Dr Greenberg’s laboratory research focuses on evaluating molecular abnormalities in myelodysplastic syndromes (MDS) with specific interest in gene expression profiling of marrow stem and progenitor cells using RNA Seq and microarray methodologies and proteomic analysis of aberrant antigen expression in plasma. As Director of the Stanford MDS Center his clinical research involves design and coordination of clinical trials using experimental drugs with biologic focus for both lower and higher risk MDS patients not responding to standard therapies. He is Coordinator of the International Working Group for Prognosis in MDS (IWG-PM) which generated the IPSS-R and is now evaluating the impact of molecular mutations on this risk-based prognostic system. He is Chair of the NCCN Practice Guidelines Panel for MDS.

Clinical Focus

  • Cancer > Hematology
  • Hematology
  • Myelodysplastic Syndromes

Academic Appointments

Administrative Appointments

  • Coordinator, International Working Group for Prognosis in MDS (2009 - 2015)
  • Chair, National Comprehensive Cancer Network Myelodysplasitic Syndromes Practice Guidelines Panel (1997 - 2015)
  • Director, Stanford MDS Center (1998 - 2015)
  • Head, Hematology Section, VA Palo Alto Health Care System (1979 - 2005)
  • Acting Chief, Medical Service, VA Palo Alto Health Care System (1978 - 1979)

Honors & Awards

  • International Prize for outstanding research in myelodysplastic syndromes (MDS), J.P. McCarthy Foundation (1997)

Boards, Advisory Committees, Professional Organizations

  • Member, American Society of Hematology (1972 - Present)
  • Member, Eastern Cooperative Oncology Group, Leukemia Committee (1993 - Present)

Professional Education

  • Medical Education:George Washington University (1963) DC
  • Fellowship:Stanford University School of Medicine (1971) CA
  • Residency:Barnes Hospital (1965) MO
  • Residency:Stanford University School of Medicine (1968) CA
  • Board Certification: Hematology, American Board of Internal Medicine (1976)
  • Board Certification: Internal Medicine, American Board of Internal Medicine (1970)
  • Internship:Barnes Hospital (1964) MO
  • B.A., Johns Hopkins University, Biological Sciences (1959)
  • M.D., George Washington U Med School, Medicine (1963)

Community and International Work

  • Chair, ASH Committee on International Outreach, 1998-2001


    Scientific exchange

    Partnering Organization(s)

    American Society of Hematology

    Populations Served

    Developing world hematology community



    Ongoing Project


    Opportunities for Student Involvement


Research & Scholarship

Current Research and Scholarly Interests

The major direction of research in my laboratory is to determine the role and mechanisms of hemopoietic dysregulation in human myeloid malignancies. The relation between molecular changes and cellular phenotype / pathophysiology is being explored using microarray and next generation technologies to evaluate differential gene expression profiles of MDS and AML marrow cells. The impact of cytokines and biologic response modifiers on these molecular features and hemopoietic response is being examined in clinical investigations with MDS and AML patients in therapeutic clinical trials with these agents.

Clinical Trials

  • ON 01910.Na for Intermediate1-2, or High Risk Trisomy 8 Myelodysplastic Syndrome (MDS) Not Recruiting

    This is a phase 2 single arm study in which fourteen MDS patients with Trisomy 8 or classified as Intermediate-1, 2, or High risk who meet all other inclusion/exclusion criteria will receive ON 01910.Na 1800 mg/24h as an intravenous continuous infusion (IVCI) over 72 hours every other week for the first four 2-week cycles and every 4 weeks afterwards.

    Stanford is currently not accepting patients for this trial. For more information, please contact Mai Tran, (650) 723 - 8594.

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  • Study of KB004 in Subjects With Hematologic Malignancies (Myelodysplastic Syndrome, MDS, Myelofibrosis, MF) Recruiting

    This is a global, multicenter, open-label, repeat-dose, Phase 1/2 study consisting of a Dose Escalation Phase (Phase 1) and a Cohort Expansion Phase (Phase 2). In both phases, KB004 will be administered by IV infusion once weekly as part of a 21-day dosing cycle.

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  • Efficacy and Safety of IV Rigosertib in MDS Patients With Excess Blasts Progressing After Azacitidine or Decitabine Not Recruiting

    This study will examine the effect intravenously administered rigosertib has on the relationship between bone marrow blasts response and overall survival in myelodysplastic syndromes (MDS) patients who have 5-30% bone marrow blasts and who progressed on or after treatment with azacitidine or decitabine.

    Stanford is currently not accepting patients for this trial. For more information, please contact Savita Kamble, 650-723-8594.

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  • Oral Rigosertib in Low Risk MDS Patients Refractory to ESAs Not Recruiting

    The study will enroll low risk MDS patients who need red blood cell transfusions and who are refractory to or are not using erythropoiesis-stimulating agents. The purpose of the study is to determine whether oral rigosertib treatment results in hematological improvements according to the 2006 International Working Group criteria in these patients. The study will also record any side effects that may occur during the study.

    Stanford is currently not accepting patients for this trial. For more information, please contact Savita Kamble, 650-723-8594.

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  • A Three-part Study of Eltrombopag in Thrombocytopenic Subjects With Myelodysplastic Syndromes or Acute Myeloid Leukemia Not Recruiting

    This is a worldwide, three-part (Part 1: open-label, Part 2: randomized, double-blind, Part 3: extension), multi-center study to evaluate the effect of eltrombopag in subjects with myelodysplastic syndromes (MDS) or acute myeloid leukemia (AML) who have thrombocytopenia due to bone marrow insufficiency from their underlying disease or prior chemotherapy. This objective will be assessed by a composite primary endpoint that consists of the following: the proportion of ≥Grade 3 hemorrhagic adverse events, or platelet counts <10 Gi/L, or platelet transfusions. Patients with MDS or AML and Grade 4 thrombocytopenia due to bone marrow insufficiency from their underlying disease or prior chemotherapy will be enrolled in the study. No low or intermediate-1 risk MDS subjects will be enrolled in the study. Subjects must have had at least one of the following during the 4 weeks prior to enrolment: platelet count <10 Gi/L, platelet transfusion, or symptomatic hemorrhagic event. Supportive standard of care (SOC), including hydroxyurea, will be allowed as indicated by local practice throughout the study. The study will have 3 sequential parts. Subjects who are enrolled in Part 1 (open-label) cannot be enrolled in Part 2 of the study (randomized, double-blind); however, subjects who complete the treatment period for Part 1 or Part 2 (8 and 12 weeks, respectively) will continue in Part 3 (extension) if the investigator determines that the subject is receiving clinical benefit on treatment.

    Stanford is currently not accepting patients for this trial. For more information, please contact Savita Kamble, 650-723-8594 .

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  • Azacitidine With or Without Lenalidomide or Vorinostat in Treating Patients With Higher-Risk Myelodysplastic Syndromes or Chronic Myelomonocytic Leukemia Not Recruiting

    This randomized phase II/III trial studies how well azacitidine works with or without lenalidomide or vorinostat in treating patients with higher-risk myelodysplastic syndromes or chronic myelomonocytic leukemia. Drugs used in chemotherapy, such as azacitidine, work in different ways to stop the growth of cancer cells, either by killing the cells, stopping them from dividing, or by stopping them from spreading. Lenalidomide may stop the growth of cancer cells by stopping blood flow to the cancer. Vorinostat may stop the growth of cancer cells by blocking some of the enzymes needed for cell growth. It is not yet known whether azacitidine is more effective with or without lenalidomide or vorinostat in treating myelodysplastic syndromes or chronic myelomonocytic leukemia.

    Stanford is currently not accepting patients for this trial. For more information, please contact Joselene Sipin-Sayno, 650-736-8113.

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Journal Articles

  • Mesenchymal Stromal Cell Density is Increased in Higher Grade Myelodysplastic Syndromes and Independently Predicts Survival. Mesenchymal Stromal Cell Density is Increased in Higher Grade Myelodysplastic Syndromes and Independently Predicts Survival. Johnson, R., Kurzer, J., Greenberg, P., Gratzinger, D. 2014; 142: 795-802
  • Role of reduced-intensity conditioning allogeneic hematopoietic stem-cell transplantation in older patients with de novo myelodysplastic syndromes: an international collaborative decision analysis. Journal of clinical oncology Koreth, J., Pidala, J., Perez, W. S., Deeg, H. J., Garcia-Manero, G., Malcovati, L., Cazzola, M., Park, S., Itzykson, R., AdeS, L., Fenaux, P., Jadersten, M., Hellstrom-Lindberg, E., Gale, R. P., Beach, C. L., Lee, S. J., Horowitz, M. M., Greenberg, P. L., Tallman, M. S., DiPersio, J. F., Bunjes, D., Weisdorf, D. J., Cutler, C. 2013; 31 (21): 2662-2670


    PURPOSE Myelodysplastic syndromes (MDS) are clonal hematopoietic disorders that are more common in patients aged ≥ 60 years and are incurable with conventional therapies. Reduced-intensity conditioning (RIC) allogeneic hematopoietic stem-cell transplantation is potentially curative but has additional mortality risk. We evaluated RIC transplantation versus nontransplantation therapies in older patients with MDS stratified by International Prognostic Scoring System (IPSS) risk. PATIENTS AND METHODS A Markov decision model with quality-of-life utility estimates for different MDS and transplantation states was assessed. Outcomes were life expectancy (LE) and quality-adjusted life expectancy (QALE). A total of 514 patients with de novo MDS aged 60 to 70 years were evaluated. Chronic myelomonocytic leukemia, isolated 5q- syndrome, unclassifiable, and therapy-related MDS were excluded. Transplantation using T-cell depletion or HLA-mismatched or umbilical cord donors was also excluded. RIC transplantation (n = 132) stratified by IPSS risk was compared with best supportive care for patients with nonanemic low/intermediate-1 IPSS (n = 123), hematopoietic growth factors for patients with anemic low/intermediate-1 IPSS (n = 94), and hypomethylating agents for patients with intermediate-2/high IPSS (n = 165). Results For patients with low/intermediate-1 IPSS MDS, RIC transplantation LE was 38 months versus 77 months with nontransplantation approaches. QALE and sensitivity analysis did not favor RIC transplantation across plausible utility estimates. For intermediate-2/high IPSS MDS, RIC transplantation LE was 36 months versus 28 months for nontransplantation therapies. QALE and sensitivity analysis favored RIC transplantation across plausible utility estimates. CONCLUSION For patients with de novo MDS aged 60 to 70 years, favored treatments vary with IPSS risk. For low/intermediate-1 IPSS, nontransplantation approaches are preferred. For intermediate-2/high IPSS, RIC transplantation offers overall and quality-adjusted survival benefit.

    View details for DOI 10.1200/JCO.2012.46.8652

    View details for PubMedID 23797000

  • Hematopoietic stem cell and progenitor cell mechanisms in myelodysplastic syndromes PROCEEDINGS OF THE NATIONAL ACADEMY OF SCIENCES OF THE UNITED STATES OF AMERICA Pang, W. W., Pluvinage, J. V., Price, E. A., Sridhar, K., Arber, D. A., Greenberg, P. L., Schrier, S. L., Park, C. Y., Weissman, I. L. 2013; 110 (8): 3011-3016


    Myelodysplastic syndromes (MDS) are a group of disorders characterized by variable cytopenias and ineffective hematopoiesis. Hematopoietic stem cells (HSCs) and myeloid progenitors in MDS have not been extensively characterized. We transplanted purified human HSCs from MDS samples into immunodeficient mice and show that HSCs are the disease-initiating cells in MDS. We identify a recurrent loss of granulocyte-macrophage progenitors (GMPs) in the bone marrow of low risk MDS patients that can distinguish low risk MDS from clinical mimics, thus providing a simple diagnostic tool. The loss of GMPs is likely due to increased apoptosis and increased phagocytosis, the latter due to the up-regulation of cell surface calreticulin, a prophagocytic marker. Blocking calreticulin on low risk MDS myeloid progenitors rescues them from phagocytosis in vitro. However, in the high-risk refractory anemia with excess blasts (RAEB) stages of MDS, the GMP population is increased in frequency compared with normal, and myeloid progenitors evade phagocytosis due to up-regulation of CD47, an antiphagocytic marker. Blocking CD47 leads to the selective phagocytosis of this population. We propose that MDS HSCs compete with normal HSCs in the patients by increasing their frequency at the expense of normal hematopoiesis, that the loss of MDS myeloid progenitors by programmed cell death and programmed cell removal are, in part, responsible for the cytopenias, and that up-regulation of the "don't eat me" signal CD47 on MDS myeloid progenitors is an important transition step leading from low risk MDS to high risk MDS and, possibly, to acute myeloid leukemia.

    View details for DOI 10.1073/pnas.1222861110

    View details for Web of Science ID 000315954400082

  • Risk of Therapy-Related Secondary Leukemia in Hodgkin Lymphoma: The Stanford University Experience Over Three Generations of Clinical Trials JOURNAL OF CLINICAL ONCOLOGY Koontz, M. Z., Horning, S. J., Balise, R., Greenberg, P. L., Rosenberg, S. A., Hoppe, R. T., Advani, R. H. 2013; 31 (5): 592-598


    To assess therapy-related acute myeloid leukemia/myelodysplastic syndrome (t-AML/MDS) risk in patients treated for Hodgkin lymphoma (HL) on successive generations of Stanford clinical trials.Patients with HL treated at Stanford with at least 5 years of follow-up after completing therapy were identified from our database. Records were reviewed for outcome and development of t-AML/MDS.Seven hundred fifty-four patients treated from 1974 to 2003 were identified. Therapy varied across studies. Radiotherapy evolved from extended fields (S and C studies) to involved fields (G studies). Primary chemotherapy was mechlorethamine, vincristine, procarbazine, and prednisone (MOPP) or procarbazine, mechlorethamine, and vinblastine (PAVe) in S studies; MOPP, PAVe, vinblastine, bleomycin, and methotrexate (VBM), or doxorubicin, bleomycin, vinblastine, and dacarbazine (ABVD) in C studies; and VbM (reduced dose of bleomycin compared with VBM) or mechlorethamine, doxorubicin, vinblastine, vincristine, bleomycin, etoposide, and prednisone (Stanford V) in G studies. Cumulative exposure to alkylating agent (AA) was notably lower in the G studies compared with the S and C studies, with a 75% to 83% lower dose of nitrogen mustard in addition to omission of procarbazine and melphalan. Twenty-four (3.2%) of 754 patients developed t-AML/MDS, 15 after primary chemotherapy and nine after salvage chemotherapy for relapsed HL. The incidence of t-AML/MDS was significantly lower in the G studies (0.3%) compared with the S (5.7%) or C (5.2%) studies (P < .001). Additionally, in the G studies, no t-AML/MDS was noted after primary therapy, and the only patient who developed t-AML/MDS did so after second-line therapy.Our data demonstrate the relationship between the cumulative AA dose and t-AML/MDS. Limiting the dose of AA and decreased need for secondary treatments have significantly reduced the incidence of t-AML/MDS, which was extremely rare in the G studies (Stanford V era).

    View details for DOI 10.1200/JCO.2012.44.5791

    View details for Web of Science ID 000314820400017

    View details for PubMedID 23295809

  • The multifaceted nature of myelodysplastic syndromes: clinical, molecular, and biological prognostic features. Journal of the National Comprehensive Cancer Network : JNCCN Greenberg, P. L. 2013; 11 (7): 877-85


    The myelodysplastic syndromes (MDS) consist of a heterogeneous spectrum of myeloid clonal hemopathies. The Revised International Prognostic Scoring System (IPSS-R) provides a recently refined method for clinically evaluating the prognosis of patients with MDS. Molecular profiling has recently generated extensive data describing critical hematopoietic molecular and biologic derangements contributing to clinical phenotypes. Current molecular insights have demonstrated roles of specific somatic gene mutations in the development and clinical outcomes of MDS, including their propensity to progress to more aggressive stages, such as acute myeloid leukemia. This article focuses on these recently reported clinical and underlying pathogenetic findings. The discussion provides a synthesis of the prognostic clinical, molecular, and biologic abnormalities intrinsic to the aberrant marrow hematopoietic and microenvironmental influences in MDS.

    View details for PubMedID 23847221

  • Specific plasma autoantibody reactivity in myelodysplastic syndromes Scientific Reports Mias, G. I., Chen, R., Zhang, Y., Sridhar, K., Sharon, D., Xiao, L., Im, H., Snyder, M. P., Greenberg, P. L. 2013; 3: 3311-3319

    View details for DOI 10.1038/srep03311

  • Reduced rRNA expression and increased rDNA promoter methylation in CD34(+) cells of patients with myelodysplastic syndromes BLOOD Raval, A., Sridhar, K. J., Patel, S., Turnbull, B. B., Greenberg, P. L., Mitchell, B. S. 2012; 120 (24): 4812-4818


    Myelodysplastic syndromes (MDS) are clonal disorders of hematopoietic stem cells characterized by ineffective hematopoiesis. The DNA-hypomethylating agents 5-azacytidine and 5-aza-2'-deoxycytidine are effective treatments for patients with MDS, increasing the time to progression to acute myelogenous leukemia and improving overall response rates. Although genome-wide increases in DNA methylation have been documented in BM cells from MDS patients, the methylation signatures of specific gene promoters have not been correlated with the clinical response to these therapies. Recently, attention has been drawn to the potential etiologic role of decreased expression of specific ribosomal proteins in MDS and in other BM failure states. Therefore, we investigated whether rRNA expression is dysregulated in MDS. We found significantly decreased rRNA expression and increased rDNA promoter methylation in CD34(+) hematopoietic progenitor cells from the majority of MDS patients compared with normal controls. Treatment of myeloid cell lines with 5-aza-2'-deoxycytidine resulted in a significant decrease in the methylation of the rDNA promoter and an increase in rRNA levels. These observations suggest that an increase in rDNA promoter methylation can result in decreased rRNA synthesis that may contribute to defective hematopoiesis and BM failure in some patients with MDS.

    View details for DOI 10.1182/blood-2012-04-423111

    View details for Web of Science ID 000313115300023

    View details for PubMedID 23071274

  • Revised International Prognostic Scoring System for Myelodysplastic Syndromes BLOOD Greenberg, P. L., Tuechler, H., Schanz, J., Sanz, G., Garcia-Manero, G., Sole, F., Bennett, J. M., Bowen, D., Fenaux, P., Dreyfus, F., Kantarjian, H., Kuendgen, A., Levis, A., Malcovati, L., Cazzola, M., Cermak, J., Fonatsch, C., Le Beau, M. M., Slovak, M. L., Krieger, O., Luebbert, M., Maciejewski, J., Magalhaes, S. M., Miyazaki, Y., Pfeilstoecker, M., Sekeres, M., Sperr, W. R., Stauder, R., Tauro, S., Valent, P., Vallespi, T., van de Loosdrecht, A. A., Germing, U., Haase, D. 2012; 120 (12): 2454-2465


    The International Prognostic Scoring System (IPSS) is an important standard for assessing prognosis of primary untreated adult patients with myelodysplastic syndromes (MDS). To refine the IPSS, MDS patient databases from international institutions were coalesced to assemble a much larger combined database (Revised-IPSS [IPSS-R], n = 7012, IPSS, n = 816) for analysis. Multiple statistically weighted clinical features were used to generate a prognostic categorization model. Bone marrow cytogenetics, marrow blast percentage, and cytopenias remained the basis of the new system. Novel components of the current analysis included: 5 rather than 3 cytogenetic prognostic subgroups with specific and new classifications of a number of less common cytogenetic subsets, splitting the low marrow blast percentage value, and depth of cytopenias. This model defined 5 rather than the 4 major prognostic categories that are present in the IPSS. Patient age, performance status, serum ferritin, and lactate dehydrogenase were significant additive features for survival but not for acute myeloid leukemia transformation. This system comprehensively integrated the numerous known clinical features into a method analyzing MDS patient prognosis more precisely than the initial IPSS. As such, this IPSS-R should prove beneficial for predicting the clinical outcomes of untreated MDS patients and aiding design and analysis of clinical trials in this disease.

    View details for DOI 10.1182/blood-2012-03-420489

    View details for Web of Science ID 000309044600019

    View details for PubMedID 22740453

  • Molecular and genetic features of myelodysplastic syndromes INTERNATIONAL JOURNAL OF LABORATORY HEMATOLOGY Greenberg, P. L. 2012; 34 (3): 215-222


    Multifactorial pathogenetic features underlying myelodysplastic syndromes (MDS) relate to inherent abnormalities within the hematopoietic precursor cell population. The predominant final common pathogenetic pathway causing ineffective hematopoiesis in MDS has been the varying degrees of apoptosis of the hematopoietic precursors and their progeny. A variety of molecular abnormalities have been demonstrated in MDS. These lesions are attributable to nonrandom cytogenetic and oncogenic mutations, indicative of chromosomal and genetic instability, transcriptional RNA splicing abnormalities, and epigenetic changes. Evolutionary cytogenetic changes may occur during the course of the disorder, which are associated with disease progression. These genetic derangements reflect a multistep process believed to underlie the transformation of MDS to acute myeloid leukemia. Recent findings provide molecular insights into specific gene mutations playing major roles for the development and clinical outcome of MDS and their propensity to progress to a more aggressive stage. Use of more comprehensive and sensitive methods for molecular profiling using 'next-generation' sequencing techniques for MDS marrow cells will likely further define critical biologic lesions underlying this spectrum of diseases.

    View details for DOI 10.1111/j.1751-553X.2011.01390.x

    View details for Web of Science ID 000305694300001

    View details for PubMedID 22212119

  • Personal Omics Profiling Reveals Dynamic Molecular and Medical Phenotypes CELL Chen, R., Mias, G. I., Li-Pook-Than, J., Jiang, L., Lam, H. Y., Chen, R., Miriami, E., Karczewski, K. J., Hariharan, M., Dewey, F. E., Cheng, Y., Clark, M. J., Im, H., Habegger, L., Balasubramanian, S., O'Huallachain, M., Dudley, J. T., Hillenmeyer, S., Haraksingh, R., Sharon, D., Euskirchen, G., Lacroute, P., Bettinger, K., Boyle, A. P., Kasowski, M., Grubert, F., Seki, S., Garcia, M., Whirl-Carrillo, M., Gallardo, M., Blasco, M. A., Greenberg, P. L., Snyder, P., Klein, T. E., Altman, R. B., Butte, A. J., Ashley, E. A., Gerstein, M., Nadeau, K. C., Tang, H., Snyder, M. 2012; 148 (6): 1293-1307


    Personalized medicine is expected to benefit from combining genomic information with regular monitoring of physiological states by multiple high-throughput methods. Here, we present an integrative personal omics profile (iPOP), an analysis that combines genomic, transcriptomic, proteomic, metabolomic, and autoantibody profiles from a single individual over a 14 month period. Our iPOP analysis revealed various medical risks, including type 2 diabetes. It also uncovered extensive, dynamic changes in diverse molecular components and biological pathways across healthy and diseased conditions. Extremely high-coverage genomic and transcriptomic data, which provide the basis of our iPOP, revealed extensive heteroallelic changes during healthy and diseased states and an unexpected RNA editing mechanism. This study demonstrates that longitudinal iPOP can be used to interpret healthy and diseased states by connecting genomic information with additional dynamic omics activity.

    View details for DOI 10.1016/j.cell.2012.02.009

    View details for Web of Science ID 000301889500023

    View details for PubMedID 22424236

  • Distinctive contact between CD34+ hematopoietic progenitors and CXCL12+ CD271+ mesenchymal stromal cells in benign and myelodysplastic bone marrow Lab Investigation Flores-Figueroa E, Varma S, Montgomery K, Greenberg P, Gratzinger D 2012; 92: 1330-1341
  • Treatment of higher risk myelodysplastic syndrome patients unresponsive to hypomethylating agents with ON 01910.Na LEUKEMIA RESEARCH Seetharam, M., Fan, A. C., Tran, M., Xu, L., Renschler, J. P., Felsher, D. W., Sridhar, K., Wilhelm, F., Greenberg, P. L. 2012; 36 (1): 98-103


    In a Phase I/II clinical trial, 13 higher risk red blood cell-dependent myelodysplastic syndrome (MDS) patients unresponsive to hypomethylating therapy were treated with the multikinase inhibitor ON 01910.Na. Responses occurred in all morphologic, prognostic risk and cytogenetic subgroups, including four patients with marrow complete responses among eight with stable disease, associated with good drug tolerance. In a subset of patients, a novel nanoscale immunoassay showed substantially decreased AKT2 phosphorylation in CD34+ marrow cells from patients responding to therapy but not those who progressed on therapy. These data demonstrate encouraging efficacy and drug tolerance with ON 01910.Na treatment of higher risk MDS patients.

    View details for DOI 10.1016/j.leukres.2011.08.022

    View details for Web of Science ID 000298149100035

    View details for PubMedID 21924492

  • Myelodysplastic Syndromes: Dissecting the Heterogeneity JOURNAL OF CLINICAL ONCOLOGY Greenberg, P. L. 2011; 29 (15): 1937-1938

    View details for DOI 10.1200/JCO.2011.35.2211

    View details for Web of Science ID 000290716900016

    View details for PubMedID 21519018

  • Myelodysplastic Syndromes JOURNAL OF THE NATIONAL COMPREHENSIVE CANCER NETWORK Greenberg, P. L., Attar, E., Bennett, J. M., Bloomfield, C. D., De Castro, C. M., Deeg, H. J., Foran, J. M., Gaensler, K., Garcia-Manero, G., Gore, S. D., Head, D., Komrokji, R., Maness, L. J., Millenson, M., Nimer, S. D., O'Donnell, M. R., Schroeder, M. A., Shami, P. J., Stone, R. M., Thompson, J. E., Westervelt, P. 2011; 9 (1): 30-56


    These suggested practice guidelines are based on extensive evaluation of the reviewed risk-based data and indicate useful current approaches for managing patients with MDS. Four drugs have recently been approved by the FDA for treating specific subtypes of MDS: lenalidomide for MDS patients with del(5q) cytogenetic abnormalities; azacytidine and decitabine for treating patients with higher-risk or nonresponsive MDS; and deferasirox for iron chelation of iron overloaded patients with MDS. However, because a substantial proportion of patient subsets with MDS lack effective treatment for their cytopenias or for altering disease natural history, clinical trials with these and other novel therapeutic agents along with supportive care remain the hallmark of management for this disease. The role of thrombopoietic cytokines for management of thrombocytopenia in MDS needs further evaluation. In addition, further determination of the effects of these therapeutic interventions on the patient's quality of life is important.(116,119,120,128,129) Progress toward improving management of MDS has occurred over the past few years, and more advances are anticipated using these guidelines as a framework for coordination of comparative clinical trials.

    View details for Web of Science ID 000287217200005

  • Prospective assessment of effects on iron-overload parameters of deferasirox therapy in patients with myelodysplastic syndromes LEUKEMIA RESEARCH Greenberg, P. L., Koller, C. A., Cabantchik, Z. I., Warsi, G., Glynos, T., Paley, C., Schiffer, C. 2010; 34 (12): 1560-1565


    We report the first prospective study evaluating the effects of deferasirox on liver iron concentration (LIC), labile plasma iron (LPI) and pharmacokinetics (PK) along with serum ferritin values in patients with IPSS Low- and Intermediate-1 risk myelodysplastic syndromes (MDS) and evidence of iron overload. Twenty-four heavily transfused MDS patients were enrolled in a planned 52 weeks of therapy. PK studies showed dose-proportional total drug exposure. Data demonstrated that deferasirox was well tolerated and effectively reduced LIC, LPI and serum ferritin in the iron-overloaded patients with MDS who completed 24 and 52 weeks of therapy despite ongoing receipt of red blood cell transfusions.

    View details for DOI 10.1016/j.leukres.2010.06.013

    View details for Web of Science ID 000283845900018

    View details for PubMedID 20615548

  • Current therapeutic approaches for patients with myelodysplastic syndromes BRITISH JOURNAL OF HAEMATOLOGY Greenberg, P. L. 2010; 150 (2): 131-143


    The myelodysplastic syndromes (MDS) are a heterogeneous spectrum of disorders requiring selective therapy based on patients' specific clinical features, predominantly their prognostic subgroups, age and performance status. Guidelines for management of patients with MDS have been generated by a number of national panels. This review focuses on evidence-based data supporting therapeutic approaches, which have also been recommended by the US National Comprehensive Cancer Network MDS Panel, with discussion of accessibility of recommended drugs in the US and in other countries. For lower risk disease (International Prognostic Scoring System Low and Intermediate-1) therapy is aimed at haematological improvement whereas for higher risk disease (Intermediate-2 and High) treatment focuses on altering disease natural history. Recent information regarding additional clinical and biological features has provided useful parameters for assessing disease prognosis that aid risk-based management decisions. The rationale for use of low versus high intensity therapies with these agents, including allogeneic haematopoietic stem cell transplantation, is discussed in detail.

    View details for DOI 10.1111/j.1365-2141.2010.08226.x

    View details for Web of Science ID 000279438600001

    View details for PubMedID 20507314

  • Relationship of differential gene expression profiles in CD34(+) myelodysplastic syndrome marrow cells to disease subtype and progression BLOOD Sridhar, K., Ross, D. T., Tibshirani, R., Butte, A. J., Greenberg, P. L. 2009; 114 (23): 4847-4858


    Microarray analysis with 40 000 cDNA gene chip arrays determined differential gene expression profiles (GEPs) in CD34(+) marrow cells from myelodysplastic syndrome (MDS) patients compared with healthy persons. Using focused bioinformatics analyses, we found 1175 genes significantly differentially expressed by MDS versus normal, requiring a minimum of 39 genes to separately classify these patients. Major GEP differences were demonstrated between healthy and MDS patients and between several MDS subgroups: (1) those whose disease remained stable and those who subsequently transformed (tMDS) to acute myeloid leukemia; (2) between del(5q) and other MDS patients. A 6-gene "poor risk" signature was defined, which was associated with acute myeloid leukemia transformation and provided additive prognostic information for International Prognostic Scoring System Intermediate-1 patients. Overexpression of genes generating ribosomal proteins and for other signaling pathways was demonstrated in the tMDS patients. Comparison of del(5q) with the remaining MDS patients showed 1924 differentially expressed genes, with underexpression of 1014 genes, 11 of which were within the 5q31-32 commonly deleted region. These data demonstrated (1) GEPs distinguishing MDS patients from healthy and between those with differing clinical outcomes (tMDS vs those whose disease remained stable) and cytogenetics [eg, del(5q)]; and (2) molecular criteria refining prognostic categorization and associated biologic processes in MDS.

    View details for DOI 10.1182/blood-2009-08-236422

    View details for Web of Science ID 000272190700014

    View details for PubMedID 19801443

  • Treatment of myelodysplastic syndrome patients with erythropoietin with or without granulocyte colony-stimulating factor: results of a prospective randomized phase 3 trial by the Eastern Cooperative Oncology Group (E1996) BLOOD Greenberg, P. L., Sun, Z., Miller, K. B., Bennett, J. M., Tallman, M. S., Dewald, G., Paietta, E., van der Jagt, R., Houston, J., Thomas, M. L., Cella, D., Rowe, J. M. 2009; 114 (12): 2393-2400


    This phase 3 prospective randomized trial evaluated the efficacy and long-term safety of erythropoietin (EPO) with or without granulocyte colony-stimulating factor plus supportive care (SC; n = 53) versus SC alone (n = 57) for the treatment of anemic patients with lower-risk myelodysplastic syndromes. The response rates in the EPO versus SC alone arms were 36% versus 9.6%, respectively, at the initial treatment step, 47% in the EPO arm, including subsequent steps. Responding patients had significantly lower serum EPO levels (45% vs 5% responses for levels < 200 mU/mL vs > or = 200 mU/mL) and improvement in multiple quality-of-life domains. With prolonged follow-up (median, 5.8 years), no differences were found in overall survival of patients in the EPO versus SC arms (median, 3.1 vs 2.6 years) or in the incidence of transformation to acute myeloid leukemia (7.5% and 10.5% patients, respectively). Increased survival was demonstrated for erythroid responders versus nonresponders (median, 5.5 vs 2.3 years). Flow cytometric analysis showed that the percentage of P-glycoprotein(+) CD34(+) marrow blasts was positively correlated with longer overall survival. In comparison with SC alone, patients receiving EPO with or without granulocyte colony-stimulating factor plus SC had improved erythroid responses, similar survival, and incidence of acute myeloid leukemia transformation.

    View details for DOI 10.1182/blood-2009-03-211797

    View details for Web of Science ID 000269925000007

    View details for PubMedID 19564636

  • A phase II intra-patient dose-escalation trial of weight-based darbepoetin alfa with or without granulocyte-colony stimulating factor in myelodysplastic syndromes AMERICAN JOURNAL OF HEMATOLOGY Gotlib, J., Lavori, P., Quesada, S., Stein, R. S., Shahnia, S., Greenberg, P. L. 2009; 84 (1): 15-20


    This Phase II study evaluated darbepoetin alfa (DA) in 24 patients with predominantly low or intermediate-1 risk myelodysplastic syndrome (MDS). Intra-patient dose escalation of DA was undertaken in three 6-week dose cohorts until a major erythroid response was achieved: 4.5 mcg/kg/week, 9 mcg/kg/week, and 9 mcg/kg/week plus granulocyte-colony stimulating factor (G-CSF) 2.5 mcg/kg twice weekly. Patients with refractory anemia with ringed sideroblasts (RARS) commenced DA at 9 mcg/kg/week. The weight-based dosing regimen translated into a median starting DA dose of 390 mcg/week. Erythroid responses were observed in 16/24 patients (67%; 12 major and 4 minor), with a median response duration of 11 months in major responders. Addition of G-CSF generated a major erythroid response in 7/15 patients (47%) who suboptimally responded to DA alone. DA was well tolerated, except for worsening of baseline mild hypertension and renal insufficiency in one patient with diabetes. IPSS score <0.5 and RBC transfusions <2 units/month increased the probability of an erythroid response. A minority of subjects (12%) developed low-level non-neutralizing anti-DA antibodies. Our data indicate that weekly weight-based dosing of DA, with the addition of G-CSF in selected individuals, can be an effective erythropoietic option in a high proportion of lower-risk MDS patients.

    View details for DOI 10.1002/ajh.21316

    View details for Web of Science ID 000262219900004

    View details for PubMedID 19006226

  • NCCN Task Force Report: Transfusion and Iron Overload in Patients with Myelodysplastic Syndromes J Nat Comp Cancer Network Greenberg, P., Rigsby C, Stone RM, Deeg J, Gore S, Millenson M, Nimer S, O'Donnell M, Shami P, Kumar R 2009; 7 ((Suppl 9): S1-16
  • Myelodysplastic syndromes. Journal of the National Comprehensive Cancer Network Greenberg, P. L., Attar, E., Battiwalla, M., Bennett, J. M., Bloomfield, C. D., DeCastro, C. M., Deeg, H. J., Erba, H. P., Foran, J. M., Garcia-Manero, G., Gore, S. D., Head, D., Maness, L. J., Millenson, M., Nimer, S. D., O'Donnell, M. R., Saba, H. I., Shami, P. J., Spiers, K., Stone, R. M., Tallman, M. S., Westervelt, P. 2008; 6 (9): 902-926

    View details for PubMedID 18926100

  • The costs of drugs used to treat myelodysplastic syndromes following National Comprehensive Cancer Network Guidelines. Journal of the National Comprehensive Cancer Network Greenberg, P. L., Cosler, L. E., Ferro, S. A., Lyman, G. H. 2008; 6 (9): 942-953


    Guidelines for management of patients with myelodysplastic syndromes (MDS) have been generated by the National Comprehensive Cancer Network (NCCN) Myelodysplastic Syndromes Panel. Because MDS is a heterogeneous spectrum of disorders, these patients have been categorized into prognostic subgroups, predominantly using the International Prognostic Scoring System (IPSS). Several drugs have been used to treat these patients, and their selection and sequential recommended use by the panel depend on disease characteristics and responses to treatment. Recombinant erythropoietin alfa and darbepoetin alfa have been the mainstay of therapy for treating anemia associated with MDS. The FDA has recently approved several other drugs for treating MDS, including azacytidine and decitabine for all stages of disease, lenalidomide for low-risk anemic patients with del(5q) chromosomal abnormality, and deferasirox for treating iron overload. For iron chelation, deferoxamine is also used occasionally. Treatment with immunosuppressive therapy (antithymocyte globulin and cyclosporin) has been therapeutically beneficial for a subset of younger patients with MDS. Because the financial cost of these therapies are substantial and have received only limited attention, this article evaluates the costs of specific drugs and their sequential use in the lower-risk IPSS (low and intermediate-1) subgroups based on the NCCN guidelines. Results estimate an average annual cost for potentially anemia-altering drugs of $63,577 per patient, ranging from $26,000 to $95,000, depending on the specific therapies. In patients for whom the therapies fail, annual costs for iron chelation plus red blood cell transfusions are estimated to average $41,412. The economic impact of drug therapy should be weighed against the patient's potential for improvement in clinical outcomes, quality of life, and transfusion requirements.

    View details for PubMedID 18926103

  • International MDS Risk Analysis Workshop (IMRAW)/IPSS Re-analyzed: Impact of cytopenias on clinical outcomes in Myelodysplastic Syndrome Am J Hematology Kao JM, McMillan A, Greenberg PL 2008
  • Predictive factors of response and survival in myelodysplastic syndrome treated with erythropoietin and G-CSF Blood Park S, Grabar S, Kelaidi C, Greenberg P, et al. 2008; 111: 574-582
  • Factors affecting response and survival in patients with myelodysplasia treated with immunosuppressive therapy. J Clin Oncol Sloand EM, Wu C, Greenberg P, et al 2008; 26: 2505-2511
  • Relative response of patients with myelodysplastic syndromes and other transfusion-dependent anaemias to deferasirox (ICL670): A 1-year prospective study. Eur J Haematol Porter J, Galanello R, Saglio S, Greenberg P, et al 2008; 80: 168-176
  • Phase II Study of Lenalidomide in Transfusion-Dependent, Low and Intermediate-1-Risk Myelodysplastic Syndromes with Normal and Abnormal Karyotypes Other than Deletion 5q. Blood Raza A, Reeves JE, Feldman EJ, Dewald GW, Bennett JM, Deeg HJ, Dreisbach L, Schiffer CA, Stone RM, Greenberg PL, et al 2008; 111: 86-93
  • Myelodysplastic Syndromes: Impact of recently analyzed variables for modifying current classification methods Clinical Leukemia Kao JM, Greenberg PL 2007; 1: 172-182
  • Definitions and standards in the diagnosis and treatment of the myelodysplastic syndromes: Consensus Statements and Report from a Working Conference Leukemia Research Valent P, Horny HP, Bennett JM, Fonatsch C, Germing U, Greenberg P, et al 2007; 31: 727-736
  • Hematologic and cytogenetic response to lenalidomide in myelodysplastic syndrome with chromosome 5q deletion. New Eng J Med List A, Dewald G, Bennett J, Giagounidis A, Raza A, Feldman E, Powell B, Greenberg P, et al 2006; 355: 1456-1465
  • Myelodysplastic syndromes clinical practice guidelines in oncology. Journal of the National Comprehensive Cancer Network Greenberg, P. L., Baer, M. R., Bennett, J. M., Bloomfield, C. D., De Castro, C. M., Deeg, H. J., Devetten, M. P., Emanuel, P. D., Erba, H. P., Estey, E., Foran, J., Gore, S. D., Millenson, M., Navarro, W. H., Nimer, S. D., O'Donnell, M. R., Saba, H. I., Spiers, K., Stone, R. M., Tallman, M. S. 2006; 4 (1): 58-77

    View details for PubMedID 16403405

  • A phase II study of the farnesyltransferase inhibitor tipifarnib in elderly patients with previously untreated poor-risk acute myeloid leukemia Blood Lancet J, Gojo I, Gotlib J, Greenberg PL, et al 2006; 108: 1387-1394
  • Myelodysplastic Syndromes: Clinical and Biological Advances Cambridge University Press, Cambridge, England Greenberg, P. E. 2006
  • Myelodysplastic syndromes: iron overload consequences and current chelating therapies. Journal of the National Comprehensive Cancer Network Greenberg, P. L. 2006; 4 (1): 91-96


    Chronic red blood cell transfusion support in patients with myelodysplastic syndromes (MDS) is often necessary but may cause hemosiderosis and its consequences. The pathophysiologic effects of iron overload relate to increased non-transferrin bound iron generating toxic oxygen free radicals. Studies in patients with MDS and thalassemia major have shown adverse clinical effects of chronic iron overload on cardiac function in patients who underwent polytransfusion. Iron chelation therapy in patients with thalassemia who were effectively chelated has prevented or partially reversed some of these consequences. A small group of patients with MDS who had undergone effective subcutaneous desferrioxamine (DFO) chelation for 1 to 4 years showed substantial hematologic improvements, including transfusion independence. However, because chronic lengthy subcutaneous infusions of DFO in elderly patients have logistic difficulties, this chelation therapy is generally instituted late in the clinical course. Two oral iron chelators, deferiprone (L1) and deferasirox (ICL670), provide potentially useful treatment for iron overload. This article reviews data indicating that both agents are relatively well tolerated, were at least as effective as DFO for decreasing iron burdens in comparative thalassemia trials, and (for deferiprone) were associated with improved cardiac outcomes. These outcomes could potentially alter the tissue siderosis-associated morbidity of patients with MDS, particularly those with pre-existing cardiac disease.

    View details for PubMedID 16403408

  • Clinical application and proposal for modification of the International Working Group (IWG) response criteria in myelodysplasia. Blood Cheson BD, Greenberg PL, Bennett JM, et al 2006; 108: 419-425
  • Management of patients with higher risk myelodysplastic syndromes CRITICAL REVIEWS IN ONCOLOGY HEMATOLOGY Fukumoto, J. S., Greenberg, P. L. 2005; 56 (2): 179-192


    Higher risk myelodysplastic syndromes (MDS) include patients in the Intermediate-2 and high-risk categories of the International Prognostic Scoring System, as well as patients with MDS secondary to radiation or chemical exposure. Ideally, the goal of therapy is to alter the natural history of disease in these patients to achieve cure or durable remission. High-intensity chemotherapy can achieve moderate rates of complete remission, however, durability of remission and overall survival tend to be short. Hematopoietic stem cell transplantation (HSCT) offers the possibility of cure, with long-term disease-free survival inversely related to age. Patients who are elderly or have poor functional status are candidates for reduced intensity HSCT, although this is still an experimental modality. Azacitidine is a hypomethylating agent that is a reasonable option for many patients ineligible for high-intensity therapies. Other therapies, such as immunomodulatory agents, arsenic trioxide, and farnesyl transferase inhibitors have thus far shown limited usefulness in higher risk MDS. This paper reviews the various therapeutic options for higher risk MDS, providing rationale for specific management approaches for these patients.

    View details for DOI 10.1016/j.critrevonc.2005.04.006

    View details for Web of Science ID 000233455300001

    View details for PubMedID 15979321

  • Mitoxantrone, etoposide, and cytarabine with or without valspodar in patients with relapsed or refractory acute myeloid leukemia and high-risk myelodysplastic syndrome: A phase III trial (E2995) JOURNAL OF CLINICAL ONCOLOGY Greenberg, P. L., Lee, S. J., Advani, R., Tallman, M. S., Sikic, B. I., Letendre, L., Dugan, K., Lum, B., Chin, D. L., Dewald, G., Paietta, E., Bennett, J. M., Rowe, J. M. 2004; 22 (6): 1078-1086


    To determine whether adding the multidrug resistance gene-1 (MDR-1) modulator valspodar (PSC 833; Novartis Pharmaceuticals, Hanover, NJ) to chemotherapy provided clinical benefit to patients with poor-risk acute myeloid leukemia (AML) and high-risk myelodysplastic syndrome (MDS).A phase III randomized study was performed using valspodar plus mitoxantrone, etoposide, and cytarabine (PSC-MEC; n=66) versus MEC (n=63) to treat patients with relapsed or refractory AML and high-risk MDS.For the PSC-MEC versus MEC arms, complete response (CR) was achieved in 17% versus 25% of patients, respectively (P=not significant). For patients who had not received prior intensive chemotherapy (ie, with secondary AML or high-risk MDS), the CR rate was increased--35% versus 15% for the remaining patients (P=.018); CR rates did not differ between treatment arms. The median disease-free survival in those achieving CR was similar in the two arms (10 versus 9.3 months) as was the patients' overall survival (4.6 versus 5.4 months). The CR rates in MDR+ (69% of patients) versus MDR- patients were similar for those receiving either chemotherapy regimen (16% versus 24%). The CR rate for unfavorable cytogenetic patients (45% of patients) was 13% compared to the remainder, 28% (P=.09). Population pharmacokinetic analysis demonstrated that the clearances of mitoxantrone and etoposide were decreased by 59% and 50%, respectively, supporting the empiric dose reductions in the PSC-MEC arm designed in anticipation of drug interactions between valspodar and the chemotherapeutic agents.CR rates and overall survival were not improved by using PSC-MEC compared to MEC chemotherapy alone in patients with poor-risk AML or high-risk MDS.

    View details for DOI 10.1200/JCO.2004.07.048

    View details for Web of Science ID 000220287900017

    View details for PubMedID 15020609

  • A Decision Analysis of Allogeneic Bone Marrow Transplantation for the Myelodysplastic Syndromes: Delayed Transplantation for Low Risk Myelodysplasia is Associated with Improved Outcome Blood Cutler C, Lee SJ, Greenberg P, et al 2004; 104: 579-585
  • Comparison of interphase FISH and metaphase cytogenetics to study myelodysplastic syndrome: an Eastern Cooperative Oncology Group (ECOG) study LEUKEMIA RESEARCH Cherry, A. M., Brockman, S. R., Paternoster, S. F., Hicks, G. A., Neuberg, D., Higgins, R. R., Bennett, J. M., Greenberg, P. L., Miller, K., Tallman, M. S., Rowe, J., DeWald, G. W. 2003; 27 (12): 1085-1090


    Cytogenetic analysis can be important in determining the prognosis and diagnosis of a number of hematological disorders, including myelodysplastic syndromes (MDS). Here, we compared metaphase chromosomal analyses on bone marrow aspirates from MDS patients with interphase fluorescence in situ hybridization (FISH) using probes specific for chromosomes nos. 5, 7, 8, 11, 13 and 20. Forty-three patients enrolled in ECOG protocol E1996 for low risk MDS and five patients enrolled in ECOG protocol E3996 for high risk MDS were studied by both metaphase chromosomal analysis and interphase FISH. Excluding those with a clonal loss of the Y chromosome, an abnormal clone was detected by cytogenetic analysis in 18 of 48 samples (37.5%). In comparison, our FISH panel detected an abnormal clone in 17 of 48 samples (35.4%). Twenty-nine of 30 samples with apparently normal karyotypes, including those with a missing Y chromosome, were also normal by our FISH panel. One patient had an occult deletion of chromosome 11 that was detected by FISH. These results indicate that around 60% of patients with MDS do not have abnormalities that are detectable by either chromosomal or FISH studies. In addition, it appears that interphase FISH studies are nearly as sensitive as cytogenetic analyses and can be a useful tool in studying bone marrow aspirates where cytogenetic analysis is not possible.

    View details for DOI 10.1016/S0145-2126(03)00104-8

    View details for Web of Science ID 000185431400004

    View details for PubMedID 12921944

  • Novel biospecific agents for the treatment of myelodysplastic syndromes. J Nat Comprehensive Cancer Network Gotlib J, Greenberg P 2003; 1: 473-480
  • Myelodysplastic syndromes. Hematology / the Education Program of the American Society of Hematology. American Society of Hematology. Education Program Greenberg, P. L., Young, N. S., Gattermann, N. 2002: 136-161


    The myelodysplastic syndromes (MDS) are characterized by hemopoietic insufficiency associated with cytopenias leading to serious morbidity plus the additional risk of leukemic transformation. Therapeutic dilemmas exist in MDS because of the disease's multifactorial pathogenetic features, heterogeneous stages, and the patients' generally elderly ages. Underlying the cytopenias and evolutionary potential in MDS are innate stem cell lesions, cellular/cytokine-mediated stromal defects, and immunologic derangements. This article reviews the developing understanding of biologic and molecular lesions in MDS and recently available biospecific drugs that are potentially capable of abrogating these abnormalities. Dr. Peter Greenberg's discussion centers on decision-making approaches for these therapeutic options, considering the patient's clinical factors and risk-based prognostic category. One mechanism underlying the marrow failure present in a portion of MDS patients is immunologic attack on the hemopoietic stem cells. Considerable overlap exists between aplastic anemia, paroxysmal nocturnal hemoglobinuria, and subsets of MDS. Common or intersecting pathophysiologic mechanisms appear to underlie hemopoietic cell destruction and genetic instability, which are characteristic of these diseases. Treatment results and new therapeutic strategies using immune modulation, as well as the role of the immune system in possible mechanisms responsible for genetic instability in MDS, will be the subject of discussion by Dr. Neal Young. A common morphological change found within MDS marrow cells, most sensitively demonstrated by electron microscopy, is the presence of ringed sideroblasts. Such assessment shows that this abnormal mitochondrial iron accumulation is not confined to the refractory anemia with ring sideroblast (RARS) subtype of MDS and may also contribute to numerous underlying MDS pathophysiological processes. Generation of abnormal sideroblast formation appears to be due to malfunction of the mitochondrial respiratory chain, attributable to mutations of mitochondrial DNA, to which aged individuals are most vulnerable. Such dysfunction leads to accumulation of toxic ferric iron in the mitochondrial matrix. Understanding the broad biologic consequences of these derangements is the focus of the discussion by Dr. Norbert Gattermann.

    View details for PubMedID 12446422

  • Treatment of myelodysplastic syndrome with agents interfering with inhibitory cytokines ANNALS OF THE RHEUMATIC DISEASES Greenberg, P. 2001; 60: III41-III42


    Results of these trials provide evidence for biological activity and some clinical efficacy of agents potentially blocking inhibitory cytokines in patients with MDS. However, given the limited responses, it appears that factors additional to TNFalpha inhibitory activity contribute to the development of cytopenias in these patients. Further studies are warranted using anti-TNFalpha/anti-inhibitory cytokine approaches, either alone or in combination with other agents, capable of abrogating the effects of additional inhibitory mechanisms in MDS.

    View details for Web of Science ID 000171874400009

    View details for PubMedID 11890651

  • Implications of pathogenetic and prognostic features for management of myelodysplastic syndromes LANCET Greenberg, P. 2001; 357 (9262): 1059-1060

    View details for Web of Science ID 000167996200004

    View details for PubMedID 11297953

  • The Myelodysplastic Syndromes , . Hematology: Basic Principles and Practice. 3rd Ed., Hoffman R, Benz E, Shattil S, Furie B, Cohen H, Silberstein L, McGlave P, Eds. Churchill Livingstone, NY, Greenberg PL 2000: 1106-1129
  • Prognostic scoring systems for risk assessment in myelodysplastic syndromes. Forum (Genoa, Italy) Greenberg, P. L., Sanz, G. F., Sanz, M. A. 1999; 9 (1): 17-31


    Clinical heterogeneity complicates therapy planning and makes it difficult to evaluate clinical trials in myelodysplastic syndromes (MDS). Thus, the development of a prognostic classification of MDS is of major clinical relevance, especially when considering the advanced age of most patients and the aggressiveness of the treatment modalities available. This review summarises the results of different studies focusing on prognostic factors in MDS and describes the relative advantages of the prognostic scoring systems that have been recently developed. This paper also discusses the prognostic factors of particular subtypes of patients. The percentage of marrow blasts, cytogenetic pattern and number and degree of cytopenias are the most powerful prognostic indicators in MDS. Although some limitations are evident, the recently developed scoring systems, and particularly the International Prognostic Scoring System, are extremely useful for predicting survival and acute leukaemic risk in individuals with MDS and should be incorporated into the design and analysis of therapeutic trials in these disorders. A risk-adapted treatment strategy is now possible and highly recommended for MDS patients.

    View details for PubMedID 10101208

  • Apoptosis and its role in the myelodysplastic syndromes: implications for disease natural history and treatment LEUKEMIA RESEARCH Greenberg, P. L. 1998; 22 (12): 1123-1136


    Apoptosis (programmed cell death) is an active cellular process which regulates cell population size by decreasing cell survival. In this review the underlying cellular and molecular mechanisms of apoptosis in hemopoietic and non-hemopoietic cells are described, with specific focus on these issues in the myelodysplastic syndrome (MDS), a myeloid clonal hemopathy. Apoptosis-regulating genes exist as families whose protein products are either anti-apoptotic or pro-apoptotic. Numerous stimuli can serve as initiators of the cell death pathway, including essentially all chemotherapeutic drugs, irradiation, certain inhibitory cytokines and deprivation of relevant growth factors. Morphological evidence of increased apoptosis in marrow hemopoietic cells has been demonstrated in patients with MDS. The reviewed data provide support for the hypothesis that early in MDS, increased apoptosis is associated with ineffective progenitor and maturing hemopoietic cell survival, and occurs concomitant with cytopenias/ineffective hemopoiesis; conversely, the progression of MDS toward AML occurs in concert with decreased apoptosis and an increased degree of neoplastic cell survival, leading to subsequent expansion of the abnormal precursor cells. These processes are associated with alterations in the balance between pro- and anti-apoptotic oncoprotein expression within the hemopoietic precursors, which may be modified by cytokine treatment. Investigations evaluating apoptotic events in MDS have improved our understanding of the biology of hemopoietic cell survival as related to pathogenetic features of this disease. By modifying levels of apoptosis, such studies provide a framework for future potentially beneficial therapeutic approaches to treat patients with MDS.

    View details for Web of Science ID 000077758000006

    View details for PubMedID 9922076

  • Bcl-2 expression by myeloid precursors in myelodysplastic syndromes: relation to disease progression LEUKEMIA RESEARCH Davis, R. E., Greenberg, P. L. 1998; 22 (9): 767-777


    the bcl-2 oncogene blocks apoptosis in various cell types and is expressed by normal myeloid precursors, declining with maturation. To investigate whether bcl-2 plays a role in the increase of myeloblasts in myelodysplastic syndromes (MDS) and their progression to acute myeloid leukemia (AML), we studied bcl-2 expression in initial (pre-therapy) bone marrow biopsies from MDS at early (refractory anemia, RA, with or without ring sideroblasts) and advanced stages (RA with excess blasts, and in transformation). Sequential biopsies were also studied to evaluate the effect of time or disease progression, including evolution to AML, or therapy with granulocyte colony stimulating factor (G-CSF). Early myeloid precursors (EMPs), predominantly myeloblasts, were identified in paraffin sections after immunostaining; bcl-2-positive EMPs were enumerated as a percentage of all EMPs (Bcl-2%), and by their absolute frequency per x 900 microscopic field (Bcl-2 index).in initial biopsies, the Bcl-2% and Bcl-2 index in early MDS (9.9+/-2.6 and 1.4+/-0.6, respectively; mean+/-S.E.) were significantly lower than in advanced MDS (26.4+/-3.6, 4.6+/-1.4), but similar to controls (8.1+/-0.3 and 0.8+/-0.1). The Bcl-2% and Bcl-2 index in three patients with AML evolved from MDS (57.4+/-17.9 and 85.1+/-62.4) were similar to values for seven patients with de novo AML (63.0+/-10.0, 98.4+/-29.8) and significantly higher than values for other groups. Bcl-2% showed relative increments with time or disease progression (range, 21-273%; 11 of 18 sequential biopsies from six of ten MDS patients), which was not clearly altered by G-CSF therapy (four of six patients with, two of four patients without treatment).bcl-2 expression by EMPs (in both proportion and absolute number) correlated with initial MDS stage, progressed over time independent of G-CSF therapy, and was associated with evolution to AML. These data provide support for the hypothesis that MDS progression is related to accumulation of immature myeloid cells with increased bcl-2 expression and decreased apoptosis.

    View details for Web of Science ID 000075292300001

    View details for PubMedID 9716007

  • Risk factors and their relationship to prognosis in myelodysplastic syndromes LEUKEMIA RESEARCH Greenberg, P. L. 1998; 22: S3-S6


    Recent efforts have been directed at improving the methodology for predicting clinical outcomes in patients with myelodysplastic syndromes (MDS). This review focuses on the development of a consensual, prognostic, risk-based analysis system generated by the International MDS Risk Analysis Workshop. In the workshop, cytogenetic, morphological, and clinical data were combined and collated from a relatively large group of patients with primary MDS. Critical prognostic variables were evaluated using the data set. Based on these findings, the International Prognostic Scoring System (IPSS) was developed, compared with other systems, and shown to provide more accurate prognoses regarding survival and evolution to acute myeloid leukemia in MDS patients. The improvement was due to several features of the workshop model: more refined cytogenetic categorization, inclusion of cytopenias, improved subdivision of marrow blast percentages, four subgroups defining outcome, and separate stratification for age. The IPSS should result in better-defined clinical outcomes in MDS and provide a framework for future studies determining the possible role of molecular determinants (e.g. oncogenes, tumor suppressor genes, cytokine expression and responsiveness) for evaluating prognoses. The IPSS will likely prove useful in the design and analysis of therapeutic trials in MDS as well as in patient management.

    View details for Web of Science ID 000075727800002

    View details for PubMedID 9734692

  • NCCN Practice Guidelines for Myelodysplastic Syndromes Oncology Greenberg PL, Bishop M, Deeg J, Erba H, Gore S, Nimer S, ODonnell M, Tallman M, Bennett J, Estey E, Stone R 1998; 12 (11A): 53-80
  • International scoring system for evaluating prognosis in myelodysplastic syndromes BLOOD Greenberg, P., Cox, C., LEBEAU, M. M., Fenaux, P., Morel, P., Sanz, G., Sanz, M., Vallespi, T., Hamblin, T., Oscier, D., Ohyashiki, K., Toyama, K., Aul, C., Mufti, G., Bennett, J. 1997; 89 (6): 2079-2088


    Despite multiple disparate prognostic risk analysis systems for evaluating clinical outcome for patients with myelodysplastic syndrome (MDS), imprecision persists with such analyses. To attempt to improve on these systems, an International MDS Risk Analysis Workshop combined cytogenetic, morphological, and clinical data from seven large previously reported risk-based studies that had generated prognostic systems. A global analysis was performed on these patients, and critical prognostic variables were re-evaluated to generate a consensus prognostic system, particularly using a more refined bone marrow (BM) cytogenetic classification. Univariate analysis indicated that the major variables having an impact on disease outcome for evolution to acute myeloid leukemia were cytogenetic abnormalities, percentage of BM myeloblasts, and number of cytopenias; for survival, in addition to the above, variables also included age and gender. Cytogenetic subgroups of outcome were as follows: "good" outcomes were normal, -Y alone, del(5q) alone, del(20q) alone; "poor" outcomes were complex (ie, > or = 3 abnormalities) or chromosome 7 anomalies; and "intermediate" outcomes were other abnormalities. Multivariate analysis combined these cytogenetic subgroups with percentage of BM blasts and number of cytopenias to generate a prognostic model. Weighting these variables by their statistical power separated patients into distinctive subgroups of risk for 25% of patients to undergo evolution to acute myeloid leukemia, with: low (31% of patients), 9.4 years; intermediate-1 (INT-1; 39%), 3.3 years; INT-2 (22%), 1.1 years; and high (8%), 0.2 year. These features also separated patients into similar distinctive risk groups for median survival: low, 5.7 years; INT-1, 3.5 years; INT-2, 1.2 years; and high, 0.4 year. Stratification for age further improved analysis of survival. Compared with prior risk-based classifications, this International Prognostic Scoring System provides an improved method for evaluating prognosis in MDS. This classification system should prove useful for more precise design and analysis of therapeutic trials in this disease.

    View details for Web of Science ID A1997WP23100028

    View details for PubMedID 9058730

  • Altered oncoprotein expression and apoptosis in myelodysplastic syndrome marrow cells BLOOD Rajapaksa, R., Ginzton, N., Rott, L. S., Greenberg, P. L. 1996; 88 (11): 4275-4287


    Ineffective hematopoiesis with associated cytopenias and potential evolution to acute myeloid leukemia (AML) characterize patients with myelodysplastic syndrome (MDS). We evaluated levels of apoptosis and of apoptosis-related oncoproteins (c-Myc, which enhances, and Bcl-2, which diminishes apoptosis) expressed within CD34+ and CD34- marrow cell populations of MDS patients (n = 24) to determine their potential roles in the abnormal hematopoiesis of this disorder. Marrow cells were permeabilized and CD34+ and CD34- cells were separately analyzed by FACS to detect: (1) a subdiploid (sub-G1) DNA population, and (2) expression of Bcl-2 and c-Myc oncoproteins. Within the CD34+ subset, a significantly increased percentage of cells demonstrated apoptotic/sub-G1 DNA content in early (ie. refractory anemia) MDS patients compared with normal individuals and AML patients (mean values: 9.1% > 2.1% > 1.2%). Correlated with these findings, the ratio of expression of c-Myc to Bcl-2 oncoproteins among CD34+ cells was significantly increased for MDS patients compared to those from normal and AML individuals (mean values: 1.6 > 1.2 > 0.9). Bcl-2 and c-Myc oncoprotein levels were maturation stage-dependent, with high levels expressed within CD34+ marrow cells, decreasing markedly with myeloid maturation. Treatment of seven MDS patients with the cytokines granulocyte colony-stimulating factor plus erythropoietin was associated with decreased levels of apoptosis within CD34+ marrow cells and may contribute to the enhanced hematopoiesis in vivo that was shown. These findings are consistent with the hypothesis that altered balance between cell-death (eg, c-Myc) and cell-survival (eg, Bcl-2) programs were associated with the increased degrees of apoptosis present in MDS hematopoietic precursors and may contribute to the ineffective hematopoiesis in this disorder, in contrast to decreased apoptosis and enhanced leukemic cell survival in AML.

    View details for Web of Science ID A1996VV15200024

    View details for PubMedID 8943864

  • GM-CSF accelerates neutrophil recovery after autologous hematopoietic stem cell transplantation BONE MARROW TRANSPLANTATION Greenberg, P., Advani, R., Keating, A., Gulati, S. C., Nimer, S., Champlin, R., Karanes, C., Gorin, N. C., Powles, R. L., Smith, A., Lamborn, K., Cuffie, C. 1996; 18 (6): 1057-1064


    Patients with non-myeloid hematologic malignancies (including Hodgkin's and non-Hodgkin's lymphomas, myeloma and acute lymphoid leukemia) or solid tumors underwent cytoreductive conditioning regimens followed by either autologous bone marrow transplantation (ABMT) (n = 343) or transplantation of peripheral blood stem cells (PBSC) with (n = 44) or without bone marrow (BM) (n = 16). In a randomized double-blind phase III multi-center trial, patients received either granulocyte-macrophage colony-stimulating factor (GM-CSF, 10 micrograms/kg/day) or placebo by daily i.v. infusion beginning 24 h after bone marrow infusion and continuing until the absolute neutrophil count (ANC) had recovered to > or = 1000/mm3, or for a maximum of 30 days. Median time to neutrophil recovery was significantly shorter in the GM-CSF group (18 vs 27 days, P < 0.001), and more GM-CSF patients had neutrophil recovery by day 30 (70 vs 48%). Median duration of hospitalization was significantly shorter in the GM-CSF group (29 vs 32 days, P = 0.02). GM-CSF significantly reduced the median time to neutrophil recovery in patients receiving bone marrow only (19 vs 27 days, P < 0.001) or PBSC with or without bone marrow (14 vs 21 days, P < 0.001). The overall incidence of adverse events was comparable in the two groups, although more patients in the GM-CSF group discontinued treatment due to adverse events (17 vs 9%, P < 0.001). No difference was noted in infection incidence or time to platelet independence. GM-CSF had no negative impact on time to relapse or long-term survival. These data indicate the positive influence of GM-CSF on neutrophil recovery and hospital stay in patients receiving ABMT for a variety of clinical indications.

    View details for Web of Science ID A1996VZ81700005

    View details for PubMedID 8971373

  • Maintenance treatment of the anemia of myelodysplastic syndromes with recombinant human granulocyte colony-stimulating factor and erythropoietin: Evidence for in vivo synergy BLOOD Negrin, R. S., Stein, R., Doherty, K., Cornwell, J., Vardiman, J., Krantz, S., Greenberg, P. L. 1996; 87 (10): 4076-4081


    Patients with myelodysplastic syndromes (MDS) have refractory cytopenias leading to transfusion requirements and infectious complications. In vitro marrow culture data have indicated that granulocyte colony stimulating factor (G-CSF) synergizes with erythropoietin (EPO) for the production of erythroid precursors. In an effort to treat the anemia and neutropenia in this disorder, MDS patients were treated with a combination of recombinant human EPO and recombinant human G-CSF. Fifty-five patients were enrolled in the study of which 53 (96%) had a neutrophil response. Forty-four patients were evaluable for an erythroid response of which 21 (48%) responded. An erythroid response was significantly more likely in those patients with relatively low serum EPO levels, higher absolute basal reticulocyte counts and normal cytogenetics at study entry. Seventeen (81%) of the patients who responded to combined G-CSF plus EPO therapy continued to respond during an 8-week maintenance phase. G-CSF was then discontinued and all patients' neutrophil responses were diminished, whereas 8 continued to have an erythroid response to EPO alone. In 7 of the remaining 9 patients, resumption of G-CSF was required for recurrent erythroid responses. The median duration of erythroid responses to these cytokines was 11 months, with 6 patients having relatively prolonged and durable responses for 15 to 36 months. Our results also indicate that approximately one half of responding patients require both G-CSF and EPO to maintain an effective erythroid response, suggesting that synergy between G-CSF and EPO exists in vivo for the production of red blood cells in MDS.

    View details for Web of Science ID A1996UK87900007

    View details for PubMedID 8639764

  • Biologic and clinical implications of marrow culture studies in the myelodysplastic syndromes SEMINARS IN HEMATOLOGY Greenberg, P. L. 1996; 33 (2): 163-175

    View details for Web of Science ID A1996UG59700007

    View details for PubMedID 8722686

  • Maintenance treatment of the anemia of myelodysplastic syndromes with recombinant human G-CSF plus erythropoietin: Evidence for in vivo synergy Blood Negrin RS, Stein R, Doherty K, Cromwell J, Vardiman J, Krantz S, Greenberg PL 1996; 87: 4076-4081


    We have evaluated the use of iso-osmolar Percoll density gradients to enrich CD34+ hematopoietic progenitor cells and to reduce T cells for purposes of bone marrow or mobilized peripheral blood cell transplantation (BMT or PBCT). Samples from 12 normal BM donors and 11 patients undergoing mobilization of PB cells using chemotherapy and G-CSF were placed over a five-step density gradient from 40 to 50% Percoll. In BM, low-density fractions 1 to 3 (40 to 45% Percoll) accounted for 3% of starting nucleated cells with a 10- to 20-fold enrichment of hematopoietic progenitors (CD34+ cells) and a 20-fold reduction of CD4+ and CD8+ T cells. In PB, fractions 1 to 3 accounted for 20 to 30% of the starting nucleated cells with a five-fold enrichment of hematopoietic progenitors. Based on these values, such populations have been used for clinical transplantation using a single apheresis. The reduced cell numbers in the low-density fractions can facilitate tumor purging, and the reduced T cell numbers present in the marrow may ameliorate graft-vs.-host disease.

    View details for Web of Science ID A1995RP11800011

    View details for PubMedID 7543414

  • MODULATION OF APOPTOSIS IN HUMAN MYELOID LEUKEMIC-CELLS BY GM-CSF EXPERIMENTAL HEMATOLOGY Han, J. H., Gileadi, C., Rajapaksa, R., Kosek, J., Greenberg, P. L. 1995; 23 (3): 265-272


    Apoptosis (programmed cell death) regulates cell population size. To determine the mechanisms whereby hematopoietic growth factors (HGFs) modulate apoptosis in human myeloid leukemic cells, we evaluated the roles of protein and mRNA synthesis for altering apoptosis in growth factor-stimulated vs. quiescent leukemic TF1 cells. Lysates of cells from the granulocyte-macrophage colony-stimulating factor (GM-CSF)-dependent myeloid leukemic cell line TF1 were separated into high molecular weight (HMW) pellets of intact DNA and supernatants of fragmented low MW (LMW) DNA, and the DNA purified from these fractions was quantified. In the absence of both GM-CSF and fetal bovine serum (FBS), 70% of the DNA was fragmented after 3 days in culture, with a characteristic apoptotic ladder-like pattern on agarose gel electrophoresis, whereas this proportion had initially been < 5%. In contrast, less than 5% of the DNA was fragmented in cells incubated with GM-CSF plus FBS or GM-CSF alone. Delayed addition of GM-CSF, but not FBS, permitted partial rescue of the cells, inhibiting increasing rates of accumulation of fragmented DNA. When the macro-molecular synthesis inhibitor cycloheximide (CHX) or actinomycin D (Act D) was present for 26 hours in the absence of GM-CSF and FBS, apoptosis was inhibited. In contrast, in the presence of GM-CSF or FBS, apoptosis was enhanced upon addition of CHX or Act D. The latter effect persisted even with the late addition of CHX. These findings indicate that disparate mechanisms of enhancing or inhibiting apoptosis exist in myeloid leukemic cells related to environmental conditions, including HGF-regulated cellular synthesis of distinct proteins and mRNA.

    View details for Web of Science ID A1995QK72300014

    View details for PubMedID 7875243



    We evaluated the effects of 2 months of G-CSF treatment on in vitro hematopoiesis in 17 patients with myelodysplastic syndromes (MDS). Although in vitro marrow myeloid progenitor cell (CFU-GM) growth stimulated by G-CSF generally remained subnormal, in the majority of neutrophil responders significantly augmented incremental change (termed AIC) of CFU-GM numbers occurred after treatment, as did neutrophilic differentiation. The neutrophil non-responders had less prominent in vitro myeloid responses and lower basal neutrophil levels (p < 0.05). Following G-CSF treatment, the initially subnormal erythroid burst-forming unit (BFU-E) values underwent AIC in five of 11 patients along with increased reticulocyte responses in vivo, whereas four of the five patients who lacked AIC of BFU-E did not. Three patients with persisting cytogenetic abnormalities and increased neutrophilic differentiation in vitro also responded in vivo, suggesting that G-CSF induced in vivo cellular differentiation from the abnormal clone. Two of the three patients who developed blastic responses in vivo had increased CFU-GM growth pre- and post-therapy. These results indicate in vivo-in vitro correlations for myeloid and erythroid responses of MDS marrow cells which related to treatment with G-CSF.

    View details for Web of Science ID A1995QH98700007

    View details for PubMedID 7531261



    We treated myelodysplastic syndrome patients (MDS) with both recombinant human granulocyte colony-stimulating factor (G-CSF) and recombinant human erythropoietin (EPO) to determine whether such combination therapy resulted in improvement of their anemias. Twenty-four of 28 patients begun on study completed the protocol and were evaluable for erythroid responses. Therapy was initiated with G-CSF at 1 micrograms/kg administered by daily subcutaneous injection and adjusted to either normalize or double the neutrophil count. EPO was then administered by daily subcutaneous injection at a dose of 100 U/kg and dose-escalated to 150 and 300 U/kg every 4 weeks while continuing the G-CSF. Changes in absolute reticulocyte count, hematocrit level, and need for RBC transfusions were compared with pretreatment values as well as other blood cell counts. Ten of 24 patients (42%) had erythroid responses, whereas all patients had neutrophil responses. Six previously transfused patients no longer required RBC transfusions during the treatment period. Erythroid responses were found to be independent of patient age, French-American-British subtype, duration of disease, prior RBC transfusion requirements, or cytogenetic abnormalities at presentation. Pretreatment serum EPO levels were lower in erythroid-responding as compared with nonresponding patients (median 157 v 600 U/L; P = .05). The combined treatment modality was generally well tolerated. We conclude that a substantial percentage of MDS patients had both erythroid and myeloid responses when treated with the combination of G-CSF and EPO.

    View details for Web of Science ID A1993LQ74100008

    View details for PubMedID 7687889



    To characterize immune suppressive and hematopoietic features of enriched subsets of human marrow cells, we separated these cells on Percoll density gradients. CD4+ and CD8+ T cells (CD3+) were enriched in the high-density marrow cell fractions and reduced in low-density fractions. CD4-CD8- (CD3+) T cells expressing the alpha beta T-cell antigen receptor were at least 10 times less numerous than the CD4+ and CD8+ T cells in all fractions. Purified populations of the CD4-CD8- alpha beta + T cells obtained by flow cytometry suppressed the mixed leukocyte reaction (MLR). Another population of suppressor cells that expressed neither T-cell (CD3) nor natural killer cell (CD16) surface markers was also identified. The latter cells had the phenotypic and functional characteristics of "natural suppressor" cells. Suppressor cell activity was enriched in the low-density fractions along with hematopoietic progenitors (colony-forming unit-granulocyte-macrophage and burst-forming unit-erythroid). The progenitor and suppressor cell activities were depleted in high-density fractions. The latter fractions made vigorous responses in the MLR. The low-density fractions, which accounted for less than 10% of the input marrow cells, suppressed the MLR and did not respond. Further evaluation of the low-density fractions may be of value in allogeneic bone marrow transplantation due to the reduction of CD4+ and CD8+ T cells and the enrichment of hematopoietic progenitors as well as immune suppressor cells that may inhibit graft-versus-host disease.

    View details for Web of Science ID A1992KC83800034

    View details for PubMedID 1467527


    View details for Web of Science ID A1992HD44900005

    View details for PubMedID 1736368


    View details for Web of Science ID A1992HD44900009

    View details for PubMedID 1371018

  • Programmed cell death (apoptosis) as a mechanism for regulating haematopoietic cell population size -- Greenberg PL 1992


    Therapeutic options have been rapidly evolving for management of patients with the indolent myeloid clonal hemopathies termed myelodysplastic syndromes (MDS). Heterogeneity of MDS has been demonstrated on the basis of marrow morphology and biologic features and has been useful for prognostication into high and low risk groups for transformation to acute leukemia. Such stratification has been important for evaluating responses to various treatments. These therapeutic options include the differentiation-inducing vitamins retinoic acid and vitamin D, and cytokines such as alpha and gamma interferon, to which there has been a generally low response. The use of intensive or low dose chemotherapy has been associated with relatively low response rates, few durable responses and a high degree of hemopoietic toxicity. Allogeneic bone marrow transplantation (BMT) has shown durable responses for a subset of MDS patients, particularly those who are young and who are in the low risk subgroups. however, due to the elderly nature of the majority of MDS patients, and the toxicity associated with BMT, this option has limited utility for most of these patients. Major focus has been on the recent therapeutic use of recombinant human hemopoietic growth factors, particularly G-CSF, GM-CSF and IL3. These agents have been well-tolerated and generally produce a high incidence of sustained improvements in neutrophil counts and marrow morphology, although hemoglobin and platelet counts have generally not been altered. More extensive clinical trials evaluating the impact of these hemopoietic growth factors on the natural history of MDS are ongoing.

    View details for Web of Science ID A1991FD16900006

    View details for PubMedID 1709576


    View details for Web of Science ID A1991FN56900012

    View details for PubMedID 1912599



    We investigated functional interactions between granulocyte-monocyte-colony-stimulating factor (GM-CSF) and the insulin family hormones using the GM-CSF- and insulin-dependent human acute myeloid leukemia cell line AML-193. Recombinant human GM-CSF and insulin enhanced AML-193 cell proliferation 3- and 5-fold, respectively, and showed a synergistic 10-fold increase when added in combination. Insulin-like growth factors I and II (IGFI and IGFII) increased AML-193 cell proliferation 4-fold and 2-fold, respectively, and also demonstrated synergy when combined with GM-CSF. Blocking experiments with monoclonal antibodies against the insulin and IGFI receptors indicated that the proliferative effects of insulin and IGFI were mediated through both their homologous and heterologous receptors. Pertussis toxin and cholera toxin, which ADP ribosylate GTP-binding proteins (G proteins), and the cyclic AMP analogue, dibutyryl cyclic AMP, decreased the proliferation induced by GM-CSF or insulin. Specific receptor binding of 125I-insulin, -IGFI, and -GM-CSF to AML-193 cells was demonstrated and not affected by preincubation with pertussis toxin or cholera toxin. Radiolabeled GM-CSF, insulin, and IGFI did not cross-compete with the heterologous ligands for receptor binding. These studies demonstrate (a) association between receptor binding and proliferative effects of GM-CSF and the insulin family hormones, (b) involvement of the G proteins in signal transduction provoked by these hormones which occurs at a postreceptor-binding level, and (c) synergistic mitogenic interactions between GM-CSF and the insulin family hormones, suggesting that their receptors are linked to divergent signaling mechanisms in addition to sharing G protein-coupled pathways.

    View details for Web of Science ID A1990EC41000006

    View details for PubMedID 1698537



    Marrow cells from 36 patients with myelodysplastic syndromes (MDS) (13 refractory anemia [RA], 14 refractory anemia with excess of blasts [RAEB], 9 RAEB in transformation [RAEB-T]) were evaluated for their in vitro proliferative and differentiative responsiveness to recombinant human granulocyte colony-stimulating factor (G-CSF) or granulocyte-monocyte CSF (GM-CSF). GM-CSF exerted a stronger proliferative stimulus than G-CSF for marrow myeloid clonal growth (CFU-GM) in these patients (44 v 12 colonies per 10(5) nonadherent buoyant bone marrow cells [NAB], respectively, P less than .025). GM-CSF stimulated increased CFU-GM growth in the 16 patients with abnormal marrow cytogenetics in comparison with the 20 patients who had normal cytogenetics (52 and 30 colonies per 10(5) NAB, respectively, P less than .05), whereas no such difference could be demonstrated with G-CSF (11 and 16 colonies per 10(5) NAB, respectively). In contrast, granulocytic differentiation of marrow cells was induced in liquid culture by G-CSF in 15 of 32 (47% patients), while GM-CSF did so in only 4 of 18 (22%) patients (P less than .025) including, for RAEB/RAEB-T patients: 9 of 18 versus 0 of 9, respectively (P less than .025). For MDS patients with normal cytogenetics, G-CSF- and GM-CSF-induced marrow cell granulocytic differentiation in 12 of 18 (67%) versus 3 of 11 (27%), respectively (P less than .025), contrasted with granulocytic induction in only 3 of 14 (21%) and 1 of 7 (14%) patients with abnormal cytogenetics, respectively. We conclude that G-CSF has greater granulocytic differentiative and less proliferative activity for MDS marrow cells than GM-CSF in vitro, particularly for RAEB/RAEB-T patients and those with normal cytogenetics.

    View details for Web of Science ID A1990EB07800006

    View details for PubMedID 1698477



    Myelodysplastic syndromes (MDS) are characterized by chronic refractory cytopenias resulting in increased risk of infection, bleeding, and conversion to acute leukemia. In an effort to improve these cytopenias we have treated 18 patients over a 6- to 8-week period with increasing daily subcutaneous doses of recombinant human granulocyte colony-stimulating factor (G-CSF). Sixteen patients responded with improvement in neutrophil counts. On cessation of treatment these counts returned to baseline values over a 2- to 4-week period. To maintain these improved blood counts 11 patients were treated with G-CSF for more prolonged periods. Ten patients again responded with an increase in total leukocyte counts (1.6- to 6.4-fold) and absolute neutrophil counts (ANC) (3.6- to 16.3-fold), with responses persisting for 3 to 16 months. A significantly decreased risk of developing bacterial infections was noted during periods with ANC greater than 1,500/mm3 as compared with periods of time with ANC less than 1,500/mm3. Two anemic patients had a greater than 20% rise in hematocrit over the study period, and 2 additional patients had a decrease in red blood cell transfusion requirements during G-CSF treatment. Bone marrow myeloid maturation improved in 7 of 9 maintenance phase patients. Three patients progressed to acute myeloid leukemia during treatment. The drug was generally well-tolerated and no severe toxicities were noted. These data demonstrated that G-CSF administered to MDS patients by daily subcutaneous administration was well-tolerated and effective in causing persistent improvement of the neutrophil levels and marrow myeloid maturation. These effects were associated with a decreased risk of infection and, in some patients, with decreased red blood cell transfusion requirements.

    View details for Web of Science ID A1990DM15500005

    View details for PubMedID 1694702



    Non-adherent Percoll-separated large granular lymphocytes (LGLs) fractionated by fluorescence-activated cell sorter into CD16+ CD4- natural killer (NK) cells and CD16- CD4+ T cells, were co-cultured with bone marrow (BM) cells previously depleted of adherent T and/or NK cells by immunoadsorption (panning) and plated in a clonogenic assay to assess myeloid colony formation (CFU-gm growth). LGLs, NK cells and LGL T cells [low buoyant density (LBD) T cells] each significantly reduced colony-stimulating factor (CSF)-dependent CFU-gm growth to 70% of control values (p less than 0.05). Non-LGL T cells [high buoyant density (HBD) T cells] did not affect this growth. Incubation of the effector cells with human recombinant interleukin 2 prior to co-culturing did not alter these findings. The supernatants obtained from LGLs, NK cells and LBD T cells co-cultured with BM cells also inhibited CFU-gm growth to 70% of the control, whereas supernatants from effector cells which were not co-cultured with BM had no such effect. These supernatants from the LGL:BM co-cultured cells possessed NK cytotoxic factor (NKCF), but lacked alpha and gamma interferons, tissue necrosis factor-alpha, and prostaglandin E2. These results suggest that BM cells stimulate LGLs to produce NKCF, and that LGLs, CD16+ NK cells, and CD4+ CD16- LBD T cells activated by contact with BM cells inhibit CFU-gm growth.

    View details for Web of Science ID A1990DE70100003

    View details for PubMedID 2140585



    We evaluated the effects of recombinant human granulocyte colony stimulating factor (rhG-CSF) and granulocyte-monocyte colony stimulating factor (rhGM-CSF) on the in vitro proliferative, differentiative, and regenerative responsiveness of marrow cells from myelodysplastic syndrome patients (MDS) in comparison to those from normal individuals. Our studies showed decreased primary clonogenicity of myeloid (CFU-GM) and erythroid (BFU-E) hemopoietic progenitor cells from the MDS patients. rhGM-CSF had more potent stimulatory effects than rhG-CSF for MDS marrow CFU-GM growth; no enhanced cellular proliferation in the MDS patients was observed in liquid culture with either rhGM-CSF or rhG-CSF. Decreased myeloid clonal cell self-generation and/or recruitment occurred in the MDS patients upon exposure to either rhG-CSF or rhGM-CSF. rhG-CSF demonstrated more potent granulocytic differentiation effects than rhGM-CSF both for normals and MDS patients using marrow enriched for immature myeloid cells with lesser differentiation noted for MDS. Cytogenetic abnormalities, present with or without additional normal karyotypes in native marrow of four MDS patients, persisted after culture with rhG-CSF, indicating induced differentiation of both normal and abnormal clones. Although proliferative and differentiative effects were seen with both factors these data show MDS marrow cells in vitro to have predominantly differentiative responsiveness to rhG-CSF and proliferative responsiveness to rhGM-CSF.

    View details for Web of Science ID A1990DB45100007

    View details for PubMedID 1690318



    We explored the expression of a lymphocyte homing-associated cell adhesion molecule (H-CAM, CD44) on hematopoietic progenitors. We demonstrate that immature myeloid and erythroid leukemic cell lines stain intensely with monoclonal antibodies Hermes-1 and Hermes-3, which define distinct epitopes on lymphocyte surface H-CAM, a glycoprotein involved in lymphocyte interactions with endothelial cells. Using fluorescence-activated cell sorting (FACS), human marrow cells were fractionated into Hermeshi, Hermesmed, and Hermeslo populations according to the expression of both the Hermes-1 and Hermes-3 epitopes. Granulocyte-macrophage colony-forming unit and erythroid burst-forming unit precursors were found predominantly in the brightly positive fractions. Two-color FACS analysis confirmed that the My10 (CD34) positive populations of cells in bone marrow, which contain most of the progenitor cell activity, are brightly positive for Hermes-1. Finally, we demonstrate that among bone marrow cells, the highest levels of H-CAM are expressed on myeloid and erythroid progenitors as well as mature granulocytes and lymphocytes. Thus we provide evidence that molecules related or identical to the H-CAM homing receptor are expressed on marrow progenitor cells. H-CAM may contribute to progenitor cell interactions with marrow endothelial and stromal cell elements important to the maintenance and regulation of hematopoiesis.

    View details for Web of Science ID A1990CL57700009

    View details for PubMedID 1688719



    To determine the hematopoietic effects and toxicity of recombinant human granulocyte colony-stimulating factor (G-CSF) in patients with myelodysplastic syndromes.The G-CSF was administered by daily subcutaneous injection to outpatients in a phase I-II trial. Dose was escalated every 2 weeks between 0.1 to 3.0 micrograms/kg body weight.d over an 8-week treatment period.Outpatient clinical research center at a university hospital.Twelve consecutive patients with myelodysplastic syndromes: two refractory anemia, seven refractory anemia with excess of blasts, three refractory anemia with excess of blasts in transformation.In 10 of 12 patients, elevations in blood leukocyte counts (2- to 10-fold) and absolute neutrophil counts (5- to 40-fold) were seen over the 8-week treatment period. Five of seven severely neutropenic patients (absolute neutrophil count, less than 0.5 x 10(9)/L) had a rise in count to 1.2 to 16.3 x 10(9)/L. Increased reticulocyte counts occurred in 5 patients, and were associated with decreased transfusion requirements in 2 of 9 erythrocyte transfusion-dependent patients. Treatment with G-CSF enhanced marrow myeloid cell maturation in 9 of 11 evaluable patients. Neutrophil chemotaxis and phagocytosis in vitro were improved or unchanged after treatment in 6 of 8 patients tested. In 11 of 12 patients, there were no substantial changes in platelet, lymphocyte, eosinophil, or monocyte counts. Three responding patients initially had abnormal cytogenetics that persisted after G-CSF therapy, suggesting induced differentiation of the abnormal clone. The therapy was associated with minimal toxicity. None of the patients' conditions converted to acute leukemia during treatment or in short-term follow-up.Treatment with G-CSF administered by subcutaneous injection is well tolerated and effective for improving the neutropenia, and less commonly the transfusion-dependent anemia, over 6 to 8 weeks in patients with myelodysplastic syndromes.

    View details for Web of Science ID A1989AB29600006

    View details for PubMedID 2471429



    Because T lymphocytes and natural killer (NK) cells produce a variety of growth factors and interleukin 2 (IL2) modulates the activity of both, we assessed the ability of IL2 to stimulate human T cells and NK cells to produce hematopoietic growth factors detectable in clonogenic marrow culture. Human recombinant interleukin 2 (rIL2) added directly to cultures of human bone marrow that had been depleted of monocytes or depleted of both monocytes and T cells caused no significant alteration of myeloid (CFU-GM) or erythroid colony formation. Conditioned media harvested from rIL2-stimulated (greater than 100 U/mL) peripheral blood mononuclear cells, T cells, Leu-2 cells, and Leu-3 cells all had erythroid burst-promoting activity (BPA) but lacked myeloid colony-stimulating factor (GM-CSF) or CFU-GM-inhibitory activity. These T cells were IL2 receptor-negative, and the addition of anti-IL2 receptor monoclonal antibody (anti-Tac) to T cell cultures did not abrogate this IL2-stimulated BPA production. In addition, Percoll gradient-enriched, large granular lymphocytes (LGL) were separated by fluorescence-activated cell sorting into Leu-11+ (NK) cells and Leu-11- (low-density Leu-4+ T) cell fractions. rIL2 stimulated LGL, Leu-11+ and Leu-11- cells to produce BPA but not detectable GM-CSF or CFU-GM-inhibitory activity. Leu-11+ (NK) cells were Tac-negative from days 0 through 14 of culture. We conclude that rIL2 at high concentrations stimulated T cells, Leu-2 and Leu-3 cell subsets, LGL, and NK cells to produce BPA but not GM-CSF and that this stimulation may be mediated by an IL2 receptor distinct from Tac or by an epitope of the IL2 receptor not recognized by the anti-Tac antibody.

    View details for Web of Science ID A1988M985300012

    View details for PubMedID 2833331



    Insulin and insulinlike growth factors I and II (IGF-I and IGF-II) influence mesodermal cell proliferation and differentiation. As multiple growth factors are involved in hemopoietic cell proliferation and differentiation, we assessed the receptor binding and mitogenic effects of these peptides on a panel of mesodermally derived human myeloid leukemic cell lines. The promyelocytic cell line HL60 had the highest level of specific binding for these 125I-labeled ligands, with lower binding to the less differentiated myeloblast cell line KG1 and undifferentiated blast variants of these cell lines (HL60blast, KG1a). Insulin binding affinity and receptor numbers were reduced significantly by chemically induced granulocytic differentiation of HL60 cells and was unchanged following induced monocytic differentiation. No substantial alteration in IGF-I or -II binding occurred with induced HL60 cell differentiation. Insulin and IGF-I demonstrated cross competition for receptor binding and down-regulated their homologous receptors without detectable cross modulation of the heterologous receptors on HL60 cells. IGF-I and insulin increased HL60 cell proliferation, as assessed by 3H-thymidine uptake, IGF-I greater than insulin. IGF-I binding and mitogenic effects were blocked by the monoclonal anti-IGF-I receptor antibody IR3, indicating that IGF-I-induced proliferative effects were mediated via its homologous receptor. In contrast, insulin binding and mitogenesis displayed blocking by both anti-IGI-I and anti-insulin receptor antibodies, indicating mediation of its activity through both receptors. These data demonstrate specific binding and mitogenic interactions between insulin, IGFs, and hemopoietic cells which are associated with their state of differentiation.

    View details for Web of Science ID A1987L056600003

    View details for PubMedID 2960684



    In the myelodysplastic syndromes (MDS) clonogenic marrow cell culture studies have demonstrated intrinsic hemopoietic stem cell and progenitor cell abnormalities consistent with these disorders representing clonal hemopathies. Abnormal responsiveness of these cells to stimulatory and inhibitory growth factors indicate the contribution of regulatory abnormalities in these patients. These in vitro growth abnormalities have prognostic import and the defects progress as subsets of these patients evolve into a blastic transformation stage. Maturation-inducing agents such as retinoic acid and vitamin D alter clonal growth patterns and enhance myeloid differentiation in the MDS, and correlations between in vitro and in vivo responsiveness of hemopoietic cells to retinoic acid have been demonstrated. Studies will be reviewed indicating the role of these biologic parameters for understanding pathogenetic mechanisms underlying the MDS.

    View details for Web of Science ID A1987M133600017

    View details for PubMedID 2829490

  • Granulopoiesis in acute myeloid leukemia and preleukemia New Engl J Med Greenberg PL, Nichols WC, Schrier SL 1971; 284: 1225-1232

Conference Proceedings

  • EFFECTS OF CSFS IN PRELEUKEMIA Greenberg, P. L., Negrin, R., Nagler, A. STOCKTON PRESS. 1990: 121-126


    Based on pre-clinical and in vitro studies demonstrating enhanced granulocytic proliferation and differentiation induced by granulocyte-monocyte and granulocyte-colony stimulating factors (GM-CSF and G-CSF), these recombinant human hormones have been used to treat cytopenic patients with preleukemia [i.e., myelodysplastic syndromes (MDS)]. To date, five studies have been reported using GM-CSF short-term (generally 7-14 days, x 1-5 courses). Thirty-eight of 45 treated patients had improvements in neutrophil counts, 14 had increased reticulocyte counts with three of these individuals having decreased RBC transfusion requirements, and eight had transient increases in platelets. In 12 patients an increase in marrow and/or peripheral blood blasts was noted. Seven patients progressed to acute myeloid leukemia (AML), particularly patients with greater than 15% marrow blasts. In a longer term study, five patients received GM-CSF for 2 to 9 weeks, although only one individual maintained increased neutrophil counts, one developed antibodies to GM-CSF and one evolved into AML. Eighteen patients have been treated for 2 months with G-CSF, 16 of whom had normalization of neutrophil counts with improved marrow maturation, five had increased reticulocyte counts with three having decreased transfusion requirements, no substantial changes in platelet counts were noted. Eleven patients have received maintenance therapy with G-CSF for 6-16 months, ten had persistent increases in neutrophil counts with enhanced marrow myeloid maturation and five had increased reticulocytes. Decreased infectious episodes were notedat times of neutrophil improvements. Four of the 18 individuals have subsequently developed AML after 6-16 months.(ABSTRACT TRUNCATED AT 250 WORDS)

    View details for Web of Science ID A1990DU04800030

    View details for PubMedID 1697191



    In vitro marrow hemopoietic cultures were utilized to determine the possible efficacy of recombinant human granulocyte colony-stimulating factor (G-CSF) for treating the refractory cytopenias present in the myelodysplastic syndromes (MDS). Our studies showed responsiveness of enriched hemopoietic precursors in vitro to the proliferative and granulocytic differentiative stimuli of G-CSF, generally without increased clonal self-generation. These in vitro parameters correlated with in vivo hematologic responses in our Phase I and II clinical trials. In this study 18 patients were treated for two months with s.c. administration (0.1-3 micrograms/kg/day) of G-CSF, escalating doses every two weeks. This study indicated normalization of neutrophil courses in 16 patients and reticulocyte responses with decreased red blood cell (RBC) transfusion requirements in three of 12 transfusion-dependent patients. Marrow myeloid maturation improved in the responding patients. Extended treatment for additional six- to 16-month periods has indicated persisting neutrophil responses. The relative risk of developing bacterial infections was significantly decreased in patients whose neutrophil level normalized (absolute neutrophil count greater than 1,500/mm3) during G-CSF therapy, compared to such episodes in their pretreatment neutropenic period. This therapy was well-tolerated, without serious toxicity being noted. In vitro neutrophil function (chemotaxis and phagocytosis) remained normal or improved in six of the eight tested patients. Transformation to acute myelogenous leukemia occurred in two patients with refractory anemia with excess blasts in transformation (RAEB-T) during or within a month of the treatment period. Marrow cytogenetic studies indicate persistence of the initial normal and/or abnormal clones.(ABSTRACT TRUNCATED AT 250 WORDS)

    View details for Web of Science ID A1990CT55300028

    View details for PubMedID 1691248

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