While previous studies have indicated that H3K36me3, which is mediated by Setd2, may regulate the cell fate of mesenchymal stem cells (MSCs) both in vitro and in vivo, the specific role of MSCs in the onset and progression of MDS remains unclear. Thus, the histone methyltransferase Setd2 is implicated in MDS-associated leukemia. This study utilized NUP98-HOXD13 (NHD13) mice with targeted deletion of Setd2 in MSCs. Here, we found that Setd2-deficient mice undergo faster leukemia transformation than control mice do, as evidenced by the abnormal differentiation of hematopoietic stem progenitor cells in the bone marrow, abnormal hematopoiesis, and increased number of blast cells. Compared with that of control mice, the morphology of NHD13 mouse MSCs with Setd2 deficiency was irregular, and the support function of hematopoietic cells was compromised. This study demonstrated that targeted deletion of Setd2 in MSCs facilitates the advancement of MDS. Furthermore, we identified increased expression of coagulation factor XII as a key leukemic transformation mediator in Setd2-deficient MSCs. Moreover, we found that Setd2 expression is significantly lower in high-risk MDS patients than in low-risk MDS patients, further suggesting that the targeted deletion of Setd2 in MSCs is associated with MDS progression. Collectively, our results suggest that Setd2 in MSCs suppresses MDS progression to leukemia through coagulation factor XII-mediated suppression of the stem cell support capacity of MSCs. Overall, this study sheds light on the pathogenesis of MDS and provides a therapeutic strategy for regulating the microenvironment in patients with MDS who cannot be cured by haematopoietic stem cell transplantation.

Therapeutic options remain limited for patients with myelodysplastic neoplasms (MDS) with increased blasts who are ineligible for, intolerant of or decline hypomethylating agents (HMAs). We retrospectively investigated the efficacy, predictors of response, survival outcomes and clonal evolution of thalidomide in 56 patients with MDS and increased blasts. Among 50 evaluable patients, the overall response rate was 52.0%, and treatment was well tolerated without grade ≥ 3 non-hematologic adverse events. Multivariable analyses identified male sex, lower baseline lymphocyte count, and higher platelet count as independent predictors of treatment response. Patients who achieved a treatment response experienced significantly longer overall survival (OS) and leukemia-free survival (LFS). Older age, higher IPSS-R category, and STAG2 mutation independently predicted inferior OS, whereas SF3B1 mutation was associated with favorable LFS. Serial molecular analyses demonstrated persistent clonal evolution in 58.3% of patients, predominantly through acquisition of new mutations, with ASXL1 emerging as the most frequently acquired mutation. Overall, thalidomide demonstrated clinical activity with acceptable tolerability in selected patients. Persistent clonal evolution despite morphologic response suggests that the therapeutic benefit of thalidomide reflects disease control rather than eradication of the founding malignant clone, supporting longitudinal molecular monitoring for treatment assessment.

Myelodysplastic syndromes with bone marrow fibrosis (MDS-F) have been delineated as a distinct disease subtype in the latest WHO classification; nevertheless, specific therapeutic strategies for this entity remain undefined. This study was conducted to systematically evaluate the impact of bone marrow fibrosis on treatment response, long-term survival, and adverse event profiles in patients with MDS-F undergoing Hypomethylating agents (HMA) therapy. This retrospective analysis included 200 patients with MDS with excess blasts (MDS-EB) who received HMA monotherapy at Shanghai Sixth People's Hospital between March 2010 and March 2023. Survival analyses were performed using the Kaplan–Meier method, and prognostic factors were evaluated with Cox proportional hazards regression models. The median age was 65 years; 118 patients had MDS‑EB‑1 and 82 had MDS‑EB‑2. Overall response rates (ORR) were comparable between MF‑2/3 and MF‑0/1 groups (50.9

OBJECTIVE:To explore the clinical features and prognosis of myelodysplastic syndrome with ring sideroblasts (MDS-RS) patients with wild-type splicing factor 3B subunit 1 (SF3B1 ). METHODS:The bone marrow samples from 132 patients with MDS-RS who were initially diagnosed at Shanghai Sixth People's Hospital affiliated to Shanghai Jiao Tong University School of Medicine from January 2009 to February 2021 were collected. Next generation sequencing (NGS)was used to obtain gene mutation information of patients (covering all core mutation genes of MDS), with a particular focus on analyzing the clinical characteristics, co-mutation profiles, and prognosis of MDS-RS patients with wild-type SF3B1 . RESULTS:Among the 132 MDS-RS patients, 50 cases (37.9%) were negative for SF3B1 mutations, of which 39 patients (78%) had concurrent mutations in other genes. The common accompanying mutations were TP53 (15 cases), DNMT3A (10 cases), U2AF1 (8 cases), TET2 (7 cases), ASXL1 (7 cases), and RUNX1 (6 cases), and SETBP1 (3 cases). In the 82 cases (62.1%) who were positive for SF3B1 mutations, the highest occurrence frequency was SF3B1 K700E mutation (42 cases). Additionally, 57 patients (69.51%) had concurrent mutations in other genes, with the top three highest mutation frequencies observed in ASXL1 (13 cases), DNMT3A (11 cases), and RUNX1 (7 cases). Compared to patients with SF3B1 mutations, those with wild-type SF3B1 exhibited significant pancytopenia and higher risk of IPSS-R and IPSS-M prognostic scores. The median overall survival (OS) of patients with wild-type SF3B1 was 22 months, which was significantly shorter than 55 months of SF3B1 mutated patients (P < 0.05), and they also had a higher risk of transformation to acute myeloid leukemia (AML) (P < 0.05). Multivariate analysis revealed that SF3B1 mutation was not an independent prognostic factor affecting MDS-RS, and its prognostic value might be influenced by mutation sites, co-mutations, and other factors. CONCLUSION:Patients with wild-type SF3B1 have a significantly shorter OS compared to those with SF3B1 mutations, and they also have a higher risk of transformation to AML, which may be associated with TP53 mutations.

Myelodysplastic syndromes with moderate-to-severe bone marrow fibrosis (MDS-F) represent a distinct entity with poor prognosis, yet their molecular landscape and precise risk stratification remain poorly defined. This study aimed to characterize the genetic landscape of MDS-F and develop an integrated prognostic model. In this study, clinical and genetic data from 102 treatment-naïve MDS patients with moderate to severe marrow fibrosis (MF-2 and MF-3) were analyzed retrospectively. The cohort comprised 63 MF-2 and 39 MF-3 cases showing comparable clinical characteristics and survival outcomes. Targeted next-generation sequencing of 29 myeloid-associated genes demonstrated distinct mutational patterns: 19.6

Colony-stimulating factor 1 receptor (CSF1R) is primarily expressed in microglia. Its monoallelic mutation causes CSF1R-associated microgliopathy (CAMP), a major form of adult-onset leukoencephalopathy with axonal spheroids and pigmented glia (ALSP) and a fatal neurological disease without clinical cure. We developed mouse models harboring human hotspot mutations of CAMP and replaced CSF1R-deficient microglia with CSF1R-normal cells through microglia replacement by bone marrow transplantation (Mr BMT), which attenuated pathology in mice. We further demonstrated that, in the context of CSF1R deficiency, traditional bone marrow transplantation (tBMT) in ALSP functions similarly to Mr BMT, efficiently replacing microglia and reducing disease progression. We then replaced CSF1R-deficient microglia in eight patients by tBMT. The disease progression was halted during the 24-month follow-up. Together, microglia replacement corrects pathogenic mutations and halts disease progression in mice and humans.

Objective To observe the clinical efficacy and safety of luspatercept in managing refractory anemia among patients with myelodysplastic syndrome with ring sideroblast(MDS-RS).Methods A retrospective analysis was performed on consecutive MDS-RS patients with refractory anemia who were treated with luspatercept at Department of Hematology,Shanghai Sixth People's Hospital,Shanghai Jiao Tong University School of Medicine between August 2022 and December 2023.Eligible patients met the 2016 WHO diagnostic criteria for MDS-RS and were in the very low-,low-,or intermediate-risk groups according to the revised International Prognostic Scoring System(IPSS-R).Luspatercept was administered per label instructions,and a consistent transfusion strategy was required for each patient before and during treatment.Hematologic data and red blood cell transfusion episodes were recorded for each treatment cycle,and hematologic improvement(HI)was assessed using the revised International Working Group(IWG)2018 criteria.Results 9 patients were enrolled.7 patients achieved HI,among whom 5 achieved HI-erythroid(HI-E)and 2 achieved red blood cell transfusion independence(TI-RBC)for≥8 weeks.The median duration of HI response was 17(9-46)weeks.5 of the 7 responding patients experienced loss of response,with a median time to first loss of 15(9-23)weeks.During the study,impacted by the COVID-19 pandemic,5 patients experienced 6 infection episodes.Treatment delays occurred 11 times in 6 patients,and all delays led to a decrease in hemoglobin[mean decrease,(18±6)g/L]or the need for red blood cell transfusions,directly resulting in 5 dose escalation and loss of response in 2 cases.3 patients reported bone pain.1 patient showed progression to grade 3 marrow fibrosis.33.3％(3/9)reported bone pain,and 1 case showed progression to grade 3 marrow fibrosis.Conclusions This study confirms the real-world efficacy of luspatercept in patients with MDS-RS and refractory anemia.However,its efficacy is influenced by baseline transfusion burden and treatment delays,and depended on continuous and regular administration.

Objective:To explore the effects and mechanisms of chidamide on the osteogenic differentiation of bone marrow mesenchymal stromal cells(MSC)from myelodysplastic syndromes(MDS).Methods:MSC were isolated and cultured from bone marrow of MDS patients and healthy donors.CCK-8 assay was used to detect the effects of chidamide on the proliferation of MSC.The effects of chidamide on the activity of histone deacetylase(HD AC)in MSC was measured by a fluorescence assay kit and Western blot.Alkaline phosphatase(ALP)activity was detected on day 3 and calcium nodule formation was observed by Alizarin Red staining on day 21 after osteogenic differentiation.The expression of early and late osteogenic genes was detected on day 7 and day 21,respectively.RT-PCR and Western blot were used to detect the effects of chidamide on mRNA and protein expression of RUNX2 which is the key transcription factor during osteogenesis.Results:As the concentration of chidamide increased,the proliferation of MSC was inhibited.However,at a low concentration(1 μmol/L),chidamide had no significant inhibitory effect on MSC proliferation but significantly inhibited HD AC activity.In MSC from both MDS patients and healthy donors,chidamide(1 μmol/L)significantly increased ALP activity,calcium nodule formation,thereby mRNA expression of osteogenic genes,and restored the reduced osteogenic differentiation ability of MDS-MSC compared to normal MSC.Mechanistic studies showed that the osteogenic-promoting effect of chidamide may be related to the upregulation of RUNX2.Conclusion:Chidamide can inhibit HD AC activity in MSC,upregulate the expression of the osteogenic transcription factor RUNX2,and promote the osteogenic differentiation of MDS-MSC.

In low-risk myelodysplastic syndromes (MDS), the proinflammatory signaling is excessive, and the proliferation and differentiation potentials of mesenchymal stromal cells (MSCs) are strongly impaired. Eltrombopag (ELT) has been demonstrated recently effective and relatively safe in low-risk MDS with severe thrombocytopenia. However, its impact on the MDS-MSCs has not been investigated in any detail. Here, for the first time, we investigated the changes induced by ELT in MSCs' viability, proliferation, apoptosis, senescence, multilineage differentiation properties, and stem cell support capacity in low-risk MDS patients. We demonstrated that ELT may act on improving the impaired inflammatory profile and reactivating the downregulated canonical WNT signaling pathway in low-risk MDS, and also restoring the self-renewal capacity and the balance in adipose-osteogenic differentiation of MDS-MSCs.

The independent prognostic significance of bone marrow fibrosis (BMF) in myelodysplastic syndromes (MDS) is challenged under currently molecular prognostic models. In this study, the clinical and genetic data from 438 MDS patients were analyzed retrospectively. The patients were randomly divided into training (n = 306) and validation (n = 132) cohorts. The independent significant prognostic factors included age, IPSS-R, BMF, TP53 and U2AF1. Using their weighted coefficients, we developed a simplified prognostic system. Four risk groups were produced: low, intermediate, high and very high. The new model yielded more clearly separated survival curves than the IPSS-R. In addition, our model achieved higher C-indexes (0.61 in the training cohort and 0.63 in the validation cohort) than the IPSS-RM model (0.59 and 0.58) and IPSS-R (0.57 and 0.56). In conclusion, BMF was an independent significant prognostic factor for MDS, and adding BMF into the IPSS-R improved its predictive capability.

Relapse remains the main cause of treatment failure in patients with myeloid malignancies even after allogeneic hematopoietic stem cell transplantation (allo-HSCT). We observed a particularly low incidence of relapse in patients prepared with fludarabine, busulfan and melphalan in our previous study and this multicenter retrospective analysis aimed to confirm the feasibility of the regimen and to identify the potential prognostic factors. This study was performed using registry data from adults patients with myeloid malignancies who underwent their first allo-HSCT following fludarabine(≥100 mg/m2), busulfan (≥3.2 mg/kg) and melphalan (≥100 mg/m2) based conditioning at nine transplantation centers in China between Jan. 2020 and Mar. 2022. A total of 221 consecutive patients (AML n = 171, MDS-IB-1 or 2 n = 44, CMML n = 6) with median age of 46 were enrolled in this study. The median follow-up was 507 days for survivors. The 2-year NRM, CIR, OS and DFS were 10.6% ± 2.2%, 14.8% ± 3.3%, 79.4% ± 3.7% and 74.6% ± 3.7%, respectively. In multivariate analyses, high HCT-CI (≥3) was the only independent factor for higher NRM [hazard ratio (HR), 2.96; 95% confidence interval (CI), 1.11 to 7.90; p = 0.030] and ECOG score ≥2 was the only independent factor for inferior OS (HR, 2.43; 95%CI, 1.15 to 5.16; p = 0.020) and DFS (HR, 2.12; 95%CI, 1.13 to 4.02; p = 0.020). AML diagnosis and positive measurable residual disease (MRD) at transplantation were predictors for higher CIR (HR = 7.92, 95%CI 1.05-60.03, p = 0.045; HR = 3.64, 95%CI 1.40-9.44, p = 0.008; respectively), while post-transplantation cyclophosphamide based graft-versus-host disease prophylaxis was associated with lower CIR (HR = 0.24 95%CI 0.11-0.54, p = 0.001). The intensity of conditioning regimen did not impact CIR, NRM, DFS and OS. These results supported that double alkylating agents of busulfan and melphalan based conditioning regimens were associated with low relapse rate and acceptable NRM in adult patients with myeloid malignancies. The optimal dose remained to be confirmed by further prospective studies.

Objective To analyze the blood transfusion and adverse reactions in myelodysplastic syndroms (MDS) patients, so as to improve transfusion management in MDS patients. Methods The diagnosis and treatment information of MDS patients with blood transfusion in our hospital from January 2003 to December 2022 were collected, and the component transfusion and adverse reactions were investigated. Results The average infusion volume of red blood cells(RBCs) and platelets were respectively (27.46±43.11 ) and (16.41±24.81 ) in 799 MDS patients, which had no correlation with gender and blood type. The incidence of adverse reactions was 18.27% (146/799), with the most common adverse reactions as delayed serologic transfusion reaction (DSTR) (9.01%, 72/799), followed by non hemolytic fever reaction (4.76%, 38/799) and allergic reaction (4.38%, 35/799). Compared with all patients with transfusion, DSTR was more common in females (P<0.05), with elder age and had more RBCs consumption (all P<0.01). 86.11%(62/72) were Rh system, and 40.28% (29/72) had 2 or more antibodies. The occurrence time of DSTR in some patients was not related to the volume of RBCs trans infusion. Conclusion MDS patients, with more average transfusion volume and higher incidence of adverse reactions especially DSTR, were recommended a strictly limited transfusion schedule and Rh phenotype matching RBC products. The investigation of immune status of MDS patients at different periods is helpful to provide new aspects and therapeutic measures for the pathogenesis of DSTR, and the antibody screening time may adjusted appropriately.

In recent studies, the tolerable safety profile and positive bone marrow (BM) response suggest a beneficial use of anti-PD-1 agents in the treatment of Myelodysplastic Syndromes (MDS), but the underlying mechanism is still unknown. MDS is mainly characterized by ineffective hematopoiesis, which may contribute to inflammatory signaling or immune dysfunction. Our previous studies focused on inflammatory signaling, and the results showed that S100a9 expression was higher in low-risk MDS and lower in high-risk MDS. In this study, we combine the inflammatory signaling and immune dysfunction. SKM-1 cells and K562 cells co-cultured with S100a9 acquire apoptotic features. Moreover, we confirm the inhibitory effect of S100a9 on PD-1/PD-L1. Importantly, PD-1/PD-L1 blockade and S100a9 can both activate the PI3K/AKT/mTOR signaling pathway. The cytotoxicity is higher in lower-risk MDS-lymphocytes than in high-risk MDS-lymphocytes, and S100a9 partially rescues the exhausted cytotoxicity in lymphocytes. Our study demonstrates that S100a9 may inhibit MDS-associated tumor escape via PD-1/PD-L1 blockade through PI3K/AKT/mTOR signaling pathway activation. Our findings indicate the possible mechanisms by which anti-PD-1 agents may contribute to the treatment of MDS. These insights may provide mutation-specific treatment as a supplementary therapy for MDS patients with high-risk mutations, such as TP53, N-RAS or other complex mutations.

Myelodysplastic syndrome is one of the main hematological malignancies that threaten the health of the elderly. However, biomarkers which predict the progression and prognosis of MDS are still controversial and puzzling. FOXO1 gene plays an important role in a variety of intracellular functions, including tumor suppression and cellular immune regulation. However, there is no research report on the correlation between FOXO1 and the clinical features of MDS including immune environment. In this study, we observed that FOXO1 expression is associated with neutrophil count, blasts, chromosome and different MDS scoring systems. FOXO1 expression is closely related to MDS cell immune polarization, and the increase expression of FOXO1 is significantly related to the amplification of immune cell polarization ratio. In addition, FOXO1 expression is associated with progression-free survival and overall survival in MDS patients. Moreover, in a multivariate model FOXO1 low-expression was an independent predictor of poor survival in MDS. In summary, FOXO1 may play a candidate tumor suppressor in MDS, and FOXO1 is a useful independent prognostic predictor in MDS, and it may provide a candidate target therapy in future.

Abstract DNA G-quadruplexes (G4s) structures are abundantly present in mammalian genomes and correlated with genome instability. However, the mechanism by which G4s are timely resolved remains unknown. Here, we report that DHX9 functions as a resolvase to unwind G4s globally in activated B cells. DHX9-deficient B cells show gross DNA double-strand breaks at the accumulated G4 sites, which are clustered together and form liquid condensates. We demonstrate that DHX9 also undergoes phase separation and fuses with G4 condensates for the productive unwinding of G4s in an ATP-dependent manner. Physiologically, G4-accumulation-induced DNA breaks can promote immunoglobulin class-switch recombination for producing high-affinity antibodies. Surprisingly, the DHX9Y1189C mutant identified in Hashimoto’s thyroiditis patients shows compromised phase separation and G4 unwinding abilities, causing elevated DNA damage and abnormal antibody production. Our findings suggest a DHX9-dependent G4 condensation-resolving mechanism to prevent DNA damage in mammalian cells. Disrupting this homeostasis may induce autoimmune disorders and lymphoid malignancies.

The prognostic significance of bone marrow fibrosis (MF) grade in patients with myelodysplastic syndrome (MDS) is still debated and the molecular changes remain unclear. In our large cohort, a normal reticulum was found in 211 (25.9%) patients, whereas MF1, MF2 and MF3 were detected in 478 (58.7%), 90 (11.1%) and 35 (4.3%) patients at initial diagnosis, respectively. Patients with MF often correlated with some poor prognostic characteristics, including older age, anemia, unfavorable karyotype, higher BM blast and a higher IPSS-R category. For the entire cohort, the median OS was not reached, 30, 16 and 15 months for patients with MF 0, 1, 2 and 3, respectively. After adjusting for IPSS-R, the hazard ratio for mortality was 1.56 (95% CI, 1.18–2.06) for patients with MF1, 2.29 (95% CI, 1.61–3.27) for patients with MF2 and 2.75 (95% CI, 1.69–4.49) for patients with MF3 compared with those with MF0. The mutational landscape of 370 patients showed that TP53, U2AF1 and KMT2D mutations were more frequent in patients with MF2-3. In addition, of the 408 patients with MF0-1, 62 patients (15.1%) progressed to MF2-3 during the follow-up interval. The clinical features, mutation landscape and prognosis of patients with progressed fibrosis were similar to those of patients with MF2-3 at diagnosis. We concluded that BM fibrosis (MF1, 2 and 3) was an adverse prognosis feature in primary MDS and correlated with TP53 mutations both at the time of initial diagnosis and during the course of the disease. Therefore, BM fibrosis should be included in the revised prognostic scoring system and carefully considered in treatment selection.

Objectives We aim to explore and analyze the related influencing factors of liver and cardiac iron overload in MDS patients detected by magnetic resonance imaging (MRI).Methods We have detected cardiac T2* and liver T2* by MRI in 105 MDS patients. Among them, 20 patients accepted MRI examination before and after iron chelation therapy (ICT). Results: We found that adjusted ferritin (ASF) was significantly correlated with liver T2* and cardiac T2*. RBC transfusion volume, brain natriuretic peptide (BNP) and age were the related factors of cardiac T2*, while RBC transfusion volume and erythropoietin (EPO) were related factors of liver T2*. After ICT, the changes of ASF and liver T2* were earlier than cardiac T2*. Chronic hepatitis but virus copy normal's has no significant effect on liver iron deposition.Conclusion These results showed special attention should be paid to these related influencing factors of liver and cardiac T2* expression when we evaluated iron overload and detected the efficacy of ICT in MDS patients.

Despite the improvements in prognostication of the revised International Prognostic Scoring System (IPSS-R) in myelodysplastic syndrome (MDS), there remain a portion of patients with lower risk (low/intermediate risk, LR) but poor prognostics. This study aimed to evaluate the relative contribution of mutational status when added to the IPSS-R, for estimating overall survival (OS) and progression-free survival (PFS) in patients with LR-MDS. We retrospectively analyzed clinical and laboratory variables of 328 patients diagnosed with MDS according to the FAB criteria. Twenty-nine-gene NGS assay was applied to bone marrow samples obtained at diagnosis. 233 (71.04%) patients were classified as LR-MDS. Univariate analysis showed association between inferior outcome (OS and PFS) and presence of JAK2 (p = 0.0177, p = 0.0002), RUNX1 (p = 0.0250, p = 0.0387), and U2AF1 (p = 0.0227, p = 0.7995) mutations. Multivariable survival analysis revealed JAK2 (p < 0.0001) and RUNX1 (p = 0.0215) mutations were independently prognostic for PFS in LR-MDS. Interestingly, bone marrow blast >1.5% could further predict disease progression of patients with LR-MDS (HR 8.06, 95%CI 2.95–22.04, p < 0.0001). Incorporation of JAK2, RUNX1 mutation and bone marrow blast in the IPSS-R can improve risk stratification in patients with LR-MDS. In summary, our result provided new risk factors for LR-MDS prognostics to identify candidates for early therapeutic intervention.

Objective:To summarize and analyze the clinical data of Chinese patients with colony-stimulating factor 1 receptor (CSF1R)-related leukoencephalopathy, and clarify the phenotypic and genetic characteristics of Chinese patients.Methods:Medical history of patients with CSF1R-related leukoencephalopathy diagnosed from April 1, 2018 to January 31, 2021 in the department of neurology of 22 hospitals in China was collected, and scores of Mini-Mental State Examination (MMSE), Montreal Cognitive Assessment Scale (MoCA), magnetic resonance severity scale were evaluated. Group comparison was performed between male and female patients.Results:A total of 62 patients were included, and the male-female ratio was 1∶1.95. The age of onset was (40.35±8.42) years. Cognitive impairment (82.3%, 51/62) and motor symptoms (77.4%,48/62) were the most common symptoms. The MMSE and MoCA scores were 18.79±7.16 and 13.96±7.23, respectively, and the scores of two scales in male patients (22.06±5.31 and 18.08±5.60) were significantly higher than those in females (15.53±7.41 , t=2.954, P=0.006; 10.15±6.26, t=3.328 , P=0.003). The most common radiographic feature was bilateral asymmetric white matter changes (100.0%), and the magnetic resonance imaging severity scale score was 27.42±11.40, while the white matter lesion score of females (22.94±8.39) was significantly higher than that of males (17.62±8.74 , t=-2.221, P<0.05). A total of 36 CSF1R gene mutations were found in this study, among which c.2381T>C/p.I794T was the hotspot mutation that carried by 17.9% (10/56) of the probands. Conclusions:The core phenotypic characteristics of CSF1R-related leukoencephalopathy in China are progressive motor and cognitive impairment, with bilateral asymmetrical white matter changes. In addition, there exist gender differences clinically, with severer cognitive impairment and imaging changes in female patients. Thirty-six CSF1R gene mutations were found in this study, and c.2381T>C/p. I794T was the hotspot mutation.