Clinical and Molecular Characteristics Associated with Vitamin C Deficiency in Myeloid Malignancies; Real World Data from a Prospective Cohort

Abstract Background: Vitamin C is an essential water-soluble vitamin required for many redox reactions in our body and its deficiency causes scurvy, a well characterized disease with multiple hematological manifestations. Studies dating back to 1950's demonstrated that patients with myeloid neoplasms tend to have lower plasma levels of vitamin C than healthy controls. Recent studies have shown that as much as 80% of patients with hematological malignancies in a cohort from Denmark had low vitamin C levels. Myeloid neoplasms tend to harbor mutations in epigenetic regulators which play a role in DNA methylation. One such mutation commonly seen in myeloid neoplasms and clonal hematopoiesis of indeterminate potential (CHIP) is TET2 for which vitamin C serves as a cofactor. There is a scarcity of clinical data on patients with low vitamin C level in myeloid neoplasms. Our study investigated the rates of vitamin C deficiency and the disease clinical and genomic characteristics associated with it at our center. Methods: We retrospectively collected data from a prospectively maintained list of patients treated for myeloid neoplasms at a large tertiary cancer center on whom vitamin C levels where serially collected during the study period. We obtained multiple baseline characteristics at the time of diagnosis including cytogenetic and molecular mutational data. Baseline characteristics were defined using descriptive statistics. Categorical variables were compared using a Fisher's exact test and continuous variables were analyzed using Mann Whitney U test for statistical significance. Institutional review board approval was obtained for the study. Statistical analysis was done using R Studio version 1.4.1717. Results: A total of 50 patients with myeloid neoplasms were identified with vitamin C levels available at least once during the study period. Nine (18%) patients had a low vitamin C level (LOW) defined as less than 0.4 mg/dl as per the Mayo lab testing with a reference range between 0.4 to 2.0 mg/dl. Baseline characteristics of patients with low vitamin C level and patients with normal vitamin C level (NORMAL) are shown in Table 1. The median vitamin C level in the LOW group was 0.2 mg/dl and NORMAL group was 1 mg/dl (p <0.001). The median age at diagnosis for patients in the LOW cohort was 64 years compared to 72 years for patients with normal vitamin C level (p = 0.015). Twenty-two (53.6%) of patients were female in the NORMAL cohort while six patients (66.7%) were females in the LOW cohort (p=NS). In the vitamin C LOW group only 55% of the patients were white compared to 83% in the NORMAL group (p = 0.093). The majority of patients in the Vit C LOW group had acute myeloid leukemia (AML) 44.5%, compared to 9.8% in the group with normal vitamin C levels (p = 0.03). Median white blood cell count, platelet counts, peripheral blast count and bone marrow blast count were not statistically significant amongst the 2 groups. Majority of patients in both groups 56.1% (NORMAL) vs 77.8% (LOW) had normal cytogenetics at the time of diagnosis (p = 0.284). There was a higher tendency to harbor ASXL1 and IDH2 mutation in the cohort with LOW levels 44.5% (p = 0.09) and 22.2% (p value = 0.143) compared to 17% and 4.8% respectively in the NORMAL cohort. Conclusions: Our analysis of the baseline characteristics of patients with myeloid neoplasms with vitamin C levels reveals interesting findings including a lower age at diagnosis for patients with low vitamin C levels and higher proportion of patients with acute myeloid leukemia compared to the cohort with normal levels. We also noted a higher tendency for occurrence of certain molecular mutations including ASXL1 and IDH2 among the patients with low vitamin C level. With recent papers implicating the role of ASXL1 in leukaemogenesis these findings suggest the hypothesis that vitamin C deficiency could accelerate clonal evolution with a higher tendency to transform into acute leukemia at a lower age. Further multi-institutional studies are needed to understand the relevance of low vitamin C level in myeloid neoplasms and the role of therapeutic vitamin C supplementation to retard leukaemogenesis. Figure 1 Figure 1. Disclosures Patel: Celgene-BMS: Membership on an entity's Board of Directors or advisory committees; Agios: Membership on an entity's Board of Directors or advisory committees; PVI: Honoraria. Awan: Cardinal Health: Consultancy; Abbvie: Consultancy; Merck: Consultancy; Beigene: Consultancy; Johnson and Johnson: Consultancy; Astrazeneca: Consultancy; BMS: Consultancy; Janssen: Consultancy; Genentech: Consultancy; Dava Oncology: Consultancy; Verastem: Consultancy; ADCT therapeutics: Consultancy; Incyte: Consultancy; MEI Pharma: Consultancy; Karyopharm: Consultancy; Kite pharma: Consultancy; Celgene: Consultancy; Gilead sciences: Consultancy; Pharmacyclics: Consultancy. Anderson: Celgene, BMS, Janssen, GSK, Karyopharm, Oncopeptides, Amgen: Consultancy, Honoraria, Membership on an entity's Board of Directors or advisory committees, Research Funding. Madanat: Blue Print Pharmaceutical: Honoraria; Stem line pharmaceutical: Honoraria; Onc Live: Honoraria; Geron Pharmaceutical: Consultancy.

Download Full-text

Azacitidine in Patients with Acute Myeloid Leukemia: Assessing the Potential Negative Impact of Elevated Baseline White Blood Cell Count on Outcome

Blood ◽

10.1182/blood.v124.21.3683.3683 ◽

2014 ◽

Vol 124 (21) ◽

pp. 3683-3683

Author(s):

Lisa Pleyer ◽

Sonja Burgstaller ◽

Reinhard Stauder ◽

Michael Girschikofsky ◽

Werner Linkesch ◽

...

Keyword(s):

Board Of Directors ◽

Myeloid Leukemia ◽

Research Funding ◽

Negative Impact ◽

Advisory Committees ◽

Treatment Line ◽

Baseline Characteristics ◽

Proliferative Disease ◽

Line Setting ◽

Acute Myeloid

Abstract Background Recent phase III data indicate that azacitidine (AZA) is active, and well tolerated, in patients with acute myeloid leukemia (AML) and baseline white blood cell (WBC) counts of <15G/L.1 However, few studies have assessed whether proliferative disease (WBC ≥15G/L) is a negative prognostic indicator in patients with World Health Organization (WHO)-AML treated with AZA.2,3 Methods In this retrospective study of the Austrian AZA Registry (N=346), we assessed outcomes in patients with WHO-AML who received ≥1 dose of AZA, according to baseline WBC count. Patients were divided according to WBC <15G/L (n=297) and ≥15G/L (n=49), and AZA treatment line. Baseline characteristics and outcomes were compared. Results A comparison of baseline characteristics between the two groups revealed significantly higher levels of serum lactate dehydrogenase (LDH), peripheral blood (PB) and bone marrow (BM) blasts in patients with WBC ≥15G/L vs those with WBC <15G/L, indicative of more proliferative disease (Figure 1). Other baseline characteristics were evenly matched between the groups. Overall, both groups received a median of 4 AZA cycles (range: 1‒24 and 1‒46 in the WBC ≥15G/L and <15G/L groups, respectively). Similar patient numbers received AZA 1st line (<15G/L, n=147; ≥15G/L, n=23) or ≥2nd line (<15G/L, n=150; ≥15G/L, n=26). In the 1st line setting, overall response rate (ORR) was similar in the WBC <15G/L and ≥15G/L groups according to International Working Group (IWG) 20034 (36.1 vs 34.8%; p=0.877), IWG 20065 (36.1 vs 34.8%; p=0.569) or combined (complete response [CR]/CR with incomplete blood count recovery [CRi]/partial response [PR]/hematologic improvement [HI]) criteria (55.8 vs 56.5%; p=0.950; Figure 1). Median overall survival (OS) was 12.8 vs 13.5 months (p=0.250; Figure 2a), respectively. In contrast, in the ≥2nd line setting, ORR was significantly higher in the WBC <15G/L than the ≥15G/L group (24.7 vs 7.7% [CR/CRi/PR], p=0.003; 40.7 vs 23.1% [CR/CRi/PR/HI], p=0.028). Median OS was higher in the WBC <15G/L group (7.5 vs 3.3 months; p=0.016; Figure 2b). Irrespective of treatment line, median response duration and relapse-free survival were numerically lower in the WBC ≥15G/L group. Different baseline factors appeared to significantly impact OS in the </≥15G/L cohorts. In the <15G/L group, but not the ≥15G/L group, PB blasts >0% and LDH >225IU/L negatively affected OS, irrespective of treatment line. Adverse cytogenetics reached statistical significance for the whole <15G/L cohort and in the AZA ≥2nd line setting, whereas Eastern Cooperative Oncology Group Performance Status (ECOG PS) was significant for the whole <15G/L cohort and in the AZA 1st line setting. The only baseline factor that significantly impacted OS in the ≥15G/L cohort was number of comorbidities >3, primarily in the AZA 1st line setting. Conclusions Previous retrospective studies have suggested that WBC ≥15G/L has a negative impact on OS in AML patients treated with AZA.2,3 This report is the first to describe the impact of WBC (<15G/L vs ≥15G/L) on outcomes in patients who received AZA in both 1st or ≥2nd line settings and indicates that AZA can elicit favorable clinical outcomes, even in patients with elevated WBC counts when treated with AZA 1st line. In particular, a median OS of 13.5 months in patients with WBC ≥15G/L treated with 1st line AZA, despite elevated PB and BM blasts, as well as elevated LDH levels, is encouraging. These data suggest that AZA could be an effective treatment option in patients with proliferative AML in the 1st line setting. This is currently an unmet medical need; elderly patients with proliferative AML ineligible for intensive chemotherapy generally only receive best supportive care with hydroxyurea, and outcomes are poor. Based on these ‘real world’ data, randomized trials should assess AZA in patients with proliferative AML. 1. Dombret H, et al. Oral presentation at EHA 2014. Abstract LB-2433 2. Thepot S, et al. Am J Hematol 2014;89:410–6 3. van der Helm LH, et al. Leuk Res 2013;37:877–82 4. Cheson BD, et al. J Clin Oncol 2003;21:4642–9 5. Cheson BD, et al. Blood 2006;108:419–25 Figure 1 Figure 1. Figure 2 Figure 2. Disclosures Pleyer: Celgene: Consultancy, Honoraria; AOP Orphan Pharmaceuticals: Honoraria; Novartis: Consultancy, Honoraria; Bristol-Myers Squibb: Consultancy, Honoraria. Off Label Use: Vidaza (azacitidine) is indicated for the treatment of adult AML patients who are not eligible for haematopoietic stem cell transplantation with 20–30 % blasts and multi-lineage dysplasia, according to WHO classification. This cohort also includes AML-patients with >30% bone marrow blasts.. Burgstaller:AOP Orphan Pharmaceuticals: Honoraria; Novartis: Honoraria; Mundipharma: Honoraria; Celgene: Consultancy. Stauder:Ratiopharm: Honoraria, Research Funding; Celgene: Consultancy, Honoraria, Research Funding; Novartis: Research Funding. Girschikofsky:Pfizer: Honoraria, Research Funding; Mundipharm: Consultancy, Honoraria. Pfeilstöcker:Janssen-Cilag: Honoraria; Novartis: Consultancy, Honoraria; Celgene: Consultancy, Honoraria. Lang:Celgene: Consultancy. Sperr:Phadia: Research Funding; Novartis: Honoraria; Celgene: Consultancy, Honoraria, Membership on an entity's Board of Directors or advisory committees. Valent:Celgene: Honoraria, Membership on an entity's Board of Directors or advisory committees; BMS: Membership on an entity's Board of Directors or advisory committees; Novartis: Membership on an entity's Board of Directors or advisory committees. Greil:Amgen: Honoraria, Research Funding; Eisai: Honoraria; Mundipharma: Honoraria, Research Funding; Merck: Honoraria; Janssen-Cilag: Honoraria; Genentech: Honoraria, Research Funding; Novartis: Honoraria; Astra-Zeneca: Honoraria; Boehringer-Ingelheim: Honoraria; Pfizer: Honoraria, Research Funding; Roche: Honoraria; Sanofi Aventis: Honoraria; GSK: Research Funding; Ratiopharm: Research Funding; Celgene: Consultancy, Research Funding; Cephalon: Consultancy, Honoraria, Research Funding; Bristol-Myers-Squibb: Consultancy, Honoraria.

Download Full-text

Outcomes By Best Response with Hypomethylating Agent Plus Venetoclax in Adults with Previously Untreated Acute Myeloid Leukemia

Blood ◽

10.1182/blood-2021-149782 ◽

2021 ◽

Vol 138 (Supplement 1) ◽

pp. 2292-2292

Author(s):

Virginia Olivia Volpe ◽

Akriti G Jain ◽

Onyee Chan ◽

Eric Padron ◽

David A. Sallman ◽

...

Keyword(s):

Overall Survival ◽

Acute Myeloid Leukemia ◽

Board Of Directors ◽

Myeloid Leukemia ◽

Research Funding ◽

Free State ◽

Advisory Committees ◽

Best Response ◽

Baseline Characteristics ◽

Acute Myeloid

Abstract Background: Venetoclax plus hypomethylating agents (HMA) (HMA+VEN) is a standard of care treatment for patients with acute myeloid leukemia (AML) who are unfit for intensive chemotherapy. In the phase 3 VIALE-A trial, azacididine (aza)+VEN compared to aza alone demonstrated an improved overall survival of 14.7 months versus 9.6 months, respectively. A common toxicity with HMA+VEN is myelosuppression. The prognostic implications of incomplete count recovery despite leukemia free state after HMA+VEN treatment in AML is unclear. We aimed to compare the outcomes of those who achieved complete remission (CR), complete remission with incomplete hematologic recovery (CRi), or morphologic leukemia-free state (MLFS) in AML patients treated frontline with HMA+VEN. Methods: Patients seen at Moffitt Cancer Center between 2019 and 2021 diagnosed with AML and treated with frontline HMA+VEN were retrospectively evaluated and included for analysis. Patients were stratified by best response; either CR, CRi, or MLFS. Baseline characteristics were compared by chi square (categorical variables) and t- test (continuous variables). Survival estimates were calculated using the Kaplan-Meier method from date of diagnosis and groups were compared using log-rank test. Results: Of the 102 patients treated with HMA+VEN in the frontline setting, 48% (n=49) had blast clearance with a best response of CR in 27/102 (26.4%), CRi in 16/102 (15.7%), or MLFS in 6/102 (5.9%). The remainder had residual disease. Baseline characteristics were similar among the three response groups (Table 1) as was mutational distribution (Table 2). There was no difference between AML WHO classification subtype (p= .148). Decitabine or aza was used at the discretion of the treating physician did not significantly impact responses (p= .225). In those who achieved CR, 14% had prior therapy related AML compared to 37.5% in CRi and 33.3% in MLFS (p= .314). Antecedent MDS or MPN with transformation to AML was seen in 22.2%, 18.8%, and 66.7% of CR, CRi, and MLFS respectively (p= .029). Of those, 3.7% in CR group had HMA use for prior MDS/MPN compared to 0% in CRi and 50% in MLFS (p= .000). The median relapse free survival was not reached for CR, CRi, and MLFS (Figure 1), it is important to note that 3 of the 6 MLFS patients died without relapse . At median follow up of 23 months, median overall survival (OS) in the CR group was significantly longer, 31 months, compared to 18 months in the CRi group and 8.5 months in the MLFS group (p=0.0415) (Figure 2). Transplant was achieved in 26% of CR and 6.3% of CRi and 0% of MLFS and was not significant among the groups (p = .124). Conclusion: Patients who received frontline HMA+VEN for AML directed therapy and achieved CR/CRi had better survival compared to those who achieved MLFS. Our data suggest that incomplete recovery of blood counts plays a significant role in overall survival regardless of leukemia free state. Further, the data demonstrate significantly higher secondary AML with antecedent MDS or MPN in the MLFS group compared to CR and CRi groups. Of those, prior HMA therapy was also identified as significantly higher in the MLFS group compared to CR and CRi groups which may contribute to the prolonged cytopenias and worse OS. While the limitation to this study is overall small number of patients, it suggests that a goal of CR over CRi or MLFS is desirable for superior OS. In the future, it would be of interest to incorporate the rates of responses and variables that may have an impact such as therapy dose adjustment, time to response, and delays in therapy due to cytopenia. Additional studies identifying dose adjustments or other ways to improve hematologic recovery would be valuable to potentially improve outcomes in this difficult to treat population. Figure 1 Figure 1. Disclosures Padron: Stemline: Honoraria; Taiho: Honoraria; BMS: Research Funding; Incyte: Research Funding; Blueprint: Honoraria; Kura: Research Funding. Sallman: Bristol-Myers Squibb: Membership on an entity's Board of Directors or advisory committees, Speakers Bureau; Takeda: Consultancy; Shattuck Labs: Membership on an entity's Board of Directors or advisory committees; AbbVie: Membership on an entity's Board of Directors or advisory committees; Incyte: Speakers Bureau; Intellia: Membership on an entity's Board of Directors or advisory committees; Aprea: Membership on an entity's Board of Directors or advisory committees, Research Funding; Agios: Membership on an entity's Board of Directors or advisory committees; Syndax: Membership on an entity's Board of Directors or advisory committees; Novartis: Consultancy, Membership on an entity's Board of Directors or advisory committees; Magenta: Consultancy; Kite: Membership on an entity's Board of Directors or advisory committees. Komrokji: Novartis: Consultancy, Honoraria, Membership on an entity's Board of Directors or advisory committees; AbbVie: Consultancy; Acceleron: Consultancy; Jazz: Consultancy, Speakers Bureau; Geron: Consultancy; BMSCelgene: Consultancy, Membership on an entity's Board of Directors or advisory committees, Speakers Bureau; Taiho Oncology: Membership on an entity's Board of Directors or advisory committees; PharmaEssentia: Membership on an entity's Board of Directors or advisory committees. Lancet: AbbVie: Consultancy; Astellas: Consultancy; Jazz: Consultancy; Agios: Consultancy; Millenium Pharma/Takeda: Consultancy; ElevateBio Management: Consultancy; Daiichi Sankyo: Consultancy; Celgene/BMS: Consultancy; BerGenBio: Consultancy. Sweet: AROG: Membership on an entity's Board of Directors or advisory committees; Gilead: Membership on an entity's Board of Directors or advisory committees; Novartis: Honoraria, Membership on an entity's Board of Directors or advisory committees; Astellas: Consultancy, Membership on an entity's Board of Directors or advisory committees; Bristol Meyers Squibb: Honoraria, Membership on an entity's Board of Directors or advisory committees.

Download Full-text

Clinical Impact of Copy Number Variation Revealed By Next Generation Sequencing in Acute Myeloid Leukemia

Blood ◽

10.1182/blood-2021-153302 ◽

2021 ◽

Vol 138 (Supplement 1) ◽

pp. 4463-4463

Author(s):

Kamila Janusz ◽

Ruth Stuckey ◽

Clara Aparicio Pérez ◽

Cristina Bilbao ◽

Inmaculada Fernández Camacho ◽

...

Keyword(s):

Board Of Directors ◽

Copy Number ◽

Myeloid Leukemia ◽

Genetic Material ◽

Median Number ◽

Advisory Committees ◽

Additional Information ◽

Myeloid Neoplasms ◽

Number Variation ◽

Generation Sequencing

Abstract Introduction: Conventional karyotype analysis is one of the most important diagnostic tools to determine the prognosis of acute myeloid leukemia (AML), in which more than 50% of cases are affected. However, the low sensitivity of this technique hampers the detection of small genetic alterations like Copy Number Variation (CNV) that could affect the pathophysiology and prognosis of the disease. Current modern genomic technologies based on next generation sequencing (NGS) are capable to detect CNV at low frequencies. Objective: To analyse CNV of genes related to myeloid neoplasms profile in AML patients at diagnosis and evaluate their connection with the mutational profile, and its possible influence on the clinical-biological phenotype and prognosis of the disease. Materials and methods: The CNV and mutational profile were analysed in samples from 380 AML patients, from PLATAFO-LMA reference centres (IMIBIC, Córdoba and Dr Negrín Las Palmas de Gran Canaria) by NGS, applying a panel of 30 genes (154 regions) related to myeloid neoplasms (Sophia Myeloid Solution®) on Ilumina Myseq platform. Results: NGS detected CNV in at least one gene in 103 AML patients (27.1%). NGS detected 103 gains and 206 losses of genetic material. The median number of genes affected by CNV was 2 (range 1-12). When comparing with conventional karyotype information, CNV provided additional information in 51% of the cases. The chromosomes 7, 11 and 21 were most affected with CNV, occurring in 79 (76.7%), 40 (38.8%) and 36 (35%) patients, respectively. The gains of genetic material occurred more frequently on chromosome 21 in U2AF1 and RUNX1 genes, in 13 patients each. The loss of genetic material in EZH2 and BRAF genes occurred mutually. Interestingly, we observed the tendency that patients with CNV (loss) in NPM1 gene had shorter overall survival compared to cases with NPM1 mutated and without CNV in this gene (1 month vs. 13 months, p = 0.072) (Figure 1). Moreover CNV (loss) in TP53 gene was associated with mutations in this gene, other than deletions (p <0.05). In addition, NGS detected 390 mutations distributed in 29 genes in 103 AML with CNV. The median number of mutations was 3 (range 1-10) (Figure 2). Furthermore, only 2 patients did not have any mutation in genes analysed. The distribution and frequency of genes affected by CNV and by mutations was different (Figure 3). Conclusions: The CNV of genes related to myeloid neoplasms are frequent in AML patients (27.1%) and provides additional information to the conventional karyotype in half of the cases. The loss of NPM1 gene could affect survival of AML patients. The use of NGS with CNV analysis provides important information on copy number alterations that are not detected by the karyotype, which could significantly affect the pathophysiology of AML and with potential clinical impact, especially in patients with normal karyotype. Figure 1 Figure 1. Disclosures Hernández Rivas: Pfizer: Honoraria, Membership on an entity's Board of Directors or advisory committees; Novartis: Honoraria, Membership on an entity's Board of Directors or advisory committees, Research Funding; Celgene/BMS: Honoraria, Membership on an entity's Board of Directors or advisory committees, Research Funding; Amgen: Membership on an entity's Board of Directors or advisory committees.

Download Full-text

Increased Monocytic Myeloid-Derived Suppressor Cells in the Marrow of Relapsed/Refractory Acute Myeloid Leukemia Patients Following Induction Chemotherapy

Blood ◽

10.1182/blood-2018-99-120082 ◽

2018 ◽

Vol 132 (Supplement 1) ◽

pp. 5270-5270

Author(s):

Amanda Przespolewski ◽

Paul K. Wallace ◽

Tara Cronin ◽

Eunice S. Wang

Keyword(s):

Overall Survival ◽

Board Of Directors ◽

Induction Chemotherapy ◽

Myeloid Leukemia ◽

Potential Role ◽

Suppressor Cells ◽

Advisory Committees ◽

Free Survival ◽

Relapsed Disease

Abstract Background: Acute myeloid leukemia (AML) is an aggressive malignancy associated with poor long-term outcomes. This malignancy arises in the context of an immunosuppressive milieu, which fosters immune escape and tumor growth. Myeloid-derived suppressor cells (MDSCs) represent a heterogeneous group of immature myeloid cells with immunosuppressive activity, the most potent of which are the monocytic MDSCs (mMDSCs). The presence of mMDSCs within the bone marrow microenvironment of patients with AML, along with their impact on disease relapse and overall survival has yet to be fully characterized. Therefore, we sought to address this unanswered question through a retrospective analysis of a cohort of AML patients (pts) at Roswell Park Comprehensive Cancer Center. Methods: Medical records were retrospectively reviewed under an IRB approved protocol in order to identify pts aged 18-70 years old with normal karyotype (NK) AML treated with standard cytarabine and anthracycline based chemotherapy with refractory or subsequent relapsed disease. Demographics, disease-specific variables, baseline clinical characteristics, treatment response, and adverse events were analyzed using descriptive statistics. Overall survival and relapse-free survival were estimated utilizing Kaplan-Meier (KM) analysis. Detailed analysis of previously collected clinical multiparameter flow cytometric data was performed utilizing WinList software to identify mMDSCs at serial clinical time points (diagnosis, after induction chemotherapy, and relapse). A mononuclear gate was created utilizing CD45 vs. SSC (blasts excluded), followed by FSC vs. SSC to eliminate dead cells and aggregates. Based on the scientific literature, mMDSCs were defined as the subset of marrow cells co-expressing CD14+ and HLA-DR dim, and was reported as the percentage of total monocytes in the marrow aspirate sample. Results: Six pts with NK-AML who received induction chemotherapy with cytarabine, daunorubicin, and etoposide (ADE) were identified. Mean age was 56 years (range 35 - 67), with 3/6 male pts (50%) (Table 1). NPM1 was mutated in 2/6 pts at diagnosis, with no FLT3-ITD mutations identified. In addition, 2 pts had an elevated WBC at presentation. Following induction therapy, 2 pts had primary refractory disease with four achieving complete remission (CR). Furthermore, each of the 6 pts relapsed. All 6 pts had marrow aspirate samples containing detectable mMDSCs by flow cytometry at multiple time points. Of note, 5 of 6 pts had elevated mMDSCs (average 76.2%; range 72.8% - 82.6% of total marrow monocytes) detected at time of response assessment following induction. Median relapse-free survival was 48 months (Figure 1). Overall survival not yet been reached. Mean duration of follow up was 85 months (range 61 - 119 months). Conclusions: This retrospective analysis suggests that high numbers of marrow mMDSCs (>72%) are associated with relapsed/refractory AML in a small patient cohort. Of note, other risk factors for refractory/relapsed disease (i.e. elevated WBC at presentation and FLT3 mutation) were not consistently present in our cohort, thus supporting a potential role of mMDSCs in promoting disease recurrence. Additional studies to further quantify and delineate the biological role of mMDSCs in a larger pt cohort are needed to corroborate these findings and determine the potential role of these immune cells in therapy resistant AML. Disclosures Wang: Abbvie: Consultancy, Membership on an entity's Board of Directors or advisory committees; Novartis: Speakers Bureau; Jazz: Speakers Bureau; Amgen: Consultancy; Pfizer: Consultancy, Membership on an entity's Board of Directors or advisory committees; Amgen: Consultancy; Novartis: Speakers Bureau; Jazz: Speakers Bureau; Abbvie: Consultancy, Membership on an entity's Board of Directors or advisory committees; Pfizer: Consultancy, Membership on an entity's Board of Directors or advisory committees.

Download Full-text

Day 14 Measurable Residual Disease As a Predictor of Post-Induction Response in Patients with Acute Myeloid Leukemia

Blood ◽

10.1182/blood-2021-150808 ◽

2021 ◽

Vol 138 (Supplement 1) ◽

pp. 1287-1287

Author(s):

Reyes María Martín-Rojas ◽

Jon Badiola ◽

Pablo Silva De Tena ◽

Ana Pérez-Corral ◽

Ignacio Gómez-Centurión ◽

...

Keyword(s):

Bone Marrow ◽

Board Of Directors ◽

Myeloid Leukemia ◽

Residual Disease ◽

Bone Marrow Aspiration ◽

Advisory Committees ◽

Post Induction ◽

Measurable Residual Disease ◽

Acute Myeloid

Abstract INTRODUCTION Several studies have shown that morphological remission at day 14 is a predictor of post-induction response in patients with acute myeloid leukemia (AML) undergoing an intensive treatment. However, the role of measurable residual disease (MRD) by multiparameter flow cytometry (MFC) at day 14 remains unknown. The aim of our study is to explore the role of MRD at day 14 and its association with outcomes of patients with AML undergoing an intensive treatment. METHODS We conducted a retrospective study in adult patients with newly a diagnosed AML in our center between 2007 and 2020. Adult patients who received intensive chemotherapy, excluding those with an acute promyelocytic leukemia, were included. Bone marrow aspiration was performed at day 14 after induction to assess morphological response and MRD by MFC. Early blast clearance (EBC) was defined as <5% of blasts and negative MRD was defined as <0.1% abnormal cells within mononucleated cells by MFC. Day 14 aspiration findings were compared with clinical data. This study was approved by our Institutional Ethics Committee. Data were analyzed using IBM SPSS Statistics version 24. RESULTS A total of 131 patients were analyzed. Median age was 55.6 years (IQR 42.3-64.2). The most frequent AML subtype was AML with myelodysplasia-related changes (34.4%), followed by NPM1-mutated AML (32.1%). The most commonly used induction regimen was "7+3" (96.2%) (Table 1). On day 14 bone marrow aspiration, median cellularity was 0.5/5 (IQR 0.5-1). 107 patients (81.7%) showed a blast reduction >50% compared to diagnosis and 87 patients (66.4%) had less than 5% of blasts. In this latter group, 28.6% of patients had a positive MRD and 71.4% had a negative MRD. NPM1-mutated AML showed the highest EBC rates while AML with myelodysplasia-related changes had the lowest rates (83.3% versus 55.5%; p=0.04). Furthermore, there were statistically significant differences in EBC rates based on the 2017 European Leukemia Net risk stratification, with 80% of EBC in low risk, 66.6% in intermediate risk and 53.4% in high risk AML (p=0.038). No differences were observed in MRD at day 14 based on AML subtypes or risk stratification. We subsequently analyzed the negative (NPV) and positive predictive values (PPV) of day 14 bone marrow aspiration results by morphology and MFC to predict post-induction results. As a predictor of post-induction CR, day 14 EBC had a NPV of 82% and a PPV of 69%, while day 14 MRD had a NPV of 86% and a PPV of 49%. However, for predicting post-induction MRD, day 14 EBC had a NPV of 49% and a PPV of 15%, while day 14 MRD had a NPV of 71% and PPV of 74%. The correlation between day 14 and post-induction bone marrow aspiration is shown in Table 2. Bivariate analysis showed that achieving CR with negative MRD in post-induction bone marrow aspiration was associated with EBC (p<0.001) and negative MRD (p=0.04) at day 14 bone marrow aspiration. No statistically significances were observed based on marrow cellularity. A multivariate analysis using logistic regression showed that negative MRD by MFC at day 14 was the only independent predictor variable to achieve post-induction CR with negative MRD (OR 4.95% CI 1.0-15.9; p=0.04). CONCLUSION Patients showing EBC with negative MRD on day 14 bone marrow aspiration are more likely to achieve post-induction CR with negative MRD, with day 14 MRD by MFC being the only independent factor able to predict post-induction CR with negative MRD in our cohort. However, further prospective studies are needed to confirm our findings. Figure 1 Figure 1. Disclosures Martín-Rojas: Celgene-BMS: Consultancy, Membership on an entity's Board of Directors or advisory committees; Gilead: Membership on an entity's Board of Directors or advisory committees; Pfizer: Membership on an entity's Board of Directors or advisory committees. Kwon: Novartis, Celgene, Gilead, Pfizer: Consultancy, Honoraria.

Download Full-text

Do Not Miss Karyotyping at Chronic Myeloid Leukemia Diagnosis: An Italian Campus CML Study on the Role of Complex Variant Translocations

Blood ◽

10.1182/blood-2020-139826 ◽

2020 ◽

Vol 136 (Supplement 1) ◽

pp. 43-44

Author(s):

Massimiliano Bonifacio ◽

Chiara Elena ◽

Mariella D'Adda ◽

Luigi Scaffidi ◽

Mairi Pucci ◽

...

Keyword(s):

Board Of Directors ◽

Myeloid Leukemia ◽

Research Funding ◽

Advisory Board ◽

Newly Diagnosed ◽

Advisory Committees ◽

Optimal Response ◽

Frontline Treatment ◽

Tki Treatment

Background. The Philadelphia (Ph) chromosome (chr.) is the hallmark of chronic myeloid leukemia (CML) and typically results from the reciprocal translocation t(9;22)(q34;11.2). Complex variant translocations (CVT) involving one or more additional chr. are identified in less than 5% of newly diagnosed CML. There are conflicting reports about the prognostic impact of CVT in the achievement of optimal response to tyrosine kinase inhibitor (TKI), and very few studies addressed the role of frontline treatment with imatinib or second generation (2G)-TKI in patients with CVT. Aims. To assess the response to imatinib or 2G-TKI in a large cohort of newly diagnosed CML with CVT, and to explore the impact of the different chr. translocations on outcome. Methods. This observational retrospective study was conducted in 19 hematologic centers in the framework of Campus CML, a network of Italian physicians involved in the management of CML patients. All newly diagnosed CML from 2000 to 2019 were evaluated and patients with CVT were selected for the present analysis. Karyotypes were defined according to the 2016 International System for Human Cytogenetic Nomenclature. Responses to frontline treatment were retrospectively categorized according to the 2013 ELN recommendations, as they include cytogenetic milestones. Deep molecular response (DMR, i.e. MR4or better) was defined as BCR-ABLIS ratio ≤0.01% or undetectable disease with ≥10,000 ABL copies. Patients with DMR lasting ≥2 years and at least a Q-PCR test every 6 months were defined as stable DMR responders. Failure-free survival (FFS) was calculated from the start of frontline TKI treatment to progression to advanced phase, death, or switch to other treatments for resistance. For FFS calculation, patients were censored at TKI stop for treatment-free remission (TFR) or in case of switch for intolerance only. Differences between subgroups according to the partner chr. were presented for descriptive purposes. Results. CVT were identified in 109 (3.2%) patients from a whole population of 3,361 subjects with newly diagnosed CML. Ninety-five out of 109 patients (87%) exhibited three-way translocations, with chr. 1, 4, 6, 10, 11, 12, 14, 15 and 17 representing the most common additional partners (figure). Four- and five-way translocations were identified in 13 and 1 patients, respectively. Additional chr. abnormalities (ACA) in the Ph+ cells were observed in 15/109 (13.8%) patients and were more common in older individuals (p=0.018). Overall, median age at diagnosis was 50.6 years (range 20-90). Risk distribution according to the ELTS score was 54%, 28% and 8% for L, I and H risk, respectively (10% missing). Cytogenetic result was available before the choice of frontline treatment in 45% of cases and represented a decisive factor in 28% of them (i.e. clinicians selected a 2G-TKI or high-dose imatinib, according to the available options). Frontline TKI treatment was imatinib in 80 cases (73%) and 2G-TKI (nilotinib n=22, dasatinib n=6, bosutinib n=1) in the remaining cases. The frequency of optimal response at 3, 6 and 12 months was 48%, 45% and 53%, respectively, for imatinib-treated patients, and 76%, 83% and 76%, respectively, for the 2G-TKI cohort (p<0.05 for all comparisons). Stable DMR was achieved by 39% of patients and 42% of them attempted a TFR. After a median follow-up of 91.3 months (range 1-236), 5-year FFS was 66% (95%CI: 53.4-76.4) and 84% (95%CI: 62.4-93.6) for imatinib and 2G-TKI treated patients, respectively (p=ns). The estimated 10-year OS for the entire cohort was 84.4% (95%CI: 73.6-91). The subtype of CVT had an impact on response and long-term outcome. Patients with CVT involving chr. 1, 4, 6, 11 or 12 had a higher frequency of MMR at 12 months than patients with CVT involving chr. 10, 14, 15 or 17 (75.8% vs 30.4%, respectively, p=0.001), higher frequency of stable DMR (48.7% vs 22.2%, respectively; p=0.04) and tended to have better median FFS (p=0.07), regardless of the type of frontline TKI and of the ELTS score. Conclusions. Due to its retrospective nature, this study does not allow to define which is the optimal therapy for CML harboring CVT at diagnosis. However, our data reinforce the usefulness of bone marrow karyotyping in CML. The observed differences between partner chr. may also depend on the breaking points, which are variable. Further dissection of CVT will help to identify which are associated to a poor response to TKIs. Figure Disclosures D'Adda: Incyte: Other: Advisory board; Novartis: Other: Advisory board; Pfizer: Other: Advisory board. Galimberti:Novartis: Speakers Bureau; Incyte: Honoraria. Crugnola:Celgene: Honoraria; Janssen: Honoraria; BMS: Honoraria; Novartis: Honoraria. Bocchia:Incyte: Honoraria; CELGENE: Honoraria. Krampera:Janssen: Membership on an entity's Board of Directors or advisory committees; Novartis: Membership on an entity's Board of Directors or advisory committees. Breccia:Incyte: Consultancy, Honoraria; Pfizer: Consultancy, Honoraria; Abbvie: Consultancy; Bristol-Myers Squibb/Celgene: Consultancy, Honoraria; Novartis: Consultancy, Honoraria. Saglio:Novartis: Research Funding; Ariad: Research Funding; Pfizer: Research Funding; Bristol-Myers Squibb: Research Funding; Incyte: Research Funding; Roche: Research Funding.

Download Full-text

Molecular and Clinical Characterization of Patients with Myeloid Neoplasms Carrying the 12p Deletion

Blood ◽

10.1182/blood.v128.22.2007.2007 ◽

2016 ◽

Vol 128 (22) ◽

pp. 2007-2007

Author(s):

Vera Adema ◽

Cassandra M. Hirsch ◽

Bartlomiej P Przychodzen ◽

Andrea Pellagatti ◽

Jacqueline Boultwood ◽

...

Keyword(s):

Mrna Expression ◽

Board Of Directors ◽

Transcriptional Factors ◽

Chromosome 12 ◽

Complex Karyotype ◽

Advisory Committees ◽

Expression Levels ◽

Myeloid Neoplasms ◽

Mrna Expression Levels

Abstract Background: Cytogenetic abnormalities have been described in almost 50% of patients with MDS and area strong and independent risk factor for prognosis. The interstitial deletion in the short arm of the chromosome 12 [del(12p)], is a characteristic but rare abnormality in MDS patients. Del(12p) abnormality has been described in approximately 1-5% of patients as a sole anomaly and is also found in up to 4% of patients along with an additional cytogenetic alteration. Isolated del(12p) is classified as a good risk abnormality according to the Revised International Prognostic Scoring Systems (IPSS-R). The commonly deleted region between 12p12.2 and 12p13.1 encompasses the ETV6 gene. To date, besides mutations in the transcriptional factor ETV6 and in the cell signaling KRAS gene, no other molecular mutations have been associated with del(12p). Murine studies have highlighted a role of the transcriptional factors ETV6 and RUNX1 in the impairment of both erythroid and platelets maturation. Here we investigated the presence of alternative molecular factors associated with del(12p) possibly influencing clinical outcomes and disease phenotypes. Methods: We studied the molecular and clinical data of a total of 2834 patients with myeloid neoplasms and found that 3% (93/2834) had alterations in chromosome 12. The median age was 67 years (24-84), with a male: female ratio of 56:37. Del(12p) occurred in 71% of cases (66/93); among them 14% (9/66) had isolated del(12p), 9% (6/66) had del(12p) + 1 additional alteration and 77% (51/66) carried a complex karyotype. The additional alteration to del(12p) included -7/del 7q (N=3), del(5q) (N=1) and t(X;20) (N=1). Cases with del(12p) were also classified according to disease type (MDS=40, AML=16; MDS/MPN=10; P=.057) and according to MDS risk group [lower-risk (33%, 22/66) and higher-risk (45%, 30/66)]. We applied whole exome sequencing and a targeted deep sequencing panel of 64 most frequently mutated genes in myeloid neoplasms. The ETV6 (12p13.2) gene was deleted in 55% (36/66) of cases while the KRAS (12p12) gene was deleted in 32% (21/66) of cases. One-third (32%, 21/66) of patients had deleted both genes. Two patients were hemizygous for KRAS. Results: Comparing patients with del(12p) (isolated, +1 alteration) to patients without alterations in chromosome 12 (n=2741), those with del(12p) had lower hemoglobin levels compared to patients without 12p aberrations (9.2 g/dL (6-16) vs. 9.7 g/dL (3-17); P=.009) and lower platelets counts (47 x109/L (8-577) vs. 73 x109/L (2-2336); P=.04). We noted that patients with isolated del(12p) had a longer median OS compared to patients with del(12p) associated with a complex karyotype [14 months (1-27) vs. 7 months (5-8)] although this difference was not significant. We then analyzed the mutational profile of the del(12p) cohort (isolated, +1 alteration) and compared their mutational spectrum with that of cases diploid for 12p. The most recurrently mutated genes in cases with del(12p) compared to cases diploid for 12p included RUNX1 (27% vs. 7%; P=.01) and DNMT3A (27% vs. 9%; P=.04). When we analyzed all the cases with del(12p) abnormalities (isolated, +1 alteration and complex) the significantly mutated genes were the transcriptional factors TP53 (38% vs. 4%; P=.0001) and RUNX 1 (14% vs. 7%; P=.04) and the histone modifier ASXL1 (21% vs. 10%; P=.01) We then analyzed the gene expression profile of patients carrying the del(12p) abnormality and found that KRAS mRNA expression levels of patients with MDS with del(12p) had a 2-fold reduction compared to the levels of healthy subjects (P=.017). Similarly, we observed also a decrease in ETV6 mRNA expression levels in patients with del(12p) (P=.07). Conclusions: Patients with del(12p) had lower levels of hemoglobin and platelets counts compared to patients without this cytogenetic abnormality. Mutations in transcriptional factors such as RUNX1 were commonly detected in this cohort, suggesting a possible mechanism contributing to the role of ETV6 in the impairment of erythroid and megakaryocytic cell maturation. Disclosures Sole: Celgene: Membership on an entity's Board of Directors or advisory committees. Maciejewski:Alexion Pharmaceuticals Inc: Consultancy, Honoraria, Speakers Bureau; Celgene: Consultancy, Honoraria, Speakers Bureau; Apellis Pharmaceuticals Inc: Membership on an entity's Board of Directors or advisory committees.

Download Full-text

Role of High-Dose Melphalan and Autologous Stem Cell Transplantation in Multiple Myeloma Patients Presenting with t(11;14)

Blood ◽

10.1182/blood-2019-129880 ◽

2019 ◽

Vol 134 (Supplement_1) ◽

pp. 4580-4580 ◽

Cited By ~ 1

Author(s):

Eduardo Sobejano ◽

Veronica Gonzalez De La Calle ◽

Victor Higuero ◽

Fernando Escalante ◽

Ramón García-Sanz ◽

...

Keyword(s):

Multiple Myeloma ◽

High Risk ◽

Board Of Directors ◽

Research Funding ◽

University Hospital ◽

First Line ◽

Advisory Committees ◽

Baseline Characteristics ◽

Standard Risk

INTRODUCTION The t (11; 14) by fluorescent in situ hybridization (FISH) is found in 15-20% of patients with multiple myeloma (MM) . Although it was classically considered a standard risk translocation or even a good prognosis, recent studies conducted in the era of new drugs show contradictory results and it is not well established if they have to be considered intermediate or standard risk. The possibility of using targeted therapy with venetoclax for patients harboring t(11;14) makes the investigation of the outcome of newly diagnosed multiple myeloma (NDMM) with t(11;14) as relevant. METHODS We analyzed the baseline characteristics and outcome of patients with t(11;14)and receiving HDT-ASCT within the series of 647 patients with NDMM between 1988 and 2018 according to the current criteria at each moment at two academic hospitals in Spain (University Hospital of Salamanca and Hospital of Leon) . The FISH was performed on selected cells according to international regulations and centralized at the University Hospital of Salamanca. For this purpose, a descriptive cross-sectional study was first conducted comparing the characteristics of patients with t (11; 14) versus the rest. The final objective wasto evaluate the role of HDT-ASCT in NDMM with t(11;14). RESULTS The baseline characteristics of the whole series were: a median age of 71years (yrs) (range:30-96). 217 patients (33,5%) were under 65 years. 352 (56.2%) were IgG; 161 (25.7%) IgA; 87 (13.9%) Bence Jones; 19 (3%) non-secretors, and 5 and 2 cases were IgD and IgM, respectively. 320 (53.2%) received novel agents as part of the first line of therapy. Overall, 153 (27.8%) achieved complete response (CR) after first line, and 403 (73.1%) at least a partial response. After a median follow-up for living patients of 4.26 yrs (range: 0,1-27.3), the OS of the entire series was 2.74 years. T(11;14) was performed in 440 NDMM patients and was positive in 80 (18.2%). Only in 5 patients other high-risk alterations (t (14:16), t (4:14) or del17p (p53)) were detected. The baseline characteristics of patients with and without t (11:14) did not show significant differences, except for the heavy chain pattern(p <0,001). IgA was lower in patients with t(11:14) 12,8% (10 out of 78)vs 27,7% (98 out of 353). Of note, most patients with non-secretory MM (10 out of 16, 62,5%) had the t(11;14) whilst in the conventional secretory MM patients, t(11;14) was observed in 68out of 415(16,4%). In addition, the plasma cell bone marrow infiltration was significantly higher in patients with t(11;14)(> 60% Plasma Cells) 32.8% vs 13.3%(p <0.001)). HDT-ASCT was performed in 162 patients (25%)and 22 of them (13,5%) were positive for the t(11:14) and only in 2 patients, other high-risk alterations were detected.The induction therapy received in both treatments arms was homogeneous basically consisted on combinations of proteasome inhibitors plus immunomodulatory drugs. The median OS for NDMM patients undergoing ASCT was 4,33 years. (range: 0,47-26,85) and the median PFS for this patients was 2,25 yrs (range: 0,1-27,25) The median PFS for patients with t (11/14) undergoing ASCT trended to be higher than that observed in patients without t(11;14) who received also HDT-ASCT (99.1 vs 54.9 months), without obtaining significant results, (p 0.205) maybe due to the small number of patients (Figure 1).The median OS in the group of patients with and without t(11:14) undergoing ASCT was 120,8 vs 140 months (p= 0,829). In the cohort of non eligible ASCT patients both median PFS and OS for patients with t(11:14) was similar than that observed in patients without t(11:14)(median PFS of 19,9 vs 19,4 months) (p 0,438) and (median OS of 31,5 vs 44 months) (p 0,424), respectively. CONCLUSION T(11;14) seems to be a cytogenetic abnormality more frequently observed in patients with NDMM and non secretory phenotype what requires further investigation. Patients with t(11;14) benefit the most if they received HDT-ASCT and it would represent a therapeutic strategy of choice if the patient is transplant-eligible. Figure 1 Disclosures Puig: Celgene: Consultancy, Honoraria, Membership on an entity's Board of Directors or advisory committees, Research Funding, Speakers Bureau; Janssen: Consultancy, Honoraria, Research Funding; The Binding Site: Honoraria; Takeda, Amgen: Consultancy, Honoraria. Mateos:Abbvie: Membership on an entity's Board of Directors or advisory committees; GSK: Membership on an entity's Board of Directors or advisory committees; Pharmamar: Membership on an entity's Board of Directors or advisory committees; Janssen: Honoraria, Membership on an entity's Board of Directors or advisory committees; Celgene: Honoraria, Membership on an entity's Board of Directors or advisory committees; Takeda: Honoraria, Membership on an entity's Board of Directors or advisory committees; Adaptive: Honoraria; EDO: Membership on an entity's Board of Directors or advisory committees; Amgen: Honoraria, Membership on an entity's Board of Directors or advisory committees.

Download Full-text

Long-Term Subgroup Analyses from Azacitidine Vs. Decitabine in Unfit Newly Diagnosed Acute Myeloid Leukemia Patients: Results from the Pethema Registry

Blood ◽

10.1182/blood-2021-150649 ◽

2021 ◽

Vol 138 (Supplement 1) ◽

pp. 1256-1256

Author(s):

Jorge Labrador ◽

Adolfo de la Fuente ◽

David Martínez-Cuadrón ◽

Rebeca Rodríguez-Veiga ◽

Josefina Serrano ◽

...

Keyword(s):

Bone Marrow ◽

Board Of Directors ◽

Subgroup Analysis ◽

Myeloid Leukemia ◽

Research Funding ◽

Real Life ◽

Advisory Committees ◽

Baseline Characteristics

Abstract INTRODUCTION The hypomethylating agents (HMAs), decitabine (DEC) and azacitidine (AZA), have made it possible to treat more elderly patients with acute myeloid leukemia (AML). Both HMAs have demonstrated efficacy in monotherapy and in combination with targeted therapies. However, there is little direct comparative data on AZA and DEC in first-line treatment, and we do not know which group of patients might benefit from each drug. Results of the full analysis set (FAS) were presented previously (Labrador J, et al. ASH 2020). Here, we report long-term clinical efficacy from prespecified patient subgroup analyses. METHODS We conducted a retrospective study to compare real-life clinical outcomes between AZA and DEC in patients with AML ineligible for intensive chemotherapy included in the PETHEMA registry, and analyzed clinical variables associated with response and overall survival (OS) between AZA and DEC. RESULTS A total of 626 patients were included for the FAS between 2006 and 2019. 487 (78%) received AZA and 139 (22%) received DEC. Baseline characteristics were comparable in both groups, except for the percentage of bone marrow blasts (44% vs. 34% in the DEC group compared to AZA, p=0.010). In the FAS, there was no difference in the CR, CR/CRi or ORR (CR/RCi + PR) rate: 18%, 20.5% and 32% with AZA vs. 23%, 25% and 39.5% with DEC (p=0.20, p=0.27 and p=0.12). In the subgroup analysis, DEC was associated with higher CR/CRi rate than AZA in patients with ECOG ≥ 2 (95% CI: 0.088 - 0.801), bone marrow blast count < 50% (95% CI: 0.293 - 0.965), secondary AML (95% CI: 0.223 - 0.918) and adverse cytogenetics (95% CI: 0.171 - 0.857) (Figure 1A). DEC was associated with higher ORR rate than AZA in patients with ECOG ≥ 2 (95% CI: 0.116 - 0.782), leukocytes < 10 x10 9/L (95% CI: 0.321 - 0.920) and bone marrow blasts < 50% (95% CI: 0.321 - 0.920) (Figure 1B) 120 days-mortality was 25.4% after AZA and 27.1% after DEC, p=0.70. Patients who did not achieve at least a PR had significantly higher 120-day mortality with both HMAs (OR 8.85 and 8.22 for AZA and DEC, respectively). In the subgroup analysis, patients with leukocytes ≥ 10 x10 9/L (95% CI: 1.069 - 4.157) and those with estimated glomerular filtration rate (eGFR) ≥ 45 mL/min/1.73m 2 (95% CI: 1.249 - 4.664) had higher 120-day mortality with DEC than with AZA (Figure 1C) With a median follow-up of 12 months, median OS was 10.4 months (95% CI: 9.2 - 11.7) for AZA vs. 8.8 months (95% CI: 6.7 - 11.0) for DEC (p = 0.455). The subgroup analysis revealed that patients ≥ 80 years (95%: CI 1.005 - 2.341), with leukocytes ≥ 10 x10 9/L (95% CI 1.039 - 2.062), platelet count <20 x10 9/L (95% CI: 1.150 - 3.422) and those with eGFR ≥ 45 mL/min/1.73m 2 (95% CI: 1.040 - 2.059) did benefit for treatment with AZA compared to DEC (Figure 1D). CONCLUSIONS Our study provides real-life data on the outcomes of AML patients treated with AZA compared to DEC in a large retrospective cohort with long-term follow-up. In addition, we identify for the first time some baseline characteristics that could benefit from AZA or DEC in terms of responses, 120-day mortality and OS. These findings could help us to choose the most appropriate HMA in monotherapy or for the development of new combinations. Figure 1 Figure 1. Disclosures de la Fuente: Novartis: Research Funding; Abbie: Consultancy, Speakers Bureau; Incyte: Consultancy, Speakers Bureau; BMS: Consultancy, Speakers Bureau. Tormo: 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; Astellas: Consultancy, Membership on an entity's Board of Directors or advisory committees, Speakers Bureau. Pérez-Simón: Novartis: Consultancy, Membership on an entity's Board of Directors or advisory committees, Research Funding, Speakers Bureau. Montesinos: Forma Therapeutics: Consultancy; Tolero Pharmaceutical: Consultancy; Karyopharm: Membership on an entity's Board of Directors or advisory committees, Research Funding; Novartis: Membership on an entity's Board of Directors or advisory committees, Research Funding, Speakers Bureau; Pfizer: Membership on an entity's Board of Directors or advisory committees, Research Funding, Speakers Bureau; Sanofi: Membership on an entity's Board of Directors or advisory committees, Speakers Bureau; Janssen: Membership on an entity's Board of Directors or advisory committees, Research Funding, Speakers Bureau; Incyte: Membership on an entity's Board of Directors or advisory committees, Speakers Bureau; Daiichi Sankyo: Consultancy, Membership on an entity's Board of Directors or advisory committees, Research Funding, Speakers Bureau; Celgene: Consultancy, Membership on an entity's Board of Directors or advisory committees, Research Funding, Speakers Bureau; Glycomimetics: Consultancy; Agios: Consultancy; Stemline/Menarini: Consultancy; Teva: Membership on an entity's Board of Directors or advisory committees, Research Funding, Speakers Bureau; AbbVie: Membership on an entity's Board of Directors or advisory committees, Research Funding, Speakers Bureau; Astellas Pharma, Inc.: Consultancy, Honoraria, Other: Advisory board, Research Funding, Speakers Bureau.

Download Full-text

Stroma-Based Activation of pSTAT3Y705 Confers Resistance to FLT3 Inhibitors in FLT3 ITD-Positive AML

Blood ◽

10.1182/blood.v128.22.34.34 ◽

2016 ◽

Vol 128 (22) ◽

pp. 34-34 ◽

Cited By ~ 1

Author(s):

Ami Patel ◽

Anthony D. Pomicter ◽

Anna M. Eiring ◽

Than Hein ◽

William L. Heaton ◽

...

Keyword(s):

Tyrosine Kinase ◽

Board Of Directors ◽

Cell Lines ◽

Myeloid Leukemia ◽

Research Funding ◽

Clinical Relapse ◽

Intrinsic Resistance ◽

Advisory Committees ◽

Tki Resistance

Abstract Acute myeloid leukemia (AML) is an aggressive hematopoietic neoplasm that carries the worst prognosis among the hematologic malignancies. Up to 30% of AML patients exhibit activating mutations in FLT3 tyrosine kinase. FLT3 internal tandem duplications (ITDs) comprise ~70% of these mutations and are associated with a poor prognosis. Most patients treated with a single-agent FLT3 tyrosine kinase inhibitor (TKI) relapse within months due to secondary mutations in the FLT3 tyrosine kinase domain (TKD). Results from trials of FLT3 TKIs in AML reveal that leukemic blasts are more easily cleared from peripheral blood than from bone marrow (BM), suggesting that the BM microenvironment promotes survival of AML cells, including leukemia initiating cells, despite inhibition of FLT3. In this conceptual framework, extrinsic factors allow AML cells to survive TKI exposure until AML cell-intrinsic resistance is conferred by FLT3 TKD mutations, leading to clinical relapse. Here, we investigated the role of the BM microenvironment in protection of FLT3+AML cells from treatment with AC220 (quizartinib), a clinically available FLT3 TKI. To investigate the potential of the BM microenvironment to mediate TKI resistance in AML, we cultured FLT3-ITD+ AML cell lines, including MOLM-13, MOLM-14 and MV411, and the CML cell line, K562 (control; FLT3 wild-type), with graded concentrations of AC220 under the following conditions: (i) in regular medium (RM), (ii) in direct contact (DC) with human HS-5 BM stromal cells, or (iii) in HS-5 conditioned medium (CM). Cell proliferation and apoptosis assays revealed that, in RM,AC220 reduced proliferation and increased apoptosis of MOLM-13, MOLM-14 and MV411 cells, but had no effect on K562 cells. DC greatly reduced the effects of AC220 in all three FLT3-ITD+ AML cell lines, with comparable results observed between DC and CM. To confirm these data using primary cells, CD34+ blasts from a patient with newly diagnosed FLT3-ITD+ AML were similarly cultured in RM versus CM ± AC220. Consistent with results in cell lines, CM rescued primary AML cells from AC220-mediated cell death. These data indicate that soluble factors from the BM environment protect FLT3-ITD+ cells from the effects of FLT3 inhibition. Our lab and others have demonstrated that HS-5 DC and CM activate STAT3 in chronic myeloid leukemia, which mediates resistance to BCR-ABL1 TKIs (Bewry et al. Mol Cancer Ther 2008, Traer et al. Leukemia 2012, Eiring et al. Leukemia 2015). To interrogate the role of STAT3 in BM-mediated protection of AML cells from FLT3 inhibition, all cell lines were assessed for pSTAT3Y705 and total STAT3 by immunoblot analysis under each culture condition. In FLT3-ITD+ AML cells grown in RM, pSTAT3Y705 was undetectable, irrespective of AC220 dose. In contrast, pSTAT5Y694 was readily detected at steady state and suppressed by AC220. AML cells cultured in HS-5 DC or in HS-5 CM exhibited strong upregulation of pSTAT3Y705 that was unaffected by AC220, suggesting that soluble factor(s) promote STAT3 activation in AML. pSTAT5Y694, on the other hand, was slightly elevated by HS-5 DC or CM, but remained under control of FLT3 kinase activity. In order to mechanistically implicate STAT3 activation in stroma-based protection, we used a retroviral shRNA construct to knockdown STAT3 (shSTAT3) compared to an empty vector control (LMP) in MOLM-14 cells. STAT3 knockdown (~70%) was confirmed by qRT-PCR and immunoblot analyses. Cells containing shSTAT3 and LMP were cultured for 72 hours in RM or CM ± AC220, followed by analysis using MTS assays. As expected, CM increased the IC50 of AC220 from 1.37 nM to 6.24 nM in LMP-expressing cells (n=3). In contrast, shSTAT3 reduced the IC50 of AC220 from 6.24 nM to 2.87 nM (n=3) in CM, with minimal effects in RM. Similarly, pharmacologic inhibition of STAT3 using the novel STAT3 inhibitor, BP-5-087 (Eiring et al. Leukemia 2015), reduced the IC50 of AC220 from 10.07 nM to 5.91 nM in CM. Analogous experiments in additional FLT3-ITD+cell lines and primary AML cells, using shSTAT3, dominant-negative STAT3 constructs and BP5-087 are ongoing. Our data suggest that STAT3 is a critical signaling node in FLT3-independent TKI resistance mediated by the BM microenvironment. Therapeutic strategies designed to combine FLT3 and STAT3 inhibition may inhibit the survival of leukemic cells in the BM niche, thereby preventing subsequent clinical relapse conferred by TKD mutations. Disclosures Deininger: Incyte: Consultancy, Membership on an entity's Board of Directors or advisory committees; BMS: Consultancy, Research Funding; Pfizer: Consultancy, Membership on an entity's Board of Directors or advisory committees, Research Funding; Novartis: Consultancy, Membership on an entity's Board of Directors or advisory committees, Research Funding; Gilead: Research Funding; CTI BioPharma Corp.: Membership on an entity's Board of Directors or advisory committees; Celgene: Research Funding; Bristol Myers Squibb: Consultancy, Research Funding; Ariad: Consultancy, Membership on an entity's Board of Directors or advisory committees.

Download Full-text