Unsuccessful diagnostic cytogenetic analysis is a poor prognostic feature in acute myeloid leukaemia

Abstract Introduction: Therapy-related acute myeloid leukaemia (AML) is a well known event which can occur few years after a chemotherapy with alkylating agents or topoisomerase II inhibitors received for primary malignancies such as Hodgkin and non-Hodgkin lymphomas, Acute lymphoblastic leukaemia (ALL) or solid tumors. More exceptional are acute B or T-ALL following AML (11 cases in literature so far, Liso et al, Haematologica, 1998; Leung et al, Leukemia, 2001; Tsuboi et al, Int J Hematol, 2003) raising the question of the origin of this second event. Among 1486 AML cases diagnosed between 1985 and 2006 in our institution, we report only 2 cases of B-cell ALL occurring 1 and 19 years after AML. Case1: A 36-year-old man was admitted in our institution in 1985. The peripheral blood examination showed: Hemoglobin level 6.2 g/dL, leukocyte count 27.8 *109/L with 32% of monocytes and platelet count 52 *109/L. Blast cell infiltrate was 40% on blood and 55% on bone marrow smears, with 80% exhibiting myeloperoxydase (MPO) activity. Morphology was typical of FAB-M4 AML with eosinophil subtype. Unfortunately, phenotype and caryotype evaluations were not performed. Patient was treated according to POF trial. Complete Remission (CR) was achieved after induction therapy and persisted 19 years after 3 consolidations. In 2004, blast cells reappeared in the blood (7%) and bone marrow (96%) aspirates Interestingly, MPO activity was negative and flow cytometer analysis revealed a CD19+ CD10+ TdT+ CD79a+ (EGIL-BII) B-Cell Precursor (BCP) ALL immunophenotype with only the sole CD13+ myeloid marker expression. Cytogenetic studies showed a hypodiploidy (33–35 chromosomes) without Bcr-Abl and MLL rearrangements. Patient achieved CR after induction chemotherapy according to GRAALL2003 trial. He then received consolidation by high-dose methotrexate but develop a polyneuropathy and died rapidly. Case2: A AML, FAB-M5B subtype, was first diagnosed in 2005 in a 48-year-old woman. Hemoglobin level was 10.4 g/dL, leukocyte count 73.2 *109/L with 79.5% of abnormal monocytic cells and platelet count 100 *109/L. Typically, monoblastic bone marrow cells (71%) showed a low (5%) MPO and a strong (80%) butyrate activities, together with a CD13+ CD14+ CD15+ CD33+ CD34+ CD36+ CD65+ CD117− immunophenotype without B-cell marker expression. Cytogenetic analysis showed no caryotypic abnormalities. The patient was treated according to LAM2001 trial and CR was achieved after 2 courses of induction chemotherapy. The patient was autografted in October 2005. She presented with a pancytopenia in April 2006 and the diagnosis of BCP-ALL was made. The bone marrow was infiltrated with 76.5% of MPO negative, butyrate negative blasts exhibiting a CD19+ CD10−CD79a+TdT+ (EGIL-BI/Pro-B subtype without any myeloid marker expression. Cytogenetic analysis showed a t (4;11) (q21;q23) with MLL rearrangement on 44% of the blasts. The patient achieved CR after induction therapy according to GRAALL2003 trial but developed a disseminated fusariosis. She is still alive in CR but due to the persistence of the infectious complication, she has not yet received consolidation. Conclusion: Our study shows that ALL occurring after AML is a very occasional event. Prognosis seems poor related to treatment toxicity. We found no argument supporting a link between both leukaemia subtypes or a relationship with therapy. Additional cases are warranted to determine if this association is unrelated or not.

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Impact of p53 and BCL2 Expression on Prognosis in Patients with Acute Myeloid Leukaemia

Blood ◽

10.1182/blood-2020-140920 ◽

2020 ◽

Vol 136 (Supplement 1) ◽

pp. 29-30

Author(s):

Laura McDonald ◽

Brian Hennessy ◽

Senthil Kumar ◽

Mutaz Nur ◽

Christine Schilling ◽

...

Keyword(s):

Acute Myeloid Leukaemia ◽

Myeloid Leukaemia ◽

Cytogenetic Analysis ◽

P53 Gene ◽

P53 Mutation ◽

Refractory Disease ◽

P53 Overexpression ◽

Normal Cytogenetics ◽

Bcl2 Expression ◽

Acute Myeloid

Introduction Acute myeloid leukaemia (AML) is a heterogenous disorder that arises from clonal expansion of malignant hematopoietic precursor cells. The tumor suppressor p53 gene plays an important role in regulation of the cell cycle and apoptosis. Somatic mutations of the p53 gene have been reported in 5-10% of all patients with AML, although the rate is higher in therapy-related disease and elderly patients. Alteration or loss of p53 is one of the most powerful independent indicators of poor outcome. BCL2 positivity in AML and its impact on prognosis is less well described. Methods This is a single-centre, retrospective analysis of AML patients treated over a ten year period (2006-2016). Patients were identified through our pathology database. P53 expression (as a surrogate marker for tp53 mutation) and BCL2 expression were analysed by immunohistochemical (IHC) analysis of marrow biopsies (greater than 30% was considered positive). We analyzed AML presentation, management and overall survival (OS), and correlated these with presence of p53 mutation and BCL2 expression. Results We identified 48 patients; the majority were elderly (median age 68.5 years). Thirty-four patients (71%) haddenovopresentation of AML, 6 had underlying Myelodysplastic Syndrome (13%), 4(8%) progressed to AML from underlying Myelofibrosis, and 8% had therapy-associated AML. Patient and disease characteristics are outlined inTable 1. Median blast count by IHC of bone marrow biopsies was 70%. The results of cytogenetic analysis were available for 38 patients (79%). Fourteen patients (37%) had normal cytogenetics, but a wide range of genetic abnormalities were identified(Table 1). NPM1 (for 22 patients) and FLT3 mutation analysis (for 33 patients) were available, and reported as positive in 4(18%) and 5(15%) respectively. p53 overexpression was identified in 6 patients (12.5%). 50% of these had secondary AML, and the remainder weredenovopresentations. Four of these patients (66%) had complex cytogenetics, one had deletion 5q and cytogenetic analysis was not available for the remaining patient. Median age of patients who were p53 positive was 60 years, compared to 70 years in those without p53 overexpression. BCL2 expression analysis showed a median value of 60% (range 5-100%). BCL2 positivity was seen in 39 patients (81.2%); half of this cohort (15 patients) had normal cytogenetics and only five patients (16%) had abnormalities that indicated poor risk cytogenetics (complex, deletion 7q, etc.). Thirty-nine patients (83%) received active treatment and nine received supportive care only due either to frailty or patient choice. Twenty-two patients (60%) had induction chemotherapy, 7(19%) received Azacitadine, and a further 7 patients had low-dose cytarabine. Nineteen patients (51%) had relapsed/refractory disease. Five patients (13.5%) with BCL2 positive disease received Venetoclax as a single agent for relapsed or refractory disease. Median OS was 11.5 months (range 0-72); 39 patients (81%) had died at the time of analysis. 26 died from disease progression (79%), and 7(19%) of sepsis. One patient was lost to follow up. OS in those with wild-type p53 was 11.5 months, which compared favorably to 7.5 months in those with p53 mutation. BCL2 overexpression also conferred a poorer prognosis; median OS was 10 months compared to 17 months in BCL2 negative disease. Conclusion This study reflects the potential use of p53 and BCL2 in real-life practice in assessing prognosis in AML patients outside of a clinical trial setting. We confirmed the previously reported poor prognosis of p53 alterations in AML (OS 7.5 months), and the study also indicates a poorer prognosis in patients with BCL2 positivity. The widespread availability of IHC techniques for trephine biopsies and the potential for rapid turn-around times in routine clinical laboratories suggests that further studies of the prognostic impact of such gene alterations are warranted. Disclosures No relevant conflicts of interest to declare.

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Prognostic Significance and Risk Stratification in Acute Myeloid Leukaemia Patients in the Absence of Successful Cytogenetic Analysis

Blood ◽

10.1182/blood.v126.23.1379.1379 ◽

2015 ◽

Vol 126 (23) ◽

pp. 1379-1379

Author(s):

Lucy Chilton ◽

Christine Harrison ◽

Anthony V. Moorman ◽

Iona Ashworth ◽

Alan K. Burnett ◽

...

Keyword(s):

Risk Stratification ◽

Acute Myeloid Leukaemia ◽

Myeloid Leukaemia ◽

Cytogenetic Analysis ◽

Prognostic Significance ◽

Intermediate Risk ◽

Younger Patients ◽

Risk Patients ◽

Acute Myeloid ◽

Better Than

Abstract Cytogenetic analysis is a key tool in risk stratification of patients with acute myeloid leukaemia (AML). Sometimes samples are not sent or metaphase analysis fails (~10% cases). In these situations, a cytogenetic risk score cannot be assigned, preventing risk stratification. It has been suggested that in the absence of cytogenetic data, both missing and failed, patients have a poor outcome (Mederios et al (Br. J. Haematol. 2014 164(2): 245-50); Lazarevic et al (Eur. J. Haematol. 2015 94(5): 419-23)). In this study, we investigated the characteristics and prognostic significance of the provision of samples, and their successful analysis across the MRC UK series of AML trials (AML10 - AML16). Data from 14265 non-APL patients recruited to successive UK AML trials (1988 - 2012) were analysed. Patients were classified based on whether a sample was sent for cytogenetic analysis and the outcome of the analysis. Rates of successful cytogenetic analysis were higher in patients treated on intensive chemotherapy protocols (intensive: 11104/13081 (85%); non-intensive 850/1184 (72%), p<.0001). In intensively treated patients, there was a significant association between increasing age and missing or failed cytogenetic samples (p<.0001). Stratification of intensively treated patients with successful cytogenetics, according to the criteria of Grimwade et al (Blood 2010 116(3):354-65), into favourable (18%), intermediate (62%) and adverse risk (19%) were analysed for outcomes and showed 10 year survival of 66%, 30% and 12%, respectively. Survival at 10 years was 24% when no sample was sent compared to 32% when a sample failed cytogenetic analysis. Survival for patients with failed cytogenetics was not significantly different from those with intermediate risk cytogenetics in either univariate analysis (p=0.10) or after adjustment for age, performance status, white cell count and secondary disease (p=0.06). Outcomes were significantly better than those for adverse risk patients (p<.0001 for both analyses). For those with no sample, survival was significantly worse than for the intermediate risk (p<.0001 in both analyses), although the effect size was not large (HR 1.18 in adjusted analyses), yet significantly better than adverse risk patients (p<.0001, HR 0.57). While outcomes worsened with increasing age, a similar pattern was seen across all age groups (favourable/intermediate/adverse/no sample/failed: age<16 81%/57%/49%/63%/62%; age 16-59 67%/36%/13%/30%/41%; age 60+ 32%/12%/2%/8%/9%). In the most recent trial, AML17 (2009-14) of younger patients, 97% had successful cytogenetic analysis, compared to 86% in AML10-15. Here too, there was no suggestion of poor outcomes for those patients with no cytogenetic result. These results indicate that cytogenetic analysis is possible in the vast majority of younger patients, and suggest that absence of cytogenetic information is not in itself an adverse prognostic factor. This poor prognosis identified in other studies may be due to selection bias in the decision to send samples. The experience of AML17 demonstrates that, when cytogenetic analysis is required to guide treatment decisions, if results can be provided in real time, high levels of compliance can be achieved, not only in sending, but also in the quality of samples. Figure 1. Figure 1. Disclosures No relevant conflicts of interest to declare.

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