Phase II Prospective Multicentre Study Testing The Efficacy and Safety Of a Clofarabine (Clo), I.v. Busulfan (Bu) and Antithymocyte Globulins (ATG)-Based Reduced-Intensity Conditioning Regimen (RIC) Before Allogeneic Stem Cell Transplantation (allo-SCT) For High-Risk Myelodysplastic Syndrome Or Acute Leukemia: The Cloric Trial

Abstract Introduction Clofarabine (Clo) is a purine analogue which was developed to overcome limitations and to incorporate the favorable pharmakokinetic properties of fludarabine and cladribine. This agent has also a significant antileukemic activity. Thus, can one exploit both the antileukemic and immunosuppressive effects of Clo for further improving outcome after RIC allo-SCT for patients with high-risk myelodysplastic syndrome (MDS) or acute leukemia. Here we report the results of a prospective multicentre trial testing the use of Clo in replacement of fludarabine in combination with i.v. Busulfan (Bu) and ATG in 30 patients with high-risk MDS/acute leukemia (clinicaltrials no. NCT00863148). Patients and Methods Thirty patients (male n=18, female n=12) from 6 centres were included in this study between October 2009 and August 2012. Sixteen patients were diagnosed with high-risk MDS (n=5) or acute myeloid leukemia (AML, n=11), while 13 patients had high-risk acute lymphoblastic leukemia (ALL, Ph+ n= 2, Ph- n=11) and 1 patient a biphenotypic leukemia. All patients were in first (AML/MDS, n= 10; ALL/biphenotypic n=10) or second (AML n= 3; ALL n= 4) complete remission, or in stable disease (MDS n=3) at time of transplant. Median age at transplant was 58.8 years (range: 20.5-64.5). The median interval between diagnosis and transplant was 6 months (range: 3.8-124). Karnofsky’s performans status at transplant was: 100% (n=19); 90% (n=6); and 80% (n=4).The RIC regimen consisted of: i.v. Clo 30 mg/m²/day for 4 days (day-8 to day-5), i.v. Bu 3.2 mg/Kg/day for 2 days (day-4 and day-3) and ATG (Thymoglobuline) 2.5 mg/kg/day for 2 days (day -2 and day-1). All patients received G-CSF-mobilized PBSCs and cyclosporine alone for GVHD prophylaxis, irrespective of the type of donor (sibling donors n=14; 10/10 MUD, n=16). For the purpose of this study, the single case of binephotypic leukemia was considered as ALL for comparison between AML/MDS and ALL patients. The primary endpoint of the trial was the assessment of leukemia-free survival (LFS) at one year after allo-SCT. Results Engraftment was observed in all patients (100%). Median time for neutrophils (>500 /µL) and platelets (>50.000/µL) recovery was 18 (range: 14-26) and 12 (range: 0-23) days, respectively. With a median follow-up of 23 months (range: 12-37), the 1-year and 2-year overall survival (OS), leukemia-free survivals (LFS), relapse incidence (RI) and non relapse mortality (NRM) rates were 63±9% and 58+-10%, 57±9% and 53+-9%, 40±9% and 44+-9%, and 3.3±3% and 3.3±3%, respectively. Thirteen patients relapsed (43%) at a median time of 3.5 months (range: 2.3-13.1) after allo-SCT. Overall, 13 patients died, with the cause of death being relapse in 11 and GVHD in 2 (including one after donor lymphocyte injection). 1-year and 2-year OS were significantly higher for AML/MDS patients compared to ALL patients (75±10% vs 50±13%, and 75±10% vs 37±14%, p=0.04). There were trends for higher 1-year and 2-year LFS (69±12% vs 43±13%, and 69±12% vs 34±13%, p=0.08) and lower RI (57±14% vs 25±11%, and 66±14% vs 25±11%, p=0.05) for AML/MDS patients compared to ALL patients. Finally, 1-year and 2-year NRM were similar between both groups (AML/MDS: 6±6% vs 0%, p=0.36). Conclusion This phase 2 prospective multicentre trial shows that a Clo-i.v. Bu-ATG RIC regimen prior to allo-SCT in high-risk MDS/leukemia is feasible allowing for full engraftment and very low toxicity. Disease control appears to be satisfactorily, especially in AML/MDS, warranting a prospective comparison with other widely used fludarabine-based RIC regimens (e.g. Fludarabine, i.v. Bu, ATG versus Clo, i.v. Bu, ATG). Genzyme/Sanofi provided clofarabine and financial support for the study. Disclosures: No relevant conflicts of interest to declare.

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Unmanipulated Graft Transplantation From Family Haploidentical Donors: A Survey On 183 Adult Patients with Acute Leukemias On Behalf of the Acute Leukemia Working Party of the European Group for Blood and Marrow Transplantation (EBMT)

Blood ◽

10.1182/blood.v120.21.1987.1987 ◽

2012 ◽

Vol 120 (21) ◽

pp. 1987-1987

Author(s):

Fabio Ciceri ◽

Myriam Labopin ◽

Paolo Di Bartolomeo ◽

William Arcese ◽

Stella Santarone ◽

...

Keyword(s):

Multivariate Analysis ◽

High Risk ◽

Acute Leukemia ◽

Advanced Disease ◽

Conflicts Of Interest ◽

Lymphoblastic Leukemia ◽

Conditioning Regimen ◽

Treatment Algorithm ◽

Working Party ◽

Acute Leukemias

Abstract Abstract 1987 Background. Allogeneic stem cell transplantation from an haploidentical family donor has been recently developed through unmanipulated graft platforms. Methods. We collected in 57 EBMT centers 183 haploidentical transplants (haploSCT) from unmanipulated peripheral blood (PB) and bone marrow (BM) graft in adults patients (pts) with de novo acute myeloid leukemia (AML) and acute lymphoblastic leukemia (ALL) reported to EBMT registry from 2007 to 2010 and analysed the outcome according to the known risk factors. Results. Overall, 120 AML patients underwent transplantation in CR1 (39), CR2 (22) or in advanced disease (54). Overall, 63 ALL pts underwent transplantation in CR1 (26), CR2 (14) or in advanced disease (22). Median age was 42y (18–75). Graft composition was based on non ex-vivo T-cell depleted BM in 52 (28%) or PB in 131 (72%). Conditioning regimen was myeloablative (MAC) in 95 and reduced-intensity (RIC) in 88 pts. Primary engraftment was documented in 160 pts (88%), with ANC 0.5 ×109/L in a median of 19 days (BM) and 16 days (PB). Graft-versus-Host Disease (GvHD) prophylaxis was based on Anti-thymocyte globulins (ATG) + cyclosporine-methotrexate (24%) or cyclosporine-mycophenolate (18%), rapamycine-mycophenolate (25%), tacrolimus-mycophenolate (15%), others (7%). The cumulative incidence of acute GvHD >=II was 26%. With a median follow-up of 13 months (1–49), the estimated leukemia-free survival (LFS) at 1 years i was 53 +/−7%, 36 +/−8% and 22 +/−5% for CR1, CR2 and advanced patients respectively. In multivariate analysis for competing risks, relapse incidence (RI) at 1 y was 23 +/−5%, 20 +/−7%, 48 +/−6% for CR1, CR2 and advanced. The non-relapse mortality (NRM) at 1 y was 23 +/−6%, 43 +/−5%, 29 +/−6% for CR1, CR2 and advanced patients. On multivariate analysis, the only factor relevant for LFS was disease status at transplant. Conclusion. EBMT registry analysis of haploidentical transplantation from unmanipulated donor graft confirms relevant LFS for patients with high risk acute leukemia. These results suggest that this procedure should be considered prospectively int treatment algorithm for high risk adults patients in early stages. Disclosures: No relevant conflicts of interest to declare.

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Busulfan (Bu) in Combination with Double Nucleoside Analogues Fludarabine (Flu) and Clofarabine (Clo) Plus Vorinostat As a Novel Reduced Toxicity Conditioning Regimen for Allogeneic Hematopoietic Cell Transplantation (HCT) in Patients (pts) with Acute Leukemia

Blood ◽

10.1182/blood.v128.22.64.64 ◽

2016 ◽

Vol 128 (22) ◽

pp. 64-64

Author(s):

Partow Kebriaei ◽

Wei Wei ◽

Peter F Thall ◽

Celina Ledesma ◽

Benigno C. Valdez ◽

...

Keyword(s):

High Risk ◽

Acute Leukemia ◽

Disease Control ◽

Median Time ◽

Acute Gvhd ◽

Conditioning Regimen ◽

Nucleoside Analogues ◽

Unrelated Donor ◽

Equity Ownership

Abstract The combination of IV Bu and Flu is an effective and well-tolerated HCT conditioning regimen for patients with advanced acute leukemia. However, relapse remains the main reason for treatment failure. We combined two nucleoside analogues Flu and Clo, and showed cytotoxic synergy when combined with Bu, first in pre-clinical models, and subsequently in a randomized clinical study (Andersson BBMT 2011). We selected the optimized regimen from Andersson et al, and combined with escalating doses of the histone deacetylase inhibitor vorinostat in attempts to augment disease control without increasing toxicity. Herein, we describe our initial experience with this novel regimen for patients with advanced acute leukemia or MDS undergoing allogeneic HCT. Methods: Vorinostat (200mg to 1200mg) was escalated in cohorts of 3 patients, and administered 1 hour prior to the fixed regimen of Flu 10 mg/m2 followed by Clo 40 mg/m2 followed by Bu. The nucleoside analogs were infused over 1 hour once daily for 4 days, followed on each day by Bu, infused over 3 hours to a pharmacokinetically targeted daily area under the curve (AUC) of 5500 μMol-min ± 5%. Dilantin was given for seizure prophylaxis. GVHD prophylaxis was based on tacrolimus andmini-MTX, with the addition of rabbit anti-thymocyte globulin (4 mg/kg total dose) for unrelated donor transplants. The presence of minimal residual disease (MRD) was determined by multiparameter flow cytometry. Results: 21 patients (7 AML, 14 ALL) with median age 43 years (range 19-60) received an allogeneic matched sibling (n=10) or unrelated donor (n=11) HCT in CR1 (n=13), CR2 (n=1), primary induction failure (n=5), or relapse (n=2). Twelve patients had MRD or overt disease present at time of HCT. Ten patients had high-risk karyotype defined by t(9;22) (n=3), t(4;11) (n=2), complex (n=2), or del 5 or 7 (n=3). Median time from diagnosis to HCT was 5 months (range 3-48). Median time to ANC > 0.5 x 109/L and platelets > 20 x 109/L were 11 (range 10-15) and 12 days (5-30), respectively. Excluding grade 1 toxicities, the most commonly reported toxicities were nausea with maximum grade 2 (71%), followed by grade 2 or 3 mucositis (64%). Grade 2 or 3 reversible elevation of liver function tests was noted in 54% of pts, including 1 case of reversible VOD. No renal toxicities were noted. Two patients with prior systemic treatment for acute GVHD died of infections (disseminated adenovirus and E.coli sepsis). Ten patients achieved CR and clearance of MRD by day +30 after HCT; one patient had progressive disease and on patient died before disease restaging. Eighteen patients achieved 100% donor chimerism at 30 days following HCT, 2 patients remain with mixed chimerism by 100 day assessment following HCT, and 1 patient died before assessment. The incidence of grades II-IV acute GVHD is 43% and chronic extensive GVHD among 18 evaluable patients is 24%. With a median follow-up of 10 months among surviving patients (1-22), overall and progression-free survival at 6 months is 95% and 71%, respectively. Early results suggest excellent disease control in MRD negative patients (Figure). Conclusion: The Vorinostat-Flu-Clo-Bu combination is well-tolerated and did not add appreciable toxicity in these patients with high-risk leukemia. Longer follow-up is needed to better assess disease control. Figure Figure. Disclosures Ciurea: Spectrum Pharmaceuticals: Other: Advisory Board; Cyto-Sen Therapeutics: Equity Ownership. Patel:Ziopharm Oncology: Equity Ownership, Patents & Royalties; Intrexon: Equity Ownership, Patents & Royalties.

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Mechanisms of CRLF2 Rearrangement with IGH and P2RY8 in B-Cell Acute Lymphoblastic Leukemia.

Blood ◽

10.1182/blood.v114.22.3243.3243 ◽

2009 ◽

Vol 114 (22) ◽

pp. 3243-3243 ◽

Cited By ~ 1

Author(s):

David M Miller ◽

Akinori Yoda ◽

Yuka Yoda ◽

David M Weinstock

Keyword(s):

Acute Lymphoblastic Leukemia ◽

High Risk ◽

B Cell ◽

Transcriptional Control ◽

Conflicts Of Interest ◽

Single Case ◽

Lymphoblastic Leukemia ◽

Receptor Gene ◽

Great Majority ◽

Cell Acute Lymphoblastic Leukemia

Abstract Abstract 3243 Poster Board III-180 Introduction Precursor B-cell acute lymphoblastic leukemia (B-ALL) is the most common malignancy in children. While the great majority of these children achieve long-term remission, the disease exacts a high mortality in adults, and children with high-risk features. Fusion oncogenes such as BCR-ABL, MLL-AF4, E2A-PBX and TEL-AML1 are present in 60% of B-ALL cases. Cloning of these rearrangements has provided significant insight into the mechanisms involved in their formation. The gene alterations that affect the remaining 40% are poorly understood. We and others have recently identified CRLF2, a subunit of the thymic stromal lymphopoietin receptor, as a novel oncoprotein in B-ALL. Approximately 15% of adult and high-risk pediatric B-ALL that lack other characteristic gene rearrangements overexpress CRLF2, while leukemias with these rearrangements do not. In cases with CRLF2 overexpression, CRLF2 appears to be the driver of STAT activation, either alone or in combination with gain-of-function mutations in Janus Kinases (JAKs). CRLF2 overexpression results from rearrangements involving the CRLF2 locus, which is located in the pseudoautosomal regions on chromosomes X and Y. These rearrangements can either involve translocation with the immunoglobulin heavy chain (IGH) locus (t(X;14)(p22;q32) or t(Y;14)(p11;q32)) or interstitial deletion (del(X)(p22.33p22.33) or del(Y)(p11.32p11.32)). We sought to define the mechanisms of cleavage and repair that mediate these rearrangements. Methods For the translocations, we performed a series of polymerase chain reaction (PCR) assays to amplify junctions between IGHJ segments on chr.14 and the region upstream (i.e., centromeric) of CRLF2 on chr.X/Y. For the deletions, we used single nucleotide polymorphism (SNP) arrays and quantitative PCR to define the extent of deletions and then amplified junctions by PCR. Results We successfully amplified IGHJ/CRLF2 translocation junctions from six B-ALL with CRLF2 overexpression. Junctions involved chr.X/Y sequence between 8-16kb upstream of the CRLF2 translation start site. Five of 6 clustered near putative V(D)J recombinase recognition signal sequences (RSS). Additional evidence for involvement of the V(D)J recombinase was identified in all cases, including the presence of nontemplated nucleotides. In contrast, deletions resulted in juxtaposition of the full length CRLF2 coding sequence to P2RY8. A similar event involving t(X;12) that resulted in SOX5 translocation to P2RY8 has been described in a single case of splenic follicular lymphoma. P2RY8 is a member of the purine nucleotide G-protein coupled receptor gene family and is highly expressed in lymphocytes. Conclusion CRLF2 rearrangements result in overexpression through juxtaposition to alternate transcriptional control elements. While translocations appear to be mediated by aberrant V(D)J recombination, deletions likely involve an alternate sequence-dependent mechanism that targets downstream of the P2RY8 promoter. Disclosures No relevant conflicts of interest to declare.

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Acute Leukemia and Myelodysplastic Syndrome: Outcomes in Patients with Chronic Lymphocytic Leukemia (CLL) At MD Anderson Cancer Center (MDACC)

Blood ◽

10.1182/blood.v118.21.981.981 ◽

2011 ◽

Vol 118 (21) ◽

pp. 981-981

Author(s):

Francesco Paolo Tambaro ◽

Guillermo Garcia-Manero ◽

Stefan Faderl ◽

Susan O'Brien ◽

Alessandra Ferrajoli ◽

...

Keyword(s):

Risk Factors ◽

High Risk ◽

Acute Leukemia ◽

Myelodysplastic Syndrome ◽

Median Survival ◽

Conflicts Of Interest ◽

Median Number ◽

Lymphocytic Leukemia ◽

Cancer Center ◽

Cell Transplant

Abstract Abstract 981 Acute leukemia (AL) and myelodysplastic syndrome (MDS) are uncommon in patients (pts) with CLL and have mainly been attributed with exposure to chemotherapy and radiotherapy. In contrast, CLL is frequently associated with second solid malignancies. Associations between AL, MDS and CLL have rarely been reported and large series of outcomes for such patients are lacking; available literature typically consists of studies with fewer than 10 such pts. We identified 95 pts (out of 8685 CLL pts) evaluated at MDACC between August ‘81 and August ‘10 who had a diagnosis (Dx) of CLL and were concurrently (n=5) or subsequently (n=90) diagnosed with AL (n=38) or MDS (n=57). The median age at CLL Dx was 60 (25–83) and at AL/MDS Dx 66 (41–85) yrs; 76% were male. The median follow up time from presentation to MDACC was 58 mo (7–191). There were 12 pts who had no prior CLL chemotherapy (Table). The median number of prior CLL chemotherapy regimens to AL and MDS Dx was 2 (0–9) and 1 (0–8), respectively. For pts who received 1 prior CLL treatment before transformation, 90% (34/38) received fludarabine-based therapy (26 FCR, 3 FC, 1 CFAR, 4 fludarabine monotherapy). The median times from CLL Dx to AL/MDS Dx, survival from CLL Dx, and overall survival from AL/MDS Dx are shown (Table). There currently are 11 living pts (AL n=4; MDS n=7), their median survival is 95 mo from CLL Dx and 27 mo from AL/MDS Dx. Seven pts underwent allogeneic stem cell transplant for AL/MDS, 3 are living.TablenPts with # Prior CLL TxMedian Time (mo)01≥2Time CLL Dx to AL/MDS DxSurvival from CLL DxSurvival from AL/MDS DxAL384142057655MDS578252467809.3 Of the 38 pts who developed AL, 33 were AML (FAB: 4 M0, 5 M1, 5 M2, 4 M4, 5 M5, 4 M6, 6 missing), 3 were ALL (1Ph+), 1 was biphenotypic, and 1 had extramedullary (bladder) AML. The median % bone marrow (BM) blasts at AL Dx was 40%; median WBC, HGB, and PLT were 5.1K/μl, 9.9 gm/dl, and 38K/μl, respectively. CLL was present in BM in 42% at AL Dx. Unfavorable AML karyotype was noted in 26 (68%) and intermediate-risk in 7 (18%) pts. CD7 was detected by flow cytometry in 6 AML pts. The median number of treatments for AL was 1 (0–4); 1 pt was untreated. The most common treatment was cytarabine-based (30 pts). Survival for pts with CD7 expression by AML blasts was 2 mo vs. 7 mo for pts without CD7 expression (p<.001). There was no association between # of prior CLL regimens, karyotype category, or presence of CLL at AL Dx and survival from AL. In the 57 pts diagnosed with MDS, all IPSS were represented: 6 low-, 15 Int-1-, 25 Int-2-, 7 high-risk, and 4 missing. The median % BM blast was 3%; and median ANC, HGB, and PLT were 1.27K/μl, 9.8 gm/dl, and 53K/μl, respectively at MDS Dx. CLL was present in the BM in 49% at MDS diagnosis. MDS karyotype was unfavorable in 36, intermediate in 6, and favorable in 12 pts (3 missing). The median number of treatments for MDS was 1(0–4); 9 pts were untreated. The most common treatments were hypomethylating agents (19 pts) and cytarabine-based regimens (11 pts). 10 pts with MDS subsequently transformed to AML; median time from MDS to AML transformation was 6.5 mo. Survival from MDS Dx was correlated with IPSS: 25 mo for low-, 10.2 mo for Int-1-, 6.7 mo for Int-2-, and 7.4 mo for high-risk (p=.003). In addition, pts who had no prior CLL chemotherapy had median survival of 37 mo vs. 9.7 mo for pts with 1 prior CLL treatment and 5.9 mo for those with ≥2 (p=.007). Pts who had favorable karyotype had superior survival (25 mo), compared to patients with intermediate (7 mo) or poor-risk (8 mo) karyotype (p=.002). There was no association between presence of CLL at MDS Dx and survival from MDS. Detailed analyses of prior CLL treatment and other risk factors for AL/MDS are ongoing as are comparisons of outcomes for pts with non-CLL associated secondary AL/MDS. In conclusion, outcomes for pts with CLL who are subsequently diagnosed with AL or MDS are poor; AL/MDS may occur in the absence of CLL chemotherapy. In pts who received 1 prior CLL treatment, the most common regimen was purine analogue combined with alkylating agent±mAb. Outcomes for AL in CLL are similar to reports for secondary, poor prognosis ALs. Survival from MDS was correlated with IPSS, karyotype, # of prior CLL regimens. Risk factors for AL/MDS are being assessed. Effective therapies for these pts are desperately needed. Disclosures: No relevant conflicts of interest to declare.

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Unsuccessful Cytogenetics and Outcomes in Acute Leukemia

Blood ◽

10.1182/blood-2018-99-110470 ◽

2018 ◽

Vol 132 (Supplement 1) ◽

pp. 2673-2673

Author(s):

Lauren Lee ◽

Helene Bruyere ◽

Michael J Barnett ◽

Raewyn Broady ◽

Donna L. Forrest ◽

...

Keyword(s):

Bone Marrow ◽

High Risk ◽

Acute Leukemia ◽

Conflicts Of Interest ◽

Lymphoblastic Leukemia ◽

White Blood Count ◽

Prognostic Impact ◽

Intermediate Risk ◽

Steroid Use ◽

High Risk Disease

Abstract Introduction: Cytogenetic features at diagnosis have significant independent prognostic impact in acute myeloid leukemia (AML) and acute lymphoblastic leukemia (ALL). Failed or unsuccessful cytogenetics (UC) is estimated to occur in 10% of AML cases and 25-30% of ALL cases (Grimwade, 2010; Pullarkat, 2008). Previous studies suggest worse outcomes in AML patients (pts) with UC, similar to pts with unfavorable karyotype with lower response rates to induction chemotherapy and poor 5-year (yr) survival rates (Medeiros, 2014; Lazarevic, 2015). Hydroxyurea (HU) and steroids are often given urgently for cytoreduction prior to obtaining cytogenetics. The effects of such pretreatment on rates of UC have not been studied previously. In this study, we compared clinical outcomes of acute leukemia pts with UC versus successful cytogenetics (SC) and determined whether the use of HU or steroids affects cytogenetics success rates. Methods: All pts <70 yrs with de novo acute leukemia (AML or ALL) with available diagnostic bone marrow and cytogenetics testing seen at the Leukemia/Bone Marrow Transplant (BMT) Program of British Columbia between January 2010 and December 2016 were included. Pertinent information was reviewed from the program database. Cytogenetic failure was defined by the presence of <10 metaphases with a normal karyotype in the absence of a clinically actionable FISH abnormality. Pts with SC were risk stratified based on NCCN guideline criteria (NCCN, 2018). Baseline features of pts with SC and UC were compared using Chi-squared and two-tailed t-testing. Overall survival (OS) was calculated from the date of initial diagnosis to the date of death from any cause. Disease free survival (DFS) was calculated from the date of attaining first complete remission (CR1) to the date of relapse or death from any cause. Survival outcomes were estimated using the Kaplan-Meier method, with p values determined using the log rank test. A p < 0.05 was considered significant. Results: We identified 654 cases of acute leukemia (AML N=515; ALL N=139). Of these, 39 (6%) had UC (AML N=16, 3%; ALL N=23, 17%). There was no difference in age at diagnosis between groups (UC vs SC, 46 vs 51 yrs, p=0.08). AML pts with UC had higher initial white blood count (WBC) at diagnosis (71 vs 34, p<0.001). No effect of WBC was seen in ALL pts with UC versus SC. HU and/or steroid use prior to cytogenetics was similar between UC and SC groups in both AML and ALL pts (UC vs SC, HU: 8% vs 12%, p=0.61; steroids: 5% vs 1%, p=0.07. Therapy with intensive induction was also similar between groups (UC vs SC, 92% vs 90%; p=1.00). 137 (27%) of AML pts with SC had favorable risk disease, 182 (37%) intermediate, and 180 (36%) high risk. In ALL pts with SC, 32 (28%) had standard risk, and 84 (72%) had high risk disease. Follow up time in UC and SC groups was similar (32 vs 27m, p=0.18). CR rates in AML pts with UC was 81%, which was similar to pts with intermediate risk disease (84%, p=0.72) and better than CR rates of 39% observed in high risk pts (p=0.03). Compared to pts with SC, AML pts with UC had similar 5-yr OS and DFS as pts with intermediate risk disease (5-yr OS 25% vs 37%, p=0.45; 5-yr DFS 28% vs 28%, p=0.84), superior survival to high risk pts (5-yr OS 25% vs 17%, p=0.01; 5-yr DFS 28% vs 13%, p=0.036), and inferior survival to favorable risk pts (5-yr OS 25% vs 68%, p=0.07, 5-yr DFS 28% vs 52%, p=0.008), Figure 1. CR rates in ALL pts with UC was 83% and not significantly different than standard (94%, p=0.22) or high risk pts (86%, p=0.74). Compared to pts with SC, ALL pts with UC had similar 5-yr OS and DFS to pts with standard and high risk disease (UC vs standard vs high; 5-yr OS 58% vs 51% (p=0.93) vs 55% (p=0.85); 5-yr DFS 50% vs 37% (p=0.86) vs 36% (p=0.27)). Subgroup analysis of UC pts demonstrated no difference in survival in UC pts receiving BMT (N=12) vs no BMT (N=27). UC pts with high WBC >20 (N=14) had inferior survival compared to those with WBC ≤ 20 (N=25) (5-yr OS 60% vs 29%, p=0.025; 5-yr DFS 52% vs 12%, p=0.013). Conclusions: Unsuccessful cytogenetics was more frequently observed in ALL as compared to AML pts, though at lower rates than reported in previous studies. HU and steroid use had no effect on the rates of cytogenetic success. In comparison to previous reports, UC in AML was not associated with inferior outcomes, and survival was similar to intermediate risk pts. High initial WBC count was prognostic in pts with UC, and further studies are warranted to evaluate factors that affect outcomes in pts with UC. Disclosures No relevant conflicts of interest to declare.

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Haploidentical Transplantation Using Double Source of Hematopoietic Stem Cells and Post-Transplant Cyclophosphamide for Acute Leukemias

Blood ◽

10.1182/blood-2019-130876 ◽

2019 ◽

Vol 134 (Supplement_1) ◽

pp. 5728-5728

Author(s):

Ana Marcela Rojas Fonseca-Hial ◽

Katya Parisio ◽

José Salvador Rodrigues de Oliveira

Keyword(s):

Stem Cells ◽

Bone Marrow ◽

High Risk ◽

Acute Leukemia ◽

Acute Gvhd ◽

Conflicts Of Interest ◽

Lymphoblastic Leukemia ◽

Acute Leukemias ◽

Hematopoietic Stem ◽

Post Transplant

Allogeneic stem cell transplantation (allo-SCT) represents a curative option for intermediate- and high-risk acute leukemias (AL). The number of unmanipulated haploidentical allo-SCT (haplo-SCT) is increasingly used with favorable outcomes. Incidence of graft-versus-host disease (GvHD) in haploidentical bone marrow (BM) transplants using post-transplant cyclophosphamide (PTCy) is low, counterbalanced by an excess in disease recurrence; and acute GvHD using mobilized peripheral blood stem cells (PBSC) ranges between 30% and 40%. The ultimate choice of graft source depends on the design of the full transplantation package based on transplantation center experience. We conducted a retrospective analysis of 32 patients (59% male), who received an haplo-PTCy with double source of stem cells, G-CSF primed bone marrow plus G-CSF-mobilized PBSC, for high-risk or advanced acute leukemia in two Brazilian centers, Hospital Santa Marcelina (n=23) and Hospital São Paulo (n=9), from 2013 to 2019. The median age patients were 27.5 years (range 17-60 years). Median disease time before haplo-PTCy was 8.9 months (3.6-108). There were 13 acute myeloid leukemia (AML), 17 acute lymphoblastic leukemia (ALL), one mixed phenotype acute leukemia and one dendritic cell leukemia. 6/17 ALL were Ph1 positive. 34% of the patients received 2 treatment protocols to achieve CR and 12.5% had submitted to more than two treatments. So, at the time of transplant 75% (n=24) was in first CR (CR1) although one (3%) patient was minimal residual disease (MRD) positive and six (18.7%) there were no MRD available. The others patients (n=8, 25%) were on second or third CR. The HCT-CI comorbidities was ≥ 3 in two patients, and there were 15 patients (46%) with carbapenem-resistant gram-negative bacilli (CRGNB) colonization before transplant. Panel reactive antibody was positive in two patients. The donor was a sibling in 68.7% (n=22), father, mother and child in two (6%), three (9%) and five (15%) patients, respectively. The conditioning was reduced intensity (RIC) in 87.5% (n=28) patients, with fludarabine, cyclophosphamide and total body irradiation (TBI) 200 cGy. After conditioning, patients received G-CSF primed bone marrow grafts in combination with PBSC no ex-vivo T cells depleted, and cyclophosphamide 50 mg/Kg/day IV on days +3 and +4 post-transplant, as well as GVHD prophylaxis. Six (18.7%) patients died for sepsis before 60 days (10 to 58 days), all had had CRGNB before transplant, four those ones with no grafting, died from days +10 to +19. Acute GvHD grade III-IV was observed in two patients, who died at +48 and +95 days. High mortality related to transplant (TRM) was observed considering all patients. CRGNB was a determining factor in these early deaths. If we excluded all CRGNB patients of this study the mortality could be 11% (2 patients with GVHD in 17 patients transplanted). Four patients (16%) has severe cGvHD. Nine patients (37%) relapsed in two years. Two years OS and DFS were 40% and 37.5%, respectively. In conclusion, with a median follow-up of 2 years, haplo-PTCy with double source leads to 40% overall survival in 32 patients with high-risk advanced acute leukemia, with 16% (n=2) being in treatment for cGvHD. The causes of death were relapse 43% (n=7), early sepsis in patients with CRGNB colonization 37.5% (n=6), grade IV acute GvHD in 12,5% (n=2), and one patient died for pneumonia community at D+285. Our data suggests that haplo-PTCY double source is a feasible option in these cases. However, CRGNB colonization in aggressive disease is the main factor that should be considered as exclusion for haplo-SCT in development countries. Disclosures No relevant conflicts of interest to declare.

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Pre-Emptive Therapy with IFN-α-2b for Acute Leukemia Patients with High Risk of Relapsing Tendency Post Allo-HSCT

Blood ◽

10.1182/blood.v128.22.2250.2250 ◽

2016 ◽

Vol 128 (22) ◽

pp. 2250-2250

Author(s):

XiaoWen Tang ◽

Xiaoji Lin ◽

Aijing Wang ◽

Feng Chen ◽

Xiao Ma ◽

...

Keyword(s):

Survival Rate ◽

High Risk ◽

Acute Leukemia ◽

Median Time ◽

Conflicts Of Interest ◽

Disease Free Survival ◽

Hematopoietic Stem ◽

Free Survival ◽

Donor Chimerism ◽

Significant Difference

Abstract Objective: To determine the efficacy and safety of IFN-α-2b pre-emptive therapy for acute leukemia(AL) patients with relapsing tendencies after allogeneic hematopoietic stem cell transplantation (allo-HSCT). Methods: Retrospectively analyzed 986 acute leukemia patients undergoing allo-HSCT from Jan ,2006 to Mar ,2014 in our hospital. After allo-HSCT, 986 AL patients were periodically monitored the minimal residual disease(MRD) including: bone marrow smear, leukemia-associated immunophenotype (LAIP), leukemia specific or related fusion genes, and donor chimerism through multi-parameter detection to evaluate disease status. Patients were given IFN- a -2b 3 million units / day by subcutaneous injection for preemptive treatment once a relapse tendency was detected, such as: increasing proportion of blast in bone marrowbetween 3-5%, or MRD>1.0×10-3, or leukemia specific fusion gene transfrom negative to positive, or dynamic incressing copy number of WT1 more than 200 copies/104 abl, or decreasing of donor chimerism(≤ 90%). There were 98 patients who presented increasing tendency of MRD and were enrolled in this study. Among them, 31 patients received IFN-α-2b pre-emptive therapy, and 67 patients received non-IFN-α-2b therapy such as: withdraw immunosupressant, traditional DLI or DC-CIK immunotherapy. Results: There were no significant differences in disease characteristics between two groups. For the 31 patients who received IFN-α-2b pre-emptive therapy(IFN group), the median time of IFN-αtreatment was 60 days (range: 5-720 days), Twenty five patients had responsed to the treatment without progressing to hematological relapse (response rate 80.6%). 2 patients developed to hematological relapse again after temporary response; 3 patients had no response and eventually progressed to hematological relapse. Regarding 67patients who received non-IFN-α-2b therapy(non IFN group), 22 patients responsed to the treatment (RR 32.8%), 45 patients failed to the treatment and progressed to hematological relapse at a median time of 35 (range: 6-940) days, There was significant difference of RR between two group(P=0.000) . 31 patients of IFN group tolerate well and no patient terminated therapy due to side effects. During the treatment of IFN, 18 patients(58.1%) developed GVHD: 6 patients (19.4%) with aGVHD and 14 (45.2%) with limited cGVHD . The median follow-up time was 21 (4.5-78.5) months. 22 of 31 cases of IFN group maintained disease-free survival. The 5-year overall survival rate (OS) and the leukemia-free survival rate (LFS) of IFN group were 47.0%±13.9% and 38.7%±13.1% respectively. However, the 5-yr OS and LFS of non IFN group were 14.5%±10.7% and12.5%±9.4% respectively.The difference were significantly (P=0.000,P=0.002 respectively). Patients with GVHD had significantly better response than patients without GVHD (88.9% vs 53.8%, P=0.043, P <0.05). Conclusion: IFN-α-2b pre-emptive therapy can effectively prevent high-risk patients with relapsing tendencies for disease progression post allo-HSCT. Further large-scale investigation is warranted. Disclosures No relevant conflicts of interest to declare.

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Mutational Characteristics and Changing Pattern from Idiopathic Cytopenia of Undetermined Significance to High-Risk Myelodysplastic Syndrome Stratified By IPSS-R

Blood ◽

10.1182/blood-2019-125236 ◽

2019 ◽

Vol 134 (Supplement_1) ◽

pp. 3009-3009

Author(s):

Eun-Ji Choi ◽

Young-Uk Cho ◽

Seongsoo Jang ◽

Chan-jeoung Park ◽

Han-Seung Park ◽

...

Keyword(s):

Bone Marrow ◽

High Risk ◽

Myelodysplastic Syndrome ◽

Rna Splicing ◽

Conflicts Of Interest ◽

Low Risk ◽

International Prognostic Scoring System ◽

Intermediate Risk ◽

Sequencing Data ◽

Undetermined Significance

Background: Unexplained cytopenia comprises a spectrum of hematological diseases from idiopathic cytopenia of undetermined significance (ICUS) to myelodysplastic syndrome (MDS). Revised International Prognostic Scoring System (IPSS-R) is the standard tool to assess risk in MDS. Here, we investigated the occurrence, characteristics, and changing pattern of mutations in patients with ICUS and MDS stratified by IPSS-R score. Methods: A total of 211 patients were enrolled: 73 with ICUS and 138 with MDS. We analyzed the sequencing data of a targeted gene panel assay covering 141 genes using the MiSeqDx platform (Illumina). The lower limit of variant allele frequency (VAF) was set to 2.0% of mutant allele reads. Bone marrow components were assessed for the revised diagnosis according to the 2016 WHO classification. Lower-risk (LR) MDS was defined as those cases with very low- or low-risk MDS according to the IPSS-R. Higher-risk (HR) MDS was defined as those cases with high- or very high-risk MDS according to the IPSS-R. Results: Patients with ICUS were classified as very low-risk (39.7%), low-risk (54.8%), and intermediate-risk (5.5%) according to the IPSS-R. Patients with MDS were classified as LR (35.5%), intermediate-risk (30.4%), and HR (34.1%). In the ICUS, 28 (38.4%) patients carried at least one mutation in the recurrently mutated genes in MDS (MDS mutation). The most commonly mutated genes were DNMT3A (11.0%), followed by TET2 (9.6%), BCOR (4.1%), and U2AF1, SRSF2, IDH1 and ETV6 (2.7% for each). IPSS-R classification was not associated with mutational VAF and the number of mutations in ICUS. In the 49 LR MDS, 28 (57.1%) patients carried at least one MDS mutation. The most commonly mutated genes were SF3B1 (20.4%), followed by TET2 (12.2%), U2AF1 (10.2%), DNMT3A (10.2%), ASXL1 (10.2%), and BCOR (6.1%). Higher VAF and number of mutations were observed in LR MDS compared to ICUS patients. In the 42 intermediate-risk MDS, 27 (64.3%) patients carried at least one MDS mutation. The most commonly mutated genes were ASXL1 (23.8%), followed by TET2 (21.4%), RUNX1 (16.7%), U2AF1 (14.3%), DNMT3A (14.3%), SF3B1 (9.5%), and SRSF2, BCOR, STAG2 and CBL (7.1% for each). In the 47 HR MDS, 36 (76.6%) patients carried at least one MDS mutation. The most commonly mutated genes were TET2 (25.5%), followed by DNMT3A (14.9%), TP53 (14.9%), RUNX1 (12.8%), U2AF1 (10.6%), ASXL1 (10.6%), and SRSF2 and KRAS (6.4% for each). As the disease progressed, VAF and number of the MDS mutations gradually increased, and mutations involving RNA splicing, histone modification, transcription factor or p53 pathway had a trend for increasing frequency. Specifically, ASXL1, TP53, and RUNX1 mutations were the most striking features in patients with advanced stage of the disease. Cohesin mutations were not detected in ICUS, whereas these mutations were detected at a relatively high frequency in HR MDS. Our data were summarized in Table 1. Conclusions: We demonstrate that on disease progression, MDS mutations are increased in number as well as are expanded in size. Furthermore, a subset of mutations tends to be enriched for intermediate- to HR MDS. The results of this study can aid both diagnostic and prognostic stratification in patients with unexpected cytopenia. In particular, characterization of MDS mutations can be useful in refining bone marrow diagnosis in challenging situations such as distinguishing LR MDS from ICUS. 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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