Intensive Chemotherapy for High-Risk ALL in Children - the Nordic Collaborative Approach

OS for childhood ALL is now >90%, but high-risk (HR) cases still need to improve. The NOPHO ALL2008 protocol restricted very intensive HR chemotherapy to patients with an inferior early minimal residual disease (MRD) response or HR genetics, and we here report the results for this subset. HR patients had WBC >100K at diagnosis and/or T-ALL; and an MRD of either >25% day 15 or >0.1% day 29; and/or a KMT2A-re or hypodiploidy (<45 chr). MRD was assessed by flow cytometry (BCP) or PCR (T-ALL). If no marker was found with one, the alternative method was used. Thus, >98% had a suitable MRD marker. All HR patients received a 3-drug induction chemotherapy (VCR 2 mg/m2 x5), DOX (40 mg/m2 x2), PRED (60 mg/m2/d for 4 weeks for BCP-ALL with WBC <100K) or DEXA (10 mg/m2/d for 3 weeks for all others). This was followed by 9 (A1-B1-C1-A2-B2-C2-A3-B3-C3) or 7 (if MRD after 1st HR block <0.1%; C2/C3 deleted) blocks, 60 weeks of interim maintenance with oral 6MP/MTX and HD-MTX x3 (5g/m2/d), delayed intensification, and maintenance therapy until a total of 2.5 years from diagnosis. Post-induction, a total of 12 doses of i.m. Peg-asp (1,000 IU/m2) was given (Toft, Leukemia 2018). A-blocks included cyclophosphamide (440 mg/m2/d x5), etoposide (100 mg/m2/d x5), and Peg-asp (1000 IU/m2). B-blocks consisted of HD-MTX (5g/m2), HD-AraC (2x2g/m2 /d x2), 6MP (100 mg/m2/d x5), DEXA (20 mg/m2/d x5), VCR (2 mg/m2 x2), Peg-asp (1000 IU/m2). C-blocks included idarubicin (8 mg/m2), fludarabine (30 mg/m2/d x5), HD-AraC (2g/m2 /d x5), Peg-asp (1000 IU/m2). Patients were allocated to hSCT if MRD >5% at end of induction, or >0.1% after 2 HR-blocks or ~3 months of LR-chemotherapy. HSCT-patients are not included here. Data on 18 toxic adverse events was prospectively collected at three-month intervals. The Kaplan-Meier method was used for OS and EFS analyses. CI of Rel (CIR) and TRM (CITRM) were estimated accounting for competing events. Cox-models were used to compute hazard ratios and proportional hazard assumptions were evaluated using Schoenfeld residuals. 132 subjects 1-≤18 years of age at diagnosis were eligible for HR chemotherapy accounting for 16% of the study cohort with a median age of 6.6 years as compared to 4.6 years in the entire cohort. Of the HR chemotherapy subjects 26% received PRED in induction. Five-year EFS was 67% (95% CI, 59-76%) and OS was 74% (95% CI, 67-82%) in the HR chemo cohort. CIR at five years was 18% (95% CI, 11-24%). We found no difference in EFS by cell lineage (BCP-ALL: 69%, 95% CI, 59-80% vs. T-ALL 65%, 95% CI 52-77%). KMT2A-re occurred in 34 patients, 62% of whom had MRD <0.1% after induction. Their five-year EFS and OS were 88% (95% CI, 77-99%). KMT2A-re patients with a leukocyte count <100K and EOI MRD <0.1% had no relapses, but toxic deaths resulting in a 5-year EFS of 80% (95% CI, 55-100%). Hypodiploid patients had a five-year EFS and OS of 55% (95% CI, 34%-76%) and 58% (95% CI, 39-78%), respectively. Strikingly, KMT2A-re and hypodiploid patients with a negative MRD at EOI, suffered no relapses. 29 patients shifted to HR-blocks at day 15 due to MRD >25% (T-ALL (N=17), BCP with WBC >100K (N=7), KMT2A-re (N=4), or hypodiploid ALL (N=1). Their five-year EFS was 47% (95% CI, 21-73%) and CIR 44% (95% CI, 18-70%). During the HR chemotherapy blocks, 70% (N=93) of patients encountered at least one toxic event beyond bacteremia and febrile neutropenia, the most common of which was fungal infections (25%), referral to intensive care (23%), and asparaginase associated anaphylaxis (21%). The NOPHO ALL2008 stratification strategy led to allocation of 16% of patients to the HR arm with an EFS of 67% and OS of 74%. Due to the intensity of chemotherapy a significant risk of toxic death was encountered, and the risks of toxic death and relapse were very similar. Patients with rearranged KMT2A and a low EOI MRD could be candidates for future reduction of treatment intensity. These findings are integrated into the upcoming European ALLTogether1 protocol opening in 14 European countries early 2020, where the use of the NOPHO ALL2008 HR blocks will be restricted to the 3% of patients with the poorest prognosis. Figure - EFS with 95% Cis, CITRM (short dash) and CIR (long dash) for the NOPHO ALL-2008 high-risk chemotherapy patients Disclosures No relevant conflicts of interest to declare.

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IKZF1 Deletion Is An Independent Predictor of Outcome In Pediatric Acute Lymphoblastic Leukemia Treated According to the ALL-BFM 2000 Protocol

Blood ◽

10.1182/blood.v116.21.409.409 ◽

2010 ◽

Vol 116 (21) ◽

pp. 409-409

Author(s):

Petra Breithaupt ◽

Barbara Meissner ◽

Martin Zimmermann ◽

Anja Möricke ◽

André Schrauder ◽

...

Keyword(s):

Treatment Outcome ◽

High Risk ◽

Cox Regression ◽

Conflicts Of Interest ◽

Residual Disease ◽

Risk Group ◽

Independent Predictor ◽

Lymphoblastic Leukemia ◽

Time Points ◽

Pediatric All

Abstract Abstract 409 Alteration of the IKZF1 gene – encoding the transcription factor IKAROS, a key player in lymphoid development and tumor suppression – has been reported to be associated with a poor outcome in pediatric precursor B-cell ALL, especially in cases positive for the BCR-ABL1 fusion gene. In order to assess the prognostic value of IKZF1 deletions in a representative cohort of pediatric ALL patients treated on the German ALL-BFM 2000 study protocol, we screened 409 patients by applying a multiplex ligation-dependent probe amplification (MLPA) assay covering all eight IKZF1 exons (P335-A3 ALL-IKZF1 probemix; MRC-Holland, Amsterdam, The Netherlands). In ALL-BFM 2000, risk group stratification (standard, SR; intermediate, MR; high, HR) was based on minimal residual disease (MRD) analysis at two different time points (TP) and required two MRD targets with sensitivities of ≤10−4 (Flohr et al. Leukemia 2008). SR patients were MRD-negative on treatment days 33 (TP1) and 78 (TP2). HR patients had residual disease (≥10−3) at TP2. MRD MR patients had positive MRD detection at either one and or both time points but at a level of <10−3 at TP2. Although MRD-based stratification criteria were introduced in ALL-BFM 2000, established high-risk parameters were also retained: patients with prednisone poor-response or ≥5% leukemic blasts in the bone marrow on day 33 or positivity for a t(9;22) or t(4;11) or their molecular equivalents (BCR/ABL1 or MLL/AF4 fusion RNA) were stratified into the high-risk group independent of their MRD results. First results on MRD and outcome were published earlier (Conter et al. Blood 2010). Out of the 409 patients analyzed in our study, 46 (11%) displayed a deletion in at least one of the eight IKZF1 exons. Forty-three out of the 46 cases showed heterozygous deletions, while 3 patients displayed homozygous loss of IKZF1 exons. MLPA results of 11 patients were validated with results derived from copy number/LOH analyses using Affymetrix SNP 6.0 arrays. IKZF1 deletion was significantly more common in precursor B compared to T cell ALL (13% vs. 4%, P = 0.03) and less frequent in TEL/AML1-positive ALL (3% vs. 13%, P = 0.004). Out of 11 BCR/ABL1-positive samples, only two were characterized by an IKZF1 deletion. Forty-four patients with IKZF1-deleted ALL had results of MRD analyses available for both informative time points (day 33 after induction and day 78 after consolidation). Despite a trend towards increasing incidence of IKZF1 deletion in patients with slow response, the distribution of IKZF1-deleted ALL patients over the risk groups was not significantly different from non-deleted ALL (SR: 40.9 vs. 41.9; MR: 45.5 vs. 52.3; HR: 13.6 vs. 5.7%; P = 0.153). Regarding treatment outcome, patients with an IKZF1 deletion had a significantly lower 5-year event-free survival (EFS) compared to non-deleted patients (0.78±0.06 vs. 0.86±0.02; P = 0.015). This result was due to a higher cumulative incidence of relapses in IKZF1-deleted patients (0.16±0.05 vs. 0.10±0.02; P = 0.031). In multivariate Cox regression analyses including known prognostic variables (gender, immunophenotype, WBC count at diagnosis, TEL/AML1 status, risk group criteria of ALL-BFM 2000), IKZF1 deletion conferred a risk of 2.16 (95% confidence interval 1.14 – 4.10; P = 0.018) for an event when compared to non-deleted patients. We conclude that IKZF1 deletion is an independent predictor of treatment outcome for patients enrolled on the ALL-BFM 2000 protocol and represents a candidate marker to be integrated in future algorithms for early risk stratification in pediatric ALL. Disclosures: No relevant conflicts of interest to declare.

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Post-Treatment FDG-Avid Splenic Lesions in DLBCL: Clinical and Radiographic Characteristics for Risk Assessment

Blood ◽

10.1182/blood-2019-121473 ◽

2019 ◽

Vol 134 (Supplement_1) ◽

pp. 5358-5358

Author(s):

Boaz Nachmias ◽

Geremy Godefroy ◽

Chezi Ganzel ◽

Neta Goldschmidt ◽

Eyal Rozenbach ◽

...

Keyword(s):

False Positive ◽

Conflicts Of Interest ◽

Residual Disease ◽

Statistical Significance ◽

B Cell Lymphoma ◽

Response To Therapy ◽

Study Cohort ◽

True Positive ◽

Discriminative Ability ◽

Pet Ct

PET-CT has been widely incorporated in the treatment of diffuse large B cell lymphoma (DLBCL) and Hodgkin's lymphoma (HD) both for staging at diagnosis and for evaluation of response to therapy. Residual FDG-avid lesions at the end of treatment (EOT) are often due to infectious or inflammatory process and not due to refractory lymphoma. Nonetheless, such lesions prompt diagnostic and therapeutic interventions. In the present study, we evaluate clinical and radiological characteristics of patients with EOT FDG-avid splenic lesions in hope to provide better tools to discern false from true lesions. The study cohort included patients with DLBCL or HD who had residual EOT FDG-avid splenic lesion with no evidence of active disease in other sites. Patients were concluded as false positive or true positive according to pathological results or long-term follow-up. Clinical and PET-CT characteristics were compared between the two groups. Our cohort included 9 patients with DLBCL and 2 with HD, of which 6 patients were determined to have false positive lesions and 5 true positive. Comparing metabolic volume (MV) ratio between EOT to interim (EOT/interim) tests showed a marked difference between false positive and true positive lesions (0.5 vs 3.6, p= 0.02). Notably, comparing EOT to diagnosis (EOT/Dx) MV showed a similar trend that did not reach statistical significance, highlighting MV EOT/interim ratio as a parameter with higher discriminative ability. EOT SUVmax was also significantly different between false positive and true positive (7 vs. 19, p=0.02). A MV EOT/interim ratio >3 has a 75% sensitivity and 100% specificity for the true positive group. Other clinical and PET-CT characteristics were not found to statistically differ between the groups. To date, this is the first report showing predictive ability of PET-CT characteristics to discern true from false positive residual FDG-avid splenic lesions. Our cohort is of small numbers, nonetheless, EOT/interim MV shows a clear opposite ratio with a decrease in the false positive compared to an increase in the true positive groups. We suggest EOT/interim MV ratio might be a tool to identify patients at low risk of refractory disease allowing non-invasive surveillance. Further larger studies will be needed to validate the role MV EOT/interim ratio as a tool to discriminate residual disease from false positive FDG-avid lesions. Disclosures No relevant conflicts of interest to declare.

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Single Immunophenotypical Evaluation of Minimal Residual Disease before Autotransplantation of Non-Cryopreserved Bone Marrow Is Insufficient for Prediction of Outcome in High Risk Adult Acute Lymphoblastic Leukemia.

Blood ◽

10.1182/blood.v104.11.4439.4439 ◽

2004 ◽

Vol 104 (11) ◽

pp. 4439-4439

Author(s):

Beata M. Stella-Holowiecka ◽

Krystyna Jagoda ◽

Aleksandra M. Holowiecka-Goral ◽

Tomasz Czerw ◽

Sebastian Giebel ◽

...

Keyword(s):

Bone Marrow ◽

High Risk ◽

Minimal Residual Disease ◽

Residual Disease ◽

Lymphoblastic Leukemia ◽

Conditioning Regimen ◽

Long Term Results ◽

Color Flow ◽

Childhood All ◽

Minimal Residual

Abstract For high-risk adult ALL patients alloHCT is a preferable option. However, a significant proportion of those not having a suitable donor may be successfully treated with autotransplantation (autoHCT). Based on our experience this treatment ensures low transplant related mortality below 3% and a reasonable overall survival and disease free survival of 60% and 45% respectively. The status of the disease before transplantation is an important factor for long term results. In childhood ALL most studies suggest that the level of minimal residual disease (MRD) after induction evaluated immunophenotypically or with bio-molecular methods is predictive for outcome after different treatments including chemotherapy, alloHCT and autoHCT. The results in adult ALL are more controversial. Patients selection. Among 1205 haematopoetic cell transplantations performed in our institution 224 (147 autologous, 77 allogeneic) were performed in 205 adults with ALL. For this study we selected an uniform group of 81 patients fulfilling following criteria’s: Ph (-) ALL, status CR1, evaluable MRD, strictly defined autoBMT procedure performed until the end of 2003. Methods. MRD was tested before autoBMT (median interval 10 days) using 2 ore 3-color flow-cytometry, as appropriate. The atypical immunophenotypes were evaluated using the “quadrans” analysis in all cases and since 2002 also the “empty spaces” technique. The sensitivity equals at least 0.0001. For all autoHSCT bone marrow was used as a source of stem cells. The CAV conditioning regimen consisted of cyclophosphamide 60mg/kg on d. -3, -2, cytarabine 2 g/m2 d. -3, -2, -1, etoposide 800 mg/m2 d. -3, -2. Bone marrow was not cryo-preserved after collection but stored in 40 C and re-transplanted after 72h. Results. In 41 patients; age med. 26 y (15–53), F/M=12/29, the MRD level was <0,001: the MRD (−) group. In 40 patients; age med. 29 y (16–53), F/M=18/22, the MRD was detected at the level =/> 0,001; MRD+ group. The ALL-immunophenotypes of MRD−/MRD+ groups were as follows; proB 4/7, preB 2/6, Common 18/19, B 0/1, preT 5/2, T 12/1). The interval from DGN to BMT was similar in both groups. The probability of LFS and OS at 10y calculated with median follow up time of 5y equaled; in the MRD(−) group 47% and 62% and in the MRD+ one 48% and 57% respectively (p=ns). The main reason of failure in both groups was a relapse which occurred after a median time of 277 days in the MRD(−) group and 134 days in MRD+ one (p=0.19). Conclusion and comment. Based on this observation we conclude that a single evaluation stratifying patients before autoBMT according to MRD level below or above 0.001 is not predictive for DFS and OS, because it informs only about the current amount of the disease but not about its opportunistic nature. In this respect a repeatedly confirmed MRD positivity should be more significant. Taking into consideration that the main reason of failures were relapses, this finding suggests also that in patients with chemotherapy-responsive ALL confirmed by stabile CR, the myeloablative CAV regimen is sufficiently strong to eliminate the residual disease at the level ranging 0.01–0.001. It may be speculated only that the 72h lasting incubation of bone marrow product before re-transplantation has also some kind of purging effect for leukemic blasts.

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Graft-Versus-Leukemia (GVL) Effect After Reduced Intensity Conditioning (RIC) Allogeneic Stem Cell Transplantation (allo-SCT) as Treatment for Acute Myeloid Leukemia (AML): a Survey From the Acute Leukemia Working Party of the EBMT.

Blood ◽

10.1182/blood.v114.22.3313.3313 ◽

2009 ◽

Vol 114 (22) ◽

pp. 3313-3313

Author(s):

Frederic Baron ◽

Myriam Labopin ◽

Mohamad Mohty ◽

Nadezda Basara ◽

Dietger Niederwieser ◽

...

Keyword(s):

High Risk ◽

Lower Risk ◽

Conflicts Of Interest ◽

Chronic Gvhd ◽

Working Party ◽

Cox Models ◽

Landmark Analysis ◽

Factors Associated ◽

The Impact ◽

Risk Of Relapse

Abstract Abstract 3313 Poster Board III-201 RIC allo-SCT has been increasingly used as treatment for AML patients (pts) ineligible for myeloablative allo-SCT. Previous studies have observed a lower risk of relapse in pts who experienced chronic GVHD after RIC allo-SCT versus in those who did not. The objective of the current study was to further investigate the association between chronic GVHD and relapse in a large cohort of pts given RIC allo-SCT as treatment for AML. Data from 1188 AML pts in first or second CR transplanted between 2000 and 2008 following a RIC regimen at EBMT affiliated centers were analyzed. Patients were given PBSC from HLA-identical sibling (MRD, n=879), or from HLA-matched unrelated donors (MUD, n=309). RIC was defined as Busulfan conditioning regimens containing ≤ 8mg/kg total dose, or TBI <6 Gy. Median pt age at transplantation was 55 (range, 18-76) yrs in pts given grafts from MRD, versus 57 (range, 19-72) yrs in those given grafts from MUD. 54 pts had good risk (4.5%), 564 standard-risk (47.5%), and 116 high-risk (9.8%) cytogenetics, while cytogenetic was unknown in 454 pts (38.2%). The impact of chronic GVHD on relapse risk, non-relapse mortality (NRM) and leukemia-free survival (LFS) was assessed by time-dependent multivariate Cox models and in a landmark analysis. Three-yr incidences of relapse, NRM and LFS were 35 ± 2%, 14 ± 2%, and 50 ± 2%, respectively, while 2-yr incidence of chronic GVHD was 49 ± 2%. In a landmark analysis at 18 months after allo-SCT, 5-year relapse rates were 10 ± 2% versus 19 ± 3% for patients with or without chronic GVHD (P=0.04), respectively. In multivariate Cox models, CR2 versus CR1 (P=.003), pt age > 55 yrs (P=.008), alemtuzumab use in the RIC (P=.048), TBI-based RIC (P=.006), high-risk cytogenetics (P=.001), and absence of chronic GVHD (P=.015) were each associated with higher risk of relapse. Factors associated with high NRM were MUD versus MRD (P=.003), grade II-IV acute GVHD (P<.001), and chronic GVHD (P=.002). Factors associated with lower LFS were CR2 versus CR1 (P=.003), pt age > 55 yrs (P=.007), alemtuzumab use in the RIC (P=.012), and high-risk cytogenetics (P=.003). In conclusion, in this cohort of AML patients transplanted in remission, chronic GVHD was associated with a lower risk of relapse while profound in-vivo T cell depletion with alemtuzumab was associated with higher relapse rate suggesting that GVL effects play a role in preventing AML relapse in patients given RIC allo-SCT. Therefore, closed surveillance of patients in this setting not presenting chronic GVHD such as decreasing of immunosuppression should be further investigated. Disclosures No relevant conflicts of interest to declare.

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Detection of Immunophenotypic Residual Disease After Induction Therapy Is An Independent Prognostic Factor for Duration of Remission In Older AML Patients Treated Intensively

Blood ◽

10.1182/blood.v116.21.2714.2714 ◽

2010 ◽

Vol 116 (21) ◽

pp. 2714-2714

Author(s):

Sylvie Freeman ◽

Robert Hills ◽

Paul Virgo ◽

Steve Couzens ◽

Mark W Lowdell ◽

...

Keyword(s):

Bone Marrow ◽

High Risk ◽

Cumulative Incidence ◽

Conflicts Of Interest ◽

Residual Disease ◽

Flow Cytometric Analysis ◽

Intensive Treatment ◽

Multiparameter Flow Cytometry ◽

Sensitivity Threshold ◽

Adjusted Analysis

Abstract Abstract 2714 Introduction: The majority of acute myeloid leukaemia (AML) patients are older than 60 years but little progress has been made in improving their poor outcome. Recent studies have used analysis of pre-treatment risk factors to identify patient subgroups most likely to tolerate and respond to more intensive treatment approaches. There are as yet no data on whether treatment effectiveness measured by the level of residual disease has independent prognostic value in determining the duration of response for older patients achieving a remission. Here we report the largest prospective series of immunophenotypic residual disease monitoring in older adult AML. Methods: We prospectively and sequentially assessed the utility of residual disease (MRD) monitoring by multiparameter flow cytometry in older AML or high risk myelodysplastic (MDS) patients (excluding APL) receiving intensive treatment as part of the ongoing MRC AML16 trial for adults over 60 years. Patients were randomised to 2 or 3 courses of either daunorubicin/cytarabine or daunorubicin/clofarabine with or without mylotarg for the first course. Samples from consented patients (treated from 2006 to 2009) were processed by reference laboratories using an identical 4 colour antibody panel and standard operating procedure. Leukemic aberrant phenotypes (LAPs) were defined in pretreatment bone marrow and/or blood samples and then quantified using selected panel antibody combinations in post chemotherapy cycle bone marrow samples. MRD was reported as positive if detected above the LAP sensitivity threshold. Results: As previously shown for younger AML patients, immunophenotypic MRD monitoring was applicable to the majority of AML/high risk MDS patients over 60 years treated intensively. At least one LAP was identified in >90% of 224 analysed patients (median age 66, range 57–77) in whom an adequate pretreatment sample was received. Selected LAP sensitivity thresholds ranged from 0.05% to 0.2% as determined by analysis of control bone marrows. Most of patients in whom suitable LAPs could not be identified had AML M5. Aberrant CD7 expression in patients pretreatment (n=49) was associated with a poorer outcome (2 year OS of 11% (CD7+) v 40% (CD7-), HR adjusted for baseline characteristics 2.22 (1.33-3.70), p=0.002). 170 patients in remission were evaluable for MRD after cycle 1 (C1). 90/170 patients (58%) were MRD positive (MRD+) of whom 12% were high risk MDS (10-20% blasts) pretreatment v 11% of MRD negative (MRD-) patients. 2 year cumulative incidence of relapse was 88% (median RFS 8 months) for C1 MRD+ patients v 45% (18 months) for C1 MRD- patients. Adjusted analysis (allowing for age, sex, WBC, cytogenetics, secondary disease, performance status) shows MRD+ after course 1 is highly prognostic for relapse; HR 4.08 (2.05-8.10) p<0.0001. Post cycle 2 (C2) 57/147 patients (39%) were MRD+ with a 2 year cumulative incidence of relapse of 78% (median RFS 8 months) v 66% (13 months) for C2 MRD- (adjusted HR for relapse 2.36 (1.33-4.20) p=0.003). Only 30 patients were evaluable after 3 cycles of chemotherapy. MRD positivity at this time point was again prognostic from adjusted analysis of relapse but with wide confidence intervals due to small numbers: HR 83.58 (1.91-3654.09) p=0.003. These results suggest that flow cytometric analysis of residual disease in AML patients >60 treated intensively, particularly after course 1, may be useful in predicting the duration of remission, thus informing risk assessment for further treatment. Further data are needed to determine whether available treatment options can improve outcome of older AML patients with MRD positive disease. This research was funded by a grant from Cancer Research UK. Disclosures: No relevant conflicts of interest to declare.

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Is Antifungal Prophylaxis Useful In Stem Cell Transplantation (SCT) During Hospitalization?.

Blood ◽

10.1182/blood.v116.21.4541.4541 ◽

2010 ◽

Vol 116 (21) ◽

pp. 4541-4541

Author(s):

Giuseppe Irrera ◽

Messina Giuseppe ◽

Giuseppe Console ◽

Massimo Martino ◽

Cuzzola Maria ◽

...

Keyword(s):

High Risk ◽

Conflicts Of Interest ◽

Fungal Infections ◽

Mucosal Damage ◽

Invasive Disease ◽

Secondary Prophylaxis ◽

Antifungal Prophylaxis ◽

Antifungal Drugs ◽

High Risk Patients ◽

Risk Patients

Abstract Abstract 4541 Introduction: Limited data demonstrate to what extent preventing fungal exposures is effective in preventing infection and disease. Further studies are needed to determine the optimal duration of fluconazole prophylaxis in allogeneic recipients to prevent invasive disease with fluconazole-susceptible Candida species during neutropenia. Oral, nonabsorbable antifungal drugs might reduce superficial colonization and control local mucosal candidiasis, but have not been demonstrated to reduce invasive candidiasis. Anti-fungal prophylaxis is recommended in a subpopulation of autologous recipients with underlying hematologic malignancies with prolonged neutropenia and mucosal damage. Methods: This is a retrospective study of 1007 SCT performed in our center between 1992 and 2009 in 809 consecutive patients, irrespective of diagnosis. HEPA filter and environmental monitoring (air, water, surfaces) are attributes of our transplant center. Results: The main characteristics of the patients are reported in Table 1. Systemic prophylaxis was used according to the guidelines (Table 2): fluconazole in the nineties, then itraconazole and from 2004 was either abolished or substituted with non-adsorbable prophylaxis in transplants with standard risk. Secondary prophylaxis was prescribed for high risk patients (with infectious fungal history, suggestive iconography, positive fungal biomarker). In 17 years our Center has never been colonized by mould. Only 3 probable aspergillosis infections and 4 proven fungal infections (fusarium, mucor and 2 aspergillosis) were diagnosed, all in allogeneic patients (2 haplotipical, 1 singenic, 1 sibiling, 1 MUD and 2 mismatched), resulting in death in all cases. No infection was documented in autologous setting, while the infection rate in allogenic setting was 3.6% with an incidence rate of 1.1 infection per 10000 transplants/year. These results are significantly lower than published reports. Conclusion: Systemic antifungal prophylaxis should not be performed in autologous SCT patients. The abuse of systemic prophylaxis targeting yeasts has influenced the change of epidemiology in the transplant setting with prevalence of mould infections. The identification of high risk patients is useful to select patients for systemic antifungal or secondary prophylaxis to reducing overtreatment, incidence of resistant strains and costs. Disclosures: No relevant conflicts of interest to declare.

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Investigating the Expression of the MRD Marker CD58 on Leukaemia Initiating Cells in Childhood Acute Lymphoblastic Leukaemia

Blood ◽

10.1182/blood.v118.21.1887.1887 ◽

2011 ◽

Vol 118 (21) ◽

pp. 1887-1887 ◽

Cited By ~ 1

Author(s):

Charlotte Victoria Cox ◽

Paraskevi Diamanti ◽

Allison Blair

Keyword(s):

Acute Lymphoblastic Leukaemia ◽

Lymphoblastic Leukaemia ◽

Conflicts Of Interest ◽

Residual Disease ◽

Model Systems ◽

Childhood All ◽

Therapy Assessment ◽

Childhood Acute Lymphoblastic Leukaemia

Abstract Abstract 1887 Further improvements in outcome for childhood acute lymphoblastic leukaemia (ALL) will require a better understanding of the underlying biology of this disease and the fundamental mechanisms of drug resistance. The discoveries that a few populations can initiate leukemia in mouse models and that new populations of leukaemia initiating cells (LIC) can be detected following an initial round of transplantation in these models raises important questions about the biology of the leukaemias. If several cell populations have LIC properties, what are the relationships of these populations to each other and which populations are most important to target with therapy? It will also be important to determine whether there is any correlation in the biological properties of LIC identified in the model systems with the response of the patients to therapy. Assessment of minimal residual disease (MRD) levels provides a sensitive measurement of early treatment response and permits detection of the in vivo selected drug resistant population. CD58 (leucocyte function-associated antigen 3; LFA-3) is a useful marker in MRD tracking of B cell precursor (BCP) ALL. CD58 is over expressed in these cases permitting discrimination of leukaemia blasts from normal B cells. In this study we investigated whether CD58 is expressed on LIC populations in childhood ALL. Expression of CD58 and CD34 was assessed in a cohort of 12 diagnostic samples with mixed prognoses and compared to levels detected in 11 normal bone marrow (NBM) samples. Levels of CD58 were significantly higher in the ALL cases (57.4±37.7%) than on NBM cells (21.1±12.2%; p=0.007). Likewise, the CD34+/CD58+ population was larger in ALL cases than in normal cells (22.2±34.7% and 0.25±0.25%, respectively; p=0.05). Cells from eight of the 12 patients, were sorted on the basis of expression or lack of expression of these markers and the functional ability of the sorted subpopulations was assessed in vitro and in vivo. On sorting, the majority of cells were CD34−/CD58− (43.7±39.2%), 20.7±30.7% were CD34−/CD58+, 19±14.3% were CD34+/CD58+ and the CD34+/CD58− population accounted for 16.6±35.3%. Unsorted cells and all 4 sorted populations were set up in long-term culture to assess proliferative capability and the in vivo propagating potential was assessed in NSG mice. All 4 sorted subpopulations proliferated over the 6 week period but the highest levels of expansion were observed in the cultures of CD34+/CD58+ (6–420 fold) and CD34+/CD58− (3–24 fold) cells. Cytogenetic analyses confirmed that leukaemia cells were maintained in the culture system. Results from the in vivo analyses on 5 cases to date indicate that all 4 subpopulations contain LIC. In these cases, higher levels of engraftment were observed with CD34+/CD58+ (up to 20%) and with CD34−/CD58− subpopulations (6.1-98%). Serial transplantation studies will determine whether there are differences in the repopulating and self-renewal abilities of these LIC. These findings suggest that using CD58 alone or in combination with CD34 would be insufficient to track disease progression in ALL. Incorporating additional markers that are commonly used in MRD panels will provide valuable information on LIC populations and facilitate development of improved disease monitoring. Disclosures: No relevant conflicts of interest to declare.

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Minimal Residual Disease Monitoring By Quantitative RT-PCR In t (8; 21) AML Early After Allogeneic HSCT Can Predict Clinical Outcomes and Allow Further Risk Stratification

Blood ◽

10.1182/blood.v122.21.3386.3386 ◽

2013 ◽

Vol 122 (21) ◽

pp. 3386-3386

Author(s):

Yu Wang ◽

Yanrong Liu ◽

Yazhen Qin ◽

Xiao-Jun Huang

Keyword(s):

High Risk ◽

Conflicts Of Interest ◽

Residual Disease ◽

Fusion Gene ◽

Early Time ◽

Preemptive Therapy ◽

Clinical Relapse ◽

Log Reduction ◽

Multi Center Study ◽

The Impact

Abstract Background Recent results from our prospective multi-center study identified patients with t (8; 21) AML as high-risk according to their MRD status after the second consolidation chemotherapy and allo-HSCT can benefit this part of patients; however, the relapse rate was reported to be 22% even after allo-HSCT for those high-risk patients. To date, there have been no studies to answer the question of whether the specific fusion gene, RUNX1/RUNX1T1 can be used to further distinguish between patients with low and high risks of relapse in allo-HSCT setting, just like the already established standard for MRD measurement in CML and APL. Methods Sixty consecutive AML patients with t (8; 21) and identified as high-risk according to the criteria from our recently published report patients who received allo-HSCT were enrolled between January 2006 and January 2013. Serial MRD monitoring by RQ-PCR post HSCT was done. The impact of MRD monitoring on transplant outcomes was assessed. Results A > 3 log reduction at 1 month after HSCT in RUNX1/RUNX1T1 transcripts from diagnosis, is associated with 2-year CIR of 17% in the 88% of patients achieving it, compared with 43% in the remaining (p=.02). A > 3 log reduction at 2 months after HSCT in transcripts from diagnosis, is associated with a CIR of 9% and LFS of 66% in the 86% of patients achieving it, compared with CIR of 100% and LFS of 0% in the remaining (both p<.001). A > 3 log reduction at 3 months after HSCT in RUNX1/RUNX1T1 transcripts from diagnosis, is associated with a CIR of 11% and LFS of 73% in the 78% of patients achieving it, compared with CIR of 44% and LFS of 0% in the remaining (both p<.001). Of the 60 patients analyzed, 28 patients had positive MRD, occurring at a median of 110 days (30-540 days) after transplant. The predictive value of sequential monitoring could be demonstrated in 8 patients culminating in clinical relapse (representing 73% of all relapsing patients). The median time from MRD positivity in BM to morphological relapse was 95 days (range, 33-140 days). Conclusions A > 3 log reduction at the first 3 months after HSCT in RUNX1/RUNX1T1 transcripts from diagnosis is highly prognostic. We conclude that MRD monitoring by RQ-PCR at regular early time points post HSCT in t (8; 21) AML allows further identification of patients at high risk of relapse even after allo-HSCT and could now be incorporated in clinical trials to evaluate the role of risk directed prophylactic/preemptive therapy. This work was partly supported by The Key Program of National Natural Science Foundation of China £¨Grant No. 81230013£©, Beijing Municipal Science & Technology Commission (No.Z121107002812033) and Bejing Municipal Science & Technology Commission£¨No.Z111107067311070). Disclosures: No relevant conflicts of interest to declare.

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Exchange Transfusion and Leukapheresis in Pediatric AML Patients with High Risk of Early Death for Bleeding and Leukostasis

Blood ◽

10.1182/blood.v126.23.3741.3741 ◽

2015 ◽

Vol 126 (23) ◽

pp. 3741-3741

Author(s):

Ursula Creutzig ◽

Claudia Rossig ◽

Michael Dworzak ◽

Arendt von Stackelberg ◽

Wilhelm Woessmann ◽

...

Keyword(s):

Risk Factors ◽

High Risk ◽

Exchange Transfusion ◽

Clinical Symptoms ◽

Conflicts Of Interest ◽

Significant Risk ◽

Early Death ◽

Myelogenous Leukemia ◽

Acute Monocytic Leukemia ◽

Metabolic Disturbances

Abstract Background. The risk of early death (ED) due to bleeding and/or leukostasis is high in AML patients with initial hyperleukocytosis (white blood cell count [WBC] > 100 000/µl) and highest in those with hyperleukocytosis and mono- or myelomonocytic leukemia (FAB M4/M5). (Creutzig, et al 1987) Within the AML-BFM studies, emergency strategies for children with AML and high risk for bleeding and leukostasis included exchange transfusion (ET) or leukapheresis (LPh). In order to determine whether these interventions reduced the rate of ED, 1251 AML-BFM patients from the trials AML-BFM 98 and 04 were analyzed. Risk factors for ED and interventions performed were verified focusing on patients with hyperleukocytosis. Patients . 238 of 1251 (19%) AML-patients <18 years of age (FAB M3 excluded) presented with hyperleukocytosis. Twenty-three out of 1251 (1.8%) patients died by bleeding and leukostasis within 15 days from diagnosis, 18 (78%) of these 23 ED patients had hyperleukocytosis. Seventy-two patients received ET and 17 LPh (including 14 patients with WBC counts < 100 000/µl). 149 patients with hyperleukocytosis did not receive ET/LPh. The median age of patients receiving ET was significantly lower compared to those with LPh (3.5 years vs 12.6 years, p = 0.015). WBC counts were similar in both treatment groups (ET median 224 000/µl vs LPh 218 000/µl, p = 0.20). Results. The percentage of ED by bleeding/leukostasis increased with higher WBC counts and was highest in 105 patients with WBC > 200 000/µl (14.3%). The ED rates were even higher in patients with FAB M4/M5 and hyperleukocytosis >200 000/µl compared to others with WBC >200 000/µl (M4/M5 13/65 [20%] vs. others 2/40 [5%], p=0.04). Patients with WBC counts >200 000/µl did slightly better with ET or LPh compared to those without ET/LPh (ED rate 7.5 % vs 21.2 %, p=0.055). Patients with WBC between 100 000/µl and 200 000/µl received ET/LPh less frequently compared to those with WBC >200 000/µl (22/133 [17%] vs. 53/105 [50%]). ET/LPh was mainly given in case of clinical symptoms of bleeding or leukostasis or coagulopathies or insufficient reduction (or increase) of WBC counts despite low dose chemotherapy. 15/80 (19%) patients with FAB M4/5 and WBC 100 000-200 000/µl received ET/LPh and none of these patients died early. ET/LPh was even given in 14 patients with WBC <100 000/µl because of clinical symptoms of bleeding or leukostasis or coagulopathies or rising WBC counts. In multivariate analysis WBC >200 000/µl was the strongest independent risk factor for ED (hazard ratio =15.0, 95% confidence interval 4.9-46.3, p(chi)<0.0001). FAB M4/M5 subtypes, general condition grade 4 and initial bleeding were also significant risk factors. Application of ET/LPh seems to have a non-significant benefit for a reduced ED rate by bleeding/leukostasis (p=0.13). The assessment of the general clinical condition of the patients plays a major role for the decision for ET/LPh. However, this possibly selective cofactor could not be included completely in our calculation because of lack of standardized assessments and documentation of clinical reasons for decision making in particular in patients without ET/LPh. There was no difference in ED rates between ET and LPh. (2/17 vs 5/72, p =0.61). Compared to LPh, ET can be given without time delay. ET is easier to perform especially in young children who need smaller exchange volumes, as well as in adolescents where it can be applied also as partial ET. ET also corrects metabolic disturbances and avoids deterioration of coagulation. Conclusion. Our data confirm the high risk of bleeding/leukostasis in patients with hyperleukocytosis. Although we could only disclose a trend for a clinical benefit of ET/LPh in this retrospective analysis - probably due to some negative selection bias in patients with the intervention - we strongly advocate ET/LPh in AML patients with WBC >200 000/µl, and in particular in those with FAB M4/M5 subtypes or with clinical symptoms of bleeding or leukostasis or coagulopathies even with lower WBC (100 000/µl - 200 000/µl). Creutzig, U. et al. (1987) Early deaths due to hemorrhage and leukostasis in childhood acute myelogenous leukemia: Associations with hyperleukocytosis and acute monocytic leukemia. Cancer,60, 3071-3079. Disclosures No relevant conflicts of interest to declare.

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98% IGHV Gene Identity Is Still the Optimal Cutoff to Predict the Prognosis of Chronic Lymphocytic Leukemia Patients in China

Blood ◽

10.1182/blood-2018-99-118141 ◽

2018 ◽

Vol 132 (Supplement 1) ◽

pp. 5545-5545

Author(s):

Yi Xia ◽

Ke Shi ◽

Qian Sun ◽

Chun Qiao ◽

Huayuan Zhu ◽

...

Keyword(s):

Prognostic Factor ◽

Chronic Lymphocytic Leukemia ◽

Conflicts Of Interest ◽

Somatic Hypermutation ◽

Lymphocytic Leukemia ◽

Study Cohort ◽

Optimal Cutoff ◽

Entire Cohort ◽

Mutational Status ◽

Significant Difference

Abstract Background: Immunoglobulin heavy chain variable region (IGHV) has been an important prognostic factor for chronic lymphocytic leukemia (CLL) for decades. 98% being a cut-off value for IGHV is a mathematical choice and researches on the best cut-off value have never been stopped. Chinese CLL patients are known to differ from Caucasian CLL patients on both clinical and genetical features. However, the optimal cutoff for IGHV mutational status has not yet been studied in this particular ethnic group. Method: We carried out a study on 595 Chinese CLL patients in order to find out whether 98% is the best cut-off value for IGHV in Chinese CLL patients. Genomic DNA from peripheral blood or bone marrow was subjected to PCR amplification following the IGH Somatic Hypermutation Assay v2.0 protocol (InVivoScribe). Sequences were aligned to ImMunoGeneTics/V-QUEry and Standardization (IMGT/-VQUEST) database. Result: 600 sequences were received after IGHV rearrangement sequencing. IGHV3-23, IGHV4-34, IGHV3-7, IGHV4-39 and IGHV1-69 were the most frequently used IGHV genes. 352 (58.7%) cases were IGHV-mutated while 248 (41.3%) cases were IGHV-unmutated if the classical 98% classification by ERIC was used. In order to determine the optimal cut-off value, we used 1% as the interval to divide the entire cohort into 7 groups according to the mutational rate, which were <95%, 95%-95.99%, 96%-96.99%, 97%-97.99%, 98%-98.99%, 99%-99.99% and 100% respectively. Binet A patients had a relatively indolent course of disease and cases with different IGHV mutational rates had no significant differences in time to first treatment (TTFT) apart from truly unmutated (100%) cases. For the whole study cohort, significant difference appeared at 98% interval (P<0.001 and P=0.005 for TTFT and OS respectively) while intervals less than 98% had no significant difference compared with the <95% group. Similarly, there was no clear dissimilarities among 98%, 99% and 100% intervals (Table 1a and b). All the other prognostic factors including del(17p), del(11q), TP53 mutation, MYD88 mutation, NOTCH1 mutation, SF3B1 mutation, CD38, ZAP-70, Binet staging, gender, β2-microglobulin and EBV-DNA were differently distributed between group <98% and group ³98%, but not among subgroups in ³98%. In multivariate analysis, the 98% IGHV was also an independent prognostic factor for TTFT and OS. Conclusion: 98% is the optimal cutoff value for IGHV mutational status to predict the prognosis of CLL patients in China. Table 1. Table 1. Disclosures No relevant conflicts of interest to declare.

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