NOVEL KEY VARIABLES IN THE SURVIVAL OF PATIENTS WITH MYELODYSPLASTIC NEOPLASMS: A PRACTICAL APPROACH USING MACHINE LEARNING

Introduction: Prognostic models like the IPSS-R play a crucial role in assessing outcomes for patients with myelodysplastic neoplasms (MDS). However, recent advancements in machine learning (ML) offer the potential to uncover novel predictive variables and enhance prognostic accuracy. Models like ElasticNet are particularly adept at handling multidimensional data, thereby expanding the scope beyond the variables considered in IPSS-R. Objectives: Assessing the performance of ML in predicting overall survival in MDS patients by incorporating clinical and hematological variables not traditionally included in prognostic models. Methods: We conducted a retrospective cohort study at a single reference center involving patients diagnosed with MDS between 2004 and 2024. We included patients with available clinical outcomes, missing data was handled using the ’cart’ multiple imputation, following confirmation of non-random missingness through Little's test. The dataset was then randomly split into a training group (70%) and a testing group (30%). Utilizing group elastic net machine learning, an artificial intelligence model capable of selecting relevant variables and assessing their discriminative power, we constructed 3 receiver operating characteristic (ROC) curves to predict 1, 3, and 5-year survival, extracting the area under the curve (AUC) and identifying variables with non-zero coefficients. Based on these coefficients, we categorized our dataset into “High Risk” and “Low Risk” groups. Subsequently, we conducted a multivariate Cox proportional hazard regression analysis, adjusting for the new risk variable, age at diagnosis, sex, and transfusion burden. All statistical analyses were performed using R, with the involvement of packages such as ‘mice’, ‘gpreg’, ‘gplasso’, and ‘survfit’. Results: 162 patients were included in this study. Using the group ElasticNet model, we identified 10 critical variables with notable predictive power: hemoglobin count, mean corpuscular volume, platelet count, presence of dysgranulopoiesis, presence of dysmegakaryopoiesis, serum iron, transferrin saturation, bone marrow cellularity, percentage of blasts in bone marrow, and percentage of ring sideroblasts. ROC curve analysis utilizing these variables'coefficients yielded AUCs of 0.863, 0.822, and 0.719 for predicting 1-year, 3-year, and 5-year survival, respectively. The coefficients were then extracted and used for risk stratification. 5-year survival rates were 24.3% for the High Risk group and 70.4% for the Low Risk group (p < 0.001, log-rank test). In multivariable Cox regression analysis, the risk group variable was the most discriminative predictor (HR = 3.56, p < 0.001), with sex, age at diagnosis, and transfusion burden also being significant (p = 0.01, 0.009, and 0.002, respectively). Discussion: The strong performance of the model, as evidenced by the ROC curve analysis, suggests that the selected variables offer substantial discriminative power. ML models offer more refined risk stratification than traditional methods, which may be useful in identifying occult relationships between variables. Validation in independent datasets may be necessary to strengthen the relationships herein exhibited. Conclusion: ML is a valuable tool for risk classification and survival prediction, offering significant insights for clinical decision-making and patient management that may be overlooked by other methods

THE DYNAMIC OF MDS DIAGNOSIS: FROM MULTI-LINEAGE DYSPLASIA AND HIGH BLASTS TO LMMC - A CASE REPORT

Introduction: Myelodysplastic neoplasms (MDS) is a heterogeneous group of hematologic diseases characterized by cytopenias in one or more hematologic lineages and multiple dysplasias. Myeloproliferative neoplasms (MPN) are characterized by an increase in production of differentiated hematopoietic cells. MDS/MPN overlap syndromes diagnoses have different clinical manifestations and the most common of them is chronic myelomonocytic leukemia (CMML) which is defined by an abnormal production of monocytic cells and an increase of risk to secondary acute myeloid leukemia (AML) progression. According to the 2016 World Health Organization (WHO) classification, CMML, listed amongst the MDS/MPN overlap disorders, is divided into CMML-0 (cases with 2% blasts in the blood and 5% blasts in the bone marrow), CMML-1 (2 to 4% blasts in the blood and/or 5 to 9% blasts in the bone marrow), and CMML-2 (5 to 19% blasts in the blood and 10 to 19% blasts in the bone marrow). This report aims to exhibit the importance of follow-up patients to detect progression from MDS with a high percentage of blasts to CMML. Case report: A 73-year-old woman with asymptomatic pancytopenia was submitted to our care in 2018. The bone marrow aspiration and immunohistochemical exam showed multilineage dysplasia, 4% of blasts and the bone biopsy presented 85% cellularity. Also, the monocytic count was 1115/mm3. The karyotype was normal in 20 metaphases. In 2019, the patient appeared with ecchymosis and new exams showed bicytopenia, 6% of blasts with 85% cellularity and the monocytic count was less than 1800/mm3. In 2020, she was diagnosed with MDS with an IPSS-R score of 3.5, bicytopenia and the monocytic count was less than 1400. But, in 2021, the monocytic count rose to 6100/mm3. It was then that her clinical condition evolved to a CMML-1. She was 76 years old when it was decided that she be treated with hydroxyurea. The first response wasn't as expected, so the medication was replaced to azacitidine in the middle of 2022. The second response to treatment was very well documented, however, the treatment with azacitidine suffered several interruptions due to lack of medicine which led the monocyte count to rise. Discussion: Patients with MDS who showed relative monocytosis (≥10% in peripheral blood) and an increase of absolute count of monocytes (≥ 1 × 10̂9/L) are related to a high risk of progression to CMML with a positive predictive value (PPV) of 71,4%. The follow-up and the correct diagnosis is essential in MDS/MPN overlap syndromes since their prognosis and clinical implications differ from these isolated disorders. The patient in question started to be followed up in 2018 where multiple exams were made to discard other diseases, but the monocyte count was always carefully observed due to the risk of progression to CMML, which was detected in 2021. Then, the treatment was required. The use of hypomethylating agents can be considered for CMML patients if excess blasts or poor prognosis factors are present. The azacitidine was used and was able to revert to a normal monocyte profile with improved hemoglobin count, although the interruption of treatment because of lack of medicine in Unified Health System (SUS) demonstrates a treatment failure. Conclusion: Monitoring the progress of MDS in the patient was able to detect CMML at the beginning and already start the treatment

ASSOCIATION OF PRE-TREATMENT BLOOD TRANSFUSION WITH CERVICAL CANCER OUTCOMES: A SYSTEMATIC REVIEW AND META-ANALYSIS

Introduction: Cervical cancer (CC) is one of the leading causes of cancer-related deaths in low- and middle-income countries, where it is often diagnosed as symptomatic, which is common in advanced stages. The most common symptom of CC is vaginal bleeding, which can lead to anemia and an indication of blood transfusions (BT) before initiating cancer treatment. However, the implication of BT in the survival of patients with CC remains unclear. Objective: We conducted a systematic review and meta-analysis that investigated the association between BT and survival outcomes in patients with CC. Methodology: A systematic search of the PubMed, Embase, and Cochrane databases was conducted in July 2024. The search strategy employed the MeSH terms: “cervical cancer” AND “blood transfusion.” Inclusion criteria were (1) articles reporting on CC patients who received blood transfusions before curative treatment (2) report of disease-free survival (DFS) and overall survival (OS) as main outcomes. Exclusion criteria included (1) reviews, (2) case reports (3) BT after or during oncology treatment. Data extraction and quality assessment were performed independently by two reviewers. Hazard ratios (HR) for DFS and OS were calculated using a random-effects model, with heterogeneity assessed using the I2 metric and Cochran's Q test in Review Manager 5.4 software. Results: The initial search yielded 723 articles, of which 3 met the inclusion criteria and were included in this review. These studies encompassed 1301 patients, of whom 492 (37.8%) received BT before their curative therapy, which was chemoradiation. The analysis demonstrated that patients who received BT had a worse prognosis, with an HR of 2.78 for OS (95% CI 1.27-6.11; p = 0.01; I2 = 0%). An analysis with 2 studies demonstrated an HR of 2.55 for DFS (95% CI 1.41-4.62; p = 0.01; I2 = 0%). Discussion: Our findings demonstrate that in patients with CC, pre-treatment BT is associated with noticeably poorer OS and DFS. This result suggests that BT is a poor predictor of survival outcomes. There are numerous possible explanations for this correlation. Given that BT is known to cause immunosuppression, tumor development and metastasis may be encouraged. Furthermore, pro-inflammatory mediators that may be present in BT may further contribute to an unfavorable tumor microenvironment. Although these elements were not examined in our analysis, additional variables including the length of time blood products are stored or the existence of particular blood groups may potentially be important. Conclusion: Our findings suggest that pre-treatment blood transfusion is associated with significantly worse OS and DFS in cervical cancer patients. These results highlight the need for further prospective research to confirm this association, as well as to explore alternative strategies to manage anemia and cancer-related blood loss in this population, promoting personalized treatment strategies that optimize outcomes for women with cervical cancer

IS FERRITIN A GOOD PREDICTOR OF SURVIVAL ACROSS ALL RISK LEVELS IN MYELODYSPLASTIC NEOPLASMS? INSIGHTS FROM A STRATIFIED COHORT STUDY

Introduction: Myelodysplastic neoplasms (MDS) are a heterogeneous group of hematologic malignancies characterized by ineffective hematopoiesis. The Revised International Prognostic Scoring System (IPSS-R) is widely used to stratify MDS patients into different risk categories, guiding treatment decisions and predicting survival outcomes. Ferritin has been implicated in the pathophysiology of MDS. Elevated ferritin levels may reflect iron overload, inflammation, or both. However, the prognostic value of ferritin across different risk levels in MDS remains unclear. Objective: This study aims to evaluate the prognostic significance of ferritin in patients with MDS, stratified by IPSS-R risk categories. Methods: A retrospective cohort study at a single reference center reviewed patients diagnosed with MDS between 2004 and 2024. The study included patients with available clinical outcomes and ferritin values. Missing data for other variables were addressed using the classification and regression tree analysis (CART) Multiple imputation method, following confirmation of non-completely at random missingness through Little's test. Patients were stratified into two groups based on IPSS-R scores: ’high risk’, comprising those categorized as ’High’ or ’Very High’, and ’low risk’, encompassing all other IPSS-R categories. The CART method was utilized to determine the optimal ferritin cut-off for predicting overall survival, applying Martingale residuals from a univariate Cox model adjusted for ferritin. Kaplan-Meier curves were subsequently generated to assess survival rates at 1, 3, and 5 years post-diagnosis for patients below and above the ferritin cut-off, with comparisons conducted using log-rank tests. All statistical analyses were performed using R software, leveraging the ’mice’ package for imputation and the ’survfit’ package for survival analysis. Results: A total of 143 patients with available ferritin values and clinical outcomes were included in the study. Using the CART method, an optimal ferritin cut-off of 888.5 was determined, classifying the cohorts into “High Ferritin” (32 patients) and “Low Ferritin” (111 patients). Kaplan-Meier 1, 3, and 5-year survival curves were constructed for both the ’high risk’ (17 patients) and ’low risk’ (126 patients) groups. Among the ’low risk’ patients, those with low ferritin levels, compared to those with high ferritin levels, had significantly higher 3 (78.6% vs 44.3%, p < 0.001) and 5-year (57.3% vs. 34.8%, p < 0.001) survival rates, although no difference was seen in 1-year rates (p = 0.45). Within the ’high risk’ group, no difference between the high and low ferritin groups was seen in 1, 3, or 5-year survival rates (p = 0.26, 0.066, and 0.066, respectively). Discussion: Ferritin, a marker of iron overload and inflammation, plays a role in the pathophysiology of MDS. Our study shows that ferritin levels predict long-term survival in low-risk MDS patients, consistent with previous studies, but are less predictive in high-risk patients. This suggests ferritin's impact may be overshadowed by other factors in high-risk MDS. Conclusion: Ferritin level at diagnosis is a good predictor of long-term survival for non-high risk MDS patients, but its efficacy in predicting outcomes for high-risk patients and general short-term survival is less evident

TRENDS IN MYELODYSPLASTIC SYNDROMES-RELATED MORTALITY IN BRAZIL FROM 2014 TO 2023

Objectives: This study aims to analyze the epidemiology of myelodysplastic syndromes (MDS)-related deaths among Brazilian patients, thereby helping to understand the disorder's behavior and to formulate public health strategies to mitigate its impact. Material and methods: This is a retrospective, observational study with data from the Secretariat of Health Surveillance (SVS). Deaths from January 2014 to December 2023 identified as related to MDS (ICD-10 D46) were included, categorized by sex, age, race, location and calendar year. Statistical analysis was performed considering absolute and relative frequencies. Results: In total, 9,659 deaths related to MDS occurred in Brazil during the period, meaning an average of around 966 deaths per year. Males accounted for 5,082 (52.6%) deaths, while females accounted for 4,576 (47.4%). The number of reported deaths increased with age, from 56 deaths in patients aged 01-09 years old to 2,687 deaths in patients aged 70-79 and 4,045 deaths in patients aged 80+; overall, patients under 60 years old represented 14% of all deaths, while 86% were patients 60+ years old. The white population was the most affected, with 6,498 (63.7%) deaths; 2,284 (23.6%) were brown; 471 (4.9%) were black; and 406 (4.2%) were yellow, indigenous or did not have their race recorded. Regarding location, 5,271 (54.6%) deaths occurred in the Southeast, 1,752 (18.1%) in the South, 1,692 (17.5%) in the Northeast, 592 (6.1%) in the Central-West and 352 (3.6%) in the North. The year with the most deaths was 2023 with 1,120 (15.9% above average), whilst the year with the least was 2015 with 835 (13.6% beneath average). Discussion: The slight male predominance observed, which is greater relative to the Brazilian male/female proportion (48.5/51.5 in 2022 according to IBGE), might be related to genetic and hormonal differences and to environmental exposure to risk factors such as smoking, which may lead to worse survival. The age range reveals that MDS are significantly more prevalent in the elderly, likely due to genetic mutations and age-related changes in bone marrow that are more common with aging. Comorbities and a weakened immune system may as well contribute to a higher death rate in older patients with MDS. The preponderance of reported deaths among whites is possibly due to genetic predisposition or to disparities in socioeconomic backgrounds and access to healthcare services, causing the white population to be more assertively diagnosed, as MDS diagnosis often requires specialized services. This might also explain the regional discrepancies in deaths relative to the population, with proportionally more deaths in the South and Southeast and fewer in the Northeast, North and Central-West, as there is a higher rate of whites and greater access to specialized medical services in the South and Southeast. Yearly mortality remained reasonably stable, with a subtle increase that might be associated with population aging or improved diagnosis capability. Conclusion: The data demonstrates a clear relation between age and mortality, with a significant number of deaths among the elderly population. This highlights the necessity for the development of new treatments that might reduce the risk associated with MDS in older individuals. The higher occurrence of reported deaths in regions and demographics with greater socioeconomic status and access to healthcare exhibits the need for public health strategies to address these disparities

SJÖGREN-LARSSON SYNDROME ASSOCIATED WITH MYELODYSPLASTIC SYNDROME: A CASE REPORT

Introduction: The Sjögren-Larsson Syndrome (SSL) is a rare autoimmune disease that causes glandular inflammation, normally in salivary and lacrimal glands. It can be classified as primary, when it is isolated, or secondary, when it is concomitant with other syndromes. Several studies correlate immune diseases with bone-marrow neoplasias, between them, the Myelodysplastic neoplasms (MDS). MDS is a heterogeneous group of hematologic diseases characterized by cytopenias in one or more hematologic lineages. Also, immunological disorders and chronic immunological stimulation are shown to be a trigger to ineffective hematopoiesis in patients with genetic predisposition. This report aims to describe MDS diagnosis in a patient with a rare immune disease and to demonstrate the complications associated with this condition. Case report: A 76-year-old woman, diagnosed with secondary SSL and autoimmune hemolytic anemia (AHAI), mastectomized, returned to a follow-up declaring fatigue and indisposition. The hematologic perfil showed: direct coombs positive, reticulocytes 8.0%, hemoglobin 7.7 g/dL, leukocytes 1280, platelets 318,000, homogeneous nuclear ANA 1/640, hypergammaglobulinemia, anti-SSA 240.0 and Schirmer positive. She was submitted to multiple treatments with antihistamines and immunosuppressants, but had infectious complications and hospital admissions. In 2023, it was indicated a splenectomy due to refractory disease and she started to be followed up by a hematologist, who suggested treatment with rituximab (500 mg in two sections with intervals of 14 days) as an alternative to active AHAI secondary to SSL. The treatment showed a good clinical result with the hemoglobin increased to 10,6 g/dL. However, at the end of 2023, the patient was unable to undergo a new pulse therapy of mabthera due to changes in the follow-up examinations of previously treated breast adenocarcinoma. A new biopsy showed multiple adenopathy attributed to the SSL itself. In 2024, a new bone marrow aspirate was taken which showed dyserythropoiesis, dysgranulopoiesis, 2% blasts and, in the cytogenetics test, 47,XX,+14[4]/46,XX[16]. In this context, the patient was diagnosed with MDS with a low percentage of blasts (MDS-LB). Discussion: The immunological dysregulation and hyperactivation of T and B lymphocytes will destroy self-antigens present in the epithelium of the exocrine glands, characterizing SSL, and in the erythrocytes, as in AHAI, leading to the release of hemoglobin into the plasma and dysfunction in gas transport. Studies show that autoimmune manifestations can lead to secondary diseases in bone marrow and MDS is one of them. Recently, studies linked UBA1 somatic mutations as the recurrent cause of clinically complex diagnoses with overlapping hematologic features. This new disease entity is known as VEXAS (vacuoles, E1 enzyme, X-linked, autoinflammatory, somatic) syndrome. VEXAS syndrome is frequently associated with hematological disorders, around 30-50% of these patients have concurrent MDS. Interestingly, the 14 trisomy finding has been associated with hematologic neoplasias and MDS overlap syndromes. In addition, it is crucial to confirm UBA1 mutation to VEXAS-associated diagnoses in this context of inflammatory clinical presentation. The correct diagnosis of MDS overlap syndromes is essential because their prognosis differs from isolated disorders and may require specific treatments due to unique molecular vulnerabilities

THE ATAXIA-TELANGIECTASIA MUTATED (ATM) GENE PLAYS A PIVOTAL ROLE IN THE REPAIR OF DNA IN CASES OF MYELODYSPLASTIC NEOPLASM

Myelodysplastic Neoplasm (MDS) is an age-associated neoplasia characterized by frequent epigenetic abnormalities being hypermethylation the most common, frequently associated with transformation to acute myeloid leukemia (AML). DNA repair genes have been constantly downregulated in MDS during progression to AML, but these genes have not been evaluated regarding methylation status or mutational profile. Using three different cohorts of MDS (Cohort A- 56 patients; Cohort B- 100 patients; Cohort C- 76 patients) in three sequential steps we evaluated with complementary methods (pyrosequencing, real-time PCR, immunohistochemistry, cytogenetics and search of mutations) the DNA repair genes for the following analyses: methylation of single-strand (XPA, XPC, XPG-ERCC5, CSA-ERCC8, and CSB-ERCC6) and double-strand (ATM, BRCA1, BRCA2, LIG4, and RAD51) DNA repair genes by pyrosequencing; gene expression by RT-qPCR of the ATM gene; and protein expression by immunohistochemistry of ATM, 5-methylcytosine (5mC), and 5-hydroxymethylcytosine (5-hmC). Additionally, we used cBioPortal to search for mutations in single-strand and double-strand DNA repair genes. Regarding methylation of single strand repair genes, we detected XPA with higher methylation for low risk MDS than high risk MDS (p < 0.0001) while for double-strand repair pathway, only ATM showed higher methylation for patients who transformed to AML compared to cases who did not transform into AML (p = 0.016). In a second step, we evaluated the gene expression of ATM, showing downregulation in MDS compared to controls (p = 0.042). In a third step, when we divided patients according to WHO classification of 2022, we detected a progressive reduction of ATM expression from subtypes considered as low risk disease (Hypoplastic MDS, MDS with Ring Sideroblasts, MDS with deletion (5q)) compared to high risk MDS (increased of blasts 1 and 2) and AML. We also detected patients who transformed into AML showed a higher ratio of 5mc/5hmC than cases who did not transform (p = 0.045). In addition, we observed a higher tissue methylation score (M-score of 5mC%) in patients classified as poor cytogenetic risk by the IPSS-R than patients classified as good cytogenetic risk (p = 0.035). Finally, using the most recent platform CBioportal (including the cases of Molecular IPSS with more than 7000 patients), we detected ATM as the most mutated, among the DNA repair genes, with the greater variety of mutations such as frameshift, missense and splice compared to others and only ATM mutations were classified as oncogenic according to the standards for the classification of pathogenicity of somatic variations in cancer (SOP 2022). We believe all the results presented herein suggest that ATM is silenced or down regulated in MDS by methylation or mutations, ultimately increasing the chance of AML transformation

BLASTING BEYOND THE OBVIOUS: IDENTIFICATION OF OVERLOOKED PREDICTIVE FACTORS FOR LEUKEMIC CONVERSION IN MYELODYSPLASTIC NEOPLASMS

Introduction: Myelodysplastic neoplasms (MDS) are a group of clonal hematopoietic disorders characterized by dysplasia in one or more myeloid cell lines, ineffective hematopoiesis, and an increased risk of progression to acute myeloid leukemia (AML). The transition from MDS to AML is a pivotal event that significantly impacts patient outcomes. While the blast percentage in bone marrow is a well-established predictor of leukemic conversion, it often overshadows other potentially significant prognostic factors. Objective: This study aims to identify independent predictive factors for leukemic conversion in patients with MDS, adjusting for the blast percentage in the bone marrow. Methods: We conducted a retrospective cohort at a single reference center, involving patients diagnosed with MDS between 2004 and 2024. We included patients with available data on survival and leukemic conversion outcomes. Missing data for other variables were handled using the ’cart’ multiple imputation method, following confirmation of non-completely at random missingness through Little's test. We performed multivariate Cox proportional hazards (PH) regression to model leukemic conversion, adjusting for multiple relevant clinical parameters, including blast percentage, allowing for the evaluation of the independent effects of other variables. All statistical analyses were conducted using R software, utilizing the ’mice’ package for imputation and the ’survival’ package for survival analysis. Results: 162 patients were included in this study. In the multivariable Cox PH regression, we adjusted for blast percentage, sex, age at diagnosis, cytogenetic prognostic, presence of dysplasia in specific lineages in bone marrow, complete hemogram parameters, iron-related parameters, and transfusion burden. Optimal cut-offs were defined based on clinical relevance. In our analysis, only blast percentage, male sex, transfusion burden, hemoglobin count lower than 10 g/dL and serum iron higher than 65 μg/dL were significant (p < 0.001, < 0.001, 0.03, 0.012, and 0.03, respectively). Other than blast percentage, the most discriminative variable was sex, with males having a HR of 10.46 (95% CI: 3.31-33.08) for AML conversion in comparison to females. Transfusion burden (HR = 6.16, 95% CI: 1.85 - 20.52) and hemoglobin higher than 10 ng/dL (HR = 4.31, 95% CI: 1.36 - 13.65) were also relevant predictors for leukemic conversion, while serum iron higher than 65 μg/dL (HR = 0.28, 95%CI: 0.09-0.86) was a protective factor. Discussion: Male sex has been associated with worse outcomes in MDS, such as a higher incidence of transformation to AML, which is partly due to a higher prevalence of high-risk somatic mutations in men. Transfusion burden has also been associated with AML conversion, as iron overload can contribute to leukemic transformation due to the accumulation of free iron radicals, which can cause DNA damage and promote leukemogenesis. However, the protective impact of high serum iron may relate to premature death, as these patients may be less susceptible to AML conversion. Similarly, although higher hemoglobin levels have been associated with better survival, its impact on leukemic transformation in our study may be due to death as a competing risk. Conclusion: Our study identified important discriminative factors for AML transformation in MDS patients when adjusting for blast percentage. These factors will allow for a more refined risk stratification in this population