Reverse Phase Protein Assay (RPPA) Defines Specific Patterns in Childhood Acute Lymphoblastic Leukemia (ALL)

Abstract Background. ALL is the most frequent cancer in childhood. Although current chemotherapy protocols reach an event free survival (EFS) greater than 70%, the remaining cases relapse and ALL is still the first cause of death in children with cancer. Several efforts have been made to better understand the underlying mechanism involved in ALL. Current chemotherapy protocols have reached a plateau of effectiveness. The detection of minimal residual disease (MRD) during the course of treatment will definitively allows us to stratify children with ALL in standard (SR), intermediate (MR) and high (HR) risk, respectively. In the latter group we included patients with a prednisone poor response, with t(9;22) and t(4;11) (HR by default). Despite of this better definition of therapeutic response, the majority of relapses are included in the MR group, suggesting that we are treating different forms of ALL in this subset. For this reason new biomarkers and molecular targets are highly mandatory. The objective of functional proteome analyses of ALL is to bridge clinical applications with new biomarker discoveries that will be useful for determining prognosis and response to therapy and to identify potential new more selective treatments. Materials and Methods. We analyzed 81 diagnostic samples (peripheral blood and/or bone marrow) with B precursor ALL, that were diagnosed and treated at our centers (Catania and Padova) and enrolled in the AIEOP-LLA 2000 protocol. Reverse phase proteomic assay (RPPA) was used to interrogate the expression of 81 phosphorylated or native protein endpoints in our patients’ samples. We evaluated Pro- and Anti-Apoptotic, Protein Kinase, and Growth factor receptor cell signaling pathways. For statistical purposes, we considered the following characteristics: age at diagnosis, gender, immunophenotype, karyotype, white blood cell count and percentage of blast at diagnosis, response to prednisone, level of MRD at day 33 (TP1) and day 78 (TP2) during the induction phase. We distributed patients in 4 groups, based on risk (SR 21, MR 31, HR 10) and occurrence of relapse (19). We also studied patient specimens both at diagnosis and relapse only in those samples with a blast rate greater than 50% (10 cases out of 19). All findings obtained with RPPA were confirmed by Western blot analyses. We applied the Wilcoxon Test and the t-Test, using the ‘R’ software. Both univariate and multivariate analyses were performed. Results. Comparing subgroups for gender, WBC count (higher vs less than 50.000/ml), immunophenotype (Common vs others), karyotype (t(12;21) positive vs negative), prednisone good (PGR) vs poor (PPR) responders, analysis of MRD (SR vs MR, MR vs HR, SR vs HR, MR vs MR relapsed) and diagnoses vs relapses, we did not find any statistically significant data. Conversely, we found a statistically significant higher expression of FosB and Annexin II in the group of children with WBC >50.000/ml (p value <0,05); and of Zap70 (Y319)/Syk (Y352) in the subgroup of MR cases who did not suffer from relapse (p value <0,05). Our study showed that in the apoptotic pathway, we detected a higher expression of all the pro-apoptotic proteins [Bax, SMAC/DIABLO, Caspase 7 total and cleaved (D198)], a low expression of anti-apoptotic proteins (Bcl-xL, XIAP) associated with a reduction or a lack of PARP total or cleaved (D214). We also found that a specific pattern of expression (higher PTEN (S380), PARP cleaved, Caspase 7 cleaved, PDK (S241), PKAc (T197), p90RSK (S380), MEK ½ (S217–221), IKBA (S32), GRB2; lower Beta Catenine) selected a subgroup of children (n°9) with a better survival when compared with other cases (p value <0,05). Conclusions. Our preliminary data showed that RPPA in association with Western blot analysis, is a reliable strategy for the identification of biomarkers and/or molecules for targeted therapy. Application of this methodology on specific subgroups of children with ALL will allow us to identify new therapeutic strategies.

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Pharmacokinetic and Pharmacodynamic Characterization of Graspa Versus Native L-Asparaginase in Combination with Cooprall Chemotherapy in a Phase 3 Randomized Trial for the Treatment of Patients with Relapsed Acute Lymphoblastic Leukemia (NCT01518517)

Blood ◽

10.1182/blood.v126.23.2492.2492 ◽

2015 ◽

Vol 126 (23) ◽

pp. 2492-2492 ◽

Cited By ~ 1

Author(s):

Xavier Thomas ◽

Yves Bertrand ◽

Andre Baruchel ◽

Nicolas Blin ◽

Emmanuelle Tavernier ◽

...

Keyword(s):

Residual Disease ◽

Lymphoblastic Leukemia ◽

Clinical Signs ◽

Phase Iii ◽

Disease Rate ◽

P Value ◽

Induction Phase ◽

Phase 3 ◽

Logrank Test ◽

Asparaginase Activity

Abstract Background Asparaginase is a cornerstone in the treatment of ALL, but its utility is limited by toxicities including hypersensitivity. Clinical allergy is associated with inactivation of asparaginase by antibodies, which can also neutralize asparaginase without any clinical signs of hypersensitivity (silent inactivation). GRASPA (eryaspase - proposed INN) is an L-asparaginase encapsulated into the red blood cells. In a recent Phase III trial, it has shown to prolong the asparaginase activity and significantly reduce the incidence of allergic reactions in pts with relapsed ALL. Methods This open, randomized international Phase 3 study enrolled pts with relapsed ALL. The co-primary endpoints were the mean duration of asparaginase (ASPA) activity > 100 IU/L and incidence of hypersensitivity reactions during induction phase. Key secondary endpoints were safety, tolerability, complete remission and minimal residual disease rate, pharmacokinetic (PK), pharmacodynamics (PD) and anti-ASPA antibodies at baseline. Pts (n=80), aged 1-55 years without prior hypersensitivity were randomized to GRASPA (150 IU/kg, n=26, Arm A) or native L-asparaginase (L-ASP, 10,000 IU/m², n= 28, Arm B). Additionally, 26 pts with prior hypersensitivity were treated with GRASPA in a single stratum (Arm C, GRASPA-s). All pts received COOPRALL protocol as a backbone chemotherapy. Here we report the report the PK of asparaginase activity, and PD effects. Results A total of 80 pts enrolled into the trial. A total 100% and 96% of patients had at least one day with asparaginase level >100 IU/L during induction, with GRASPA and L-ASP, respectively. Only one patient in L-Asp group did not reach this threshold. All patients in Arm C have also achieved total blood asparaginase level > 100 IU/L during induction. Prolonged ASPA activity was maintained across several key subpopulations as follows: Table 1. GRASPA L-ASP GRASPA L-ASP Age group Children Adults N 21 21 5 7 Mean (SD) 20.8 (5.3) 11.4 (7.3) 19.3 (5.5) 3.2 (2.8) Median 22.0 8.3 22.1 2.3 Risk Score S1/S2 S3/S4 N 16 15 10 13 Mean (SD) 20.2 (6.0) 12.0 (8.6) 20.9 (3.9) 6.3 (4.4) Median 22.4 9.0 22.0 6.2 F1-F2/VANDA F1-F2 VANDA N 16 15 10 13 Mean (SD) 19.5 ± 6.5 11.5 (9.0) 22.0 (0.2) 6.9 (4.2) Median 22.9 8.8 22.0 6.9 The total ASPA activity >100 IU/L until the loss of that activity demonstrated that the activity was retained in the majority of pts in the GRASPA arm (89%) compared to only 26% in the L-ASP arm. The median times from first assessment of activity > 100 IU/L to loss of activity was not reached in the GRASPA arm by Day 28, but was 15 days in the L-ASP arm. The difference was statistically significant (table below). Similar trend was also observed with GRASPA-s. Table 2. Time from first assessment showing ASPA activity > 100 IU/L until loss of ASPA activity > 100 IU/L Number (%) of events Median [95% CI] Hazard ratio 95% CI Logrank test: p-value for superiority L-ASPN= 28 27 (96.4) 15[11; 21] 0.14 0.07, 0.28 <0.001 GRASPAN= 26 26 (100) NR* NR: not reached Additional information correlating ASPA with asparagine depletion and other amino acid changes (aspartate, glutamic acid, and glutamate) will be provided at the meeting. Conclusion GRASPA consistently demonstrated activity compared to L-ASP for the treatment of pts with relapsed ALL, and is therefore a suitable option for patients with relapsed ALL. Disclosures Thomas: ERYTECH Pharma: Consultancy. Bertrand:ERYTECH Pharma: Consultancy, Membership on an entity's Board of Directors or advisory committees. Vey:Celgene: Honoraria; Roche: Honoraria; Janssen: Honoraria. Bonin:ERYTECH Pharma: Employment. Godfrin:ERYTECH Pharma: Employment. El Hariry:ERYTECH Pharma: Employment.

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Pharmacogenetics of minimal residual disease response in children with B-precursor acute lymphoblastic leukemia: a report from the Children's Oncology Group

Blood ◽

10.1182/blood-2007-09-114082 ◽

2008 ◽

Vol 111 (6) ◽

pp. 2984-2990 ◽

Cited By ~ 33

Author(s):

Stella M. Davies ◽

Michael J. Borowitz ◽

Gary L. Rosner ◽

Kristin Ritz ◽

Meenakshi Devidas ◽

...

Keyword(s):

Bone Marrow ◽

Acute Lymphoblastic Leukemia ◽

Minimal Residual Disease ◽

Residual Disease ◽

Lymphoblastic Leukemia ◽

Response To Therapy ◽

Oncology Group ◽

Risk Status ◽

Prognostic Features ◽

Minimal Residual

Abstract Minimal residual disease (MRD) as a marker of antileukemic drug efficacy is being used to assess risk status and, in some cases, to adjust the intensity of therapy. Within known prognostic categories, the determinants of MRD are not known. We measured MRD by flow cytometry at day 8 (in blood) and at day 28 (in bone marrow) of induction therapy in more than 1000 children enrolled in Pediatric Oncology Group therapy protocols 9904, 9905, and 9906. We classified patients as “best risk” if they had cleared MRD by day 8 of therapy and as “worst risk” if they had MRD remaining in bone marrow at day 28, and tested whether MRD was related to polymorphisms in 16 loci in genes hypothesized to influence response to therapy in acute lymphoblastic leukemia (ALL). After adjusting for known prognostic features such as presence of the TEL-AML1 rearrangement, National Cancer Institute (NCI) risk status, ploidy, and race, the G allele of a common polymorphism in chemokine receptor 5 (CCR5) was associated with more favorable MRD status than the A allele (P = .009, logistic regression), when comparing “best” and “worst” risk groups. These data are consistent with growing evidence that both acquired and host genetics influence response to cancer therapy.

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Early Response to Therapy Is Significantly Associated with Genetic Subtype of Acute Lymphoblastic Leukemia: A Report from the Children’s Oncology Group.

Blood ◽

10.1182/blood.v110.11.758.758 ◽

2007 ◽

Vol 110 (11) ◽

pp. 758-758

Author(s):

Mignon L. Loh ◽

Elizabeth Raetz ◽

Meenakshi Devidas ◽

Stephen B. Linda ◽

Michael J. Borowitz ◽

...

Keyword(s):

Bone Marrow ◽

Real Time ◽

Induction Therapy ◽

Classification System ◽

Residual Disease ◽

Lymphoblastic Leukemia ◽

Early Response ◽

Response To Therapy ◽

Oncology Group ◽

Genetic Features

Abstract Improved outcomes for children with acute lympboblastic leukemia (ALL) have been achieved, in part, from adaptation of risk-stratified therapy. The Children’s Oncology Group (COG) has implemented a real-time risk classification system (AALL03B1) using a combination of NCI-Rome risk criteria, blast cell genetic features, and early treatment response to determine the intensity of post-induction therapy. Between December 29, 2003 and June 1, 2007, more than 4,000 children over 1 year of age with B-precursor ALL were enrolled on AALL03B1, including 2293 (62%) with NCI Standard Risk (SR) and 1406 (38%) with NCI High Risk (HR) features who were subsequently enrolled on companion clinical trials. The most favorable genetic features used in AALL03B1 were identified in legacy COG studies and included TEL/AML1(TEL) or triple trisomies of chromosomes 4, 10, and 17 (TT). Unfavorable genetic features included the presence of BCR/ABL, MLL rearrangements, or extreme hypodiploidy (DNA index <.81 or chromosomes <44). Overall, 26% of patients were TEL+ and 24.7% had TT. These genetic subsets occurred more frequently in NCI SR vs. HR patients (30.7% and 30.9% vs. 14.5% and 11.7% respectively). Children achieving an M1 day 15 bone marrow (BM) who also had minimal residual disease (MRD) < 0.1% measured by flow cytometry on day 29 of induction therapy were deemed rapid early responders (RER), while those with either an M2/M3 day 15 marrow or MRD > 0.1% at day 29 were defined as slow early responders (SER). Among the favorable cytogenetic subsets, patterns of early response differed. The presence of TEL was significantly associated with an RER to induction therapy in both NCI SR and HR groups (p< 0.0001), while the presence of TT was not (p=0.058). For NCI SR patients, the presence of TEL was significantly associated with the achievement of an M1 bone marrow by day 8 (50.9% of TEL+ pts vs. 41.2% of TEL- pts, p< 0.0001). Patients with an M1 or M2 BM on day 29 who had MRD >1% received extended induction (EI) for two weeks followed by an additional evaluation of BM morphology and MRD at day 43 of induction. One hundred and nineteen patients received EI, with 40% having NCI SR features at diagnosis. Of the patients who received EI, 63% achieved an M1 marrow with MRD < 1% by day 43 and were eligible to continue on protocol therapy. This was more likely to occur in NCI SR patients (77% vs. 55%, p<0.013). Not surprisingly, 31% of the NCI HR patients receiving EI were BCR/ABL positive, and the presence of BCR/ABL was associated with a slower early response overall. While the presence of the BCR/ABL was associated with a greater likelihood of EI, MLL rearrangements and hypodiploidy were not. These data indicate that early response to induction therapy differs among genetic subsets of pediatric patients with newly diagnosed ALL. In addition a centralized classification system allows for robust collection of data from local and centralized reference laboratories that can be used for real time treatment assignment of ∼2000 patients/year with ALL from > 220 COG institutions.

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Line Treatment of Adult Ph+ Acute Lymphoblastic Leukemia (ALL) Patients. Final Results of the GIMEMA LAL1205 Study

Blood ◽

10.1182/blood.v112.11.305.305 ◽

2008 ◽

Vol 112 (11) ◽

pp. 305-305 ◽

Cited By ~ 10

Author(s):

Robert Foà ◽

Antonella Vitale ◽

Anna Guarini ◽

Maria Sefania De Propris ◽

Loredana Elia ◽

...

Keyword(s):

Residual Disease ◽

Lymphoblastic Leukemia ◽

Disease Free Survival ◽

Leukemic Cells ◽

Remission Induction ◽

Induction Treatment ◽

Induction Phase ◽

Significant Prognostic Factor ◽

Rt Pcr ◽

Active Inhibitor

Abstract Background: Dasatinib is a potent, oral inhibitor of the BCR-ABL, c-KIT and SRC kinase family, which has proven to be a more active inhibitor of BCR-ABL and c-KIT than imatinib in preclinical studies. Clinically, it has been shown to be effective in chronic myeloid leukemia and in Ph+ ALL patients resistant or intolerant to imatinib. Aims: The primary objective of the study was to assess the activity of dasatinib in de novo adult Ph+ ALL patients in terms of complete hematological remission (CHR); the secondary objectives were treatment toxicity, rate of immunophenotypic and molecular responses, disease-free survival (DFS), relapse rate and overall survival (OS). Methods: The GIMEMA LAL 1205 protocol was designed for patients ≥18 years (no upper age limit) who receive dasatinib po, 70 mg BID. A steroid pre-phase is started 7 days prior to dasatinib administration and continued up to day 31, and then tapered. The pre-phase allows identification of the BCR/ABL transcript. Dasatinib is given for 12 weeks. Two intrathecal methotrexates are administered at days +22 and +43. All cases are analyzed through a central handling of samples at presentation for morphology, immunophenotype, cytogenetics and molecular biology at the coordinating center in Rome. Minimal residual disease (MRD) is also centrally investigated by flow-cytometry and Q-RT-PCR at days +22, +43, +57 and +84. The protocol was designed for 48 patients. Results: Recruitment started in November 2006 and was completed in August 2008. The median age of the 48 enrolled BCR/ABL+ ALL patients was 54 years (range 24-76), 26 were females and 22 males. The median WBC count was 20.1 (range 2.2–133). The last analysis has been conducted on 36 patients. One patient stopped treatment after 14 days due to intestinal toxicity and 1 patient refused treatment. Thus, to date 34 patients are evaluable for response. Nineteen cases were p190+ and 15 p210+ (5 were p190/p210+). A >75% response to the steroid pre-phase was recorded in 82.7% of patients. All 34 patients (100%) have witnessed a CHR: 32 (94.12%) at the 1st determination at day +22, 1 at the 2nd at day +43 and 1 at the 3rd at day +57. No fatalities have been observed. In 13 patients, at least 1 severe adverse event (SAE) has been recorded, for a total of 26 SAEs. Overall, the compliance has been good; only 1 patient stopped treatment at day 67 due to toxicity while in CHR. The median follow-up is so far 11.2 months. The OS at 10 months is 80.7%. Immunophenotypic and BCR/ABL Q-RT-PCR monitoring of MRD has shown a very marked clearance of leukemic cells by day +22, progressively strengthened at the subsequent timepoints. In p190+ cases the minimal MRD value was reached at day +43, while in p210+ cases this was observed at day +84, documenting a lower susceptibility to dasatinib by this molecular subgroup. So far, 9 patients have relapsed, at a median of 72 days from the end of induction; in agreement with the MRD data, 7/9 relapses occurred within the p210+ cases and 2/9 within the p190+ cases. The presence of mutations has been investigated in 8/9 relapsed samples: 5 showed a T315I mutation, 1 an E255K mutation and 2 were wt. Cloning experiments allowed to detect in 2 cases low levels of T315I mutations already at presentation and on MRD cells at the end of the induction treatment. The first multivariate analysis has been conducted for DFS and the degree of PCR reduction − ≤10−3 vs ≥10−3 - has so far emerged as the only significant prognostic factor. Conclusions: This study demonstrates that in adult Ph+ ALL dasatinib monotherapy is capable of inducing a CHR in virtually all patients, irrespective of age, without important toxicities and with no fatalities. The hematological response is associated with a very marked and rapid debulking of the neoplastic clone documented at the MRD level, particularly for p190+ cases. The degree of PCR response is of prognostic relevance. No relapses have been observed during the induction phase. The optimal post-induction treatment strategy, which was not part of the study, remains to be defined, particularly in light of the genetic instability of Ph+ ALL and of the selection/induction of mutations. These results, together with those previously reported by our group with imatinib alone for elderly patients, question the use of chemotherapy, with or without a TK inhibitor, for the remission induction of Ph+ ALL.

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Chemoimmunotherapy with a Modified Hyper-CVAD and Rituximab Regimen Improves Outcome for Patients with De Novo Philadelphia Negative Precursor B-Cell Acute Lymphoblastic Leukemia (ALL).

Blood ◽

10.1182/blood.v114.22.836.836 ◽

2009 ◽

Vol 114 (22) ◽

pp. 836-836

Author(s):

Deborah A. Thomas ◽

Hagop M. Kantarjian ◽

Stefan Faderl ◽

William G. Wierda ◽

Jorge Cortes ◽

...

Keyword(s):

B Cell ◽

De Novo ◽

Conflicts Of Interest ◽

Residual Disease ◽

Lymphoblastic Leukemia ◽

Disease Free Survival ◽

High Dose ◽

Induction Phase ◽

Liposomal Daunorubicin ◽

Cd20 Expression

Abstract Abstract 836 The hyper-CVAD regimen is an effective frontline program for de novo adult ALL and LL [Kantarjian, JCO 18:547, 2000; Kantarjian, Cancer 101:2788, 2004, Thomas, Blood 104:1624, 2004]. Intensive chemotherapy with hyper-CVAD (fractionated cyclophosphamide, vincristine [VCR], doxorubicin, dexamethasone) alternates with high dose methotrexate (MTX) and cytarabine every 21 days for 8 courses, followed by maintenance therapy with POMP (6-mercaptopurine, MTX, VCR, prednisone). Historical CR rate was 92% with 3-year disease-free survival (DFS) rate of 38%. The regimen was modified in 1999. Induction chemotherapy was given in a protective environment owing to higher mortality in patients (pts) aged 60 years or older (17% vs 3%). Course 2 of liposomal daunorubicin and cytarabine was incorporated owing to reports suggesting benefit of early anthracycline intensification. Rituximab 375 mg/m2 (days 1 & 11 of hyper-CVAD, days 1 & 8 of methotrexate-cytarabine) was given if CD20 expression was 20% or greater due to its association with disease recurrence [Thomas, Blood 113:6330, 2009]. The maintenance phase was extended to 30 months with additional intensifications owing to late relapses after completion of POMP therapy. Newly diagnosed or primary refractory (1 course only) pts with ALL (n=204) or LL (n=27) were treated on the two sequential studies. Burkitt-type leukemia/lymphoma (BLL) and Philadelphia positive ALL were treated on alternative protocols. From May 2000 to December 2001, 69 pts were treated with modified hyper-CVAD with anthracycline intensification (9 induction-consolidation courses). Course 2 was then eliminated from the regimen (8 courses), with an additional 162 pts treated to date (pts age 30 years or less are now treated with augmented BFM). Median age was 43 yrs (range, 15–83). CD20 expression was noted in 49%. Overall CR rate of the evaluable group (n=225) was 93%; 7 pts achieved PR (LL with residual disease), five failed to respond, and 4 died during the induction phase. Three-yr CRD and OS rates were 70% and 62%, respectively after a median follow-up of 50 months (range, 2–106+). In the younger CD20 positive precursor B-cell ALL subset (n=99), rituximab improved outcome compared to historical experience with hyper-CVAD alone (n=127), with 3-yr CRD rates (75% vs 45%, p<.001) and OS rates (65% vs 38%, p<.001) approaching those of their CD20 negative counterparts. In contrast to the Burkitt experience, rituximab was not beneficial for the elderly subgroup (OS rates 28% vs 34%, p NS). Anthracycline intensification did not improve outcome. The addition of rituximab to the hyper-CVAD regimen appears to benefit the younger pts (age less than 60 yrs) with CD20 positive precursor B-cell ALL. Incorporation of rituximab and other monoclonal antibodies (e.g., ofatumumab, epratuzumab) into frontline chemotherapy regimens for ALL should be investigated systematically. Disclosures: No relevant conflicts of interest to declare.

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Predictive Value of Minimal Residual Disease: Analysis By Flow-Cytometry in Children with Relapsed Acute Lymphoblastic Leukemia

Blood ◽

10.1182/blood.v126.23.2494.2494 ◽

2015 ◽

Vol 126 (23) ◽

pp. 2494-2494

Author(s):

Myriam Ruth Guitter ◽

Jorge Gabriel Rossi ◽

Elisa Sajaroff ◽

Carolina Carrara ◽

Pizzi Silvia ◽

...

Keyword(s):

Flow Cytometry ◽

Residual Disease ◽

Lymphoblastic Leukemia ◽

P Value ◽

Time Points ◽

Group 3 ◽

Group 2 ◽

To Receive ◽

Group 1

Abstract Introduction: Despite the advances observed in the outcome of pediatric acute lymphoblastic leukemia (ALL) treatment during the last 20 years, relapse remains the most common cause of treatment failure in childhood ALL. Several factors have been associated to the prognosis of these patients; however, minimal residual disease (MRD) emerges as a relevant predictor of outcome. Objectives: The aims of this study were to assess MRD by flow-cytometry in relapsed ALL and to evaluate its prognostic impact as a predictor factor of outcome at the end of the induction therapy and prior to hematopoietic stem cell transplantation (HSCT). Patients and Methods: From Aug'10 to Jun'15, 123 ALL patients were treated at our center. MRD determination at least at two time-points during relapse treatment was a requirement for considering a patient eligible for the present study. Sixty-six cases were excluded due to the following causes: 10 patients died during induction, 2 died early in complete remission (CR), 29 did not respond to chemotherapy, in 13 patients MRD determination was not performed: 4 did not have clinical data available, 4 patients were Down Syndrome and 4 children received treatment for relapse in other centers. Thus, fifty-seven patients achieved CR and were evaluated for MRD at two time points. Of them, 56 patients belonged to S4 and S3 and 1 patient to S1 group as defined by the Berlin-Frankfurt-Münster stratification for relapsed ALL. MRD was analyzed by multiparametric flow-cytometry following ALL-IC 2009 guidelines. Negative MRD was defined as disclosing less than 0.1% of blasts. For this analysis, patients were stratified based on MRD levels at two different time points: after end of induction, before HSCT or at any other time point during the follow-up for patients who did not undergo HSCT. Three groups were defined: Group-1: negative at both time points (n= 23), Group-2: positive at 1 time point (n= 13) and Group-3: positive at both time points (n= 21). Patients who relapsed before receiving HSCT were considered Group-3. Twenty-five patients underwent HSCT: 13 of them from Group-1, 9 from Group-2 (2 had positive MRD previous to receive HSCT) and 3 patients from Group-3. HSCT was performed with matched familiar donor in 16 cases and matched unrelated donor in 9 cases. Results: The distribution of events according to receiving or not HSCT was: 5 died due to transplant related mortality (TRM), 9 relapsed after receiving HSCT and 16 during treatment with chemotherapy. With a median follow-up of 16 (range: 6-67) months, overall 3-year EFS probability (EFSp) (SE) was 32 (8)%. The 3-year EFSp was 75 (11)% for Group-1, 24 (14)% for Group-2 and 0% for Group-3 (p-value <0.00001). Comparing patients who did not receive HSCT vs. patients who did, EFSp (SE) was 32 (12)% and 29 (11)% respectively (p-value: non-significant). The EFSp (SE) according to MRD groups in patients who underwent HSCT was: Group-1: 53 (19)%, Group-2: 14 (13)% and 0% for Group-3 (p-value: 0.06). Conclusions: MRD quantification by flow-cytometry demonstrated to be a significant prognostic factor for relapsed ALL. Both, TRM and death in CR rates, were high and should be decreased by improving supportive measures. MRD determination by flow-cytometry in patients who underwent HSCT showed a trend to achieve a better EFSp, thus representing a relevant tool for stratifying relapsed ALL patients in order to achieve a better selection of patients to receive HSCT. Disclosures No relevant conflicts of interest to declare.

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Effect of High-Dose Methotrexate (HD-MTX) Vs Capizzi Methotrexate/Pegaspargase (C-MTX/ASNase) on Osteonecrosis (ON) Incidence in Children and Young Adults with T-Acute Lymphoblastic Leukemia (T-ALL): Results of Children’s Oncology Group (COG) Study AALL0434

Blood ◽

10.1182/blood.v124.21.3649.3649 ◽

2014 ◽

Vol 124 (21) ◽

pp. 3649-3649 ◽

Cited By ~ 5

Author(s):

Leonard A. Mattano ◽

Meenakshi Devidas ◽

Si Chen ◽

Natia Esiashvili ◽

Barbara Asselin ◽

...

Keyword(s):

Cumulative Incidence ◽

Residual Disease ◽

Lymphoblastic Leukemia ◽

Clinical Severity ◽

P Value ◽

High Dose ◽

Age Cohort ◽

Drug Scheduling ◽

B Lineage ◽

N 93

Abstract Introduction: Augmented post-induction (IND) intensification therapy improved event free (EFS) and overall survival (OS) among patients (pts) 1-20 years (yr) with NCI high-risk (HR) B- and T-ALL on CCG-1961 (Seibel, Blood 2008) but was associated with significant ON (Mattano, Lancet Oncol 2012). Successor COG trials for HR B-ALL (AALL0232) and T-ALL (AALL0434) have investigated modifications of augmented therapy to further improve outcome and reduce ON risk. HD-MTX delivered during interim maintenance (IM) provided an EFS advantage over escalating dose (Capizzi) MTX/ASNase on AALL0232 (Larsen, ASCO 2011) and confirmed a lower ON incidence with alternate-week (AWD) vs continuous (CD) dexamethasone (DEX) during delayed intensification (DI) (Mattano, ASH 2012). Additionally, ON incidence was lower among pts 10+ yr receiving IND prednisone (PDN) vs DEX, especially those randomized to HD-MTX. We now report results for ON incidence among T-ALL pts receiving comparable therapy on AALL0434. Methods: AALL0434 opened 1/2007 and completed accrual 7/2014, with 1155 evaluable T-ALL pts 1-30 yr included in this report (data freeze 6/30/2014). All pts received standard 4-drug IND (vincristine, PDN 60 mg/M2 days 1-28, pegaspargase, daunorubicin, intrathecal MTX). Following IND, pts received augmented therapy with a 2x2 randomization to HD-MTX vs C-MTX/ASNase (during a single IM phase) with or without six 5-day (d) courses of nelarabine (NEL) (during consolidation (CON), DI, and MTC cycles 1-3). Pts meeting low-risk (LR) criteria (age 1-9 yr, WBC <50,000/microliter, no central nervous system or testicular leukemia, and rapid marrow response (<5% blasts by d15 and end-IND minimal residual disease <0.1%)) were not eligible for the NEL randomization. Initially, pts 1-9 yr received CD (10 mg/M2 d1-21) during DI, and all pts received DEX pulses (6 mg/M2 d1-5) every 28d during MTC. After 9/2008, based on AALL0232 ON interim analyses, all pts received AWD (d1-7,15-21) during DI and PDN pulses (40 mg/M2 d1-5) during MTC. To accommodate drug scheduling, pegaspargase dose intervals were increased on NEL regimens during CON and DI by 7-14d, CON was extended by 21d, and 3 fewer steroid pulses were given during MTC cycles 1-3. MTC duration was 1 yr longer for males. Results: Among 1155 evaluable pts (617 with 36+ months follow-up), 69 (6%) developed imaging-confirmed ON (58/527 (11%) 10+ yr, 11/628 (2%) 1-9 yr; 54/861 (6%) males, 15/294 (5%) females). Symptom onset was pre-MTC in 13%, during MTC in 86%, after therapy completion in 1%, and within 36 months in 93%. Maximum reported ON clinical severity (CTCAE v4.0) was 11.6% grade 1, 60.9% grade 2, 27.5% grade 3. The overall 36-month ON cumulative incidence was 8.0±1.2% and was higher for pts 10+ yr (14.6±2.3 vs 2.6±1.0%, RHR 5.7, p<0.0001). Males 10+ yr had a numerically higher ON incidence that was not statistically significant (15.5±2.7 vs 10.9±4.8, RHR 1.4, p=0.4). Higher ON rates were seen among pts randomized to C-MTX/ASNase or HD-MTX without NEL (Table). Among pts 13+ yr treated without NEL, ON rates for C-MTX/ASNase (26.4±5.8%) and HD-MTX (23.0±6.2%) were similar to those seen in comparably treated B-ALL pts on AALL0232 regimens PC (18.9±2.7%) and PH (17.3±2.5%). Conclusions: T- and B-lineage ALL pts are at similar overall risk for developing ON when given comparable therapy, particularly those age 10+ yr. Increased pegaspargase exposure likely contributes to the increased ON rates seen with C-MTX/ASNase in both populations, whereas longer intervals between pegaspargase doses and fewer steroid pulses during early MTC appear associated with significantly lower rates for T-ALL pts on NEL regimens. Unlike B-ALL, the observed higher rate among males may be due to the expected T-ALL gender imbalance and resulting low numbers of female pts. AWD during DI is now considered standard care for all ALL populations on COG ALL trials. ON will continue to be closely monitored through completion of this trial. Table: Randomized Regimens, 36-Month Cumulative Incidence Rate (% ± SE) Without Nelarabine With Nelarabine Age (yr) C-MTX/ASNase HD-MTX C-MTX/ASNase HD-MTX P* 1-30 11.6±2.2 8.2±1.9 5.2±4.0 3.2±3.5 0.04 n=363 n=442 n=138 n=171 10-30 20.6±4.0 16.0±3.7 10.2±7.7 6.1±6.2 0.07 n=158 n=185 n=71 n=93 *P value for 4-way comparison of regimens by age cohort Disclosures Hunger: Sigma Tau Pharmaceuticals: Honoraria; Jazz Pharmaceuticals: Honoraria.

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Updated Clinical Activity of Graspa Versus Native l-Asparaginase in Combination with Cooprall Regimen in Phase 3 Randomized Trial in Patients with Relapsed Acute Lymphoblastic Leukemia (NCT01518517)

Blood ◽

10.1182/blood.v126.23.3723.3723 ◽

2015 ◽

Vol 126 (23) ◽

pp. 3723-3723 ◽

Cited By ~ 4

Author(s):

Andre Baruchel ◽

Yves Bertrand ◽

Xavier Thomas ◽

Nicolas Blin ◽

Emmanuelle Tavernier ◽

...

Keyword(s):

Relapse Rate ◽

Residual Disease ◽

Lymphoblastic Leukemia ◽

Clinical Signs ◽

Phase Iii ◽

Induction Treatment ◽

Clinical Activity ◽

P Value ◽

Phase 3 ◽

Alternative Treatment Option

Abstract Background Asparaginase is a cornerstone in the treatment of ALL, but its utility is limited by toxicities including hypersensitivity. Clinical allergy is associated with inactivation of asparaginase by antibodies, which can also neutralize asparaginase without any clinical signs of hypersensitivity (silent inactivation). GRASPA (proposed eryaspase, E-Coli L-Asparaginase encapsulated into red blood cells) improves pharmacokinetics, tolerability and maintain circulating asparaginase (ASPA) activity due to the protective barrier of the erythrocyte membrane. In a recent Phase III trial, it has shown to prolong the asparaginase activity and significantly reduce the incidence of allergic reactions in pts with relapsed ALL. In the non-allergic pts, GRASPA significantly reduced the incidence of hypersensitivity (0% vs 46%; p<0.001). ASPA activity >100 IU/l was 21 ± 5 vs 9 ± 7 days in GRASPA and L-ASP, respectively (p<0.001). Methods This open, randomized international Phase 3 study enrolled pts with relapsed ALL. The co-primary endpoints were the duration of ASPA activity > 100IU/L and the incidence of hypersensitivity during induction. Key secondary endpoints were complete remission, minimal residual disease, relapse rate, event free survival (EFS) and overall survival (OS). Pts (n=80), aged 1-55 years without prior hypersensitivity were randomized to GRASPA (150 IU/kg, n=26, Arm A) or native L-asparaginase (L-ASP, 10,000 IU/m², n= 28, Arm B). Additionally, 26 pts with prior hypersensitivity were treated with GRASPA in a single stratum (Arm C). All pts received COOPRALL protocol as a backbone chemotherapy. Results A total of 80 pts with relapsed and or refractory ALL were enrolled into the trial. There were a greater proportion of pts who completed the induction treatment in GRASPA arm (65%) than in the L-ASP arm (46%). The main reasons for treatment discontinuation were: target levels of asparagine depletion not reached (64%) in GRASPA arm, and adverse events (58%) in the L-ASP arm. In addition, in the L-ASP arm, 5 (19%) pts prematurely discontinued treatment due to disease progression. As of the cut-off date (28th August 2014), the majority of pts (63%) still continued in the study and followed-up for survival. The relapse rate at 6 and 12 mo was low, and accounted for 3 (13%; 95% CI: 2.6; 32.4) and 5 (26%; 95% CI: 9.1; 51.2) in the GRASPA arm, compared to 1 pt (5%) and 3 (17%; 95% CI: 3.6; 41.4) in the L-ASP arm, respectively. Except for L-ASP, and adult patients, the median EFS and OS were not reached for GRASPA in the entire set or in children, either at 12 months. Overall, there was a trend across all groups with lower EFS and OS event rates with GRASPA compared to L-ASP, as presented in table below. The 2-year follow up will be additionally provided at the meeting Table 1. GRASPA vs L-ASP All patients GRASPA = 26 L-ASP = 28 Children GRASPA = 21 L-ASP = 21 Adults GRASPA = 5 L-ASP = 7 12 mo EFS Median (mo) NR vs 11.6 NR 4.6 vs 1.6 Events 30.8% vs 50.0% 19.1% vs 38.1% 80% vs 85.7% HR 0.54 0.47 0.69 95% CI 0.23; 1.26 0.15; 1.47 0.20; 2.44 P Value* 0.153 0.196 0.569 12 mo OS Median (mo) NR NR 10 vs 8.2 Events 23.1% vs 32.1% 4.8% vs 14.3% 20% vs 42.8% HR 0.63 0.34 0.39 95% CI 023; 1.74 0.05; 2.42 0.05; 2.81 P Value* 0.377 0.424 0.705 *P value in all subsets is not statistically significant Conclusion GRASPA has demonstrated both safety and activity in pts with relapsed ALL, and provides an alternative treatment option for those patients. Disclosures Bertrand: ERYTECH Pharma: Consultancy. Thomas:ERYTECH Pharma: Consultancy. Vey:Roche: Honoraria; Janssen: Honoraria; Celgene: Honoraria. Bonin:ERYTECH Pharma: Employment. El Hariry:ERYTECH Pharma: Employment.

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Early Deaths in Pediatric Acute Leukemia; A Challenge in Developing Countries

Blood ◽

10.1182/blood.v128.22.5160.5160 ◽

2016 ◽

Vol 128 (22) ◽

pp. 5160-5160

Author(s):

Hanafy Ahmed Hafez ◽

Rawaa Solaiman ◽

Dalia Bilal ◽

Lobna m Shalaby

Keyword(s):

Developing Countries ◽

Acute Leukemia ◽

Supportive Care ◽

Death Rate ◽

Conflicts Of Interest ◽

Lymphoblastic Leukemia ◽

Survival Rates ◽

Early Death ◽

Response To Therapy ◽

P Value

Abstract Background and objectives: The survival rates of children with acute leukemia is consistently improving, due to the lower relapse rates in addition to reducing treatment-related mortality, which is mainly a result of infectious causes. The aim of the study is to describe the incidence and risk factors associated with early deaths (first 42 days in treatment) among children with acute leukemia. Methods: This is a retrospective study included newly diagnosed patients with acute leukemia who presented to the National Cancer Institute, Cairo University between Jan. 2011 to Dec. 2013. Patients' data were collected from their files and analyzed for the total and early death rates and proposed causes of death. Results: The study included 370 patients, 253 with acute lymphoblastic leukemia (ALL), 100 with acute myeloid leukemia (AML) and 17 with mixed phenotypic acute leukemia (MPAL). The total death rate among the whole group was 40.5% (n=150) and induction death rate was 19.2% (n=71). AML was accompanied with higher rates of total and induction deaths as they were 58% and 25% respectively, compared to 33.6% and 17.4% in ALL. These early deaths were attributed mostly to infection 64.7% (n=46) and cerebrovascular accidents 18.3% (n=13). Early deaths were significantly higher in patients with age below 2 years old (p. value=0.008), and in those with poor response to therapy (p. value= 0.001). Using enhanced supportive care measures as better infection control, appropriate antibiotic guidelines and available intensive care unit during 2013 had significantly reduced the overall and induction mortality rates (27.8% and 13.8% respectively in 2013 versus 45% and 20.3% in 2011 and 49% and 25% in 2012). Conclusion: Induction deaths in pediatric acute leukemia remain a major challenge in developing countries and constitute an increasing fraction of all deaths. Accordingly, using a well equipped cancer centers with better supportive care guidelines is essential to further improve the survival in these group of patients. Key words: Acute Leukemia- Pediatrics- Early Death- Infection Disclosures No relevant conflicts of interest to declare.

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Rapid molecular response during early induction chemotherapy predicts a good outcome in childhood acute lymphoblastic leukemia

Blood ◽

10.1182/blood.v95.3.790.003k48_790_794 ◽

2000 ◽

Vol 95 (3) ◽

pp. 790-794 ◽

Cited By ~ 138

Author(s):

E. Renate Panzer-Grümayer ◽

Monika Schneider ◽

Simon Panzer ◽

Karin Fasching ◽

Helmut Gadner

Keyword(s):

Acute Lymphoblastic Leukemia ◽

Risk Stratification ◽

Residual Disease ◽

Lymphoblastic Leukemia ◽

Early Response ◽

Response To Therapy ◽

Childhood Acute Lymphoblastic Leukemia ◽

Induction Treatment ◽

Molecular Response ◽

Significant Difference

Early response to therapy is an independent prognostic factor in childhood acute lymphoblastic leukemia. Although most patients have rapid early responses, as detected by morphology, 15% to 20% of patients have relapses. The authors evaluated residual disease by molecular methods on day 15 of minimal residual disease (MRD) therapy and compared these data with their recently established MRD-based risk stratification, defined by MRD levels 5 weeks after induction treatment and before consolidation. All 68 children treated according to current Berlin-Frankfurt-Münster (BFM) protocols went into morphologically complete remission after induction. There was a significant difference in outcome between children with rapid disease clearance and those with high levels of day-15 MRD (P = .035). Among patients with high levels of day-15 MRD, only the MRD-based risk stratification was predictive of the outcome. All patients with negative or low day-15 MRD had excellent prognoses and were in the MRD-based low-risk group. Thus, after only 2 weeks of treatment, the authors were able to identify a patient population of 20% who may benefit from the least intensive treatment.

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