Biological Predictive Scoring System in Low Risk Myelodysplastic Syndromes (LR-MDS)
Authors: Dine Gerard Daniel , Brahimi Said , Misra Srimanta , Rehn Yves , Vergnolle Sebastien , Gaillard Baptiste , Banzakour Said , Nacoulma Eric , Fumagalli Gabriela 
Published: November 2019

Abstract
Background
Myelodysplastic syndrome (MDS) is a pre-leukemia disease affecting the erythroid, myeloid and megakaryocytic bone marrow production. MDS patients are classified according to the WHO classification of myeloid neoplasms. During the past 15 years management of MDS patients has been stratified according to the International Prognostic Scoring System (IPSS) risk score. Recently a revised version of IPSS has been introduced (IPSS-R). One quarter of LR-MDS in this new IPSS-R were reclassified as having a higher risk and a substantial subset of high risk-MDS (HR-MDS) were reclassified as lower risk. In LR-MDS a differentiation block is observed in the erythroid lineage. The diagnosis and follow up of cytopenias in particular anemia must be the main objective (1). The soluble transferrin receptor (sTfR) directly reflects the erythropoietic activity in individuals without iron defiency and may appreciate ineffective dysplastic erythropoiesis in LR-MDS.
In LR-MDS there is also an inverse relationship between EPO level and the degree of anemia but a wide range of EPO levels is found in patients with similar Hb concentrations. Thus the highest EPO levels are found in patients with erythroid hypoplasia in bone marrow.
Aims
The combination of several biomarkers: Hb, ferritin, EPO and sTfR may be useful in LR-MDS for diagnosis and follow up.
Methods
A total of 192 patients with LR-MDS were investigated. Median age of the 192 patients was 71 years (21-92) with 56% males, median survival: 54 months, median follow up: 102 months. The stratification according to the WHO criteria and IPSS risk score was realized. Bone marrows were studied and cytogenetic assessment was realized in the same time. Serum concentrations of ferritin, EPO and sTfR has been analyzed by immuno-assays. Hb level was determined on Beckman Coulter apparatus. The follow up of Hb, ferritin, EPO and sTfR was realized every 2 months in patients with supportive care only until the first specific treatment. A multivariate logistic regression analysis to ascertain the correlations between disease progression and studied biological parameters was realized.
Results
The logistic regression analysis of our results is significant to define a biological evolutive profile of LR-MDS patients with these biomarkers. The combination of these routine parameters may represent a functional erythropoietic follow up in LR-MDS patients (table 1). This biological tool is an easy method to observe the red cell lineage of LR-MDS patients. This combination informs about the progressive ineffective and dysplatic erythropoiesis in LR-MDS patients. The measurement of ferritin which is a correlated parameter in LR-MDS shows the level of iron overload. A normal or high level without inflammation condition excludes an iron deficiency. The EPO level can give a predictive information about the future efficacy of ESA (endogenous EPO < 500 U/l).
Conclusion
With our results and a correlative logistic regression analysis, we can propose a biological scoring system to appreciate the evolutive anemia of LR-MDS progression in patients. In LR-MDS the management of patients may be based on personalized medicine according a risk assessment with IPSS-R, cytogenetics, mutations and HLA typing (2). But an additional biological and functional predictive scoring system informs about the important independent role of dysplasias particularly anemia in LR-MDS patients before to choose a suitable therapy: transfusions, iron chelation, ESA, TGF-ï¢ pathway inhibitors, G-CSF, immun suppressive treatment, lenalidomide, azacytidine, allogeneic HSCT
Table 1. Hb Â± EPO Â± ïƒ¬ sTfRDysplastic erythropoiesis without anemia Hb Â± ïƒ¬ EPO ïƒ¬ sTfRStabilized dysplastic erythropoiesis ïƒªHb ïƒ¬ EPO ïƒ¬ sTfRUnstabilized dysplactic erythropoiesis ïƒªHb ïƒ¬ EPO ïƒª sTfRIneffective dysplastic erythropoiesis EPO < 500 U/l : ESA may be efficient> 500 U/l : ESA will be inefficientFerritin level : iron overload
References Giagounidis A
Management of low-risk myelodysplastic syndromes
Hematology Education, 2015, 9 (1), 219-225 Platzbecker U et al
Personalized medicine in myelodysplastic syndromes: wishful thinking or already clinical reality?
Hematologica, 2015, 100 (5), 568-571

Disclosures
No relevant conflicts of interest to declare.