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Editorials
indices as well as the R-IPSS (0.551). The authors con- cluded that the EBMT risk index is a better composite prognostic tool for MDS transplantation outcomes than existing indices, albeit acknowledging that the benefit is modest. However, we have caveats. In general, the c-sta- tistic for an index would be expected to decrease slightly when applied to an external validation dataset (in com- parison to the parent dataset from which it was derived) and this must be considered when comparing c-statistics for the externally validated GITMO and CIBMTR indices to the non-externally validated EBMT risk index. Validation of the EBMT risk index in an independent cohort of patients would provide a better estimate of its
discriminatory power. Furthermore, as the authors acknowledge, the Hematopoietic Cell Transplantation- Comorbidity Index (HCT-CI), a well validated and wide- ly used tool to predict NRM,7 was not part of the vari- ables examined (due to insufficient data) and the EBMT predictive model would be expected to improve if the HCT-CI had been incorporated.
Although the above indices incorporate information on MDS karyotype, they lack MDS genomic data, which are increasingly important for predicting relapse and, to an extent NRM, after transplantation. A large analysis using the CIBMTR database (n=1,514) examined the associa- tion between pre-transplant mutational profile and post-
Figure 1. Nomogram adapted from Gagelmann et al.8 showing an example calculation. In this example a 55-year old, cytomegalovirus (CMV)-positive patient with a Karnofsky performance status of 90, platelet count of 150x109/L, very good cytogenetics, <1% blasts and a matched sibling donor would get 160 points with a 2- year survival in the 50-60% range. The c-statistic for the EBMT index was 0.609 (95% confidence interval: 0.588 t0 0.629. We also highlight factors not included in the original nomogram – myelodysplastic syndrome (MDS) mutations, minimal residual disease (MRD) and Hematopoietic Cell Transplantation Comobidity Index (HCT-CI) – which could enhance the discriminatory power of the index.
haematologica | 2019; 104(5)