Thrombin Generation Test During Asparaginase Treatment In Children With Acute Lymphoblastic Leukemia

Abstract Asparaginase (Aase) and corticosteroid (CS) used to treat acute lymphoblastic leukemia (ALL) in children during the Induction and Late Intensification phases have adverse effects on coagulation and increase the incidence of thrombotic events. Aase and CS reduce both pro- and antithrombotic factors and most studies have evaluated the individual components of the coagulation system to infer the prothrombotic profile. However, global haemostatic potential of these children and its changes during treatment are poorly reported. We aimed to characterize the global haemostatic phenotype of ALL patients during native Aase therapy, using a global haemostatic assay, the Calibrated Automated Thrombogram® (CAT) method of thrombin generation (TG) in B lineage ALL children treated according to the latest CLG-EORTC first-line protocol (a BFM derived protocol). CAT method was performed on platelets-poor plasma (PPP) at diagnosis (day 1), before each Aase infusion (8 during Induction and 4 during Late Intensification), and at distance of Aase infusion (during and after Interval Therapy and at start of Maintenance). TG was triggered using 1pM tissue factor (TF) and 4µM phospholipids (PL), with and without addition of thrombomodulin (TM). Endogenous Thrombin Potential (ETP) and Peak were monitored and the interquartile range was compared to the [2,5 – 97,5] percentile range of normal controls (NC) of the same range of age (n=28). Protein C activity (PC), free Protein S (PS), antithrombin (AT) and fibrinogen levels were also measured. Results Thirty six children were included (20 boys and 16 girls). Their median age at diagnosis was 3.7 years (range 1-14). Twenty had pre-B ALL and 16 common ALL. Elevated ETP and Peak of TG in ALL patients above the 97,5 percentile of NC were noted at diagnosis and persisted during all the Induction phase. During Interval Therapy and later at start of Maintenance, ETP and Peak returned to values below 97.5 percentile of NC. During Late Intensification, ETP and Peak levels increased above the 97.5 percentile of NC. At all time points studied the variation of ETP and Peak levels were similar in the presence and absence of TM. PC, PS, AT and fibrinogen levels decreased during Induction phase with median PS level remaining within the 2.5-97.5 percentile of NC and median AT and PC levels reaching a value lower than the 2.5 percentile of NC at the time of the 7th and 8th Aase infusion respectively (day 32 and 35). Fibrinogen levels were below the 2.5 percentile of NC during Induction from day 15 to day 29. Among the 36 analyzed patients, 2 experienced 3 symptomatic thromboses. One sub-clavian thrombosis occurred during Induction on day 22 and 1 jugular vein thrombosis occurred in a second child after completion of Induction on day 50 (13 days after the 8thAase infusion). These 2 events were concurrent with a central venous catheter infection. The second patient also developed during Late Intensification a cerebral thrombosis in the longitudinal sinus. Concomitant to these three events, ETP and Peak values of these patients were above the P75 value of ALL patients sampled at the same time points compatible with a marked prothrombotic profile and a higher risk of thrombosis. This study suggests that TG is a promising global assay to evaluate the hypercoagulable state in ALL children under treatment. TG reveals an increased thrombin potential which is present early at diagnosis, persists during Induction and reappears during Late Intensification. This observation is consistent with the high incidence of thrombotic events previously described during Induction and until 10 days after the last Aase infusion. TG profiles observed in patients who experienced thrombotic events suggest that this assay could be used as a predictive tool since their TG parameters were above P75 value of the ALL children tested. Further investigations are needed to address this issue. Disclosures: No relevant conflicts of interest to declare.

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Pediatric Therapy In Adult Acute Lymphoblastic Leukemia: Updated Experience of a Single Centre

Blood ◽

10.1182/blood.v116.21.4338.4338 ◽

2010 ◽

Vol 116 (21) ◽

pp. 4338-4338

Author(s):

Stefania Paolini ◽

Sarah Parisi ◽

Ilaria Iacobucci ◽

Cristina Papayannidis ◽

Maria Chiara Abbenante ◽

...

Keyword(s):

Acute Lymphoblastic Leukemia ◽

Conflicts Of Interest ◽

Lymphoblastic Leukemia ◽

Hematological Toxicity ◽

Induction Phase ◽

Single Centre ◽

Phase Ib ◽

Small Series ◽

Significant Difference

Abstract Abstract 4338 Background. Acute lymphoblastic leukemia (ALL) presents with different outcome in children and adults, with event-free-survival (EFS) rates of 70–80% and 30–40% at 5 years, respectively. This reflects both a different disease biology and different therapeutic approaches. Recently, results apparently improved in young adults/adolescents aged 15–21 years, with de novo ALL, when treated with pediatric intensive regimens rather than with typical adult regimens. Similarly, clinical studies are ongoing in older patients, toxicity related-therapy seeming the limiting issue. Aims. We report a single centre experience on adult ALL patients treated with an intensive pediatric-inspired schedule, designed to assess its tolerability and efficacy. Methods. From November 2007 to June 2010 seventeen ALL patients (M/F=12/5) were treated at our Center according to a modified AIEOP LAL2000 regimen. Treatment consisted of 7 days steroid pre-treatment, and four drugs 78-days induction (phase IA and phase IB) after which high risk (HR) patients were treated with three polychemotherapy blocks, while intermediate (IR) and standard risk (SR) patients went on 8-weeks consolidation and subsequent delayed intensification. Allo-SCT was planned for all patients with HLA-matched donor, as alternative to 2-years maintenance therapy. Median age was 31 years (range, 17–47). According to cytogenetic, response to steroid and minimal residual disease patients were classified into HR (n=7), IR (n=6) and SR (n=4). Results. 15/17 patients completed the induction phase IA, two being out for toxicity (grade IV infection and intestinal occlusion). Twelve (71%) obtained a complete remission (CR); three were refractory. However, one of them subsequently achieved CR after polychemotherapy blocks, for an overall response rate of 76% (13/17). Eleven patients then completed the 28-days induction IB. One patient is ongoing. Median induction duration was 92 days (range 82–136). Delays were mostly due to extra-hematological toxicity, the commonest being gastrointestinal (n=12), infective (n=7) and thrombotic (n=3). Delays were accumulated in both induction phases without significant difference between phase IA (median 18.5 days, range 4–37) and phase IB (median 17 days, range 9–66), despite an absolute number of moderate-severe AE superior in phase-IA versus phase-IB (12 vs 5). After induction, 4/12 patients already received consolidation therapy; 2/4 then received allo-SCT. The median duration of consolidation was 51 days (range 22–94). Conversely, 6/12 patients received polychemotherapy-blocks, one patient went directly on alloSCT and the remaining is ongoing. After polychemotherapy-blocks, five out six patients received allo-SCT. The median CR duration was 13 months (range 1+-42+); two patients relapsed, both after allo-SCT. With a median follow-up of 11 months (range 2–43) 11/17 (65%) patients are alive, 9 in CR (5 undergone allo-SCT). Six patients dead, three in CR for infectious complications, 3 for relapsed/refractory disease. Conclusions. Though in a small series, pediatric-like intensive chemotherapy seemed to be feasible in adult ALL. Extra-hematological toxicity, however, caused significant treatment delays during induction. Finally, the overall outcome appeared promising, though longer follow-up and larger populations are needed to draw definitive conclusions. Acknowledgments. BolognAIL, European LeukemiaNet, AIRC, Fondazione Del Monte di Bologna e Ravenna, FIRB 2006, PRIN 2008, Ateneo RFO, Project of Integrated Program (PIO), Programma di Ricerca Regione – Università 2007–2009. Disclosures: No relevant conflicts of interest to declare.

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Treatment of Acute Lymphoblastic Leukemia in Children and Adolescents with An Anthracycline Based Regimen, but without High Doses of Cytarabine and Methotrexate: Preliminary Results of the LAFAMI-LLA-2002 Protocol.

Blood ◽

10.1182/blood.v114.22.4104.4104 ◽

2009 ◽

Vol 114 (22) ◽

pp. 4104-4104

Author(s):

Gregorio Campos-Cabrera ◽

Virgina Campos-Cabrera ◽

Jose-Luis Campos-Villagomez

Keyword(s):

Flow Cytometry ◽

Acute Lymphoblastic Leukemia ◽

High Risk ◽

Hospital Admissions ◽

Conflicts Of Interest ◽

Lymphoblastic Leukemia ◽

High Dose ◽

Induction Phase ◽

Efficient Treatment

Abstract Abstract 4104 Background acute lymphoblastic leukemia (ALL) is the most common malignancy in children and adolescences, improvements in the 5 year survival rate continue to be seen since middle 80's, in the 1996 – 2004 SEER data reaching 84 % for children and young adults less than 19 years of age. In Mexico, a developing country, where the minimum salary is less than 3.5 dollars per day and more than a half of the population earn less than that and had no social security the need for an effective with high rate survival but low cost treatment is a priority. We developed a treatment based in the protocol ALL:SWOG9400; Blood 92(10)(Suppl.1): 676a (#2788) (1998) and Blood 100(11):756a (#2991) (2002) and weekly anthracycline induction intensification: protocol ALL-BMF90; Blood 84:3122-3133 (1994) and Blood 95:3310-3322 (2000); and named the LAFAMI-LLA-2002. Methods patients younger than 18 years old with ALL by bone marrow aspirate (BMA), flow cytometry and kariotype analysis; risk-based treatment assignment for children with acute lymphoblastic leukemia, (Ching-Hon Pui en J Clin Oncol 1996;14:18-24 and N Engl J Med 1998;339:605-615). Treatment with LAFAMI-LLA-2002 protocol consist in induction phase (IP) con prednisone 60 mg/m2/d for 28 days and taper to zero betwen day 29 and day 42; doxorubicine 30 mg/m2 days 1,8,15 y 22; vincristine 1.4 mg/m2 (maximum 2 mg) days 1,8,15,22,29 y 35; L-asparaginase 10,000u/m2 days 33 al 42; allopurinol 300 mg/m2 days 1 to 14; patients with high risk also receive ciclofosfamide 750 mg/m2 days 1,15 y 29; after complete IP a BMA is taken and if it is in complete remission then start CNS directed therapy with intratecal chemotherapy (IT CT) twice a week for 4 weeks, triple drug without folinic acid rescue: methotrexate 15/m2 mg, citarabine 40/m2 mg and dexametasone 8 mg; patients with positive CNS involvement and high risk patients also receive cranial irradiation (RT) 2400 cGy; maintenance initiating after IR and during IT CT with mercaptopurine 60 mg/m2/d y metotrexate 20 mg/m2 weekly during 3 years and bi monthly chemotherapy alternating one month IT CT and another month IV CT: dexametasone 40 mg/m2 days 1 to 4, ciclofosfamide 750 mg/m2 day 1, vincristine as mentioned above and citarabine 75 mg/m2 days 3 to 6 y 10 to 13; every 4 months an extra dose of doxorubicine is given with th IV CT. At the end of the treatment flow cytometry for minimal residual disease is taken and if negative go to follow up, then monthly CBC and every six months MRD by FC to complete 5 years. Echocardiograms were performed before IP and every six months until complete the end of the 5 years. Results from January 2002 to July 2009 13 patients were included, 8 male y 5 female, ages from 2 to 17 years; 12 B lineage an 1 T lineage; all with normal kariotype; 10 low risk and 3 high risk; 8 patients completed treatment and are in follow up, 4 patients are in maintenance phase, and one died from relapse during maintenance. All patients completed IP and CNS directed therapy, CR was demonstrated in all and each one. All 8 that completed treatment are in follow up and are negative in MRD, the minimum follow up is 13 months and the maximum is 35; 5 patients from this group have more than 24 months without treatment. No cardiac toxicity was seen; all had normal echocardiogram at the end and every six months after the end of treatment. Conclusions this is an efficient treatment for ALL in patients younger than 18 years, reaching until now 100% of CR in IR and CNS directed therapy; with 92.3 % of global and free event survival: similar results than in protocols using high dose cytarabine and methrotexate but without the toxicity of them; reducing financial costs and hospital admissions because it is an ambulatory treatment that can be given in almost all cities, even in developing countries. Disclosures: No relevant conflicts of interest to declare.

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Pediatric-Like Intensified Therapy In Adult Acute Lymphoblastic Leukemia: A Single Centre Experience

Blood ◽

10.1182/blood.v118.21.4261.4261 ◽

2011 ◽

Vol 118 (21) ◽

pp. 4261-4261

Author(s):

Sarah Parisi ◽

Stefania Paolini ◽

Ilaria Iacobucci ◽

Cristina Papayannidis ◽

Mariachiara Abbenante ◽

...

Keyword(s):

Acute Lymphoblastic Leukemia ◽

Conflicts Of Interest ◽

Lymphoblastic Leukemia ◽

Hematologic Toxicity ◽

Induction Phase ◽

Consolidation Therapy ◽

Single Centre ◽

Phase Ib ◽

Single Centre Experience

Abstract Abstract 4261 Background Acute lymphoblastic leukemia (ALL) shows different outcome in children and adults, with event-free-survival (EFS) rates of 70–80% and 30–40% at 5 years, respectively. Results improved in young adults/adolescents with de novo ALL, when treated with pediatric intensive regimens rather than with adult regimens. Clinical studies are ongoing in older patients, toxicity related-therapy seeming the limiting issue. Aims We report a single centre experience on adult ALL patients treated with an intensive pediatric-inspired schedule, aiming to assess its tolerability and efficacy. Methods From 11/07 to 03/11 we treated 24 ALL patients (M/F=17/7) according to modified AIEOP-LAL2000 regimen. Treatment consisted of 7 days steroid pre-treatment, and four drugs 78-days induction (phase IA and IB) after which high risk (HR) patients were treated with three polychemotherapy blocks, while intermediate (IR) and standard risk (SR) patients went on 8-weeks consolidation and subsequent intensification. A 2 cycle consolidation therapy with nelarabine was planned for T-ALL patients. Patients with HLA-matched donor underwent allo-SCT; 2-years maintenance therapy was given to the others. Median age was 30 years (17–47). Results 22/24 patients completed the phase IA, 2 being out for grade IV toxicity (intestinal occlusion and sepsis). 17 (70.8%) obtained a complete remission (CR), 5 (21%) were refractory. One of the resistant patients achieved CR after polychemotherapy blocks, two after phase IB. Median induction duration (IA+IB) was 95 days (82–136); delays were mostly experienced after phase IB, hematologic toxicity being an important cause of delay, with median time to neutrophil count recovery of 28 days (18–34) and 39 days (16–62) for phase IA and IB respectively. A higher absolute number of adverse events during phase IA than during IB was registered (infections and gastrointestinal), without a significant prolongation of phase IA. After induction, 3 of the 19 CR patients received consolidation therapy, then 2/3 underwent allo-SCT. 6 patients received blocks: 3/6 undewent allo-SCT, 2/6 dropped out after the first and the second block for reversible grade II-III renal toxicity and one relapsed. 5 patients were treated with nelarabine, then 2/5 underwent allo-SCT. 3/19 directly underwent allo-SCT, while 1 patient completed the whole therapeutic program because no suitable donors for allo-SCT were found. One patient died after phase IB for pulmonary infection. With a median follow up of 12 months (3–50), 14/24 (58,3%) patients are alive, 8 in CR (5 underwent allo-SCT). 10 patients died, 5 for relapsed/refractory disease, 5 in CR (3 after allo-SCT). Conclusions A pediatric-inspired therapeutic regimen demonstrated a significant hematologic and a subsequent infective toxicity in adult ALL patients, this causing a lack in dose-intensity maintenance. The overall outcome seemed to be comparable to the one reached in other studies conducted on larger population but a longer follow-up and a larger population are needed to draw definitive conclusions. Acknowledgments. BolognAIL, European LeukemiaNet, AIRC, Fondazione Del Monte di Bologna e Ravenna, FIRB 2006, PRIN 2008, Ateneo RFO, Project of Integrated Program (PIO), Programma di Ricerca Regione - Università 2007–2009. Disclosures: No relevant conflicts of interest to declare.

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Philadelphia-Like Signature In Childhood Acute Lymphoblastic Leukemia: The AIEOP Experience

Blood ◽

10.1182/blood.v122.21.353.353 ◽

2013 ◽

Vol 122 (21) ◽

pp. 353-353 ◽

Cited By ~ 6

Author(s):

Geertruy te Kronnie ◽

Daniela Silvestri ◽

Elena Vendramini ◽

Grazia Fazio ◽

Franco Locatelli ◽

...

Keyword(s):

Gene Expression ◽

Acute Lymphoblastic Leukemia ◽

Conflicts Of Interest ◽

Lymphoblastic Leukemia ◽

Philadelphia Chromosome ◽

Gene Expression Signature ◽

Induction Phase ◽

Dna Index ◽

Study Gene Expression ◽

Significant Difference

Abstract Background Despite the current risk-based stratification and therapies, up to 20% of pediatric patients with B-cell precursor acute lymphoblastic leukemia (BCP-ALL) experience relapse. A major research effort is dedicated to identifying poor prognostic subgroups in the larger subset of patients with intermediate-risk disease, where most relapses occur. Recently, two groups in the US and the Netherlands independently identified a novel BCP-ALL subtype negative for the BCR/ABL fusion gene but with a gene-expression profile similar to Philadelphia chromosome-positive (Ph+) ALL. This ‘Ph-like’ (or ‘BCR/ABL-like') subtype encompasses 10-15% of BCP-ALL patients, predicts high incidence of relapses and defines a candidate subgroup for targeted treatment with tyrosine kinase inhibitors and alternative drugs. Aim Aim of this project was to identify BCP-ALL Ph-like cases and their prognosis in patients treated in Study Protocols of the Italian Association of Pediatric Hematology and Oncology (AIEOP) Methods In the context of the Microarray Innovations in LEukemia (MILE) study, gene expression profiling was successfully performed on 400 Italian childhood BCP-ALL cases enrolled in AIEOP-BFM ALL2000/R2006 protocols, from whom material was available. The MILE classifier recognized the most common genetic subgroups, namely t(4;11), t(12;21), t(1;19) or t(9;22) positive, or high hyperdiploid (DNA index≥1.16). Out of 400 BCP-ALL cases, 143 negative for common fusion transcripts, non-high hyperdiploid (DNA index<1.16) and non-Down Syndrome, were defined as ‘B-others’. Results Using signatures of known ALL subgroups, the likelihood to be close to one of the ‘known’ classes was defined for each of the B-others samples. Specifically, 43 B-other cases (43/143=30.1%, about 10% of total BCP-ALL cohort) presented as a cluster with a gene expression signature close to the BCR/ABL signature, therefore referred to as ‘Ph-like’. Among B-others, Ph-like cases had a significantly increased proportion of males, age>10 years and WBC>20x109/L. The 5y event-free survival (EFS) of Ph-like patients was 54.8% (SE 8.2) vs 83.1% (3.9) in the remaining B-others patients (p<0.001), mostly due to an increased cumulative incidence of relapse (CIR: 33.9% (7.4) vs 14.9% (3.7); p=0.009). Notably, Ph-like patients did not differ for prednisone (PDN) and minimal residual disease (MRD) response or final risk stratification. Indeed, out of 36/43 stratified by MRD, only 7 patients had high-risk MRD, while 20 were MRD intermediate and 9 even MRD standard risk. Only 3 non-HR cases by MRD were then classified as HR based on PDN response. Of relevance, the significant difference in 5y EFS was confirmed in the 33 Ph-like patients with no HR features (59.8% (9.2) vs 88.5% (3.9) in the remaining B-others patients with similar features (p<0.001), with a significantly increased CIR (32.1% (8.4) vs 10.2% (3.7); p=0.005). Among 43 Ph-like cases, 1 was resistant and 1 died during the induction phase. Out of the 14 relapses, 10 were isolated medullary, and 4 combined with an extramedullary site (no CNS relapses). Two patients died in remission and no secondary malignancies occurred during the observation period. Overall, 25/43 (58.1%) Ph-like patients are alive in complete remission versus 84/100 (84.0%) in B-others, non Ph-like patients. Conclusions and perspectives We identified a ‘Ph-like’ subgroup in the Italian cohort of children with BCP-ALL, associated to a poor outcome. Ph-like patients, independently of the other known risk features, could be considered eligible for alternative treatments. The genetic characterization of this subgroup is ongoing within the AIEOP-BFM research trial cooperative group, which is aimed at further defining the pathogenetic mechanisms and identifying the therapeutic translation. Disclosures: No relevant conflicts of interest to declare.

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L-Asparaginase and the effect of age on coagulation and fibrinolysis in childhood acute lymphoblastic leukemia

Thrombosis and Haemostasis ◽

10.1160/th07-10-0620 ◽

2008 ◽

Vol 100 (08) ◽

pp. 330-337 ◽

Cited By ~ 29

Author(s):

Wim C. J. Hop ◽

Carla van Kessel-Bakvis ◽

Rolinda Stigter ◽

Rob Pieters ◽

Inge M. Appel

Keyword(s):

Acute Lymphoblastic Leukemia ◽

Thrombin Generation ◽

Lymphoblastic Leukemia ◽

Age Groups ◽

Clot Lysis ◽

Induction Treatment ◽

Induction Phase ◽

Activation Markers ◽

Age Related ◽

Coagulation And Fibrinolysis

SummaryAlterations in haemostasis are frequently observed in children with acute lymphoblastic leukemia (ALL). It was the objective of this study to analyse age-related disturbances in coagulation and fibrinolysis parameters during the induction phase of the anti-leukemic treatment. Sixty-four children were classified by age into three groups (1–5, 6–10, 11–16 years), and studied during induction treatment of ALL including four weeks of dexamethasone, followed by two weeks tapering of dexamethasone during which 6,000 IU/m2 native L-Asparaginase (total 4 doses) was administered intravenously twice weekly. Blood samples were collected immediately before each L-Asparaginase infusion to analyze procoagulant (fibrinogen, factor [F] II, FV, FVII, F IX, F X) and anticoagulant factors (antithrombin [AT], protein C, protein S), parameters of thrombin generation (F1+2, TAT) and fibrinolysis (α2-antiplasmin, plasminogen, PA P , D-dimer). Children were in a hypercoagulable state after four weeks of dexamethasone due to upregulation of coagulation parameters. Upregulation was highest in the two youngest age groups. During L-Asparaginase treatment the 11– to 16-year- olds showed lower values in procoagulant and, even more, in anticoagulant factor levels compared to the younger children. Activation markers of thrombin generation and fibrinolysis did not change over time during the study period. Decreased synthesis of α2-antiplasmin and plasminogen during L-Asparaginase treatment resulted in less potential of clot lysis by plasmin in children older than 11 years of age. In conclusion, a more severe decline of anticoagulant and fibrinolytic parameters in children between 11 and 16 years of age underline that these children are at higher risk of thrombosis during ALL induction treatment.

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Dose-Intensity Impacts On Survival of Adolescents and Young Adults with Acute Lymphoblastic Leukemia Treated in Adult Departments by a Pediatric Protocol (FRALLE 2000BT)

Blood ◽

10.1182/blood.v120.21.3561.3561 ◽

2012 ◽

Vol 120 (21) ◽

pp. 3561-3561 ◽

Cited By ~ 6

Author(s):

Thomas Cluzeau ◽

Nathalie Dhedin ◽

Françoise Huguet ◽

Emmanuel Raffoux ◽

Sebastien Maury ◽

...

Keyword(s):

Young Adults ◽

Acute Lymphoblastic Leukemia ◽

Conflicts Of Interest ◽

Lymphoblastic Leukemia ◽

Univariate Analysis ◽

Dose Intensity ◽

Adolescents And Young Adults ◽

Induction Phase ◽

Long Term Outcome ◽

Response To Chemotherapy

Abstract Abstract 3561 Background: Adolescents (15–19y) with acute lymphoblastic leukemia (ALL) markedly benefit from pediatric rather than adult chemotherapy regimens, as highlighted by many retrospective studies (Boissel et al., JCO 2001). In young adults with ALL, there are now strong evidences that pediatric or pediatric-inspired protocols may also improve long-term outcome (Huguet et al., JCO 2009). However, whether care environment (adult vs pediatric unit) may impact this outcome remains an open issue. To address this question, we explored the outcome of adolescents and young adults (AYA, 15–29y) treated in adult hematology departments by the pediatric FRALLE 2000-BT protocol. Methods: From February 2001 to June 2011, 89 AYAs with Ph-negative ALL including 60 adolescents (15–19y) and 29 YAs (20–29y) were treated according to the pediatric FRALLE 2000-BT protocol in 13 French and Belgian adult hematology units (median follow-up, 5 years). After a prednisone prephase and a four-drug induction (prednisone, daunorubicin, vincristine and L-asparaginase), patients achieving CR received four 8-week phases of treatment: consolidation, 1st delayed intensification (DI), interphase, 2nd DI, and maintenance. According to FRALLE protocol recommendations, each phase should begin after hematological recovery of previous phase (ANC>1 G/L, Platelets>100 G/L). Twenty-five patients (18 adolescents and 7 YAs) underwent allogeneic transplantation after consolidation phase or 1stDI. Results: Apart age (median age, 18 vs 23y; p<.0001), adolescent and YAs cohorts had similar characteristics, including WBC, B/T lineage distribution, and high-risk karyotype (t(4;11)/MLL-AF4, hypodiploidy)), except for initial CNS involvement (1/60 vs 4/29 respectively, p=.02). Initial peripheral response to prednisone (PDN) at D7 and bone marrow response to chemotherapy at D21 were better in the adolescent subgroup, without reaching significance (slow PDN-responders: 30% vs 38%, p=.42; slow chemo-responders: 13% vs 21%, p=.37). Overall CR rate was 99% and did not differ between both cohorts (98% in adolescents, 100% in YAs). 5y-OS and 5y-EFS were estimated respectively at 66% and 61%. Despite similar CR rates, 5-year EFS was significantly shorter in adolescents than in YAs (47% vs 79%, p=.02). A non significant shorter 5y-OS was also observed in adolescents (58% vs 81%, p=.11). To explain this difference, we looked at dose-intensity disparities between both subgroups. During induction phase, no differences in drug cumulative doses were observed. To further explore potent difficulties to respect protocol schedules in younger patients, we compared intervals from induction D1 to start of different trial phases between both subgroups. In comparison to YAs, intervals from induction D1 to consolidation, 1st DI, 2nd DI and maintenance phases were progressively delayed in adolescents: 4 days for consolidation (p=.24), 6 days for 1st DI (p=.19), 9 days for 2nd DI (p=.005), and finally 25 days for maintenance phase (p=.0002). In univariate analysis, among age (adolescents vs YAs), B/T lineage, WBC, cytogenetics, and time to 1st DI, only age and time to 1st DI significantly affected EFS (p=.05 and p=.001 respectively). In bivariate analysis, age and time to 1st DI were identified as independent prognostic factors for EFS (p=.03 and p=.004, respectively). The same observation was done with interval time to 2ndDI. Conclusion: The outcome of AYAs treated in adult units with the pediatric FRALLE 2000 protocol is encouraging, particularly in YAs. The poorer outcome observed in adolescents may be related to increasing intervals from initial induction to the different phases of treatment. Prospective trials are required to register individual reasons that lead physicians and patients to progressively delay therapy. This study suggests that trial itself is not sufficient to improve the outcome in adolescents with cancer and that AYA programs are needed to explore the difficulties encountered by patients and care teams to adhere to therapy. Disclosures: No relevant conflicts of interest to declare.

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IKZF1 Deletion Is An Independent Predictor of Outcome In Pediatric Acute Lymphoblastic Leukemia Treated According to the ALL-BFM 2000 Protocol

Blood ◽

10.1182/blood.v116.21.409.409 ◽

2010 ◽

Vol 116 (21) ◽

pp. 409-409

Author(s):

Petra Breithaupt ◽

Barbara Meissner ◽

Martin Zimmermann ◽

Anja Möricke ◽

André Schrauder ◽

...

Keyword(s):

Treatment Outcome ◽

High Risk ◽

Cox Regression ◽

Conflicts Of Interest ◽

Residual Disease ◽

Risk Group ◽

Independent Predictor ◽

Lymphoblastic Leukemia ◽

Time Points ◽

Pediatric All

Abstract Abstract 409 Alteration of the IKZF1 gene – encoding the transcription factor IKAROS, a key player in lymphoid development and tumor suppression – has been reported to be associated with a poor outcome in pediatric precursor B-cell ALL, especially in cases positive for the BCR-ABL1 fusion gene. In order to assess the prognostic value of IKZF1 deletions in a representative cohort of pediatric ALL patients treated on the German ALL-BFM 2000 study protocol, we screened 409 patients by applying a multiplex ligation-dependent probe amplification (MLPA) assay covering all eight IKZF1 exons (P335-A3 ALL-IKZF1 probemix; MRC-Holland, Amsterdam, The Netherlands). In ALL-BFM 2000, risk group stratification (standard, SR; intermediate, MR; high, HR) was based on minimal residual disease (MRD) analysis at two different time points (TP) and required two MRD targets with sensitivities of ≤10−4 (Flohr et al. Leukemia 2008). SR patients were MRD-negative on treatment days 33 (TP1) and 78 (TP2). HR patients had residual disease (≥10−3) at TP2. MRD MR patients had positive MRD detection at either one and or both time points but at a level of <10−3 at TP2. Although MRD-based stratification criteria were introduced in ALL-BFM 2000, established high-risk parameters were also retained: patients with prednisone poor-response or ≥5% leukemic blasts in the bone marrow on day 33 or positivity for a t(9;22) or t(4;11) or their molecular equivalents (BCR/ABL1 or MLL/AF4 fusion RNA) were stratified into the high-risk group independent of their MRD results. First results on MRD and outcome were published earlier (Conter et al. Blood 2010). Out of the 409 patients analyzed in our study, 46 (11%) displayed a deletion in at least one of the eight IKZF1 exons. Forty-three out of the 46 cases showed heterozygous deletions, while 3 patients displayed homozygous loss of IKZF1 exons. MLPA results of 11 patients were validated with results derived from copy number/LOH analyses using Affymetrix SNP 6.0 arrays. IKZF1 deletion was significantly more common in precursor B compared to T cell ALL (13% vs. 4%, P = 0.03) and less frequent in TEL/AML1-positive ALL (3% vs. 13%, P = 0.004). Out of 11 BCR/ABL1-positive samples, only two were characterized by an IKZF1 deletion. Forty-four patients with IKZF1-deleted ALL had results of MRD analyses available for both informative time points (day 33 after induction and day 78 after consolidation). Despite a trend towards increasing incidence of IKZF1 deletion in patients with slow response, the distribution of IKZF1-deleted ALL patients over the risk groups was not significantly different from non-deleted ALL (SR: 40.9 vs. 41.9; MR: 45.5 vs. 52.3; HR: 13.6 vs. 5.7%; P = 0.153). Regarding treatment outcome, patients with an IKZF1 deletion had a significantly lower 5-year event-free survival (EFS) compared to non-deleted patients (0.78±0.06 vs. 0.86±0.02; P = 0.015). This result was due to a higher cumulative incidence of relapses in IKZF1-deleted patients (0.16±0.05 vs. 0.10±0.02; P = 0.031). In multivariate Cox regression analyses including known prognostic variables (gender, immunophenotype, WBC count at diagnosis, TEL/AML1 status, risk group criteria of ALL-BFM 2000), IKZF1 deletion conferred a risk of 2.16 (95% confidence interval 1.14 – 4.10; P = 0.018) for an event when compared to non-deleted patients. We conclude that IKZF1 deletion is an independent predictor of treatment outcome for patients enrolled on the ALL-BFM 2000 protocol and represents a candidate marker to be integrated in future algorithms for early risk stratification in pediatric ALL. Disclosures: No relevant conflicts of interest to declare.

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Phloridzin Docosahexaenoate (PZ-DHA) : A Novel Naturally Derived Drug Active in T-Cell Acute Lymphoblastic Leukemia (T-ALL)

Blood ◽

10.1182/blood.v128.22.5197.5197 ◽

2016 ◽

Vol 128 (22) ◽

pp. 5197-5197

Author(s):

Niroshaathevi Arumuggam ◽

Nicole Melong ◽

Catherine K.L. Too ◽

Jason N. Berman ◽

H.P. Vasantha Rupasinghe

Keyword(s):

Acute Lymphoblastic Leukemia ◽

T Cell ◽

Conflicts Of Interest ◽

Lymphoblastic Leukemia ◽

Xenograft Model ◽

Jurkat Cells ◽

Interferon Α ◽

Omega 3 ◽

Cell Acute Lymphoblastic Leukemia

Abstract T-cell acute lymphoblastic leukemia (T-ALL) is an aggressive malignant disease that accounts for about 15% of pediatric and 25% of adult ALL. Although risk stratification has provided more tailored therapy and improved the overall survival of T-ALL patients, clinical challenges such as suboptimal drug responses, morbidity from drug toxicities, and drug resistance still exist. Plant polyphenols have therapeutic efficacy as pharmacological adjuvants to help overcome these challenges. They can be acylated with fatty acids to overcome issues concerning bioavailability, such as poor intestinal absorption and low metabolic stability. Phloridzin (PZ), a flavonoid found in apple peels, was acylated with an omega-3 fatty acid, docosahexaenoic acid (DHA), to generate a novel ester called phloridzin docosahexaenoate (PZ-DHA). The cytotoxic effect of PZ-DHA was studied in the human Jurkat T-ALL cell line. PZ-DHA significantly reduced the viability and cellular ATP levels of treated cells. PZ-DHA was found to selectively induce apoptosis in Jurkat cells, while sparing normal murine T-cells. Apoptosis was further confirmed by demonstrating the ability of PZ-DHA to induce morphological alterations, DNA fragmentation, caspase activation, and the release of intracellular lactate dehydrogenase. PZ-DHA also significantly inhibited cell division in Jurkat cells. Furthermore, interferon-α-induced phosphorylation of the transcription factor, STAT3, was downregulated following PZ-DHA treatment. The in vitro efficacy of PZ-DHA was recapitulated in vivo in an established zebrafish xenograft model, where the proliferation of transplanted Jurkat cells was inhibited when PZ-DHA was added to the embryo water. Overall, these findings provide evidence for PZ-DHA as a novel therapeutic agent with activity in T-ALL. Studies examining the effect of PZ-DHA on patient-derived ALL cells engrafted in zebrafish are currently underway. Disclosures No relevant conflicts of interest to declare.

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The Role of Protein Tyrosine Phosphatase PTP4A3 in T-Cell Acute Lymphoblastic Leukemia Progression

Blood ◽

10.1182/blood-2019-126256 ◽

2019 ◽

Vol 134 (Supplement_1) ◽

pp. 2539-2539

Author(s):

Min Wei ◽

Jessica Blackburn

Keyword(s):

Acute Lymphoblastic Leukemia ◽

T Cell ◽

T Cell Activation ◽

Protein Tyrosine Phosphatase ◽

Conflicts Of Interest ◽

Lymphoblastic Leukemia ◽

Tyrosine Phosphatase ◽

Causative Role ◽

Protein Tyrosine ◽

Cell Acute Lymphoblastic Leukemia

The tyrosine protein tyrosine phosphatase PTP4A3 has been extensively reported to play a causative role in numerous cancers, including several types of acute leukemia. We found PTP4A3 to be highly expressed in T-cell Acute Lymphoblastic Leukemia samples, and show that PTP4A3 accelerates T-ALL onset and increases the invasive ability of T-ALL cells in a zebrafish model, and is required for T-ALL engraftment and progression in mouse xenograft. Our in vitro studies showed that PTP43A3 enhances T-ALL migration, in part via modulation of SRC signaling. However, whether SRC is a direct substrate of PTP4A3, and whether the phosphatase activity of PTP4A3 actually plays a role in T-ALL or other types of leukemia progression is unknown and remains a major question in the field. We used a BioID-based proximity labeling approach combined with PTP4A3 substrate trapping mutant pull down assay to capture the PTP4A3 substrates candidates. BioID, a biotin ligase, was fused to PTP4A3 to generate a Biotin-PTP4A3 (BP) fusion protein. The overexpression of BP in T-ALL cell lines led to biotin modification of 288 PTP4A3 proximal proteins, including the potential direct PTP4A3 substrates. PANTHER pathway analysis showed that PTP4A3 interacting proteins are largely clustered in the T-cell activation, PDGF signaling, and angiogenesis. We are in process of validating potential substrates using immunoprecipitation and phosphoenrichement assays. Finally, we are using a novel zebrafish Myc+PTP4A3 induced T-ALL model to assess the function of PTP4A3 in leukemia progression. We have created several PTP4A3 protein mutants, including a phosphatase-dead mutant, a mutant unable to bind magnesium transporter, and a prenylation deficient mutant, and are in process of assessing the effects of these mutants in T-ALL onset and progression in our in vivo model. In total, these studies will allow us to better understand function of PTP4A3 in T-ALL progression, and may provide a strong rationale for the development of PTP4A3 inhibitors for use in leukemia. Disclosures No relevant conflicts of interest to declare.

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