results: Our analysis showed that these 10 MDS patients exhibit methylation profiles distinct from healthy controls. Based on the degree of methylation, MDS patients could be clustered into subgroups with distinctive patterns. The subgroup with the highest degree of methylation was exclusively composed of patients with advanced morphological subtype (RAEB or RAEB-t) at diagnosis and aneuploidic karyotypes: monosomy 7 alone or monosomy 7 and trisomy 8. In contrast, most patients with DNA methylation patterns resembling normal control patterns were diagnosed with the less advanced refractory cytopenia subtype. Computational analyses of epigenetic and sequence features of aberrantly methylated regions demonstrated their frequent association with the PcG-mark H3K27me3 in hematopoietic stem cells as well as a distinct composition of transcription factor binding motifs. Conclusions: We present the first genome-wide analyses of aberrant DNA methylation in familiar childhood MDS sharing predisposing mutations in GATA2. Our data suggest that DNA methylation changes might be associated with morphologic subtype and disease progression and warrant further studies in larger cohorts.

Background: The EUMDS registry is a prospective observational registry to collect data on lower risk MDS. 17 Countries and 133 centers are participating. We analyzed serum from 101 patients for ferritin, hepcidin, growth differentiation factor 15 (GDF15) and C-reactive protein (CRP) at six-month intervals in order to evaluate temporal changes in iron metabolism. Objective: To explore hepcidin and GDF15 levels over time in lower risk MDS patients and their relation with WHO2001 subtype, transfusion history and conventional iron parameters. Results: The median age of the study population was 73 years (range 44-95 years). The majority was male: 64%. Distribution according to WHO2001 MDS subtype was RCMD (41%), RARS (25%), RA (14%), RAEB (11%), 5q-syndrome (6%) and RCMD-RS (3%). Table 1 shows iron parameters at registration, 1 year and 2 years follow-up both in transfusion-dependent (TD) and transfusion-independent (TI) patients and stratified according to MDS subtypes: RS (RARS/RCMD-RS) or MDS Other (RA/RCMD/RAEB/5q-syndrome). Serum ferritin was increased in TD patients with a median concentration at registration of 550µg/L and at 2 years 818µg/L, compared to TI patients (median 10 red blood cell (RBC) units: median at registration 1482µg/L - 2 years 1970µg/L. Ferritin correlated significantly with hepcidin (r=0.57; p50mg/L. Median serum hepcidin levels were elevated in TD patients at registration and remained elevated during follow-up, especially in patients with >10 RBC units transfused (median 27.4nmol/l at registration, 12.8nmol/l at 2 years). Remarkable fluctuation in hepcidin levels occurred in patients with elevated hepcidin during follow-up. Even in the longitudinal cohorts hepcidin fluctuated considerably, maybe due to the interval between the previous transfusion and the measurement of hepcidin or due to diurnal fluctuation. Hepcidin was lowest in MDS RS TI patients and showed a tendency to decrease over time from a median level of 4.4nmol/l at registration to 2.4nmol/l after 2 years, associated with ineffective erythropoiesis. This is supported by the high median GDF15 in these patients. Lowest GDF15 was found in TD patients with ‘MDS Other’ associated with transfusional load. The number of transfused RBC units did not affect the median GDF15 levels. Conclusions: Hepcidin levels were influenced by RBC transfusion history, but hepcidin levels appear to decrease over time in the RS subtype only. Interestingly, increase in hepcidin after transfusions was already visible early in follow-up, depending on the transfusional load and erythropoietic activity of the bone marrow. GDF15 concentration appeared to be most related to MDS subtype, functioning as a marker of ineffective erythropoiesis. Table1: ferritin, hepcidin and GDF15 during-follow-up Registration 1 yr follow-up 2 yrs follow-up N Median (p25-p75) N Median (p25-p75) N Median (p25-p75) Ferritin (µg/L) 101 286 (138 - 558) 83 287 (149 - 845) 66 347 (191 - 818) MDS Other: TI 53 205 (87 - 389) 31 148 (78 - 288) 25 202 (71 - 319) MDS Other: TD 20 479 (279 - 877) 29 845 (481 - 1538) 22 841 (323 - 2387) RARS/RCMD-RS: TI 25 268 (195 - 558) 19 233 (170 - 323) 10 319 (222 - 379) RARS/RCMD-RS: TD 3 610 (108 - 1382) 4 1909 (1206 - 2935) 9 712 (590 - 1222) Hepcidin (nmol/L) 100 5.2 (3.0 - 9.9) 83 5.8 (2.7 - 14.0) 66 5.2 (2.5 - 9.9) MDS Other: TI 53 4.6 (2.8 - 8.4) 31 4.4 (2.3 - 8.1) 25 4.2 (2.5 - 6.8) MDS Other: TD 20 11.1 (4.9 - 21.0) 29 17.2 (9.2 - 22.3) 22 9.6 (4.5 - 17.1) RARS/RCMD-RS: TI 24 4.2 (2.1 - 6.1) 19 3.5 (1.6 - 5.1) 10 2.4 (1.6 - 3.9) RARS/RCMD-RS: TD 3 9.8 (6.0 - 11.1) 4 9.3 (7.3 - 12.1) 9 5.2 (2.9 - 9.3) TI: 0 RBC units 81 4.5 (2.8 - 8.4) 51 4.0 (2.0 - 7.5) 37 3.1 (2.1 - 6.7) TD: ≤10 RBC units 17 10.6 (4.7 - 14.9) 14 9.2 (5.3 - 17.2) 14 4.3 (2.4 - 8.7) TD: >10 RBC units 2 27.4 (15.7 - 39.1) 18 18.1 (12.7 - 24.5) 15 12.8 (9.3 - 21.3) GDF15 (ng/L) 101 1945 (1207 - 3611) 82 2467 (1659 - 4318) 66 2582 (1519- 5332) MDS Other: TI 53 1831 (1100 - 3176) 31 1902 (1076 - 2698) 25 1702 (1136 - 3564) MDS Other: TD 20 1452 (1169 - 2789) 28 2583 (1937 - 4493) 22 2556 (1661 - 4050) RARS/RCMD-RS: TI 25 3532 (2124 - 4211) 19 3148 (2195 - 4560) 10 3661 (1986 - 5524) RARS/RCMD-RS: TD 3 2196 (1869 - 2893) 4 2996 (1806 - 5141) 9 5555 (3204 - 7488) Disclosures Hellström-Lindberg: Celgene: Research Funding. Symeonidis:Celgene: Research Funding; Novartis Oncology: Research Funding; Amgen: Research Funding; Novartis Oncology: Consultancy; Amgen: Consultancy. de Witte:Novartis: Research Funding; Novartis: Honoraria; Celgene: Consultancy; Novartis: Consultancy.

Background: Complex karyotypes in patients with myelodysplastic syndromes (MDS) are defined by the presence of 3 or more cytogenetic abnormalities and are considered indicators of a poor prognosis by nearly all models in clinical use. There is evidence that the prognostic significance of complex karyotypes in MDS can be refined by considering the number of cytogenetic abnormalities or the presence of specific lesions, the presence of monosomy, and the mutation status of the TP53 gene. Mutations of TP53 are strongly associated with adverse clinical features including complex karyotypes, yet still have independent prognostic significance. Whether these mutations or other elements associated with complex karyotypes carry the greatest prognostic significance is unknown and has been the subject of recent contradictory findings. Here we examine the relationship between TP53 mutations, the number and type of chromosomal abnormalities, and clinical features including overall survival in a combined analysis of MDS patients with complex karyotypes. Methods: Data on 258 complex karyotype MDS patients from the US and Europe gathered by members of the International Working Group for Prognosis in MDS-Molecular Committee were combined for this analysis. Patients gave informed consent to have their data and clinical samples collected at their respective institutions in accordance with the Declaration of Helsinki. Tumor samples were examined for TP53 mutations primarily with next generation sequencing techniques. Categorical variables were compared using a Fisher exact test or Kruskal-Wallis test as appropriate, while continuous variables were compared using a Wilcoxon rank-sum test. All p-values reported are two-sided, unadjusted for multiple testing, and considered significant at the 0.05 level. Results: Of the 258 complex karyotype MDS samples examined, TP53 mutation status was determined in 223, of which 133 (60%) carried a TP53 mutation. Patients with TP53 mutations were slightly older than unmutated patients (median age 70.8 vs. 65.5 years, p=0.055), were more thrombocytopenic (median platelet count 42 vs. 78 x109/L, p=0.002), and had a greater percentage of bone marrow blasts (7.75% vs 4%, p=0.03). Mutated patients were also more likely to have a monosomal karyotype (85% vs. 59%, p Patients with TP53 mutation had a significantly shorter median overall survival of 7.7 months compared to 23.4 months for patients with unmutated TP53 (p Discussion: Despite strong associations with adverse clinical and cytogenetic abnormalities incorporated into existing prognostic scoring systems, TP53 mutations carry significant independent prognostic value for patients with MDS. In our multivariable analyses, TP53 mutation appears to dominate over monosomal karyotype as an adverse prognostic marker in MDS patients with complex cytogenetics. Many of the TP53 mutations identified had a small variant allele fraction suggesting that they were present in a disease subclone. The small number of mutant cells in these cases may be insufficient to alter clinical measures, but could still indicate a poor prognosis if they represent a clone capable of treatment resistance and rapid disease progression. This combined analysis is a work in progress that will include data from additional groups and explore mutation status of other MDS-related genes, TP53 variant allele fraction, clinical risk scores, and data from patients without complex karyotypes. Conclusions: Somatic TP53 mutations are highly enriched in MDS patients with complex karyotypes and identify a group with significantly shortened overall survival. Sequencing of TP53 can improve the prediction of prognosis in MDS patients with 3 or more chromosomal abnormalities. Figure 1 Figure 1. Disclosures Bejar: Genoptix Medical Laboratory: Consultancy, Honoraria, Licensed IP, no royalties Patents & Royalties, Membership on an entity's Board of Directors or advisory committees; Celgene: Membership on an entity's Board of Directors or advisory committees. Haferlach:MLL Munich Leukemia Laboratory: Other. Garcia-Manero:Celgene: Research Funding. Sekeres:Celgene: Membership on an entity's Board of Directors or advisory committees; Amgen Corp: Membership on an entity's Board of Directors or advisory committees; Boehringer-Ingelheim Corp: Membership on an entity's Board of Directors or advisory committees. Campbell:14M Genomics Limited: Consultancy, Equity Ownership.

BCR-ABL negative myeloproliferative neoplasms (MPNs), such as polycythemia vera (PV), essential thrombocythemia (ET) and myelofibrosis (MF) are chronic myeloid malignancies characterized by overproduction of hematopoietic cells. JAK2 mutations are found in most patients with PV, and in only 50-60% of patients with ET and MF. JAK2 mutation testing has greatly simplified MPN diagnosis, but distinguishing JAK2-wildtype ET from reactive thrombocytosis remains a diagnostic challenge. Mutations in signalling pathways (MPL, LNK) and epigenetic regulators (TET2, DNMT3A, IDH1/2, EXH2, ASXL1) have been found in a minority of MPNs. However genome-wide data are lacking and the pathogenesis of MPNs that do not harbor JAK2 or MPLmutations remains obscure. Methods Exome sequencing was performed in 151 MPN patients on matched tumor and constitutional samples. CALR status was assessed in 3412 samples using Sanger sequencing and analysis of exome/genome sequencing data. Presence of CALR mutations in hematopoietic stem and progenitor cells was assessed by flow sorting and sequencing. Phylogenetic trees were established using hematopoietic colonies. Calreticulin cellular localisation was assessed in patient samples and cell lines expressing CALR variants by flow cytometry and immunofluorescence. Results Exome sequencing identified 1498 somatic mutations with a median of 6.5 mutations in PV and ET, and 13 in MF (MF vs ET, P=0.0002; MF vs PV, P=0.008). JAK2V617F was found in all cases of PV (n=48), 56% of ET (35/62), and 69% of MF (27/39), and MPL mutations in 7 ET and MF cases. Mutations in epigenetic regulators TET2, DNMT3A, ASXL1, EZH2, and IDH1/2 were identified in 22, 12, 12, 4, 3 patients respectively, and components of the splicing machinery (U2AF1, SF3B1 or SRSF2) were mutated in 9 patients. Mutations in rare genes reported to be mutated in MPNs were found in four patients (1 CBL; 2 NFE2; 1 SH2B3/LNK). We found novel somatic mutations in CHEK2 (1 PV, 1 ET and 1 MF) which have not been previously reported in MPNs. The mutation spectrum showed a predominance of C>T transitions. Pairwise associations between MPN genes demonstrated that ASXL1 and SRSF2 mutations were positively correlated with mutations in epigenetic modifiers. Novel somatic mutations in calreticulin (CALR) were identified by exome sequencing in the majority (26/31) of JAK2 or MPL unmutated patients. CALR and JAK2/MPL mutations were mutually exclusive, and 97% of patients harbored a mutation in 1 of these 3 genes. In an extended follow up screen of 1345 hematological malignancies, 1517 other cancers and 550 controls we found CALR mutations in 71% of ET (80/112), 56% of idiopathic MF (18/32), 86% of post ET-MF (12/14) and 8% of myelodysplasia (10/115), but not in other myeloid, lymphoid or solid cancers. Compared to JAK2-mutated MPNs, those with CALR mutations presented with higher platelet counts (Wilcoxon rank-sum, P=0.0003), lower hemoglobin levels (Student’s t test, P=0.02) and showed a higher incidence of transformation to MF (Fishers exact, P=0.03). All CALR mutations were insertions or deletions affecting exon 9, with 2 common variants L367fs*46 (52 bp deletion) and K385fs*47 (5 bp insertion). Loss of heterozygosity over CALR was seen in a minority of patients. Of 148 CALR mutations identified, there were 19 distinct variants. Remarkably, all generated a +1 basepair frameshift, which results in loss of most of the C-terminal acidic domain of the protein as well as the KDEL Golgi-to-endoplasmic reticulum (ER) retrieval signal, raising the possibility of compromised ER retention. Mutant proteins were readily detected in transfected cell lines and localised to the ER in the same manner as wildtype CALR, without Golgi or cell surface accumulation. These results are consistent with studies reporting KDEL-independent mechanisms of ER retention. Mutation of CALR was detected in highly purified hematopoietic stem/progenitor cells. Clonal analyses demonstrated CALR mutations in the earliest phylogenetic node in 5/5 patients, consistent with it being an initiating mutation in these individuals. Conclusions We describe the mutational landscape of BCR-ABL negative MPNs and demonstrate that somatic mutations in the endoplasmic reticulum chaperone CALR are found in the majority of patients with JAK2-unmutated MPNs. These results reveal a novel biological pathway as a target for tumorigenic mutations and will simplify diagnosis of MPN patients. Disclosures: Bowen: Celgene: Honoraria. Harrison:S Bio: Honoraria, Membership on an entity’s Board of Directors or advisory committees; Shire: Speakers Bureau; Celgene: Honoraria; YM Bioscience: Honoraria, Membership on an entity’s Board of Directors or advisory committees; Sanofi: Honoraria, Membership on an entity’s Board of Directors or advisory committees, Speakers Bureau; Novartis: Honoraria, Membership on an entity’s Board of Directors or advisory committees, Research Funding, Speakers Bureau; Gilead: Honoraria, Membership on an entity’s Board of Directors or advisory committees. Vannucchi:Novartis: Honoraria, Membership on an entity’s Board of Directors or advisory committees.

Introduction Outcomes in core binding factor AML have improved over the past 25 years from a 5 year survival of 59% in 1988 to 84% post 2008. Patients were originally treated with 2 courses of DA followed by consolidation with MACE (amsacrine/etoposide) and MidAC (mitoxantrone/Ara-C). In 2002, the AML15 trials introduced an induction randomisation including FLAG-Ida, a 1:1 randomisation to add gemtuzumab ozogamicin (GO) to induction, and a 1:1 randomisation to high dose Ara-C consolidation (2 courses). For younger patients with non-CBF AML survival has improved partially because of a reduction in induction deaths and deaths in CR attributable to improved supportive care. We previously reported that GO significantly improved OS in AML [Burnett AK et al J Clin. Oncol. 2011,29: 369-377], and have recently confirmed that high dose Ara-C was superior to MACE/MidAC. Here we investigate which factors have contributed to the improvements in survival, by performing a prognostic factor analysis including date of diagnosis, and the introduction of GO and high-dose ara-C as covariates. Methods A total of 896 patients with cytogenetically confirmed core binding factor leukaemia from the MRC AML10, 12, 15 trials and the NCRI AML17 trial were included in the analysis. Date of diagnosis ranged from 1988 to 2012. Patients were aged between 16 and 60 years of age. A prognostic model was built using Cox regression with forward selection, at an entry probability of p Results In multivariate analysis of survival, the following variables were significant, in order of entry to the model: use of GO in induction (HR 0.40 (0.26-0.61) p Conclusions Core binding factor leukaemia is now highly curable with the most important contribution being the introduction of GO in induction followed by the adoption of high dose Ara-C (2 courses) in consolidation. When combined we observe an OS of 89% Disclosures: Off Label Use: Gemtuzumab Ozogamicin for AML.

Background There is conflicting data on the effect of the addition of ATRA to chemotherapy in AML. Two large randomised trials showed no benefit (Estey et al Blood 1999; 93, 2478 (n=215); Burnett et al. Blood 2010, 115: 9482 (n=1075)), or benefit which was limited to patients with an NPM1 mutation (n=14) when given in combination with ICE (Idarubicin/Ara-C/Etoposide) (Schlenk et al, Leukemia 2004, 18; 1798 (n=242)) but not with DA alone. In an effort to prospectively clarify if this is predictive treatment for NPM1+ patients and whether the effect was etoposide dependent, we randomised 616 patients to DA vs ADE and ATRA vs no ATRA in a 2x2 factorial design. Methods Between August 2010 and May 2012, 616 patients were randomised. The median age was 67(53-82) years: 75% had de novo, 16% had secondary, and 8% had high risk MDS (marrow blasts 10-19%): 4%, 75% and 21% had favourable, intermediate or poor risk cytogenetics: ITD and NPM1 data was available on 422 and 404 patients, with mutation rates of 19% and 24%. A total of 56 patients (14% of those with data) were molecularly good risk (NPM1 mutant, ITD wild type). By Wheatley risk score, 24%, 40% and 36% had good, standard or poor risk disease. The demographic, cytogenetic, molecular and allocated treatments were balanced between the arms. Follow-up is complete to 1st January 2013 (median follow-up 18.7 months) Patients were given Daunorubicin 50mg/m2 days 1-3 + Ara-C 100mg/m2 bid days 1-10 (course 1) or days 1-8 (course 2). Those allocated ATRA were treated at 45mg/m2/day for 60 days; Etoposide in the ADE arm was given at 100mg/m2/day on days 1-5 of courses 1 and 2 of chemotherapy. Results The overall response rate (ORR) was 69% (CR 53%+ CRi 16%) and survival at 2 years was 35%. The ORR was not different between DA: 68% (CR 53%, CRi 15%) and ADE: 70% (CR 53%, CRi 17%), odds ratio (OR) 0.92 (0.65-1.30) p=0.6, although remission rates were non-significantly lower in patients given ATRA (ORR 66% (CR 53%, CRi 13%) vs 73% (CR 54%, CRi 19%), OR 1.39 (0.98-1.95) p=0.06) with significantly higher 30-day (16% vs 8%, p=0.005) and 60-day mortality (20% vs 12%, p=0.005). There were no differences in early mortality between ADE and DA arms. At 2 years, neither survival nor RFS differed between the arms: (ADE vs DA OS: 33% vs 36%, HR 1.07 (0.86-1.32) p=0.6; RFS: 23% vs 36% HR 1.15 (0.88-1.49) p=0.3; ATRA vs Not OS: 35% vs 35% HR 1.13 (0.91-1.40) p=0.3; RFS: 31% vs 30% HR 0.93 (0.71-1.20) p=0.6). Overall there was no interaction between the two treatments (OS, test for heterogeneity p=0.12). In an analysis stratified by Etoposide and by NPM1/ITD risk group there was no significant heterogeneity of the effect of ATRA (p=0.1, Figure). Importantly, when looked at by the underlying chemotherapy, no beneficial effect of ATRA in NPM1 mutant/ITD WT patients appeared for patients receiving ADE (p=1.0 for heterogeneity). Conclusions Neither the addition of Etoposide nor ATRA improves outcomes in this group of patients, with ATRA being associated with significantly greater early mortality. Importantly, an analysis by NPM1/FLT3 genotype fails to reproduce the large benefits seen by Schlenk et al in ATRA treated patients with an NPM1 mutant/ITD wild type genotype, either overall or for patients treated with ADE, thus failing to substantiate a benefit for ATRA in either context. Based upon the results of AML16, neither Etoposide nor ATRA improve outcomes for older patients given intensive DA chemotherapy. Acknowledgments This study received research support from Cancer Research UK, and the Cardiff Experimental Cardiff Medicine Centre. Disclosures: No relevant conflicts of interest to declare.

Background The EUMDS registry was initiated to provide an overview of the real-world demographics, diagnostics and disease-management of MDS. The first patient was registered in December 2007 and today 16 countries and 131 centers are participating. In 1997 the International Prognostic Scoring System (IPSS) was developed to predict clinical outcomes for patients with MDS and is still the most widely used prognostic scoring system. Recently, the IPSS has been revised (IPSS-R). Objective To validate the prognostic discrimination of the IPSS and IPSS-R in the first 1000 newly diagnosed lower risk MDS patients. Results The median age of the population at diagnosis was 75 years (range 19-95). WHO 2001 classification was RCMD (35%), RARS (18%), RA (18%), RAEB-1 (12%), RCMD-RS (7%), 5q- syndrome (6%), MDS-U (3%) and RAEB-2 (0.4%). Within the first two years of follow-up 57% of the patients received MDS specific treatment: 48% received erythropoiesis stimulating agents (ESA), 11% granulocyte colony-stimulating factor (G-CSF), 51% received at least one red blood cell transfusion and 8% iron chelation therapy. IPSS risk score was Low in 49%, Intermediate-1 in 45% (0.5=32%, 1=13%) and unknown in 6% (no cytogenetic analysis) of the patients. IPSS-R risk score was Very Low in 25%, Low in 44%, Intermediate in 16%, High/Very high in 4% of the patients, and 10% unknown (Figure 1; Table 1). 77% of IPSS karyotypes were Good, 15% Intermediate, 1% Poor and unknown in 6%. 7% of the IPSS-R cytogenetic groups were Very good, 72% Good, 11% Intermediate, 1% were each Poor or Very poor and 8% unknown. Overall survival (OS) and disease progression (DP) (high risk MDS/Leukaemia) were both evaluated. Median follow-up time was 2.1 years (range 0 - 4.9 years). The mortality rate in patients with IPSS Low was 23% and 38% among those with an Intermediate IPSS (HR 2.09, 95%CI: 1.64-2.66; Figure 2A). The mortality rate in patients according to the IPSS-R was Very Low (21%; HR 0.77, 95%CI: 0.55-1.07), Low (26%; HR 1), Intermediate (51%; HR 2.53, 95%CI: 1.90-3.38) and High/Very high (65%; HR 4.47, 95%CI: 2.94-6.78) (Figure 2B). The prognostic discrimination of the scoring systems was assessed using the Akaike Information Criterion (AIC) from univariate proportional hazards models; the lower the AIC value the more informative the prognostic scoring system. The AIC of the IPSS and IPSS-R models were 3198.77 and 3154.48, respectively for OS and 1323.16 and 1274.19, respectively for DP (Table 1). A similar assessment of the components of the IPSS and IPSS-R scores revealed comparable fits to both OS and DP, regardless of which component was considered (Table 2). Conclusion IPSS and IPSS-R both predict OS and DP very well. IPSS-R was slightly superior in evaluating the clinical outcome, but it identified a subgroup (4.5% of all patients) of High and Very High-risk patients with a very poor prognosis, and another subgroup of good prognosis patients (IPSS-R Very Low) within the IPSS INT-1 cohort (13.6% of IPSS INT-1). Both scoring systems appear to be more strongly associated with predicting the risk of developing DP than OS. This observation may be due to the average high age at diagnosis of MDS reflecting the effect of competing causes of death associated with high age. Disclosures: Guerci-Bresler: Novartis: Honoraria; BMS: Honoraria; Celgene: Honoraria; Amgen: Honoraria.

Introduction AC220 (Quizartinib) is a novel FLT3 inhibitor that has shown a high level of activity as monotherapy in patients with advanced FLT3 +ve disease, and more modest activity in FLT3 -ve patients across Phase 1 and 2 studies. This is the first presentation of quizartinib use in combination with chemotherapy in newly diagnosed (FLT3 +ve and FLT3 -ve) older AML patients. Study Aim In preparation for a prospective Phase 3 trial (NCRI AML 18) in older patients with newly diagnosed AML, we tested the feasibility and dose of AC220 which could be sequentially given two days after each of two courses of ADE (Ara-C/ Daunorubicin/ Etoposide) followed by one course of DA (2+5) in patients over age 60 with FLT3 +ve or FLT3 –ve newly diagnosed AML. Six cohorts with escalating doses (60mg, 90mg or 135mg based on doses used in the Phase 2 ACE study with quizartinib) for 7 or 14 days were planned. If 60mg was not tolerated there was provision to de-escalate to 40mg for 7 or 14 days. The study was based on a 3+3 design whereby if 1 of 3 developed a DLT a cohort expansion was required but if >2 of 6 had a DLT, the cohort failed. A DLT was defined as any grade 4 non-haematological toxicity or failure of count recovery by day 42 in the absence of marrow blasts, or a grade 3 toxicity that did not recover to at least grade 2 within 7 days. Because of the increased sensitivity in females to QTc prolongation, each cohort required a minimum of 3 females. The day of safety evaluation was on completion of the chemotherapy in course 2. Results 55 patients with a median age of 69 years (62-87) entered of whom 48 were evaluable. 4 patients were FLT3 ITD +ve. 13 patients (4 males, 9 females) entered cohort 1 (AC220 60mg for 7days). No DLTs were seen in males but 3 DLTs occurred in females (all grade 4:1 cardiac (MI), 1 hypokalaemia; 1 mucositis) so this cohort exceeded tolerability for females. 8 patients (all males) entered cohort 2 (AC220 60mg for 14 days) where 4 DLTs (all grade 3; 3 QTC, 1 appetite loss) were seen, so this cohort exceeded tolerability for males. The de-escalation cohort (cohort 3) was activated (AC220 40mg for 7 days). 2 DLTs (1 grade 4 lung; 1 lung infection grade 3 >7days) in 7 evaluable females and 0 DLTs in 9 evaluable males were seen, so both males and females progressed to Cohort 4 (AC220 40mg for 14 days). There was 1 DLT (haematological) of 5 evaluable males and 0 of 8 evaluable females had a DLT. The DLTs were similarly distributed between males (5/25) and females (5/23). Induction death (death with 30 days) occurred in 3/46 (6.5%) evaluable patients. CR was achieved in 33/42 (79%; including all 4 FLT3 ITD +ve) of patients evaluable for CR or 60% of all 55 patients. Overall median time to neutrophil and platelet count recovery (neutrophils to 1.0x109/l; platelets to 100x109/l) was prompt (28 and 22 days post course 1; 22 and 19 days post course 2 respectively). No patients received SCT. The median OS is currently 15 months. Conclusion AC220 at 40mg for 14 days can safely be given sequentially after chemotherapy in older patients with newly diagnosed AML. The Phase 3 AML 18 study is planned to start in early 2014 and will incorporate AC220 into multiple courses of DA therapy as well as maintenance therapy. On behalf of the UK NCRI AML Working Group. We acknowledge the support from Ambit Biosciences for this study. Disclosures: Burnett: Ambit: Membership on an entity’s Board of Directors or advisory committees, Research Funding. Off Label Use: AC220 for newly diagnosed AML. Hills:Ambit: Consultancy.