The Prognostic Relevance of Serum Lactate Dehydrogenase and Mild Reticulin Fibrosis in Essential Thrombocythemia
Authors: Mudireddy Mythri , Barraco Daniela , Hanson Curtis A. , Pardanani Animesh , Gangat Naseema , Tefferi Ayalew 
Published: October 2019

Abstract
Background
The International Working Group for Myeloproliferative Neoplasms (MPN) Research and Treatment (IWG-MRT) previously published on 1104 patients with "essential thrombocythemia (ET)" and identified 180 (16%) misdiagnosed cases with early/prefibrotic primary myelofibrosis (PMF); the latter diagnosis was associated with inferior overall (OS), leukemia-free (LFS) and myelofibrosis-free (MFFS) survival (J Clin Oncol. 2011; 29:3179). Among the 891 patients with "true" World Health Organization (WHO)-defined ET, risk factors for OS included age ≥60 years, leukocyte count ≥11 x 10(9)/L and history of thrombosis (Blood2012120:1197). In the current study, we explored the possibility that increased serum lactate dehydrogenase (LDH) level or mild grade-1 reticulin fibrosis might identify occult cases of early/prefibrotic PMF in otherwise WHO-defined ET and contribute to disease prognostication.
Methods
Study patients were selected from the Mayo Clinic institutional database of MPN based on their meeting the 2008 WHO criteria for diagnosis of ET (Blood. 2009;114:937). The degree of bone marrow (BM) reticulin fibrosis was based on "real life" BM reports from Mayo Clinic hematopathologists and often in accordance with the European consensus scoring system (Haematologica 2005;90:1128). Serum LDH levels were obtained at time of diagnosis or within 12 months of diagnosis, in the absence of any treatment. Information on the two most frequent non-driver mutations seen in ET (i.e. TET2 and ASXL1) was available in a subset of the patients (Blood 2015 126:354). Statistical analyses considered clinical and laboratory parameters obtained at time of diagnosis
Results
Patient characteristics:
183 patients (57% females) were evaluable for BM reticulin grading; median (range) levels were for age 59 years (15-88), hemoglobin 14 g/dL (9.1-17.1), platelets 812 x 10(9)/L (454-3300) and leukocyte count 8.5 x 10(9)/L (3.1-31.5). Palpable splenomegaly was reported in 27 (15%) patients and 12% displayed leukoerythroblastosis (LES). Driver mutational status was JAK2 in 72%, CALR 17%, MPL 2% and triple-negative in 9%. Thrombosis history at diagnosis was obtained from 13% of the patients and 12% experienced the same post diagnosis. Risk stratification according to the International Prognostic Scoring System for ET (IPSET) was 19% high, 43% intermediate and 38% low (Blood2012120:1197). BM reticulin fibrosis was graded "0" in 113 (62%) patients and "1" in 70 (38%). Serum LDH information was available in 110 patients (median194 U/L; range 135-669) and was increased in 31 (28%) patients. Mutational status for TET2 and ASXL1was available in 76 patients with mutational frequencies of 8% each.
Clinical and laboratory correlates for mild reticulin fibrosis and serum LDH:
We found no significant correlation between mild reticulin fibrosis (grade-1) and a number of clinical parameters, including age, sex, hemoglobin level, leukocyte count, platelet count, driver mutational status, LES, presence of palpable splenomegaly, thrombosis history or serum LDH (p=0.36). In contrast, increased serum LDH was associated with increased leukocyte count (p=0.002), increased platelet count (p<0.001), presence of palpable splenomegaly (p=0.03) and higher IPSET score (p=0.002); there were no significant correlations with age, sex, hemoglobin level, LES, thrombosis history, driver mutational status or TET2/ASXL1mutations.
Survival analysis:
After a median follow-up of 91 months, 42 (23%) deaths, 2 (1%) leukemic transformations, 7 (4%) fibrotic progressions and 22 (12%) thrombotic events were documented. In univariate analysis, risk factors for OS included age ≥60 years (p=0.002; HR 10.2, 95% CI 2.3-44.6), male sex (p=0.02; HR 3.2, 95% CI 1.2-8.2), leukocyte count ≥15 x 10(9)/L (p=0.007; HR 4.7, 95% CI 1.5-14.6), and increased serum LDH (p=0.004; HR 3.7, 95% CI 1.5-9.1), but not BM reticulin fibrosis (p=0.17). In multivariable analysis, age, sex and LDH remained significant; serum LDH also remained significant for OS, in the context of IPSET, whereas it did not appear to influence thrombosis-free survival (p=0.58), LFS (p=0.84) or MFFS (p=0.34).
Conclusions
The current study suggests that serum LDH might supersede leukocyte count as an independent risk factor for overall survival in ET; in contrast, mild reticulin fibrosis was irrelevant in terms of both prognostic value and disease phenotype.

Disclosures
No relevant conflicts of interest to declare.