Genomic Aberrations Dramatically Improve The Strong Prognostic Impact Of IGHV Mutational Status In Chronic Lymphocytic Leukemia (CLL)

Abstract CLL is a heterogeneous disease with patients (pts) experiencing rapid disease progression and others living for years without requiring treatment. Recently, next generation sequencing has revealed new molecular alterations, targeting the NOTCH1 and BIRC3 genes which occur in about 10% CLL at diagnosis and correlate with poor outcome. Given the possibility of targeting NOTCH1 and BIRC3 with drugs currently under development, the primary endpoints of our research were: 1) to determine overall survival (OS) upon IGHV, NOTCH1, TP53 and BIRC3 in univariate analysis; 2) to correlate these genomic aberrations with other biological or clinical prognostic factors, and finally 3) to confirm NOTCH1, BIRC3 and TP53 as independent prognostic factors. We investigated 475 pts with a median age of 65 years (range 33-89), whose 160 had low Rai stage, 301 intermediate stage and 14 high stage. NOTCH1 mutations (mut) were studied by ARMS PCR for c.7544-7545delCT and by Sanger sequencing of NOTCH1 exon 34. Mutations of TP53 were analysed by DNA direct sequencing, while BIRC3 disruption (disr) was studied by Sanger sequencing for mutations and by interphase FISH for deletions. All these alterations were studied at diagnosis or before any chemotherapeutic approach. NOTCH1mut and TP53mut pts were 52 (10.9%) and 36/475 (7.6%), respectively. Thirty four patients were BIRC3mut (7.2%) and 26 BIRC3 deleted (5.5%) for a total of 46 cases (9.7%) BIRC3disr. NOTCH1, TP53 and BIRC3 alterations were mutually exclusive. There were significant correlations between NOTCH1 (P<0.00001), TP53 (P=0.004), BIRC3 status (P=0.00004) and IGHV mutations. Concerning FISH cytogenetics (460 patients), a significant correlation (P<0.0001) was found between NOTCH1mut and trisomy 12 (20/62; 32%). TP53mut were strictly associated with del17p (15/25; 60%; P<0.0001), while BIRC3disr was found mainly within 11q22-q23 deletions subset (22/46;49%; P<0.0001). With regard to clinical outcome, 30 (83%) of 36 TP53mut pts (P=0.00009), 47 (90%) of 52 NOTCH1mut (P<0.00001) and 40 (87%) of 46 BIRC3disr pts had received chemotherapy at the time of analysis. Twenty nine NOTCH1mut (56%), 15 TP53mut (42%) and 18 BIRC3disr (39%) pts underwent at least two lines of treatment (P<0.0001). Noteworthy, shorter OS was observed in IGHV unmutated (UM) patients (12% vs 80% at 18 years, P<0.00001), in NOTCH1mut pts (12% vs 71% at 16 years, P<0.00001), in TP53mut pts (9% vs 76% at 14 years, P<0.00001) and in BIRC3disr pts (29% vs 65% at 16 years, P=0.00001). To further explore the prognostic impact of NOTCH1mut, TP53mut and BIRC3disr, we investigated them within the UM (153 pts) IGHV subset, notoriously at worst prognosis. As a matter of fact, NOTCH1mut (16% vs 45% at 14 years, P=0.012), TP53mut (0% vs 43% at 13 years, P=0.002) and BIRC3disr (0% vs 57% at 11 years, P=0.011) pts showed significant shorter OS [Figure]. Within the mutated IGHV subgroup we obtained similar results. In multivariate analysis of OS, TP53mut (HR 5.2, P<0.00001), age >60 years (HR 3.8, P=0.00002), IGHV UM status (HR 0.30, P=0.0001), intermediate/high Rai stages (HR 2.8, P=0.0002), NOTCH1mut (HR 2.6, P=0.001), and BIRC3disr (HR 2.5, P=0.005) were confirmed to be independent adverse prognostic factors. Noteworthy, here, we demonstrated that genomic aberrations are able to improve the historical prognostic ability of the IgHV mutational status. In conclusion, genomic aberrations, particularly TP53mut, NOTCH1mut and BIRC3disr should be considered as novel important prognostic parameters in CLL and therefore they have to be necessarily considered in updated scoring prognostic systems. Disclosures: No relevant conflicts of interest to declare.

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ID1 Expression Correlates with CEBPA Mutational Status and Is Not An Independent Risk Factor in Cytogenetically Normal AML,

Blood ◽

10.1182/blood.v118.21.3554.3554 ◽

2011 ◽

Vol 118 (21) ◽

pp. 3554-3554

Author(s):

Katharina Wagner ◽

Frederik Damm ◽

Michael A Morgan ◽

Felicitas Thol ◽

Haiyang Yun ◽

...

Keyword(s):

Multivariate Analysis ◽

Prognostic Factors ◽

Prognostic Factor ◽

Conflicts Of Interest ◽

Univariate Analysis ◽

High Expression ◽

Prognostic Impact ◽

Mutational Status ◽

Negative Prognostic Factor ◽

Cebpa Mutations

Abstract Abstract 3554 Background: Acute myeloid leukemia with normal karyotype (CN-AML) is a heterogenous disease. During the last years, mutations in several genes (e.g. NPM1, FLT3, CEBPA, WT1, IDH1, IDH2) have been identified which are involved in the pathogenesis of AML and affect the prognosis of these patients. Moreover, deregulated expression of genes such as MN1, BAALC, ERG and WT1 was demonstrated to be predictive of outcome in CN-AML. Recently, high expression of the ID1 gene was described as a negative prognostic factor in AML (Tang et al. Blood 2009, 114:2993–3000). Aims: We have shown that C/EBPα, a transcription factor encoded by the CEBPA gene, binds to a regulatory element in the promoter region of the ID1 gene and regulates ID1 expression in leukemic cells (Wagner et al. Proc Natl Acad Sci USA 2006, 103:6338–6343). Therefore, we wanted to analyze the prognostic impact of ID1 expression in CN-AML in the context of other molecular markers, in particular CEBPA mutations. Methods: ID1 expression was quantified normalized to ABL by real time RT-PCR in 269 patients (age 16–60 years) with CN-AML treated with intensive double induction and consolidation therapy within the AMLSG 295 and 0199 trials (NCT00209833). The patients were also analyzed for mutations in the genes NPM1, FLT3, CEBPA, WT1, IDH1 and IDH2. Median follow up was 79 months. Results: Expression of ID1 varied over a 3-log range. High expression of ID1 (ID1high, defined as > median expression level) was significantly associated with the presence of a FLT3 -ITD or an IDH2 mutation and WT1 wildtype. Moreover, ID1 expression was closely associated with CEBPA mutational status. Altogether, 41 patients (15%) harboured a CEBPA mutation (24 monoallelic and 17 biallelic mutations). ID1 expression in the CEBPA wildtype patients was significantly higher than in patients with monoallelic CEBPA mutations and these patients had a significantly higher ID1 expression compared to patients with biallelic CEBPA mutations (p = 0.001). ID1high patients had a trend to a lower complete remission (CR) rate (74% vs. 84%; p = 0.07), but in multivariate analysis only blast clearance on day 15 after induction 1, age and WT1 SNP rs16754 were independent predictors for the achievement of CR. In univariate analysis, ID1high patients had an inferior overall survival (OS) compared to patients with low expression (median OS 29 vs. 78 months, 5 year OS 39% vs. 53%, p = 0.026). ID1high status was an independent negative prognostic factor in multivariate analysis when analyzed together with NPM1, FLT3 -ITD, WT1, IDH1, IDH2, extramedullary disease and platelet counts (HR 1.51; 95% CI 1.06–2.19). However, when also CEBPA mutational status was entered into the model, ID1 expression lost its prognostic impact and the only independent prognostic factors were age, platelets, CEBPA mutations, NPM1 /FLT3 -ITD risk group and WT1 SNP rs16754. Likewise, ID1high patients had a trend to an inferior relapse-free survival (RFS; HR 1.36, 95% CI 0.96–1.93, p = 0.086) in univariate analysis. However, in multivariate analysis including CEBPA mutational status, ID1 expression had no impact on RFS and the only prognostic factors for RFS were NPM1 and CEBPA mutations and WT1 SNP rs16754. In CEBPA wildtype patients, ID1 expression had no impact on CR-rate, OS or RFS in univariate or multivariate analysis. Conclusions: CEBPA mutations seem to deregulate ID1 expression in CN-AML. Therefore, ID1 expression is not an independent prognostic factor in CN-AML. Disclosures: No relevant conflicts of interest to declare.

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Clinical Significance of Apoptosis in Chronic Lymphocytic Leukemia (CLL)

Blood ◽

10.1182/blood.v124.21.834.834 ◽

2014 ◽

Vol 124 (21) ◽

pp. 834-834

Author(s):

Giovanni Del Poeta ◽

Maria Ilaria Del Principe ◽

Michele Dal Bo ◽

Francesco Buccisano ◽

Dario Ragusa ◽

...

Keyword(s):

Flow Cytometry ◽

Prognostic Factor ◽

Conflicts Of Interest ◽

Intermediate Stage ◽

Independent Prognostic Factor ◽

Lymphocytic Leukemia ◽

Prognostic Impact ◽

Development Of Resistance ◽

Beta 2 Microglobulin ◽

Very High

Abstract Impaired programmed cell death is an important factor both in the pathogenesis of CLL (Berndt et al, Nat Genet 2013) and in the development of resistance to chemoimmunotherapy (Fegan et al, Adv Exp Med Biol 2013). It has become increasingly clear that in CLL the balance between the pro- (Bax) and anti-apoptotic members (Bcl-2) of the Bcl-2 family determines the chemotherapy sensitivity and ultimately progression free (PFS) and overall survival (OS). Moreover, the today availability in clinical use of novel potent oral pro-apoptotic BH3 peptidomimetics such as ABT 199 (Seymour et al, ASH 2013) emphasized the importance of Bcl-2 family-targeted therapy, prompting us to analyze the real impact of Bax/Bcl-2 ratio on CLL prognosis. The primary aims of our research were: 1) to correlate Bax/Bcl-2 ratio with other clinical and biological prognostic factors; 2) to determine PFS and OS upon Bax/Bcl-2 ratio; 3) to confirm Bax/Bcl-2 as an independent prognostic factor. Therefore we investigated 502 pts, median age 65 years (range 33-89), 279 males and 223 females. With regard to modified Rai stages at diagnosis, 170 patients had a low stage, 318 an intermediate stage and 14 a high stage. Bax/bcl-2 ratio was calculated by flow cytometry, dividing mean fluorescence intensity (MFI) of bax by MFI of bcl-2 on CD19+CD5+ CLL cells. The threshold was set at the median value >1.5 (range 0.27-6.10). Two hundred sixty- six patients were Bax/Bcl-2 ratio positive (266/502; 53%). Higher Bax/Bcl-2 ratio was significantly associated with low Rai stage, lymphocyte doubling time >12 months, beta-2 microglobulin <2.2 mg/dl and soluble CD23<70 U/ml (P<0.0001). Moreover, higher Bax/Bcl-2 was greatly represented within the low risk (normal or del13q) cytogenetics (221/341; P<0.0001). Noteworthy, significant correlations were found between lower Bax/Bcl-2 ratio and IGHV unmutated status (130/168; P<0.0001) or NOTCH1 (49/58; P<0.0001) or TP53 mutations (29/37; P=0.00007). With regard to clinical outcome, significant shorter PFS and OS were observed in patients with lower Bax/Bcl-2 ratio (10% vs 52% at 16 years; P<0.0001 and 46% vs 79% at 16 years; P<0.0001, respectively). To further explore the prognostic impact of Bax/Bcl-2 ratio, we investigated its expression within IGHV unmutated (168 pts) and TP53 mutated subgroups (37 pts), notoriously at worst prognosis. As a matter of fact, higher Bax/Bcl-2 ratio identified patients with a significant longer PFS (43% vs 10% and 50% vs 10% at 7 years; P=0.00002 and P=0.039, respectively, Figure), so suggesting its very high prognostic impact. In multivariate analysis of PFS (489 patients), Bax/Bcl-2 ratio (P<0.0001) together with modified Rai stages (P<0.0001), cytogenetics (P=0.0001), IGHV status (P<0.0001) and TP53 (P=0.001) was confirmed to be an independent prognostic factor. Therefore, the apoptotic index Bax/Bcl-2, performed by flow cytometry, is a powerful prognostic marker being able to identify patients at different prognosis also within IGHV unmutated and TP53 mutated subsets which are at very high risk. The modern strategies to downregulate Bcl-2 and shift the balance toward cellular demise, such as the BH3 mimetic ABT 199, could be carefully and precisely monitored by using this simple but powerful flow cytometric approach. Figure 1 Figure 1. Disclosures No relevant conflicts of interest to declare.

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Lymphocyte Doubling Time As A Key Prognostic Factor To Predict Time To First Treatment In Early-Stage Chronic Lymphocytic Leukemia

Frontiers in Oncology ◽

10.3389/fonc.2021.684621 ◽

2021 ◽

Vol 11 ◽

Author(s):

Fortunato Morabito ◽

Giovanni Tripepi ◽

Riccardo Moia ◽

Anna Grazia Recchia ◽

Paola Boggione ◽

...

Keyword(s):

Prognostic Factors ◽

Chronic Lymphocytic Leukemia ◽

Doubling Time ◽

Lymphocytic Leukemia ◽

Prognostic Impact ◽

Newly Diagnosed ◽

Prognostic Role ◽

Mutational Status ◽

Binet Stage ◽

Time To First Treatment

The prognostic role of lymphocyte doubling time (LDT) in chronic lymphocytic leukemia (CLL) was recognized more than three decades ago when the neoplastic clone’s biology was almost unknown. LDT was defined as the time needed for the peripheral blood lymphocyte count to double the of the initial observed value. Herein, the LDT prognostic value for time to first treatment (TTFT) was explored in our prospective O-CLL cohort and validated in in two additional CLL cohorts. Specifically, newly diagnosed Binet stage A CLL patients from 40 Italian Institutions, representative of the whole country, were prospectively enrolled into the O-CLL1-GISL protocol (clinicaltrial.gov identifier: NCT00917540). Two independent cohorts of newly diagnosed CLL patients recruited respectively at the Division of Hematology in Novara, Italy, and at the Hospital Clinic in Barcelona, Spain, were utilized as validation cohorts. In the training cohort, TTFT of patients with LDT >12 months was significantly longer related to those with a shorter LDT. At Cox multivariate regression model, LDT ≤ 12 months maintained a significant independent relationship with shorter TTFT along with IGHV unmutated (IGHVunmut) status, 11q and 17p deletions, elevated β2M, Rai stage I-II, and NOTCH1 mutations. Based on these statistics, two regression models were constructed including the same prognostic factors with or without the LDT. The model with the LTD provided a significantly better data fitting (χ2 = 8.25, P=0.0041). The risk prediction developed including LDT had better prognostic accuracy than those without LDT. Moreover, the Harrell’C index for the scores including LDT were higher than those without LDT, although the accepted 0.70 threshold exceeded in both cases. These findings were also confirmed when the same analysis was carried out according to TTFT’s explained variation. When data were further analyzed based on the combination between LDT and IGHV mutational status in the training and validation cohorts, IGHVunmut and LDT>12months group showed a predominant prognostic role over IGHVmut LTD ≤ 12 months (P=0.006) in the O-CLL validation cohort. However, this predominance was of borden-line significance (P=0.06) in the Barcelona group, while the significant prognostic impact was definitely lost in the Novara group. Overall, in this study, we demonstrated that LDT could be re-utilized together with the more sophisticated prognostic factors to manage the follow-up plans for Binet stage A CLL patients.

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Characterization and Prognostic Impact of Multiple Productive IGHV Rearrangements in CLL

Blood ◽

10.1182/blood.v128.22.3207.3207 ◽

2016 ◽

Vol 128 (22) ◽

pp. 3207-3207

Author(s):

Sabine Jeromin ◽

Claudia Haferlach ◽

Frank Dicker ◽

Manja Meggendorfer ◽

Torsten Haferlach ◽

...

Keyword(s):

Prognostic Factors ◽

Lymphocytic Leukemia ◽

Prognostic Impact ◽

Employment Equity ◽

Mutational Status ◽

Treatment Naïve ◽

Trisomy 12 ◽

Equity Ownership ◽

The Impact

Abstract Background: In chronic lymphocytic leukemia (CLL) one of the strongest prognostic factors is IGHV mutational status. Infrequently, patients present not only with a single IGHV rearrangement but with multiple productive rearrangements. In about 2% of all CLL patients analyzed on cDNA level multiple rearrangements display the same mutational status and are categorized accordingly following ERIC recommendations. In another 1% rearrangements with discordant IGHV mutational status are detected and preclude a definite risk assignment. Only limited data exist on these rare subgroups. Aim: To characterize treatment-naive CLL patients with multiple productive IGHV rearrangements and determine the impact on prognosis. Patients and Methods: Out of 8,016 treatment-naive CLL patients between 2005 and 2015 and with data on IGHV mutational status we identified 204 (3%) with multiple productive rearrangements. IGHV mutational status was analyzed on cDNA and in all cases according to ERIC recommendations. IGHV mutated status (M) was defined by sequence identity <98% and unmutated status (U) by ≥98%. Chromosome banding analysis was available in 102 cases and interphase FISH with probes for 17p13, 13q14, 11q22 and centromeric region of chromosome 12 in 191. Male:female ratio was 3:1 and median age 68 years (range: 38-89). Additionally, data on SF3B1 and TP53 mutations was present in all cases. Follow-up data on time to first treatment (TTT) and overall survival (OS) was available in 105 cases with a median follow-up of 4 years. For statistical comparison we used a cohort of 1,262 untreated CLL patients with single IGHV rearrangement (median age: 67 years; range: 30-91, median follow-up: 6 years). Results: Out of 204 patients with multiple, productive rearrangements 199 (98%) presented with two and 5 patients (2%) with three IGHV rearrangements. Concordant IGHV mutated status (MM) was present in 120 cases (59%), whereas concordant unmutated status (UU) was seen in 34 patients (17%). In 50 cases (25%) a mixed IGHV status (UM) was detected. We analyzed frequencies of complex karyotype by CBA, biclonality according to immunophenotype (concurrent kappa restricted and lambda restricted subpopulations) and/or CBA, TP53 disruption (TP53mut and/or del(17p)), SF3B1mut, del(11q), trisomy 12, and del(13q). Overall, a higher frequency of biclonality was detected in patients with multiple vs. single IGHV rearrangements (16% vs. 1%, p<0.001). However, association to neither MM, UU nor UM existed. MM presented with molecular and cytogenetic characteristics similar to M. Correspondingly, UU showed similar frequencies of mutations and aberrations to U, except for higher frequency of trisomy 12 in UU vs. U (42% vs. 19%, p=0.003). Interestingly, UM presented with characteristics similar to U and UU. UM was associated with TP53 disruption vs. M (16% vs. 5%, p=0.003) and vs. MM (5%, p=0.035) as well as with SF3B1mut vs. M (16% vs. 5%, p=0.008). Furthermore, UM cases showed high frequency of del(11q) vs. M (29% vs. 3%, p<0.001) and vs. MM (1%, p<0.001) and less frequently del(13q) sole vs. M (41% vs. 60%, p=0.011) and MM (41% vs. 69%, p=0.001). No significantly differences in TTT were observed between MM and M (median: 13 vs. 14 years) and between UU and U (6 vs. 4 years), respectively. However, the difference between MM vs. UU (p=0.022) and M vs. U (p<0.001) was significant. The UM subgroup presented with a TTT (median: 4 years) similar to U and UU, whereas it was significantly shorter vs. M (p=0.003) and MM (p=0.006), respectively. A similar picture emerged for survival. 5-year OS of MM was not different vs. M (94% vs. 90%) but vs. U (78%, p=0.001). The statistical analysis of OS in UU was hampered by low case numbers. UM presented again with similar 5-year OS vs. U (81% vs. 78%, n.s.) and significantly worse OS vs. M (90%, p=0.049) and vs. MM (94%, p=0.014). Conclusions: (1) Patients with multiple productive IGHV rearrangements and concordant IGHV status show similar prognosis and characteristics to patients with single rearrangement with the respective IGHV status. (2) Cases with mixed IGHV status show similar prognosis to patients with IGHV unmutated status and accordingly are characterized by high frequencies of adverse prognostic factors like TP53 disruption, SF3B1mut, and del(11q), whereas del(13q) sole is less frequent. Disclosures Jeromin: MLL Munich Leukemia Laboratory: Employment. Haferlach:MLL Munich Leukemia Laboratory: Employment, Equity Ownership. Dicker:Munich Leukemia Laboratory: Employment. Meggendorfer:MLL Munich Leukemia Laboratory: Employment. Haferlach:MLL Munich Leukemia Laboratory: Employment, Equity Ownership. Kern:MLL Munich Leukemia Laboratory: Employment, Equity Ownership.

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Prognostic Factors For Overall Survival In Elderly Patients With Relapsed Acute Myeloid Leukemia – Retrospective Study On Behalf Of The East German Study Group For Hematology and Oncology (OSHO)

Blood ◽

10.1182/blood.v122.21.1409.1409 ◽

2013 ◽

Vol 122 (21) ◽

pp. 1409-1409

Author(s):

Thomas Heinicke ◽

Rainer Krahl ◽

Christian Jakob ◽

Christoph Kahl ◽

Hans-Heinrich Wolf ◽

...

Keyword(s):

Overall Survival ◽

Prognostic Factors ◽

Myeloid Leukemia ◽

Univariate Analysis ◽

Initial Diagnosis ◽

Prognostic Impact ◽

Mutational Status ◽

First Relapse ◽

Relapsed Acute Myeloid Leukemia ◽

Median Interval

Abstract Purpose In patients with relapsed acute myeloid leukemia (AML) > 60 years of age we analyzed age at relapse, interval from first complete remission (CR1) to relapse, cytogenetic risk at initial diagnosis, prior allogeneic stem cell transplantation (alloSCT) and FLT3/NPM1 mutational status as possible prognostic factors for overall survival (OS). Introduction After achieving CR1 more than 50% of elderly AML patients eventually relapse. Prognostic factors for OS are poorly defined in this patient population. For younger patients with relapsed AML a risk score has been described including age at relapse, interval from CR1 to relapse, cytogenetic risk at initial diagnosis and prior stem cell transplantation (SCT) as prognostic factors. We sought to investigate whether these are also prognostic factors in elderly patients with relapsed AML. In addition, we assessed the prognostic impact of FLT3- and NPM1 mutational status (wild-type (wt) or mutated (mut)) at diagnosis. Patients and methods In the ongoing multicenter OSHO trial #69 for AML patients > 60 years we evaluated data of all relapsed patients. Overall survival was calculated from the day of first relapse until the day of death using the Kaplan Meier method. Univariate analysis was performed to test for the influence of age at relapse, interval from CR1 to relapse, cytogenetic risk at initial diagnosis, prior alloSCT and FLT3/NPM1 mutational status. Subsequently, independent prognostic factors were defined in a multivariate analysis with age at relapse, time from CR1 to relapse, cytogenetic risk at initial diagnosis and prior alloSCT as covariates. Results From April 2005 until April 2013 904 patients were registered. 733 of these received intensive induction chemotherapy which resulted in CR1 in 447 (61%) pts. In this patient group 260 relapses were observed after a median interval, calculated from the day of CR1, for living patients of 2.7 years (range 0.1 to 7.5). Median age at relapse was 69 years (range 60 – 85) with 129 (49.6%) pts. being 60 to 68 years old, 102 (39.2%) pts. being 69 to 74 years old and 29 (11.1%) pts. being 75 to 85 years old. Median interval from CR1 to relapse was 0.58 years (0.07 – 6.28). 114 (43.8%) relapses occurred up to 6 months after CR1, 119 (45.8%) between 7 and 18 months after CR1 and 27 (10.4%) later than 18 months after CR1. Only five (1.9%) relapsed pts. showed good risk cytogenetics at diagnosis, whereas it was of intermediate risk in 159 (61.1%) pts., of poor risk in 68 (26.2%) pts. and unknown in 28 (10.8%) pts. Forty-one (15.8%) pts. had received prior alloSCT in CR1. Information on FLT3- and NPM1 mutational status at diagnosis was available in 194 (74.6%) pts. 110 (42.3%) pts. had FLT3/NPM1 wt/wt, 48 (18.5%) pts. had FLT3/NPM1 wt/mut, 23 (8.8%) pts. had FLT3/NPM1 mut/wt and 13 (5.0%) pts. had FLT3/NPM1 mut/mut. OS rate at 2 years of all relapsed pts. was 13 ± 2%. For patients younger than 69 years and for those 69 years of age or older OS rate at 2 years was 17 ± 4% and 9 ± 3%, respectively (p=0.03). The interval between CR1 and first relapse also affected 2 year-OS with 7 ± 3%, 15 ± 4% and 36 ± 12% for pts. with relapse up to 6 months, 7 to 18 months and later than 18 months after CR1, respectively ( 18 months: p=0.009). OS rate at 2 years was also influenced by cytogenetic risk at initial diagnosis with 17 ± 3% for pts. having good or intermediate risk cytogenetics and 3 ± 2% for those with poor risk cytogenetics (p< 0.0005). Prior alloSCT had a negative influence on OS. Two-year OS rate was 10 ± 5 and 13 ± 3% (p= .015) for patients with prior alloSCT vs. those without prior alloSCT, respectively. FLT3/NPM1 mutational status at diagnosis had no impact on OS. In univariate analysis age at relapse (p<0.04), interval from CR1 to relapse (p< 0.0005), cytogenetic risk at initial diagnosis (p<0.02) and prior alloSCT (p<0.02) were shown to be prognostic factors for OS, whereas FLT3/NPM1 mutational status was not significant (p=0.82). In multivariate analysis the same factors remained significant but only interval from CR1 to relapse (p<0.0005) and prior alloSCT (p=0.003) were independent. Conclusion In AML patients >60 years in first relapse OS is poor. Longer interval from CR1 to relapse and no prior alloSCT are independent beneficial prognostic factors for OS. FLT3/NPM1 mutational status at diagnosis has no prognostic impact on OS. Disclosures: Wedding: Roche: Speakers Bureau; Amgen: Speakers Bureau; Chugai: Speakers Bureau; Janssen-Cilag: Speakers Bureau; Novartis: Speakers Bureau; Cephalon: Speakers Bureau; Prostarkan: Speakers Bureau; Pfizer: Speakers Bureau. Niederwieser:Novartis: Consultancy.

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Telomere Length Has Prognostic Impact in B-Cell Chronic Lymphocytic Leukemia (B-CLL).

Blood ◽

10.1182/blood.v104.11.4768.4768 ◽

2004 ◽

Vol 104 (11) ◽

pp. 4768-4768

Author(s):

Irene Ricca ◽

Daniela Drandi ◽

Alberto Rocci ◽

Mara Compagno ◽

Roberto Francese ◽

...

Keyword(s):

Clinical Outcome ◽

Telomere Length ◽

Germ Line ◽

Direct Sequencing ◽

Prognostic Significance ◽

Staging System ◽

Good Prognosis ◽

Lymphocytic Leukemia ◽

Prognostic Impact ◽

Mutational Status

Abstract BACKGROUND. Germinal Center (GC) experience is a basic prognostic feature in B-CLL. Patients with VH-mutated GC-experienced CLL have a good prognosis while those with VH-unmutated GC-inexperienced CLL have a poor prognosis. In a recent study we demonstrated that telomere length (TL) of lymphoproliferative disorders strongly correlates with GC, pre-GC or post-GC origin (Ladetto M et al, Blood 2004). Aims of this study were to further define the relationship between TL and VH mutational status in B-CLL and correlate both these parameters with clinical outcome. PATIENTS AND METHODS. 109 B-CLL patients have been analyzed for telomere restriction fragments (TRF) length and are under evaluation for VH mutational status. All samples were taken at diagnosis or during the "watch and wait" phase. Male were 68, females 41. Median age was 62 years (range 34–87). Fifty-three patients were in stage A, 30 patients were in stage B and 16 were stage C according to Binet staging system. Our patient population has been monitored for a median time of 53 months (range 1–290). Sixty-three patients have been already treated for their disease while 46 have not required treatment, so far. TRF length was evaluated by Southern blot and VH mutational status by direct sequencing, as previously described (Ladetto M et al, Blood 2004). The standard cut-off of 2% deviation from any germ line VH sequence was employed to define VH mutational status. Survival analyses were performed using the Kaplan-Meier method. RESULTS. Overall, median TRF length was 5898bp (range 1737–14837bp). There was no correlation between TRF length and patient age, sex or stage. A cut-off of 4500bp discriminated two subgroups of patients characterized by different clinical outcome in terms of time to first treatment (TTFT) and time to disease progression (TTP) following first line treatment. Patients with TL < 4500bp had a median TTFT of 16 months and a median TTP of 14 months while patients with TL > 4500bp had a median TTFT of 36 months and a median TTP of 50 months (p<0.05 and p<0.005, respectively). VH sequencing is currently available in 72 patients. A comparison between TRF length (using the previously defined 4500bp cut-off) and VH mutational status showed the following: a) 100% concordance between VH-mutated status and TRF length >4500bp; b) 62% concordance between unmutated VH-status and TRF length <4500bp; c) the 10 discordant patients with VH-unmutated status and TRF >4500bp had a clinical outcome similar to that observed in patients with VH-mutated status (median TTFT: 22 months; median TTP:80 months). CONCLUSIONS Our data demonstrate that: 1) TL in B-CLL has a good correlation with VH mutational status; 2) TRF length has prognostic significance in B-CLL in terms of TTFT and TTP; 3) when discordance exists between these two parameters, the clinical behavior seems to be better predicted by TRF length compared to VH mutational status.

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The Amount of Spontaneous Apoptosis Is An Independent Strong Disease Progression Indicator in B-Cell Chronic Lymphocytic Leukemia (B-CLL)

Blood ◽

10.1182/blood.v114.22.1252.1252 ◽

2009 ◽

Vol 114 (22) ◽

pp. 1252-1252 ◽

Cited By ~ 1

Author(s):

Giovanni Del Poeta ◽

Maria Ilaria Del Principe ◽

Francesco Buccisano ◽

Daniela Piccioni ◽

Luca Maurillo ◽

...

Keyword(s):

Flow Cytometry ◽

Conflicts Of Interest ◽

Progression Free Survival ◽

Intermediate Stage ◽

Lymphocytic Leukemia ◽

Progression Rate ◽

Prognostic Impact ◽

Spontaneous Apoptosis ◽

Clinical Prognosis ◽

Beta 2 Microglobulin

Abstract Abstract 1252 Poster Board I-274 Bcl-2 levels has emerged as the most important protein in predicting survival between 11 proteins in CLL cells that are implicated in the control of apoptosis, proliferation and differentiation (Faderl, 2002). In fact, malignant cells are arrested in the G0/early G1 phase of the cell cycle, and inhibition of spontaneous apoptosis with upregulation of the anti-apoptotic protein bcl-2 may define clinical prognosis. The today availability both of bcl-2 antisense oligonucleotides and of novel pro-apoptotic BH3 peptidomimetic prompted us to evaluate the real impact of apoptosis pathways on B-CLL prognosis. The primary aims of our study were: 1) to determine progression-free survival (PFS) and overall survival (OS) upon bax/bcl-2 ratio, 2) whether bax/bcl-2 ratio and ZAP-70 show additive prognostic impact and finally 3) whether bax/bcl-2 is an independent prognostic factor. Therefore we investigated 356 patients (pts), median age 65 years (range 37-89), 164 males and 192 females. With regard to modified Rai stages, 115 pts had a low stage, 229 an intermediate stage and 12 a high stage. Bax/bcl-2 ratio was determined by flow cytometry, dividing mean fluorescence intensity (MFI) of bax by MFI of bcl-2 on CD19+CD5+ B-CLL cells. We obtained the bax/bcl-2 ratio and the threshold was set at the median value >1.45 (range 0.27-13.6). ZAP-70 was quantified by multicolor flow cytometry and the cut-off was fixed at >20%. Two hundred-three pts were bax/bcl-2 ratio positive (203/356; 57%). Higher bax/bcl-2 ratio was significantly associated with low Rai stage (80/115; P=0.003), lymphocyte doubling time >12 months (183/299; P=0.0003), beta-2 microglobulin (B-2M) <2.2 mg/dl (129/200; P=0.001) and soluble CD23 (sCD23) <70 U/ml (141/228; P=0.005). Moreover, there were significant correlations between higher bax/bcl-2 ratio and IgVH gene mutated status (216 cases, 96/154; P=0.015) or low risk (normal or 13q-) FISH cytogenetics (255 cases, 109/187; P=0.011). Noteworthy, a very strict association was found between higher bax/bcl-2 ratio and lower ZAP-70 (147/220; P<0.00001), suggesting that low ZAP-70 expression is characterized by high apoptosis levels. With regard to clinical outcome, significant shorter PFS and OS were observed in pts with lower bax/bcl-2 ratio (10% vs 60% at 14 years; P<0.00001 and 51% vs 74% at 16 years; P=0.005, respectively) as well as in ZAP-70+ pts (5% vs 57% at 12 years; P<0.00001 and 30% vs 85% at 16 years, respectively). To further explore the prognostic impact of bax/bcl-2 ratio, we investigated its expression associated with ZAP-70 protein. As a matter of fact, higher bax/bcl-2 ratio plus ZAP-70 <20% identified the pts subset with the longest PFS (70% vs 2% at 12 years; P <0.00001, Figure) and OS (92% vs 33%; P<0.00001). The discordant pts presented an intermediate outcome (Figure). In multivariate analysis of PFS, in which cytogenetics, IgVH status, ZAP-70, CD38, bax/bcl-2, sCD23 entered, bax/bcl-2 (P=0.02), cytogenetics (P=0.02) and ZAP-70 (P=0.04), resulted to be independent prognostic factors. In conclusion, our apoptotic index (bax/bcl-2 ratio), performed by flow cytometry, was very useful to identify pts at different progression rate and since the ZAP-70 negative subset represents a large and heterogeneous B-CLL population with a variable progression, other biological factors, such as the amount of apoptosis, have to be added in order both to identify early and treat timely progressive pts. Disclosures No relevant conflicts of interest to declare.

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Prognostic Impact Of Comorbidity In Multiple Myeloma

Blood ◽

10.1182/blood.v122.21.5340.5340 ◽

2013 ◽

Vol 122 (21) ◽

pp. 5340-5340 ◽

Cited By ~ 1

Author(s):

Rafael Ríos Tamayo ◽

Joaquín Martínez López ◽

Manuel Jurado ◽

María Esther Clavero Sánchez ◽

Fátima López Jiménez ◽

...

Keyword(s):

Multiple Myeloma ◽

Prognostic Factors ◽

Liver Disease ◽

Plasma Cell ◽

Cox Regression ◽

Conflicts Of Interest ◽

Statistical Significance ◽

Univariate Analysis ◽

Prognostic Impact ◽

Alcoholic Fatty Liver

Abstract Multiple myeloma (MM) is a heterogeneous disease. Evaluation of prognostic factors and risk stratification at diagnosis is necessary to compare outcome. Attempts have been made to apply a comorbidity score in the clinical sitting, but a standardized general approach is still lacking. We hypothesized that a comprehensive examination of every associated disease in a large cohort of patients could better highlight the prognostic impact of comorbidity in MM. All consecutive patients diagnosed in our institution, from 1993 to 2013, with symptomatic MM according to IMWG criteria were included in our population-based MM registry. Patients with plasma cell leukemia or with palliative management were excluded. Clinical variables analyzed were: age, sex, Durie-Salmon, International Scoring System (ISS), percentage of plasma cell in bone marrow by morphology (PC), serum creatinine (Cr) and estimated glomerular filtration rate according with Modification of Diet in Renal Disease (eGFR-MDRD). The following comorbodities were analysed: hypertension (HTA), diabetes (DM), obesity (OB) (body mass index > 30 Kg/m2), hyperlipaemia (HL), prior malignancy (PM), hepatitis B virus (HBV), hepatitis C virus (HCV), human immunodeficiency virus (HIV), peptic ulcer (PU), thromboembolism (TE), renal transplant (RT), splenectomy (S), cutaneous disease (CD), amyloidosis (AM), heart disease (HD) (arrhythmia, congestive heart failure, coronary artery disease, other), lung disease (LD) (chronic obstructive pulmonary disease, asthma, other), liver disease (HE) (cirrhosis, non-alcoholic fatty liver disease, other), neurological disorder (ND), psychiatric disorder (PD) and rheumatologic disorder (RD). Kaplan-Meier method was used to estimate OS curves. Cox regression was used to determine the prognostic impact of each comorbidity in a univariate and multivariate model. 311 patients were eligible. Median age was 66 years (12-91), 148 men (47.6 %) and 163 women. Percentage of comorbidities was: HTA 45; OB 32.5; DM 20.4; HD 20.4; LD 15.2; PU 10; HL 9.7; ND 8; PM 7.8; PD 6.5; HBV 3.9; HE 3.9; TE 3.6; RD 3,5; AM 2.3; HCV 1.9; CD 1.6; S 1; RT 0.6; HIV 0.3. 63 patients (20.4 %) showed no comorbidities. Univariate analysis (table 1) demonstrated that AM (P=0.022), HCV (0.038), HIV (0.022), PD (0.015) and ND (0.05) were significantly associated with shorter OS. The variables associated with mortality in the multivariate analysis were age (p=0.002), ISS (III vs I: p=0.01), PC (p=0.05) and Cr (p=0.02). Results will be validated in another MM series and presented during the meeting. The overall prognosis of MM depends on a variety of host and disease-related characteristics. We confirm age, ISS, PC and Cr as robust and independent prognostic factors. Adjusting for these factors, no isolated comorbidity reach statistical significance; however, comorbidity seems to have a role in MM prognosis. More studies are warranted to define the prognostic impact of comorbidities in MM. Disclosures: No relevant conflicts of interest to declare.

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Outcome and Prevalence of Hyperdiploidy and Hypodiploidy in Adults with Newly Diagnosed Acute Lymphocytic Leukemia: A SWOG Study

Blood ◽

10.1182/blood.v118.21.2555.2555 ◽

2011 ◽

Vol 118 (21) ◽

pp. 2555-2555

Author(s):

Anjali S. Advani ◽

Holly Gundacker ◽

Marilyn L. Slovak ◽

Karl S. Theil ◽

Stephen J. Forman ◽

...

Keyword(s):

Prognostic Factors ◽

Acute Lymphocytic Leukemia ◽

Conflicts Of Interest ◽

Lymphocytic Leukemia ◽

High Dose ◽

Prognostic Impact ◽

Cell Transplant ◽

Newly Diagnosed ◽

Poor Risk ◽

Poor Outcomes

Abstract Abstract 2555 High hyperdiploidy is present in 30% of children with acute lymphocytic leukemia (ALL), and is associated with a favorable prognosis. We evaluated pts with newly diagnosed ALL treated on SWOG trials S9400 (1995–2000) and S0333 (2005–2010) to determine the prevalence and prognostic impact of hyperdiploidy in adults with ALL. Additionally, we examined the prognostic impact of hypodiploidy, a feature typically associated with a poor prognosis in children. Methods: One-hundred and eighty-five pts treated on S9400 and S0333 with successful cytogenetic (CG) analysis were included. The treatment regimens were: S9400 [Induction: Daunorubicin (D), vincristine (V), prednisone (P), PEG-asparaginase (PEG); Consolidation: Cytoxan (Cy), cytarabine (AraC), 6-mercaptopurine (6MP), intrathecal methotrexate (IT Mtx). Consolidation was followed by allogeneic stem cell transplant or maintenance chemotherapy] and S0333: Double Induction Chemotherapy [Induction 1: D, V, P, PEG; Induction 2: high dose AraC, mitoxantrone, decadron. Consolidation: Cy, AraC, 6MP, Mtx; consolidation was followed by maintenance therapy]. Karyotypes were centrally reviewed and clonal abnormalities described according to ISCN (2009). Hyperdiploidy was defined as: low hyperdiploidy [47–49 chromosomes (cs)], high hyperdiploidy (51–65 cs), near triploidy (66–79 cs), and near tetraploidy (84–100 cs). Hypodiploidy was defined as: near haploidy (25–29 cs), low hypodiploidy (31–39 cs), and high hypodiploidy (42–45 cs). When more than one cell line was present, ploidy was assigned by the most complex clonal karyotype. Hypodiploidy and hyperdiploidy were analyzed as prognostic factors for complete response (CR) rate and residual disease (RD) by logistic regression and chi-square tests; and for overall survival (OS) and relapse-free survival (RFS) by proportional hazards. Multivariable analyses were stratified by study and using the baseline variables: age, WBC, lineage, and CG risk. Results: The median age was 32 yrs (range 17–64), and median WBC at diagnosis 17.2 K/uL (range 0.6–396.6). CG risk was ascribed by (Pullarket V et al. Blood 2008; 111: 2563). Forty-five pts (24%) had normal CG, and 73 (39%) had poor risk CG. Fourteen pts (8%) had hypodiploidy (2: low hypodiploidy; 12: high hypodiploidy). Fifty-three pts (29%) had hyperdiploidy [40: low hyperdiploidy, 10: high hyperdiploidy (5%), 3: near tetraploidy or tetraploidy (2%)]. The CR rate for all pts was 72%; with a median RFS of 15 mos (95% CI: 12–29 mos) and median OS of 28 mos (95% CI: 21–36 mos). There was no significant association with ploidy status and age, WBC, or lineage. However, there was an increased prevalence of the t(9;22) in the high hypodiploidy group compared to the normal/pseudo diploidy group (p=0.049). Neither hypodiploidy nor hyperdiploidy were predictive of CR or RD; although pts with hypodiploidy had a higher rate of RD (p=0.062). The 2 pts with low hypodiploidy had very poor outcomes (1 had RD and died after 11 mos; the other relapsed after 3 mos from CR and died 4 mos after study registration). There were no statistically significant differences in OS, CR rate, or RFS between the ploidy groups even after adjusting for baseline characteristics in multivariate analysis. Surprisingly, when excluding pts with poor risk CG there was still a trend towards a worse RFS (29 vs. 32 months, p=0.20) and OS (40 vs. 68 mos, p=0.29) in pts with hyperdiploidy compared to normal/pseudodiploidy. In addition, the 3 pts in the high hyperdiploidy group without poor risk CG had poor OS (median 23 mos). Conclusions: The prevalence of high hyperdiploidy is much lower in adults with ALL, compared to children. The prevalence of hypodiploidy and near tetraploidy/tetraploidy is comparable to that seen in children with ALL. Hypodiploidy and high hyperdiploidy were not prognostic factors for outcome in this group of patients. Given the low prevalence of these abnormalities, it is possible that larger numbers of pts may be needed to detect such a difference. The poor outcomes of pts with low hypodiploidy are consistent with findings by Moorman et al. (Blood 2006; 109: 3189). However, in contrast to Moorman's results, there was no evidence of an association of hyperdiploidy with age/WBC, and there was a trend towards a worse prognosis in this subset of patients. This suggests that the biology and prognosis of high hyperdiploidy may be affected more by WBC and age in the adult population. Disclosures: No relevant conflicts of interest to declare.

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Immunotherapeutic Maintenance Strategy Prolongs Response Duration and Overall Survival Preventing Relapse in Chronic Lymphocytic Leukemia (CLL),

Blood ◽

10.1182/blood.v118.21.3906.3906 ◽

2011 ◽

Vol 118 (21) ◽

pp. 3906-3906 ◽

Cited By ~ 1

Author(s):

Giovanni Del Poeta ◽

Maria Ilaria Del Principe ◽

Pietro Bulian ◽

Francesco Buccisano ◽

Annalisa Biagi ◽

...

Keyword(s):

Overall Survival ◽

High Risk ◽

Maintenance Therapy ◽

Conflicts Of Interest ◽

Response Duration ◽

Lymphocytic Leukemia ◽

Hematologic Toxicity ◽

Prognostic Impact ◽

Mutational Status ◽

Grade 3

Abstract Abstract 3906 Today the treatment target of CLL is the attainment of an optimal disease control combining chemotherapy with monoclonal antibodies (MoAbs). This approach produces more complete molecular remissions and longer response duration (RD), remaining often a minimal residual disease (MRD) detectable by flow cytometry. In addition, consolidation and maintenance therapy with MoAbs might provide a further RD and overall survival (OS) benefit in CLL, as it has been already clearly demonstrated in indolent non-Hodgkin lymphomas. We treated in first line 145 CLL symptomatic patients (pts), median age 63 years (37–80), with six monthly courses of intravenous (25 mg/m2) or oral fludarabine (30–40 mg/m2) and then, after a median time of 30 days, with four weekly doses (375 mg/m2) of rituximab (rtx). Before treatment, 15 pts had a modified low Rai stage, 127 an intermediate stage and only 3 a high stage. We defined as high risk pts having at least two of these markers: unmutated IgVH, CD38>30%, ZAP-70>20%, intermediate/poor cytogenetics (trisomy 12 or del11q or del17p). Sixty-three pts (43.5%) belonged to the high risk subset. For MRD flow cytometric study, the threshold was set at >1% CD19+CD5+CD79b+/− bone marrow (BM) CLL cells. Based on NCI criteria (Cheson, 1996), 111/145 (76%) pts achieved a complete remission (CR), 27/145 (19%) a partial remission (PR) and 7/145 (5%) no response or progression. Phenotypic CR (CD19+CD5+CD79b- BM cells <1%) was achieved in 85/145 (59%) CLL pts. Interestingly, MRD+ pts showed a significant shorter overall survival (OS) in comparison with MRD- pts (25% vs 73% at 16 years, P=0.00096). During the induction and consolidation/maintenance time, 13 pts underwent grade 2–3 (sec.WHO) infective lung toxicity and 2 pts progressed towards Richter's syndrome. Hematologic toxicity was mild including mainly neutropenia (grade 3 and/or 4 in 60 pts) and thrombocytopenia (grade 3 and/or 4 in 9 pts). Fifty-nine pts (43%) either in CR with B-CLL BM cells >1% (MRD+, n=16 pts) or in CR MRD negative, but developing MRD positivity within 2 years after induction (n=25 pts) or in PR (n=18 pts), underwent consolidation and maintenance therapy with four monthly cycles of rtx at 375 mg/m2 followed by twelve monthly doses of rtx at 150 mg/m2. The median follow-up duration was 63 months. Noteworthy, both persistently MRD negative pts (n=56) and pts undergoing consolidation/maintenance therapy (n=59) showed a longer RD vs MRD+ not consolidated pts (n=23) [75% vs 58% vs 0% at 5 years; P<0.0001, Figure]. Equally, OS was shorter in MRD+ not consolidated pts in comparison with the other two subsets (0% vs 63% vs 78% at 16 years; P=0.03, Figure). Moreover, ZAP-70+ or unmutated IgVH pts revealed shorter RD (17% vs 53% at 16 years, P=0.001; 16% vs 53% at 6.5 years, P<0.0001). Noteworthy, within the high risk subset (n=63), pts in persistent phenotypic CR (n=18) and consolidated pts (n=23) showed a longer RD (90% vs 66% vs 8% at 2.7 years, P=0.00024) vs MRD+ not consolidated pts (n=15). In multivariate analysis, only consolidation/maintenance (P<0.0001) and biologic risk classes (P=0.001 and P<0.0001) were confirmed as independent prognosticators with regard to RD and OS. Therefore rituximab consolidation/maintenance therapy improve RD and OS in CLL, also within the high risk subset, taking into account that historical biological markers (ZAP-70 and IgVH mutational status) retain their prognostic impact with our chemoimmunotherapeutic strategy. Disclosures: No relevant conflicts of interest to declare.

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