scholarly journals Clinical Heterogeneity of AML Is Associated with Mutational Heterogeneity

Blood ◽  
2018 ◽  
Vol 132 (Supplement 1) ◽  
pp. 5240-5240
Author(s):  
Mahesh Swaminathan ◽  
Kiyomi Morita ◽  
Yan Yuanqing ◽  
Feng Wang ◽  
Jared K Burks ◽  
...  
Keyword(s):  
Bone Marrow ◽  
Dna Sequencing ◽  
Research Funding ◽  
Clinical Presentation ◽  
De Novo ◽  
Hot Spot ◽  
Bone Marrow Blast ◽  
Trisomy 8 ◽  
Immunological Parameters ◽  
Exon 2

Abstract BACKGROUND: AML is a group of clinically heterogeneous diseases. We hypothesized that heterogeneous presentation of AML is a reflection of equally heterogeneous genetic process during the leukemogenesis. METHODS: 536 AML patients (pts) bone marrow samples were analyzed by targeted capture exome sequencing of 295 genes. Extensive clinical-genotype correlation was performed using well annotated clinical data. RESULTS: The median age of the cohort was 62 years (IQR: 51-72) including 297 (55%) elderly (age ≥60), and 239 (45%) young (age <60) pts. Of the 536 pts, 308 (57%) pts had de novo AML (dnAML), and 103 (19%) had secondary or therapy-related AML (stAML). DNA sequencing revealed 1,586 high-confidence somatic mutations (922 SNVs and 664 indels) in 79 genes in 493 (92%) pts [median 3 (IQR 2-4) mutations/patient]. Cytogenetics were favorable in 10 (2%), intermediate in 326 (61%), and adverse in 177 (33%) (All defined by ELN 2017criteria); 23 (4%) pts had no cytogenetics data. Elderly pts and young pts had distinct mutational landscape. (1.3-9.6), p = 0.0079] were significantly more enriched in elderly AML, whereas young AML pts were enriched with mutations in FLT3 [OR 0.6 (0.4-0.9), p = 0.0089], NPM1 [OR 0.5 (0.3-0.9), p = 0.0113], PTPN11 [OR 0.2 (0.2-0.7), p = 0.0033], and WT1 [OR 0.4 (0.2-0.7), p = 0.0033]. Some of the mutations enriched in elderly pts are frequently observed in pts with clonal hematopoiesis with indeterminate potential. Based on the ontogeny of AML, PTPN11 [OR 7.6 (1-57.2), p=0.0210], NPM1 [OR 3.0 (1.5-6.1), p = 0.0007], WT1 [OR 2.9 (1.1-7.4), p=0.0279] mutations were significantly enriched in dnAML, while SF3B1 [OR 0.4 (0.18-0.89), p=0.0376], SRSF2 [OR 0.5 (0.3-0.85), p = 0.0109], TP53 [OR 0.5 (0.3-0.8), p = 0.0131], ASXL1 [OR 0.6 (0.36-0.95), p=0.0451] mutations were more enriched in stAML (Figure A). We then correlated mutation data with clinical and immunological parameters that are routinely tested in AML. Mutations in NPM1, FLT3, PTPN11 and NRAS were associated with significantly higher white blood cell (WBC) counts, bone marrow blast and LDH, which is consistent with their hyperproliferative activity as class 1 genes. In contrast, pts with mutations in TP53, STAG2 and ASXL1 presented with significantly low bone marrow blast, circulating blast, and WBC. Mutations in BCOR and ASXL1 was associated with significantly low LDH. Interestingly, pts with IDH2 mutations presented with significantly higher platelet, which is consistent with anecdotal report (DiNardo et al. Am J Hematology). Not surprisingly, TP53 mutations were associated with complex cytogenetics, whereas SRSF2, NPM1, IDH2, FLT3, and CEBPA mutations were associated with good and intermediate cytogenetics by ELN classification (Figure B). Pts with NPM1, IDH2, and IDH1 mutations were associated with less HLA-DR and CD34 expression in blast by flow cytometry. This is consistent with the frequent presentation of these AML sub-types with cuplike nuclei (Rakheja et al. BJH). DNA sequencing of a large cohort also allowed us to detect mutations that have not been as commonly reported in AML. We detected hot-spot mutations in exon 2 of MYC and MYCN genes in 9 (2%) AML pts. Additionally, internal tandem duplication (ITD) in MYC was also detected in one patient. Immunohistochemical staining showed that MYC expression was significantly elevated in patients with MYC mutations than in patients without the mutations (median H score 22 vs. 15 in MYC mutated vs. normal karyotype control, p < 0.001, 22 vs. 13.5 in MYC mutated vs. trisomy 8 control). These data suggest that a subset of AML is driven by the strong MYC signaling, consistent with a prior study (Ohanian et al. Leuk Lymphoma). CONCLUSION: Heterogeneous clinical presentation of AML has significant association with genetic heterogeneity, which suggest that distinct genetic basis of leukemogenic process has strong role in defining clinical presentation of AML. These data also help stratifying the patients for the likely target of precision medicine. Disclosures DiNardo: Medimmune: Honoraria; Celgene: Honoraria; Agios: Consultancy; Abbvie: Honoraria; Karyopharm: Honoraria; Bayer: Honoraria. Kadia:Celgene: Research Funding; Pfizer: Consultancy, Research Funding; BMS: Research Funding; Jazz: Consultancy, Research Funding; Abbvie: Consultancy; Abbvie: Consultancy; Amgen: Consultancy, Research Funding; BMS: Research Funding; Pfizer: Consultancy, Research Funding; Jazz: Consultancy, Research Funding; Takeda: Consultancy; Amgen: Consultancy, Research Funding; Takeda: Consultancy; Novartis: Consultancy; Celgene: Research Funding; Novartis: Consultancy. Cortes:novartis: Research Funding. Daver:Daiichi-Sankyo: Research Funding; Pfizer: Consultancy; Alexion: Consultancy; ARIAD: Research Funding; Karyopharm: Consultancy; ImmunoGen: Consultancy; Kiromic: Research Funding; Otsuka: Consultancy; Sunesis: Consultancy; Novartis: Research Funding; BMS: Research Funding; Incyte: Consultancy; Novartis: Consultancy; Sunesis: Research Funding; Karyopharm: Research Funding; Pfizer: Research Funding; Incyte: Research Funding. Pemmaraju:SagerStrong Foundation: Research Funding; celgene: Consultancy, Honoraria; cellectis: Research Funding; samus: Research Funding; daiichi sankyo: Research Funding; Affymetrix: Research Funding; stemline: Consultancy, Honoraria, Research Funding; plexxikon: Research Funding; novartis: Research Funding; abbvie: Research Funding.

A Phase II Study of the Combination of Oral Rigosertib and Azacitidine in Patients with Myelodysplastic Syndromes (MDS)

Blood ◽  
2015 ◽  
Vol 126 (23) ◽  
pp. 910-910 ◽  
Author(s):  
Shyamala C. Navada ◽  
Lewis R. Silverman ◽  
Katherine P. Hearn ◽  
Rosalie Odchimar-Reissig ◽  
Erin P. Demakos ◽  
...  
Keyword(s):  
Bone Marrow ◽  
Phase I ◽  
Phase Ii ◽  
Research Funding ◽  
De Novo ◽  
Standard Dose ◽  
Single Agent ◽  
Leukemic Cells ◽  
Bone Marrow Blast ◽  
Recommended Phase Ii Dose

Background: Rigosertib (RIG) is a Ras-mimetic that inhibits the PI3K and PLK cellular signaling pathways by binding directly to the Ras-binding Domain found in Ras effector proteins. It has been tested as a single agent in patients (pts) after failure of hypomethylating agents (HMAs). In vitro, the combination of RIG with azacitidine (AZA) inhibits growth and induces apoptosis of leukemic cells in a sequence-dependent fashion (RIG administered prior to AZA) (Skidan et al 2006). Phase I results of this study in pts with MDS or AML showed combination of oral RIG and standard-dose AZA to be well-tolerated with evidence of efficacy (Navada et al, Blood 2014). Phase II was initiated to further study the combination in pts with MDS. Methods: Results from pts in Phase II with MDS previously untreated with an HMA, or who had failed to respond to or progressed on a prior HMA, are presented, while response data from Phase I MDS pts are updated. Pts with CMML are analyzed separately. Oral RIG was administered twice daily on Day 1-21 of a 28-day cycle at the recommended Phase II dose (RPTD: 560 mg qAM and 280 mg qPM). AZA 75 mg/m2/d SC or IV was administered for 7 days starting on Day 8. A CBC was performed weekly and a bone marrow aspirate and/or biopsy was performed at baseline, day 29, and then every 8 weeks thereafter. Results: The combination of oral RIG and AZA has been administered to a total of 45 pts within Phase I (N=18) and Phase II (N=27). Pts were classified into the following MDS risk categories per the IPSS (Greenberg et al, Blood 1997): intermediate-1 (4), intermediate-2 (10), high-risk (14), and IPSS classification pending (4). Five pts had CMML and 8 had AML. Median age was 66 years; 69% of pts were male; and ECOG performance status was 0, 1, and 2 in 27%, 67%, and 6%, respectively. Twelve pts [MDS (9), CMML (3)] received prior HMA therapy: AZA (11 pts), decitabine (1 pts). Patients have received 1-21+ cycles of treatment to date (median, 3 cycles), with median duration of treatment of 14 weeks. Among 15 evaluable MDS pts treated with the RPTD (1 pt in Phase I, 14 pts in Phase II), marrow responses were observed in 10: marrow CR (mCR) (8), marrow PR (mPR) (2). Responses according to IWG criteria were observed in 10 pts: complete remission (CR) (1), mCR (7), hematologic improvement (HI) (2). Table 1. Responses for MDS Patients Treated at the Recommended Phase II Dose Pt Prior HMA Best BMBL at Nadir1 IWG Response2 Hematologic Improvement 102-008 None mCR mCR Platelet 101-010 None mCR CR Erythroid & Neutrophil 101-011 None mCR mCR None 101-013 None mCR mCR Erythroid 102-010 None SD SD None 101-014 AZA PD PD None 102-011 AZA mPR HI Erythroid & Platelet 101-016 AZA SD SD None 101-017 AZA mCR mCR None 102-013 None NE NE NE 101-019 None SD SD None 101-021 None PD PD None 101-024 None mCR mCR None 101-022 AZA mCR mCR None 101-025 None mCR mCR None 101-026 AZA NE NE NE 101-027 None NE NE NE 102-016 None mPR HI Platelet 1 Silverman et al, Hematol Oncol 2014 2 IWG = International Working Group (Cheson et al, Blood 2006) NE = not evaluable BMBL = bone marrow blast Overall, in pts with MDS treated on Phase I and Phase II, marrow responses were observed in 15 out of 20 evaluable pts: mCR (13), mPR (2). Responses according to IWG 2006 criteria were observed in 14 out of 19 evaluable MDS pts: CR (2), mCR (10), HI (2). Among the 7 evaluable pts with MDS in both the Phase I and Phase II who had failed to respond or progressed on prior treatment with an HMA, 5 had a response after RIG was added: CR (1), mCR (3), HI (1). Analyzed as a separate subgroup, 2 out of 5 (40%) pts with CMML had a mCR. The most frequent adverse events (AEs) in Cycle 1 included nausea (21%) and fatigue (15%), which were also the most frequent AEs in all cycles (fatigue, 28%; nausea, 26%). Six deaths have been observed so far. Three pts were treated for more than 1 year and continue on study. Conclusions: The combination oforalrigosertib and standard-dose AZA was well tolerated in repetitive cycles in pts with MDS. Marrow CR was observed in 65% of pts, both with de novo MDS and after failure of prior HMA therapy. In pts who received the RPTD, 67% of pts with MDS had a bone marrow blast and IWG response. These results suggest potential synergistic interaction of the combination and support continued study of this unique combination in patients with MDS. Disclosures Silverman: Onconova Therapeutics Inc: Honoraria, Patents & Royalties: co-patent holder on combination of rigosertib and azacitdine, Research Funding. Daver:ImmunoGen: Other: clinical trial, Research Funding. DiNardo:Novartis: Research Funding. Konopleva:Novartis: Research Funding; AbbVie: Research Funding; Stemline: Research Funding; Calithera: Research Funding; Threshold: Research Funding. Pemmaraju:Stemline: Research Funding; Incyte: Consultancy, Honoraria; Novartis: Consultancy, Honoraria, Research Funding; LFB: Consultancy, Honoraria. Fenaux:CELGENE: Honoraria, Research Funding; JANSSEN: Honoraria, Research Funding; AMGEN: Honoraria, Research Funding; NOVARTIS: Honoraria, Research Funding. Fruchtman:Onconova Therapeutics Inc: Employment. Azarnia:Onconova Therapeutics Inc: Employment.

Phase 1 Results of FF-10501-01, a Novel Inosine 5'-Monophosphate Dehydrogenase Inhibitor, in Advanced Acute Myeloid Leukemia (AML) and Myelodysplastic Syndromes (MDS), Including Hypomethylating Agent (HMA) Failures

Blood ◽  
2016 ◽  
Vol 128 (22) ◽  
pp. 1640-1640 ◽  
Author(s):  
Guillermo Garcia-Manero ◽  
Hui Yang ◽  
Zhihong Fang ◽  
Hagop M. Kantarjian ◽  
Courtney D. DiNardo ◽  
...  
Keyword(s):  
Bone Marrow ◽  
Disease Progression ◽  
Cell Lines ◽  
Dose Level ◽  
Research Funding ◽  
De Novo ◽  
Phase 1 ◽  
Clinical Activity ◽  
Guanine Nucleotide ◽  
Bone Marrow Blast

Abstract Inosine 5'- monophosphate dehydrogenase (IMPDH) is a rate-limiting enzyme that catalyzes de novo synthesis of the guanine nucleotide and is overexpressed in both hematologic and solid tumors. FF-10501-01 is a potent new competitive IMPDH inhibitor. We investigated the anti-leukemia effect of FF-10501-01 in a Phase 1 clinical study in advanced AML and MDS, including HMA failures. Previous preclinical studies demonstrated potent anti-proliferative and apoptotic effects of FF-10501-01 on AML cell lines, including HMA-resistant derivatives, through inhibition of de novo guanine nucleotide synthesis. Therefore, we performed a standard 3+3 dose-escalation Phase 1 trial to access the safety and clinical activity of FF-10501-01 in patients with advanced AML, MDS and chronic myelomonocytic leukemia (CMML). Eligibility criteria: age ≥ 18 years, high risk MDS/CMML, AML with documented PD following previous therapy, AML ≥ 60 years of age and not a candidate for other therapy, adequate renal and hepatic function, and no known history of significant cardiac disease. A total of 29 patients, 15M and 14F (23 AML, 6 MDS) have been treated in 7 dose cohorts (50 - 500 mg/m2 PO BID) for 14 days on and 14 days off, and 400 mg/m2 for 21 days on and 7 days off, each 28-day cycle. Median (range) values: age 75 yrs (59 - 88); baseline bone marrow blast counts for AML 34% (12 - 82), for MDS 10% (5 - 16), and overall 30% (5 - 82); and prior treatment regimens 2 (1 - 7). All patients relapsed from, or progressed on, prior HMAs. At baseline, mutations in FLT3, NPM1, GATA2, TET2, ASXL1, DNMT3A, NOTCH1, JAK2, IDH2, PTPN11, KRA, TP53, RUNX1, EZH2 and/or MDM2 were present in 13 of 29 (45%) of patients. Atrial fibrillation (Gr 2) was reported in 2 subjects at a dose of 500 mg/m2 BID. This met the definition of dose-limiting toxicity (DLT) and no further enrollment was made at this dose level. The maximally tolerated dose (MTD) was declared at 1 dose level lower, 400 mg/m2 BID, and this cohort was expanded to 6 subjects. No DLTs have been observed in N=7 total subjects treated at 400 mg/m2 BID x 14 days. FF-10501-01 has been very well tolerated through 24 cycles. The most frequent drug-related AEs have been Gr 1-2 nausea, diarrhea and fatigue. Drug-related thrombocytopenia, neutropenia and bone marrow aplasia (all Gr 4) were reported in 1 patient at 200 mg/m2 BID. The median number of FF-10501-01 cycles received to date is 2 (range 1 - 24). Partial remissions have occurred in 2 AML patients (50 and 100 mg/m2 BID) after 3 cycles, lasting for 5 and 24 cycles, respectively, with the higher dose patient still on study after 24 cycles. A total of 8/23 (34.8%) AML patients, including the 2 PRs, have attained stable disease (SD) control with no disease progression over 3 - 24 cycles. Three AML patients remain on study through 3, 23 and 24 cycles, respectively. A bone marrow complete response was achieved in 1 MDS patient treated at 400 mg/m2 BID after 1 cycle. Although the bone marrow blast counts have increased since, this patient remains stable and is still on therapy through 14 cycles. Three of 6 MDS patients (50%), including the marrow CR, attained SD control with no disease progression over 3, 14 and 14 cycles, and 2 remain on study through 3 and 14 cycles, respectively. FF-10501-01 was rapidly absorbed with mean Tmax of 2.74 hours and mean t1/2 of 4.05 hours. Drug exposure (AUC0-24 and AUCcourse) increased with dose in a near linear manner. Potent suppression of circulating xanthine monophosphate (XMP), a marker of IMPDH activity, has been observed following FF-10501-01 administration on Day 1 of Cycles 1 and 2 at dose levels of 50 mg/m2 BID and above. FF-10501-01 is a promising new agent for the treatment of advanced AML and MDS in patients who have failed or progressed on HMAs and with one or more baseline mutations in pathways known to be affected in AML and MDS. Preclinical activity was seen in multiple leukemia cell lines, including HMA-resistant derivatives. In a Phase 1 trial, clinical activity with a marrow CR, PRs, long-term disease stabilization (≥ 5 cycles) and a highly tolerable safety profile were observed. The Phase 2a expansion phase of the study is soon to begin. Disclosures DiNardo: Agios: Research Funding; Daiichi Sankyo: Research Funding; Celgene: Research Funding; Novartis: Research Funding; Abbvie: Research Funding. Jabbour:ARIAD: Consultancy, Research Funding; Pfizer: Consultancy, Research Funding; Novartis: Research Funding; BMS: Consultancy. Daver:BMS: Research Funding; Kiromic: Research Funding; Pfizer: Consultancy, Research Funding; Otsuka: Consultancy, Honoraria; Ariad: Research Funding; Karyopharm: Honoraria, Research Funding; Sunesis: Consultancy, Research Funding. Denton:Westat Corporation: Employment. Smith:Westat Corporation: Employment. Tiefenwerth:Westat Corporation: Employment. Iwamura:FUJIFILM Corporation: Employment. Gipson:Strategia Therapeutics, Inc.: Employment. Rosner:Strategia Therapeutics, Inc.: Employment. Myers:Strategia Therapeutics, Inc.: Employment. Paradiso:Strategia Therapeutics, Inc.: Employment.

NPM-1, but Not FLT3-ITD Mutations Predict Early Blast Cell Clearance and CR Rate in Patients with Normal Karyotype AML or High-Risk Myelodysplastic Syndrome (MDS).

Blood ◽  
2006 ◽  
Vol 108 (11) ◽  
pp. 805-805 ◽  
Author(s):  
Karsten Spiekermann ◽  
Annika Dufour ◽  
Gudrun Mellert ◽  
Evelin Zellmeier ◽  
Jan Braess ◽  
...  
Keyword(s):  
Bone Marrow ◽  
Prognostic Factors ◽  
De Novo ◽  
Blast Cell ◽  
High Dose ◽  
Bone Marrow Blast ◽  
Npm1 Mutation ◽  
Free Survival ◽  
Cell Clearance ◽  
High Dose Cytarabine

Abstract Background: Mutations in the NPM1 gene represent the most frequent alterations in patients with AML and are associated with a favourable clinical outcome. Patients and Methods: We analyzed 803 patients that were treated in the AMLCG2000 study. Patients with de novo or secondary AML or high-risk myelodysplastic syndrome (MDS) were randomly assigned upfront for induction therapy containing one course with standard dose and one course with high-dose cytarabine, or two courses with high-dose cytarabine, and in the same step received postremission prolonged maintenance or busulfan/cyclophosphamide chemotherapy with autologous stem-cell transplantation. At diagnosis mutations in the NPM1 and FLT3 gene were analyzed by routine molecular techniques. Results: The median age of all patients was 60 years and the median observation time 23 months. Results of the mutations status of FLT3 (FLT3-ITD) and NPM1 were available in 761/803 (94,8 %) and 690/803 (85,9 %) patients, respectively. NPM1 and FLT3-ITD mutation were found in 352 (51,1%) and 199 (28,9%), respectively. On the basis of these two molecular markers, patients were grouped in 4 subgroups: 1. NPM1+/FLT3−, N=214 (31%), 2. NPM1+/FLT3+, N=138 (20%); 3. NPM1−/FLT3−, N=276 (40%); NPM1−/FLT3+ (9%). The CR-rates were significantly higher in NPM1+ (74,4%) than in NPM1− (55,9%) patients, but were unaffected by the FLT3-ITD status. Overall survival (OS), event-free survival (EFS) and relapse free survival (RFS) was significantly higher in NPM1 positive and FLT3-ITD negative patients. In a multivariate analysis age, WBC, the presence of the NPM1 mutation and de novo AML were independent prognostic factors for the CR-rate. The NPM1− and FLT3 mutation status, age and LDH were identified as independent prognostic factors for RFS. To further characterize the biological effects of NPM1 and FLT3 mutations, we analyzed the in vivo blast cell clearance measured by the residual bone marrow blast cells one week after the end of the first induction cycle (d+16 blasts). The percentage of patients with adequate blast cell reduction (residual bone marrow blast &lt;10%) was significantly higher in NPM1+ patients (87,3%) compared to NPM1− (65,7%) patients. The presence of a FLT3-ITD mutation had no effect on early blast cell clearance. Conclusions: The presence of a NPM1 mutation represents an independent positive prognostic factor for the CR-rate and RFS/OS. In contrast, FLT3-ITD mutations do not affect the CR-rate, but have a negative prognostic impact on RFS and OS. The higher sensitivity of NPM1-positive blasts towards the induction therapy point to a central role of NPM1 in the regulation of apoptotic cell death in AML.

Will a Peripheral Blood (PB) Sample Yield the Same Diagnostic and Prognostic Cytogenetic Data as the Concomitant Bone Marrow (BM) In Myelodysplasia? An International Study Comparing Cytogenetics and Interphase FISH Using Parallel PB and BM Samples

Blood ◽  
2010 ◽  
Vol 116 (21) ◽  
pp. 2922-2922
Author(s):  
Athena M Cherry ◽  
Marilyn L. Slovak ◽  
Lynda J Campbell ◽  
Kathy Chun ◽  
Virginie Eclache ◽  
...  
Keyword(s):  
Bone Marrow ◽  
Peripheral Blood ◽  
Research Funding ◽  
De Novo ◽  
International Study ◽  
Chromosome Abnormalities ◽  
International Prognostic Scoring System ◽  
Second Phase ◽  
Interphase Nuclei ◽  
Interphase Fish

Abstract Abstract 2922 The myelodysplastic syndromes (MDS) are a heterogeneous group of hematological malignancies characterized by ineffective hematopoiesis and a highly variable clinical course, for which novel treatments are beginning to emerge. Conventional cytogenetic studies (CCS) of bone marrow (BM) are routinely used in clinical practice to detect abnormal clones in proliferating (metaphase) cells, identifying clonal aberrations in ∼50% of de novo MDS cases. Cytogenetics is also one of the key International Prognostic Scoring System (IPSS) components used to estimate overall survival and leukemia-free survival in MDS. Chromosome abnormalities may be quantified at presentation and during treatment by the use of fluorescence in situ hybridization (FISH) with DNA probes for specific chromosome loci (e.g., chromosomes 5, 7, 8 and 20) in non-proliferating (interphase) nuclei. However, it is not clear whether or not peripheral blood CCS will yield the same diagnostic and prognostic data as bone marrow CCS at disease presentation or whether patients without apparent chromosome abnormalities by CCS have “hidden” abnormalities that can be identified by interphase FISH. To answer these questions, 15 members of the International Working Group on MDS Cytogenetics agreed to perform CCS and FISH in parallel on both peripheral blood and bone marrow samples collected from MDS patients. To be certain that all participating sites scored and interpreted their individual FISH data in a similar fashion, a quality assurance (QA) study was completed with each site studying two identical test (proficiency) samples. Concordance among sites was very good to excellent allowing for the establishment of a standardized protocol with clear scoring criteria before patient samples were processed. In the second phase of the study, a total of 77 MDS patients were accrued to the study with 61% showing an abnormal karyotype. A FISH panel consisting of eight probe sets [-5/5q-, -7/7q-/der(1;7), +8/8q-, -11/+11/11q-/add(11q), 12p-/+21/t(12;21), -13/13q-, 17p- and 20q-/i(20q)/i(20p), Abbott Molecular, Inc.] was performed on both specimen types. While CCS was frequently unsuccessful (57.5%) in the PB specimens, FISH was informative (concordant with BM/PB CCS) in 92% of cases, with 49% of PB FISH demonstrating an abnormal clone. FISH was discordant in 4 of 77 BM and PB samples (5%), while CCS and FISH on BM and PB were discordant in 6 of 77 BM specimens (8%) and 6 of 73 PB specimens (8%). The data suggest that evaluation of interphase nuclei from PB on follow-up (non-diagnostic) FISH studies on MDS patients will be equally informative (and less costly and stressful) as a BM sample. Disclosures: Slovak: PerkinElmer: Employment. Haferlach:MLL Munich Leukemia Laboratory: Employment, Equity Ownership, Research Funding. Ohyashiki:Nippon Shinyaku Co., Ltd.: Research Funding.

Time-to-Treatment in Chronic Myelomonocytic Leukemia - a Novel Prediction Model

Blood ◽  
2016 ◽  
Vol 128 (22) ◽  
pp. 5547-5547
Author(s):  
Florian Huemer ◽  
Lukas Weiss ◽  
Viktoria Faber ◽  
Daniel Neureiter ◽  
Alexander Egle ◽  
...  
Keyword(s):  
Bone Marrow ◽  
Platelet Count ◽  
Lactate Dehydrogenase ◽  
High Risk ◽  
Prediction Model ◽  
Scoring System ◽  
Research Funding ◽  
Treatment Initiation ◽  
Bone Marrow Blast ◽  
Time To Treatment

Abstract Introduction For chronic myelomonocytic leukemia (CMML) several scores exist which prognosticate overall survival (OS) based on different clinical and genetic parameters. The time-to-treatment (TTT) among CMML patients is highly variable, and a predictive model to specifically estimate TTT in CMML has not been described so far. The aims of this single-center retrospective study were (a) to test and validate established myelodysplastic syndrome (MDS)-specific and CMML-specific prognostic scores in our patient cohort, (b) to evaluate which baseline factors were relevant to the time point of treatment initiation with either hydroxyurea or azacitidine, and (c) to propose a prediction model for TTT in CMML. Methods This retrospective analysis was based on the data of 55 unselected, consecutive CMML patients diagnosed and/or treated at our tertiary center between 2004 and 2015. We applied the following published prognostic models to our CMML cohort, using both OS and TTT as endpoints: the MD Anderson Prognostic Score (MDAPS), the modified MDAPS (MDAPS M1), the CMML-specific Prognostic Scoring System (CPSS), the Mayo Prognostic Model, the Düsseldorf Score, the International Prognostic Scoring System (IPSS), and the Revised International Prognostic Scoring System (IPSS-R). Results According to the CMML-specific MDAPS, 27% of our patients were classified as "higher-risk" (23% intermediate-2, 4% high-risk) (Figure 1). At the time of data analysis, 38% and 24% of patients had received azacitidine and hydroxyurea as first-line treatment. A total of 40 (73%) patients had died at the time point of data analysis. The median time of follow-up was 24.8 months (range 1.7-74.8 months). All applied MDS-specific (Düsseldorf Score, IPSS, IPSS-R) and CMML-specific (MDAPS, MDAPS M1, CPSS, Mayo Prognostic Model) prediction scores were able to significantly discriminate patient cohorts with different OS probabilities. The following variables were associated with a shorter TTT in the univariate analysis: the presence of immature myeloid cells in the peripheral blood, white blood cell count ≥14.5 G/L, platelet count <55 G/L, absolute neutrophil count ≥6 G/L, absolute lymphocyte count ≥2.3 G/L, absolute monocyte count ≥2.8 G/L, serum lactate dehydrogenase ≥223 G/L, peripheral blood blasts >0%, bone marrow blast percentage ≥7.5%, red blood cell transfusion-dependence, palpable spleen and/or symptomatic splenomegaly, and the presence of B-symptoms at the time of initial diagnosis. In multivariate analysis, the following factors remained independently associated with TTT: lactate dehydrogenase (HR 5.428; p = 0.008), bone marrow blast count (HR 4.570; p = 0.001), and platelet count (HR 2.660; p = 0.027). These three clinical parameters were included in the TTT prediction model and CMML patients were stratified into three subgroups: low-risk, intermediate-risk and high-risk. Median TTT was not reached for low-risk patients, 16.5 months for intermediate-risk patients, and almost immediate treatment initiation (0.6 months) was observed in the high-risk group (Figure 2). Conclusions We validated seven existing MDS-specific and CMML-specific prognostic scores in 55 CMML patients treated at the center in Salzburg. We were able to demonstrate that lactate dehydrogenase, bone marrow blast percentage and platelet count at initial diagnosis were the most relevant parameters for predicting time to treatment initiation in our CMML cohort. Based on these three parameters, we propose the first TTT prediction score for treatment-naïve CMML patients. Clinical implications of this score include the identification of CMML patients for early investigational trials, as well as the tailoring of individual follow-up intervals. Disclosures Huemer: Roche: Other: Travel funding; Merck: Other: Travel funding. Egle:Gilead: Consultancy, Honoraria; Janssen: Consultancy, Honoraria, Other: travel support; Celgene: Consultancy, Honoraria; Roche: Consultancy, Honoraria, Other: travel support. Greil:Pfizer: Honoraria, Research Funding; Boehringer-Ingelheim: Honoraria; Eisai: Honoraria; Celgene: Consultancy, Honoraria, Research Funding; Amgen: Honoraria, Research Funding; Mundipharma: Honoraria, Research Funding; Merck: Honoraria; Janssen-Cilag: Honoraria; Genentech: Honoraria, Research Funding; Novartis: Honoraria; AstraZeneca: Honoraria; Roche: Honoraria, Research Funding; Sanofi Aventis: Honoraria; GSK: Research Funding; Ratiopharm: Research Funding; Cephalon: Consultancy, Honoraria, Research Funding; Bristol-Myers-Squibb: Consultancy, Honoraria. Pleyer:Celgene: Consultancy, Honoraria; Bristol-Myers-Squibb: Consultancy, Honoraria; Novartis: Consultancy, Honoraria; AOP Orphan Pharmaceuticals: Honoraria.

scholarly journals Iron Overload in Patients Aged 60 Years and Older with Acute Myeloid Leukemia May Impact Adversely on Overall Survival

Blood ◽  
2018 ◽  
Vol 132 (Supplement 1) ◽  
pp. 3982-3982
Author(s):  
Colleen A. C. Wong ◽  
Chantal Leger ◽  
Heather A. Leitch
Keyword(s):  
Bone Marrow ◽  
Overall Survival ◽  
Clinical Outcomes ◽  
Myeloid Leukemia ◽  
Research Funding ◽  
Low Dose ◽  
De Novo ◽  
Iron Stores ◽  
Baseline Characteristics ◽  
Ecog Ps

Abstract Background: Analyses in myelodysplastic syndromes (MDS) and other acquired anemias suggest an association between iron overload and inferior clinical outcomes. There are minimal data examining iron levels in patients with acute myeloid leukemia (AML) and its relation to clinical outcomes. Patients with AML aged 60 years or older have inferior outcomes in general and no studies examine iron load and clinical outcomes in these patients. We wished to determine whether iron levels might contribute to the prognosis of these patients. Methods: We performed a retrospective analysis of patients with AML aged ≥60 years diagnosed from 2002-2018. Patients were identified from the clinical database and charts reviewed. Clinical data extracted included baseline characteristics (demographics; AML presentation; ECOG performance status [PS]; comorbidities [Charlson Comorbidity Index (CI) and Hematopoietic Stem Cell Transplantation CI]; predisposing conditions; prior transfusions; blood counts; bone marrow findings; cytogenetic analysis) AML treatment received, status at last follow up and cause of death (COD). Serum ferritin level (SF) and bone marrow iron stores (BMIS) at AML diagnosis were recorded. BMIS were: absent, 0; reduced, 1; normal, 2; increased, 3; and markedly increased, 4. Elevated iron was: SF>750ng/mL or BMIS ≥3. Statistical analyses were performed using SPSS for Windows, version 25. Results: Of 369 AML patients, 101 were ≥60 years and had adequate data for analysis. The median age at AML diagnosis was 70 (range 60-93) years and 60 (59.4%) were male. ECOG PS was 0, 1, 2, 3 and 4 in 7 (6.9%), 17 (16.8%), 48 (47.5%), 23 (22.8%) and 4 (4%) patients, respectively. 51 (50.5%) were de novo AML, and 49 (48.5%) had predisposing conditions, including MDS (n=39; 38.6%), MPN (n=7; 6.9%), and prior chemotherapy (CT) or radiation (n=3; 3.0%). Cytogenetic risk group was intermediate in 47 (46.5%) and adverse in 33 (32.7%). Treatment received included supportive care in 41 (40.6%), low dose chemotherapy (hydroxyurea, n=18; low dose cytarabine, n=4) in 22 (21.8%), induction CT in 18 (17.8%), and azacitidine in 20 (19.8%). Infection or inflammation were documented in 8 (7.9%). Comorbidities were present in 43 (42.6%) patients, and the median (range) number of comorbidities per patient was 1 (1-3). SF was available in 55 (54.5%), BMIS in 68 (67.3%), and both in 22 (21.8%). There was a significant correlation between SF >750ng/mL and BMIS ≥3 (r=0.555, p=0.008). A composite score including SF and BMIS revealed elevated iron stores (ELFE) in 39 (38.6%) and normal to decreased iron stores in 62 (61.4%). In univariate analysis, factors significant for overall survival (OS) included ECOG PS, p<0.0001; de novo versus secondary AML, p=0.02; neutrophil count, p<0.0001; platelet count, p<0.0001; bone marrow blast %, p=0.04; cytogenetic risk group, p=0.02; and AML treatment received, p<0.0001. Factors with a trend toward significance included the presence of dysplasia, p=0.07; and ELFE, p=0.07. In pairwise comparisons, dysplasia and AML treatment received lost significance, p=0.09. Factors remaining significant for OS when paired with ELFE included ECOG PS, p=0.02; and AML treatment (trend), p=0.05. In a multivariate analysis including ELFE, ECOG PS and AML treatment, ELFE and ECOG PS were significant for OS: p=0.046, hazard ratio (HR) for death 2.5, 95% confidence intervals (CI) 1.02-6.14, and p=0.006, HR=4.1, 95% CI=1.50-11.36, respectively. The median OS for patients receiving induction CT with no ELFE was 18 (range 0.2-82) months versus 10.1 (0.1-18.2) months with ELFE (p=0.05, see Figure). Baseline characteristics in the subgroup receiving induction CT were not significantly different between ELFE non-ELFE patients, with the exception of hemoglobin (p=0.008). COD in all patients were: AML progression, n=72 (71.3%); infection, n=4 (4.0%); and bleeding, n=4 (4.0%); with no significant difference in COD between patients with and without ELFE (p=0.4). Conclusions: In this retrospective, non-controlled analysis, for patients aged ≥60 years with a new diagnosis of AML, elevated iron appears to be associated with inferior overall survival, particularly in those receiving induction chemotherapy. To our knowledge, these are the first data examining clinical outcomes in AML patients ≥60 years of age according to iron status. These results should be confirmed in larger, prospective analyses. Disclosures Leitch: AbbVie: Research Funding; Alexion: Honoraria, Research Funding; Celgene: Honoraria, Research Funding; Novartis: Honoraria, Research Funding, Speakers Bureau.

scholarly journals Development of Somatic NRAS Mutation Associated with Rapid Transition from Germline GATA2 Mutation Associated Myelodysplastic Syndrome to Acute Myeloid Leukemia

Blood ◽  
2015 ◽  
Vol 126 (23) ◽  
pp. 3616-3616 ◽  
Author(s):  
Yanqin Yang ◽  
Yubo Zhang ◽  
Jun Zhu ◽  
Catherine E. Lai ◽  
Jingrong Tang ◽  
...  
Keyword(s):  
Bone Marrow ◽  
Flow Cytometry ◽  
Acute Myeloid Leukemia ◽  
Myelodysplastic Syndrome ◽  
Myeloid Leukemia ◽  
Research Funding ◽  
Bone Marrow Aspirate ◽  
Nras Mutation ◽  
Trisomy 8 ◽  
Acute Myeloid

Abstract There is increasing recognition of the role of inherited germline predisposition for myeloid disorders such as myelodysplastic syndrome (MDS) and acute myeloid leukemia (AML). The additional somatic genetic events required for development of a malignant phenotype are however poorly understood. A 25 year old woman was referred to the NHLBI hematology branch in March 2014 for a seven year history of pancytopenia. Her medical history included recurrent pneumonias, oral ulcers, severe varicella infection and arthralgias. Prior bone marrow examinations at ages 21 and 23 at outside institutions reported normocellular marrow, tri-lineage hematopoiesis and mild dyspoiesis. Cytogenetics were remarkable for trisomy 8 in 80% (aged 21) or 90% (aged 23) of metaphases. Previously unrecognized lymphedema was noted on examination. Peripheral blood counts showed WBC 2.28 K/ul [normal range: 3.98-10.04], HGB 9.9 g/dL [11.2-15.7], PLT: 67 K/ul [173-369], ALC: 0.36 K/ul [1.18-3.74] and AMC: 0.06 [0.24-0.86]. Peripheral blood flow cytometry demonstrated decreased CD3+ CD4+ (T) cells, CD19+ (B) cells and NK cells. HLA-DR15 negative. Bone marrow examination showed trilineage hematopoiesis, 50-60% cellularity, mild erythroid predominance and mildly increased, mildly atypical megakaryocytes. Blasts less than 5%. Bone marrow flow cytometry revealed severely decreased B-cells and monocytes, absent B-cell precursors, absent dendritic cells, inverted CD4:CD8 ratio, and atypical myeloid maturation pattern. Cytogenetics demonstrated stable trisomy 8 in 90% of metaphases. On the basis of this assessment the diagnosis of MDS was confirmed. Sanger sequencing revealed a GATA2 L375S mutation in the second zinc finger of known pathogenic significance. Four months later she developed increased fatigue and easy bruising with worsening thrombocytopenia (PLT: 10K/ul). Bone marrow was dramatically changed; now markedly hypercellular (90-100%) with diffuse sheets of immature cells consistent with blasts having fine chromatin, distinct or prominent nucleoli, and visible cytoplasm. Blasts were positive for CD33, CD56, CD64, CD123, and CD163; and were negative for CD34, CD14, and myeloperoxidase. Cytogenetics showed a new trisomy 20 in 65% of metaphases, in addition to previously seen trisomy 8 in 100%. A diagnosis of acute monoblastic leukemia (M5a subtype) was made. At both clinic visits bone marrow aspirate was collected on an IRB approved research sample acquisition protocol. Whole exome sequencing of 1ug DNA was performed using Agilent SureSelect v5 Exome enrichment Kits on an Illumina HiSeq 2000 with 100-bp paired-end reads (Macrogen, Rockville, MD). Data was mapped to hg19 (BWA) and processed using an in-house pipeline (Samtools/Picard/GATK/VarScan/Annovar). Mean read depth of target regions was 157 and 149. There was high correlation between both samples with the exception of a NRAS:NM_002524:exon3:c.C181A:p.Q61K mutation (57 of 180 reads) seen only in the later sample. Confirmatory ultra-deep sequencing for NRAS was performed using Illumina TruSight Myeloid Sequencing Panel on an Illumina MiSeq. No evidence of the NRAS Q61K mutation was found in the earlier March MDS bone marrow sample even when sequenced to a depth greater than 1750 reads (see figure). The mutation was confirmed in the August AML sample at a variant allele frequency of 35%. If heterozygous this would reflect a clone size of 70%, consistent with data from both cytogenetics (new trisomy 20 in 65% of metaphases) and the 76% blasts documented by bone marrow aspirate smear differential. We report here the rapid progression to AML in a patient with germline GATA2 MDS associated with development of a new trisomy 20 karyotype and a NRAS Q61K mutation. The NRAS mutation was not detectable after the patient achieved a complete remission following induction chemotherapy further supporting this association. This NRAS mutation has been implicated in the pathogenesis of multiple cancers by constitutive activation of proliferative signaling. GATA2 associated MDS is a high-risk pre-leukemic condition with the potential for rapid evolution to AML. This is the first report of acquired somatic mutations in the RAS/RTK signaling pathway in the context of germline GATA2 insufficiency associated with acute leukemic transformation. Figure 1. Figure 1. Disclosures Townsley: Novartis: Research Funding; GSK: Research Funding.

Therapy-Related Myeloid Neoplasms Following Treatment for Multiple Myeloma : A Single-Center Analysis

Blood ◽  
2019 ◽  
Vol 134 (Supplement_1) ◽  
pp. 4261-4261
Author(s):  
Amelie Boquoi ◽  
Soraya Magdalena Banahan ◽  
Judith Strapatsas ◽  
David Lopez y Niedenhoff ◽  
Guido Kobbe ◽  
...  
Keyword(s):  
Multiple Myeloma ◽  
Bone Marrow ◽  
Complete Remission ◽  
Median Time ◽  
Median Survival ◽  
Partial Remission ◽  
Research Funding ◽  
De Novo ◽  
Remission Status ◽  
Support Research

Introduction Myelodysplastic syndromes (MDS) and acute myeloid leukemia (AML) comprise late complications following mutagenic treatment. Limited data is available on the outcome of patients (pts) developing therapy-related MDS and AML (tMDS, tAML) after treatment for multiple myeloma (MM). Methods From 1976 to 2011, 3814 pts were entered into the Düsseldorf MDS registry. We identified 200 pts with tMDS or tAML. Of those, 41 pts had also been diagnosed with multiple myeloma (mm-MDS/AML). We compared these 41 pts to pts with de novo MDS (n=3614) and to pts with tMDS with other underlying diseases (n=159, 55 pts with other hematological diseases (34.5%), 93 with solid tumors (58.5%) and 11 with other diseases (7%)). Patient characteristics Median time between MM diagnosis and the onset of MDS was 5.5 years (range 0-28.5 years). Median age at the time of diagnosis of mm-MDS/AML was 67.8 years (range 32.5-84.6 years). Of all 41 mm-MDS pts, 13 developed AML (32%). Median time to progression from MDS to AML was 5 months (range 0.5-68 months). According to the WHO classification of 2016, there were 7 MDS-SLD, 10 MDS-MLD, 1 MDS-RS SLD, 13 MDS-RS MLD, 7 MDS-EB I, 2 EB-2, 1 MDS del(5q). 58% of mm-MDS pts had a complex karyotype, mostly affecting chromosomes 5 (22%) and 7 (17%), less often affected were chromosomes 17 (13%), 20 (13%) and 21 (13%). At MDS diagnosis, 11 MM pts were in complete remission (22%), 29 pts showed partial remission (58%), and 10 pts a stable disease (20%). 84.4% of pts with mm-MDS/AML had received conventional chemotherapy, mostly anthracyclines and alkylating agents. 94.4% had received melphalan. 15% of pts had received novel agents including immunomodulatory drugs and proteasome inhibitors. Results Both mm-MDS pts and tMDS pts were significantly younger than de novo MDS pts, however, there was no age difference between mm-MDS and tMDS (mm-MDS: mean 67.8 years, range 32-85, tMDS: mean 64.3 years, range 21-85, p<0.05, de novo MDS: 71,9 years, range 18-105; p<0.05). Both mm-MDS pts and de novo MDS pts showed significantly more males than females (mm-MDS 67% male versus 33% female, de novo MDS 57% versus 43%, p<0.05) while tMDS pts showed an equal ratio (48% versus 52%). When we compared risk group distribution according to IPSS-R we found significantly fewer mm-MDS pts to be in the lower risk categories (p<0.05 for both mm-MDS versus t-MDS and mm-MDS versus de novo MDS). Both mm-MDS and tMDS pts had a significantly worse karyotype when compared to de novo MDS (p<0.05). More cell lineages were affected in mm-MDS and tMDS pts than in de novo MDS (p<0.05). 50% of mm-MDS pts were pancytopenic versus 26% of de novo pts (p<0.05). Hemoglobin levels were significantly lower in mm-MDS and tMDS pts than de novo MDS pts (p<0.05). mm-MDS pts showed significantly higher blast counts in the bone marrow than all tMDS (p<0.05). Progression to AML occurred significantly more often in mm-MDS pts. At 12 months we discovered 12% of de novo MDS pts to have transformed to AML, 19% of tMDS and 24% of mm-MDS. At 36 months, 20% of de novo MDS pts had transformed to AML, 34% of tMDS and 39% of mm-MDS (p<0.05). When mm-MDS pts transformed to AML their survival was very poor, however, not significantly different compared to mm-MDS without AML transformation (7 months versus 11 months, p>0.05). Median survival of de novo MDS pts was 32 months (CI 29.940 - 34.192, range 1-345 months). In contrast, median overall survival of both mm-MDS and all other t-MDS was significantly shorter with 13 months in both groups (p<0.05, mm-MDS: CI 5.262 - 20.692, range 1-99 months; tMDS: CI 10,016 - 15,939, range 0-160 months). Myeloma remission status had no impact on survival: pts in complete remission showed a median survival of 6 months (95% CI, range 0 - 35 months), pts with partial remission 7 months (95% CI, range 5 - 9 months) (p>0.05). Conclusion Pts developing a myeloid neoplasm after treatment for multiple myeloma present with biological characteristics similar to those seen in pts with other tMDS. However, both clinical and molecular features are more severe with higher bone marrow blast counts, worse karyotypes, a more unfavourable IPSS-R score, and a significantly higher rate of transformation to AML. Yet despite a more aggressive phenotype, prognosis is equally poor and independent of myeloma remission status in mm-MDS/AML pts suggesting secondary myeloid neoplasia to govern the stem cell niche independent of previous disease or treatment. Disclosures Boquoi: Celgene: Other: Travel, Accommodation, Expenses; Janssen: Other: Travel, Accommodations, Expenses; BMS: Honoraria; Amgen: Honoraria, Other: Travel, Accommodations, Expenses. Kobbe:Takeda: Honoraria, Other: Travel support; Novartis: Honoraria, Other: Travel support; Medac: Honoraria, Other: Travel support; Jazz: Honoraria, Other: Travel support; Roche: Honoraria, Other: Travel support; MSD: Honoraria, Other: Travel support; Neovii: Honoraria, Other: Travel support; Abbvie: Honoraria, Other: Travel support; Pfizer: Honoraria, Other: Travel support; Biotest: Honoraria, Other: Travel support; Celgene: Honoraria, Other: Travel support, Research Funding; Amgen: Honoraria, Other: Travel support, Research Funding. Gattermann:Takeda: Research Funding; Novartis: Honoraria; Alexion: Research Funding. Germing:Amgen: Honoraria; Celgene: Honoraria, Research Funding; Novartis: Honoraria, Research Funding; Jazz Pharmaceuticals: Honoraria. Schroeder:Celgene Corporation: Consultancy, Honoraria, Research Funding. Fenk:Takeda: Honoraria; Janssen: Honoraria; BMS: Honoraria, Other: Travel, Accomodation, Expenses; Amgen: Honoraria; Celgene: Honoraria, Research Funding.

Phase 2 Trial of the Histone Deacetylase Inhibitor Valproic Acid as a Monotherapy or in Combination with All-Trans Retinoic Acid in 24 Patients with Acute Myeloid Leukemia.

Blood ◽  
2004 ◽  
Vol 104 (11) ◽  
pp. 1808-1808
Author(s):  
Andrea Kuendgen ◽  
Corinna Strupp ◽  
Barbara Hildebrandt ◽  
Sabine Knipp ◽  
Baerbel Junge ◽  
...  
Keyword(s):  
Bone Marrow ◽  
Valproic Acid ◽  
Side Effects ◽  
De Novo ◽  
Intensive Chemotherapy ◽  
Bone Marrow Blast ◽  
Blast Count ◽  
De Novo Aml ◽  
A Minor ◽  
To Receive

Abstract Valproic acid (VPA) has been shown to inhibit histone deacetylase activity, and to synergize with ATRA in the differentiation induction of leukemic myeloid blast cells in vitro. We applied VPA to 20 patients (16 sAML/MDS, 2 de-novo-AML, 2 sAML/OMF) too old or physically unfit to receive intensive chemotherapy. VPA monotherapy was targeted to reach serum concentrations of 50–100mg/ml. ATRA was added (80mg/m2/d in two divided doses, every other week) in some of the patients who did not respond or who relapsed. To enhance responses, we treated an additional 4 patients (2 sAML/MDS, 1 sAML/ET, 1 de novo AML) with VPA+ATRA from the start. Median age was 70 years (51–84). Median bone marrow blast count was 30% (10–80). 5 patients had only 10–15% marrow blasts but were included because they showed treatment failure or relapse after chemotherapy and were unable to receive further cytotoxic treatment. Median treatment duration was 99 days (20–396) for VPA and 79 days (18–339) for ATRA. Responses according to international working group (IWG, Cheson et al., 2003) criteria were observed in 5 patients (25%) on VPA monotherapy (4PR, 1CR). Of the responding patients two have ongoing responses (CR, PR) for 12 and 13 months, respectively. 1 patient reaching PR discontinued VPA when her physical condition had improved sufficiently to allow further chemotherapy. 1 patient relapsed after 2 months and was switched to VPA+ATRA, without response. 1 patient died of infectious complications. 8 additional patients showed stable disease without increases in peripheral blast count. Responses lasted for a median of 4 months (2–13). Among the 4 patients receiving VPA+ATRA from the start, 1 (25%) achieved PR. When he stopped VPA after 3 months because of side effects, he continued on ATRA, achieving a CRi (CR with incomplete recovery of platelets) lasting for 8 months. 4 of 14 nonresponders were switched to VPA+ATRA, but none of them showed a response. Response to VPA treatment was not associated with FAB subtype or karyotype. Median bone marrow blast count was 28 (13–45)% in responders, 30 (10–75)% in patients with stable and 41 (25–80)% in patients with progressive disease. Since our patients mainly had secondary AML, we also analyzed our results according to the proposals of the IWG for MDS (Cheson et al., 2000). Among patients receiving VPA monotherapy 1 patient had a major trilineage response. 2 patients showed a minor erythroid and one a minor neutrophil response. In the second group of patients one had a major erythroid response. Concerning side effects, VPA caused tremor in four cases, leading to cessation of treatment in two. Regarding ATRA, grade 1–2 skin toxicity was observed in 4, grade 1–2 gastrointestinal toxicity in 2, and pleural effusion in 1 patient. In summary, we observed responses according to IWG criteria in 25% of our patients (6/24). The best responses to VPA or VPA+ATRA in AML patients occurred in patients with low blast count, mainly in patients who showed relapsed or refractory disease shortly after intensive chemotherapy. These data indicate that VPA might be most effectively applied after or in addition to intensive chemotherapy.

ON 01910.Na Suppresses Cyclin D1 Accumulation in trisomy 8 Myelodysplastic Syndromes Patients While Decreasing Bone Marrow CD34+ Blast Counts and Aneuploid Clone Size.

Blood ◽  
2009 ◽  
Vol 114 (22) ◽  
pp. 120-120
Author(s):  
Elaine M Sloand ◽  
Matthew J. Olnes ◽  
Naomi Galili ◽  
Aarthi Shenoy ◽  
Loretta Pfannes ◽  
...  
Keyword(s):  
Bone Marrow ◽  
High Risk ◽  
Cyclin D1 ◽  
Research Funding ◽  
Treatment Options ◽  
Cell Cycle Control ◽  
Trisomy 8 ◽  
Clone Size ◽  
Monosomy 7

Abstract Abstract 120 Patients with high risk MDS can be successfully treated with 5-azacytidine, or with lenalidomide but non-responding patients have few treatment options. Chemotherapy produces significant morbidity and very short remissions and most patients are too old for bone marrow transplantation. We previously demonstrated up-regulation of c-myc, survivin, and cyclin D1 in CD34+ cells in patients with trisomy 8 (and selected patients with monosomy 7). siRNA-mediated knockdown of survivin or c-myc decreased trisomy 8 cell growth in vitro (Sloand et al, Blood 2007, 110: 822). We postulated that increased cyclin D1 causes upregulation of survivin, resulting in resistance of these cells to apoptosis. The styryl sulfone, ON 01910.Na, decreases cyclin D1 accumulation in cultured bone marrow from patients with high risk trisomy 8 MDS and in some monosomy 7 patients (who also show upregulation of cyclin D1), while selectively decreasing blasts and aneuploidy with this cytogenetic abnormality (ASH Abstracts Nov 2008; 112: 1651). Here we examine the clinical response to ON1910 in an ongoing phase I/II clinical trial in which 13 evaluable patients with intermediate-1(int-1) to high risk MDS and treatment-refractory trisomy 8 AML were enrolled. Patients were treated with escalating doses of ON 01910.Na at 800 mg/m2 × 2 days every 3/4 weeks, 800 mg/m2 × 3 days every 2 weeks, 800 mg/m2 × 5 days every 2 weeks, and 1500 mg/m2 × 2 days every 3/4 weeks at two institutions. No significant toxicity could be ascribed to the drug. Patients with trisomy 8 and monosomy 7 demonstrated significant declines in aneuploidy measured by florescence in situ hybridization (FISH) (mean aneuploidy; 50% before and 24% after 1 cycle of treatment; p=0.02 :Fig below). Rather than becoming cytopenic, many patients showed substantial improvements of blood counts and one patient (01-02; graphic shown below) became red cell transfusion-independent and maintains his remission 14 months after stopping therapy. Cyclin D1 measurement by flow cytometry showed decreases of this protein in both CD34 and CD33 cells during infusion of ON 1910 infusion (example shown in Fig below). Results from individual evaluable patients are shown in table 1. These results indicate that modulation of cell cycle control by cyclin D1 may represent a novel targeted approach for trisomy 8 and monosomy 7 MDS. Disclosures: Sloand: Onconova: Research Funding. Olnes:Onconova: Research Funding. Galili:Onconova: Research Funding. Wilhelm:Onconova: Employment. Groopman:Onconova: Membership on an entity's Board of Directors or advisory committees. Raza:Onconova: Research Funding.

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