Cytohematologic and Cytogenetic Prognostic Factors at Diagnosis and in tile Evolution in 46 Primary Myelodysplastic Syndromes Ana Isabel Gonz lez Manso, Ana Garcia Marcilla, Emilia Barreiro, and Florinda Gilsanz

ABSTRACT: The m y e l o d y s p l a s t i c syndromes (MDS) are a heterogeneous group of diseases with different prognosis a n d evolution. Most of the studies on prognostic factors performed previously have i n d e p e n d e n t l y evaluated the clinico-hematologic or cytogenetic data at diagnosis. In the present paper, 46 primary MDS were clinically, hematologically, and cytogenetically investigated at diagnosis, in order to determine the principal factors affecting the survival probability between a great n u m b e r of characteristics. A univariate regression analysis of all the data allows one to recognize that the m a i n factors are: the c o m p l e x i t y of karyotype ( p = 0.00001), the percentage of type I and total marrow blast cells ( p = 0.001), a n d the abnormal localized immature myeloid precursors' (ALIP) presence ( p = 0.001). Twenty-five patients underwent consecutive studies during their evolution. The k a r y o t y p e instability gives information both on the likely evolution to acute leukemia and on poor survival.

INTRODUCTION The Primary M y e l o d y s p l a s t i c S y n d r o m e s (MDS) are a heterogeneous group of clonal stem cell disorders [1, 2] characterized by ineffective and dysplastic hematopoiesis in one or more cell lines. They present one or several cytopenias in peripheral blood (PB) w h i l e the bone marrow (BM) aspirate is usually normo- or hypercellular, with p r o m i n e n t maturation abnormalities. The classification system for MDS p r o p o s e d by the French-American-British (FAB) Cooperative Study Group ]31 is based on qualitative and quantitative morphologic criteria in PB and BM smears. Five MDS subgroups are recognized: refractory anemia (RA), RA with ring sideroblasts (RAS}, RA w i t h excess of blast cells (RAEB), RAEB in transformation (RAEB-T), and chronic m y e l o m o n o c y t i c leukemia (CMMoL). This classification does not resolve all the diagnostic situations, as those posed by cases with intermediate characteristics among different MDS subgroups [4], or b e t w e e n MDS and myeloproliferative syndromes [5] or acute myelogenous leukemia (AML) [6]. Furthermore, this classification does not explain the very different prognosis in patients classified in the same sub-

From the Servicio de Hematologia (A. I. G. M.), Seccidn de Gen~tica, Hospital Puerta de Hierro, Madrid; and Servicio de Hematologia (A. G. M., F. G.) and Servicio de Gen~tica (E. B.), Hospital 12 de Octubre, Madrid, Spain. Address reprint requests to: Dr. A. I. Gonzdlez Manso, Servicio de Hematologia, Hospital Puerta de Hierro, c~ san Martin de Porres 4, 28035 Madrid, Spain. Received November 6, 1991; accepted March 16, 1992. 174 Cancer Genet Cytogenet61:174 182 (1992) O165-4608/92/$05.00

group as the variability in the evolution of each case of MDS. Some works have tried to establish the p r i n c i p a l prognostic factors in the p r i m a r y MDS. Several of these studies established s i m p l e scoring systems [7-11] in which, using three or four hematologic features, the patient prognosis m a y be predicted. The majority of the studies [12-17] report that the most i m p o r t a n t prognostic factors are the following ones: the FAB classification, the percentage of blast cells in PB and BM, the presence of abnormal localized immature m y e l o i d precursors (ALIP) and, n o w in a day, the cytogenetic result. It must be pointed out, however, that the MDS studies analyzing cytogenetic data together w i t h hematologic characteristics, in order to d e t e r m i n e prognostic factors, are very few [14, 18[ and not exhaustive. The present study takes into account cytogenetic data (according to three classifications) together with a great number of clinic and hematologic data in order to establish the real importance of the cytogenetic results as a prognostic factor. Cytogenetic data are also evaluated in the evolution of the patients.

MATERIALS AND METHODS Patients and Clinical Data Forty-six consecutive patients with the diagnosis of MDS according to the FAB criteria were i n c l u d e d in this analysis. Cases with m y e l o d y s p l a s i a s e c o n d a r y to alcoholism, metabolic disorders, chronic inflammations, liver cirrhosis, side © 1992 Elsevier Science Publishing Co., Inc. 655 Avenue of the Americas, New York, NY 10010

Prognostic Factors in M y e l o d y s p l a s t i c S y n d r o m e s

effects of drugs, v i t a m i n B12 or folic acid deficiency were not considered. Therapy-related MDS were also excluded. Patients were d i a g n o s e d a n d s t u d i e d in the Divisions of Hematology and Genetics of the 12 de Octubre Hospital, Madrid. Forty-one consecutive patients were diagnosed and followed in their evolution from January 1988 to December 1990. Five more cases (patients 2, 13, 16, 28, and 43), previously diagnosed and with complete available cytogenetic and hematologic data, were also i n c l u d e d in this study. Clinical, hematologic, and cytogenetic investigation was performed on all the patients at presentation; in twenty-five patients these data were also obtained during the evolution. The criteria used for repeating the study were changes in clinical picture or an interval of 9 - 1 2 months between the studies. Studies were performed with patient consent. Clinical features, at presentation and in the evolution, were recorded to determine a possible exposure to mutagenic agents or irradiations, the beginning of the symptoms, systemic s y m p t o m s (weakness, anorexia, weight loss), liver, spleen, and nodes enlargement, and complications such as infections and bleeding. Thirty~three patients received only supportive treatment w h i l e the r e m a i n i n g thirteen patients were treated with different protocols generally based on single-agent chemotherapy w h e n a progression of the disease was observed. The most c o m m o n l y used drugs were 13 cis-retinoic acid (2 cases), h y d r o x y u r e a (2 cases), erythropoietin (2 cases), and low-dose cytosine arabinoside (7 cases).

Hematologic Features Hematologic examinations were performed using standard methods. Peripheral blood (PB) and bone marrow (BM) Wright and Prussian blue-stained films were available in all cases. Marrow cell differential counts were performed on at least 500 cells; in these counts type I and type II blast cells were separately evaluated according to the FAB definition [3]. The percentage of ringed sideroblasts was calculated from a m i n i m u m of 100 erythroblasts counted. Criteria used for defining and grading dyspoiesis are illustrated in Table 1. Biopsies were obtained from anterior or posterior iliac crest w i t h a Jamshidi needle. Samples were fixed, embedded in paraffin, and stained with hematoxylin-eosin, Prussian blue, and Grocott reticulyn stains. All cases were r e v i e w e d i n d e p e n d e n t l y by two observers and were allocated to the a p p r o p r i a t e FAB subgroups. The cases, w h i c h shared features c o m m o n to different FAB subgroups, were assigned to the subgroup that in theory had the worst prognosis. W h e n there was a d i s c r e p a n c y between PB and BM percentage of blast cells affecting FAB classification, BM features were given priority. Transformation to acute l e u k e m i a was defined as the presence of more than 30% blast cells in BM.

Cytogenetic Analyses The BM cells u n d e r w e n t two different treatments: a) a culture in RPMI 1640 with 20% fetal calf serum m e d i u m for 2 hours and b) a s y n c h r o n i z a t i o n with metothrexate. The results obtained with the previous treatments were similar.

175

Table 1 Qualitative criteria for the d y s p l a s i a definition Dyserythropoiesis PB: morphologic abnormalities of the erythroid cells BM: gigantism multinuclearity multilobularity karyorrhexis internuclear bridges asynchrony of maturation between nucleus and cytoplasm punctate basophilia Howell-Jolly bodies cytoplasmic vacuolation Dysgranulopoiesis PB: hypogranular cells abnormalities in the nuclear segmentation: hypo- and hypersegmentation BM: hypogranular cells abnormalities in the nuclear segmentation: hypo- and hypersegmentation abnormal distribution and persistence of basophilia gigantism cytoplasmic vacuolation Dysmegakaryocytopoiesis PB: gigantism BM: micromegakaryocytes mononuclear megakaryocytes multinucleated megakaryocytes For each cell line, the dysplasia grade was considered: 0 + : one or more abnormalities affecting 0-5% of the cells of this line. 1 + : one or more abnormalities affecting 5 to 20% of the cells of this line. 2 + : more than two abnormalities affecting 20 to 50% of the cells of this line. 3 + : more than two abnormalities affecting more than 50% of the cells of this line. Abbreviations: PB. peripheral blood; BM. bone marrow.

In a few cases, in substitution of the BM, u n s t i m u l a t e d PB cells were cultured for 24 hours. A culture of stimulated PB cells was always performed in order to establish the constitutional karyotype of all the patients. Trypsin-Giemsa b a n d i n g was done in all cases and, in required cases, the C-banding m e t h o d was a d d i t i o n a l l y performed. In each case a m i n i m u m of 20 m e t a p h a s e s was analyzed. Chromosome identification and n o m e n c l a t u r e were in accordance with the r e c o m m e n d a t i o n of the International System for H u m a n Cytogenetic N o m e n c l a t u r e [19]. An abnormal clone was designated according to the International Workshops on Chromosomes in Leukemias [20]. Results of cytogenetic studies were g r o u p e d according to the usual criteria [21] in two classifications w i t h the following definitions: NN-NA-AA Classification (Classification 1): NN: no clonal a b n o r m a l i t y found; NA: mixture of normal cells and cells w i t h a clonal chromosome abnormality;

176 Table 2

A . I . G . Manso et al. Survival univariate analysis

Variables at presentation Clinical characteristics: Age; sex; liver; spleen enlargement; hemorrhages; infections; transfusional requirements; treatment. Hematologic features in PB: Hb; Hct; MCV; WBC; neutrophils; platelets; blast cells; nucleated RBC. Hematologic features in BM: ALIP; M/E; Type I, II, and total blast cells; high dysplasy in none, one, two, or three cell lines; dyserythropoiesis (global and for each characteristics); dysgranulopoiesis (global and for each characteristic); dysmegakaryocytopoiesis (global and for each characteristic). Others: FAB classification; cytogenetic result (classifications 1, 2, and 3). Variables in the evolution FAB evolution; cytogenetic evolution. Abbreviations: Hb, hemoglobin; Hct. hematocrit; MCV, mean corpuscular volume; WBC.white blood cell; RBC, red blood cell; ALIP,abnormal localization of immature myeloid precursors: M/E, myeloid/erythroid relation.

AA: all cells deriving from c h r o m o s o m a l l y abnormal clone(s). Complexity Classification (Classification 2): NN: no clonal a b n o r m a l i t y found; MIKA (Minor Karyotype Abnormalities): no more than three clonal abnormalities; M A K A (Major Karyotype Abnormalities): more than three clonal abnormalities. The patients were also g r o u p e d in a third classification (Classification 3) according to the recurrent chromosomes alterations in our results: no c h r o m o s o m e alterations found; alterations only on c h r o m o s o m e 5 (del(5q)); alterations on c h r o m o s o m e 5 (del(5q), - 5) and other chromosomes; alterations on c h r o m o s o m e 7 ( - 7 ) ; alterations on c h r o m o s o m e 11; alterations on other chromosomes (principally chromosomes 8, 19, 20).

Statistical Analysis of Prognostic Factors A total of thirty-eight features d o c u m e n t e d at initial study (and another two during the evolution) were evaluated in the prognostic factor analysis to establish their relationship to survival (Table 2). The Kaplan-Meier product limit method [22] was used to estimate the probability of survival. Survival was measured from hematologic diagnosis to death. All deaths, whether related or not to MDS, were considered as the e n d p o i n t of the follow-up interval. Statistical comparisons between different actuarial curves were based on Log-Rank Test method. The value of p was considered statistically

significant if less than 0.05. All analyses were performed by using the Statistical Package for Social Sciences (SPSS 4.0) run on an IBM 3070 microcomputer.

RESULTS Of the 46 patients, 17 were w o m e n and 29 were m e n (sex ratio 1 : 1.7). The mean age was 68 years (range 29 to 86); only two patients (4.6% of the total) were u n d e r 50 years, and they were classified as RA. Twelve patients had RA (26%), 11 had RAS (24%), 13 had RAEB (28%), 4 had RAEB-T (9%), and 6 had CMML

(13%). The cytogenetic results, g r o u p e d in the three classifications, are reported in Table 3. Transformation to overt l e u k e m i a was observed in five cases (11%) after a m e d i a n time of 17 m o n t h s from the initial study. Except for patients classified as RAS, in the other subgroups there were some cases of evolution to leukemia, particularly in the RAEB-T subgroup (2/4 cases) (Table 3). At the end of the present study, 18 patients were dead; the principal cause was the marrow failure (62%) while the evolution to l e u k e m i a only represents 28% of the total deaths. There were no prognostic differences between patients untreated and treated.

Univariate Analysis of Prognostic Survival Factors The characteristics with prognostic significance are reported in Table 4. Among the clinical and hematologic features in PB, the following ones d e t e r m i n e d a short survival: the transfusional requirements ( p = 0.002), the presence of more than 5% of blast cells in PB (p = 0.001), the WBC higher than 10 × 109/L (p = 0.04), and the Hb less than 7 g/dL ( p = 0.001). The presence of positive ALIP ( p = 0.001) and the presence of BM type I (p = 0.0002) and total (p = 0.0001) blast cells with percentages higher than 10% were strongly associated with a poor prognosis. No differences in survival were found between the group of patients with less than 5% and those with 5 - 1 0 % (type I or total) blast cells, or between the patients with 1 0 - 2 0 % and those with more than 20% total blast cells. Dysmyelopoietic features also had an influence on survival; h y p o s e g m e n t a t i o n ( p = 0.008) and h y p o g r a n u l a r i t y (p = 0.03) were particularly associated with a poor prognosis w h e n they affected more than 20% of the total cells. A m o n g dysmegakaryocytic features, only the high presence of micromegakaryocytes d e t e r m i n e d a short survival ( p

0.01). The FAB classification established prognostic differences ( p = 0.02) among certain subgroups. These differences were present w h e n c o m p a r i n g RAS and RAEB ( p = 0.05), RAS and RAEB-T (p = 0.005), RAS and CMML (p ~0.05), and RA and RAEB-T (p = 0.01). The group of patients classified as RA and RAS had a better prognosis than the group of patients classified as RAEB, RAEB-T, or CMML. The cytogenetic result, u n d e r the three classifications considered, was the strongest prognostic factor of survival. A statistical significance was observed w h e n c o m p a r i n g

Prognostic Factors in Myelodysplastic Syndromes

Table 3

177

Cytogenetic findings at presentation and clinical course of the 46 patients with primary MDS No cases

Classification 1 NN NA AA Classification 2 MIKA MAKA Classification 3 7 5 5 + others 11 others Survival (months) Leuk. trans.

RA (12)

RAS (11)

RAEB (13)

RAEB-T (4)

CMML (6)

Survival (m)

Leuk. trans.

23 20 3

7 5 0

5 5 1

6 7 0

0 2 2

5 1 0

> 60 17 1

2 3 0

19 4

5 0

6 0

5 2

2 2

1 0

23 1

3 0

5 3 4 4 7

1 2 0 1 1 > 60

0 1 1 3 1 > 60

3 0 1 0 3 19

1 0 2 0 1 17

0 0 0 0 1 29

7 30 6 > 33 23

2 0 0 0 1

5

1

0

1

2

1

Abbreviations: NN, normal karyotype; NA, mixture of normal cells and cells with a clonal chromosomeabnormality;AA, all cells

derivingfroma chromosomallyabnormalclone/s;MIKA,karyotypewith no morethan three clonalabnormalities;MAKA,karyotype with more than three clonal abnormalities;m, months.

the survival curves of patients with normal karyotype and the NA situation (p = 0.008) or w i t h i n NA and AA situations ( p = 0.04). The strongest relation with survival length was established w h e n comparing patients with NN and AA (p = 0.001), NN and MAKA (p = 0.0001), and even with MIKA and MAKA (p = 0.0007). Concerning the recurrent chromosome alterations, a good prognosis was associated with del(5q) (survival of 30 months) while a very poor prognosis was indicated w h e n chromosome 5 plus others (survival of 6 months) and the chromosome 7 (survival of 7 months) were altered. The univariate analysis of survival prognosis was also performed on the following variables: the FAB evolution and the cytogenetic evolution. The cytogenetic evolution (p = 0.004) was more strongly associated with a poor prognosis than the FAB evolution (p = 0.02).

Evolution Nine of the 46 patients died before the realization of a second study. Eighty-nine percent of these patients had an abnormal karyotype, principally MAKA karyotype (50%). Twelve of the 46 initial patients were lost for follow-up. Two or more studies were performed in the evolution of twenty-five patients. In these cases, the global percentage of cytogenetic alteration was 36% (in comparison with the global value of 50% in the initial group). Table 5 reports the cytogenetic results at presentation and in the evolution of these patients classified in the following groups: la) patients with stable karyotype and without FAB evolution; lb) patients with stable karyotype and with FAB evolution; 2a) patients with unstable karyotype and without FAB evolution; and 2b) patients with unstable karyotype and with FAB evolution. Forty percent of these cases (10/25) showed cytogenetic changes. Fifteen patients (60%) had stable karyotype. Ten of these

patients (67%) were classified as RA or RAS. At diagnosis, twelve of these cases (80%) presented a normal karyotype; thirteen of the cases (87%) were cytologically stable. Patient 43 presented a cytologic evolution w i t h o u t cytogenetic evolution; it must be reported, however, that for the third study of this case a PB culture (and not a BM culture) with a slow n u m b e r of blast cells was used. Ten patients (40%) had an unstable karyotype, either by increasing the percentage of abnormal cells or by developing new abnormal clones: six of them had an initial abnormal karyotype and in the other four, it was normal. In five patients the cytogenetic evolution was a c c o m p a n i e d by cytologic changes. Two patients (numbers 4 and 27) changed first to a more aggressive type of MDS and then to AML while three other patients (numbers 24, 37, and 38) changed directly to AML.

DISCUSSION The MDS are a heterogenous group of primary hematologic disorders with variable evolution. The therapeutic decisions are also variable [23]; the great majority of the patients receive only support therapy while others are treated with cytotoxic drugs, growth factors, or differentiation agents. Recently, some of them have undergone bone marrow transplantation. The establishment of a poor prognosis at presentation, or in the course of the disease, is therefore very important to determine the best therapy. On this ground, prognostic factor studies are very useful. Mortality in the MDS is generally associated with bone marrow failure or with leukemia transformation. In accord with the literature [7, 17, 24], our results confirm that marrow failure (infection and/or b l e e d i n g ) i s the principal cause of death in primary MDS (62% in our results). There are substantial differences in the reported values of inci-

178

A.I.G.

Table 4

Characteristics with influence on survival

Characteristic Transfusional requirements Hb (g/dL)

WBC (× 109/L)

Blasts cells (%) in PB ALIP Type I Blasts cells (%) in BM Type II Blasts cells (%) in BM Total Blasts cells (%) in BM

Dysgranulopoiesis in BM Hyposegmentation in BM Hypogranularity (mature elements) in BM Micromegakaryocytes FAB

Cytogenetic classification 1 Cytogenetic classification 2 Cytogenetic classification 3

FAB evolution Cytogenetic evolution

No patients

Survival (months)

< 5 5-10 > 10 < 5 -> 5 < 5 5-10 11-19 20-30 0 + -1 + 2+-3+ 0 + -1 + 2+-3+ 0 + -1 + 2 + -3 +

14 32 6 17 22 10 21 11 3 29 12 4 11 34 36 3 6 41 4 28 11 3 3 24 21 32 13 21 24

13 > 60 7 24 > 50 11 > 60 > 44 2 > 60 20 7 9 > 60 > 60 > 31 5 > 60 7 > 60 20 5 14 > 60 13 > 60 13 > 60 19

0 +-1 + 2+-3+ RA RAS RAEB RAEB-T CMML NN NA AA NN MIKA MAKA none 5 5 + others 7 11 others Yes No Yes No

29 12 12 11 13 4 6 23 20 3 23 19 4 23 3 4 4 5 7 7 18 10 15

> 60 13 > 6O > 60 19 17 29 > 60 17 1 > 60 23 1 > 60 30 6 7 > 33 23 23 > 60 20 > 60

Category Yes No < 7 7-10 10 < 2.5 2.5-5 5-10 10 0 1-4 >- 5 +

p

0.002

0.05

0.04

0.005 0.001

0.001 0.002

0.0009

d e n c e of p r o g r e s s i o n to A M L i n MDS, r a n g i n g f r o m 6% to 4 7 % [7, 10, 13, 17, 24], b u t t h e m a j o r i t y of w o r k s a g r e e o n a v a l u e i n t h e r a n g e 1 5 - 2 0 % . E l e v e n p e r c e n t of o u r p a t i e n t s evolved into acute leukemia. Patients with RAEB-T had m o r e t e n d e n c y to e v o l v e to A M L (50% i n o u r r e s u l t s ) t h a n p a t i e n t s w i t h R A or R A S (8% a n d 0%). T h e m e d i a n s u r v i v als of p a t i e n t s w i t h RA, RAS, RAEB, a n d C M M o L (Table 3) w e r e s i m i l a r to t h o s e r e p o r t e d i n o t h e r w o r k s , w h e r e a s s u r v i v a l of p a t i e n t s w i t h R A E B - T w a s l o n g e r (17 m o n t h s ) t h a n t h e r e p o r t e d m e d i a n (5 m o n t h s ) [25]. T h i s c a n b e d u e to t h e s m a l l n u m b e r of p a t i e n t s i n t h i s s u b g r o u p (4) a n d also to t h e fact t h a t t h e e v o l u t i o n of t h e s e p a t i e n t s w a s v e r y different: t w o s u r v i v e d o n l y 1 m o n t h w h i l e t h e o t h e r t w o s u r v i v e d 18 a n d 23 m o n t h s . T h e l o n g e v o l u t i o n of s o m e cases w i t h R A E B - T h a s b e e n d e s c r i b e d p r e v i o u s l y [26, 27] a n d h i g h l i g h t s t h e i m p o r t a n c e of t h e c y t o g e n e t i c data. In fact, t h e t w o cases w i t h l o w s u r v i v a l p r e s e n t a M A K A karyotype /median survival 1 month), whereas the two o t h e r cases p r e s e n t a M I K A k a r y o t y p e ( m e d i a n s u r v i v a l 23 months). T h e u n i v a r i a t e a n a l y s i s (Table 4) s h o w e d t h a t t h e l e v e l s of Hb, t h e n u m b e r of WBC, a n d t h e t r a n s f u s i o n a l r e q u i r e m e n t s are i m p o r t a n t p r o g n o s t i c factors. P e r i p h e r a l c y t o p e n i a s d u e to m a r r o w f a i l u r e p l a y a n i m p o r t a n t role i n t h e s u r v i v a l of p a t i e n t s w i t h M D S [24]. In o u r r e s u l t s , p a t i e n t age d o e s n o t s e e m to p l a y a role as a p r o g n o s t i c factor. T h i s m a y b e e x p l a i n e d b y c o n s i d e r ing t h a t t h e age of t h e p a t i e n t g r o u p is v e r y h o m o g e n o u s ;

0.01 0.008 0.03

F i g u r e I Survival curves, according to the complexity of karyotype at diagnosis, reported as cumulative proportion surviving (p) vs. survival months (m/. (1/Major karyotype alterations (number of patients, 4; survival, 1 month); (2) minor karyotype alterations (number of patients, 19; survival, 23 months); (3) normal karyotype (number of patients, 23; survival, > 60 months).

0.01

O.02

L L

O.O02

0.00001

0.6

l

0.001 0.02 0,004

Abbreviations: Hb, hemoglobin; WBC. white blood cell; ALIP. abnormal

localization of immature myeloid precursors.

M a n s o et al.

l

0 0

12

I

I

24

36 m

i

I

48

~

I

60

179

Table 5

Case

S e q u e n t i a l c h r o m o s o m e a n a l y s i s a n d c y t o l o g i c e v o l u t i o n of 25 p a t i e n t s Date of study

FAB

1. Stable Karyotype la. Without FAB evolution 2 11/81 RA 4/89 RA 12/89 RA 3 10/88 RA 1/90 RA 12/90 RA 7 10/89 RA 9/90 RA 8 3/90 RA 12/90 RA 13 4/87 RAS 11/88 RAS 9/89 RAS 4/9O RAS 15 3/88 RAS

18 19 20

25/O 23/O 26/O 25/O 21/0 24/0 12/12 20/4 25/0 24/0 22/0 24/0 2O/0 23/0 17/7

24/0 25/0 21/0 26/0 23/0 24/O 23/0 24/0 25/0 21/0 25/0 24/O 22/0 22/0 25/0 25/0

46,XX 46,XX 46,XY 46,XY 46,XY

14/7 12/12 0/24 0/21 21/0 13/12

46,XX/46,XX,del(11)(q13q24) 46,XX/46,XX,del(11)(q13q24) 46,XX,del(11)(q13q24) 46,XX,del(11)(q13q24) 46,XX 46,XX/46,XX, der(17)t(15;17)(q14;p12) 46,XY 46,XY/46,XY,dic(4;?) (q25;?) 46,XY/46,XY,dic(4;?)(q25;?)

RAS

18/7

8/89 10/90 9/89 11/90 1/88

RAS RAS RAS RAS RAS

25/O 22/0 20/0 25/0 16/8

10/90

RAS

15/7

1/88 RAEB 12/88 RAEB 9/89 RAEB 11/90 RAEB 29 5/89 RAEB 10/89 RAEB 12/90 RAEB 41 12/88 CMMoL 11/89 CMMoL 45 9/89 CMMoL 12/90 CMMoL lb. With FAB evolution 1 2/89 RA 11/89 RAEB 43 10/86 CMMoL 1/89 CMMoL 3/89 LMA 2. Unstable Karyotype 2a. Without FAB evolution 14 4/88 RAS 12/88 RAS 9/89 RAS 4/9O RAS 16 4/84 RAS 9/88 RAS 10/88 8/89 11/89

RAEB RAEB RAEB

Karyotype

46,XX 46,XX 46,XX 46,XX 46,XX 46,XX 46,XY/47,XY, + 8 46,XY/47,XY, + 8 46,XX 46,XX 46,XY 46,XY 46,XY 46,XY 46,XY/46,XY,der(11)t(1;11) (q12;q23) 46,XY/46,XY,der(11)t(1;11) (q12;q23) 46,XY 46,XY 46,XY 46,XY 46,XX/45,XX, del(5)(q12q34), - 22 46,XX/45,XX, del(5)(q12q34),- 22 46,XX 46,XX 46,XX 46,XX 46,XY 46,XY 46,XY 46,XY 46,XY 46,XY 46,XY

11/89

26

25

Mitosis ~ normal/abnormal

21/0 20/5 15/7

Status

dead 2/90 infection

alive alive alive

alive

alive alive alive

alive

alive

alive alive alive

alive

dead 3/89 LMA

alive

dead 2/89 SMD dead 1/90 infection (Continued)

180

A . I . G . Manso et al.

Table 5 Case 28

32 2b. 4

24 27

37 38

(Continued) Date of study

FAB

Mitosis a normal/abnormal

10/86 7/88

RAEB RAEB

4/89

RAEB

8/14

7/90

RAEB

7/14

3/90 RAEB 7/90 RAEB With FAB evolution 11/88 RA 2/89 RAEB 5/89 LMA 7/88 RAEB 3/89 LMA 5/88 RAEB 3/89 RAEB 9/89 RAEB-T 12/90

LMA

3/89 11/89 2/89 1/90

RAEB-T LMA RAEB-T LMA

25/0 17/6

5/20 0/22 10/13 5/20 0/25 22/0 5/20 8/12 0/24 0/24/4 0/18/8 19/6 0/24 11/9 0/21

Karyotype 46,XX 46,XX/46,XX,del(5)(q12q34), del(20)(qllq13) 46,XX/46,XX,del(5)(q12q34), del(20)(qllq13) 46,XX/46,XX,del(5)(q12q34), del(20)(qllq13) 46,XX/45,XX - ,7 45,XX,- 7 46,XY/45,XY, - 7 46,XY/45,XY,- 7 46,XY, - 7, + 8 46,XY 46,XY/45,XY,- 7 46,XY/46,XY,t(4;12)(p14;q23) 46,XY,t(4;12)(p14;q23) 46,XY,t(4;12)(p14;q23)/47,XY, t(4;12)(p14;q23), + 8 46,XY,t(4;12)(p14;q23)/47,XY, t(4;12)(p14;q23), + 8 46,XY/45,XY,- 7 45,XY, - 7 46,XY/46,XY, - 19, + mar 46,XY, - 19, + mar

Status

alive dead 7/90 infection

dead 12/89 LMA dead 5/89 LMA

alive dead 9/90 LMA dead 11/90 LMA

" AnalyzedMitosis: normal/abnormal

in fact, very few patients (4.6%) were less than 50 years old at diagnosis. As reported in the literature [17], patients with ages less than 50 years have a survival probability different from that of older patients. Some works point out that dysplastic features are important prognostic factors [13, 28, 29]. Our results also confirm that hypogranularity, hyposegmentation, and micromegakaryocytes are factors correlated with survival. Dysplastic features reflect the degree of marrow failure and are important both for the diagnosis of the MDS and for the establishment of the prognosis. The percentage of blast cells in PB and BM and the presence of ALIP [14, 29] in the biopsies are very important prognostic factors. We found that 10% of blast cells in the BM was the limit value between favorable and unfavorable prognosis instead of the 5% limit of FAB classification [3]. Our results confirm that, according to FAB classification, two m a i n prognostic groups can be found: the first one, with a large survival, would include RA and RAS subgroups, while the second one, with a survival time far less than the previous one, would include RAEB, RAEB-T, and CMML. As several authors have pointed out [21, 27, 30], the FAB groups are not completely homogeneous, as they comprise subgroups that have different patterns of behavior, evolution, and prognosis. Cytogenetic data may help to distinguish different subgroups. In fact, we have found that the cytogenetic data are an important prognostic factor. Karyotype complexity is the most important i n d e p e n d e n t prognostic factor [31, 32]. The m a i n difference in survivals

was shown between normal karyotypes and MAKA karyotypes, but a certain difference also existed between normal karyotypes and AA type karyotypes. In our results, the MAKA karyotypes were associated with RAEB and RAEB-T subgroups, but in literature these karyotypes are also associated with other subgoups [33]. I n d e p e n d e n t l y of the FAB subgroup, the presence or the absence of a MAKA karyotype are the factors that determine a very poor or a favorable prognosis. The presence of a MAKA karyotype reflects a strong genomic, and so cellular, disease that may be accompanied by an increase of blast cells in PB and BM. As is well k n o w n [25], and as our results confirm, the alterations on chromosomes 5 (del(5q)) and 7 ( - 7 / d e l ( 7 ) ) constitute groups with their own characteristics and prognosis. Cytogenetic data inform the prognosis not only at diagnosis but also during the evolution [30, 34, 35]. In some cases cytogenetic evolution occurred prior to cytologic changes. This cytogenetic evolution is frequent in patients with primary MDS [34]; we found changes in 40% of our patients. A great n u m b e r (87%) of patients with stable karyotype also presented clinical and cytologic stability; they also presented a normal karyotype at diagnosis and most of them were classified as RA or RAS according to FAB. In these cases, the presence of stable karyotype indicates that the disorders are probably determinated by stable cellular clones with low proliferative capacity and a low t e n d e n c y to evolve to AML [36]. Patients with unstable karyotype show poor prognosis [34]. Five patients (50%) with unstable karyotype exhibited

Prognostic Factors in Myelodysplastic Syndromes

cytologic changes. They progressed to more aggressive FAB subgroups or directly to overt leukemia. Three of the five patients with unstable karyotype and no changes in FAB subtype died due to complications from marrow failure less than 5 months after the finding of cytogenetic changes. Cases with unstable karyotype may i n c l u d e both unstable cellular clones with low (patients 14, 16, 25, 27, and 28) and high (patients 4, 24, 32, 37, and 38) proliferative capacity. All these patients, if they do not die from marrow failure, w o u l d eventually develop acute leukemia. Our results clearly show that cytogenetic evolution in MDS is a good index of cytologic evolution and/or premature death. The cytogenetic information obtained at diagnosis and during evolution may be the main single factor to be considered in therapeutic decisions.

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