IPSS-M has improved prognostication in MDS by integrating clinical, cytogenetic, and molecular data. Here, we investigate the potential added value of considering frailty and comorbidity for improving prognosis prediction. Using data from a training set of 412 subjects with newly diagnosed MDS, we develop “Integrated IPSS-M”, a risk-stratification model that recalibrates IPSS-M based on age, frailty, and comorbidity. We then confirm the model’s performance on a validation set of 275 subjects. The Integrated IPSS-M showed higher concordance scores for overall survival compared with the IPSS-M (training set, 0.77 [95-percent confidence interval [CI], 0.73, 0.80] vs. 0.68 [0.64, 0.72], P < 0.001; validation set, 0.73 [0.68, 0.78] vs. 0.69 [0.64, 0.74], P = 0.03). Our study indicates that integration of IPSS-M, age, frailty, and comorbidity enhances prognostic accuracy in MDS. These findings suggest that Integrated IPSS-M may inform treatment decision-making and trial enrollment for new therapies.

We report a case of a 25-year-old male with recurrent oral ulcers, upper respiratory tract infections, and an 8-year history of chronic neutropenia. Previously diagnosed with Behçet's disease, the patient had undergone comprehensive hematological evaluations at multiple tertiary institutions, yet the etiology of his persistent neutropenia remained undetermined. Whole-exome sequencing revealed a TLR8-G572D mutation, leading to a diagnosis of autoimmune myelofibrosis (AIMF) secondary to TLR8 gain-of-function (GOF). While concurrent Behçet's disease and neutropenia may occur clinically, the underlying pathogenesis is often neglected. TLR8-GOF screening should be emphasized in young patients with such presentations. To our knowledge, this is the first reported association between TLR8-GOF mutation and AIMF, expanding the phenotypic spectrum of TLR8-related disorders.

RUNX1 is one of the most commonly mutated genes in myelodysplastic neoplasms (MDS) and essential for hematopoiesis. However, clinical phenotype features of RUNX1 mutated patients and the interaction between RUNX1 and other genes mutations remains incompletely explored. We enrolled 1473 consecutive adult patients with primary MDS to investigate the laboratory, genomic characteristics, and survival of RUNX1-mutated MDS subjects. We found that RUNX1 mutations are associated with older age (median, 59 vs. 56 years, p = 0.007), lower platelet counts (median, 50 × 109/L vs. 66 × 109/L; p < 0.001), higher bone marrow blasts (median, 6.0% vs. 2.5%, p < 0.001) and a higher proportion of micro-megakaryocytes (median, 26.0% vs. 18.7%, p < 0.001). Additionally, our data showed a correlation between the variant allele frequency (VAF) of RUNX1 mutations and proportion of micro-megakaryocytes (r = 0.242, p = 0.006), suggesting RUNX1 mutations burden was associated with dysmegakaryopoiesis. Mutations in ASXL1, SRSF2, EZH2 and NRAS were significantly more frequent in RUNX1-mutated patients compared with those without RUNX1 mutations (adjusted p < 0.05). RUNX1-mutated patients exhibited poorer overall survival (median OS 18 months vs. 51 month, p < 0.001), while U2AF1 co-mutations were associated with a relatively better prognosis (median OS 34 months vs. 17 months, p = 0.003), indicating a potential modifying effect of U2AF1 on the outcome of RUNX1-mutated patients.

Proinflammatory signaling is a hallmark of myeloproliferative neoplasms. Several studies have shown that monocytes are a major source of proinflammatory cytokines and that monocyte-derived fibrocytes play a pivotal role in the pathogenesis of myelofibrosis (MF). To further explore the role of monocytes in MF, we generated inducible NrasG12D/+- Jak2V617F/+ (NJ) mice. Recipients transplanted with NJ bone marrow (BM) cells developed MF with an early onset of anemia and monocytosis. In vitro, NJ recipients' BM nucleated cells exhibited an increased quantity of CD45 +CollagenI+ fibrocytes, which were mainly derived from the Ly6chigh monocytes. RNA sequencing identified a significant elevated expression of CD38 (a NAD+ hydrolase) in Ly6chigh monocytes from NJ mice, which results in a pronounced lower level of NAD +. In humans, CD14+ monocytes from patients with MF showed a significantly higher expression of CD38 than controls and monocytes from patients with polycythemia vera with grade 1 fibrosis had higher CD38 expression than those without fibrosis. Finally, boosting NAD+ via pharmacological CD38 targeting or NAD+ precursor supplementation inhibited the differentiation of fibrocytes in vitro and targeting CD38 can effectively prevent the onset of fibrosis in vivo. Collectively, our findings shed light on the role of CD38 in monocytes and suggest potential clinical applications such as the use of CD38 as a biomarker of fibrotic progression and the clinical utility of CD38 inhibition in patients with MF.

U2AF1 mutations are common in patients with myelodysplastic neoplasms (MDS), suggesting that aberrant splicing of pre-mRNAs driven by mutant U2AF1 could play a critical role in MDS pathogenesis. Previous studies have demonstrated that U2AF1S34F mutation impairs the differentiation of erythrocytes and granulocytes, but the impact on megakaryocytes (MKs) remains unclear. Here, by integrating data from MDS patients and cell lines with U2AF1 mutations, we determined that U2AF1 mutations are associated with dysmegakaryopoiesis, induce the generation of abnormal MKs, especially micro-MKs, and induce significant thrombocytopenia. We determined that mutant U2AF1-mediated aberrant splicing of DNA biosynthesis-related genes, such as CHEK1, is required for normal MK polyploidization. The mis-splicing of CHEK1, in turn, accounts for the increased number of abnormal MKs in U2AF1-mutant MDS patients. Moreover, U2AF1S34 mutations induce the deficiency of CHK1 and the activation of its phosphorylation, thereby further driving the impairment of MK polyploidization and maturation. Accordingly, treatment with selective CHK1 inhibitor significantly reduces abnormal MK production in vitro. Taken together, these findings demonstrate that U2AF1 mutations induce the generation of abnormal MKs by driving aberrant splicing of the CHEK1 cell cycle-related gene, revealing the molecular basis for dysmegakaryopoiesis in MDS and identifying a new potential target for MDS treatment.

BACKGROUND:Isolated 20q deletion [del(20q)] is a recurrent favorable abnormality in myelodysplastic syndrome (MDS) and may cause deletion of the ASXL1 gene. Meanwhile, ASXL1 mutations are also common in individuals with MDS. This study aimed to describe the biological and clinical implications of ASXL1 mutations and deletion in newly diagnosed MDS patients with isolated del(20q). METHODS:Gene mutation and copy number alterations in 178 newly diagnosed MDS patients with isolated del(20q) were analyzed using DNA next generation sequencing. RESULTS:Twenty-five (14%) of 178 patients were found to have ASXL1 mutations, which exhibited lower absolute neutrophil counts (ANC) (p = 0.006), a higher percentage of bone marrow blasts (p = 0.001), more mutant genes (p < 0.001), higher IPSS-R (p = 0.038) and IPSS-M (p = 0.001) risk groups. Furthermore, ASXL1 mutations were preferentially associated with mutations in U2AF1, and most ASXL1 mutations (68%) were observed as subclonal lesions. ASXL1 frameshift mutations were associated with a worse prognosis in MDS patients with low blasts (MDS-LB) (p = 0.043), but not in those with increased blasts (MDS-IB). Twenty-two (26.8%) of 82 patients were found to have ASXL1 deletion, which exhibited a lower IPSS-M risk group, lower platelet counts, higher ANC levels, and higher hemoglobin levels compared to ASXL1 patientsonly-mut and ASXL1wt patients. Two (2.4%) of the 82 patients exhibited biallelic ASXL1 inactivation (ASXL1mut&del). CONCLUSIONS:ASXL1 mutations are one of the late genetic events in MDS patients with isolated 20q deletion, and different types of ASXL1 gene alterations have distinct clinical and biological characteristics.

Proinflammatory signaling is a hallmark of myeloproliferative neoplasms (MPNs). Several studies have shown that monocytes are a major source of proinflammatory cytokines and monocyte-derived fibrocytes play a pivotal role in the pathogenesis of myelofibrosis (MF). To further explore the role of monocytes in MF, we generated inducible NrasG12D/+Jak2V617F/+ (NJ) mice. Recipients transplanted with NJ bone marrow cells developed MF with an early onset of anemia and monocytosis. In vitro, NJ recipients bone marrow nucleated cells exhibited increased quantity of CD45+CollagenI+ fibrocytes, which were mainly derived from the Ly6chigh monocytes. RNA sequencing identified a significant elevated expression of CD38 (a nicotinamide adenine dinucleotide (NAD)+ hydrolase) in Ly6chigh monocytes from NJ mice, which results in pronounced lower level of NAD+. In humans, CD14+ monocytes from MF patients showed significantly higher expression of CD38 than controls and monocytes from polycythemia vera (PV) patients with grade 1 fibrosis had higher CD38 expression than those without fibrosis. Finally, we tested that boosting NAD+ via pharmacological CD38 targeting or NAD+ precursor supplementation inhibited the differentiation of fibrocytes in vitro and observed that targeting CD38 can effectively prevent the onset of fibrosis in vivo. Collectively, our findings shed light on the role of CD38 in monocytes and suggest potential clinical applications such as use of CD38 as a biomarker of fibrotic progression and potential clinical utility of CD38 inhibition in patients with MF. ### Competing Interest Statement R.K.R. has received consulting fees from Constellation, Incyte, Celgene/BMS, Novartis, Promedior, CTI, Jazz Pharmaceuticals, Blueprint, Stemline, Galecto, PharmaEssentia, AbbVie, Sierra Oncology, and Disc Medicines; and research funding from Incyte, Constellation, and Stemline. The remaining authors declare no competing financial interests.

OBJECTIVES:Chromosome 7 abnormality characterized by loss of both arms [der(7)del(7p)del(7q), hereafter 'der(7)'] is very rare. The features and prognosis of patients with der(7) in myelodysplastic syndromes (MDS) remain unclear. METHODS:We identified 35 MDS cases with der(7) using Metaphase Fluorescence In Situ Hybridization (metaphase-FISH), and compared them to 178 with del(7q), 390 with monosomy 7 (-7), and 603 with a normal karyotype (NK). RESULTS:Der(7) correlated with lower karyotypic complexity (odds ratios (ORs) 0.288, P = 0.001), more solitary abnormalities (ORs 3.652, P = 0.001), and frequent co-occurrence with -7 (40.9%; ORs 3.150, P = 0.004). Compared to NK, der(7) cases presented lower platelet counts, higher ferritin levels, and more frequent ≥3 mutations (P < 0.05). Mutations in ASXL1(ORs 2.394), RUNX1(ORs 2.618), SETBP1(ORs 15.132), and ETV6 (ORs 5.525) were enriched in der(7)/-7/del(7q) patients compared to NK (all P < 0.001), while NF1 (ORs 15.492, P = 0.002) and PTPN11 (ORs 6.653, P = 0.021) mutations were more prevalent in der(7) cases relative to NK. Prognostically, der(7) was identified as an independent risk factor (Hazard Ratios (HRs) 1.368, 95% CI 1.030-1.818; P = 0.031). Median overall survival (OS) of patients with der(7) was 17 months - shorter than NK (64 months, P = 0.005) but similar to -7 (20 months) and del(7q) (30 months). Hematopoietic stem cell transplantation improved survival (P = 0.018). Notably, 5 of 10 der(7) cases with follow-up evolved to -7. CONCLUSION:Der(7) defines a distinct high-risk subgroup with a unique molecular profile and poor prognosis comparable to -7.

Over 90% of patients with myelodysplastic syndromes/neoplasms (MDS) exhibit anemia at diagnosis, primarily due to ineffective erythropoiesis. This is characterized by abnormal proliferation and differentiation of erythroid cells influenced by signaling pathways including heme synthesis, ferroptosis, senescence and apoptosis. Despite widespread anemia, the specific mechanisms and pathway alterations at different disease stages are not well understood. This study employed the NUP98-HOXD13 (NHD13) transgenic mouse model, which mimicked the erythroid changes observed in MDS patients, to explore these dynamic pathway changes during disease progression. Based on the severity of anemia and changes in mean corpuscular volume (MCV), four time points were selected: 6 weeks (non-anemic), 12 weeks (mild anemia), 16 weeks (obvious anemia) and 20 weeks (severe macrocytic anemia). The findings indicated that a reduction in erythroid-committed progenitors and impaired erythroid maturation were linked to ineffective erythropoiesis. As the disease progressed, signaling pathways dynamically changed. Heme metabolism and ferroptosis pathways were significantly upregulated in the pre-disease and early disease stages, while senescence and cell cycle pathways were activated in the early stage. The prominent roles of apoptosis, pyroptosis and inflammasome signaling pathways were observed in the late stage. Notably, changes in Gpx4 and Ncoa4 expression, along with transmission electron microscopy analysis, suggested that ferroptosis played a critical role in the early stage of the disease. To our knowledge, this is the first report of the signaling pathway dynamics associated with ineffective erythropoiesis during the pathogenesis and progression of MDS, highlighting potential targets for therapeutic intervention at various stages of the disease.

Background Myelofibrosis (MF) is characterized by abnormal clonal expansion of hematopoietic stem cells driven by mutations JAK2, CALR and MPL genes and resultant bone marrow fibrosis. Thrombocytopenia is a poor prognostic feature and limits the use of JAK1/JAK2 inhibitor ruxolitinib (Rux). Flonoltinib Maleate (FM), a new generation of JAK2 /FLT3/CDK6 inhibitor, can stabilize platelet level and improve bone marrow fibrosis via suppressing the TGF-β signal passway. In FIH trial (NCT05153343), FM achieved SVR35, best SVR35, and TSS50 of 81.8%, 93.3% and 73.3%, respectively at week-24 in MF patients. Bone marrow fibrosis improvement was also observed in 36.4% MF patients. To further explore the efficacy and safety of FM compared with Rux, a multicenter randomized, open-label, phase IIb trial were conducted in JAKi-naïve MF patients (pts) (NCT06457425). Methods 75 pts aged ≥18 years with primary MF, post-PV MF or post-ET MF, DIPSS with int-2 or high risk MF were randomized 1:1:1 to FM 50 mg low dose (FM L), 100 mg high dose (FM H) once daily or Rux BID (dosage per label) for 28-day as a cycle for core 24 weeks treatment. Key eligible criteria included platelet count ≥50 x 109/L, ANC ≥1.0 x 109/L, palpable ≥5 cm below LCM or spleen volume ≥450 cm³ by MRI/CT, PB blasts <10%. Primary endpoint was rate achieving 35% (SVR35%) by MRI or CT at week 24 by IRC. Key secondary endpoint was 50% or more reduction in total symptom score (TSS50) at week 24. Results As of Jul 29 2025, 75 MF Pts (median age was 63.0, 52% were male) have been enrolled across 24 centers, with 25 patients allocated to FM L, 26 to FM H and 24 to Rux. Baseline characteristics were generally similar across three arms, exception of the higher proportions grade 3 bone marrow fibrosis (60.0%,76.9% vs 50.0%), high risk MF by IPSS (68.0%,73.1% vs. 50.0%) and CALR mutations (32.0%, 34.6% vs. 12.5%) in FM L and FM H arms compared with RUX arm. 6 severe myelodepletive phenotype pts with PLT < 100×109/L and HGB < 100g/L at baseline enrolled in FM arms. 51 pts completed 12-week and 32 pts completed core 24-week evaluation (CT/MRI by IRC), respectively. At 12 weeks, the SVR35 were superior and achieved respective 80.0% of pts on FM L (12/15) and 100% on FM H (18/18) compared to 50.0% on Rux. The TSS50 rates were 66.7% for FM L, 83.3% for FM H vs.61.1% for Rux treated patients. Notably, CARL mutations pts achieved significantly high SVR35% response in FM L and FM H groups than Rux [66.7% (4/6), 100% (6/6) and 0% (0/2)]. At 24 weeks, pts with FM L and FM H remained significantly benefits versus Rux in SVR 35% [90.0%(9/10), 100.0% (11/11) vs, 54.5%(6/11)] and TSS 50% (80.0%,100% vs.63.6%). 87.5% (7/8) patients with CALR mutation in FM arms achieved SVR35 or CI. Pts with PLT< 100×109/L or PLT> 100×109/L treated with FM arms had higher mean platelet count and greater increase from baseline versus Rux, particularly in early treatment cycles. However, pts with baseline PLT> 100×109/L Rux experienced a rapid decline in PLT, leading to an early dose adjustment. Furthermore, in FM treated group, the proportion of patients with an improvement in bone marrow fibrosis (> 1 grade) and remained stable condition were higher than Rux treated group with 93.8% (15/16) and 60% (6/10), respectively. For FM L, FM H, and Rux arms, the most >10% common Grade ≥3 hematological TEAEs were anemia (37.5%, 52% vs. 34.8%), No Grade ≥3 non-hematological TEAEs were reported in 3 arms. Relatively high incidence of grade ≥3 anemia in both FM arms was partly related to 6 severe myelodepletive phenotype pts at baseline. The incidence of Grade ≥3 anemia in FM L, FM H and Rux for patients with baseline platelet count >100×109/L were respectively 30.0%, 47.8% and 34.8%. Dose reduction occurred in 6 pts (30%) in FM L, 17 pts (73.9%) in FM H and 16 pts (69.6%) in Rux. Only one discontinuation occurred in Rux arms due to disease progression. Conclusions FM demonstrated excellent clinical benefits in MF pts for spleen response and improved symptom compared with RUX and manageable toxicities, suggesting FM as a potential profound innovation in treating MF through a novel mechanism of JAK2 inhibition. The updated results for the phase 2b of 75 MF patients will be completed in December 2025. A pivotal phase III multicenter, randomized, positive control, double blind clinical trial in China is currently in discussion with regulatory authority.

Introduction Prognostic models like the IPSS-R and IPSS-M focus on the biology of the disease but ignore patient-related factors such as frailty and comorbidities, which are essential for clinical outcomes. We aim to develop integrated models that integrate both to improve prognosis assessment. Methods A total of 687 consecutive patients (pts) with newly diagnosed de novo MDS who visited our center from 08/2016 to 06/2023 were included. Clinical and biological characteristics were recorded at diagnosis. Pts were randomly divided into a training cohort (80%) and a test cohort (20%). Variables were selected both by variable importance (VIMP) and minimal depth. A machine learning technique, random survival forests (RSF) was used to develop the prognostic model. Five-fold cross-validation (CV) was used both for hyperparameter tuning and for internal validation of the model in the training cohort. The final model was then applied to the test cohort for external validation. The performance of the model was evaluated using Harrell's Concordance Index (C-index), Brier scores and area under the curve (AUC) of time-dependent receiver operator characteristic (ROC) curve compared with established prognostic models. Results The IPSS-R integrated model was constructed using 7 variables selected by the algorithm: IPSS-R, pulmonary, cardiac and cerebrovascular disease, hypertension, self-care ability, and solid tumor. It achieved a C-index of 0.700/0.708 and Brier scores of 0.175/0.140 in the training/test sets, respectively. According to the IPSS-R integrated model, three risk-groups were defined: low (38.0%), intermediate (35.5%), and high-risk (26.5%), with a median OS of unavailable, 37.4 (95% CI, 29.5-45.4) and 12.8 months (95% CI, 10.7-15.0), respectively(p<0.001). The 1-/3-/5-year OS rates were 90.2%/78.7%/65.3%, 82.6%/63.2%/27.9%, and 55.3%/28.2%/10.2%. AUCs at 1/3/5 years were 0.713/0.768/0.713, outperforming IPSS-R (0.688/0.714/0.660) and comparable to IPSS-M (0.717/0.754/0.700). Subgroup analyses across age, treatment types, and BM blast percentages confirmed the model's robustness (p<0.001). Among patients classified as very low- or low-risk by IPSS-R, those up-staged by the integrated model (n=49) had shorter OS (36.7 months vs. not reached; p<0.001). Among high- or very high-risk patients, those down-staged (n=148) had longer OS (37.7 vs. 12.8 months; p<0.001). We then constructed an IPSS-M integrated model combining molecular and patient-related factors, achieving AUCs of 0.759/0.806/0.755 at 1/3/5 years. Four risk-groups were defined: low (25.1%), intermediate-1 (25.3%), intermediate-2(24.3%) and high-risk (25.1%), with a median OS of unavailable, 59.0 (95% CI, 40.2-77.8), 27.6 (95% CI, 21.9-33.3) and 11.8 months (95% CI, 9.5-14.1), respectively(p<0.001). Subgroup analyses confirmed consistent performance. Among patients initially classified as very low-risk or low-risk by IPSS-M, those up-staged (n=30, median OS 36.7 months) by the IPSS-M integrated model demonstrated significantly shorter OS compared with unchanged patients (n=105, median OS unavailable, P<0.001). Notably, 60.0% of these up-staged patients were elderly individuals aged >60 years. Among patients classified as high- or very high-risk, those down-staged (n=95, median OS 54.7 months) by the IPSS-M integrated model demonstrated significantly better OS compared with unchanged patients (n=163, median OS 11.8 months, P<0.001). Moreover, in IPSS-M high-/very high-risk groups treated with hypomethylating agent treatment, the overall response rate was significantly higher in down-staged patients (17, 73.9%) compared to unchanged patients (47.6%, P=0.041), and the incidence of febrile neutropenia with infection was higher in unchanged patients (37, 72.5%) than down-staged patients (42.9%, P=0.017). Conclusion Integrating patient-related factors into IPSS-R improved risk stratification and accuracy to a level comparable with IPSS-M, providing a practical alternative where molecular testing is limited. The integration of molecular data with patient-related factors improves the accuracy of prognostic models and has important clinical implications, particularly in the elderly population.

GATA1 is one of critical transcription factors for megakaryopoiesis and platelet production. Our study aimed to explore the correlations between GATA1 expression and dysmegakaryopoiesis in myelodysplastic syndromes/neoplasm (MDS). We assessed GATA1 expression level of megakaryocytes by performing immunohistochemical staining on bone marrow biopsy sections from MDS patients. According to GATA1 expression level of megakaryocytes and positive megakaryocyte percentage, we assigned each patient a GATA1 score. Compared with TP53-wildtype patients, GATA1 scores significantly decreased in TP53-mutated patients (P < 0.001). Patients with abnormal karyotypes showed decreased GATA1 scores than those with normal karyotypes (P = 0.024). GATA1 expression levels were significantly downregulated in dysplastic megakaryocytes, especially micromegakaryocytes (P < 0.001). Furthermore, we explored the correlation between GATA1 expression levels and cytogenetic abnormalities of the same megakaryocyte using the morphology antibody chromosome (MAC) technique on fresh bone marrow smears. We found that GATA1-negative megakaryocytes had higher frequencies of cytogenetic abnormalities. Our results indicated that decreased GATA1 expression level of megakaryocytes was significantly associated with TP53 mutations, abnormal karyotypes and dysmegakaryopoiesis in MDS, suggesting that downregulation of GATA1 expression levels of megakaryocytes plays a critical role in the pathogenesis of MDS.