Overcoming NOTCH1-Driven Chemoresistance in T-Cell Acute Lymphoblastic Leukemia Via Metabolic Intervention with Oxphos Inhibitor

The inferior cure rate of T-cell acute lymphoblastic leukemia (T-ALL) is associated with inherent drug resistance. The activating NOTCH1 gene mutations have been reported to cause chemoresistance at the stem cell level1. Direct NOTCH1 inhibition has failed in clinical trials due to a narrow therapeutic window but targeting key oncogenic and metabolic pathways downstream of mutated NOTCH1 may offer novel approaches. We previously reported that rapid transformation of thymocytes at the DN3 differentiation stage into preleukemic stem cells (pre-LSC) requires elevated Notch1 in addition to the presence of Scl/Lmo11. Notably, we showed that cellular metabolism of NOTCH1-mutated T-ALLs depends on Oxidative Phosphorylation (OxPhos) and that OxPhos inhibition using the complex I inhibitor IACS-010759 (OxPhos-i) is efficacious in NOTCH1-mutated T-ALL patient derived xenografts (PDXs)2. Here, we investigated the link between NOTCH1-mutated chemoresistance and OxPhos in pre-leukemic and leukemic cells, utilizing comprehensive molecular and functional assays. We hypothesized that chemotherapy aided by OxPhos-i overcomes chemoresistance, depletes LSCs and combats T-ALL. First, we analyzed the role of OxPhos in downstream Notch1 targets at the pre- and leukemic stage considering four stages of thymocyte differentiation (D1-D4), in a mouse model of human T-ALL1. Gene set enrichment analysis (GSEA) implicated increased expression of Notch1 target genes starting at DN1, and OxPhos target genes were the highest-ranked gene set at DN3. Next, activation of Notch1 by its ligand DL4 and inhibition of OxPhos reduced viability of pre-LSCs, indicating that ligand-dependent activation of Notch1 signaling upregulates the OxPhos pathway and sensitizes pre-LSCs to OxPhos-i. To clarify the role of Notch1 signaling, we examined the effect of IACS-010759 on pre-leukemic thymocytes harboring LMO1, SCL-LMO1, NOTCH1, LMO1-NOTCH1 and SCL-LMO1-NOTCH1 with and without DL4 stimulation. We found that in the absence of DL4, only thymocytes harboring the Notch1 oncogene responded to OxPhos-i, whereas all DL4-stimulated thymocytes responded regardless of Notch1 status (Fig. 1a). In addition, at the leukemic stage, we found elevation of the OxPhos pathway driven by oncogenic Notch1 when we compared transcriptomes of SCL-LMO1 induced T-ALL in the presence or absence of the NOTCH1 oncogene. In line with the murine T-ALL NOTCH1 model, we performed transcriptome analysis of two independent T-ALL patient cohorts prior to chemotherapy, COG TARGET ALL (n=263) and AALL1231 (n=75), comparing transcriptomes of NOTCH1-mutated vs NOTCH1-wt T-ALLs. We found co-segregation of NOTCH1 mutations with significant upregulation of OxPhos and TCA cycle genes and downregulation of apoptosis signaling. Aiming to reverse the NOTCH1-controlled anti-apoptotic program and chemoresistance, we next tested the combination of Vincristine, Dexamethasone and L-Asparaginase (VXL) with IACS-010759. When compared to vehicle, OxPhos-i or VXL alone, only the VXL-OxPhos-i treatment caused an energetic crisis indicated by decreased OCR and ECAR (Seahorse), which translated to a profound reduction of viability (CTG, flow cytometry) in T-ALL cell lines (n=9) and primary T-ALL samples (n=5). Additionally, the IACS-VXL combination in vivo resulted in pan-metabolic blockade, which caused metabolic shut-down and triggered early induction of apoptosis in leukemic cells in peripheral blood, spleen and bone marrow (Fig. 1b). Single cell Proteomic analysis (CyTOF) of spleen showed reduced expression of cell proliferation marker -ki67, c-myc, ERK and p38 proteins, and reduction in number of leukemic cells. Finally, this combination therapy resulted in reduced leukemia burden and extension of overall survival across all three aggressive NOTCH1-mutated T-ALL PDX models (p<0.0001) (Fig.1 c, d). In summary, we demonstrated that targeting OxPhos with IACS-010759 in combination with chemotherapy facilitates eradication of chemoresistant NOTCH1-driven T-ALL through direct targeting of the key metabolic regulators of OxPhos conferred by mutant NOTCH1 in T-ALL. Clinical trials rewiring metabolism by incorporation of OxPhos-i to standard-of-care therapy in patients with NOTCH1-mutated T-ALL are warranted to improve patients' outcomes. Disclosures Jabbour: Pfizer: Other: Advisory role, Research Funding; Genentech: Other: Advisory role, Research Funding; BMS: Other: Advisory role, Research Funding; Takeda: Other: Advisory role, Research Funding; Amgen: Other: Advisory role, Research Funding; Adaptive Biotechnologies: Other: Advisory role, Research Funding; AbbVie: Other: Advisory role, Research Funding. Teachey:Sobi: Consultancy; Amgen: Consultancy; Janssen: Consultancy; La Roche: Consultancy. Rezvani:Takeda: Other: Licensing agreement; GemoAb: Membership on an entity's Board of Directors or advisory committees; Adicet Bio: Membership on an entity's Board of Directors or advisory committees; Virogen: Membership on an entity's Board of Directors or advisory committees; Pharmacyclics: Other: Educational grant; Affimed: Other: Educational grant; Formula Pharma: Membership on an entity's Board of Directors or advisory committees. Andreeff:Daiichi-Sankyo; Jazz Pharmaceuticals; Celgene; Amgen; AstraZeneca; 6 Dimensions Capital: Consultancy; Daiichi-Sankyo; Breast Cancer Research Foundation; CPRIT; NIH/NCI; Amgen; AstraZeneca: Research Funding; Centre for Drug Research & Development; Cancer UK; NCI-CTEP; German Research Council; Leukemia Lymphoma Foundation (LLS); NCI-RDCRN (Rare Disease Clin Network); CLL Founcdation; BioLineRx; SentiBio; Aptose Biosciences, Inc: Membership on an entity's Board of Directors or advisory committees; Amgen: Research Funding. Lorenzi:Precision Pathways: Consultancy. Konopleva:Calithera: Research Funding; Kisoji: Consultancy; AbbVie: Consultancy, Research Funding; Sanofi: Research Funding; Genentech: Consultancy, Research Funding; F. Hoffmann La-Roche: Consultancy, Research Funding; Cellectis: Research Funding; Rafael Pharmaceutical: Research Funding; Eli Lilly: Research Funding; Reata Pharmaceutical Inc.;: Patents & Royalties: patents and royalties with patent US 7,795,305 B2 on CDDO-compounds and combination therapies, licensed to Reata Pharmaceutical; Agios: Research Funding; AstraZeneca: Research Funding; Ablynx: Research Funding; Forty-Seven: Consultancy, Research Funding; Amgen: Consultancy; Stemline Therapeutics: Consultancy, Research Funding; Ascentage: Research Funding.

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Early MRD-Negativity May Predict for Favorable Outcome Irrespective of Allotransplantation in TKI-Treated Patients with Ph-Positive Acute Lymphoblastic Leukemia

Blood ◽

10.1182/blood.v128.22.1598.1598 ◽

2016 ◽

Vol 128 (22) ◽

pp. 1598-1598

Author(s):

Helena Hohtari ◽

Marjatta Sinisalo ◽

Tapio Nousiainen ◽

Perttu Koskenvesa ◽

Ulla Wartiovaara-Kautto ◽

...

Keyword(s):

Acute Lymphoblastic Leukemia ◽

Board Of Directors ◽

Research Funding ◽

Causes Of Death ◽

Lymphoblastic Leukemia ◽

Advisory Committees ◽

Term Survival ◽

Educational Grant ◽

Treatment Related Mortality ◽

Related Mortality

Abstract Introduction Tyrosine kinase inhibitors (TKIs) such asimatiniband dasatinib have markedly improved treatment results in patients with Philadelphia chromosome-positive acute lymphoblastic leukemia (Ph+ ALL). Almost all patients achieve at least a complete hematological remission with induction therapy consisting of TKImonotherapyor TKI in combination with reduced-intensity chemotherapy and corticosteroids. In eligible patients, allogeneic hematopoietic stem cell transplantation (alloHSCT) has been recommended in first complete remission, but its role inpatientsachieving rapid and deep molecular remissions with TKI-driven therapy is unresolved. Methods We analyzed data fromPh+ ALL patients in the Finnish Hematological Registry (FHR), a population-based database maintained by the Finnish Hematology Association, which includes patients participating in clinical study protocols sponsored by theTheFinnish Leukemia Group, and patients treated outside of clinical trials. The FHR contains detailed information on baseline (demographics, laboratory values,cytogenetics, molecular assays) and follow-up (therapies given and outcome). Minimal residual disease (MRD) was evaluated by standardized RQ-PCR for the bone marrow BCR-ABL1 transcripts with a minimum sensitivity of 10e-5. Therapy responses were coded according to the EuropeanLeukemiaNetguidelines. Data from 128Ph+ALLpatients diagnosed between 1983-2016 were included in the analyses. Survival outcomes were calculated with the Kaplan-Meier method and compared with the log-rank test. Differences between groups were evaluated with the independent samples t-test for parametric numeric variables. Results Of the 128 patients included in the analyses, 78 patients (61%) had received TKI treatment and 50 patients were treated prior the TKI era. The TKIs used wereimatiniband dasatinib and majority of patients concurrently received combination chemotherapy for induction and consolidation. Of the patients not treated with TKIs, 19/50 (38%) received an allotransplant and the overall survival (OS) at 5 years was 58% in the allotransplanted vs. 3% in thenontransplantedpatients (P<0.001). Of the patients treated with TKIs, 45/78 (58%) patients received analloHSCT. The mean age in thealloHSCTgroup was 41 years and in the non-alloHSCTgroup 62 years. OS at 5 years was better in thealloHSCTgroup (62% vs. 48%, P=0.004), but when analyzing causes of death, more deaths due to causes other than leukemia or its treatment were observed in the non-alloHSCTpatients (21% vs. 0 %), related to the competing causes of death in this older group of patients. In addition, there was more treatment-related mortality inalloHSCTpatients (22% vs. 6%). Relapse-free survival did not differ between transplanted and non-transplanted patients at 5 years (73 % vs. 57 %, P=0.42; Figure top panel). In TKI-treated patients, a trend for better OS was observed in patients who were MRD-negative at 3 months (Figure bottom panel). Discussion Our data indicate that up to 50% of patients withPh+ALLexperience long-term survival with TKI-driven therapy and noalloHSCT. However, robust predictive biomarkers are needed for selecting patients in whom the treatment-related mortality and morbidity ofalloHSCTare not warranted and could be treated with TKI-driven therapies only. MRD-negativity at 3 months may select for better outcome, but larger studies are needed for confirmation. In addition, disease-specific genomic andtranscriptomicprofiles (e.g. IKZF1, CDKN2 mutations) andimmunoreconstitutionmay prove valuable in this context. The advent of novel potent MRD-eradicating agents, such asbispecificCD3/CD19 antibodies, may further indicate re-evaluation of the role ofalloHSCTinPh+ALL. Figure 1 Figure 1. Figure 2 Figure 2. Disclosures Mustjoki: Bristol-Myers Squibb: Honoraria, Research Funding; Novartis: Honoraria, Research Funding; Pfizer: Honoraria, Research Funding; Ariad: Research Funding. Säily:Celgene: Other: Educational grant for congress participation; Amgen: Other: Educational grant for congress participation. Remes:Teva: Membership on an entity's Board of Directors or advisory committees; Takeda: Consultancy, Membership on an entity's Board of Directors or advisory committees; Amgen: Membership on an entity's Board of Directors or advisory committees; Janssen-Cilag: Consultancy, Membership on an entity's Board of Directors or advisory committees. Porkka:Celgene: Research Funding.

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Pre-Clinical Activity of Allogeneic Anti-CD22 CAR-T Cells for the Treatment of B-Cell Acute Lymphoblastic Leukemia

Blood ◽

10.1182/blood.v130.suppl_1.808.808 ◽

2017 ◽

Vol 130 (Suppl_1) ◽

pp. 808-808

Author(s):

Julia Wells ◽

Tianyu Cai ◽

Cécile Schiffer-Manniou ◽

Stéphanie Filipe ◽

Agnès Gouble ◽

...

Keyword(s):

T Cells ◽

Board Of Directors ◽

Cell Lines ◽

Research Funding ◽

Lymphoblastic Leukemia ◽

Surface Expression ◽

Advisory Committees ◽

Car T Cells ◽

Car T ◽

Cell Acute Lymphoblastic Leukemia

Abstract Autologous T-cells engineered with chimeric antigen receptors (CARs) against CD19 are proving to be an efficacious immunotherapy for patients with relapsed or refractory B-cell acute lymphoblastic leukemia (B-ALL). At present, CAR technology is administered through the custom-made manufacturing of therapeutic products from each patient's own T-cells. However, this patient-specific autologous paradigm is a significant limiting factor in the large-scale deployment of CAR technology. In this study, we utilized allogeneic "off-the-shelf" engineered CAR T-cells from third-party healthy donors. The CD22 surface antigen is commonly expressed in B-ALL patients as well as in healthy B-cells. Here, its potential as a CAR target was investigated using allogeneic off-the shelf engineered CAR T-cells against human CD22 (UCART22). UCART22 cells harbor surface expression of an anti-CD22 CAR (CD22 scFv-41BB-CD3z) and the RQR8 ligand, a safety feature rendering the T-cells sensitive to the monoclonal antibody rituximab. To reduce the potential for alloreactivity, the cell surface expression of the T-cell receptor (TCR) is abrogated through the inactivation of the TCRα constant (TRAC) gene using Cellectis' TALEN® gene-editing technology. The level of CD22 cell surface molecules was measured using BD Quantbrite beads for both patient peripheral blood samples and B-ALL cell lines. B-ALL cell lines (n=8) expressed a greater amount of CD22 molecules per cell than patient samples (n=14) (5,028 +/- 1,342 compared to 951 +/-160 molecules/cell, p=0.044), with highest expression of CD22 in two Ph-like B-ALL cell lines (MUTZ5, shown in Figure1A and MHH-CALL4). The in vitro cytotoxic activity of UCART22 cells was evaluated by co-culturing UCART22 or non-transduced CAR(-) TCRαβ(-) control T-cells (NTD) with B-ALL cell lines and primary human samples, at a maximum 10:1 effector to target ratio (represented in Figure1B). Using flow cytometry, significant antigen-specific cytotoxic activity of UCART22 cells was found compared to NTD controls and correlated with CD22 expression factored by the %kolmogorov-smirnov max difference in CD22-PE fluorescence compared to unstained controls (Pearson correlation r-squared for cell lines= 0.6850, p=0.0001 and r-squared for patient samples=0.6204, p=0.0008). Secretion of 13 cytokines was measured after 1:1 co-incubation of effector and target cells. UCART22 cells stimulated by CD22(+) B-ALL, but not NTD cells, secreted high levels of IFNγ, TNFα, IL-5, IL-17A and IL-17F in the culture supernatants, with cytokine levels being proportionate to CD22 abundance (represented in Figure1C). In addition, immune compromised mice engrafted with Daudi cells, a CD22(+) expressing Burkitt's lymphoma cell line, were treated with UCART22 cells. Treatment doses of 1-10x10^6 cells per mouse reduced disease burden (Figure 1D), measured by bioluminescence imaging, and extended survival in a dose-dependent fashion compared to saline or NTD treated controls. Additional PDX studies using B-ALL patient derived xenografts are ongoing and will be presented. Altogether, these results show supporting evidence for the future use of allogenic UCART22 in B-ALL immunotherapy. Disclosures Schiffer-Manniou: Cellectis SA: Employment. Filipe: Cellectis: Employment. Gouble: Cellectis SA: Employment. Galetto: Cellectis SA: Employment. Jain: ADC Therapeutics: Honoraria, Membership on an entity's Board of Directors or advisory committees, Research Funding; Novartis: Honoraria, Membership on an entity's Board of Directors or advisory committees; Celgene: Research Funding; Verastem: Research Funding; Pfizer: Honoraria, Membership on an entity's Board of Directors or advisory committees, Research Funding; Pharmacyclics: Honoraria, Membership on an entity's Board of Directors or advisory committees, Research Funding; BMS: Research Funding; Abbvie: Research Funding; Incyte: Research Funding; Genentech: Research Funding; Novimmune: Honoraria, Membership on an entity's Board of Directors or advisory committees; Servier: Honoraria, Membership on an entity's Board of Directors or advisory committees, Research Funding; Adaptive Biotechnologies: Honoraria, Membership on an entity's Board of Directors or advisory committees. Jabbour: Bristol-Myers Squibb: Consultancy. Smith: Cellectis Inc: Employment.

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Allogeneic Hematopoietic Stem Cell Transplant Versus No Transplant in Adult Patients with Philadelphia Chromosome Positive Acute Lymphoblastic Leukemia in First Complete Remission and Complete Molecular Remission

Blood ◽

10.1182/blood-2020-141143 ◽

2020 ◽

Vol 136 (Supplement 1) ◽

pp. 46-48 ◽

Cited By ~ 1

Author(s):

Armin Ghobadi ◽

Kahee A Mohammed ◽

Rawan Faramand ◽

Hagop M. Kantarjian ◽

Elias Jabbour ◽

...

Keyword(s):

Board Of Directors ◽

Research Funding ◽

Lymphoblastic Leukemia ◽

Chronic Gvhd ◽

Philadelphia Chromosome ◽

Advisory Board ◽

Adult Patients ◽

Advisory Committees ◽

Free Survival ◽

Advisory Role

Introduction: Allogeneic hematopoietic cell transplantation (HCT) in first complete remission (CR1) is the standard of care for adult patients with Philadelphia Chromosome Positive (Ph+) Acute Lymphoblastic Leukemia (ALL). The addition of tyrosine kinase inhibitors (TKI) to therapy have resulted in significantly higher rates of complete molecular remissions (CMR) and better overall outcomes. Given the increased toxicity associated with HCT, we aimed to study the benefit of HCT in adult patients with Ph+ ALL in CR1 in CMR. Methods: We performed a multi-institutional, retrospective analysis of 186 patients ≥18 years of age who received induction therapy including TKI for Ph+ ALL from January 2001 through December 2018 and achieved a CMR CR1. Patients achieving CMR within 3 months of diagnosis were included. Sixty-six patients underwent HCT consolidation (HCT group) and 120 patients did not receive HCT in CR1 (no HCT group). Primary outcomes of interest were overall survival (OS), relapse free survival (RFS), cumulative incidence of relapse (CIR), non-relapse mortality (NRM), and GVHD free relapse free survival (GRFS). GRFS was defined as being alive without grade III-IV acute GVHD, extensive or systemic chronic GVHD requiring therapy, or relapse. Although GRFS in no HCT group should be exactly as RFS, GRFS comparison was done to compare the composite outcome of quality of life in addition to survival in two groups. Landmark analysis was performed at 3 months to ensure CMR in all subjects at time 0. Survival end points were estimated using Kaplan-Meier method and analyzed with the log-rank test and Cox proportional hazard regression models. Gray's test was used for the comparison of cumulative incidence between cohorts. Results: Patient characteristics at diagnosis are summarized in Table 1. Compared to the non-transplanted patients, HCT patients were younger (median age 45 years vs. 56 years, p <0.001) and had better performance status at diagnosis (Karnofsky score > 90% in 90% of patients vs. 60%, p<0.001). Among patients in the no HCT group, 92.5% were treated with TKI as maintenance therapy with 43% receiving the treatment for more than 3 years. In the HCT group, 86.4% underwent myeloablative conditioning, 81.8 % had a matched related or unrelated transplant, and 47% had TKI as maintenance therapy after transplantation. The rates of patients with transplantation-comorbidity index (HCT-CI) of 0, 1-2, and 3 or more at transplant were 26.7%, 33.3% and 40% respectively. Median follow-up for survivors was 73.2 months (range, 4.3-206 months). Among transplant patients, 65.2% developed acute GVHD with 48.8% of them having a maximum grade of 2. Additionally, 51.6% developed chronic GVHD. In both univariate and multivariate analysis, there was no statistically significant difference in OS or RFS between the two treatment groups (Figure 1A and 1B). Compared to the non-transplanted patients, HCT patients had higher rates of NRM (HR: 3.57; 95% CI: 1.62-7.85), lower rates of CIR (Figure 1C), and a trend toward lower GRFS (Figure 1D). Five-year estimates of the probabilities of OS, RFS, CIR, and GRFS were 65%, 59%, 21%, and 38% for allo-HCT group and 58%, 54%, 28%, and 54% for no allo-HCT group, respectively. Conclusions: Comparing transplant versus chemotherapy only consolidation in CR1, this multicenter retrospective study shows that adult patients with Ph+ ALL in CMR have similar estimates of OS and RFS. Lower CIR in the HCT group was offset by higher NRM, resulting in similar RFS. Results of this study need to be confirmed in a prospective randomized trial. Disclosures Ghobadi: Kite: Consultancy, Research Funding; BMS: Consultancy; Amgen: Consultancy, Research Funding; EUSA: Consultancy; WUGEN: Consultancy. Kantarjian:Janssen: Honoraria; Pfizer: Honoraria, Research Funding; Novartis: Honoraria, Research Funding; Jazz: Research Funding; Immunogen: Research Funding; Actinium: Honoraria, Membership on an entity's Board of Directors or advisory committees; Daiichi-Sankyo: Honoraria, Research Funding; Sanofi: Research Funding; Oxford Biomedical: Honoraria; BMS: Research Funding; Amgen: Honoraria, Research Funding; Abbvie: Honoraria, Research Funding; Ascentage: Research Funding; BioAscend: Honoraria; Aptitute Health: Honoraria; Adaptive biotechnologies: Honoraria; Delta Fly: Honoraria. Jabbour:AbbVie: Other: Advisory role, Research Funding; Adaptive Biotechnologies: Other: Advisory role, Research Funding; Genentech: Other: Advisory role, Research Funding; BMS: Other: Advisory role, Research Funding; Amgen: Other: Advisory role, Research Funding; Takeda: Other: Advisory role, Research Funding; Pfizer: Other: Advisory role, Research Funding. Short:Astellas: Research Funding; Amgen: Honoraria; AstraZeneca: Consultancy; Takeda Oncology: Consultancy, Honoraria, Research Funding. Uy:Daiichi Sankyo: Consultancy; Astellas Pharma: Honoraria; Agios: Consultancy; Pfizer: Consultancy; Jazz Pharmaceuticals: Consultancy; Genentech: Consultancy. DiPersio:Magenta Therapeutics: Membership on an entity's Board of Directors or advisory committees. Champlin:Actinium: Consultancy; Johnson and Johnson: Consultancy; DKMS America: Membership on an entity's Board of Directors or advisory committees; Genzyme: Speakers Bureau; Takeda: Patents & Royalties; Cytonus: Consultancy; Omeros: Consultancy. Ravandi:Macrogenics: Research Funding; Amgen: Consultancy, Honoraria, Research Funding; Orsenix: Consultancy, Honoraria, Research Funding; Xencor: Consultancy, Honoraria, Research Funding; AstraZeneca: Consultancy, Honoraria; Abbvie: Consultancy, Honoraria, Research Funding; Jazz Pharmaceuticals: Consultancy, Honoraria, Research Funding; Celgene: Consultancy, Honoraria; BMS: Consultancy, Honoraria, Research Funding; Astellas: Consultancy, Honoraria, Research Funding. Kebriaei:Amgen: Other: Research Support; Jazz: Consultancy; Pfizer: Other: Served on advisory board; Kite: Other: Served on advisory board; Novartis: Other: Served on advisory board; Ziopharm: Other: Research Support.

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Genomic Data Improves Prognostic Stratification in Adult T-Cell Acute Lymphoblastic Leukemia Patients Enrolled in Measurable Residual Disease-Oriented Trials

Blood ◽

10.1182/blood-2021-148263 ◽

2021 ◽

Vol 138 (Supplement 1) ◽

pp. 3486-3486

Author(s):

Celia González-Gil ◽

Mireia Morgades ◽

Francisco Fuster-Tormo ◽

Jesus García-Chica ◽

Pau Montesinos ◽

...

Keyword(s):

Acute Lymphoblastic Leukemia ◽

Board Of Directors ◽

Research Funding ◽

Residual Disease ◽

Lymphoblastic Leukemia ◽

Prognostic Significance ◽

Gene Signature ◽

Advisory Committees ◽

Cell Acute Lymphoblastic Leukemia ◽

Measurable Residual Disease

Abstract Background: Genetic information has become critical to understand the development of T-cell acute lymphoblastic leukemia (T-ALL) and to elucidate the origin of disease relapse. Several genetic markers, together with measurable residual disease (MRD), are considered strong predictors of patient outcome. However, the prognostic significance of genetic markers can varie according to treatment. Aim: We used targeted deep sequencing to analyze the genetic profile of 125 T-ALL patients enrolled in three consecutive MRD-oriented trials from the Spanish PETHEMA (Programa Español de Tratamientos en Hematología) group. Genomic information was analyzed together with the main clinical and biologic data in a subset of 111 patients with detailed clinical and outcome data to determine the prognostic significance for overall survival (OS) and cumulative incidence of relapse (CIR). Methods: Genetic mutations were detected using a custom gene panel and sequenced on a MiSeq platform. Alignment, variant calling, filtration and annotation of variants were done using standardized pipelines. OS curves were plotted by the Kaplan-Meier method and compared by the log-rank test. CIR was estimated using cumulative incidence functions by competing risks analysis. A Cox proportional hazard regression model was used to identify predictive factors for OS. Statistical significance was set at (two-sided) p-values <0.05. Results: Recurrently mutated genes found in ≥4/125 patients involved transcription factor tumor suppressor genes (PTEN, BCL11B, RUNX1, GATA3, ETV6), epigenetic regulators (PHF6, DNMT3A, EP300, KMT2C, EZH2, TET2), DNA mismatch repair genes (MSH2), ribosomal (RPL5) and RNA splicing (U2AF1) genes, and genes involved in the RAS/MAPK (NRAS), WNT (FAT1, FAT3), IL7R-JAK-STAT (JAK3, JAK1, IL7R) and NOTCH1 signaling pathways, respectively. Mutations in the latest pathway (NOTCH1 & FBXW7) was found in 88/125 (70%) patients. Clinical-genetic correlations revealed that patients with mutations in JAK3, DNMT3A, N/KRAS, IL7R, MSH2 or in U2AF1 were associated with lower OS (vs unmutated patients). None of the mutated genes had impact on CIR. Upon grouping the mutated genes according to their functional role and potential biological impact on T-ALL, two gene signatures were defined. These included the aging gene signature (DNMT3A and U2AF1) characterized by mutations in genes identified in clonal hematopoiesis of indeterminate potential (CHIP); and the treatment resistance gene signature (JAK3, N/KRAS, IL7R and MSH2), defined by mutations in genes involved in resistance to the ALL therapy. Both clusters identified patients with poorer response to therapy (poorer blast clearance on day 14 of induction treatment and lower CR rates). Therefore, we considered together (worse outcome genetics [WOG] signature) for univariate and multivariate analyses. WOG and MRD level (0.1% cut-off) on day 35 after induction therapy (+35d MRD) showed significant prognostic impact in the univariable and multivariable analyses for OS (3y) with a hazard ratio (95% CI) of 2.4 (1.2; 4.8) and 2.7 (1.4; 5.1), respectively (Table 1). OS according to these two variables allowed risk stratification of T-ALL into low, intermediate- and high-risk (HR) patients with significantly different outcomes (p<0.001) (Figure 1). Conclusion: A genetic signature with independent prognostic significance of MRD has been identified in this cohort of patients included in MRD-oriented trials. This gene signature (WOG) together with MRD could help to improve risk-stratification of adult T-ALL patients and would be of interest in the search for new therapies for HR patients Funding: Support from AECC (GC16173697BIGA); ISCIII (PI19/01828 and PI19/01183), co-funded by ERDF/ESF, "A way to make Europe"/"Investing in your future", CERCA/Generalitat de Catalunya SGR 2017 288 (GRC)/ C González-Gil was supported by AGAUR grant (2020 FI_B2 00210). Figure 1 Figure 1. Disclosures Diaz-Beyá: Jazz: Membership on an entity's Board of Directors or advisory committees, Speakers Bureau; Astellas: Membership on an entity's Board of Directors or advisory committees, Speakers Bureau; Novartis: Membership on an entity's Board of Directors or advisory committees, Speakers Bureau; Celgene: Membership on an entity's Board of Directors or advisory committees, Speakers Bureau. Mercadal: Gilead Sciences, Inc.: Honoraria, Speakers Bureau; Roche: Honoraria, Membership on an entity's Board of Directors or advisory committees, Speakers Bureau. Tormo: Astellas: Consultancy, Membership on an entity's Board of Directors or advisory committees, Speakers Bureau; Novartis: Consultancy, Membership on an entity's Board of Directors or advisory committees, Speakers Bureau; Jazz Pharmaceuticals: Consultancy, Membership on an entity's Board of Directors or advisory committees, Speakers Bureau; Pfizer: Consultancy, Membership on an entity's Board of Directors or advisory committees, Speakers Bureau; Amgen: Consultancy, Membership on an entity's Board of Directors or advisory committees, Speakers Bureau. Barba: Amgen, Celgene, Gilead, Incyte, Jazz Pharmaceuticals, MSD, Novartis, Pfizer and Roche, Jazz Phar,aceuticals: Honoraria; Cqrlos III heqlth Institute, aSOCIACION espanola contra el cancer, PERIS: Research Funding. Maciejewski: Regeneron: Consultancy; Novartis: Consultancy; Bristol Myers Squibb/Celgene: Consultancy; Alexion: Consultancy. Ribera: ARIAD: Consultancy, Research Funding, Speakers Bureau; AMGEN: Consultancy, Research Funding, Speakers Bureau; Pfizer: Consultancy, Research Funding, Speakers Bureau; TAKEDA: Consultancy, Research Funding, Speakers Bureau; NOVARTIS: Consultancy, Speakers Bureau; SHIRE: Consultancy, Speakers Bureau.

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Outcome after Inotuzumab Ozogamicin for Patients with Relapsed or Refractory B-Cell Acute Lymphoblastic Leukemia and Extramedullary Disease

Blood ◽

10.1182/blood-2021-147446 ◽

2021 ◽

Vol 138 (Supplement 1) ◽

pp. 3404-3404

Author(s):

Sabine Kayser ◽

Chiara Sartor ◽

Marlise R. Luskin ◽

Jonathan Webster ◽

Fabio Giglio ◽

...

Keyword(s):

Bone Marrow ◽

Board Of Directors ◽

Research Funding ◽

Progressive Disease ◽

Lymphoblastic Leukemia ◽

Response Assessment ◽

Inotuzumab Ozogamicin ◽

Advisory Committees ◽

Pet Ct ◽

Cell Acute Lymphoblastic Leukemia

Abstract Background: Extramedullary B-cell acute lymphoblastic leukemia (EM-ALL) is a rare occurrence characterized by dismal outcome and no defined therapeutic approach. The monoclonal antibody inotuzumab ozogamicin (InO) is approved for treatment of CD22+ B-ALL. Aims: To characterize a series of relapsed/refractory (r/r) adult EM-ALL patients (pts) and evaluate outcome after treatment with InO. Methods: We studied 31 r/r pts (median age, 31 years; range, 19-81 years), who were treated with InO between 2015 and 2021 within a compassionate use program (n=7) or on-label after FDA or EMA approval (n=24) All pts were CD22 positive at relapse/progressive disease. Up to 6 InO cycles (≤2 cycles, n=19; 3-4 cycles, n=7; 5-6 cycles, n=5) were administered according to the previously approved regimen. EM response assessment was performed by CT or PET-CT. Prior therapy consisted of intensive chemotherapy +/- tyrosine kinase inhibitors. Allogeneic hematopoietic stem cell transplantation (allo-SCT) was performed in 18 pts (first line or at relapse, n=9, each). Prior to InO, blinatumomab was administered in n=14 and local irradiation in n=5 pts. Results: Overall, pts had in median 2 EM manifestations (range, 1-9). Localization of EM disease is shown in Table 1. In addition to EM disease, n=16 (52%) pts had a relapse in bone marrow. At the time of r/r EM-ALL median white blood cell and platelet counts were 5.1/nl (range, 0.04-24.7/nl) and 110.5/nl (range, 6-337/nl), respectively. Fifteen pts (48%) were female; ECOG was ≤ 2 in 29 pts and 3 in 2 pts. Cytogenetic analysis at the time of r/r EM-ALL was available in 13 (42%) pts. Of those, 6 pts had a normal karyotype, 4 were complex, 2 pts displayed a t(9;22) and 1 had an additional X-chromosome. Seven (23%) of the 31 pts had no response assessment after the first induction cycle including 1 patient who died at day 11 of the first InO cycle due to cerebral hemorrhage. Complete remission assessed by PET-CT (CR; including EM and hematological/bone marrow CR) after the first InO cycle was achieved in 10 of 24 assessed pts (42%), 9 pts (37.5%) had a partial remission (PR), 2 (8%) had stable disease (SD) and 3 (12.5%) showed resistant/progressive disease (RD/PD). After 2 InO cycles, CR was achieved in 17 of 31 pts (55%), PR in 9 (29%); 1 patient (3%) experienced early death and 4 pts with SD+RD/PD did not receive further InO treatment (13%). Median follow-up was 29 months (95%-CI, 21 months - not reached) and median overall survival (OS) 12.8 months (95%-CI, 9.9-16.2 months; Figure 1). One-year and 2-years OS rates were 53% (95%-CI, 37-76%) and 18% (95%-CI, 8-43%), respectively. In Cox regression analysis age as a continuous variable had no impact on OS (P=0.83). This was also true when using 60 years as cut-off (P=0.2). Twelve pts went on to allo-SCT (CR, n=6; PR, n=3; PD, n=3). Prior to allo-SCT 8 pts received ≤2 InO cycles and 4 pts ≤4 cycles. Sinusoidal obstruction syndrome (SOS) was reported in 1 patient after transplant; conditioning in this patient consisted of treosulfan/fludarabine/thiotepa. In pts achieving a CR after InO treatment (n=16), median OS was 10 months with no difference (P=0.80) in relapse-free survival (RFS) if an allo-SCT was performed (n=6) or not (n=10). There was no difference on OS (P=0.08) or RFS (P=0.2) if pts had EM manifestations only as compared to EM disease and bone marrow involvement. In patients with CR/PR after InO treatment, relapse occurred in 10 of 26 pts (38%; after allo-SCT, n=3); of those, all except than one succumbed of their disease. Two pts died in remission (sepsis, SOS/multi-organ failure, n=1; each). One patient experienced a molecular relapse, which could be successfully treated with InO again. Ten pts are in ongoing CR (n=9) or PR (n=1), including the patient with prior molecular relapse and InO re-exposure. Conclusions: This outcome analysis demonstrates that treatment with InO is an effective and promising approach in r/r-ALL patients with EM disease. However, allo-SCT alone seems not to be effective in maintaining disease control. Thus, autologous chimeric antigen receptor T-cells or advanced bi-specific antibodies as consolidation therapy should be evaluated in the future. Figure 1 Figure 1. Disclosures Webster: Pfizer: Consultancy; AmGen: Consultancy. Brunner: Keros Therapeutics: Consultancy; GSK: Research Funding; AstraZeneca: Research Funding; Aprea: Research Funding; Agios: Consultancy; Acceleron: Consultancy; Janssen: Research Funding; Takeda: Consultancy, Research Funding; BMS/Celgene: Consultancy, Research Funding; Novartis: Consultancy, Research Funding. Levis: AbbVie: Consultancy, Honoraria, Membership on an entity's Board of Directors or advisory committees; Amgen, Astellas Pharma, Daiichi-Sankyo, FujiFilm, and Menarini: Honoraria; Pfizer: Consultancy, Honoraria; Takeda: Honoraria; BMS: Consultancy, Honoraria, Membership on an entity's Board of Directors or advisory committees; Jazz: Consultancy, Honoraria; Astellas and FujiFilm: Research Funding. Schlenk: Agios: Honoraria; Astellas: Honoraria, Research Funding, Speakers Bureau; Celgene: Honoraria; Daiichi Sankyo: Honoraria, Research Funding; Hexal: Honoraria; Neovio Biotech: Honoraria; Novartis: Honoraria; Pfizer: Honoraria, Research Funding, Speakers Bureau; Roche: Honoraria, Research Funding; AstraZeneca: Research Funding; Boehringer Ingelheim: Research Funding; Abbvie: Honoraria. Papayannidis: Pfizer, Amgen, Novartis: Honoraria.

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Dysregulated Mirnas after Uniform Treatment Predict Outcome of Newly-Diagnosed Multiple Myeloma

Blood ◽

10.1182/blood-2019-130343 ◽

2019 ◽

Vol 134 (Supplement_1) ◽

pp. 4348-4348

Author(s):

Tessa Han ◽

Stephane Minvielle ◽

Anil Aktas Samur ◽

Mariateresa Fulciniti ◽

Florence Magrangeas ◽

...

Keyword(s):

Board Of Directors ◽

Research Funding ◽

Target Genes ◽

Progression Free Survival ◽

Rank Test ◽

Newly Diagnosed ◽

Advisory Committees ◽

Free Survival ◽

Paired Samples

Multiple myeloma (MM) is a malignancy of the plasma cell in which clonal plasma cells infiltrate the bone marrow. Although increasingly effective treatment has significantly improved management of the disease, most MM patients ultimately relapse. Previous studies suggest that miRNA expression patterns may function as biomarkers for diagnosis, subtyping, and prognosis of the disease. However, the role of miRNAs in MM relapse and prognosis is not sufficiently understood. Therefore, in this study, we sought to understand the biological and prognostic role of dysregulated miRNAs between newly diagnosed and relapsed MM. We performed RNA-seq as well as microarray-based miRNA profiling on 319 MM samples from newly diagnosed MM patients enrolled in the 2009 IFM/DFCI clinical trial. This included 40 samples from patients with paired samples from diagnosis and at relapse while we had additional 239 samples collected at the time of diagnosis. Using the 40 diagnosis-relapse paired samples, we identified 48 miRNAs that are differentially expressed between diagnosis and relapse (FDR < 0.15). Of these 48 miRNAs, we found five miRNAs (miR-4484, miR-663b, miR-3687, miR-670-5p, miR-4417) whose expression level at diagnosis, expression level at relapse, and log2FC from diagnosis to relapse were significantly associated with overall survival or progression-free survival among the 40 patients with paired samples (p < 0.05). We next investigated the prognostic role of these five miRNAs through unsupervised hierarchical clustering of 239 independent, newly diagnosed MM samples. The two groups identified by the unsupervised hierarchical clustering differed significantly in both overall survival (log rank test, p = 0.009) and progression-free survival (log rank test, p = 0.012), suggesting that these five miRNAs are predictive of disease prognosis. We then performed an integrative analysis of the miRNA and mRNA expression data in our cohort of newly diagnosed samples and identified the potential protein-coding target genes of these five miRNAs. We further filtered the target gene list using TargetScan which predicts the biological targets of miRNAs by searching for the presence of conserved 8mer, 7mer, and 6mer sites that match the seed region of each miRNA. After filtering the target genes, we found that each miRNA targets 126 mRNAs [range 26 - 258] and key MM genes, including MAF, BCL2, 14-3-3 and MYEOV, were among the top candidates. The target genes of these select miRNAs are involved in such biological pathways as NF-kB signaling, antigen processing and presentation of endogenous peptide antigen via MHC class I via ER pathway, and positive regulation of cell death and apoptosis. In conclusion, this integrative analysis of miRNA and mRNA expression data from uniformly treated MM samples offers a unique perspective on the role of miRNAs in MM biology and prognosis. The study identified five miRNAs that target key MM genes, play a role in the biological processes associated with MM progression, and carry prognostic information predictive of overall and progression-free survival with prospect for future therapeutic application. Disclosures Richardson: Amgen: Membership on an entity's Board of Directors or advisory committees; Janssen: Membership on an entity's Board of Directors or advisory committees; Bristol-Myers Squibb: Research Funding; Takeda: Membership on an entity's Board of Directors or advisory committees, Research Funding; Celgene: Membership on an entity's Board of Directors or advisory committees, Research Funding; Oncopeptides: Membership on an entity's Board of Directors or advisory committees, Research Funding; Karyopharm: Membership on an entity's Board of Directors or advisory committees; Sanofi: Membership on an entity's Board of Directors or advisory committees. Moreau:AbbVie: Consultancy, Honoraria; Amgen: Consultancy, Honoraria; Takeda: Consultancy, Honoraria; Celgene: Consultancy, Honoraria; Janssen: Consultancy, Honoraria. Anderson:Sanofi-Aventis: Other: Advisory Board; Bristol-Myers Squibb: Other: Scientific Founder; Oncopep: Other: Scientific Founder; Amgen: Consultancy, Speakers Bureau; Janssen: Consultancy, Speakers Bureau; Takeda: Consultancy, Speakers Bureau; Celgene: Consultancy, Speakers Bureau. Munshi:Celgene: Consultancy; Amgen: Consultancy; Adaptive: Consultancy; Abbvie: Consultancy; Janssen: Consultancy; Takeda: Consultancy; Oncopep: Consultancy.

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MGA deletion Leads to Richter's Transformation Via NME1

Blood ◽

10.1182/blood-2021-148953 ◽

2021 ◽

Vol 138 (Supplement 1) ◽

pp. 252-252

Author(s):

Prajish Iyer ◽

Bo Zhang ◽

Tingting Liu ◽

Meiling Jin ◽

Kevyn Hart ◽

...

Keyword(s):

B Cells ◽

Cell Growth ◽

Mitochondrial Dysfunction ◽

Board Of Directors ◽

Cell Lines ◽

Research Funding ◽

Leukemic Cells ◽

Aggressive Lymphoma ◽

Advisory Committees

Abstract Although large-scale sequencing studies have elucidated key mutations in chronic lymphocytic leukemia (CLL), the molecular pathways underlying CLL transition to aggressive lymphoma (Richter's transformation, RT) are not completely understood. Co-expression of the two most common human CLL genomic alterations, 13q deletion, and SF3B1 mutation, in murine B cells results in indolent CLL. Seventy percent of RT cases involve MYC network aberrations, and MGA (Max-gene-associated), a functional MYC suppressor, is recurrently mutated/deleted in ~10% of RT cases. Given the function of MGA in MYC dysregulation, we sought to determine if loss-of-function MGA mutations accelerate CLL transformation. To determine the function of Mga deletion in CLL-RT, we in-vitro edited the genome of LSK (Lin - Sca-1 + Kit +) cells derived from the conditional CD19Cre/Cas9(GFP)/Mdr/Sf3b1-expressing mice (donor mice:CD45.2) to introduce Mga deletion in B cells with Mdr and the Sf3b1K700E mutations. Mga and control sgRNAs were lentivirally transduced in LSK cells and then transplanted into sub-lethally irradiated recipient mice (N=15, per group; C57BL/6: CD45.1). CLL onset (B220 +CD5 + CLL-like cells) was monitored bimonthly by flow-cytometry of peripheral blood, between ages 6 and 24 months. Three of 15 mice with Mga deletion had a clonal expansion of B220 +CD5 + cells with leukemic cells infiltration in the spleen and bone marrow by 21-months of age. However, no RT signs were observed in these mice. Transplantation of the CLL-like splenic cells into immunocompromised NSG or immunocompetent sub-lethally irradiated CD45.1 mice, led to rapid expansion of B220 + cells along with CD5 loss at 3 weeks post-engraftment and leukemic cells infiltrated various lymphoid tissues. H&E staining of splenic sections revealed the presence of CLL-like cells with a morphology resembling leukemia in the primary engrafted mice; however, these cells were larger and resembled aggressive lymphoma (RT) upon secondary engraftment. CLL and RT features were further confirmed by IHC staining of PAX5, CD5, Ki67, and MYC, suggesting the establishment of a murine CLL-to-RT transition murine model. MYC was reported to contribute to cell growth by promoting mitochondrial dysfunction. To characterize mitochondrial changes in our RT model, oxidative phosphorylation (OXPHOS) was measured by Seahorse, and electron microscopy was performed on RT and no disease splenic B cells. Murine RT cells exhibited increased basal respiration and mitochondrial mass coupled with elevated mitochondria number and structural changes. To pinpoint the underlying transcriptional program, we performed RNA seq using splenic B cells derived from control, CLL, and RT mice. Through differential gene expression analysis, we identified >200 genes (mainly hallmark MYC targets and OXPHOS associated pathways) associated with CLL and RT. Of the 75 upregulated genes shared between CLL and RT cells, we focused on Nme1 (Nucleoside diphosphate kinase), an MGA transcriptional target reported in human lung adenocarcinoma. We confirmed Nme1 upregulation at both RNA and protein levels in murine and human RT samples by RT-PCR, immunoblot, and IHC, implicating a role of NME1 during CLL to RT transition. To determine if the MGA/MYC/NME1 axis can be recapitulated in human cells, we generated combined genetic lesions in two human B-cell lines (harboring SF3B1K700E Nalm6E [E] or control Nalm6K [K]) by Crispr-Cas9 mediated deletion of MGA and MDR. In both MGA and MDR-MGA KO(Knockout) cells, NME1 RNA and protein were upregulated. MGA KO E cells displayed a mixture of large and small-sized cells with increased cell growth whereas K cells had no morphology change. Moreover, large E cells displayed increased mitochondria mass, basal and maximal OXPHOS, broken cristae, fully recapitulating the mitochondrial dysfunction observed in murine RT cells. Harnessing these cell lines, we discovered that NME1 KO diminished cell growth and OXPHOS in E/K cells, which can be rescued by NME1 overexpression, highlighting an essential but unrecognized role of NME1 in driving the CLL-RT transition. With our established murine CLL-to-RT model, we demonstrated an RT-associated mitochondrial phenotype and revealed a novel role of the MGA/MYC/NME1 axis in driving the CLL-to-RT transition through mitochondrial regulation. This study opens a new therapeutic avenue for RT patients by targeting the MGA/MYC/NME1 axis. Figure 1 Figure 1. Disclosures Siddiqi: Juno Therapeutics: Membership on an entity's Board of Directors or advisory committees, Research Funding; BeiGene: Membership on an entity's Board of Directors or advisory committees, Research Funding, Speakers Bureau; AstraZeneca: Membership on an entity's Board of Directors or advisory committees, Speakers Bureau; Pharmacyclics LLC, an AbbVie Company: Membership on an entity's Board of Directors or advisory committees, Research Funding, Speakers Bureau; Kite Pharma: Membership on an entity's Board of Directors or advisory committees, Research Funding; BMS: Membership on an entity's Board of Directors or advisory committees, Research Funding, Speakers Bureau; Celgene: Membership on an entity's Board of Directors or advisory committees; Janssen: Speakers Bureau; Oncternal: Research Funding; TG Therapeutics: Research Funding. Danilov: Abbvie: Consultancy, Honoraria; Takeda Oncology: Research Funding; Genentech: Consultancy, Honoraria, Research Funding; TG Therapeutics: Consultancy, Research Funding; Beigene: Consultancy, Honoraria; Pharmacyclics: Consultancy, Honoraria; Gilead Sciences: Research Funding; Bristol-Meyers-Squibb: Honoraria, Research Funding; Rigel Pharm: Honoraria; Bayer Oncology: Consultancy, Honoraria, Research Funding; SecuraBio: Research Funding; Astra Zeneca: Consultancy, Honoraria, Research Funding.

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A novel PAX5-ELN fusion protein identified in B-cell acute lymphoblastic leukemia acts as a dominant negative on wild-type PAX5

Blood ◽

10.1182/blood-2006-05-025221 ◽

2006 ◽

Vol 109 (8) ◽

pp. 3417-3423 ◽

Cited By ~ 55

Author(s):

Marina Bousquet ◽

Cyril Broccardo ◽

Cathy Quelen ◽

Fabienne Meggetto ◽

Emilienne Kuhlein ◽

...

Keyword(s):

Acute Lymphoblastic Leukemia ◽

B Cell ◽

Target Genes ◽

Lymphoblastic Leukemia ◽

Quantitative Polymerase Chain Reaction ◽

Dominant Negative ◽

Leukemic Cells ◽

Dominant Negative Effect ◽

Wild Type ◽

Cell Acute Lymphoblastic Leukemia

Abstract We report a novel t(7;9)(q11;p13) translocation in 2 patients with B-cell acute lymphoblastic leukemia (B-ALL). By fluorescent in situ hybridization and 3′ rapid amplification of cDNA ends, we showed that the paired box domain of PAX5 was fused with the elastin (ELN) gene. After cloning the full-length cDNA of the chimeric gene, confocal microscopy of transfected NIH3T3 cells and Burkitt lymphoma cells (DG75) demonstrated that PAX5-ELN was localized in the nucleus. Chromatin immunoprecipitation clearly indicated that PAX5-ELN retained the capability to bind CD19 and BLK promoter sequences. To analyze the functions of the chimeric protein, HeLa cells were cotransfected with a luc-CD19 construct, pcDNA3-PAX5, and with increasing amounts of pcDNA3-PAX5-ELN. Thus, in vitro, PAX5-ELN was able to block CD19 transcription. Furthermore, real-time quantitative polymerase chain reaction (RQ-PCR) experiments showed that PAX5-ELN was able to affect the transcription of endogenous PAX5 target genes. Since PAX5 is essential for B-cell differentiation, this translocation may account for the blockage of leukemic cells at the pre–B-cell stage. The mechanism involved in this process appears to be, at least in part, through a dominant-negative effect of PAX5-ELN on the wild-type PAX5 in a setting ofPAX5 haploinsufficiency.

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Role of Remission Status and Prior Transplant in Optimizing Survival Outcomes Following Allogeneic Hematopoietic Stem Transplantation (HSCT) in Patients Who Received Inotuzumab Ozogamicin (INO) for Relapsed / Refractory (R/R) Acute Lymphoblastic Leukemia (ALL)

Blood ◽

10.1182/blood.v130.suppl_1.886.886 ◽

2017 ◽

Vol 130 (Suppl_1) ◽

pp. 886-886

Author(s):

Partow Kebriaei ◽

Matthias Stelljes ◽

Daniel J. DeAngelo ◽

Nicola Goekbuget ◽

Hagop M. Kantarjian ◽

...

Keyword(s):

Board Of Directors ◽

Survival Probability ◽

Research Funding ◽

Employment Equity ◽

Inotuzumab Ozogamicin ◽

Advisory Committees ◽

Allogeneic Hsct ◽

Post Transplant ◽

Equity Ownership

Abstract Introduction: Attaining complete remission (CR) prior to HSCT is associated with better outcomes post-HSCT. Inotuzumab ozogamicin (INO), an anti-CD22 antibody conjugated to calicheamicin, has shown significantly higher remission rates (CR/CRi and MRD negativity) compared with standard chemotherapy (SC) in patients (pts) with R/R ALL (Kantarjian et al. N Engl J Med. 2016). Pts treated with INO were more likely to proceed to HSCT than SC, which allowed for a higher 2-yr probability of overall survival (OS) than patients receiving SC (39% vs 29%). We investigated the role of prior transplant and proceeding directly to HSCT after attaining remission from INO administration as potential factors in determining post-HSCT survival to inform when best to use INO in R/R ALL patients. Methods: The analysis population consisted of R/R ALL pts who were enrolled and treated with INO and proceeded to allogeneic HSCT as part of two clinical trials: Study 1010 is a Phase 1/2 trial (NCT01363297), while Study 1022 is the pivotal randomized Phase 3 (NCT01564784) trial. Full details of methods for both studies have been previously published (DeAngelo et al. Blood Adv. 2017). All reference to OS pertains to post-HSCT survival defined as time from HSCT to death from any cause. Results: As of March 2016, out of 236 pts administered INO in the two studies (Study 1010, n=72; Study 1022, n=164), 101 (43%) proceeded to allogeneic HSCT and were included in this analysis. Median age was 37 y (range 20-71) with 55% males. The majority of pts received INO as first salvage treatment (62%) and 85% had no prior SCT. Most pts received matched HSCTs (related = 25%; unrelated = 45%) with peripheral blood as the predominant cell source (62%). The conditioning regimens were mainly myeloablative regimens (60%) and predominantly TBI-based (62%). Dual alkylators were used in 13% of pts, while thiotepa was used in 8%. The Figure shows post-transplant survival in the different INO populations: The median OS post-HSCT for all pts (n=101) who received INO and proceeded to HSCT was 9.2 mos with a 2-yr survival probability of 41% (95% confidence interval [CI] 31-51%). In patients with first HSCT (n=86) the median OS post-HSCT was 11.8 mos with a 2-yr survival probability of 46% (95% CI 35-56%). Of note, some patients lost CR while waiting for HSCT and had to receive additional treatments before proceeding to HSCT (n=28). Those pts who went directly to first HSCT after attaining remission with no intervening additional treatment (n=73) fared best, with median OS post-HSCT not reached with a 2-yr survival probability of 51% (95% CI 39-62%). In the latter group, 59/73 (80%) attained MRD negativity, and 49/73 (67%) were in first salvage therapy. Of note, the post-HSCT 100-day survival probability was similar among the 3 groups, as shown in the Table. Multivariate analyses using Cox regression modelling confirmed that MRD negativity during INO treatment and no prior HSCT were associated with lower risk of mortality post-HSCT. Other prognostic factors associated with worse OS included older age, higher baseline LDH, higher last bilirubin measurement prior to HSCT, and use of thiotepa. Veno-occlusive disease post-transplant was noted in 19 of the 101 pts who received INO. Conclusion: Administration of INO in R/R ALL pts followed with allogeneic HSCT provided the best long-term survival benefit among those who went directly to HSCT after attaining remission and had no prior HSCT. Disclosures DeAngelo: Glycomimetics: Research Funding; Incyte: Consultancy, Honoraria; Blueprint Medicines: Honoraria, Research Funding; Takeda Pharmaceuticals U.S.A., Inc.: Honoraria; Shire: Honoraria; Pfizer Inc.: Consultancy, Honoraria, Research Funding; Novartis Pharmaceuticals Corporation: Consultancy, Honoraria, Research Funding; BMS: Consultancy; ARIAD: Consultancy, Research Funding; Immunogen: Honoraria, Research Funding; Celgene: Research Funding; Amgen: Consultancy, Research Funding. Kantarjian: Novartis: Research Funding; Amgen: Research Funding; Delta-Fly Pharma: Research Funding; Bristol-Meyers Squibb: Research Funding; Pfizer: Research Funding; ARIAD: Research Funding. Advani: Takeda/ Millenium: Research Funding; Pfizer: Consultancy. Merchant: Pfizer: Consultancy, Research Funding. Stock: Amgen: Consultancy; Pfizer: Consultancy, Membership on an entity's Board of Directors or advisory committees; Seattle Genetics: Consultancy, Membership on an entity's Board of Directors or advisory committees. Wang: Pfizer: Employment, Equity Ownership. Zhang: Pfizer: Employment, Equity Ownership. Loberiza: Pfizer: Employment, Equity Ownership. Vandendries: Pfizer: Employment, Equity Ownership. Marks: Pfizer: Consultancy, Honoraria, Speakers Bureau; Amgen: Consultancy, Honoraria, Speakers Bureau.

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Phase I Study of Ixazomib Added to Chemotherapy in the Treatment of Acute Lymphoblastic Leukemia in Older Adults

Blood ◽

10.1182/blood-2020-139661 ◽

2020 ◽

Vol 136 (Supplement 1) ◽

pp. 41-42

Author(s):

Philip C. Amrein ◽

Karen K. Ballen ◽

Kristen E. Stevenson ◽

Traci M. Blonquist ◽

Andrew M. Brunner ◽

...

Keyword(s):

Overall Survival ◽

Acute Lymphoblastic Leukemia ◽

Complete Remission ◽

Board Of Directors ◽

Research Funding ◽

Lymphoblastic Leukemia ◽

Advisory Committees ◽

Survival Estimate ◽

Grade 3 ◽

Experienced Grade

Introduction: While progress has been made in the treatment of childhood leukemia, the outlook for patients >60 years of age with acute lymphoblastic leukemia (ALL) is poor with complete remission rates (CR) of approximately 60% and 3-year survivals (OS) of less than 15%. Intensified treatment in a later CALGB trial showed little improvement with a CR=61% and 5-year OS=6% (Stock, Cancer 2013). Ixazomib is an oral proteasome inhibitor, which has shown single agent activity and promising combination activity in pediatric ALL patients (Messinger, Blood 2012). We sought to assess the safety and tolerability, as well as early efficacy of adding ixazomib to a current MGH-DFCI/HCC multi-agent regimen for older adults with ALL. Methods: Patients aged 51 to 75 years of age with newly diagnosed B-ALL and T-ALL were screened for eligibility. Patients with mature ALL (including Burkitt's) were excluded. Patients with Philadelphia chromosome positive ALL (BCR-ABL1+) were eligible, and dasatinib was added to the chemotherapy on Day 10 for these patients. The chemotherapy treatment schedule from induction through maintenance is outlined in Table 1. A standard 3 + 3 patient cohort dose escalation design was used to determine the maximum tolerated dose (MTD) of ixazomib during induction for these patients, the primary objective of the trial. After consolidation I, patients in complete remission (CR) with a suitable donor were offered a hematopoietic stem cell transplantation (HSCT) as per institutional guidelines. Those not going to HSCT continued therapy as noted in the table. Results: There were 19 patients with B-ALL enrolled, none with T-ALL. Among these patients, 7 harbored BCR-ABL1 rearrangements. The median age was 65 years, 74% were male, and 90% had a performance status 0 or 1. The MTD was 2.3 mg of ixazomib, as 2 patients at 3.0 mg developed DLT's: a grade 3 peripheral neuropathy and a grade 5 acute kidney injury (Table 2). Grade 3 and 4 toxicities encountered at any time consisted mainly of grade 4 neutropenia in 13 patients and grade 4 thrombocytopenia in 12 patients. One patient experienced grade 3 neutropenia and 5 patients experienced grade 3 thrombocytopenia. Two patients with grade 2 neuropathy did not meet the definition of DLT. Among the 19 patients, 15 (79%, [95% confidence interval (CI), 54-94%]) achieved CR (14) or CRi (1), and 5 patients went on to HSCT. The median follow-up time was 2 years (range, 1-5) for 8 patients remaining alive. The 1-year overall survival estimate was 53% [95% CI, 29-72%], while the 2-year overall survival estimate was 47% [95% CI, 24-67%]. Conclusions: A dose of 2.3 mg of ixazomib in combination with induction chemotherapy among older patients with ALL was well-tolerated and associated with a promising rate of complete remission. Disclosures Amrein: Takeda: Research Funding; AstraZeneca: Consultancy, Research Funding; Amgen: Research Funding. Brunner:Celgene: Membership on an entity's Board of Directors or advisory committees, Research Funding; Takeda: Research Funding; AstraZeneca: Research Funding; Forty-Seven Inc: Membership on an entity's Board of Directors or advisory committees; Jazz Pharmaceuticals: Membership on an entity's Board of Directors or advisory committees; Novartis: Research Funding. Hobbs:Novartis: Honoraria; Celgene/BMS: Honoraria; Jazz: Honoraria; Constellation: Honoraria, Research Funding; Incyte: Research Funding; Merck: Research Funding; Bayer: Research Funding. Neuberg:Celgene: Research Funding; Pharmacyclics: Research Funding; Madrigak Pharmaceuticals: Current equity holder in publicly-traded company. Fathi:Takeda: Consultancy, Research Funding; Agios: Consultancy, Research Funding; PTC Therapeutics: Consultancy; Amphivena: Consultancy; Astellas: Consultancy; Daiichi Sankyo: Consultancy; Novartis: Consultancy; Newlink Genetics: Consultancy; Pfizer: Consultancy; Blueprint: Consultancy; Trillium: Consultancy; Kura Oncology: Consultancy; Forty Seven: Consultancy; Jazz: Consultancy; Boston Biomedical: Consultancy; BMS/Celgene: Consultancy, Research Funding; Kite: Consultancy; Trovagene: Consultancy; Amgen: Consultancy; Seattle Genetics: Consultancy, Research Funding; Abbvie: Consultancy. OffLabel Disclosure: MLN 9708, ixazomib is FDA approved for multiple myeloma. In this trial it is used to treat acute lymphoblastic leukemia.

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