Minimal diagnostic criteria for myelodysplastic

syndromes and separation fromICUS and IDUS:

update and open questions
P. Valent
*
and H.-P. Horny

*
Medical University of Vienna, Vienna, Austria,

Institute of Pathology, Ansbach, Germany
ABSTRACT
Although a classication for myelodysplastic syndromes (MDS) has been proposed by several working groups
and by the World Health Organization (WHO), with criteria useful to discriminate between disease variants, the
important issue of minimal diagnostic criteria of MDS has only recently been addressed. In the current article,
proposed minimal diagnostic criteria for MDS are discussed together with two conditions that do not meet these
criteria, although cytopenia or dysplasia is present. These two conditions, idiopathic cytopenia of unknown
signicance and idiopathic dysplasia of unknown signicance should be kept in mind as a provisional (potential)
diagnosis in patients with suspected MDS. Both conditions can progress to frank MDS over time. Therefore,
once diagnosed, these patients should have a haematological follow-up. The diagnosis MDS, on the other hand,
needs to be based on robust criteria and exclusion of all other causes of cytopenia and dysplasia, which requires
detailed and sometimes extensive investigations, including a bone marrow biopsy, cytogenetic analyses,
molecular studies and ow cytometry.
Keywords Diagnostic criteria, ow cytometry, histopathology, ICUS, IDUS, MDS.
Eur J Clin Invest 2009; 39 (7): 548553
Introduction
Myelodysplastic syndromes (MDS) are clonal disorders of hae-
matopoietic stem cells characterized by a maturation defect in
myelopoietic (progenitor) cells, peripheral cytopenia and clonal
instability with enhanced risk to transform into acute myeloid
leukaemia (AML) [14]. Before 2001, MDS have been classied
according to criteria provided by the FrenchAmericanBritish
(FAB) co-operative study group [5]. In 2001 and 2008, the
World Health Organization (WHO) adapted and extended the
FAB classication [6,7]. Although solid criteria for the discrimi-
nation of MDS variants from each other have been provided in
these formulations, minimal diagnostic criteria for MDS were
discussed only recently.
In most patients with MDS, the bone marrow smear reveals
substantial dysplasia in one or more of the major bone marrow
cell lineages (erythroid, neutrophilic, megakaryocytic) [1,2,57].
Monocytosis or and an increase in blast cells are recorded in a
group of patients and typical chromosome defects are com-
monly detected [57]. In addition, typical blood count abnor-
malities such as macrocytic anaemia and abnormal neutrophils
(Pseudo-Pelger-Huet cells) are usually found. Thus, in a
majority of patients with MDS, the diagnosis can be established
easily by examination of blood lms and bone marrow smears
and by applying appropriate cytomorphological and clinical
criteria. In other patients, the diagnosis can be revealed or
conrmed by an abnormal karyotype [69]. However, there is
an increasing number of patients in whom it is difcult to
dene whether mild cytopenia or mild dysplasia is indeed
caused by an underlying MDS, prephase of MDS or another
myeloid or non-haematological disorder, especially when no
abnormal karyotype is found [10]. In other patients, it may be
difcult to discriminate between advanced MDS and AML or a
myelodysplastic myeloproliferative neoplasm (MDN MPN
overlap). For these conditions, it is important to dene
generally accepted minimal diagnostic criteria.
Minimal diagnostic criteria
Minimal diagnostic criteria for MDS have been discussed exten-
sively in a Working conference in the year 2006 [10] as well as
in the WHO consortium and other MDS Working groups.
548 European Journal of Clinical Investigation Vol 39
DOI: 10.1111/j.1365-2362.2009.02151.x
REVIEW
Based on discussions in 2006, minimal diagnostic criteria of
MDS include (i) marked and constant (> 6 months) peripheral
cytopenia in at least one major haematopoietic lineage (ery-
throid, neutrophilic, platelet), (ii) MDS-specic bone marrow
features (one or more of the following: dysplasia 10% in one
or more major lineage, ring sideroblasts 15%, myeloblasts
5%, or an MDS-related karyotype) and (iii) exclusion of all
other haematopoietic and non-haematopoietic disorders as pri-
mary reason for dysplasia and or cytopenia [10] (Table 1).
Based on these denitions, all MDS patients must have a bone
marrow biopsy to exclude or reveal another underlying disease,
e.g. AML when blast cells are increased [10,11]. This is essential
when bone marrow smears are contaminated with blood, a dry
tap was obtained or clinical or laboratory features are pointing
at another (potential) diagnosis [10,11]. Using proposed criteria,
the diagnosis of MDS may sometimes be difcult to substan-
tiate in cytopenic patients in whom MDS co-exists with another
unrelated disease or another bone marrow neoplasm that may
also cause cytopenia or even (mild) dysplasia (example: masto-
cytosis coexisting with MDS). In these cases, it is important to
look at bone marrow sections to dene whether cytopenia
could be caused by MDS or by the co-existing disease and to
reveal and document additional criteria for MDS [10,11].
Morphological criteria
Bone marrowcell dysplasia, recorded in a good quality smear,
remains the most important MDS-related criterion [1,2,57,10].
In fact, in most patients with MDS, bone marrow cells display
substantial dysplasia in at least one of the three major cell lin-
eages (erythroid, neutrophilic, megakaryocyte). Morphological
features dening dysplasia have been discussed extensively
during the past decade [57,10,12]. More recently, several work-
ing groups have also discussed minimal morphological criteria
for bone marrowdysplasia. Based on these discussions, at least
10%of all cells in a given lineage should showsigns of dysplasia
to full this important criterion [7,10]. This may sometimes be
difcult to assess, especially in the megakaryocytic lineage, i.e.
when the numbers of megakaryocytes are lowand many of
these cells represent immature precursors. It is recommended to
include the haematopathology assessment in these cases and to
apply reliable immunohistochemical stains for detection of
(abnormal) megakaryocytes in bone marrow sections [10,11].
Similarly, it may often be difcult to estimate the percentage of
myeloblasts in bone marrowsmears in patients with MDS, espe-
cially when samples are contaminated with blood cells (often
seen) or the quality of the smear is suboptimal. Therefore, it is
of great importance to apply CD34 by immunohistochemistry
in bone marrowsections in all cases [10,11].
An increase in blast cells should per se be regarded as a sign
of bone marrow dysplasia. Whereas normal bone marrow
smears usually contain less than 3% blasts, the cut off level for
MDS, rst proposed by the FAB group, remains 5% [57].
With regard to ring sideroblasts, the previously recommended
threshold cut off level of 15% seems a reasonable diagnostic cri-
terion [57,10,12]. Specic recommendations for proper evalua-
tion of blast cells and ring sideroblasts in MDS have recently
been presented [12]. In bone marrow studies in MDS, the clear
advantage of histopathological assessment (haematopathology)
is that such analysis can be performed long after the diagnostic
procedure was initiated which is not the case in ow cytometric
assessments unless cells are routinely frozen at the time of
diagnosis. The advantage of ow cytometric assessment is its
high sensitivity, the possibility to determine several different
markers in one cell lineage by multicolour ow cytometry of
bone marrow cells and the rapidity of the assay yielding results
within hours.
Table 1 Minimal diagnostic criteria for myelodysplastic
syndromes (MDS)
Criteria Major (diagnostic) test
Prerequisite criteria (both must be fullled)
Constant cytopenia Blood counts (over 6 months)
Exclusion of all other diseases
as primary cause of cytopenia
dysplasia
BM smear and BM histology,
cytogenetics, ow cytometry,
molecular markers, other
relevant investigations*
MDS-related criteria (one of these must be fullled)
Morphological dysplasia in one
of the three major BM lineages
BM and PB smear, in certain
situations: BM histology
Blast cell count 5% BM smear and BM histology
Ring sideroblasts 15% Iron stain
Typical karyotype anomaly Conventional karyotyping
and FISH
Co-criteria
BM stem cell function Circulating CFC, reticulocytes
Abnormal immunophenotype
of BM cells
Multicolour ow cytometry,
immunohistochemisty
Monoclonality of myeloid cells Molecular markers, mutations
Abnormal gene expression
prole
mRNA proling assays
BM, bone marrow; PB, peripheral blood; FISH, uorescence in situ
hybridization; CFC, colony-forming progenitor cells.
*Investigations depend on the case history and overall situation in each case,
and should always include a complete chemistry prole with inammation
parameters, immunoglobulins, a serum erythropoietin level, and a serum
tryptase level.
Major lineages: erythroid cells, neutrophils, megakaryocytes.
European Journal of Clinical Investigation Vol 39 549
DIAGNOSTIC CRITERIA FOR MYELODYSPLASTIC SYNDROMES
Blood count criteria
Constant and marked peripheral blood cytopenia is a major
diagnostic nding in MDS [57,10]. It is of importance to note
that cytopenia needs to be substantial: The proposed cut off
levels (haemoglobin < 11 g dL
)1
, neutrophils < 1500 lL
)1
blood, platelets < 100 000 lL
)1
) are somehow arbitrary [10].
Moreover, cytopenia has to be recorded for at least 6 months,
unless other clear signs for an MDS (e.g. karyotype) are present.
In fact, in patients with a karyotype characteristic for MDS, the
diagnosis MDS can immediately be established in a clearly
cytopenic patient, which is important as some of these patients
may be candidates for intensive treatment (e.g. search for a
transplant donor). Other examples are patients who are clearly
transfusion-dependent and in need of a relatively high
haemoglobin level to have an adequate quality of life (e.g.
elderly patient with coexisting cardiac or pulmonary disease).
In these patients, constant transfusion-dependence should be
employed as cytopenia-related MDS criterion replacing the
arbitrary haemoglobin cut-off level.
Exclusion of other diagnoses
The diagnosis MDS is based on both MDS-related (positive
dening) criteria and exclusion of other disorders as primary
reason for cytopenia or dysplasia [10]. The exclusion criterion
is of importance as also other haematopoietic and non-haemat-
opoietic disorders can present with cytopenia and or myelo-
dysplasia. In patients with increased blast counts, differential
diagnoses include acute myeloid leukaemia and MDN MPN.
In patients with low blast counts, important differential
diagnoses include aplastic anaemia, toxic bone marrow dam-
age, copper deciency, other deciency syndromes, chronic
autoimmune disorders and chronic infectious diseases
including HIV infection. In each case, it is mandatory to exclude
all these potential differential diagnoses by appropriate
investigations [10]. Therefore, the bone marrow biopsy with
conventional histology and immunohistochemistry is an
essential step in the diagnostic work up in patients with
suspected MDS [10,11]. Likewise, the provisional diagnosis
MDS RAEB established from a bone marrow smear will change
to AML when the pathologist has convincingly documented
that the bone marrow is fully packed with blast cells in a
CD34-stained bone marrow section. Bone marrow histology is
also crucial for the detection of certain (rare) variants of MDS,
such as hypocellular (often secondary) MDS, MDS with brosis
(MDS-F) and MDS associated with systemic mastocytosis
(SM-MDS) [10,11]. A limited panel of antibodies have been
shown to be of superior value for immunohistochemical bone
marrow analysis in MDS [10,11]: CD34 for determining blast
cell numbers and reliable detection of even small compact blast
cell inltrates (when blast cells are CD34-negative, CD117 KIT
is recommended as an alternative marker); CD61 (or other
platelet-associated markers) for the assessment of numbers and
distribution of megakaryocytes and detection of scattered
megakaryoblasts and anti-tryptase for detection of compact
mast cell inltrates in cases with associated systemic
mastocytosis but also to look for an increase in basophilic
granulocytes found in a group of MDS patients.
An important aspect is that MDS can coexist with other
myeloid, mast cell-, or even lymphoid neoplasms, such as
multiple myeloma [10,11,13]. In these cases, it is important to
assess the bone marrow carefully with markers and techniques
sufcient to dene both disorders employing currently
available diagnostic (WHO) criteria.
Co-criteria for the denition of MDS
In a group of cytopenic patients with suspected MDS, disease-
related criteria (dysplasia, karyotype, ring sideroblasts) are not
found (not fullled), although clinical features are highly sug-
gestive (e.g. macrocytic transfusion-dependent anaemia). In
these patients, it is of importance to ask for co-criteria determin-
ing bone marrow stem cell function and clonality of bone
marrow cells (Table 1). Bone marrow stem cell function is
almost invariably reduced in MDS and is best examined by the
colony-forming unit (CFU) assay [1416]. The numbers of
circulating colony-forming cells (CFC) are an excellent para-
meter to dene bone marrow function. In a very early phase of
MDS, the numbers of CFC in the blood may be normal [17].
However, in almost all patients with frank MDS, CFC levels are
severely depressed [1417]. In other words, a normal CFC
count excludes MDS as a potential diagnosis with relatively
high accuracy. This is also important as in most patients with
cytopenia developing on the basis of a non-haematopoietic
disease, CFC levels are normal and in almost all patients with
MPN, CFC levels are elevated.
Clonality in MDS is best documented by conventional
karyotyping and FISH [810]. However, in patients with a
normal karyotype, other parameters indicating monoclonality
have to be employed. One important approach is to ask for
certain (somatic) mutations in critical target genes, such as
RUNX, RAS, JAK2 or KIT [3,4,10,18]. Another approach is to
screen for monoclonal patterns in mRNA expression proles
by gene array (gene chip) analysis or proteomics [19,20].
However, these techniques are not standardized and may be
less specic for MDS. Another approach is to determine cell
surface antigen patterns in CD34
+
blast cells and more mature
myeloid cells by ow cyometry [2124]. Likewise, ow
cytometry is a powerful tool for assessment of aberrant
marker expression in CD34
+
blasts [2124]. Again, results
obtained by this technique are not specic for MDS. However,
550 2009 The Authors. Journal Compilation 2009 Stichting European Society for Clinical Investigation Journal Foundation
P. VALENT AND H.-P. HORNY www.ejci-online.com
ow cytometry and molecular studies are reliable and
sensitive techniques that may help in reaching the conclusion
that the patient is suffering from a monoclonal myeloid
disorder resembling MDS [1923]. In addition, using new
techniques, it may also be possible to quantify the various
bone marrow lineages in MDS by ow cytometry [25].
If one or more co-criteria are documented in a cytopenic
patient with typical blood ndings (macrocytic transfusion-
dependent anaemia) in whom all other causes for cytopenia
were excluded, but no dysplasia and no abnormal karyotype is
found, the diagnosis MDS-like disease or highly suspective
for MDS may be appropriate.
What if a patient does not full minimal MDS
criteria: ICUS and IDUS
A diagnostic challenge are patients who do not full minimal
diagnostic criteria for MDS but are suffering from constant
(> 6 months) or even progressive cytopenia or unexplained
dysplasia [10]. In these patients, repeated investigations of
the bone marrow and an extensive search for an underlying
disease may be required. Repeated testing may reveal an
underlying haematological or non-haematological disease. If
this is not the case, a provisional diagnosis should be estab-
lished: in those with marked constant cytopenia (haemoglo-
bin < 11 g dL
)1
and or neutrophils < 1500 lL
)1
and or
platelets < 100 000 lL
)1
) but no dysplasia and no abnormal
karyotype the diagnosis idiopathic cytopenia of
undetermined uncertain signicance (ICUS) should be
considered [10,17] and in those with marked dysplasia
(> 10% in a major cell lineage) but no or only mild cytopenia,
the term idiopathic dysplasia of undetermined uncertain
signicance (IDUS) should be applied [26] (Table 2).
By denition, the presence of both ICUS and IDUS is
exclusive as coexistence of these condition is diagnostic (meets
criteria) for MDS. However, for patients with mild cytopenia
(haemoglobin 11 g dL
)1
; neutrophils 1500 lL
)1
; platelets
100 000 lL
)1
) but clearly demonstrable dysplasia (> 10%),
the diagnosis IDUS should be appropriate. Most of these
patients progress to frank MDS over time, although some
(e.g. with 5q)) are found to progress to an MDN MPN overlap
disease or a MPN [26,27].
Practical approach to patients with ICUS
All patients with ICUS should have a haematological follow-up
to document or exclude evolution to MDS [10,17]. In fact, it has
been reported that at least some patients with ICUS develop
frank MDS over time [17]. An important parameter in ICUS-
patients is the serum erythropoietin level. In most older
patients with ICUS, serum erythropoietin levels are (relatively)
low even if the kidney function is (otherwise) normal [26,28]. In
these patients, treatment with erythropoietin can be considered
once transfusion-dependence has developed. In that case or if
Table 2 Proposed denitions for the terms ICUS and IDUS
Term Denition criteria Other features
Idiopathic cytopenia of unknown
signicance (ICUS)
Constant marked cytopenia* Older patients, low EPO level, FISH
may reveal a very small clone
No MDS found by criteria
No dysplasia, no karyotype
No Co-criteria
No other disease as reason for cytopenia found
Idiopathic dysplasia of unknown
signicance (IDUS)
No constant marked cytopenia* Younger patients, usually detected
in a routine blood test
(e.g. Pseudo-Pelger-Huet cells
or macrocytosis)
No MDS found by criteria
Dysplasia and or karyotype
No other disease as reason for Dysplasia karyotype found
EPO, erythropoietin.
*Constant marked: for at least 6 months: haemoglobin < 11 g dL
)1
, neutrophils < 1500 lL
)1
blood, platelets < 100 000 lL
)1
.
Criteria refer to reference [10].
Diagnostic dysplasia: > 10% of cells; karyotypes typically found in MDS.
If one or more co-criteria are found, the condition should be termed highly suspective for a clonal myeloid disease MDS.
European Journal of Clinical Investigation Vol 39 551
DIAGNOSTIC CRITERIA FOR MYELODYSPLASTIC SYNDROMES
other potential signs of an emerging MDS are found, it is rec-
ommended to repeat bone marrow investigations [10]. A most
important diagnostic approach in patients with ICUS is uores-
cence in situ hybridization (FISH) of bone marrow interphases
[10,17]. In several of the patients with ICUS, FISH may reveal
the presence of a small population of clonal cells carrying an
MDS-related cytogenetic defect [17]. Sometimes, when
recorded over time, the size of the clone (number of FISH-posi-
tive interphases) increases, bone marrow function and thus the
numbers of CFC decrease, and frank MDS is diagnosed [17].
Practical approach to patients with IDUS
Although IDUS may not be a rare condition, the number of well
documented cases is very low [26,27]. In fact, these patients
have only mild or no cytopenia. Several of them are referred
because of unexplained macrocytosis or the unexplained obser-
vation (presence) of Pseudo-Pelger-Huet cells in a blood lm
[27]. Similar to patients with ICUS, patients with IDUS should
have a haematological follow-up to document or exclude evolu-
tion to MDS [26,27]. This is important as patients with IDUS
usually are younger than those with ICUS. The relatively high
haemoglobin levels recorded in IDUS patients in whom an
MDS-like clone was found is best explained by an adequate
erythropoietin production and response of colonal cells in these
patients [26,27]. It is therefore assumed that when these patients
are older and thus their erythropoietin production (their capac-
ity to respond to lower haemoglobin by increasing erythropoie-
tin levels) decreases, frank MDS might develop following the
formula: ICUS + IDUS = MDS.
Bone marrowinvestigations should be repeated as soon as
cytopenia develops or other signs for a frank MDS are found in
patients with IDUS. In several of these patients, MDS is then
diagnosed. However, not all (younger) patients with IDUS
develop an MDS even when recorded over many years [27].
Concluding remarks
The diagnosis of MDS should be based on minimal diagnostic
criteria, including constant cytopenia, MDS-related bone
marrow ndings (dysplasia, ring sideroblasts, myeloblasts,
karyotype) and exclusion of other haematological and non-
haematological causes of cytopenia or and dysplasia. The latter
criterion may require a bone marrow biopsy and molecular
studies. If the diagnosis is in question, co-criteria including ow
cytometry and mutation analysis are applied. In patients in
whom no MDS and no other disease can be diagnosed, but
cytopenia or dysplasia ( mild cytopenia) are present, the
provisional diagnosis ICUS or IDUS, respectively, has to be
established, with recognition that both conditions can progress
to frank MDS over time.
Address
Division of Hematology & Hemostaseology, Department of
Internal Medicine I, Medical University of Vienna, Vienna,
Austria; and Ludwig Boltzmann Cluster Oncology, Vienna,
Austria (P. Valent); Institute of Pathology, Ansbach, Germany
(H.-P. Horny).
Correspondence to: Peter Valent, MD, Division of Hematology
& Hemostaseology, Department of Internal Medicine I, Medical
University of Vienna, Waehringer Guertel 18-20, A-1090
Vienna, Austria. Tel.: +43 1 40400 5488; fax: +43 1 40400 4030;
e-mail: peter.valent@meduniwien.ac.at
Received 24 March 2009; accepted 31 March 2009
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