Clinical Utility of Morphological Evaluation of Day 14 Bone Marrow Biopsies in Acute Myeloid Leukemia Patients Undergoing Standard Induction Chemotherapy: Time to Change Practice?

Abstract Introduction Early bone marrow (BM) evaluation (during aplasia or at “day 14” (D14)) in patients with AML undergoing conventional induction therapy has been adopted from clinical practice in pediatric acute lymphoblastic leukemia (ALL). While it has been shown that early persistence of AML correlates with decreased complete remission (CR) rates and overall survival (OS), unlike in ALL, there are no data to indicate that early initiation of re-induction therapy based on these findings will positively influence outcome. In fact, early re-induction, especially in older patients, may increase morbidity and mortality from prolonged cytopenias, infectious complications, and longer hospital stays. Moreover, it can be challenging to determine the nature of scattered blasts identified in a hypocellular BM at D14, as they may represent normal recovering marrow elements or malignant blasts. Even if malignant, the chemosensitivityof these cells will only be fully determined by later assessment of the BM at the time of expected count recovery (“day 28”). For these reasons, early re-induction therapy may not be advisable. In this retrospective study, we sought to evaluate the validity of D14 BM assessments as post-therapy prognostication to guide treatment decisions in AML. Methods We conducted a retrospective institutional study (2006-2014) of AML patients undergoing routine induction chemotherapy where diagnostic, interim (around D14) and recovery (D21-42) BM evaluations were available for review. Clinical information and pathology data were retrieved from our institutional database. Responses at D14 were categorized morphologically into three categories: optimal response (OR, blasts ≤5%), indeterminate response (IR, blasts 6-19%), and residual leukemia (RL, blasts ≥20% or a relative decrease in blast count from baseline of <20%). Published response criteria were used to define responses at marrow recovery. Suboptimal response (SOR) at D14 was defined as either IR or RL during the assessment period. Mann-Whitney's U test was used to compare non-normally distributed variables. The Fisher's exact test was employed to assess for associations between response to treatment at D14 and likelihood of recovering in CR. The sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of a D14 BM to predict CR were calculated for patients that were observed without re-induction. Results Evaluable patients (n=98) had a mean age of 51 years (20-73), and 45% were male. The median BM blast percentages at diagnosis, D14 and recovery were respectively 54.5%, 0% and 2.5% (Figure 1). There was a significantly greater absolute decrease in blast percentage from diagnosis to D14 in patients who recovered in CR compared to those who did not achieve CR (median: 53.5% vs 23.0%, P = 0.001). In patients that got early re-induction therapy for SOR at D14, the relative differential in baseline and D14 BM blasts was significantly lower compared to patients with D14 SOR who did not get re-induction therapy (median: 21.8% vs 77.8%, P=0.004) Ninety patients did not receive early re-induction therapy. Of these, 86 (95.6%) achieved CR and 4 patients (4.4%) recovered counts with residual leukemia. Fourteen (14.3%) patients were classified as SOR at D14. Of these, 6 (6.7%) did not receive re-induction therapy and 4 of these 6 patients (67%) achieved a CR. Eight patients received early re-induction therapy based on SOR at D14 (IR = 2, RL = 6); of these, 4 patients (50%) achieved CR at count recovery. Achieving an OR at D14 was predictive of achieving CR at recovery (sensitivity = 95.3%, PPV = 97.6%). However, not achieving an OR at D14 had low specificity (50%) and NPV (33.3%) for achieving CR (P = 0.021). Conclusions Our results indicate that a SOR at the D14 BM evaluation does not uniformly identify patients with primary induction failure (low NPV) and should not be used to dictate the timing of re-induction therapy. We confirmed the PPV of achieving an OR at D14 as previously reported, but we argue that no additional prognostic data is provided by an OR at D14, beyond what can already be predicted by pre-treatment variables (e.g., age and chromosomal abnormalities). We suggest that the D14 BM should be omitted from the routine evaluation of AML patients during induction therapy outside the context of a clinical trial. Figure 1 Figure 1. Progression and percentage of blasts at diagnosis, day 14 and recovery assessments (n = 98). Disclosures No relevant conflicts of interest to declare.

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Probability of Eventual CR After Course 1 of Induction Therapy for Newly-Diagnosed AML As a Function of Speed of Neutrophil and Platelet Recovery

Blood ◽

10.1182/blood.v118.21.1498.1498 ◽

2011 ◽

Vol 118 (21) ◽

pp. 1498-1498

Author(s):

Laura F Newell ◽

Ravinder K Sandhu ◽

Pamela S Becker ◽

John M. Pagel ◽

Paul C. Hendrie ◽

...

Keyword(s):

Bone Marrow ◽

Induction Chemotherapy ◽

Induction Therapy ◽

Conflicts Of Interest ◽

Residual Disease ◽

Cell Transplant ◽

Specific Patient ◽

Platelet Recovery ◽

Hematologic Disorder ◽

Count Recovery

Abstract Abstract 1498 Background: After the initial induction chemotherapy for AML, physicians are often reluctant to offer further treatment if the bone marrow has <5% blasts, even in the setting of persistently low neutrophil (ANC) and/or platelet (plt) counts. This reluctance would seem to presume that complete remission (CR) might still occur in these patients without further treatment. However, it has been shown that there is an inverse relation between (A) time to achievement of CR after course 1 of induction therapy and subsequent survival1 and (B) level of ANC and plt count at CR and subsequent relapse-free survival2, with (A) and (B) independent of each other and of cytogenetics and antecedent hematologic disorder. Because patients often present with low ANC and plt counts, these data suggested that their persistence was a clinical indicator of minimal residual disease (MRD) in the marrow, and prompted us to examine whether slow ANC and/or plt recovery despite a marrow with <5% blasts affected the probability of subsequent CR. Methods: We included patients who, at various times after course 1 of induction chemotherapy, had not achieved both ANC >500 and plt >50,000, despite a bone marrow in the prior week with <5% blasts by morphology and flow cytometry. We originally selected these times to be day 28, day 35, day 42, and day 49; however because patients were often treated as outpatients, counts at these specific days were not uniformly available, and thus “day 28” included days 21–28, etc. A variety of “intensive” induction regimens were used. We examined whether incomplete count recovery, defined as (a) neither ANC >500 nor plt >50,000 or (b) either ANC >500 or plt >50,000 but not both, affected eventual CR rates as a function of days from induction chemotherapy. Results: Seventy-five patients were eligible for analysis, including 3 patients with blood and marrow assessments done at 2 time points (ANC <500 and plt <50,000 at days 28/42, 35/42, and 35/42). Median patient age was 53 years (range 18–78), with an antecedent hematologic disorder seen in 28 patients (37%). By SWOG cytogenetic risk categories, 12 patients (16%) had favorable, 35 (47%) intermediate, 21 (28%) unfavorable, and 7 (9%) unknown risk. Eventual course 1 CR rates for the specific patient groups are indicated below, with only the first time point included for each of the above 3 patients with multiple evaluations. At day 28, patients with ANC <500 and plt<50,000 were much less likely to obtain CR than patients with either ANC >500 or plt>50,000 (31% vs. 85%, p=0.001). As time from start of treatment increased without rise in ANC to >500 and plt to >50,000, the probability of subsequent CR decreased (p=0.03) despite a marrow with < 5% blasts by both morphologic and flow assessment. Conclusion: Persistence of ANC <500 and/or plt <50,000, despite the presence of <5% bone marrow blasts, is predictive of low eventual CR rates after induction chemotherapy, with the likelihood of obtaining CR decreasing with greater time from start of induction chemotherapy. We are particularly interested in seeing whether blood count recovery data adds information to such pretreatment predictors of CR as cytogenetics, age, and presence of antecedent hematologic disorder, and in examining the relation between sluggish count recovery and induction regimen, marrow cellularity, and degree of MRD by flow. However, our data suggests that optimism regarding the possibility of CR without further therapy (e.g. hematopoietic cell transplant) should wane in the setting of slow ANC and/or platelet recovery after course 1 of induction chemotherapy. Disclosures: No relevant conflicts of interest to declare.

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Correlation of Erythropoietin Stimulating Agents (ESAs) with the Post-Therapy Micro-Vessel Density (MVD) in Newly Diagnosed Myeloma Patients: a Possible Mechanism of ESAs Association with Reduced Survival Rates.

Blood ◽

10.1182/blood.v114.22.4873.4873 ◽

2009 ◽

Vol 114 (22) ◽

pp. 4873-4873

Author(s):

Eirini Katodritou ◽

Evangelos Terpos ◽

Vassiliki Kaloutsi ◽

Evgenia Verrou ◽

Vassiliki Gastari ◽

...

Keyword(s):

Bone Marrow ◽

Multivariate Analysis ◽

Conflicts Of Interest ◽

Independent Predictor ◽

Survival Rates ◽

Response To Treatment ◽

Newly Diagnosed ◽

Bone Marrow Biopsies ◽

Group Post ◽

Post Therapy

Abstract Abstract 4873 Angiogenesis plays a significant role in the biology of multiple myeloma (MM). Erythropoiesis stimulating agents (ESAs) have been recently associated with reduced survival in a subset of cancer patients who receive ESAs, including MM but the etiology for this correlation has not been sufficiently explored. It is known that the endothelial cells produce angiogenic factors, promote the growth and survival of MM cells and carry erythropoietin receptors which in hypoxic conditions they transport the signal for their own proliferation and expansion under the influence of the endogenous erythropoietin. The aim of this study was to investigate the possible impact of ESAs administration on post-therapy angiogenesis. We studied 84 newly diagnosed MM patients (47M/37F; median age: 65 years, range: 39-82 years) who underwent conventional anti-myeloma therapy: 62 patients received VAD (53 of whom within the context of the randomized study VAD vs. TVAD, conducted by the Greek Myeloma Study Group) and 22 patients received MP. Fifty-two patients received ESAs for at least 8 weeks (ESA group), while 32 did not receive ESA (non-ESA group). MVD was assessed in bone marrow biopsies at baseline and at the time of best response by using monoclonal antibodies targeting CD34. The number of microvessels expressing the CD34 antibody was counted by two experienced pathologists through a grid at a magnification of 400x and was finally divided to the number of the high power fields used for screening the whole marrow surface. The counts were finally expressed as number of vessels per mm2 area of the involved marrow. Fifteen individuals with normal findings in the bone marrow were used as controls. Furthermore, the following cytokines that are involved in the angiogenesis process in MM were measured in the serum of both patients and controls on the day of the trephine biopsy performance: VEGF, bFGF, TGF-b, IL-6, soluble IL-6R (sIL-6R), IL-1b and TNF-α, using an ELISA methodology (R&D, Minneapolis, MN, USA). Patients characteristics between the ESA and non-ESA groups at baseline were well balanced except of Hb which was, as expected, significantly lower in the ESA-group (p<0.001). The median follow-up was 84 months (range 5-154). The median number of baseline MVD in the ESA group was 18.5/mm2 (range: 1-29.3) and in the non-ESA group 17.7/mm2 (range: 2-28.5; p=NS) and was higher compared to controls (median 1.2/mm2, range: 0-9; p<0.001 for both comparisons). The post-therapy MVD in the two groups were 16/mm2 (range: 1.8-26) for ESA and 12.8/mm2 (range: 2-29) for non-ESA group, respectively (p=0.03); the % reduction between baseline and post-therapy value was significantly greater in the non-ESA group (non-ESA group: 24.9%, range -36% to +76.6%, ESA group: 14.5%, range -410% to +85.6%, p=0.04). Myeloma patients before treatment had increased serum levels of VEGF (p=0.029), bFGF (p=0.012), IL-6 (p=0.007) and sIL-6R (p=0.047) compared to controls and showed no differences between ESA and non-ESA groups and no alterations post-therapy. Post-therapy, MVD positively correlated with the baseline MVD and baseline β2-microglobulin and negatively correlated with baseline Hb, response to treatment and PFS (p<0.05). In the ESA group but not in the non-ESA group, post-therapy MVD was negatively correlated with response to treatment (p<0.05). In the multivariate analysis, age and post-therapy MVD were the only independent predictors for OS (p=0.04 and p=0.005, respectively; Hz ratio for post-therapy MVD: 1.2, 95% CI: 1.04-1.28). In the ESA group, the multivariate analysis showed that post-therapy MVD >14/mm2 was the only independent predictor for survival (p=0.04; Hz ratio 0.136, 95% CI: 0.02-0.9) whereas in the non-ESA group, post-therapy MVD did not show any significant prognostic value, either used as a continuous or a dichotomous variable. The median PFS for patients with post-therapy MVD >14/mm2, was 13 months (95% CI: 8.5-17.5) and for patients with MVD <14/mm2 was 33 months (95% CI: 25-41; p=0.001). The median OS in patients with MVD >14/mm2 was 37 months (95% CI: 29-45) and for those with MVD <14/mm2 was 63 months (95% CI: 50-75; p=0.04). These results suggest that ESAs may negatively influence the post-therapy MVD. In the ESA group MVD negatively correlated with disease response and MVD >14/mm2 was the only independent predictor for OS. These findings could partially explain the possible association of ESAs with reduced survival rates in newly diagnosed MM patients. Prospective studies are required in order to fully investigate this current issue. Disclosures No relevant conflicts of interest to declare.

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Is Time of the Essence in Adult Acute Myeloid Leukemia (AML)? Time to Blast Clearance and Time to Induction Therapy Fail to Predict Overall Survival (OS).

Blood ◽

10.1182/blood.v114.22.1617.1617 ◽

2009 ◽

Vol 114 (22) ◽

pp. 1617-1617

Author(s):

Holbrook E Kohrt ◽

Samit Patel ◽

Michelle Ho ◽

Terri Owen ◽

Ravindra Majeti ◽

...

Keyword(s):

Induction Chemotherapy ◽

Induction Therapy ◽

Mayo Clinic ◽

Conflicts Of Interest ◽

Lymphoblastic Leukemia ◽

Univariate Analysis ◽

Prognostic Significance ◽

Cleveland Clinic ◽

Risk Groups ◽

Adult Patients

Abstract Abstract 1617 Poster Board I-643 Background A rapid decline of circulating blasts in response to induction therapy is one of the most important prognostic factors of clinical outcome in childhood acute lymphoblastic leukemia. However, the prognostic significance of time to blast clearance in adult AML has not been well-established. The Mayo Clinic recently reported improved OS with early clearance ('3 days) of peripheral blood (PB) blasts among 86 adult patients with AML. In a separate series, age is suggested to modify the effect of time with shorter interval from diagnosis to induction therapy (TDT) predicting improved OS in younger but not older AML patients. We retrospectively reviewed the Stanford Leukemia Database to validate the prognostic relevance of time and age as a putative effect modifier with respect to OS in AML. Methods From 1993 to 2008 outcomes of 1,909 adult patients with leukemia were reviewed to select eligible patients with previously untreated AML (non-acute promyelocytic leukemia) having received cytarabine-based induction regimens. We defined the day of PB blast clearance (the first day after initiating induction chemotherapy that PB blasts were absent), and three “blast risk groups” (good, intermediate and poor, according to PB blast clearance on or before day 3, on days 4 or 5, or on day 6 or beyond, respectively) identical to the Mayo Clinic model. A 100 cell manual slide differential count was evaluated from the first day of induction through nadir with PB blasts enumerated unless the WBC was less than 0.5 ×109/L. For purposes of TDT analysis, patients receiving therapy on day of diagnosis were excluded (24 patients) as performed in the Cleveland Clinic-MD Anderson (CC-MDA) model. We defined delayed versus immediate treatment (delayed meaning more than 5 days from day of diagnosis to first day of induction therapy) identical to the CC-MDA model. Results Among 333 patients (55% males; median age 53y, range 18-88, including 224 patients<60y) with previously untreated AML, the median and range of white blood cell count (WBC), PB blast percent, and TDT were 10 × 109/L (range: 0.1–332), 23.0% (range: 0–98), and 4 days (range: 0-91) respectively. Karyotype was classified as favorable, intermediate and unfavorable in 9.7%, 59.3% and 31% of cases, respectively. At the time of analysis, 56% had died, primarily of relapse. Median OS was 59 weeks (range: 0-558) in all patients, 76.2 (range: 3.4-558) and 38.3 (range: 0-342) weeks in patients younger than 60 years, and older patients, respectively. The median time to PB blast clearance was six days (range: 1– >11). The distribution of good, intermediate and poor blast risk groups was 28.3%, 26.1%, and 45.6%, without significantly different median OS of 63.8, 56.2, and 51.6 weeks, respectively (Fig 1, p=0.61). In univariate analysis there was no relationship between TDT and OS among all patients as a continuous variable (p=0.791) or classified as delayed versus immediate treatment (Fig 2, p=0.92). When stratified by older and younger AML patients, age did not modify the effect. Conclusion In adults with non-APL AML, both TDT and PB blast clearance after induction chemotherapy with cytarabine-based regimens failed to predict OS. Current practice standards should not be modified until further studies validate the significance of time from diagnosis to treatment and to clearance of circulating blasts. Disclosures No relevant conflicts of interest to declare.

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Early T Acute Lymphoblastic Leukemia in Childhood: Prevalence and Clinical Characteristics

Blood ◽

10.1182/blood.v124.21.3656.3656 ◽

2014 ◽

Vol 124 (21) ◽

pp. 3656-3656

Author(s):

Jorge Gabriel Rossi ◽

Carolina Carrara ◽

Patricia L. Rubio ◽

Cristina N. Alonso ◽

Andrea Bernasconi ◽

...

Keyword(s):

Chromosomal Abnormalities ◽

Conflicts Of Interest ◽

Lymphoblastic Leukemia ◽

Poor Response ◽

Early Response ◽

Response To Treatment ◽

Differentiation Potential ◽

Lineage Switch ◽

Conventional Cytogenetics

Abstract Background: Early T precursor ALL has been defined as a poor prognosis subtype, characterized phenotypically by absence of CD1a and CD8, CD5 weak expression and presence of at least one myeloid and progenitor cell marker. Objectives: Our aims were to identify Early T-ALL among our T ALL cases, based on the characteristic phenotype and thus evaluate the prevalence, biological characteristics and outcome of this particular subset of T-ALL Methods: From April ’94 to December ’13, 197 T-ALL cases were diagnosed and 20 of them showed the typical Early T marker profile by flow cytometry (FC). Conventional cytogenetics, FISH and RT-PCR studies were performed according to standard techniques. Clonality assessment for TRG, TRB, TRD, IGH and IGK was performed by PCR (Biomed-2), heteroduplex and sequencing. Results: Sex distribution was: 16 males and 4 females; median of age: 7.9 (range: 0.3-16.6) years; median WBC: 14.9 (range: 0.6-254.0) x109/L. All but one case expressed CD34, 70% HLA-DR, 61% CD117 and 50% TdT. The most frequently expressed myeloid markers were: CD33 (85%) and CD13 (55%). Three cases expressed g/d TCR. Chromosomal abnormalities were detected in 14 of 16 evaluated cases, in 5 of them compromising 12p13 region. TCR/IgH rearrangements were detected in 63% (10/16). FLT3-ITD mutations were found in 14 % (2/14). Patients were treated with BFM-based ALL schedules and were stratified as Intermediate Risk ALL (n: 7) and High Risk ALL (n: 13) according to protocol criteria. Early response to treatment was poor in 16 cases: 6 presented poor response to prednisone (day 8), 3 MRD >10%, 5 presented bone marrow M2-M3 and 2 non response. Seventeen cases (85%) achieved CR on day 33 and 2 achieved CR later. Five patients underwent HSCT in first CR. Three patients relapsed at 5, 6 and 65 months from diagnosis and one showed lineage switch to M5-AML at 12 months from CR. Three pts died in CR (2 after HSCT and 1 patient with primary immunodeficiency due to pneumonia) and one is in palliative care. Twelve patients remain in CR with a median follow-up of 54 (r: 8-144) months. Conclusions: The prevalence of Early T precursor phenotype within T ALL was 10.5% in our setting. The most frequent progenitor marker was CD34 and CD33 among myeloid markers. Of note, translocations involving 12p13 region were found in 5 patients. Sixty percent of patients remain disease free, although longer follow-up is needed in order to define prognosis of this group in our cohort of patients. The lineage switch case supports the notion of the myeloid differentiation potential of these blasts. Disclosures No relevant conflicts of interest to declare.

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P-ERK1/2 Is a Predictive Factor of Response to ESA Treatment in Myelodysplastic Syndromes.

Blood ◽

10.1182/blood.v114.22.294.294 ◽

2009 ◽

Vol 114 (22) ◽

pp. 294-294

Author(s):

Emilie Frisan ◽

Patrycja Pawlikowska ◽

Cécile Pierre-Eugène ◽

Valérie Bardet ◽

Laure Gibault ◽

...

Keyword(s):

Bone Marrow ◽

Flow Cytometry ◽

Myelodysplastic Syndromes ◽

Conflicts Of Interest ◽

Marrow Cell ◽

Wilcoxon Test ◽

Response To Treatment ◽

Erythroid Cell ◽

Erythroid Progenitors ◽

Bone Marrow Biopsies

Abstract Abstract 294 Endogenous serum erythropoietin (sEPO) less than 500UI/L and a transfusion requirement lower than 2 units per month are the best predictive factors for response to treatment by erythropoiesis-stimulating agents (ESA) in low/int-1 myelodysplastic syndromes (MDS). However, the highest response rate hardly reaches 60% suggesting that other factors may influence the response. To investigate the biological signature of response to ESA, we enrolled 100 low/int-1 MDS patients in a prospective study of erythropoiesis at diagnosis before they were treated with ESA. According to the IWG 2006 criteria, 43 patients were non-responders. These patients had significantly higher serum EPO level, higher number of transfusion per month, and lower number of bone marrow-deriving BFU-E and CFU-E than responders. Analysis of CD34+-deriving erythroid progenitors by in vitro liquid culture, demonstrated that all MDS patients (n=54) had an increased apoptosis and a delayed expression of erythroid marker, glycophorin A (GPA). A collapse of EPO-induced DNA synthesis was observed in non-responders, while EPO-dependent erythroid cell differentiation and survival to Fas-induced apoptosis was equivalent in the two groups. Thus, non-responders exhibited an early and isolated default in EPO-induced cell proliferation, suggesting a defect in EPO-R signaling. Immunofluorescence to p-ERK1/2 before and after EPO-R stimulation in immature erythroblasts was negative in 6/8 non-responders, and positive in all 11 responders. Immunohistochemistry to p-ERK1/2 on bone marrow biopsies in 5 non-responders was negative and positive in immature cells in 4 responders. By flow cytometry, p-ERK1/2 expression in the CD71+/GPA− bone marrow cell fraction corresponding to immature erythroblasts (n=30) was significantly lower in non-responders (n=16) than in responders (n=14; Wilcoxon-test: p<0.0001). Receiver operator curve (ROC) analysis of the flow cytometry test demonstrated a good predictive value for the response to ESA with a 0.96 area under the curve (AUC) [95%CI: 0.89 – 1.00]. ROC were also constructed for BFU-E number, serum EPO level, and number of transfusion per month and the AUC were computed. p-ERK1/2 was equivalent to BFU-E and superior to serum EPO level or number of transfusion in predicting the response to ESA. Although requiring validation in a larger cohort, these results suggest that p-ERK1/2 is a ready tool available for the prediction of response to ESA in MDS patients. Disclosures: No relevant conflicts of interest to declare.

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A New Model to Predict Remission Status in Acute Myeloid Leukemia (AML) Patients Based on Day 14 Bone Marrow (D14 BM) Biopsy

Blood ◽

10.1182/blood.v126.23.3852.3852 ◽

2015 ◽

Vol 126 (23) ◽

pp. 3852-3852

Author(s):

Maxim Norkin ◽

Myron Chang ◽

An Qi ◽

Helen Leather ◽

Lakshmikanth Katragadda ◽

...

Keyword(s):

Bone Marrow ◽

Prognostic Factors ◽

Complete Remission ◽

Prediction Model ◽

Induction Chemotherapy ◽

Predictive Value ◽

Clinical Laboratory ◽

P Value ◽

Persistent Disease ◽

Count Recovery

Abstract Introduction: Although day D14 BM after initiation of induction chemotherapy is accepted standard of care in AML patients (pts), it has poor predictive value and low accuracy for refractory disease. Currently there are no established clinical and laboratory factors which accurately predict which AML pts with positive D14 BM require immediate reduction chemotherapy for persistent disease and which pts achieve complete remission (CR) Methods: We retrospectively analyzed pretreatment factors and post-induction response in AML pts to determine if clinical and laboratory characteristics can improve the predictive value of the D14 BM evaluation. Results: Among 297 pts with D14 BM biopsies, 183 pts (61%) had positive D14 BM (either ≥ 5% myeloblasts or cellularity ≥ 20%). Of those with a positive D14 BM biopsy, no reinduction chemotherapy was given to 89 pts of which 57 (64%) pts had persistent disease at count recovery and 32 (36%) pts achieved CR. Persistent disease at count recovery after positive D14 BM was more likely associated with higher percentage of D14 myeloblasts, history of relapsed disease, and poor-risk disease category than pts with positive D14 BM who achieved CR. Age, D14 BM cellularity, and WBC at first day of induction chemotherapy had no significant influence on remission status in pts with a positive D14 BM (Table 1). We developed, and tested in a validation cohort, new prediction model using both D14 BM status and clinical/laboratory factors such as the percentage of blasts, history of relapsed disease, and poorer disease risk category. Then we compared results of this prediction model to that of D14 BM alone without the usage of clinical/laboratory prognostic factors. Our prediction model significantly improved the positive predictive value (84% vs.64% P=0.001) and the accuracy of prediction of recovery marrow status (0.88% vs. 80%, P=0.002) in AML pts with positive D14 BM (Table 2). Conclusion: In this study we developed and validated a new prediction model for interpreting D14 BM biopsies in AML pts after induction chemotherapy. With the addition of readily available clinical and laboratory information, our multivariable model provides a more accurate prediction of recovery bone marrow status and identification of patients with positive D14 BM who may not benefit from early reduction chemotherapy. Table 1. Clinical and Laboratory Characteristics of AML Patients with Positive D14 BM Who Did Not Receive Immediate Reinduction Chemotherapy. Persistent AML at count recovery CR+CRi P value Number 57 32 Age, years Median (min, max) 59 (19, 75) 55.5 (20, 78) 0.064* WBC Count at Induction, x 109/L Median (min, max) 5.7 (0, 285) 3 (0, 95) 0.25* D14 Cellularity, % Median (min, max) 10 (5, 40) 10 (3, 60) 0.079* D14 Blasts, % 0-10 10%-30 >30 13 20 24 15 13 4 0.0023* Disease Status Before Induction Therapy De novo Relapsed 19 38 26 6 <0.0001** Antecedent Hematologic Disorder Yes No 25 32 6 26 0.021** Risk Favorable/Normal High 13 44 19 13 0.0013*** AML, acute myeloid leukemia; CR, complete remission; CRi, complete remission with incomplete count recovery; D, day; WBC, white blood cell. *Wilcoxon rank sum test. **Fisher's exact test. ***Chi-square test Table 2. Performance of Models in Prediction of Recovery Bone Marrow using the D14 BM with and without Clinical/laboratory Diagnostic Factors (N = 203) Sensitivity Specificity PPV NPV Accuracy P value* Without prognostic factors 0.88 0.77 0.64 0.93 0.80 0.002 With prognostic factors** 0.78 0.93 0.84 0.90 0.88 *Comparison of accuracies by two-sample binomial test. **The percentage of myeloblasts in the D14 BM, disease status, and risk category were used as prognostic factors.NPV, negative predictive value; PPV, positive predictive variable. Disclosures No relevant conflicts of interest to declare.

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Fas and Fas Ligand Expression In Children with Acute Lymphoblastic Leukemia, Benign Hematological Diseases and Solid Tumors

Blood ◽

10.1182/blood.v116.21.4853.4853 ◽

2010 ◽

Vol 116 (21) ◽

pp. 4853-4853

Author(s):

Eftichia Stiakaki ◽

Georgia Martimianaki ◽

Maria Kaparou ◽

Chryssoula Perdikogianni ◽

Maria Kalmanti

Keyword(s):

Bone Marrow ◽

Solid Tumors ◽

Fas Ligand ◽

Bone Marrow Cells ◽

Conflicts Of Interest ◽

Lymphoblastic Leukemia ◽

Response To Treatment ◽

End Of Treatment ◽

Significant Difference ◽

Activated T Lymphocytes

Abstract Abstract 4853 Fas/FasL is a key pathway of cellular apoptosis. Fas receptor is expressed on membranes of both normal and neoplastic cells while, Fas ligand (FasL) mainly on activated T-lymphocytes. Fas-FasL abnormalities have been detected in malignancies and autoimmune diseases and implicated in resistance to treatment. The aim of the study was the determination of the levels of Fas, FasL and their coexpression in bone marrow cells of children with acute lymphoblastic leukaemia (ALL) at diagnosis, during the course of treatment and the comparison with relevant levels in other hematological and neoplastic diseases. Expression levels of Fas and FasL were determined with flow cytometry in children with ALL at diagnosis (ALLd, n=13), on day 15 of treatment (d15, n=6), on day33 (ALLd33, n=6), during consolidation (ALLhr, n=12) and at the end of therapy (ALLet, n=7) as well as in children with Langerhans Histiocytosis (LCH, n=4), cytopenias (Cytp, n=8) and solid tumors without bone marrow infiltration at diagnosis (STd, n=5) and on therapy (STther, n=6). Results: The lowest levels of Fas expression were detected at diagnosis of ALL and were gradually statistical significantly increased until remission of day 33 (ALLd vs ALLd33: 8.02±1.94 vs 24.04±6.11, p=0.035). At consolidation Fas levels were found to be decreased compared to day33 (16.1±4.18) and were again increased at the end of therapy (ALLd vs ALLet: 8.02±1.94 vs 24.96±7.95, p=0.024). On the contrary, FasL levels were gradually decreased and finally increased to similar to diagnosis levels at the end of treatment (ALLd: 4.59±1.41, ALLet: 5.89±1.99). In solid tumors at diagnosis Fas levels were similar to the ones while on chemotherapy (STd vs STth:16.04±2.2 vs 15.19±6.4). The highest FasL levels were detected in the group of STd with the relevant levels on treatment being lower in comparison (STd vs STther: 10.91±3.32 vs 2.92±0.79, p=0.052). In LCH both Fas and FasL levels were found to be as low as at ALL diagnosis. In cytopenias no significant difference was observed between groups for either Fas (11.05±4.49) or FasL (3.01±0.62). As for Fas+FasL+ coexpression no difference was evident between ALLd, ALLet and STd or STther [ALLd (0.73±0.38), ALLet (0.64±0.17), STd (0.68±0.095), STther (0.66±0.38)]. The lowest coexpreesion levels were observed in the group of cytopenias with statistical significant difference compared to STd (0.68±0.095 vs 0.26±0.08, p=0.031). In conclusion, at diagnosis of ALL Fas levels were expressed in lowest levels that were found to be gradually increased at remission and at the end of treatment. This finding probably correlates with the apoptotic process of the leukemia clone and possibly with response to treatment. Disclosures: No relevant conflicts of interest to declare.

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Bioimaging of Vascular Microenvironment Reveals Presence of Fli1a, Not VEGFR2, in Acute Lymphoblastic Leukemia Model in Syngeneic Zebrafish

Blood ◽

10.1182/blood.v118.21.2551.2551 ◽

2011 ◽

Vol 118 (21) ◽

pp. 2551-2551

Author(s):

Sergei Revskoy ◽

Igor Mizgirev ◽

Seth J. Corey

Keyword(s):

Bone Marrow ◽

Acute Lymphoblastic Leukemia ◽

Large Scale ◽

Molecular Mechanisms ◽

Conflicts Of Interest ◽

Lymphoblastic Leukemia ◽

Cellular Mechanisms ◽

Bone Marrow Biopsies ◽

Response To Chemotherapy

Abstract Abstract 2551 Despite great advances in the curability of children with acute lymphoblastic leukemia (ALL), outcomes for pediatric and adult patients with relapsed ALL remain poor. This highlights the need for new approaches to ALL treatment and novel tools for screening of potential therapeutics. Dysregulated angiogenesis has been implicated both in the pathogenesis of leukemia and development of chemoresistance. However, the complexity of the bone marrow microenvironment and the precise contributions by the various components cannot be easily dissected in cell lines, tissue blocks, or mouse models. For instance, leukemia-associated angiogenesis was mainly characterized by immunostaining of bone marrow biopsies. High resolution in vivo bioimaging of fluorescence-tagged tumors and their microenvironment has recently become feasible due to establishment of transplantable tumor models in clonal syngeneic zebrafish. We have applied this model to dissection of cellular mechanisms of angiogenesis during stages of progression of T-ALL, This novel animal model enables us to 1) track leukemic cell proliferation and dissemination in vivo in different temperio-spatial and vascular contexts, and 2) follow up on cellular angiogenic events in response to leukemia progression including those occurring in response to chemotherapy for leukemia. In zebrafish, angiogenesis is similar to that of mammals and has been well characterized by using VEGFR2 and Fli1a transgenic reporter systems. In embryos, the fli1a:EGFP expression pattern mirrors that of VEGFR2 fluorescence in vascular endothelial cells. However, later in the development, in larvae and adult fish, the pattern of Fli1a or VEGFR2 expression diverges. This divergence further extends to angiogenesis in areas adjacent to T-ALL with more prominent development of Fli1a vasculature. Leukemic patches are characterized by a microenvironment where Fli1a is predominant and VEGFR2 is absent. We are now using cyclophosphamide treatment of leukemic fish to dissect the role of microenvironment and whether angiogenic factors are modified. These data yield new insights into molecular mechanisms of leukemogenesis in conjunction with angiogenesis. Furthermore, our findings would have predicted the lack of efficacy of VEGFR inhibitors in leukemia therapy. Our model offers an advantage for cost-efficient in vivo large scale screening system for antiangiogenic drugs for acute leukemia. Disclosures: No relevant conflicts of interest to declare.

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Probability of Eventual CR After Course 1 of Induction Therapy for Newly-Diagnosed AML As a Function of Platelet and Neutrophil Recovery.

Blood ◽

10.1182/blood.v120.21.2598.2598 ◽

2012 ◽

Vol 120 (21) ◽

pp. 2598-2598

Author(s):

Laura F Newell ◽

Hu Xie ◽

John M. Pagel ◽

Ravinder K Sandhu ◽

Pamela S Becker ◽

...

Keyword(s):

Bone Marrow ◽

Platelet Count ◽

Induction Chemotherapy ◽

Induction Therapy ◽

Blood Count ◽

Newly Diagnosed ◽

Platelet Recovery ◽

Platelet Counts ◽

Bone Marrow Blasts ◽

Count Recovery

Abstract Abstract 2598 Background: After initial induction chemotherapy for acute myeloid leukemia (AML), it is commonplace that reinduction or intensified therapy is not indicated if the bone marrow has <5% blasts, even despite persistently low neutrophil (ANC) and/or platelet counts. This practice suggests that complete remission (CR), i.e. ANC >1000/μl and platelet count >100,000/μl per standard criteria (Cheson BD, et al. J Clin Oncol. 1990;8(5):813-9), might still occur and that the lack of blood count recovery may not bear prognostic significance. However, the time to CR after the first induction has been shown to be inversely related to subsequent duration of disease-free survival (DFS) and survival (OS), independent of age, treatment, and cytogenetics (Estey EH, et al. Blood. 2000;95(1):72-7). Additionally, the level of ANC and platelet recovery at time of CR is prognostic, with significantly better DFS among patients with higher counts (Yanada M, et al. Leuk Res. 2008;32(10):1505-9). Newly-diagnosed AML patients often present with below normal neutrophil and platelet counts, suggesting that persistence of such cytopenias after induction may be a clinical indicator of minimal residual disease (MRD) in the marrow. We therefore examined whether blood count recovery affected the probability of subsequent CR in patients with <5% bone marrow blasts. Methods: We included 85 patients who, by day 21 or thereafter of induction therapy for newly-diagnosed AML, had not met blood count criteria for CR despite a bone marrow in the prior week with <5% blasts by morphology. Patients were classified by type of induction therapy based on cytarabine dosing. G-CSF was not systematically administered. Marrows were planned for day 21 after chemotherapy and/or weekly thereafter to assess for disease status and evidence of marrow recovery. Because patients were often managed as outpatients, counts and marrows were not uniformly available and thus “day 28” included days 21–28, “day 35” included days 29–35, etc. If a patient had more than one marrow evaluation after day 21, we included only the first one. Results: Overall cohort CR rate was 64%. Eventual CR rate was significantly affected by platelet count, with 44% eventual CR for patients with platelets <30,000, 66% CR for platelets 30,000–100,000, and 95% CR for platelets >100,000. The effect of ANC recovery on eventual CR was less dramatic, with an OR 0.4 (0.2–1.0, p=0.049), for ANC <0.1 vs. >0.1 in the univariate analysis. By day 28, patients with either ANC or platelet recovery were significantly more likely to obtain CR than patients with neither count recovery (89% vs. 51%), OR 8.05 (2.2–30, p=0.002). In the multivariate analysis, (a) lack of platelet recovery to >30,000 was associated with significantly lower incidence of CR, OR 0.26 (0.1–0.8, p=0.02), and was independent of cytogenetic risk, antecedent hematologic disorder, and induction regimen, and (b) there was a suggested association between earlier count recovery and CR (>28 days vs. day 21–28), OR 0.31 (0.1–1.0, p=0.051). Conclusion: Persistence of low peripheral blood counts, despite the presence of <5% bone marrow blasts, is predictive of low eventual CR rates after induction chemotherapy. These results suggest that initiation of further and possibly different therapy, rather than continued observation, should be investigated in this setting. Disclosures: Becker: Sanofi: Research Funding.

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Serum Leptin Level in Children with Acute Lymphoblastic Leukemia

QJM ◽

10.1093/qjmed/hcab091.009 ◽

2021 ◽

Vol 114 (Supplement_1) ◽

Author(s):

Manal Fawzy Ghozlan ◽

Deena Samir Eissa ◽

Nada Ahmed Hamed AbdelRahman

Keyword(s):

Bone Marrow ◽

Acute Lymphoblastic Leukemia ◽

Induction Chemotherapy ◽

Lymphoblastic Leukemia ◽

Response To Treatment ◽

Main Function ◽

Significant Relation ◽

Anthropometric Measures ◽

Serum Leptin ◽

Post Induction

Abstract Background Acute lymphoblastic leukemia (ALL) is the most common pediatric cancer .It is a disease of monoclonal proliferation of hematopoietic precursor cells of the lymphoid series within the bone marrow. Leptin is a peptide hormone which is predominantly produced by white adipose tissue. The main function of leptin in the human body is the regulation of energy expenditure and control of appetite .It is supposed to be involved in the pathogenesis of hematological malignancy through its proliferative, anti-apoptotic, and differentiating effects on hematopoietic neoplastic cells, in addition to its synergestic effect on vascular endothelial growth factor (VGEF) . Objectives To evaluate serum leptin level in children with acute lymphoblastic leukemia at diagnosis and at day 28 post induction chemotherapy,and to test the association between serum leptin levels and anthropometric measures of ALL patients and prognostic markers of ALL as age, gender, initial WBCS count, extramedullary infiltration to organs and CSF, cytogenetics, and response to treatment . Patients and Methods This is a case- control study performed at Clinical Pathology Department, Ain Shams University Hospitals. The study was conducted on 30 ALL pediatric patients admitted to Hematology & Oncology Unit, Pediatric Department, Ain Shams University Hospitals.The patients were evaluated at diagnosis before intake of chemotherapy and at day 28 post-induction chemotherapy, and 25 healthy controls matched with patients in age, sex, BMI. Results Serum leptin level is elevated in ALL patients at diagnosis as compared to controls .It has no significant relation with patients age, sex, BMI. It is elevated in patients who received cranial radiotherapy and those who relapsed. .However, it has no significant relation with clinical data (fever, lymphadenopathy and organomegaly) and laboratory characteristics (CBC, percentage of blasts infiltrating bone marrow and peripheral blood, immunophenotyping and cytogenetics) of ALL patients. Conclusion Data from our study showed that elevated leptin level in ALL patients can be considered a risk factor involved in ALL pathogenesis.It can be used as a biomarker for ALL diagnosis, a prognostic factor for ALL patients on chemotherapy, and a predicting factor for relapse.

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