Previously considered rare, inherited hematologic malignancies are increasingly identified. Germline mutations in the RNA helicase DDX41 predispose to increased lifetime risks of myeloid neoplasms with disease often occurring later in life which presents challenges for germline recognition. To improve identification of germline DDX41, individuals presenting with ≥1 DDX41 alteration on an institutional MDS/AML next-generation sequencing based panel with at least one at >40% variant allele frequency were flagged for review and genetic counseling referral. Of 5,801 individuals, 90 (1.5%) had ≥1 DDX41 mutation(s) identified. Thirty-eight (42%) patients with a median age of 66 years were referred for genetic counseling; thirty-one were male (81.5%). Thirty-five (92%) referred patients elected to pursue germline evaluation and in 33/35 (94%) a germline DDX41 variant was confirmed. Twenty-two patients (66%) with germline variants reported antecedent cytopenias, seven (21%) had a prior history of malignancy, and twenty-seven (82%) reported a family history of cancer. Predictive genetic testing for healthy family members under consideration as stem cell transplant donors was successfully performed in 11 family members, taking an average of 15 days. Near-heterozygous DDX41 mutations identified on next-generation sequencing, particularly nonsense/frameshift variants or those at recurrent germline “hot spots” are highly suggestive of a germline mutation. Next-generation sequencing screening is a feasible tool to screen unselected myeloid neoplasms for germline DDX41 mutations, enabling timely and appropriate care.

Breast cancer remains the second leading cause of cancer-related death in women despite stratification based on standard hormonal receptor (HR) and HER2 testing. Additional prognostic markers are needed to improve breast cancer treatment. Chromothripsis, a catastrophic genome rearrangement, has been described recently in various cancer genomes and affects cancer progression and prognosis. However, little is known about chromothripsis in breast cancer. To identify novel prognostic biomarkers in breast cancer, we used molecular inversion probe (MIP) microarray to explore genome-wide copy number aberrations (CNA) and breast cancer-related gene alterations in DNA extracted from formalin-fixed paraffin-embedded tissue. We examined 42 primary breast cancers with known HR and HER2 status assessed via immunohistochemistry and FISH and analyzed MIP microarray results for correlation with standard tests and survival outcomes. Global genome-wide CNA ranged from 0.2% to 65.7%. Chromothripsis-like patterns were observed in 23/38 (61%) cases and were more prevalent in cases with =10% CNA (20/26, 77%) than in cases with <10% CNA (3/12, 25%; p<0.01). Most frequently involved chromosomal segment was 17q12-q21, the HER2 locus. Chromothripsis-like patterns involving 17q12 were observed in 8/19 (42%) of HER2-amplified tumors but not in any of the tumors without HER2 amplification (0/19; p<0.01). HER2 amplification detected by MIP microarray was 95% concordant with conventional testing (39/41). Interestingly, 21% of patients (9/42) had fibroblast growth factor receptor 1 (FGFR1)amplification and had a 460% higher risk for mortality than those without FGFR1 amplification (p<0.01). In summary, MIP microarray provided a robust assessment of genomic CNA of breast cancer.

myelocytes to segmented neutrophils, 9% eosinophils, 5% monocytes, 42% erythroid precursors, 21% lymphocytes, and 6% plasma cells. Interestingly, many mature and immature eosinophils were present with large coarse basophilic granules, abnormal nuclear segmentation, and occasional cytoplasmic vacuoles ( Fig. 1D-F). In addition, mild dysgranulopoiesis was noted. A CD34 immunohistochemical stain demonstrated the absence of blasts in the BM biopsy (inlet in Fig. 1C). PDGFRA and PDGFRB translocations were negative by fluorescent in situ hybridization (FISH). BCR/ABL1 fusion transcripts and KIT (exons 8 and 17) mutations were negative by polymerase chain reaction (PCR). Cytogenetic testing showed a 46 XY, inv(16)(p13.1q22),add(18)(p11.3) [5]/46,XY [15] karyotype (Fig. 1A). FISH analysis using break-apart probes in the BM cells confirmed the presence of CBFB/MYH11 translocation in 53 of 200 (27%) interphase nuclei (Fig. 1B). A comprehensive screening of the mutational profile of this patient was conducted on the PB mononuclear cells using a multiplexed targeted gene panel including 53 commonly mutated genes in myeloid neoplasms. Mutational analysis demonstrated mutations in KRAS (c.38G>A, p.Gly13Asp; 34.9%) and PRPF40B (c.2347C>T, p.Arg783Trp; 48.8%) genes. The patient fulfilled the criteria for a diagnosis of AML with inv (16) KIT, FLT3 and RAS [4,5]. The presence of a KRAS mutation in our patient is in agreement with other studies where secondary genetic lesions specifically in the RAS family of genes have been described in patients with AML with inv(16) and led to the hypothesis that these alterations represent cooperative secondary events with the CBFB/MYH11 translocation [5,6]. Several components of the RNA splicing machinery including PRPF40B have been found mutated in AML [7]. Eosinophilia can be related to other myeloid or lymphoid neoplasms. Eosinophils in abnormal PDGFRA, PDGRFB or FGFR1-related neoplasms or chronic myelomonocytic leukemia resemble normal eosinophils. Eosinophils in chronic eosinophilic leukemia can show a wide range of normal to abnormal eosinophils including vacuoles, atypical segmentation, sparse granules, or sometimes Charcot-Leyden crystals.Low blast counts (less than 20%) in AML patients with inv(16), t(8;21)(q22;q22) and t(15;17)(q22;q12) have been described in the literature. In a recent study of 208 cases of AML with inv(16)/t(16;16), Schwind et al. [1] found that BM blast percentages ranged from 2 to 89%.From a practical standpoint, it is not uncommon to detect blast percentages below 20% in AML with inv(16) or t(16;16) patients. However, to our knowledge this is the first described case of inv(16) associated AML with absent blasts in both PB and BM. In this case, the main morphologic clue which helped the clinical and morphologic classification of the patient was the presence of abnormal granules in eosinophilic precursors. In accordance with the WHO criteria, this case is classified as an AML despite the absence of myeloid blasts. Our report demonstrates that careful morphol...

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Background: SF3B1 mutations (SF3B1mut) in myelodysplastic syndromes (MDS) frequently involve codon K700E and have a favorable prognosis. The prognostic effect of non-K700E SF3B1mut is uncertain. Methods: We analyzed the clinical-pathologic features and outcomes of a single-institutional series of 94 SF3B1mut and 415 SF3B1wt newly diagnosed untreated MDS patients and explored the differences between K700E and non-K700E subgroups. Findings: Ninety-four (19%) patients had SF3B1mut: median age, 74 years. Fifty-five (60%) patients carried K700E. Recurrent non-K700E mutations (39, 40%) included R625, H662 and K666. Compared to SF3B1mut K700E, non-K700E patients had a lower median ANC (1.8 vs. 2.4, p=0.005) and were frequently high R-IPSS (revised International Prognostic Scoring System) [7(19%) vs. 2(4%), p=0.031]. Non-K700E MDS frequently associated with RUNX1 (26% vs. 7%, p=0.012) and exclusively with BCOR, IDH2, and SRSF2 mutations. There was no significant difference in karyotype or SF3B1 variant allele frequency. Most (~80%) were treated with hypomethylating agents. SF3B1mut had superior overall survival (OS) than SF3B1wt in all MDS categories [not-reached vs. 25.2 months, p=0.0003], low-grade MDS, and MDS with ring sideroblasts (MDS-RS). Compared to SF3B1wt, SF3B1mut K700E had superior outcomes in all MDS categories (25 months vs. not-reached, p=0.0001), low-grade MDS, and MDS-RS, but no significant difference was seen with non-K700E. By multivariate analysis, absence of SF3B1mut K700E (not non-K700E) independently associated with prognosis. Interpretation: SF3B1mut MDS show distinct clinical and mutational profiles, with K700E showing a significantly better OS compared to non-K700E mutations and SF3B1wt. Our study highlights the importance of SF3B1 mutation type in MDS risk assessment. Funding: This work was supported by grants from the Ladies Leukemia League, the National Institutes of Health (CA016672) and the MD Anderson MDS/AML Moon Shot.