Skip to main content Accessibility help
  • Print publication year: 2010
  • Online publication date: December 2010

15 - Myelodysplastic syndromes and myelodysplastic/myeloproliferative neoplasms

from Part 2 - Hematological malignancies


Myelodysplastic syndromes and myelodysplastic/myeloproliferative neoplasms

Myelodysplastic syndromes (MDS) are a group of clonal disorders of the hematopoietic stem cell (HSC) characterized by ineffective hematopoiesis. This leads to peripheral blood cytopenias, and an excess of marrow blast cells. In some cases this can progress to acute myeloid leukemia (AML). Myelodysplastic syndromes are thought to result from the accumulation of genetic or epigenetic lesions (such as promoter hypermethylation) initially in a very immature progenitor cell. This leads to a proliferative advantage of the MDS clone over normal immature progenitors. MDS lineage-committed progenitors display both abnormal terminal differentiation and an increased susceptibility to apoptosis. These two features explain the clinical consequences of blast cell accumulation and peripheral blood cytopenias.

The diagnosis of MDS is generally suggested by the presence of peripheral blood (PB) cytopenias. However, the diagnosis requires the integration of the blood manifestations with the clinical history and physical examination. Although the etiology of MDS is generally unknown, antecedent cytotoxic therapy or radiation exposure and congenital bone marrow failure syndromes can predispose to MDS. Physical examination is in general normal in MDS, while splenomegaly can be found in myelodysplastic/myeloproliferative neoplasms (MDS/MPN). Careful morphological review of bone marrow for dysplasia is central to the diagnosis of MDS and MDS/MPN, and cytogenetic analysis for prognosis. Molecular genetics and flow cytometry assays are under evaluation, and, in future, may provide information for further refinement of the prognosis. The specific features of each of these diagnostic modalities will be discussed.

Corey, SJ, Minden, MD, Barber, DLet al. Myelodysplastic syndromes: the complexity of stem-cell diseases. Nat Rev Cancer 2007;7(2):118–29.
Bennett, JM, Catovsky, D, Daniel, MTet al. Proposals for the classification of the myelodysplastic syndromes. Br J Haematol 1982;51(2):189–99.
Vardiman, JW, Harris, NL, Brunning, RD. The World Health Organization (WHO) classification of the myeloid neoplasms. Blood 2002;100(7):2292–302.
Vardiman, JW, Thiele, J, Arber, DAet al. The 2008 revision of the World Health Organization (WHO) classification of myeloid neoplasms and acute leukemia: rationale and important changes. Blood 2009;114(5):937–51.
Greenberg, P, Cox, C, LeBeau, MMet al. International scoring system for evaluating prognosis in myelodysplastic syndromes. Blood 1997;89(6):2079–88.
Fenaux, P, Mufti, GJ, Hellström-Lindberg, Eet al. Efficacy of azacitidine compared with that of conventional care regimens in the treatment of higher-risk myelodysplastic syndromes: a randomised, open-label, phase III study. Lancet Oncol 2009;10:223–32.
Garcia-Manero, G, Shan, J, Faderl, Set al. A prognostic score for patients with lower risk myelodysplastic syndrome. Leukemia 2008;22:538–43.
Malcovati, L, Porta, MG, Pascutto, Cet al. Prognostic factors and life expectancy in myelodysplastic syndromes classified according to WHO criteria: a basis for clinical decision making. J Clin Oncol 2005;23(30):7594–603.
Valent, P, Horny, HP, Bennett, JMet al. Definitions and standards in the diagnosis and treatment of the myelodysplastic syndromes: Consensus statements and report from a working conference. Leuk Res 2007;31(6):727–36.
Wimazal, F, Fonatsch, C, Thalhammer, Ret al. Idiopathic cytopenia of undetermined significance (ICUS) versus low risk MDS: the diagnostic interface. Leuk Res 2007;31(11):1461–8.
Kaloutsi, V, Kohlmeyer, U, Maschek, Het al. Comparison of bone marrow and hematologic findings in patients with human immunodeficiency virus infection and those with myelodysplastic syndromes and infectious diseases. Am J Clin Pathol 1994;101(2):123–9.
Steensma, DP, Higgs, DR, Fisher, CA, Gibbons, RJ. Acquired somatic ATRX mutations in myelodysplastic syndrome associated with alpha thalassemia (ATMDS) convey a more severe hematologic phenotype than germline ATRX mutations. Blood 2004;103(6):2019–26.
Knipp, S, Strupp, C, Gattermann, Net al. Presence of peripheral blasts in refractory anemia and refractory cytopenia with multilineage dysplasia predicts an unfavourable outcome. Leuk Res 2008;32(1):33–7.
Bennett, JM, Orazi, A. Diagnostic criteria to distinguish hypocellular acute myeloid leukemia from hypocellular myelodysplastic syndromes and aplastic anemia: recommendations for a standardized approach. Haematologica 2009;94(2):264–8.
Mufti, GJ, Bennett, JM, Goasguen, Jet al. Diagnosis and classification of myelodysplastic syndrome: International Working Group on Morphology of myelodysplastic syndrome (IWGM-MDS) consensus proposals for the definition and enumeration of myeloblasts and ring sideroblasts. Haematologica 2008;93(11):1712–17.
Lai, JL, Preudhomme, C, Zandecki, Met al. Myelodysplastic syndromes and acute myeloid leukemia with 17p deletion. An entity characterized by specific dysgranulopoiesis and a high incidence of P53 mutations. Leukemia 1995;9(3):370–81.
Apperley, JF, Gardembas, M, Melo, JVet al. Response to imatinib mesylate in patients with chronic myeloproliferative diseases with rearrangements of the platelet-derived growth factor receptor beta. New Engl J Med 2002;347(7):481–7.
Goasguen, JE, Bennett, JM, Cox, Cet al. Prognostic implication and characterization of the blast cell population in the myelodysplastic syndrome. Leuk Res 1991;15(12):1159–65.
Goasguen, JE, Bennett, JM, Bain, BJet al. Morphological evaluation of monocytes and their precursors. Haematologica 2009;94(7):994–7.
Tuzuner, N, Cox, C, Rowe, JM, Bennett, JM. Bone marrow cellularity in myeloid stem cell disorders: impact of age correction. Leuk Res 1994;18(8):559–64.
Thiele, J, Kvasnicka, HM, Facchetti, Fet al. European consensus on grading bone marrow fibrosis and assessment of cellularity. Haematologica 2005;90(8):1128–32.
Tiu, R, Gondek, L, O'Keefe, C, Maciejewski, JP. Clonality of the stem cell compartment during evolution of myelodysplastic syndromes and other bone marrow failure syndromes. Leukemia 2007;21(8):1648–57.
Orazi, A, Albitar, M, Heerema, NA, Haskins, S, Neiman, RS. Hypoplastic myelodysplastic syndromes can be distinguished from acquired aplastic anemia by CD34 and PCNA immunostaining of bone marrow biopsy specimens. Am J Clin Pathol 1997;107(3):268–74.
Della Porta, MG, Malcovati, L, Invernizzi, Ret al. Flow cytometry evaluation of erythroid dysplasia in patients with myelodysplastic syndrome. Leukemia 2006;20(4):549–55.
Yue, G, Hao, S, Fadare, Oet al. Hypocellularity in myelodysplastic syndrome is an independent factor which predicts a favorable outcome. Leuk Res 2008;32(4):553–8.
Arber, DA. Realistic pathologic classification of acute myeloid leukemias. Am J Clin Pathol 2001;115(4):552–60.
Della Porta, MG, Malcovati, L, Boveri, Eet al. Clinical relevance of bone marrow fibrosis and CD34-positive cell clusters in primary myelodysplastic syndromes. J Clin Oncol 2009;27(5):754–62.
Tricot, G, Wolf-Peeters, C, Vlietinck, R, Verwilghen, RL. Bone marrow histology in myelodysplastic syndromes. II. Prognostic value of abnormal localization of immature precursors in MDS. Br J Haematol 1984;58(2):217–25.
Korkolopoulou, P, Apostolidou, E, Pavlopoulos, PMet al. Prognostic evaluation of the microvascular network in myelodysplastic syndromes. Leukemia 2001;15(9):1369–76.
Bellamy, WT, Richter, L, Sirjani, Det al. Vascular endothelial cell growth factor is an autocrine promoter of abnormal localized immature myeloid precursors and leukemia progenitor formation in myelodysplastic syndromes. Blood 2001;97(5):1427–34.
Haase, D, Germing, U, Schanz, Jet al. New insights into the prognostic impact of the karyotype in MDS and correlation with subtypes: evidence from a core dataset of 2124 patients. Blood 2007;110(13):4385–95.
Itzykson, R, Fenaux, P. Optimal sequencing of treatments for patients with myelodysplastic syndromes. Curr Opin in Hematol 2009;16(2):77–83.
Park, S, Grabar, S, Kelaidi, Cet al. Predictive factors of response and survival in myelodysplastic syndrome treated with erythropoietin and G-CSF: the GFM experience. Blood 2008;111(2):574–82.
Sole, F, Luno, E, Sanzo, Cet al. Identification of novel cytogenetic markers with prognostic significance in a series of 968 patients with primary myelodysplastic syndromes. Haematologica 2005;90(9):1168–78.
Ebert, BL, Pretz, J, Bosco, Jet al. Identification of RPS14 as a 5q- syndrome gene by RNA interference screen. Nature 2008;451(7176):335–9.
Nilsson, L, Eden, P, Olsson, Eet al. The molecular signature of MDS stem cells supports a stem-cell origin of 5q myelodysplastic syndromes. Blood 2007;110(8):3005–14.
Li, X, Bryant, CE, Deeg, HJ. Simultaneous demonstration of clonal chromosome abnormalities and apoptosis in individual marrow cells in myelodysplastic syndrome. Int J Hematol 2004;80(2):140–5.
List, A, Dewald, G, Bennett, Jet al. Lenalidomide in the myelodysplastic syndrome with chromosome 5q deletion. New Engl J Med 2006;355(14):1456–65.
Berghe, H, Cassiman, JJ, David, Get al. Distinct haematological disorder with deletion of long arm of no. 5 chromosome. Nature 1974;251(5474):437–8.
Wei, S, Chen, X, Rocha, Ket al. A critical role for phosphatase haplodeficiency in the selective suppression of deletion 5q MDS by lenalidomide. Proc Natl Acad Sci USA 2009;106(31):12974–9.
Boultwood, J, Fidler, C, Strickson, AJet al. Narrowing and genomic annotation of the commonly deleted region of the 5q– syndrome. Blood 2002;99(12):4638–41.
Ades, L, Boehrer, S, Prebet, Tet al. Efficacy and safety of lenalidomide in intermediate-2-or high risk myelodysplastic syndromes (MDS) with 5q deletion: Results of a phase II study. Blood 2009;113(17):3947–52.
Horrigan, SK, Arbieva, ZH, Xie, HYet al. Delineation of a minimal interval and identification of 9 candidates for a tumor suppressor gene in malignant myeloid disorders on 5q31. Blood 2000;95(7):2372–7.
Wiktor, A, Rybicki, BA, Piao, ZSet al. Clinical significance of Y chromosome loss in hematologic disease. Genes Chromosomes Cancer 2000;27(1):11–16.
Iwabuchi, A, Ohyashiki, K, Ohyashiki, JHet al. Trisomy of chromosome 8 in myelodysplastic syndrome. Significance of the fluctuating trisomy 8 population. Cancer Genet Cytogenet 1992;62(1):70–4.
Breems, DA, Putten, WL, Greef, GEet al. Monosomal karyotype in acute myeloid leukemia: a better indicator of poor prognosis than a complex karyotype. J Clin Oncol 2008;26(29):4791–7.
Nucifora, G, Laricchia-Robbio, L, Senyuk, V. EVI1 and hematopoietic disorders: history and perspectives. Gene 2006;368:1–11.
Valent, P, Sperr, WR, Samorapoompichit, Pet al. Myelomastocytic overlap syndromes: biology, criteria, and relationship to mastocytosis. Leuk Res 2001;25(7):595–602.
Hellström-Lindberg, E, Cazzola, M. The role of JAK2 mutations in RARS and other MDS. Hematology Am Soc Hematol Educ Program 2008;2008:52–9.
Fenaux, P, Raza, A, Mufti, GJet al. A multicenter phase 2 study of the farnesyltransferase inhibitor tipifarnib in intermediate- to high-risk myelodysplastic syndrome. Blood 2007;109(10):4158–63.
Gelsi-Boyer, V, Trouplin, V, Adelaide, Jet al. Mutations of polycomb-associated gene ASXL1 in myelodysplastic syndromes and chronic myelomonocytic leukaemia. Br J Haematol 2009;145(6):788–800.
Vey, N, Bosly, A, Guerci, Aet al. Arsenic trioxide in patients with myelodysplastic syndromes: a phase II multicenter study. J Clin Oncol 2006;24(16):2465–71.
Cilloni, D, Saglio, G. WT1 as a universal marker for minimal residual disease detection and quantification in myeloid leukemias and in myelodysplastic syndrome. Acta Haematol 2004;112(1–2):79–84.
Epling-Burnette, PK, Painter, JS, Rollison, et al. Prevalence and clinical association of clonal T-cell expansions in myelodysplastic syndrome. Leukemia 2007;21(4):659–67.
Sloand, EM, Mainwaring, L, Fuhrer, Met al. Preferential suppression of trisomy 8 compared with normal hematopoietic cell growth by autologous lymphocytes in patients with trisomy 8 myelodysplastic syndrome. Blood 2005;106(3):841–51.
Kochenderfer, JN, Kobayashi, S, Wieder, ED, Su, C, Molldrem, JJ. Loss of T-lymphocyte clonal dominance in patients with myelodysplastic syndrome responsive to immunosuppression. Blood 2002;100(10):3639–45.
Chen, G, Zeng, W, Miyazato, Aet al. Distinctive gene expression profiles of CD34 cells from patients with myelodysplastic syndrome characterized by specific chromosomal abnormalities. Blood 2004;104(13):4210–18.
Mills, KI, Kohlmann, A, Williams, PMet al. Microarray-based classifiers and prognosis models identify subgroups with distinct clinical outcomes and high risk of AML transformation of myelodysplastic syndrome. Blood 2009;114(5):1063–72.
Ebert, BL, Galili, N, Tamayo, Pet al. An erythroid differentiation signature predicts response to lenalidomide in myelodysplastic syndrome. PLoS Med 2008;5(2):e35.
Lom, K, Hagemeijer, A, Smit, Eet al. Cytogenetic clonality analysis in myelodysplastic syndrome: monosomy 7 can be demonstrated in the myeloid and in the lymphoid lineage. Leukemia 1995;9(11):1818–21.
Gondek, LP, Tiu, R, O'Keefe, CLet al. Chromosomal lesions and uniparental disomy detected by SNP arrays in MDS, MDS/MPD, and MDS-derived AML. Blood 2008;111(3):1534–42.
Mohamedali, A, Gaken, J, Twine, NAet al. Prevalence and prognostic significance of allelic imbalance by single-nucleotide polymorphism analysis in low-risk myelodysplastic syndromes. Blood 2007;110(9):3365–73.
Sanada, M, Suzuki, T, Shih, LYet al. Gain-of-function of mutated C-CBL tumour suppressor in myeloid neoplasms. Nature 2009;460:904–8.
Kosmider, O, Gelsi-Boyer, V, Cheok, Met al. TET2 mutation is an independent favorable prognostic factor in myelodysplastic syndromes (MDS). Blood 2009;114(15):3285–91.
Quesnel, B, Guillerm, G, Vereecque, Ret al. Methylation of the p15(INK4b) gene in myelodysplastic syndromes is frequent and acquired during disease progression. Blood 1998;91(8):2985–90.
Jiang, Y, Dunbar, A, Gondek, LPet al. Aberrant DNA methylation is a dominant mechanism in MDS progression to AML. Blood 2009;113(6):1315–25.
Figueroa, ME, Skrabanek, L, Li, Yet al. MDS and secondary AML display unique patterns and abundance of aberrant DNA methylation. Blood 2009;114(16):3448–58.
Loosdrecht, AA, Alhan, C, Bene, MCet al. Standardization of flow cytometry in myelodysplastic syndromes: report from the first European LeukemiaNet working conference on flow cytometry in myelodysplastic syndromes. Haematologica 2009;94(8):1124–34.
Maynadie, M, Picard, F, Husson, Bet al. Immunophenotypic clustering of myelodysplastic syndromes. Blood 2002;100(7):2349–56.
Loosdrecht, AA, Westers, TM, Westra, AHet al. Identification of distinct prognostic subgroups in low- and intermediate-1-risk myelodysplastic syndromes by flow cytometry. Blood 2008;111(3):1067–77.
Ogata, K, Kishikawa, Y, Satoh, Cet al. Diagnostic application of flow cytometric characteristics of CD34+ cells in low-grade myelodysplastic syndromes. Blood 2006;108(3):1037–44.
Subira, D, Font, P, Villalon, Let al. Immunophenotype in chronic myelomonocytic leukemia: is it closer to myelodysplastic syndromes or to myeloproliferative disorders?Transl Res 2008;151(5):240–5.
Wells, DA, Benesch, M, Loken, MRet al. Myeloid and monocytic dyspoiesis as determined by flow cytometric scoring in myelodysplastic syndrome correlates with the IPSS and with outcome after hematopoietic stem cell transplantation. Blood 2003;102(1):394–403.
Scott, BL, Wells, DA, Loken, MRet al. Validation of a flow cytometric scoring system as a prognostic indicator for posttransplantation outcome in patients with myelodysplastic syndrome. Blood 2008;112(7):2681–6.
Westers, TM, Alhan, C, Cali, C, Ossenkoppele, GJ, Loosdrecht, AA. Quantitative dynamics of flow cytometric aberrancies during treatment with erythropoietin/G-CSF are predictive for responses in LOW/INT-I risk myelodysplastic syndromes. Blood 2008;112:5867 [Abstr].
Wang, H, Chuhjo, T, Yasue, S, Omine, M, Nakao, S. Clinical significance of a minor population of paroxysmal nocturnal hemoglobinuria-type cells in bone marrow failure syndrome. Blood 2002;100(12):3897–902.
Poulain, S, Lepelley, P, Preudhomme, Cet al. Expression of the multidrug resistance-associated protein in myelodysplastic syndromes. Br J Haematol 2000;110(3):591–8.
Kordasti, SY, Ingram, W, Hayden, Jet al. CD4+CD25high Foxp3+ regulatory T cells in myelodysplastic syndrome (MDS). Blood 2007;110(3):847–50.
Sternberg, A, Killick, S, Littlewood, Tet al. Evidence for reduced B-cell progenitors in early (low-risk) myelodysplastic syndrome. Blood 2005;106(9):2982–91.
Nyakern, M, Tazzari, PL, Finelli, Cet al. Frequent elevation of Akt kinase phosphorylation in blood marrow and peripheral blood mononuclear cells from high-risk myelodysplastic syndrome patients. Leukemia 2006;20(2):230–8.
Germing, U, Hildebrandt, B, Pfeilstocker, Met al. Refinement of the International Prognostic Scoring System (IPSS) by including LDH as an additional prognostic variable to improve risk assessment in patients with primary myelodysplastic syndromes (MDS). Leukemia 2005;19(12):2223–31.
Kotecha, N, Flores, NJ, Irish, JMet al. Single-cell profiling identifies aberrant STAT5 activation in myeloid malignancies with specific clinical and biologic correlates. Cancer Cell 2008;14(4):335–43.
Parker, C, Omine, M, Richards, Set al. Diagnosis and management of paroxysmal nocturnal hemoglobinuria. Blood 2005;106(12):3699–709.
Hillmen, P, Muus, P, Duhrsen, Uet al. Effect of the complement inhibitor eculizumab on thromboembolism in patients with paroxysmal nocturnal hemoglobinuria. Blood 2007;110(12):4123–8.
Hall, SE, Rosse, WF. The use of monoclonal antibodies and flow cytometry in the diagnosis of paroxysmal nocturnal hemoglobinuria. Blood 1996;87(12):5332–40.
Yamashina, M, Ueda, E, Kinoshita, Tet al. Inherited complete deficiency of 20-kilodalton homologous restriction factor (CD59) as a cause of paroxysmal nocturnal hemoglobinuria. New Engl J Med 1990;323(17):1184–9.
Hall, C, Richards, S, Hillmen, P. Primary prophylaxis with warfarin prevents thrombosis in paroxysmal nocturnal hemoglobinuria (PNH). Blood 2003;102(10):3587–91.
Sugimori, C, Chuhjo, T, Feng, Xet al. Minor population of CD55-CD59- blood cells predicts response to immunosuppressive therapy and prognosis in patients with aplastic anemia. Blood 2006;107(4):1308–14.
Sloand, EM, Wu, CO, Greenberg, P, Young, N, Barrett, J. Factors affecting response and survival in patients with myelodysplasia treated with immunosuppressive therapy. J Clin Oncol 2008;26(15):2505–11.
Swerdlow, SH, Campo, E, Harris, NLet al. (eds.). WHO Classification of Tumours of Haematopoietic and Lymphoid Tissues, 4th edn. Lyon: IARC Press; 2008.