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Perls Stain Grade in Bone Marrow Aspirate Correlates with Overall Survival in Low-Risk Myelodysplastic Patients
Federica Pilo1, Giovanni Caocci2, Giannalisa Mele1
1Hematology and Bone Marrow Transplant Unit, A. Businco Hospital, Department of Medical Sciences and Public Health, University of Cagliari, Cagliari, Italy.
Abstract:
Low-risk patients with myelodysplastic syndromes (MDS) are inclined to long-term accumulation of iron in the organs due mostly to red blood cell transfusion and ineffective erythropoiesis. The effect of free toxic iron species in the liver and heart sites is well known, but recent knowledge assumes that oxidant-mediated tissue injury is also effective in the bone marrow. We aimed to investigate the predictive value of bone marrow iron accumulation as demonstrated by Perls staining on the overall survival (OS) of MDS patients. We retrospectively analyzed 114 low and intermediate-I IPSS risk MDS patients who were diagnosed at our institution in the last 20 years. The median age was 70 years (range 32-93). Two different experienced hematologists analyzed all samples. Perls Prussian blue stain was used to stain the bone marrow, which was assessed by modified Gale's grading and then correlated with the outcome. Twenty-seven patients had grade 1 (+), 31 grade 2 (++), and 56 grade 3 (+++). The 20-year OS was significantly lower in patients with a higher Perls score (6.8 ± 6.1%, median 80 ± 7 months in grade 3; 18.7 ± 9.4%, median 70 ± 17 months in grade 2; 33.2 ± 16.4%, median 144 ± 18 months in grade 1; p = 0.011); bone marrow iron overload (p = 0.003; HR 1.7) and transfusion dependency (0.001; HR 2.6) negatively impacted on survival. We suggest that a higher grade of iron storage at diagnosis can impact on the outcome in MDS patients. Perls stain, together with ferritin and the blood transfusional burden, could be another marker at diagnosis of iron-related toxicity that predicts survival.
Insights
High bone marrow iron accumulation in myelodysplastic syndromes (MDS) patients predicts poorer overall survival. Perls staining can identify this risk, aiding in early diagnosis and treatment strategies for MDS.
Area of Science:
- Hematology
- Oncology
- Pathology
Background:
- Myelodysplastic syndromes (MDS) patients, particularly low-risk, experience iron overload due to transfusions and ineffective erythropoiesis.
- While liver and heart iron toxicity is known, bone marrow oxidant injury is increasingly recognized.
- Bone marrow iron accumulation's impact on overall survival (OS) in MDS requires further investigation.
Purpose of the Study:
- To evaluate the predictive value of bone marrow iron accumulation, assessed by Perls staining, on the overall survival (OS) of myelodysplastic syndromes (MDS) patients.
- To correlate Perls stain grading with patient outcomes in a cohort of low and intermediate-I IPSS risk MDS patients.
Main Methods:
- Retrospective analysis of 114 MDS patients diagnosed over 20 years.
- Bone marrow samples stained with Perls Prussian blue and graded using modified Gale's system by two hematologists.
- Correlation of Perls score, bone marrow iron overload, and transfusion dependency with overall survival.
Main Results:
- Higher Perls scores (indicating greater iron accumulation) were significantly associated with lower 20-year overall survival (p=0.011).
- Bone marrow iron overload (HR 1.7, p=0.003) and transfusion dependency (HR 2.6, p=0.001) were negative predictors of survival.
- Patients with grade 3 iron accumulation had a median OS of 80 months, compared to 144 months for grade 1.
Conclusions:
- Increased bone marrow iron storage at diagnosis is a significant predictor of poorer outcomes in MDS patients.
- Perls staining, alongside ferritin and transfusion burden, can serve as a diagnostic marker for iron-related toxicity and survival prediction in MDS.
- This study highlights the importance of assessing bone marrow iron in MDS management.
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