ARTICLE IN PRESS BJHH 2894 1–9 rev bras hematol hemoter 6;x x x(x x):xxx–xxx Revista Brasileira de Hematologia e Hemoterapia Brazilian Journal of Hematology and Hemotherapy www.rbhh.org Original article Secondary myeloid neoplasms: bone marrow cytogenetic and histological features may be relevant to prognosis Roberta Sandra da Silva Tanizawa a,∗ , Maria Claudia Nogueira Zerbini b , Ricardo Rosenfeld c , Cristina Aiko Kumeda a , Raymundo Soares Azevedo b , Sheila Aparecida Coelho Siqueira a , Elvira Deolinda Rodrigues Pereira Velloso a a b 10 c Q1 Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brazil Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brazil Hospital São Paulo, Universidade Federal de São Paulo (UNIFESP), São Paulo, SP, Brazil 11 12 a r t i c l e i n f o a b s t r a c t 13 14 Article history: Background: Secondary myeloid neoplasms comprise a group of diseases arising after 15 Received 22 July 2015 chemotherapy, radiation, immunosuppressive therapy or from aplastic anemia Few studies 16 Accepted 21 September 2016 have addressed prognostic factors in these neoplasms 17 Available online xxx Method: Forty-two patients diagnosed from 1987 to 2008 with secondary myeloid neoplasms were retrospectively evaluated concerning clinical, biochemical, peripheral blood, bone mar- 18 19 Keywords: row aspirate, biopsy, and immunohistochemistry and cytogenetic features at diagnosis as 20 Myelodysplastic syndromes prognostic factors The International Prognostic Scoring System was applied Statistical 21 Second malignancy analysis employed the Kaplan–Meier method, log-rank and Fisher’s exact test 22 Second neoplasm Results: Twenty-three patients (54.8%) were male with a median age of 53.5 years (range: 4–88 23 Secondary effect years) at diagnosis of secondary myeloid neoplasms Previous diseases included hemato- 24 Therapy-associated neoplasm ; logic malignancies, solid tumors, aplastic anemia, autoimmune diseases and conditions requiring solid organ transplantations One third of patients (33%) were submitted to chemotherapy alone, 2% to radiotherapy, 26% to both modalities and 28% to immunosuppressive agents Five patients (11.9%) had undergone autologous hematopoietic stem cell transplantation The median latency between the primary disease and secondary myeloid neoplasms was 85 months (range: 23–221 months) Eight patients were submitted to allogeneic hematopoietic stem cell transplantation to treat secondary myeloid neoplasms Important changes in bone marrow were detected mainly by biopsy, immunohistochemistry and cytogenetics The presence of clusters of CD117+ cells and p53+ cells were associated with low survival p53 was associated to a higher risk according to the International Prognostic Scoring System High prevalence of clonal abnormalities (84.3%) and thrombocytopenia (78.6%) were independent factors for poor survival ∗ Corresponding author at: Cytogenetics Laboratory, Hematology Service, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, Av Dr Enéas de Carvalho Aguiar, 155, 1◦ , Andar, 05403-000 São Paulo, SP, Brazil E-mail address: robertatani@uol.com.br (R.S Tanizawa) http://dx.doi.org/10.1016/j.bjhh.2016.09.015 ˜ Brasileira de Hematologia, Hemoterapia e Terapia Celular Published by Elsevier Editora Ltda This is an 1516-8484/â 2016 Associacáao open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/) Please cite this article in press as: Tanizawa RS, et al Secondary myeloid neoplasms: bone marrow cytogenetic and histological features may BJHH 2894 1–9 be relevant to prognosis Rev Bras Hematol Hemoter 2016 http://dx.doi.org/10.1016/j.bjhh.2016.09.015 BJHH 2894 1–9 ARTICLE IN PRESS rev bras hematol hemoter 6;x x x(x x):xxx–xxx 25 Conclusion: This study demonstrated that cytogenetics, bone marrow biopsy and immuno- 26 histochemistry are very important prognostic tools in secondary myeloid neoplasms ˜ Brasileira de Hematologia, Hemoterapia e Terapia Celular Published © 2016 Associac¸ao by Elsevier Editora Ltda This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/) 27 Introduction 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 66 67 68 69 70 71 72 73 74 75 76 Secondary myeloid neoplasms (s-MN) comprise a group of diseases arising as late complications after chemotherapy and radiation and are associated with risk factors such as congenital disorders and acquired bone marrow (BM) failure.1–4 The most studied of these s-MN are related to chemotherapy and radiotherapy The rate of these diseases is increasing as the survival of patients with cancer improves Patients submitted to autologous hematopoietic stem cell transplantation (HSCT) with intensive chemotherapy and total body irradiation (TBI), a type of complimentary therapy, have demonstrated a potential of developing secondary myeloid disorders.5 The 2008 World Health Organization (WHO) classification adopted the term therapy-related myeloid neoplasms (t-MN) for cases of myeloid malignancies after chemotherapy/radiotherapy (CH/RT) that fulfill morphological criteria including myelodysplastic syndromes (MDS), acute myeloid leukemia (AML) and myeloproliferative neoplasms (MPN) Alkylating drugs/radiation and topoisomerase II inhibitor agents are implicated in these disorders The characteristics of t-MN in the majority of cases include anemia with macrocytosis, dysplastic changes in neutrophils and basophilia BM fibrosis, three lineage dysplasia, ring sideroblasts and abnormal karyotypes are seen in the majority of cases, and almost 50% of cases have less than 5% of BM blasts The clinical course is typically progressive and resistant to conventional therapies.6 Long-surviving patients treated with immunosuppressive therapy, such as aplastic anemia (AA), autoimmune disease and recipients of solid organ grafts have an increased risk of developing s-MN.7–9 Furthermore, the concomitant use of immunosuppressive agents with hematopoietic growth factors has been associated with s-MDS.10 To date, little is known about s-MN after using immunosuppressive therapy There are few data in the literature concerning morphologic and outcome studies However, cytogenetic abnormalities are an important marker in this subgroup with anomalies usually involving chromosomes and and in particular monosomy 7.11 Genetic diseases such as Fanconi anemia, dyskeratosis congenita, Diamond-Blackfan anemia, Shwachman-Diamond syndrome and some forms of severe congenital neutropenia have an increased propensity for myeloid neoplasms.12 Furthermore, studies about host factors such as common polymorphisms in drug metabolizing enzymes and biological markers of drug- and radiation-induced genetic damage may be useful in identifying patients at risk of therapy-related complications and secondary malignancies.13,14 Data concerning overall survival (OS) and prognosis of patients with s-MN remain poor Allogeneic HSCT seems to be the only curative therapy for all subgroups included in s-MN.15 Cytogenetic status plays an important role in determining the outcome of these patients Outcome for primary disease, platelet count, hemoglobin level, age, total protein level, Creactive protein level and unfavorable karyotype have been described as prognostic factors in some studies.16–18 Despite the importance of BM studies in pathological processes of secondary disease, few investigations have been conducted concerning BM biopsies and immunohistochemistry Orazi et al.19 analyzed 14 patients with previous diseases including Hodgkin’s lymphoma, Non-Hodgkin lymphoma, breast cancer, plasma cell myeloma and skin carcinoma that evolved to therapy-related MDS Data from BM biopsies, such as abnormal localization of immature precursors, marrow fibrosis, and overexpression of CD34+ cells were associated with poor prognosis In addition, p53 protein overexpression can be frequently observed, particularly in cases associated with severe ineffective hematopoiesis.20 77 78 79 80 81 82 83 84 85 86 87 88 89 90 91 92 93 94 95 Objective The aim of this study was to analyze clinical, biochemical, morphological (peripheral blood, BM aspirate and biopsy) and cytogenetic characteristics as prognostic factors in patients with s-MN diagnosed and treated at a single center 96 97 98 99 Methods Of 428 patients with MDS in the database of HC-FMUSP, a public hospital in São Paulo, Brazil, 42 patients (10%) with s-MN after the use of chemotherapy, radiotherapy (for hematological or solid tumors) or immunosuppressive therapy (for AA, solid transplantation and autoimmune diseases) from 1987 to 2008 were retrospectively studied This study was conducted in accordance with the Declaration of Helsinki and approved by the Ethics Committee of the institution Medical charts were evaluated for clinical characteristics and laboratory data at diagnosis (Tables and 2) BM aspirates were reviewed according to morphological criteria of the WHO 2008 criteria BM biopsies were reviewed for cellularity, an estimated blast percentage, fibrosis and dyspoiesis Immunohistochemistry was carried out for myeloperoxidase, Glycophorin A, CD61, FVIII, CD20, CD3, CD138, CD34, CD117 and p53 protein expressions The latter was defined as to 3+ and considered positive if any expression was detected (Table 2) Cytogenetics was performed at diagnosis using standard G-banding21 and karyotypes were classified as normal, abnormal, complex (≥ abnormalities) or monosomy 7.22 The International Prognostic Please cite this article in press as: Tanizawa RS, et al Secondary myeloid neoplasms: bone marrow cytogenetic and histological features may BJHH 2894 1–9 be relevant to prognosis Rev Bras Hematol Hemoter 2016 http://dx.doi.org/10.1016/j.bjhh.2016.09.015 100 101 102 103 104 105 106 107 108 109 110 111 112 113 114 115 116 117 118 119 BJHH 2894 1–9 ARTICLE IN PRESS rev bras hematol hemoter 6;x x x(x x):xxx–xxx Table – Univariate analysis for prognostic factors on overall survival of patients with secondary myeloid neoplasms – clinical data Overall survival censoring allogeneic HSCT Overall survival not censoring allogeneic HSCT Gender (n = 42) Male Female Age (n = 42) 5 Bone marrow biopsy Global cellularity – n = 22 Hipocellularity Normal Hipercellularity Hipocellularity Cellularity MGK serie – n = 22 Normal Hipercellularity Dysplasia No MGK serie – n = 17 Yes Median survival (months) p-Value 15 27 5.6 5.9 0.29 15 27 5.1 5.9 0.615 12.2 0.084 31 11 5.9 2.4 0.295 14 10 9.2 1.7 0.002 17 5 6.3 0.624 8 6.3 1.7 0.037 11 11 15 19 5.9 7.1 3.6 5.6 5.1 7.1 15 12.9 5.1 0.233 25 10 6.3 3.6 0.586 14 23 5.1 5.6 0.825 34 5.9 3.5 0.243 35 5.9 3.5 0.495 35 5.9 0.139 13 12.7 9.2 1.7 0.948 7.1 9.2 1.7 15 12.2 0.79 0.977 0.608 Please cite this article in press as: Tanizawa RS, et al Secondary myeloid neoplasms: bone marrow cytogenetic and histological features may BJHH 2894 1–9 be relevant to prognosis Rev Bras Hematol Hemoter 2016 http://dx.doi.org/10.1016/j.bjhh.2016.09.015 BJHH 2894 1–9 ARTICLE IN PRESS rev bras hematol hemoter 6;x x x(x x):xxx–xxx Table – (Continued) Number of cases Architectural changes No MGK serie – n = 17 Yes ALIP – n = 19 No Yes CD34+ cells – n = 22 ≤1% >1% CD34+ cells – n = 17 (1–10%) >10% CD34+ cluster – n = 22 No Yes CD117+ cells – n = 17 ≤1% >1% CD117+ cells – n = 14 (1–10%) >10% CD117+ cluster – n = 17 No Yes p53 protein expression – n = 21 No Yes Lymphoid nodules b – n = 22 No Yes Fibrosis – n = 21