Somatic Bzip Mutations of CEBPA Are Associated with Favorable Outcome Regardless of Presence As Single Vs. Double Mutation

Somatic mutations of CEBPA in AML are present at similar rates in all age groups and have been shown to be associated with favorable outcome. The most common cooperating variant in CEBPA mutations is a second CEBPA mutation, where the cooperation of TAD and bZip mutations lead to a highly penetrant variant which is sufficient for malignant transformation. Data suggested that only double CEBPA mutations (CEBPA-dm) were associated with favorable outcome. Currently, WHO classification of AML includes CEBPA-dm as a diagnostic entity in AML. We previously reported that in children and young adults, somatic single CEBPA mutations, which almost exclusively occurred in the bZip domain, had similar outcomes to CEBPA-dm patients. We have also shown that CSF3R and GATA2 mutations occur in childhood AML and are highly associated with CEBPA mutations. In this large analysis, we sought to define the prognostic impact of CEBPA-dm vs single bZip mutations and evaluate the impact of common co-occurring mutations. This study included a total of 2,958 patients (age 0-29.94 years) treated on the 4 large Children's Oncology Group trials CCG2961 (n=562), AAML03P1 (n=266), AAML0531 (n=917), and AAML1031(n=1233). DNA binding domain of CEBPA (bZip domain) was analyzed by fragment length analysis and 160 patients with mutations were identified and verified with sanger sequencing (n=23 2961; n=15 03P1; n=51 0531; n=71 1031). In all cases where bZip mutations were detected, N terminal region was sequenced for identification of TAD mutations. Of the 160 cases with bZip mutation, 132 patients had a secondary TAD mutation (CEBPA-dm; 82.5%) and in the remaining 28 cases (17.5%) no TAD mutation was detected (CEBPA-sm). Comprehensive NGS data was available in a cohort of patients (n=106) and demonstrated dm vs. sm prevalence of 81% and 19% respectively, similar to the cohort overall. We compared clinical and biologic characteristics among CEBPA-dm vs. CEBPA-sm patients. The two groups showed no significant differences across karyotype, complete remission rates, FLT3/ITD or NPM1 status, cyto-molecular risk group, age, or diagnostic WBC. CEBPA mutations were more prevalent in Asian patients (10.5%) compared to other races (p=0.019). Evaluation of outcomes for those with CEBPA-dm vs. sm in the entire cohort demonstrated that those with CEBPA bZip mutations regardless of dm vs. sm status had identical event free survival (EFS) of 64% (Fig 1A; p=0.777). Similarly, the overall survival (OS) for CEBPA-sm was 89% vs. 81% for CEBPA-dm (p=0.259; Figure 1A). Evaluation by study cohort demonstrated that presence of bZip mutations whether as sm or dm had similar favorable clinical impact (Figure 1B-D; p=NS in each study for EFS and OS). Analysis of CEBPA+ patients with comprehensive NGS data identified somatic mutations in GATA2 (n=20; 19%) and CSF3R (n=12; 11%)(Figure 1E). Co-occurrence of a GATA2 mutation did not impact the favorable outcome conferred by CEBPA+ on EFS or OS (p=0.356 and p=0.749 respectively; Figure 1F). However, presence of CSF3R mutation significantly modulated the clinical implications of CEBPA mutations. We previously showed an overlap with CEBPA and CSF3R mutations, which occur as SNVs in the extracellular domain or truncating mutations in the cytoplasmic domain. CSF3R mutations result in aberrant CSF3R activation and expression and have been shown to be amenable to targeted therapy with either JAK or SRC family inhibitors. Given the large number of CEBPA+ patients available for analysis, we evaluated the outcomes of patients with CEBPA+/CSF3R+ (n=12) and without CSF3R mutations (n=94). Dual mutant CEBPA+/CSF3R+ patients had a significantly inferior EFS of 17% vs. 63% (p<0.001; Figure 1F) due to high rate of relapse. Importantly, despite high relapse rates these dual mutant patients were salvageable after relapse with an OS of 73% vs. 83% for CEBPA+ patients without CSF3R (p=0.563). In a large study of CEBPA mutations in pediatric AML, we show that patients with a bZip mutation, regardless of sm vs. dm status have a favorable prognosis. Further, we confirm the significant overlap of CEBPA and CSF3R mutations previously reported, and demonstrate that CEBPA+/CSF3R+ patients are at high risk for relapse and thus should not be considered a low risk cohort. Given the poor outcomes with current regimens, patients with CEBPA+/CSF3R+ mutations could be considered for addition of tyrosine kinase inhibitors with upfront therapy. Disclosures No relevant conflicts of interest to declare.

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The Molecular Basis of Long First Remissions in Normal Karyotype AML Patients

Blood ◽

10.1182/blood-2019-122967 ◽

2019 ◽

Vol 134 (Supplement_1) ◽

pp. 3827-3827

Author(s):

Francesca Ferraro ◽

Christopher A Miller ◽

Amy Abdalla ◽

Nichole Helton ◽

Nathan Salomonis ◽

...

Keyword(s):

Cell Proliferation ◽

Somatic Mutations ◽

Conflicts Of Interest ◽

Normal Karyotype ◽

High Dose ◽

Intermediate Risk ◽

The Mean ◽

Cebpa Mutations

Currently, it is not clear why some patients with acute myeloid leukemia (AML) can be "cured" with chemotherapy alone; are they living with small amounts of disease that is held in check by immunologic (or other) mechanisms, or is their disease really eradicated? The percentage of cytogenetically normal AML patients who have long (>5 years) first remissions (LFRs) after chemotherapy alone is low (about 9.1% in patients <60 years and 1.6% in >60 years1). For this reason, most intermediate risk patients are offered allogeneic transplantation to decrease their risk for relapse. To better understand mechanisms of chemotherapy sensitivity in AML, we performed an analysis of the mutation landscape and persistence, using samples from 8 normal karyotype LFR patients (without CEBPA mutations) who received standard "7+3" induction and high dose cytarabine consolidation as their only therapy. The mean age at diagnosis was 43.5 years, and the mean follow up in first remission is 7.6 years; none of these patients has relapsed to date. For each case, we performed enhanced exome sequencing at diagnosis (235x coverage of the entire exome, and ~1008x coverage of recurrently mutated AML genes). Each case had at least one documented AML driver mutation, with a median of 29 somatic mutations in the exome space. We created probes for 225 mutations (mean 28 per case), and performed error-corrected sequencing (Haloplex) for all available remission samples. The mean depth of Haloplex coverage was 1607x, and each sample had at least one AML-specific mutation assayed, with a sensitivity of 1 cell in 1,750 (0.06%). 7/8 patients demonstrated complete clearance of all mutations in all remission samples tested, which was confirmed with digital droplet PCR for 5 cases, with a sensitivity of detection of 1 cell in 100,000. In one case, we detected a persistent ancestral clone harboring DNMT3AR882H, which can be associated with long first remissions for some patients2. Strikingly, the founding clone in all 8 cases had one or more somatic mutations in genes known to drive cell proliferation (e.g. MYC, FLT3, NRAS, PTPN11, Figure 1 top panel). These are usually subclonal mutations that occur late during leukemic progression, suggesting that the presence of a "proliferative hit" in the founding clone might be important for chemotherapy clearance of all the AML cells in a given patient. To support this hypothesis, we analyzed the mutational clearance of 82 AML cases with paired diagnosis and day 30 post-chemotherapy bone marrow samples. We observed that, whether present in the founding clone or in subclones, mutations in MYC, CEBPA, FLT3, NRAS, and PTPN11 cleared after induction chemotherapy in all samples, while other mutations were often persistent at day 30 (e.g. DNMT3A, IDH1, IDH2, NPM1, TET2; Figure 1 bottom panel). Compared to other published sequencing studies of AML, MYC and NRAS mutations were significantly enriched in this small cohort (MYC p= 0.002, and NRAS p= 0.034), with MYC enrichment being particularly striking (37.5% versus 1.8%). All MYC mutations were canonical single base substitutions occurring in the highly conserved MYC Box 2 domain at the N-terminus of MYC (p.P74Q or p.T73N). Overexpression of MYCP74Q in murine hematopoietic progenitors prolonged MYC half life (89 min vs. 44 min for wild type), and enhanced cytarabine sensitivity at all concentrations tested (range 10-1000 nM, p=0.0003), both in vitro and in a MYC-driven leukemia model in vivo. MYC expression measured with flow cytometry in the blasts of the LFR samples was significantly higher (p=0.045) compared to unfavorable risk (complex karyotype) or other intermediate risk categories, but similar to good risk AML (biallelic CEBPA mutations, core binding factor fusion-associated AML, and AML with isolated NPMc), suggesting that activation of the MYC pathway may represent a shared feature of chemosensitive patients. Taken together, these data suggest that some intermediate patients who are effectively "cured" with chemotherapy alone may not have persistent subclinical disease, nor retained ancestral clones that could potentially contribute to relapse. Importantly, these patients often have mutations driving cell proliferation in the founding clone, indicating that the presence of specific mutations in all malignant cells may be critical for complete AML cell clearance with chemotherapy. 1. Blood Adv. 2018 Jul 10; 2(13): 1645-1650 2. N Engl J Med 2018; 378:1189-1199 Disclosures No relevant conflicts of interest to declare.

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Impact of persistent anaemia on mortality in patients hospitalised with acute pulmonary embolism: an Australian retrospective observational study

BMJ Open ◽

10.1136/bmjopen-2018-027112 ◽

2019 ◽

Vol 9 (4) ◽

pp. e027112

Author(s):

Wallace Chow ◽

Christopher Wong ◽

Jerrett K Lau ◽

Vincent Chow ◽

Leonard Kritharides ◽

...

Keyword(s):

Pulmonary Embolism ◽

Observational Study ◽

Acute Pulmonary Embolism ◽

Retrospective Observational Study ◽

Study Cohort ◽

Prognostic Impact ◽

Tertiary Referral Centre ◽

Baseline Haemoglobin ◽

The Impact ◽

Acute Pe

ObjectivesAnaemia is associated with increased mortality in acute pulmonary embolism (PE) patients. However, prior studies have not examined the prognostic impact of trends in plasma haemoglobin during admission. This study investigates the impact of changes in haemoglobin level on mortality during hospital stay in acute PE.Study designA retrospective observational study.SettingTertiary-referral centre in Australia.ParticipantsConsecutive patients from 2000 to 2012 admitted with confirmed acute PE were identified from a dedicated PE database. Haemoglobin levels on days 1, 3–4, 5–6 and 7 of admission were retrieved. Patients without both baseline haemoglobin and subsequent haemoglobin levels were excluded (n=327), leaving 1099 patients as the study cohort. Anaemia was defined as haemoglobin <130 g/L for men and <120 g/L for women. There were 576 patients without anaemia throughout admission, 65 with transient anaemia (anaemic on day 1, but subsequently normalised during admission), 122 with acquired anaemia (normal on day 1 but developed anaemia during admission) and 336 with persistent anaemia. A total of 71 patients received blood transfusion during admission.Main outcome measure6-month mortality was tracked from a state-wide death database and analysed using multivariable modelling.ResultsAfter adjusting for transfusion, patietns with persistent anaemia had a significantly increased 6-month mortality risk (adjusted HR 1.97, 95% CI 1.26 to 3.09, p=0.003) compared with patients without anaemia. There was no difference in mortality between patients with transient or acquired anaemia and patients without anaemia.ConclusionAmong patients who had anaemia during their admission for acute PE, only the subgroup with persistent anaemia demonstrated worse outcomes.

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Increased Expression of Macrophage Migration Inhibitory Factor (MIF) Receptor CD74 Is Associated with Inferior Outcome in Younger Patients (Pts) with Cytogenetically Normal Acute Myeloid Leukemia (CN-AML): a Cancer and Leukemia Group B (CALGB) Study.

Blood ◽

10.1182/blood.v114.22.1616.1616 ◽

2009 ◽

Vol 114 (22) ◽

pp. 1616-1616 ◽

Cited By ~ 1

Author(s):

Eyal C. Attar ◽

Kati Maharry ◽

Krzysztof Mrózek ◽

Michael D. Radmacher ◽

Susan P. Whitman ◽

...

Keyword(s):

Overall Survival ◽

Cellular Proliferation ◽

Conflicts Of Interest ◽

Advanced Pancreatic Cancer ◽

Disease Free Survival ◽

Prognostic Impact ◽

Free Survival ◽

Expression Levels ◽

The Impact ◽

Disease Free

Abstract Abstract 1616 Poster Board I-642 CD74 is a type II integral membrane protein receptor that binds its ligand MIF to induce phosphorylation of the extracellular signal-regulated kinase-1/2 (ERK-1/2) and drive cellular proliferation via nuclear factor-kappa B (NF-kB) activation. CD74 expression has been identified in human solid tumors, and its expression is associated with adverse prognosis in advanced pancreatic cancer. As CD74 is expressed and NF-kB constitutively activated in myeloblasts, we hypothesized that CD74 expression might also be associated with adverse outcome in AML. To investigate the prognostic impact of CD74 expression in the context of other predictive molecular markers in CN-AML, we assessed CD74 expression levels by Affymetrix HG-U133 Plus 2.0 microarray in 102 younger [<60 years (y)] adults with primary CN-AML, treated on the front-line CALGB 19808 trial with an induction regimen containing daunorubicin, cytarabine, etoposide and, in some cases, the inhibitor of multidrug resistance valspodar, and consolidation with autologous stem cell transplantation. Microarray data were analyzed using the Robust Multichip Average method, making use of a GeneAnnot chip definition file, which resulted in a single probe-set measurement for CD74. At diagnosis, CD74 expression, when assessed as a continuous variable, was significantly associated only with extramedullary disease involvement (P=.006) among clinical features, and with none of the molecular prognostic variables tested, including NPM1, WT1, CEBPA, FLT3 (FLT3-ITD and FLT3-TKD) mutations, MLL partial tandem duplication, or differential BAALC and ERG expression levels. Although CD74 expression levels were not associated with achievement of complete remission (CR; 83% vs 81%), higher levels of CD74 were associated with shorter disease-free survival [DFS; P=.046, hazard ratio (HR) 1.85, 95% confidence interval (CI) 1.12-3.08] and with shorter overall survival (OS; P=.02, HR 1.32, CI 1.04-1.67). In multivariable analyses, higher CD74 expression was independently associated with shorter DFS (P=.045, HR 1.98, CI 1.16-3.40), after adjusting for WT1 mutations (P<.001) and FLT3-TKD (P=.04), and shorter OS (P=.01, HR 1.58, CI 1.11-2.25) after adjusting for FLT3-TKD (P=.02), WT1 mutations (P=.007), BAALC expression levels (P=.02), white blood counts (P=.007), and extramedullary involvement (P=.04). As quartiles 2-4 had similar expression levels distinct from the lowest quartile, to display the impact of CD74 expression levels on clinical outcome only, pts were dichotomized into low (the lowest quartile) and high (the top three quartiles) CD74 expressers. The Kaplan-Meier curves for DFS and OS (Figures 1 and 2) are shown below. In conclusion, our study identifies elevated CD74 expression as associated with adverse prognosis in younger CN-AML pts. Since we previously reported that higher CD74 expression was favorably associated with achievement of CR in AML patients receiving chemotherapy plus bortezomib, an inhibitor of the proteasome and NF-kB (Attar et al., Clin Cancer Res, 2008;14:1446-54), it is possible that in future studies elevated CD74 levels can be used not only for prognostication, but also to stratify CN-AML pts to study of bortezomib-containing chemotherapy regimens. Figure 1 Disease free survival Figure 1. Disease free survival Figure 2 Overall survival Figure 2. Overall survival Disclosures No relevant conflicts of interest to declare.

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Prognostic Impact of Hematopoietic Recovery After Fludarabine, IV Busulfan and Antithymocyte Globulins (FB2 regimen) Reduced-Intensity Conditioning Regimen (RIC) Allogeneic Stem Cell Transplantation (allo-SCT)

Blood ◽

10.1182/blood.v120.21.4483.4483 ◽

2012 ◽

Vol 120 (21) ◽

pp. 4483-4483

Author(s):

Amandine Lebourgeois ◽

Marion Loirat ◽

Benoit Tessoulin ◽

Elsa Lestang ◽

Pierre Peterlin ◽

...

Keyword(s):

Conflicts Of Interest ◽

Univariate Analysis ◽

Conditioning Regimen ◽

Prognostic Impact ◽

Immune Recovery ◽

Post Transplant ◽

Factors Associated ◽

Before And After ◽

Circulating Lymphocytes ◽

The Impact

Abstract Abstract 4483 Introduction: RIC regimens are increasingly used prior to allo-SCT. The FB2 regimen (Fludarabine 120–150 mg/m2 + IV Busulfan 6.4 mg/Kg + ATG Thymoglobuline 5mg/Kg) is currently the most widely used RIC regimen in many European centres. This retrospective analysis aimed to assess the hematopoietic and immune recovery in a homogeneously treated cohort of 53 patients (males: n=33; median age: 59 years (range: 22–70)) who received the FB2 regimen between January 2007 and October 2010 in our department. Patients and Methods: Diagnoses were as follow: AML n=23; ALL n=1; biphenotypic leukemia n=1; lymphoma n=16; myelodysplastic syndrome n=9; multiple myeloma n=3. Nineteen patients (36%) had received a prior autologous SCT. The majority of patients (n=40, 75.5%) were transplanted in complete remission. Thirty patients received a graft from a matched sibling donor (56.5%). All patients, but one (who received unmanipulated bone marrow) received G-CSF-mobilized PBSCs. GVHD prophylaxis consisted of cyclosporine (CsA) alone in patients transplanted with an HLA-identical sibling, and CsA+ mycophenolate mofetyl in other cases. None of the patients received G-CSF during aplasia following transplant while nine patients received erythropoietin before day+100. Results: Engraftment was achieved in 96% of patients (n=51). Median times for neutrophils (n=51) and platelets (n=22) recovery were 17 days (range: 0–39) and 10 days (range: 4–186), respectively. The majority of patients (n=31, 58%) did not receive platelet support during aplasia. The cumulative incidences of grade II-IV and grade III-IV acute GVHD were 30% and 15%, respectively, while overall incidence of chronic extensive GVHD was 33%. With a median follow-up of 19 months (range: 2–53), the 2-year OS, DFS, relapse incidence, and NRM were 63%, 59.5%, 35% and 6%, respectively. In univariate analysis, when regarding pre-transplant factors associated with outcome, the only factor correlated with a significantly higher 2-year OS and DFS was a higher total circulating lymphocytes count at transplant (> 730/mm3) (OS: 81.5% vs 43.2%, p=0.01; DFS: 73.2% vs 45.5%, p=0.03). Regarding post-transplant factors, we found that higher recovery of leukocytes (>5000/mm3) (2-year OS: 78% vs 46%, p=0.007; 2-year DFS: 70% vs 48%, p=0.08), neutrophils (>3230/mm3) (2-year OS: 76% vs 50%, p=0.02; 2-year DFS: 67.5% vs 52.0%, p=0.09), and monocytes (>590/mm3) (2-year OS: 80% vs 47%, p=0.004; 2-year DFS: 75% vs 42%, p=0.007) at day+30 post-transplant were the most significant factors associated with outcome. In multivariate analysis, the only independent factors associated with a significantly higher OS and DFS were a better immune status at transplant (lymphocytes count >730/mm3; HR 0.22; 95%CI: 0.08–0.63, p=0.005; and HR: 0.29; 95%CI: 0.12–0.71, p=0.006, respectively) and a higher monocytes count at day+30 post-transplant (>590/mm3) (HR: 0.24; 95%CI: 0.08–0.66, p=0.006; and HR: 0.28; 95%CI: 0.11– 0.68, p=0.005; respectively). Conclusion: These results suggest that hematopoietic status and recovery before and after FB2 RIC allo-SCT can be significant predictors of outcome. This paves the way for future studies aiming to closely monitor the kinetics of immune recovery after RIC allo-SCT and to evaluate the impact of growth factors and other immunostimulatory cytokines in the setting of RIC allo-SCT. Disclosures: No relevant conflicts of interest to declare.

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Impact Of Dose-Density Delays In Diffuse Large B-Cell Lymphoma (DLBCL) Treated With R-CHOP21 Or R-CHOP14

Blood ◽

10.1182/blood.v122.21.4374.4374 ◽

2013 ◽

Vol 122 (21) ◽

pp. 4374-4374

Author(s):

Antonio Gutierrez ◽

Antonia M Bautista-Gili ◽

Leyre Bento ◽

Ines Herraez ◽

Lucia Garcia ◽

...

Keyword(s):

Conflicts Of Interest ◽

B Cell Lymphoma ◽

Complete Response ◽

University Hospital ◽

Aggressive Lymphoma ◽

High Dose ◽

Prognostic Impact ◽

Non Hodgkin Lymphoma ◽

Ann Arbor ◽

The Impact

Abstract Background DLBCL is the more common non Hodgkin lymphoma. This is an aggressive lymphoma that is treated with a standard chemotherapy regimen: R-CHOP. In the last years attempts have been done to improve the outcome both increasing dose-density (DD) (CHOP14) or intensity (CHOEP, ACVBP, frontline high dose therapy followed by autologous stem cell transplantation). Although phase 2 studies of these interventions suggested promising results, when randomized phase 3 trials have been conducted, there is no demonstrated benefit of these higher toxicity approaches when compared with R-CHOP alone. Only addition of rituximab to CHOP has proved a survival advantage. This has allowed setting R-CHOP administered every 21 days (R-CHOP21) as the standard treatment for DLBCL patients. The purpose of this study is further analyzing the prognostic impact of DD delays in two cohorts of DLBCL patients treated with R-CHOP21 or R-CHOP14. Methods All patients diagnosed between 1999 and 2013 of DLBCL in University Hospital Son Espases were identified from Pathology Department registry. Only patients treated with R-CHOP21 or R-CHOP14 +/- radiotherapy were included. Patients receiving other chemotherapy regimens or consolidations were excluded. DD delay was calculated as follows: DD delay = real number of days from first to last cycle of chemotherapy / expected number of days from first to last cycle in every regimen. Results A total of 166 cases were identified: considering inclusion and exclusion criteria finally 111 cases were selected (71 in the R-CHOP21 cohort and 40 in the R-CHOP14 cohort). Respectively for R-CHOP21 and R-CHOP14, 61% and 37% were older than 60 years (p=0.02), 26% and 35% had an ECOG PS higher than 1 (p=0.3), 49% and 62% had an Ann Arbor stage III-IV (p=0.09), 44% and 51% an a-IPI higher than 1 (p=0.47). Median DD delay was 2% versus 14% for R-CHOP21 and R-CHOP14 groups (p<0.001). Clinically significant DD delay was considered those patients with DD delay higher than the median of the R-CHOP14 group. Complete response (CR) rate in patients with or without DD delay higher than 14% was 50% versus 85% in the R-CHOP21 group (p=0.004) and 80% versus 78% for R-CHOP14 group (p=0.87). Median follow-up was 60 months (4-169). OS and PFS were not significantly different in patients treated with R-CHOP21 or R-CHOP14: respectively 5y-OS of 73% vs 82% (p=0.97) and 5y-PFS 78% vs 70% (p=0.46). However, DD delay higher than 14% influenced OS and PFS only in the R-CHOP21 group (5y-OS of 39% vs 82% with or without DD delay; p=0.002 and 5y-PFS of 61% versus 81%; p=0.024) but not in the R-CHOP14 group (5y-OS of 78% vs 84% with or without DD delay; p=0.24 and 5y-PFS of 57% versus 72%; p=0.56). Conclusions Overall in our series there were no differences in terms of response or survival between patients treated with R-CHOP21 or R-CHOP14. Significantly higher rates of DD delay were observed in the R-CHOP14 group. However, the impact of DD delays on response and survival was only observed in the R-CHOP21 group but not in patients treated with R-CHOP14. We can conclude that R-CHOP21 and R-CHOP14 are equivalent regimens in terms of response and survival only if DD delays are avoided. For patients receiving R-CHOP21 we recommend using clinical and support measures in order to avoid DD delays. Disclosures: No relevant conflicts of interest to declare.

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Allogeneic but Not Autologous Stem Cell Transplant Attenuates the Negative Prognostic Impact Dictated By Pretransplant MRD Positivity

Blood ◽

10.1182/blood.v124.21.2363.2363 ◽

2014 ◽

Vol 124 (21) ◽

pp. 2363-2363

Author(s):

Francesco Buccisano ◽

Luca Maurillo ◽

Maria Ilaria Del Principe ◽

Gottardo De Angelis ◽

Raffaella Cerretti ◽

...

Keyword(s):

Stem Cells ◽

Stem Cell ◽

Stem Cell Transplant ◽

Conflicts Of Interest ◽

Disease Free Survival ◽

Autologous Stem Cell Transplant ◽

Poor Performance Status ◽

Prognostic Impact ◽

Cell Transplant ◽

The Impact

Abstract Multiparametric flow cytometry (MPFC) detection of minimal residual disease (MRD) represents a robust surrogate for the quality of complete remission (CR) and reliably predicts clinical outcome. In our experience, MRD detection provides prognostically relevant information when assessed at the post-consolidation time point. Ten years ago we demonstrated that the amount of MRD before autologous stem cell transplant (AuSCT) affected outcome. More recently, other authors have extended this observation to allogeneic stem cell transplant (ASCT) showing that pre-transplant MRD is a major determinant of prognosis regardless of graft-versus-leukemia (GVL) effect. The aim of our study was to evaluate, in an extended series of patients submitted to AuSCT or ASCT, the impact of a pre-transplantation MRD positive (MRDpos) or negative (MRDneg) status on overall survival (OS) and disease free survival (DFS). We analyzed 173 MRDpos and 53 MRDneg patients of whom 67 were submitted to AuSCT and 51 to ASCT. Eighty-two patients received no transplant because of age, poor performance status or insufficient stem cell harvest whereas 26, all in the MRDpos group, relapsed before transplant delivery. In the AuSCT group, before transplant, 32/67 (48%) were MRDneg and 35/67 (52%) MRDpos, with MRDneg group showing a superior OS (55% vs 20%, p=0.007). In the ASCT group, before transplant, 45/51 (88%) were MRDpos and 6/51 (12%) MRDneg. For 21 out of 51 (41%) sources of stem cells were matched unrelated donors (12) or haploidentical donors (9). In this subgroup, MRDpos and MRDneg patients shared a comparable 5-years OS (60% vs 56%, p=NS), with a 36% survival gain for those MRDpos who received ASCT as compared to AuSCT. Among MRDneg patients, no survival differences were demonstrated between those submitted to AuSCT or ASCT (55% vs 60%, p=NS). Such a lack of difference is likely due to the higher treatment related mortality (ASCT 3/6, 50% vs AuSCT 2/32, 6%, p=0.003) which counterbalanced the lower relapse rate in the ASCT group (ASCT 0/6, 0% vs AuSCT 11/32, 34%, p=NS). In conclusion, ASCT confers a significant survival advantage to MRDpos patients, attenuating the negative prognostic impact of pre-transplant MRD positivity. ASCT may expose MRDneg patients to an excess of toxicity suggesting that in these patients the allogeneic option should be postponed after a second remission. In MRDpos patients, AuSCT does not represent a valid therapeutic choice and ASCT, which should be timely delivered, also considering alternative sources of stem cells. Disclosures No relevant conflicts of interest to declare.

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Incidence and Prognostic Impact of Gene Mutations in Older Patients with AML Treated in the ALFA-9801 Study.

Blood ◽

10.1182/blood.v112.11.1525.1525 ◽

2008 ◽

Vol 112 (11) ◽

pp. 1525-1525

Author(s):

Aline Renneville ◽

Sylvie Castaigne ◽

Sylvie Chevret ◽

Laura Llopis ◽

Nathalie Philippe ◽

...

Keyword(s):

Multivariate Analysis ◽

Older Patients ◽

Gene Mutations ◽

Significant Prognostic Factor ◽

Prognostic Impact ◽

Npm1 Mutation ◽

Younger Patients ◽

Mutational Status ◽

Cebpa Mutations ◽

The Impact

Abstract Introduction: The impact of gene mutations, i.e. poor-prognosis FLT3 internal tandem duplications (ITDs) and good-prognosis NPM1 or CEBPA mutations, has been welldocumented in several recent reports dealing with younger patients with acute myeloid leukemia (AML). As these mutations were associated with cytogenetically normal (CN) AML, most of these reports focused on CN-AML patients. Both FLT3-ITD and NPM1 mutations were also associated with higher WBC. The objective of the present study was to evaluate the incidence, correlations, and prognostic value of these mutations in older patients with the disease. Methods: The French ALFA group has screened a total of 583 patients, including 333 younger patients (15–50 years) treated in the ALFA-9802 trial and 250 older patients (50–70 years) treated in the ALFA-9801 trial. The older ALFA-9801 trial included 468 patients with previously untreated de novo AML and studied the role of idarubicin (IDA) as compared to high-dose daunorubicin (DNR) as well as interleukine-2 as a maintenance therapy (C. Pautas et al. ASH 2007, abstract #162). Comparison between the 250 patients tested for mutations in that trial and the 218 patients not tested showed no differences in age, sex ratio, FAB classification, bone marrow blasts percentage, randomization arm, and performance status at entry in the study. There was, however, a higher rate of patients with intermediate cytogenetics (p=.01) or increased WBC (p=.01) in the former subgroup. Results: Median age of the 250 patients tested was 60 years. Cytogenetics was studied in 232 patients (12 favorable, 174 intermediate, 46 unfavorable). One hundred twenty-two patients (49%) had CN-AML. CR rate was 67.5% and estimated 4-year OS was 26% (95% CI, 20–33). Incidences of FLT3-ITD, NPM1, and CEBPA mutations were 37/250 (15%), 64/249 (26%), and 20/249 (8%), respectively. These incidences were very similar than in the younger ALFA-9802 population [50/329 (15%), 76/321 (24%), and 24/316 (8%), respectively]. In these older AML patients, the correlation between increased WBC and FLT3-ITD (p<.001) or NPM1 mutation (p<.001) was still observed. Conversely, NPM1 mutations only (p<.001), but not FLT3-ITDs (p=.10) or CEBPA mutations (p=.99), were significantly associated with CN-AML. In the whole group of 249 patients with either normal or abnormal karyotype tested for all mutations, 46 were NPM1+/FLT3-ITDwt, 19 FLT3-ITD+/NPM1wt, 18 FLT3-ITD+/NPM1+, and 166 NPM1wt/FLT3-ITDwt. CR rate was 87%, 84%, 56%, and 75% and median OS was 20.5, 18.6, 6.0, and 14.6 months, respectively. In the 20 CEBPA+ patients, CR rate was 80% and median OS was 22.8 months. In the group of 122 CN-AML patients tested for all mutations, 36 were NPM1+/FLT3-ITDwt, 8 FLT3-ITD+/NPM1wt, 15 FLT3-ITD+/NPM1+, and 63 NPM1wt/FLT3- ITDwt. CR rate was 92%, 87.5%, 60%, and 78% and median OS was 20.5, 16.9, 7.0, and 16.8 months, respectively. In the 10 CEBPA+ patients, CR rate was 80% and median OS was not reached. In multivariate analysis including age, WBC, cytogenetics (favorable versus others), and gene mutational status (NPM1+ or CEBPA+ if FLT3-ITDwt versus others), a pejorative effect of age (p=.02) and WBC (p<.001), but a protective effect of mutational status (HR= 0.66, p=.05) and favorable cytogenetics (HR=0.43, p=.06) was observed in the whole patient population. Nevertheless, estimated 4-year OS was only 37% (95% CI, 23–50) in patients with a favorable mutational status. In those with CNAML and a favorable mutational status, estimated 4-year OS reached only 40% (95% CI, 23–56). In this subgroup of patients with CN-AML, WBC was the only significant prognostic factor identified in multivariate analysis (p<.001). Conclusion: This study conducted in a large cohort of patients aged 50 to 70 years and prospectively treated in the same trial showed that gene mutational status still affect the outcome of older patients with AML. Mutation incidences are in the same range than in younger patients. Nevertheless, their impact on OS appeared to be less marked than in younger patients, probably due to the worse general outcome observed in these older patients.

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High WT1 Expression Has An Independent Positive Influence On CR Rate and EFS in Non M3 AML Patients Treated with Chemotherapy.

Blood ◽

10.1182/blood.v114.22.4675.4675 ◽

2009 ◽

Vol 114 (22) ◽

pp. 4675-4675

Author(s):

Nicoletta Colombo ◽

Raffaella Grasso ◽

Maurizio Miglino ◽

Marino Clavio ◽

Gianmatteo Pica ◽

...

Keyword(s):

Regression Model ◽

Prognostic Value ◽

Cox Regression ◽

Conflicts Of Interest ◽

Categorical Variables ◽

P Value ◽

Prognostic Impact ◽

Chi Square Analysis ◽

The Impact

Abstract Abstract 4675 The prognostic value of WT1 expression at diagnosis is still controversial. It has been retrospectively evaluated in 99 consecutive non pretreated non M3 AML patients who had undergone a complete prognostic work up at diagnosis and had received intensive chemotherapy. Biological markers were evaluated on fresh marrow samples collected at diagnosis. WT1 expression was evaluated using TaqMan Gene Expression Assays as described. All patients received induction therapy with combination of fludarabine, Ara-C and anthracycline ± low dose gemtuzumab ozogamicin (n. 59) or with a conventional combination of Ara-C and anthracycline (n. 40) A conventional post-induction chemotherapy including intermediate dosage Ara-C was administered to all responding patients. Univariate comparisons between patients in CR vs non CR were performed using chi-square analysis or Fisher's exact test for categorical variables and t-test for continuous variables. P values < 0.05 were considered statistically significant. Analyses were performed using SPSS. The prognostic impact of WT1 expression was evaluated using quartiles as cut off point and selecting the one with the lowest p value. The event free survival and OS were calculated using the Kaplan Meier method. Non CR after the first induction course, relapse and death due to any cause were considered events. OS and EFS duration were calculated from start of treatment. The impact of multiple predictor variables was assessed by multivariate analyses according to the Cox regression model for OS and EFS while for the evaluation of RC was used the Logistic regression model. Median age of patients was 59 years (range 17-81). Cytogenetic alterations were prognostically favorable in 3 patients and belonged to the intermediate prognostic group in 77 patients (normal karyotype in 75 patients and +8 in two). Nineteen patients had a poor prognosis cytogenetics. For statistical analyses we considered two karyotipic groups: unfavorable (19 patients) and not unfavorable (80 patients). CRs were 60/99 (60%), of which 40 in 51 patients aged 60 or less (78%) and 20 in 48 older than 60 years (41%). Twenty-six patients relapsed, 54 are alive, 45 have died, with a median follow up of 360 days (range 20-2300). In Table 1 are reported clinical indicators of outcome being patients grouped according to the percentile of WT1 expression with the lowest p value (75th). Statystical analysis showed that all WT1 quartiles were balanced for other prognostic factors, such as cytogenetics, BAALC expression, FLT3 and NPMA and B mutations, age, blast count and therapy. The lack of consense on the role of WT1 level at diagnosis in the prognostic stratification indicate that further clinical studies are required. The clear correlation between the level of WT1 transcript and the tumor burden explains why WT1 is used in the follow up of leukemic patients as universal marker of residual disease, also in patients with specific chimeric products. On the contrary, the biological explanation of the prognostic impact of WT1 transcript level at diagnosis remains uncertain. Over the years WT1 gene has been considered as an oncogene or a tumor suppressor gene. In our experience the protective influence of high WT1 expression cannot be explained with an association with good prognosis biological features (such as mut NPM and / or low BAALC). The positive prognostic value of high WT1 expression might be implicated either with WT1 antioncogenic function, or with the stimulating effect of WT1 oncogene on leukemic cellular cycle, possibly associated with an enhanced response to chemotherapy.Table 1WT1 <= 2400 N./N.pts (%)WT1 > 2400 N./N.pts (%)p univ,p multiv.*RR (95% CI)CR (all karyotypes)41/ 75 (54)19/24 (82)0,0260.063.364 (0.927-12.202)CR (int/good karyot.)36/59 (61)19/210.010,0276.649 (1.240-35.645)CR (denovo AML int kar)31/45 (69)14/15 (98)0.020,03412.557 (1.218-129.446)CR (denovo, N.K.)26/40 (65)15/16 (94)0.0250.0413.430 (1.111-162.318)EFS at 24 months (all karyotypes)8%6%0.0020.050.486 (0.235-1.007)EFS at 24 months (int / good karyot.)9%64%0.0010.0230.360 (0.150-0.866)EFS at 24 months (de novo, N.K.)5%70%0.0010.0070.227 (0.077-0.671)OS (all karyot)15%55%0,110,660.837 (0.371-1.890)OS (int/good kar.)18%63%0,050,180.507 (0.186-1.381)Table 1 legend: * for multivariate analysis age, karyotype, FLT3, NPM mutation, BAALC expression, denovo/secondary disease were considered. Disclosures: No relevant conflicts of interest to declare.

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Negative Prognostic Impact Of High CD33 Expression Is Negated With The Use Of Gemtuzumab Ozogamicin: A Report From The Children’s Oncology Group

Blood ◽

10.1182/blood.v122.21.491.491 ◽

2013 ◽

Vol 122 (21) ◽

pp. 491-491 ◽

Cited By ~ 3

Author(s):

Jessica Pollard ◽

Todd A. Alonzo ◽

Robert B. Gerbing ◽

Susana C Raimondi ◽

Betsy Hirsch ◽

...

Keyword(s):

Disease Risk ◽

Risk Group ◽

Gemtuzumab Ozogamicin ◽

Phase Iii ◽

Study Cohort ◽

Prognostic Impact ◽

Cell Transplant ◽

Conventional Chemotherapy ◽

Hematopoietic Stem ◽

The Impact

Abstract CD33 is expressed on leukemic blasts of most patients with acute myeloid leukemia (AML) and is the target for gemtuzumab ozogamicin (GO), a toxin-conjugated anti-CD33 monoclonal antibody. CD33 expression of leukemic blasts was prospectively quantified within the context of COG AAML0531, a phase III randomized study for de novo AML in which patients were randomized to receive conventional chemotherapy (Arm A) vs. GO + conventional chemotherapy (Arm B) to determine the impact of CD33 expression on outcome within the context of this GO randomization. CD33 mean fluorescent intensity (MFI) of leukemic blasts was prospectively quantified in 825 diagnostic specimens. Patients were divided into quartiles (Q1-Q4) based on CD33 expression values and these levels were correlated with disease characteristics and outcome by treatment arm for the total study cohort and by cytogenetic/molecular disease risk-group. Analysis of 3 year outcome by treatment arm (N= 412 for Arm A vs. N=414 for Arm B) demonstrated that patients with high CD33 expression (Q4) in Arm A (no GO) had an overall survival (OS) from diagnosis of 55% vs. 70% for those with lower CD33 expression (Q1-3, P=.014) with a corresponding disease-free survival (DFS) from complete remission (CR) of 41% and 57%, respectively (P=.010). In contrast, for the patients in Arm B (receiving GO therapy) those with and without high CD33 expression had a similar OS from diagnosis (67% vs. 72%, P=.290) with a corresponding DFS from CR of 57% vs. 64%, respectively (P=.255). Comparison of the patients with the highest CD33 expression (Q4) who were treated with (N=105) and without (N=101) GO demonstrated that those who received GO had an OS from diagnosis of 67% versus 55% (P=.196) with a corresponding DFS from CR of 57% vs. 41% (P=.052). Analysis by cytogenetic/molecular disease risk group also showed that the effect of CD33 expression levels on outcome differed by treatment arm. Among intermediate risk (IR) patients on Arm A (N=200), those with high CD33 expression (Q4) had an OS from diagnosis of 52% vs. 62% for those with lower CD33 expression (P=0.194) with a corresponding DFS from CR of 28% vs. 53% respectively (P=.012). Conversely, for IR patients treated with GO (N=197), outcomes were similar for patients with high (Q4) and low (Q1-3) CD33 expression (OS from diagnosis of 65% vs. 64%, P=.923, DFS from CR of 50% vs. 53%, P=.687). The loss of prognostic impact of high CD33 expression for patients in Arm B may be due to improved response to GO in those with high CD33 expression (OS of IR patients in Q4 from study entry: Arm A (N=65) 52% vs. Arm B (N=70) 65%, P= .234, DFS from CR of IR patients in Q4: Arm A 28% vs. Arm B 50%, P=.033). Accurate sub analysis of the high-risk (HR) group was not feasible due to the very small number of HR patients with high CD33 expression (Q4) in Arm A (N=9) and Arm B (N=16). Similar trends were, however, observed in the low-risk (LR) group. LR patients with high (Q4) CD33 expression treated on Arm A (no GO) had an OS from diagnosis of 69% vs. 84% for those with lower CD33 expression (P=.092) with a corresponding DFS from CR of 68% vs. 64% respectively (P=0.803). For patients in Arm B (GO) those with and without high CD33 expression had an OS from diagnosis of 94% vs. 86%, respectively (P=.316) with a corresponding DFS from CR of 85% vs. 76% (P=.344). Like IR patients, those LR patients with high CD33 expression (Q4) who received GO trended towards improved outcome compared to Q4 patients treated without GO (LR OS from diagnosis: Arm A 69% vs. Arm B 94%, P= .069, LR DFS from CR: Arm A 68% vs. Arm B 85%, P=.195). However, given the small number of LR patients in Q4 (N= 27 Arm A, N=17 Arm B) we cannot state the significance of this finding with certainty. Taken together our results suggest that, for patients enrolled on AAML0531, high CD33 expression was associated with adverse outcome for those who received standard therapy and GO treatment negated the negative effect of high CD33 expression on clinical outcome for the entire study cohort and in IR and LR patients. This finding may reflect GO’s CD33 dependent mechanism of targeting and the potential for more efficient targeting in the setting of high antigen expression.It is also plausible that repeated exposure to GO, as seen within the context of treatment for all LR and some IR patients (e.g. those that did not undergo hematopoietic stem cell transplant), may also contribute therapeutic benefit within the context of high CD33 expression. Disclosures: No relevant conflicts of interest to declare.

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Double CEBPA Mutations Are Not Associated With Favorable Clinical Outcome In Pediatric AML: A Report From The Japanese Pediatric Leukemia/Lymphoma Study Group (JPLSG)

Blood ◽

10.1182/blood.v122.21.4942.4942 ◽

2013 ◽

Vol 122 (21) ◽

pp. 4942-4942

Author(s):

Hidemasa Matsuo ◽

Mio Kajihara ◽

Daisuke Tomizawa ◽

Tomoyuki Watanabe ◽

Akiko Moriya Saito ◽

...

Keyword(s):

Clinical Outcome ◽

Conflicts Of Interest ◽

Normal Karyotype ◽

Study Group ◽

Prognostic Impact ◽

Pediatric Leukemia ◽

Favorable Prognosis ◽

Pediatric Aml ◽

Cebpa Mutations ◽

Lymphoma Study Group

Abstract Background CCAAT/enhancer binding protein alpha (CEBPA) is a transcription factor that coordinates cellular differentiation. Mutations in the CEBPA genes are found in about 10% of patients with AML and are associated with favorable prognosis. However, recent data suggests that the favorable prognosis is restricted only to the patients with double CEBPA mutations and normal karyotype. These data have large implications for risk-stratified therapy and require confirmation. In this study, we investigated CEBPA mutation status and clinical outcome of the pediatric AML patients treated in the Japanese Pediatric Leukemia/Lymphoma Study Group (JPLSG) AML-05 study. Patients & Methods AML-05 study, registered at http://www.umin.ac.jp/ctr/as UMIN000000511, is a nation-wide multi-institutional study for children (age <18 years) with de novo AML enrolled from 11/1/2006 to 12/31/2010. Cases with acute promyelocytic leukemia or Down syndrome were excluded. Patients were stratified by the specific cytogenetic characters and morphological treatment response into 3 risk groups; CBF-AML patients to the low risk (LR) group, those with either unfavorable cytogenetics (-7, 5q-, t(16;21)(p11;q22), Ph1, FLT3-ITD) or poor induction responders to the high risk (HR) group, and the rest to the intermediate risk (IR) group. In this trial, morphology was prospectively diagnosed by a central review system. Cytogenetic tests were carried out in regional laboratories, but the reports were reviewed centrally. FLT3-internal tandem duplication (ITD) was examined for all patients. Using the surplus RNA from the AML-05 study, CEBPA gene mutation was analyzed by RT-PCR and direct sequencing. Results Of the 317 evaluable patients, 73 patients (23.0%) had normal karyotype, 42 patients (13.2%) were FLT3-ITD positive, and 19 patients (6.0%) had both normal karyotype and FLT3-ITD. Among the 54 cases with normal karyotype and negative FLT3-ITD, 16 patients (29.6%) had a single CEBPA mutation and 17 patients (31.5%) had double or more (hereafter described as Double) CEBPA mutations. Between the CEBPA wild type (WT) and Double mutated patients, there were no statistically significant differences in relapse-free survival (RFS) (53.9% vs. 71.1%, P=0.27) nor overall survival (OS) (68.9% vs. 64.7%, P=0.57). An in-frame insertion of 6bp (ACCCGC) in CEBPAtrans-activator (TAD2) domain, resulting in a His-Pro duplication (HP196-197 ins), was detected in 131 patients (41.3% of all patients) in the current study, a considerably high incidence. However, this insertion was previously reported as polymorphism in adult AML (Leukemia 2008). When categorizing this insertion cases as CEBPA WT, 24 patients were CEBPA mutated among the 54 cases with normal karyotype and negative FLT3-ITD; 11 patients (20.4%) with single CEBPA mutation and 13 patients (24.1%) with Double CEBPA mutations. Although not statistically significant, there was a tendency of higher RFS (83.3% vs. 55.5%, P=0.20) and OS (79.1% vs. 63.3%, P=0.39) in patients with Double CEBPA mutations versus WT patients. Conclusions The current study is the first Japanese nation-wide investigation of the clinical significance of CEBPA mutations in pediatric AML. Our results suggest that CEBPA mutations have no prognostic impact on children with AML. Disclosures: No relevant conflicts of interest to declare.

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