1. Update on Iron Toxicity in Myelodysplastic Syndromes:
I. Myelodysplastic Syndromes Update
Aristoteles Giagounidis, MD, PhD Department of Haematology and Oncology St. Johannes Hospital Duisburg, Germany 1 1

2. Cumulative Survival of 1806 Untreated Patients with Primary MDS (Düsseldorf MDS Registry, 1970–2003)
1.0
0.8
0.6
Cumulative Survival
0.4
0.2
0.0 2 4 6 8 10 12 14 16 18 20
Years
Graphic courtesy of Dr. U. Germing.

3. International Prognostic Scoring System (IPSS)
Score
Prognostic Variable
0.5
1.0
1.5
2.0
BM blasts (%)
<5
5–10 ––
11–20
21–30
Karyotype
Gooda
Intermediateb
Poorc
Cytopaeniad
0/1
2/3
Score
Risk Subgroup
Median Survival (Y)
Low
5.7
0.5–1.0
Intermediate-1
3.5
1.5–2.0
Intermediate-2
1.2
≥2.5
High
0.4
The prognostic assessment of MDS patients can be refined by using the „International Prognostic Scoring System“, which considers the percentage of blast cells in the bone marrow, the karyotype of the abnormal hematopoietic cells, and the number of cytopenias in the peripheral blood.
The IPSS defines four risk groups: low-risk, intermediate-1, intermediate-2, and high-risk, ...
aGood: normal, -Y, del(5q), del(20q); bIntermediate: other abnormalities not seen in “good” or “poor”; cPoor: complex (≥3 abnormalities) or chromosome 7 anomalies; dHaemoglobin <10 g/dL, absolute neutrophil count <1.5  109/L, platelet count < 100  109/L.
Graphic on top: with permission from Greenberg P, et al. Blood. 1997;89:

4. Prognosis of MDS according to the IPSS
Survival
AML evolution
Low
Int-1
Int-2
High
Low
Int-1
Int-2
High 10 20 30 40 50 60 70 80 90
100 1 2 3 4 5 6 7 8 9 11 12 13 14 15 16 17 18
Time (years) 10 20 30 40 50 60 70 80 90
100 1 2 3 4 5 6 7 8 9 11 12 13 14 15 16 17 18
AML Evolution (%)
Time (years)
Survival (%)
With permission from Greenberg P, et al. Blood. 1997;89: 4

5. WHO Classification-Based Prognostic Scoring System (WPSS)
Score
Parameter 1 2 3
WHO category
RA, RARS, 5q–
RCMD, RCMD-RS
RAEB-1
RAEB-2
Karyotype
Gooda
Intermediateb
Poorc ––
Transfusion
Yes
Regular
Score
Risk Subgroup
Survival, Italian Cohort (m)
Survival, German Cohort (m)
Very low
103
141 1
Low 72 66 2
Intermediate 40 48
3–4
High 21 26
5–6
Very high 12 9
aGood: normal, -Y, del(5q), del(20q); bIntermediate: other abnormalities not seen in “good” or “poor”; cPoor: complex (≥3 abnormalities) or chromosome 7 anomalies; dmedian survival.
With permission from Malcovati L, et al. Blood. 2005;106:abstract 788.

6. Survival and Risk of Leukaemic Progression According to WPSS at Diagnosis
Overall Survival
(P <.001)
Risk of AML Evolution
(P <.001)
Abbreviation: AML, acute myeloid leukaemia.
With permission from Malcovati L, et al. J Clin Oncol. 2007;25:

7. MDS-Specific Comorbidity Index 2-Y Risk of Nonleukaemic Death
To predict the impact of extra-haematologic comorbidities on survival of patients with MDS
Comorbidity
Score
Cardiac disease 2
Moderate-to-severe hepatic disease 1
Severe pulmonary disease
Renal disease
Solid tumour
Total Score
Risk
2-Y Risk of Nonleukaemic Death
Low 24
1–2
Inter- mediate 42
>2
High 61
Left graphic: with permission from Della Porta MG, et al. Blood. 2008;112:abstract 2677.

8. MDS Therapeutic Options
Low Risk
Best supportive care, including iron chelation
Haematopoietic growth factors
Immunosuppressive therapy
Differentiation agents
Farnesyltransferase inhibitors
Thalidomide/lenalidomide
Arsenic trioxide
Low-dose chemotherapy
Epigenetic treatment
Intensive chemotherapy
Allogeneic stem cell transplantation
Prognosis
Only a few years ago, best supportive care, mainly based on blood transfusions, was the only treatment available for MDS patients, with the possible exception of hematopoietic growth factors and the rare allogeneic stem cell transplantation performed in a patient who was young and fit enough.
Meanwhile, there is a range of treatment options, some of them licensed, some available only in clinical trials.
All these treatments are associated with risks and side effects and must therefore be balanced with the risk profile of the individual patient‘s bone marrow disorder. A systematic review of treatment options for MDS is beyond the scope of this presentation.
Unfortunately, many patients with MDS do not respond or only temporarily respond to the above-listed treatments, and therefore need chronic transfusion therapy,
High Risk

9. Iron Imbalance in Chronically Transfused Patients
Daily
Losses
1–2 mg
1 unit PRC
200–250 mg
About 80% of MDS patients have a hemoglobin of less than 10 g/dl at diagnosis, and the majority of these become transfusion-dependent.
Since every unit of PRCs provides 200 to 250 mg of iron to the patient, and normal daily losses are only about 1-2 mg, iron overload is practically unavoidable with chronic transfusion therapy.
However, MDS patients start accumulating iron before they receive their first blood transfusion. 9 9

10. Iron Accumulation Due to Transfusion Therapy
Moderate transfusion requirement
2 units/month
24 units/year
≥5 g iron/year
Serum ferritin
~1000 μg/L
Normal body iron: 3–4 g
No physiologic mechanism to excrete excess of iron
Gattermann N. Hematol Oncol Clin North Am. 2005;19(suppl 1):13-17. 10

11. Impact of Transfusion Dependency on Nontransplant Candidates
Transfusion-independent
Transfusion-dependent
Survival Time (months)
Cumulative Proportion Surviving
0.0
0.1
0.2
0.3
0.4
0.5
0.6
0.7
0.8
0.9
1.0 20 40 60 80
100
120
140
N = 374
P = .005
Transfusion dependency is clearly associated with a decreased likelihood of survival of MDS patients. However, this may have several causes.
On the hand, transfusion-dependent patients may develop complications of iron overload, because not all of them receive adequate iron-chelation therapy.
On the other hand, these patients may also have more severe bone marrow disease, leading to complications not directly related to iron overload.
With permission from Cazzola M, et al. N Engl J Med. 2005;352: 11

12. Overall Survival of Transfusion-Dependent MDS Patients Based on Ferritin Level
RA, RARS, or 5q–
(HR = 1.42, P <.001)
RCMD or RCMD-RS
(HR = 1.33, P = .07)
1.0
Serum ferritin (μg/L)
1000
1500
2000
2500
1.0
Serum ferritin (μg/L)
1000
1500
2000
2500
0.9
0.9
0.8
0.8
0.7
0.7
0.6
0.6
Cumulative Proportion Surviving
Cumulative Proportion Surviving
0.5
0.5
0.4
0.4
0.3
0.3
0.2
0.2
0.1
0.1
0.0
0.0 20 40 60 80
100
120
140
160
180 20 40 60 80
100
120
140
160
180
Survival Time (months)
Survival Time (months)
Abbreviations: RA, refractory anaemia; RARS, RA with ringed sideroblasts; RCMD, refractory cytopaenia with multilineage dysplasia; RS, ringed sideroblasts.
With permission from Malcovati L, et al. Haematologica. 2006;91:

13. Independent Impact of Iron Overload and Transfusion Dependency on Survival and Leukemic Evolution in Patients with Myelodysplastic Syndrome
Sanz G, Nomdedeu B, Such E, Bernal T, Belkaid M, Ardanaz MT, Marco V, Pedro C, Ramos F, del Cañizo C, Luño E, Cobo F, Carbonell F, Gomez V, Muñoz JA, Amigo ML, Bailen A, Bonanad B, Tormo M, Andreu R, Arrizabalaga B, Arilla MJ, Bueno J, Requena MJ, Bargay J, Sanchez J, Senent L, Arenillas L, de Paz R, Xicoy B, Duarte R, Cervera J.
(Spanish Registry of MDS)
50th Annual Meeting of the American Society of Hematology
San Francisco, California 8 December 2008 13 13

14. Overall Survival in Patients with MDS by RBC Transfusion Dependency
1.0
N = 2241
0.8
0.6
No RBC Transfusion Dependency
Probability of Survival
0.4
0.2
RBC transfusion dependency had a drastic influence on overall survival, ...
RBC Transfusion Dependency
P <.0001
0.0 5 10 15 20 25
Years from diagnosis
With permission from Sanz G, et al. 50th Annual American Society of Hematology Meeting; December 6-9, Abstract 640. 14

15. Leukaemia-Free Survival in Patients with MDS by RBC Transfusion Dependency
1.0
No RBC Transfusion Dependency
0.8
0.6
Probability of Survival
RBC Transfusion Dependency
0.4
0.2
... as well as leukemia-free survival.
One might argue that this is not really suprising because transfusion requirements reflect the severity of the underlying bone marrow disease.
However, Sanz and colleagues went on to show that even after transfusion requirement is accounted for, iron overload remains an independent prognostic factor.
P <.0001
0.0 5 10 15 20 25
Years from Diagnosis
With permission from Sanz G, et al. 50th Annual American Society of Hematology Meeting; December 6-9, Abstract 640. 15

16. Leukaemia-Free Survival
Prognostic Impact of Development of Iron Overload is Independent of WPSS Score
Overall Survival
Leukaemia-Free Survival
Variablea HR
P-value
Variablea HR
P-value
Iron overload
4.34
<.001
WPSS
2.24
<.001
WPSS
1.60
<.001
Iron overload
2.13
<.001
In a multivariate analysis they included the WPSS, which already incorporates transfusion dependency, and showed that iron overload with a serum ferritin above 1000 µg/l retained significant prognostic power, independent of the WPSS, both for overall survival and leukemia-free survival.
aMultivariate analyses, including WPSS and development of iron overload (time-dependent) (n = 580). Cases with less than 3 serum ferritin measurements were excluded.
With permission from Sanz G, et al. 50th Annual American Society of Hematology Meeting; December 6-9, Abstract 640. 16

17. Overall Survival in Patients with MDS by Serum Ferritin Level
1.0
0.8
Ferritin <1000 ng/mL
0.6
Probability
0.4
The respective Kaplan-Meier curves show a strong influence of elevated serum ferritin on overall survival, ...
0.2
Ferritin 1000 ng/mL
P <.0001
0.0 5 10 15 20
Years from Diagnosis
With permission from Sanz G, et al. 50th Annual American Society of Hematology Meeting; December 6-9, Abstract 640. 17

18. Leukaemia-Free Survival in Patients with MDS by Serum Ferritin Level
1.0
N = 762
Ferritin <1000 ng/mL
0.8
0.6
Probability
Ferritin 1000 ng/mL
0.4
0.2
... and leukemia-free survival.
Why should iron overload affect the rate of leukemic transformation? This is not easy to explain. Conceivably, the level of oxidative stress caused by iron overload is sufficient to aggravate the genomic instability of the preleukemic clone, thereby accelerating clonal evolution towards acute leukemia.
P <.0001
0.0 5 10 15 20
Years from Diagnosis
With permission from Sanz G, et al. 50th Annual American Society of Hematology Meeting; December 6-9, Abstract 640. 18

19. Impact of Iron Chelation on Survival in MDS28
Serum ferritin ≥ 2000 μg/L
Retrospective review of 178 patients
(36 RA, 42 RARS, 28 RAEB, 16 RAEB-T or AML, 25 CMML, 31 other) 22
Clinical evidence
of iron overload
“Although we were not able to demonstrate
a decrease in organ dysfunction
in patients receiving ICT for MDS,
there was a significant improvement in
overall survival”
First data to document improvement
in clinical outcome
in patients with MDS receiving ICT
18 DFO
ICT therapy
10 No ICT
Median overall survival
for Low or Int-1 IPSS
Not reached
at 160 mo
40 mo
(0.7–224)
Abbreviations: CMML, chronic myelomonocytic leukaemia; DFO, desferroxamine; ICT, iron chelation therapy; RAEB, refractory anaemia with excess blasts; RAEB-T, RAEB in transformation; RARS, RA with ringed sideroblasts.
(P <.03)
Leitch HA, et al. Blood. 2006;108:abstract 249. Graphic courtesy of Dr. N. Gattermann.

20. Iron Chelation May Improve Survival in MDS Patients
Median survival: 63 months (whole group); 115 months for chelated vs 51 months for nonchelated patients (P <.0001)
1.00
0.75
Survival Distribution Function
0.50
Iron chelation therapy
0.25
No iron chelation therapy
0.00 50
100
150
200
250
Time from Diagnosis to Death (months)
With permission from Rose C, et al. Blood. 2007;110:abstract 249.

21. Deferasirox in Patients with Transfusion-Dependent MDS EPIC Trial
Design
1-year, multicenter, open-label, single-arm, trial
Deferasirox 10–30 mg/kg/d for 12 months
Primary efficacy endpoint was change in serum ferritin at 12 months
Study population, N = 341
Median age 68 years
Baseline serum ferritin 2730 ng/mL
Mean transfusion dependency duration 3.6 years
Mean blood received in previous year mL/kg
Previous chelation 52%
Drug-related adverse effects, all grades
Diarrhea 32%, nausea 13%, abdominal pain 15%, vomiting 8%, and rash 7%
Conclusion: Significant reductions in serum ferritin levels over 1-year treatment with dose adjustments based on ferritin trends and safety markers
MDS, myelodysplastic syndromes.
Gattermann N, et al. Blood. 2008;112:abstract 633.

22. Serum Ferritin (ng/mL)
Change in Serum Ferritin Levels with Deferasirox in MDS EPIC1 and US032 Studies
Serum Ferritin (ng/mL)
1. Gattermann N, et al. Blood. 2008;112:abstract List AF, et al. Blood. 2007;110:abstract 1470.

23. Threshold of Normal Labile Plasma Iron Labile Plasma Iron (mol/L)
Deferasirox in Patients with MDS–Study US03 Change of Labile Plasma Iron Over 12 Months
Patients (n)
1.0
0.8
0.6
Threshold of Normal Labile Plasma Iron
Labile Plasma Iron (mol/L)
0.4
0.4
Baseline 3 6 9 12
Months from Baseline
With permission from List AF, et al. Blood. 2007;110:abstract 1470.

24. 24
Elevated Pretransplant Serum Ferritin May Impact Prognosis of Haemopoietic Stem Cell Transplant (HSCT) in Patients with MDS
In HSCT, iron overload may increase treatment-related mortality
The hazard ratio for mortality associated with serum ferritin ≥2515 μg/L was 2.6 (P =.003)
Serum ferritin is an independent prognostic marker in MDS patients undergoing HSCT
Iron chelation therapy has a possible role in the pre- and posttransplant setting
In a retrospective study, pretransplantation serum ferritin levels were assessed in 922 patients with hematologic malignancies who underwent hematopoietic stem cell transplantation (HSCT) with myeloablative conditioning at the Dana-Farber/Brigham and Women’s Hospital between 1997 and 2005.
In total, 103 patients had MDS. 88% had elevated serum ferritin levels (>300 ng/mL). Overall, median serum ferritin levels were 930 ng/mL.
Overall, there was a strong correlation between pretransplantation serum ferritin levels and survival. The 5-year survival was:
54% in patients with ferritin values 0–231 ng/mL (first quartile).
50% in patients with ferritin values 232–930 ng/mL (second quartile).
37% in patients with ferritin values 931–2034 ng/mL (third quartile).
27% in patients with ferritin values >2034 ng/mL (fourth quartile).
The 5-year disease-free survival from first to fourth quartile was 43%, 44%, 34% and 27%, respectively.
For MDS patients the hazard ratio (HR) for mortality associated with serum ferritin ≥2515 ng/mL (the fourth quartile) was 2.6 (P=0.003).
The results suggest that serum ferritin may be used as an independent prognostic marker for patients with MDS undergoing HSCT. The authors also postulate that iron chelation therapy could also have a role in the pre- and post-transplant setting, by improving transplantation outcomes for patients with MDS.
Reference
Armand P et al. Blood 2007;109:4586–4588.
Armand P, et al. Blood. 2007;109: 24

25. Outcomes According to Pretransplant Serum Ferritin Level in MDS Patients Undergoing HSCT
Serum ferritin 1st–3rd quartile
Serum ferritin highest quartile
Serum ferritin 1st–3rd quartile
Serum ferritin highest quartile
100
100 80 80
Overall Survival (%) 60
DFS (%) 60 40 40
P <.001
P <.001 20 20 1 2 3 4 5 6 7 8 1 2 3 4 5 6 7 8
Serum ferritin 1st–3rd quartile
Serum ferritin highest quartile
Serum ferritin 1st–3rd quartile
Serum ferritin highest quartile
100
100 80 80
Treatment-Related mortality (%) 60
Relapse (%) 60 40 40
P = .005 20 20
P = .7 1 2 3 4 5 6 7 8 1 2 3 4 5 6 7 8
Time from Transplantation (years)
Time from Transplantation (years)
Abbreviations: DFS, disease-free survival; HSCT, haemopoietic stem cell transplant.
With permission from Armand P, et al. Blood. 2007;109: 25

26. Deferasirox Dosing by Transfusion Requirements and Therapeutic Goals
Initial recommended dose
20 mg/kg/day
For patients receiving
pRBCs >14 mL/kg/month (~4 adult units)
30 mg/kg/day to reduce body iron
For patients receiving
pRBCs >7 mL/kg/month (~2 adult units)
10 mg/kg/day to maintain body iron
For patients well managed on desferrioxamine
Numerically half the dose of desferrioxamine
Exjade. Summary of Product Characteristics. West Sussex, UK: Novartis Europharm Ltd; 2006.

27. Update on Iron Toxicity in Myelodysplastic Syndromes:
II. Cardiac Iron Update
Alberto Roghi, MD Professor Director, Cardiac Magnetic Resonance Unit Department of Cardiology A.De Gasperis Azienda Ospedaliera Niguarda Ca’Granda Milan, Italy 27 27

28. Non–transferrin-Bound Iron Transport by L-Type Ca2+ Channels in the HeartX
Iron transport involves redox cycling between ferrous (divalent) and ferric (trivalent) states that are catalyzed by several ferric reductases such as duodenal-cytochrome b (Dcytb) as well as ferroxidases such as ceruloplasmin and hephaestin. The most prevalent method for iron transport in hepatocytes and enterocytes involves the binding of the transferrin-bound iron to type I or type II transferrin receptors. In addition to transferrin-bound iron, iron also enters cells by divalent metal transporter (DMT1) which is highly expressed in the kidney and enterocytes and less evident in the myocites. In the heart, under condition of iron overload, the most important non-transferrin-bound-iron (NTBI) seems to be L-type Ca2+ channels. In mouse studies, LTCC blockers like amlodipine and verapamil, reduced intracellular myocardial iron accumulation and reduced oxidative stress improving diastolic and systolic cardiac function,
Abbreviations: Dcytb, duodenal cytochrome B; DMT1, dimetal transporter 1.
With permission from Oudit GY, et al. J Mol Med. 2006;84:

29. Longitudinal Heart and Liver Iron Time Courses in 38 Thlassaemia Major Patients
38 patients underwent 3 or more CMR evaluations within 5 years to estimate their heart and liver iron concentration. In the top examples on the left, heart and liver iron levels at consecutive observations (labeled T1-T5) form a straight line, indicating no temporal delay between these changes. The center of mass represents the average liver iron and cardiac iron concentration.The time course passes through the center of mass if there is no time lag between the heart and the liver iron. In the second examples cardiac iron levels lag behind changes in liver iron. The greater the time lag between heart and liver iron,the greater the total triangular area. The bottom examples illustrates the time course where liver iron lags cardiac iron. On the top right are illustrated the ditribution of area under the curve of the 38 patients revealing that cardiac iron significantly lags liver iron in many patients. The aggregate time courses formed by plotting chronologic HIC and cardiac iron concentrations in the bottom right figure are condensed in the top left corner by a rectangle consisting of 4 limbs. Limb 1 demonstrate increasing HIC with no change in heart iron, limb 2 showed increase in heart iron with no change in HIC, limb 3 exhibits decrease in HIC witn no change in heart iron, limb 4 exhibits decrease in heart iron witn no change in HIC.
With permission from Noetzli LJ, et al. Blood. 2008;112:
Abbreviation: HIC, hepatic iron concentration.

30. Various Iron Loading States
The CMR T2* evaluation of hepatic and heart iron concentration allows the identification of various iron loading states: top left, no iron and hepatic overload; top right: hepatic iron overload, normal heart; bottom left: heart iron overload with normal HIC; bottom right: hepatic and heart iron overload. Time lag is more profond in patients with initially elevated cardiac and liver iron because of the intense chelation unmasking the kinetic differences between the heart and the liver.
Graphic courtesy of Dr. A. Roghi. 30

31. Hypercoagulability Endocrinopathies Iron overload Hypoxia Infections
OXIDATIVE STRESS
Myocardial
impairment
Endothelial
dysfunction
When iron levels are chronically elevated, excessive free radical generation leads to depletion of antioxidants and increased cellular damage due to oxidation of lipids, proteins and nucleic acids. Additional factors that may modulate the amount of oxidative stress include infections, endocrinopathies as diabetes and hypoxia due to chronic anemia. Oxidative stress induces direct myocardial impairment and endothelial dysfunction and increases platlets adhesivness.
Il risultato finale ha come effetto la compromissione della funzione miocardica, il deterioramento della funzione endoteliale e l’attivazione della catena emocoagulativa e dell’adesivita’ piastrinica.
Hypercoagulability
Graphic courtesy of Dr. A. Roghi. 31

32. Relationship Between Iron Overload, Oxidative Stress, and Calcium Channels in Myocardial Cells
In iron overload condition, the non-tramsferrin-bound iron enters in the cardyomyocite through the L-type Calcium Channels and as labile intracellular pool is available for reactive oxygen species production.The iron-mediated oxidative stress induces impairment on the excitation-contraction coupling,inhibiting the sarcoplasmatic reticulum activity. The final result is the reduction of peak systolic Ca+ levels and elevated diastolic Ca+ levels which contribute to the impaired systolic and diastolic function and also lead to arrhytmias, impaired electrical conduction and sudden death.
Abbreviations: NCX, sodium-calcium exchanger; ROS, reactive oxygen species; SR, sarcoplasmic reticulum; SERCA2a, sarcoplasmic reticulum Ca 2+ ATPase isoform 2.
With permission from Oudit GY, et al. J Mol Med. 2006;84:

33. Vasodilator Impairment of Aortic Ring by Iron Overload
Iron n = 3 Control n = 2
Response to Nitroglycerine
Response to Acetylcholine
With permission from Day SM, et al. Circulation. 2003;107:

34. Nonleukaemic Causes of Death and Relationship to Iron Overload2% 8% 8%
31%
51%
Death in low-risk myelodysplastic syndromes – cardiac failure is more common in transfused than nontransfused patients (P = .01)
Malcovati L, et al. J Clin Oncol. 2005;23:

35. Survival of Patients with Myelodysplastic Syndromes According to Transfusion Dependence
Overall Survival
(HR = 1.91; P <.001)
Leukaemia-Free Survival
(HR = 1.84; P = .001)
180
Cumulative Proportion Surviving
Transfusion-independent
Transfusion-dependent
0.0
0.1
0.2
0.3
0.4
0.5
0.6
0.7
0.8
0.9
1.0 20 40 60 80
100
120
140
160
Survival Time (months)
Malcovati and colleagues showed that transfusion dependency is not only associated with a decreased likelyhood of survival but also associated with a decreased likelyhood of leukemia-free survival.
Abbreviation: HR, hazard ratio.
With permission from Malcovati L, et al. J Clin Oncol. 2005;23:

36. Iron Chelation Therapy May Improve Survival in Patients with MDS
With permission from Rose C, et al. Blood. 2007;110:abstract 249.

37. Conclusions
Chronic transfusion dependence in MDS may lead to significant iron overload and may contribute to increased morbidity and mortality
Non–transferrin-bound iron causes oxidative stress and is deleterious to different organ systems, including liver and heart
Both RBC transfusions and high ferritin levels independently worsen overall survival in patients with MDS
Iron chelation with deferasirox consistently reduced serum ferritin levels and labile plasma iron levels in EPIC and US03 trials
Effective iron chelation may improve overall survival in patients with low and intermediate-1 risk MDS

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