p53 pathway dysfunction is highly prevalent in acute myeloid leukemia independent of TP53 mutational status

Leukemia ◽  
2016 ◽  
Vol 31 (6) ◽  
pp. 1296-1305 ◽  
Author(s):  
A Quintás-Cardama ◽  
C Hu ◽  
A Qutub ◽  
Y H Qiu ◽  
X Zhang ◽  
...  
Keyword(s):  
Acute Myeloid Leukemia ◽  
Myeloid Leukemia ◽  
P53 Pathway ◽  
Mutational Status ◽  
Tp53 Mutational Status ◽  
Acute Myeloid

High p53 Protein Expression LEVEL Independent Of Mutational Status Is An Adverse Prognostic Factor For Survival In ACUTE Myeloid Leukemia

Blood ◽  
2013 ◽  
Vol 122 (21) ◽  
pp. 1330-1330
Author(s):  
Alfonso Quintas-Cardama ◽  
Sean M. Post ◽  
Kensuke Kojima ◽  
Yi Hua Qiu ◽  
Michael Andreeff ◽  
...  
Keyword(s):  
Acute Myeloid Leukemia ◽  
Myeloid Leukemia ◽  
Mutant P53 ◽  
P53 Mutations ◽  
Wild Type ◽  
P53 Pathway ◽  
P53 Expression ◽  
Mutational Status ◽  
Wild Type P53 ◽  
Acute Myeloid

Abstract Background The tumor suppressor p53 is frequently mutated in human cancer, including acute myeloid leukemia (AML), particularly in cases with high-risk cytogenetics. It has been shown that p53 stabilization, which frequently occurs when the protein is mutated, can compromise its function. We have shown that p53 stabilization, regardless of the presence of mutations, suggesting alterations of other components in the p53 pathway. Methodology p53 expression was determined using high-throughput reverse phase protein array (RPPA) technology in 719 samples from 511 pts. Eleven CD34+ bone marrow (BM) and 10 normal peripheral blood (PB) lymphocyte samples were used as controls. Samples were printed as 5 serial 1:2 dilutions in duplicate using an Aushon 2470 Arrayer. Mutational status of p53 alleles was assessed by Sanger sequencing of exons 5 through 9. Expression of components of the p53 pathway was determined using standard immunohistochemical techniques. Nutlin-3a was used in in vitro culture experiments. Results Paired PB- and BM-derived AML samples expressed similar p53 levels (p=0.25). A trend towards higher p53 expression at relapsed was observed among 47 paired diagnosis/relapse samples (p=0.07). p53 expression correlated directly with CD34 (p=0.001) and inversely correlated with WBC (p=0.007), PB and BM blast burden (p=0.0001), and survival (p=0.01). High p53 (p53high) expression was more associated with unfavorable cytogenetics, particularly -5 (p=0.00001). p53high resulted in lower complete remission (CR) rates (51% vs 56%; p=??), higher relapsed rates (82% vs 62%; p=??), and shorter median overall survival (OS; 29.8 vs. 51 wks, p=0.009) compared to p53low pts. Most cases with p53high had unfavorable cytogenetics. We next correlated p53 stabilization with the presence of p53 mutations in 68 pts. p53 mutations were detected in 20/54 (37%) p53high pts and in 0/14 (0%) pts with p53low. p53high, either in the presence (29 wks) or in the absence (24 wks) of p53 mutations (p=1.0), was associated with significantly shorter OS compared with p53low pts (56 wks; p=0.05). Multivariate analysis revealed p53 expression to be an independent risk factor for survival in AML (p=0.02). p53high was positively correlated with p53pSER15 (p=0.00001), Rbp807p811 (p=0.0002), BAD (p=0.0001), cleaved PARP (p=0.002), and cleaved PARP (p=0.01), and negatively with p21 (p=0.01), and MDM2 (p=0.001).Given the similar OS in p53high pts carrying mutant or wild-type p53, we scored the immunohistochemical expression of MDM2, MDM4, and p21 in 30 p53high pts (9 p53 mutated, 21 wild-type p53). Overexpression of MDM2 was observed in 44% vs 48% pts with mutant vs wild-type p53, respectively, whereas rates were 67% vs 62% for MDM4, and 0% vs 19% for p21, for each respective genotype. Overall, of the 21 p53high pts carrying wild-type p53, 15 (71%) had overexpression of MDM2 and/or MDM4, whereas 81% had no p21 expression, indicating deficient activation of the p53 pathway similar to those cases carrying mutant p53. We are currently assessing response to nutlin-3a therapy in 24 primary AML samples (4 mutant p53, 20 wild-type p53). Results showing the impact of p53 mutation and/or stabilization, and expression levels of MDM2, MDM4, and p21 on nutlin-3a therapy will be presented. Conclusions p53 stabilization (p53high) is a powerful predictive and prognostic factor in AML, which is independent of the presence of mutant p53 alleles. Poor outcomes in pts with p53high lacking p53 mutations are very frequently associated with overexpression of negative regulators of p53 such as MDM2 and/or MDM4 and p21 downregulation, indicating a functionally altered p53 pathway. These findings may have implications for therapies targeting the MDM2/p53 axis in AML. Disclosures: No relevant conflicts of interest to declare.

scholarly journals Contribution of Idasanutlin Exposure to Safety, Pharmacodynamics and Clinical Response of Patients with Acute Myeloid Leukemia Treated with Idasanutlin + Cytarabine in Phase I and III Studies

Blood ◽  
2020 ◽  
Vol 136 (Supplement 1) ◽  
pp. 7-8
Author(s):  
Candice Jamois ◽  
Doreen Anders ◽  
Benjamin M. Beckermann ◽  
Magali Genevray ◽  
Kirsten Mundt ◽  
...  
Keyword(s):  
Acute Myeloid Leukemia ◽  
Complete Remission ◽  
Febrile Neutropenia ◽  
Phase I ◽  
Clinical Response ◽  
Myeloid Leukemia ◽  
Publicly Traded ◽  
Mutational Status ◽  
Tp53 Mutational Status ◽  
Acute Myeloid

Background: Myelosuppression, and especially severe and prolonged neutropenia, can make patients (pts) with acute myeloid leukemia (AML) susceptible to fatal infections. Idasanutlin (idasa), a MDM2 antagonist promoting p53 tumor suppressor activity, showed tolerable safety and preliminary clinical activity alone and in combination with cytarabine (C) in pts with AML in a Phase I/Ib study (NCT01773408; NP28679). In the Phase III MIRROS study (NCT02545283; WO29519) comparing idasa + cytarabine (idasa-C) to placebo-C in pts with relapsed or refractory (r/r) AML, idasa-C did not improve overall survival (OS) in TP53-wild type pts (Konopleva, EHA 2020). The proportion of pts with composite complete remission (CR) at end of induction (EoI) was higher with idasa-C vs placebo-C; however, response at EoI did not translate into OS benefit. Longer and more pronounced neutropenia was observed with idasa-C. Here we investigated the contribution of idasa exposure variability to those findings, in particular, the relationship between exposure and toxicity and efficacy in pts with AML. Methods: MIRROS and NP28679 have been previously described (Montesinos, Future Oncol, 2020; Martinelli, EHA 2016). Plasma idasa concentrations were collected during induction and consolidation in 407 pts with AML (MIRROS: 285 with r/r AML; NP28679: 122 with AML), and a population pharmacokinetic (PK) analysis was completed. For each pt, predicted average concentrations values (Cav) were computed, as the ratio of cumulative area under the curve over the duration of the induction treatment period (5 days). Tertiles of Cav (low, medium, high) were used to reflect variability in exposure among pts. Logistic regression models assessed correlations between the probability of occurrence of adverse events (serious AEs [SAEs], febrile neutropenia), the probability of being responders at EoI and idasa exposure. These PK/pharmacodynamic (PD) analyses were restricted to pts treated with the idasa spray-dried powder formulation. In addition, the relationships between concentrations of the p53 target macrophage inhibitory cytokine 1 (MIC-1) and idasa exposure was characterized using an indirect PK/PD model developed in 245 pts with solid tumors (NCT01462175; NP27872), AML (NP28679) or polycythemia vera (NCT03287245; NP39761). Results: Idasa exposure was highly variable with lower exposure mainly associated with higher body weight and male sex. In addition, pts with vomiting during treatment had reduced exposure. However, a large part of the interpatient variability remains mostly unexplained. The exposure-response analysis, conducted in 316 pts with AML, showed a higher risk of SAEs with higher idasa exposure (Cav) during induction (p=0.03). There was also an association between idasa exposure and occurrence of febrile neutropenia (p=0.022; Figure 1). However, due to exposure variability, reducing the dose from 300 mg twice daily to 300 mg daily would result in a similar risk of febrile neutropenia at the median exposures (approximately 40%). No association between idasa exposure and complete remission rates at EoI was observed (N=295, p=0.622; Figure 2). Dose-exposure related increases in MIC-1 were observed at all idasa doses investigated, starting at the 100 mg total daily dose. Pts with AML in the lower tertile of exposure (Cav: 2503-5797 ng/mL) showed lower maximum MIC-1 release from baseline, contrary to pts from the highest tertile (7981-14651 ng/mL). MIC-1 release is present regardless of TP53 mutational status, suggesting a systemic rather than tumor derived induction. No difference was seen between responders and non-responders at EoI. Conclusions: Combined clinical pharmacology data in pts with AML receiving idasa revealed 1) Variability in idasa exposure does not correlate with clinical outcomes in pts treated with idasa-C. 2) p53 engagement (i.e., MIC-1 biomarker release) is seen at all dose levels investigated; however, MIC-1 release does not correlate with clinical response at EoI or TP53 mutational status. 3) The risk of SAEs is higher in pts with greater idasa exposure. 4) Data do not support lowering the dose of idasa to mitigate the risk of febrile neutropenia while sustaining clinical efficacy at idasa-C doses investigated. Disclosures Jamois: Roche: Current Employment, Current equity holder in publicly-traded company, Other: Roche: Support of parent study and funding of editorial support. Anders:Roche: Current Employment, Other: Support of parent study and funding of editorial support. Beckermann:Roche: Current Employment, Current equity holder in publicly-traded company, Other: Support of parent study and funding of editorial support; Novartis: Current equity holder in publicly-traded company. Genevray:Roche: Current Employment, Other: Support of parent study and funding of editorial support. Mundt:Swissmedic (starting September 2020): Current Employment; Roche: Current equity holder in publicly-traded company, Other: Support of parent study and funding of editorial support. Petry:Roche: Current Employment, Current equity holder in publicly-traded company, Other: Support of parent study and funding of editorial support. Yang:Certara: Current Employment; Roche: Other: Support of parent study and funding of editorial support. Kassir:Certara: Current Employment; Roche: Other: Support of parent study and funding of editorial support. Schmitt:F. Hoffmann-La Roche Ltd: Current Employment, Current equity holder in publicly-traded company.

scholarly journals EZH2 Mutations and Impact on Clinical Outcome Analyzed in 1604 Patients with Acute Myeloid Leukemia

Blood ◽  
2018 ◽  
Vol 132 (Supplement 1) ◽  
pp. 1528-1528
Author(s):  
Sebastian Stasik ◽  
Jan Moritz Middeke ◽  
Michael Kramer ◽  
Christoph Rollig ◽  
Alwin Krämer ◽  
...  
Keyword(s):  
Bone Marrow ◽  
Acute Myeloid Leukemia ◽  
Board Of Directors ◽  
Myeloid Leukemia ◽  
Research Funding ◽  
Employment Equity ◽  
Advisory Committees ◽  
Mutational Status ◽  
Equity Ownership ◽  
Acute Myeloid

Abstract Purpose: The enhancer of zeste homolog 2 (EZH2) is a histone methyltransferase and key epigenetic regulator involved in transcriptional repression and embryonic development. Loss of EZH2 activity by inactivating mutations is associated with poor prognosis in myeloid malignancies such as MDS. More recently, EZH2 inactivation was shown to induce chemoresistance in acute myeloid leukemia (AML) (Göllner et al., 2017). Data on the frequency and prognostic role of EZH2-mutations in AML are rare and mostly confined to smaller cohorts. To investigate the prevalence and prognostic impact of this alteration in more detail, we analyzed a large cohort of AML patients (n = 1604) for EZH2 mutations. Patients and Methods: All patients analyzed had newly diagnosed AML, were registered in clinical protocols of the Study Alliance Leukemia (SAL) (AML96, AML2003 or AML60+, SORAML) and had available material at diagnosis. Screening for EZH2 mutations and associated alterations was done using Next-Generation Sequencing (NGS) (TruSight Myeloid Sequencing Panel, Illumina) on an Illumina MiSeq-system using bone marrow or peripheral blood. Detection was conducted with a defined cut-off of 5% variant allele frequency (VAF). All samples below the predefined threshold were classified as EZH2 wild type (wt). Patient clinical characteristics and co-mutations were analyzed according to the mutational status. Furthermore, multivariate analysis was used to identify the impact of EZH2 mutations on outcome. Results: EZH2-mutations were found in 63 of 1604 (4%) patients, with a median VAF of 44% (range 6-97%; median coverage 3077x). Mutations were detected within several exons (2-6; 8-12; 14-20) with highest frequencies in exons 17 and 18 (29%). The majority of detected mutations (71% missense and 29% nonsense/frameshift) were single nucleotide variants (SNVs) (87%), followed by small indel mutations. Descriptive statistics of clinical parameters and associated co-mutations revealed significant differences between EZH2-mut and -wt patients. At diagnosis, patients with EZH2 mutations were significantly older (median age 59 yrs) than EZH2-wt patients (median 56 yrs; p=0.044). In addition, significantly fewer EZH2-mut patients (71%) were diagnosed with de novo AML compared to EZH2-wt patients (84%; p=0.036). Accordingly, EZH2-mut patients had a higher rate of secondary acute myeloid leukemia (sAML) (21%), evolving from prior MDS or after prior chemotherapy (tAML) (8%; p=0.036). Also, bone marrow (and blood) blast counts differed between the two groups (EZH2-mut patients had significantly lower BM and PB blast counts; p=0.013). In contrast, no differences were observed for WBC counts, karyotype, ECOG performance status and ELN-2017 risk category compared to EZH2-wt patients. Based on cytogenetics according to the 2017 ELN criteria, 35% of EZH2-mut patients were categorized with favorable risk, 28% had intermediate and 37% adverse risk. No association was seen with -7/7q-. In the group of EZH2-mut AML patients, significantly higher rates of co-mutations were detected in RUNX1 (25%), ASXL1 (22%) and NRAS (25%) compared to EZH2-wt patients (with 10%; 8% and 15%, respectively). Vice versa, concomitant mutations in NPM1 were (non-significantly) more common in EZH2-wt patients (33%) vs EZH2-mut patients (21%). For other frequently mutated genes in AML there was no major difference between EZH2-mut and -wt patients, e.g. FLT3ITD (13%), FLT3TKD (10%) and CEBPA (24%), as well as genes encoding epigenetic modifiers, namely, DNMT3A (21%), IDH1/2 (11/14%), and TET2 (21%). The correlation of EZH2 mutational status with clinical outcomes showed no effect of EZH2 mutations on the rate of complete remission (CR), relapse free survival (RFS) and overall survival (OS) (with a median OS of 18.4 and 17.1 months for EZH2-mut and -wt patients, respectively) in the univariate analyses. Likewise, the multivariate analysis with clinical variable such as age, cytogenetics and WBC using Cox proportional hazard regression, revealed that EZH2 mutations were not an independent risk factor for OS or RFS. Conclusion EZH mutations are recurrent alterations in patients with AML. The association with certain clinical factors and typical mutations such as RUNX1 and ASXL1 points to the fact that these mutations are associated with secondary AML. Our data do not indicate that EZH2 mutations represent an independent prognostic factor. Disclosures Middeke: Janssen: Membership on an entity's Board of Directors or advisory committees, Research Funding; Abbvie: Membership on an entity's Board of Directors or advisory committees; Roche: Membership on an entity's Board of Directors or advisory committees. Rollig:Bayer: Research Funding; Janssen: Research Funding. Scholl:Jazz Pharma: Membership on an entity's Board of Directors or advisory committees; Abbivie: Other: Travel support; Alexion: Other: Travel support; MDS: Other: Travel support; Novartis: Other: Travel support; Deutsche Krebshilfe: Research Funding; Carreras Foundation: Research Funding; Pfizer: Membership on an entity's Board of Directors or advisory committees. Hochhaus:Pfizer: Research Funding; Incyte: Research Funding; Novartis: Research Funding; Bristol-Myers Squibb: Research Funding; Takeda: Research Funding. Brümmendorf:Janssen: Consultancy; Takeda: Consultancy; Novartis: Consultancy, Research Funding; Merck: Consultancy; Pfizer: Consultancy, Research Funding. Burchert:AOP Orphan: Honoraria, Research Funding; Bayer: Research Funding; Pfizer: Honoraria; Bristol Myers Squibb: Honoraria, Research Funding; Novartis: Research Funding. Krause:Novartis: Research Funding. Hänel:Amgen: Honoraria; Roche: Honoraria; Takeda: Honoraria; Novartis: Honoraria. Platzbecker:Celgene: Research Funding. Mayer:Eisai: Research Funding; Novartis: Research Funding; Roche: Research Funding; Johnson & Johnson: Research Funding; Affimed: Research Funding. Serve:Bayer: Research Funding. Ehninger:Cellex Gesellschaft fuer Zellgewinnung mbH: Employment, Equity Ownership; Bayer: Research Funding; GEMoaB Monoclonals GmbH: Employment, Equity Ownership. Thiede:AgenDix: Other: Ownership; Novartis: Honoraria, Research Funding.

scholarly journals Chromosomal Abnormalities and Prognosis in NPM1-Mutated Acute Myeloid Leukemia: A Pooled Analysis of Individual Patient Data From Nine International Cohorts

2019 ◽  
Vol 37 (29) ◽  
pp. 2632-2642 ◽  
Author(s):  
Linus Angenendt ◽  
Christoph Röllig ◽  
Pau Montesinos ◽  
David Martínez-Cuadrón ◽  
Eva Barragan ◽  
...  
Keyword(s):  
Acute Myeloid Leukemia ◽  
Myeloid Leukemia ◽  
Chromosomal Abnormalities ◽  
International Study ◽  
Study Groups ◽  
Pooled Analysis ◽  
Internal Tandem Duplication ◽  
Free Survival ◽  
Mutational Status ◽  
Acute Myeloid

PURPOSE Nucleophosmin 1 ( NPM1) mutations are associated with a favorable prognosis in acute myeloid leukemia (AML) when an internal tandem duplication (ITD) in the fms-related tyrosine kinase 3 gene ( FLT3) is absent ( FLT3-ITDneg) or present with a low allelic ratio ( FLT3-ITDlow). The 2017 European LeukemiaNet guidelines assume this is true regardless of accompanying cytogenetic abnormalities. We investigated the validity of this assumption. METHODS We analyzed associations between karyotype and outcome in intensively treated patients with NPM1mut/ FLT3-ITDneg/low AML who were prospectively enrolled in registry databases from nine international study groups or treatment centers. RESULTS Among 2,426 patients with NPM1mut/ FLT3-ITDneg/low AML, 2,000 (82.4%) had a normal and 426 (17.6%) had an abnormal karyotype, including 329 patients (13.6%) with intermediate and 83 patients (3.4%) with adverse-risk chromosomal abnormalities. In patients with NPM1mut/ FLT3-ITDneg/low AML, adverse cytogenetics were associated with lower complete remission rates (87.7%, 86.0%, and 66.3% for normal, aberrant intermediate, and adverse karyotype, respectively; P < .001), inferior 5-year overall (52.4%, 44.8%, 19.5%, respectively; P < .001) and event-free survival (40.6%, 36.0%, 18.1%, respectively; P < .001), and a higher 5-year cumulative incidence of relapse (43.6%, 44.2%, 51.9%, respectively; P = .0012). These associations remained in multivariable mixed-effects regression analyses adjusted for known clinicopathologic risk factors ( P < .001 for all end points). In patients with adverse-risk chromosomal aberrations, we found no significant influence of the NPM1 mutational status on outcome. CONCLUSION Karyotype abnormalities are significantly associated with outcome in NPM1mut/ FLT3-ITDneg/low AML. When adverse-risk cytogenetics are present, patients with NPM1mut share the same unfavorable prognosis as patients with NPM1 wild type and should be classified and treated accordingly. Thus, cytogenetic risk predominates over molecular risk in NPM1mut/ FLT3-ITDneg/low AML.

Antigen Expression Varies Significantly between Molecular Subgroups of Acute Myeloid Leukemia Patients: Clinical Applicability Is Hampered by Establishment of Relevant Cutoffs

2020 ◽  
pp. 1-10
Author(s):  
Laura Laine Herborg ◽  
Line Nederby ◽  
Rasmus Froberg Brøndum ◽  
Maria Hansen ◽  
Peter Hokland ◽  
...  
Keyword(s):  
Acute Myeloid Leukemia ◽  
Myeloid Leukemia ◽  
Area Under The Curve ◽  
Antigen Expression ◽  
Operating Characteristics ◽  
Exact Test ◽  
Clinical Applicability ◽  
Mutational Status ◽  
Type Gene ◽  
Acute Myeloid

<b><i>Introduction:</i></b> In this single-center study of 268 acute myeloid leukemia (AML) patients, we have tested if a subset of 4 routinely employed immunophenotypic stem cell-associated markers correlated with the presence of recurrently mutated genes and if the markers were predictive for mutational status. <b><i>Methods:</i></b> Immunophenotypic data from 268 diagnostic AML samples obtained in 2009–2018 were analyzed retrospectively for the antigens CD34, CD117, CD123, and CLEC12A. Correlation between immunophenotypes and mutations was analyzed by Fischer’s exact test. Clinical applicability of the markers for predicting mutational status was evaluated by receiver operating characteristics analyses, where an area under the curve (AUC) of at least 0.85 was accepted as clinically relevant. <b><i>Results:</i></b> For a number of genes, the antigen expression differed significantly between mutated and wild-type gene expression. Despite low AUCs, CD123 and CLEC12A correlated with <i>FLT3</i>+<i>NPM1−</i> and <i>FLT3</i>+<i>NPM1</i>+. Three subsets met the AUC requirements (CD34+, CD34+CD117+, and CD34−CD117+) for predicting <i>FLT3−NPM1</i>+ or <i>FLT3</i>+<i>NPM1</i>+. <b><i>Conclusion:</i></b> The value of immunophenotypes as surrogate markers for mutational status in AML seems limited when employing CD123 and CLEC12A in combination with CD34 and CD117. Defining relevant cutoffs for given markers is challenging and hampered by variation between laboratories and patient groups.

DNMT3A mutations Predict for Inferior Outcome in NPM1-Wildtype and Molecular Unfavorable Cytogenetically-Normal Acute Myeloid Leukemia: A Study of the German-Austrian AMLSG

Blood ◽  
2011 ◽  
Vol 118 (21) ◽  
pp. 415-415 ◽  
Author(s):  
Verena I. Gaidzik ◽  
Richard F. Schlenk ◽  
Peter Paschka ◽  
Anja Stölzle ◽  
Andrea Corbacioglu ◽  
...  
Keyword(s):  
Acute Myeloid Leukemia ◽  
Myeloid Leukemia ◽  
Conflicts Of Interest ◽  
Negative Impact ◽  
Epigenetic Modification ◽  
Methylation Status ◽  
Prognostic Impact ◽  
Sequencing Analysis ◽  
Mutational Status ◽  
Acute Myeloid

Abstract Abstract 415 Background: Alteration of DNA methylation, a hallmark of epigenetic modification, is currently discussed as one important pathomechanism in leukemogenesis. Using a next-generation sequencing approach, a frameshift mutation of the gene encoding the DNA methyltransferase (DNMT3A) in an acute myeloid leukemia (AML) case was identified. DNMT3A catalyses the addition of a methyl group to the cytosine residue of CpG dinucleotides, thereby affecting promoter methylation status and gene expression. Subsequent sequencing analysis in an independent cohort of 288 AML patients (pts) revealed DNMT3A mutations (DNMT3Amut) in 22% of the pts; mutations were associated with intermediate-risk cytogenetics and poor outcome. Aims: To evaluate frequency and clinical impact of DNMT3Amut in pts with AML aged 18 to 61 years who were treated within AMLSG treatment trials AML HD98A (Schlenk et al., J Clin Oncol 2010;28:4642–8) and AMLSG 07–04 (NCT00151242). Methods: DNMT3A mutation analysis was performed in 1218 AML (HD98A, n=685; AMLSG 07–04, n=533; de novo AML, n=1102; s-AML, n=45; t-AML, n=69) using a DNA-based PCR assay for all coding exons (1 to 23) followed by direct sequencing. The median follow-up was 5.06 years. Results: DNMT3A mut were found with an overall frequency of 19.6% (239/1218); 189 mutations were located in the MTase domain clustering at amino acid R882 (79%). All but one mutation were heterozygous; only 4 cases had two mutations. DNMT3A sequence alterations included 17 frameshift, 4 nonsense, and 222 missense mutations. DNMT3A mut pts were significantly older (P=.01), more frequently females (P=.001), had higher white blood cell and platelet counts (both P<.0001), and higher bone marrow blasts percentage (P=.001). DNMT3Amut were associated with cytogenetically-normal AML (CN-AML, P<.0001), while DNMT3Amut were rare in favorable and adverse-risk karyotypes (P<.0001). Correlations with other molecular markers (NPM1, CEBPA, FLT3, IDH1/2, TET2, ASXL1) revealed a significant association with NPM1 (P<.0001), FLT3-ITD (P<.0001), and IDH1/2 (IDH1R132, P<.0001; IDH2R140, P=.0003; IDH2R172, P=.03) mutations, while co-occurrence of CEBPA (P=.02) and ASXL1 (P=.02) mutations was less frequent. DNMT3A mutational status did not impact complete remission (CR) rate, event-free (EFS) and relapse-free survival (RFS), neither in the whole cohort (P=.09, P=.98, P=.11; respectively) nor in the subgroup of CN-AML (P=.39, P=.79, P=.19, respectively). DNMT3Amut had a negative impact on overall survival (OS) in trend in the whole cohort (P=.07) and significantly in CN-AML (P=.02). In multivariable analyses, DNMT3Amut were in trend associated with a negative prognostic impact on OS (hazard ratio, 1.24; P=.06). In addition, we performed subgroup analyses according to (1) the NPM1 mutational status, and (2) the molecular risk groups of CN-AML (as defined by the European LeukemiaNet classification). DNMT3Amut did not impact OS in NPM1-mutated patients in the whole cohort as well as in CN-AML (P=.34; P=.22; respectively), while in NPM1-wildtype patients DNMT3Amut were associated with inferior OS in both, the whole cohort and in CN-AML (P=.001; P=.005; respectively). In molecular unfavorable CN-AML (NPM1-wildtype with or without FLT3-ITD, NPM1-mutated with FLT3-ITD, CEBPA-wildtype), DNMT3Amut were significantly associated with worse OS (P=.002) compared with DNMT3A-wildtype pts, even outweighing FLT3-ITD as an unfavorable prognostic marker. There was no effect of DNMT3Amut in molecular favorable-risk CN-AML. Conclusions: DNMT3A mutations are confirmed as frequent genetic aberrations in AML, associated with normal karyotype, NPM1, FLT3-ITD, and IDH1/2 mutations. DNMT3Amut predicts for inferior outcome in molecularly-defined subsets of AML, that is, NPM1-wildtype AML and molecular unfavorable CN-AML. As a single marker, DNMT3Amut only had a moderate effect on outcome. Disclosures: No relevant conflicts of interest to declare.

Effect of Genetic Profiling on Prediction of Therapeutic Resistance and Survival in Adult Acute Myeloid Leukemia

Blood ◽  
2014 ◽  
Vol 124 (21) ◽  
pp. 941-941
Author(s):  
Roland B. Walter ◽  
Megan Othus ◽  
Elisabeth M. Paietta ◽  
Janis Racevskis ◽  
Hugo F Fernandez ◽  
...  
Keyword(s):  
Acute Myeloid Leukemia ◽  
Myeloid Leukemia ◽  
White Blood Cells ◽  
Therapeutic Resistance ◽  
Multivariate Models ◽  
Genetic Profiling ◽  
Basic Model ◽  
Mutational Status ◽  
Acute Myeloid

Abstract Background: Therapeutic resistance remains the primary challenge in adult acute myeloid leukemia (AML). Genetic profiling can refine the prediction of outcome across populations of AML patients and has enabled the development of integrated mutational/cytogenetic risk schemas that can separate patients with cytogenetically defined intermediate-risk AML into three subgroups with markedly different outcomes. Here, we investigated to what degree the prediction of therapeutic resistance and survival can be improved for individual patients by inclusion of data from genetic profiling. Patients and Methods: We used data on adults aged 17-60 years with newly diagnosed AML who received treatment on a recent phase 3 trial from the Eastern Cooperative Study Group that investigated the value of escalated doses of daunorubicin during induction (E1900; NCT00049517). We used several criteria for the definition of therapeutic resistance: (a) failure to attain complete remission (CR) despite surviving at least 28 days from beginning induction therapy (“primary refractory”); (b) primary refractory or relapse-free survival (RFS) ²3 months; (c) primary refractory or RFS ²6 months; and (d) primary refractory or RFS ²12 months. We used logistic regression analyses to assess the relationship between individual covariates and measures of resistance and overall survival (OS): age, gender, white blood cell (WBC) count, platelet count, bone marrow blast percentage, disease type (primary vs. secondary), cytogenetic risk, and mutational status in the following genes: ASXL1, CEBPA, DNMT3A, FLT3, IDH1, IDH2, KIT, KRAS, MLL, NPM1, NRAS, PHF6, RUNX1, TET2, TP53, and WT1. The integrated mutational/cytogenetic risk schema was used as established by Patel et al. (NEJM 2012;366:1079-1089). We then used the area under the receiver operator characteristic curve (AUC) to quantify a multivariate modelÕs ability to predict therapeutic resistance; in this approach, an AUC of 1 indicates perfect prediction while an AUC of 0.5 indicates no prediction; AUC values of 0.6-0.7, 0.7-0.8, and 0.8-0.9 are commonly considered as poor, fair, and good, respectively. Results: 298 patients surviving at least 28 days had data on all covariates and were included. 201 (67.4%) of these achieved CR and 97 (32.6%) were primary refractory; 103/297 patients (34.7%) with sufficient follow-up time were either primary refractory or had a RFS of ²3 months, 115/296 patients (38.9%) with sufficient follow-up time were either primary refractory or had a RFS of ²6 months, and 153/295 patients (51.9%) with sufficient follow-up time were primary refractory or had a RFS of ²12 months. The integrated mutational/cytogenetic risk schema was the most important individual predictor of resistance (AUCs ranging between 0.64 and 0.69 across the several definitions of resistance) and survival (AUC of 0.65), followed by cytogenetic risk and FLT3/NPM1 status (AUCs ranging between 0.59 and 0.64). Bootstrap-corrected multivariate models yielded AUCs of 0.76-0.79 for the prediction of primary refractoriness or primary refractoriness/RFS of 3 months or less, 6 months or less, or 12 months or less, respectively, and an AUC of 0.72 for the prediction of OS. Removal of information on FLT3/NPM1 status or mutational data from other profiled genes decreased the AUC to about the same degree each, yielding AUCs of 0.66-0.72 for simpler models including cytogenetic risk and other basic information (age, gender, performance status, white blood cells, platelet counts, marrow blast percentage; see table). Conclusion: Genetic profiling increases the accuracy of multivariate models predicting therapeutic resistance or survival in adult AML. Nevertheless, even with inclusion of such data, our ability to predict these outcomes based on pre-treatment information remains relatively limited. This finding would argue for the integration of treatment response measures (e.g. minimal residual disease) to optimize prediction of resistance. Table Parameter No CR No CR or RFS 3 months or less No CR or RFS 6 months or less No CR or RFS 12 months or less OS Basic model 0.60 0.60 0.63 0.63 0.59 Basic model + Cytogenetic risk 0.68 0.68 0.71 0.72 0.66 Basic model + Integrated mutational/ cytogenetic risk schema 0.68 0.68 0.71 0.74 0.68 Basic model + Cytogenetic risk + NPM1, FLT3/ITD 0.72 0.71 0.74 0.75 0.69 Basic model + Cytogenetic risk + NPM1, FLT3/ITD + Other mutations 0.76 0.76 0.78 0.79 0.72 Disclosures Levine: Novartis: Consultancy, Grant support Other.

scholarly journals Examination of the FLT3 and NPM1 mutational status in patients with acute myeloid leukemia from southeastern Poland

2016 ◽  
Vol 1 ◽  
pp. 120-128 ◽  
Author(s):  
Dorota Koczkodaj ◽  
Szymon Zmorzyński ◽  
Małgorzata Michalak-Wojnowska ◽  
Ewa Wąsik-Szczepanek ◽  
Agata A. Filip
Keyword(s):  
Acute Myeloid Leukemia ◽  
Myeloid Leukemia ◽  
Mutational Status ◽  
Acute Myeloid

scholarly journals Prognostic Impact of the Interaction between DNMT3A mutation and Internal Tandem Duplication of the FLT3 Gene (FLT3-ITD) in Patients with De Novo Mutated NPM1 (NPM1mut) acute Myeloid Leukemia

Blood ◽  
2018 ◽  
Vol 132 (Supplement 1) ◽  
pp. 1492-1492
Author(s):  
Guadalupe Oñate ◽  
Ana Garrido ◽  
Jordi Esteve ◽  
Rosa Coll ◽  
Montserrat Arnan Sangerman ◽  
...  
Keyword(s):  
Overall Survival ◽  
Acute Myeloid Leukemia ◽  
Complete Remission ◽  
Myeloid Leukemia ◽  
De Novo ◽  
Prognostic Impact ◽  
Intermediate Risk ◽  
Mutational Status ◽  
De Novo Aml ◽  
Acute Myeloid

Abstract Introduction The association of NPM1mut and FLT3-ITD in de novo acute myeloid leukemia (AML) with intermediate-risk cytogenetics has different prognostic impact depending on the FLT3 allelic burden. Previous studies published by our cooperative group showed that patients with de novo AML of intermediate-risk cytogenetics with NPM1mut and FLT3-ITD low ratio (<0.5, FLT3low) at diagnosis presented an overall survival and relapse rate similar to those with NPM1mut and FLT3wt. Therefore, in the CETLAM-2012 protocol, patients with FLT3low NPM1mut AML are not considered for allogenic hematopoietic stem cell transplant (allo-HSCT) in first complete remission (CR1). Recent studies suggest that the co-occurrence of DNMT3A mutation in FLT3-ITD NPM1mut AML patients confers a worse prognosis regardless of FLT3-ITD ratio. We analysed our data to determine whether these findings were confirmed in our cohort, specifically in the low FLT3-ITD ratio patients, since this could have therapeutic implications. Methods and patients A total of 163 patients with de novo AML, intermediate-risk cytogenetics and NPM1mut were analysed (median age 53 years (18-72); male:female 72:91 (0.79)). Eighty patients (49%) harboured an FLT3-ITD, with a high allelic ratio in 42 of 76 patients with available ITD/wt ratio (55%). They were included in the AML-2003 (n=49) and AML-2012 (n=114) CETLAM protocols. Proportion of patients undergoing alloHSCT in CR1 is detailed in table 1. Bone marrow samples from diagnosis were studied for DNMT3A mutations as previously described. The definition of complete remission (CR), overall survival (OS), leukemia-free survival (LFS) and risk of relapse (RR) followed recommended ELN criteria. The Kaplan-Meier method was used to estimate the distribution of LFS and OS, for RR cumulative incidence was used. Results Out of the 163 patients with AML of intermediate risk cytogenetics and NPM1mut, 78 presented DNMT3A mutations (48%). Of these, 62 (79%) presented mutations in codon R882 or corresponded to DNA insertions/deletions while 16 (21%) harboured missense mutations. Presence of DNMT3A mutation did not associate with FLT3-ITD (ITD/85 DNMT3Awt vs ITD/78 DNMT3Amut, p=0.394). In the entire cohort, 5-year OS, LFS and RR were 58±4.5%, 59±4.6% and 27±13.9%. FLT3-ITD ratio confirmed its prognostic impact when analysing FLT3wt (n=83) vs FLT3low (n=34) vs FLT3high (n=42) patients (5-year OS of 68±6% vs 62±8.7% vs 37±8.6%; p=0.002; and 5-year RR of 18±9.4% vs 27±16.1% vs 41±23.2%; p=0.023). On the contrary, DNMT3Amut did not exert any effect on overall outcome (5-yr OS DNMT3Awt vs DNMT3Amut 61±6.2% vs 55±6.2%; p=0.234) When DNTM3A mutational status was considered, the impact of FLT3-ITD on outcome was mitigated in wild-type DNMT3A population. Thus, we found that DNMT3Awt patients presented no statistical differences in OS according to FLT3 mutational status or ratio: FLT3wt (n=46) vs FLT3-ITD (n=39) was 67±8.5% vs 57±8.2%; p=0.122, whereas FLT3wt (n=46) vs FLT3low (n=18) vs. FLT3high (n=19) was 67±8.5% vs. 66±11.5% vs 46±11.8%; p=0.088 (image 1A).This was also seen in relation to LFS and RR according to FLT3 ratio: 5-yr LFS of FLT3wt vs FLT3low vs FLT3high was 72±7.9% vs 61±12.6% vs 51±13.4%; p=0.244 and 5-year RR of the same groups: 19±8.8% vs 26±12.5% vs 27±21.9%; p=0.724 (image 2A). In the DNMT3Amut group, patients with FLT3-ITD (n=41) presented shorter OS than those with FLT3wt (n=37) with an OS of 37±10.7% vs 69±7.8%; p=0.028. When FLT3 ratio was considered, FLT3wt (n=37) vs FLT3low (n=16) vs FLT3high (n=23) showed an OS of 69±7.8% vs. 58±13.2% vs 27±13.1%; p=0.038 (image 1B). Similar results were seen in LFS according to FLT3 ratio (FLT3wt (n=29) vs FLT3low (n=16) vs FLT3high (n=20) 71±8.6% vs 53±12.9% vs 18±13.8%; p=0.012). Finally, we observed significant differences in the 5-year RR when considering DNMT3Amut patients in relation to FLT3 ratio (FLT3wt vs FLT3low vs FLT3high 18±10.6% vs 27±20% vs 54±28.8%; p=0.021)(image 2B). Conclusions In this study, patients with NPM1mut and FLT3-ITDlow presented a similar outcome to patients with NPM1mut and FLT3wt regardless of DNMT3A mutational status. These results support the modification of alloHCST policy in CR1 in CETLAM-2012, which do not consider alloHSCT for patients with FLT3low. On the other hand, concurrence of DNMT3A mutation may have an added negative effect in patients with NPM1mut and FLT3-ITDhigh, which should be further confirmed in larger studies. Disclosures No relevant conflicts of interest to declare.

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