Comprehensive Quantitative Proteomic Profiling of the Pharmacodynamic Changes Induced By MLN4924 in Acute Myeloid Leukemia Cells Reveals Rational Targets for Combination Therapy

Abstract NEDDylation controls the ubiquitination and proteasomal degradation of proteins that are critical for cell survival, oncogenic transformation, and therapeutic sensitivity. MLN4924 (4924, Pevonedistat) is a first-in-class inhibitor of NEDDylation that has been evaluated in multiple phase I trials. Despite its preliminary efficacy in patients with relapsed/refractory acute myeloid leukemia (AML) and higher-risk myelodysplastic syndromes (MDS), the specific pharmacodynamic (PD) effects that mediate the anti-leukemic activity of 4924 have not been completely defined. We conducted comprehensive proteome profiling of MV4-11 FLT3 ITD+ cells to determine the global impact of inhibiting NEDDylation with 4924 on the AML proteome. MV4-11 cells were treated with 4924 (1 μM) for 24 hours and processed for high-throughput proteome quantification. Using a 2-fold PD change cut-off, 47 of 3,812 unique detected proteins were significantly upregulated by 4924 treatment (P < 0.05). The effects of 4924 on the levels of selected proteins were confirmed by immunoblotting. 4924 triggered increased levels of many established NEDD8 substrates including CDT1, p27, KEAP1, NUSAP1, and MLX. Other notable factors elevated by 4924 treatment included RRM2, BRD2, NQO1, regulators of cellular redox status (GCLM, TXNRD1, HMOX1), the DNA helicase DNA2, and the DNA replication factor ESCO2. Reactome network analysis demonstrated that the significantly affected proteins primarily clustered in the cell cycle, mitosis, and stress response pathways. A comparison of our proteomic data with a comprehensive SILAC analysis performed in A375 melanoma cells similarly treated with MLN4924 revealed that 34% (16/47) of the pharmacodynamically increased proteins were identical between the two analyses. These findings suggest that the repertoire of proteins that are modulated by 4924 may be tumor-type dependent. Notably, several of the proteins modulated by 4924 in our study could represent biomarkers for patient stratification. For example, the chromodomain helicase DNA binding protein CHD3 (fold change: 2.23) was reported to be elevated in patients with MYST3-CREBBP AML or AML with a monocytic phenotype and high FLT3 expression that experienced short complete remissions following conventional therapy. It would be worthwhile to investigate whether patients with high basal CHD3 levels derive less benefit from treatment with 4924. We also detected drug-induced changes in 27 members of the RNA helicase family including DDX41, in which mutations were recently reported in AML and MDS. Out of these 27 helicases, DDX24 and DDX54 were most increased (1.74- and 1.51-fold, respectively). Although the impact of drug treatment on individual helicases fell below our set threshold of significance, the collective data suggest that 4924 may have a previously undefined class effect on RNA helicase function. Further investigation is required to assess whether NEDD8 plays a novel role in the regulation of RNA helicases and to determine how this may impact 4924 efficacy. Additionally, several of the targets that were elevated following treatment with 4924 are directly actionable with existing approved and investigational drugs. For example, a proof of concept FLT3-ITD+AML xenograft study confirmed that known effects of azacitidine (AZA) on RRM2 antagonized MLN4924-mediated upregulation of RRM2 and synergistically increased efficacy (P <0.01), implying a potential relationship between RRM2 expression and clinical response that could be explored in the ongoing trial of 4924 plus AZA in elderly patients with AML (NCT0181426). The ability of 4924 to increase BRD2 levels may also heighten the sensitivity of AML cells to BET inhibitors, which represents another clinical implication that could be seamlessly translated into the clinic and investigated in trials of existing BET inhibitor combinations. We are currently assessing this possibility in preclinical models of AML. In summary, our study demonstrates that high-throughput proteomic technology is a powerful tool with potential applications in patient refinement and the identification of rational actionable targets for precision combination therapeutic strategies. These findings support the implementation of high-throughput proteomics as a synergistic complement to genomics in novel anticancer drug development. Disclosures Sekeres: Celgene Corporation: Membership on an entity's Board of Directors or advisory committees; TetraLogic: Membership on an entity's Board of Directors or advisory committees; Amgen: Membership on an entity's Board of Directors or advisory committees.

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Impact of Day 28 Absolute Lymphocyte Count on Outcome of Adult Patients with Acute Myeloid Leukemia

Blood ◽

10.1182/blood.v124.21.5256.5256 ◽

2014 ◽

Vol 124 (21) ◽

pp. 5256-5256

Author(s):

Naresh Bumma ◽

Jing Ai ◽

Xuefei Jia ◽

Sean Hobson ◽

Donna Abounader ◽

...

Keyword(s):

Overall Survival ◽

Acute Myeloid Leukemia ◽

Board Of Directors ◽

Lymphocyte Count ◽

Myeloid Leukemia ◽

Univariate Analysis ◽

Absolute Lymphocyte Count ◽

Advisory Committees ◽

The Impact ◽

Acute Myeloid

Abstract Introduction: Lymphocyte recovery after induction chemotherapy (IC) predicts outcome in adult patients (pts) with acute myeloid leukemia (AML) (Behl et al. Leukemia 2006; 20: 29-34). However, it is unknown whether absolute lymphocyte count (ALC) recovery after IC predicts outcome in those pts who are then treated with allogeneic hematopoietic stem cell transplant (AHCT) in first complete remission (CR1). We hypothesized that the prognostic impact of ALC might be nullified by AHCT in CR1 due to the abrogation of normal immunologic recovery. In this study, our aims were to (1) evaluate the impact of Day 28 ALC on all AML pts receiving IC and (2) to specifically, evaluate the impact of Day 28 ALC on the subset of AML pts proceeding to AHCT in CR1. Methods: A retrospective chart review of 180 adult AML pts (≥ 18 years of age) who were treated with IC during the years 2001- 2012 at the Cleveland Clinic was performed. Institutional Review Board approval was obtained. Pts with acute promyelocytic leukemia were excluded . Ninety-four of the 180 pts received AHCT in CR1. A total of 141 AML pts receiving IC and a total of 66 pts receiving IC and then receiving AHCT in CR1 were eligible for data analysis because Day 28 ALC was missing in the remainder of the pts. Prior studies in AML identified an ALC of < 500/ µL at Day 28 of IC as predictive of overall survival. We stratified Day 28 ALC into the following categories: (a)< 250/ µL (b) < 350/ µL (c) < 500/ µL and (d) < 500/ µL for Max ALC [Max ALC was defined as the maximum ALC value between days 26 and 30 after the initiation of IC]. Other variables collected included age at diagnosis, WBC at diagnosis, and cytogenetic (CG) risk. CG risk was ascribed by CALBG criteria. The Kaplan-Meier method was used to summarize overall survival (OS) and relapse-free survival (RFS), which were measured for all pts from the time of diagnosis. The log-rank test was used for univariate analysis of categorical factors and the Cox proportional hazards model was used for measured factors and multivariate analysis. We performed two separate analyses : one for all AML pts (n=141); and a second analysis only focusing on those receiving AHCT in CR1 (n=66). Results: Pt characteristics for the entire AML cohort: The median age was 58.0 years (20.0-80.0); 46.1% female. The median WBC at diagnosis was 11.6 K / µL (range 0.7-220.7) and median Day 28 ALC was 400/ µL (0-2.4). Twenty-seven pts (19.7%) had favorable CG, 84 (61.3%) intermediate, and 26 (19.0%) unfavorable. Most pts (91%) received "7+3" IC and 93 (66%) also received at least 1 cycle of post-remission chemotherapy. On univariate analysis, age ≥60 (HR 2.72, p< 0.001), CG risk (HR 2.13, p < 0.001), Day 28 ALC < 250/ µL (HR 1.60, p=0.022), Day 28 ALC < 350/ µL (HR 1.57, p=0.029), and max ALC < 500/ µL (HR 1.54, p=0.035) were associated with a worse OS from the initiation of treatment. Low ALC was associated with both a higher incidence of refractory disease and death during induction (p=0.015). In our second analysis of pts undergoing AHCT in CR1, although not statistically significant, max ALC < 500/ µL (during IC) was associated with a trend towards decreased OS from the start of treatment on both univariate (HR 1.88,p= 0.13) and multivariate (HR 2.16, p=0.075) analysis. Conclusions: Max ALC < 500/ µL is predictive of outcome in AML pts undergoing IC, and there is a suggestion that this effect may not be abrogated by AHCT. A larger study will be needed to further confirm these findings. Therapies to improve lymphocyte recovery may be important in the treatment of AML. Disclosures Sekeres: Boehringer-Ingelheim Corp: Membership on an entity's Board of Directors or advisory committees; Celgene: Membership on an entity's Board of Directors or advisory committees; Amgen Corp: Membership on an entity's Board of Directors or advisory committees.

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Impact of Comorbidities on Prognosis of Elderly Patients with Acute Myeloid Leukemia Who Receive Hypomethylating Agents

Blood ◽

10.1182/blood-2021-149459 ◽

2021 ◽

Vol 138 (Supplement 1) ◽

pp. 3373-3373

Author(s):

Giovanni Marconi ◽

Anna Candoni ◽

Roberta di Nicola ◽

Chiara Sartor ◽

Sarah Parisi ◽

...

Keyword(s):

Acute Myeloid Leukemia ◽

Chronic Disease ◽

High Risk ◽

Elderly Patients ◽

Board Of Directors ◽

Myeloid Leukemia ◽

Hypomethylating Agents ◽

Advisory Committees ◽

The Impact ◽

Acute Myeloid

Abstract BACKGROUND: Many efforts have been made in the attempt to address the conundrum question of fitness definition ad prognosis prediction in elderly acute myeloid leukemia (AML) patients. Parametric definitions are expected to give an advantage in patient stratification; however, clinical examination remain de facto pivotal to formulate therapy decisions and frequently the comorbidities are empirically evaluated. METHODS: We conducted a multicenter study collecting baseline comorbidity, laboratory data, CTCAE 4.0.3 adverse events (AE), and outcome of elderly patients (>65 years old) with new onset AML who received hypomethylating agents as 1st line therapy. We tested the impact on prognosis of baseline clinical and biological risk factors. Furthermore, we evaluated a score - acute myeloid leukemia-composite model, AML-CM (Mukherjee et al, 2017) - developed in chemotherapy-eligible patients, that accounts for baseline comorbidities, laboratory parameters, age and cytogenetic-molecular risk. The study was approved by local Ethical Authority (316/2019/Oss/AOUBo). RESULTS: We collected data from 131 consecutive elderly patients who received 1 st line HMAs between January 2008 and January 2021. Patients had a median age of 76 years (IQR 72 -79). Seventy-seven out of 131 patients (58.8%) had de novo AML, 32/131 (32.8%) had secondary AML, and 11/131 (8.4%) had therapy-related AML. Out of 123 evaluable patients, 43 (34.9%) had complex karyotype, 1 (0.8%) inv(16), 59 (48.4) normal karyotype, 18 (14.7%) other alterations; 8/108 patients harbored FLT3 ITD mutation (7.4%, 23 not tested), 12/101 NPM1 mutation (11.9%, 30 not tested). Based on these data, 111 patients were evaluable for ELN2010 risk stratification; 9 over 111 patients (8.1%) were stratified in the low risk, 42/111 (37.8%) in intermediate-1 risk, 17/111(15.3%) in intermediate-2 risk, and 43/111 (38.7%) in high-risk class. As expected, most of the patients had at least one comorbidity. Particularly, baseline arrhythmia was present in 29/130 (22.1%, 1 no data), cardiovascular comorbidity in 20/130 (15.4%, 1 no data), diabetes in 20/131 (15.3%), cerebrovascular comorbidity in 11/131 (8.4%), kidney disease in 15/130 (11.5%, 1 no data), lung chronic disease 19/130 (14.6% 1 no data), hypoalbuminemia in 25/111 patients (22.5%, 20 no data). With a median follow up of 28.2 months, median overall survival (OS) of the entire cohort was 15.8 months (95% C.I. 11.2-19.4). We confirmed that patient who obtained a response (complete remission, partial response, hematological improvement) after 2 months of therapy had the best OS (figure A, median OS of 21 months for responders vs 7.4 months for non-responders, p <.001). Interestingly, lung chronic disease (median OS 6.6 months in affected vs 16.5 months in non-affected, p=.013) and hypoalbuminemia (median OS 7.4 months in affected vs 18 months in non-affected p<.001) confer significantly diminished OS. ELN2010 score impacted prognosis (median OS of 8.4 months for favorable, 23.4 months for int-1, 11.1 for 1int-2 and 6.5 months for high-risk, p=.004). To test the impact of comorbidities combined with cytogenetic and molecular risk, AML-CM was used. Our results indicate that AML-CM score was able to stratify prognosis in elderly patients receiving frontline HMAs (figure B, median OS in score group 1: 29.7 months, score group 2: 16.5 months, score group 3: 11.2 months, score group 4: 6.6 months, p=.038). The worse prognosis of patients with higher AML-CM score, which includes patients with increased baseline comorbidities, may be explained with a higher incidence of AEs (84.55, 116.01, 131.45, 229.3 events for 100 patients per year for score group 1,2,3, and 4, respectively) and infections (53.80, 55.10, 85.95, 140.13 events for 100 patients per year for score group 1,2,3, and 4, respectively), in patients with higher baseline comorbidities. CONCLUSION: In this study we found that baseline comorbidities, captured by AML-CM score, may define prognosis of elderly patients receiving 1st line HMAs; parametric comorbidity scores may improve our ability to predict outcome and tailor interventions. The impact of comorbidity on OS may be increased with novel and more aggressive therapy. For this reason, specific studies on functional fitness tests and geriatric assessments are highly warranted in patients receiving HMAs plus venetoclax. This work was supported by Bologna AIL. CP and AC shared last authorship. Figure 1 Figure 1. Disclosures Martinelli: Daichii Sankyo: Consultancy; Pfizer: Consultancy, Speakers Bureau; Astellas: Consultancy, Speakers Bureau; Roche: Consultancy; Abbvie: Consultancy; Stemline Therapeutics: Consultancy; Celgene /BMS: Consultancy, Speakers Bureau; Incyte: Consultancy; Jazz Pharmaceuticals: Consultancy. Cavo: Celgene: Consultancy, Honoraria, Membership on an entity's Board of Directors or advisory committees, Other: Travel Accommodations, Speakers Bureau; Amgen: Consultancy, Honoraria, Membership on an entity's Board of Directors or advisory committees, Speakers Bureau; Takeda: Consultancy, Honoraria, Membership on an entity's Board of Directors or advisory committees, Speakers Bureau; Novartis: Honoraria; AbbVie: Consultancy, Honoraria, Membership on an entity's Board of Directors or advisory committees; Janssen: Consultancy, Honoraria, Membership on an entity's Board of Directors or advisory committees, Other: TRAVEL, ACCOMMODATIONS, EXPENSES, Speakers Bureau; Adaptive Biotechnologies: Consultancy, Honoraria; GlaxoSmithKline: Consultancy, Honoraria; Sanofi: Consultancy, Honoraria, Membership on an entity's Board of Directors or advisory committees, Speakers Bureau; Bristol-Myers Squib: Consultancy, Honoraria, Membership on an entity's Board of Directors or advisory committees, Speakers Bureau. Papayannidis: Pfizer, Amgen, Novartis: Honoraria. Curti: Abbvie: Membership on an entity's Board of Directors or advisory committees; Novartis: Membership on an entity's Board of Directors or advisory committees; Pfizer: Membership on an entity's Board of Directors or advisory committees; Jazz Pharma: Membership on an entity's Board of Directors or advisory committees.

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Outcome of Allogeneic HSCT after Chemo-Based Conditioning in Infants with Acute Myeloid Leukemia in First Complete Remission: A Multicenter EBMT-PDWP Study

Blood ◽

10.1182/blood-2021-145858 ◽

2021 ◽

Vol 138 (Supplement 1) ◽

pp. 2862-2862

Author(s):

Andre Manfred Willasch ◽

Christina Peters ◽

Adriana Balduzzi ◽

Jean-Hugues Dalle ◽

Marco Zecca ◽

...

Keyword(s):

Acute Myeloid Leukemia ◽

Missing Data ◽

Complete Remission ◽

Board Of Directors ◽

Myeloid Leukemia ◽

Research Funding ◽

Advisory Committees ◽

The Impact ◽

First Complete Remission ◽

Acute Myeloid

Abstract Background: Pediatric patients younger than two years of age with acute myeloid leukemia (AML) commonly receive a chemotherapy-based myeloablative conditioning regimen before allogeneic hematopoietic stem cell transplantation (HSCT). The optimal choice of cytotoxic agents is still controversial. Methods: A retrospective EBMT-registry based study was conducted to investigate the impact of different chemotherapy-based conditionings on the outcomes in young children. Children younger than two years of age receiving a first HSCT of bone marrow (BM), peripheral blood stem cells (PBSC) or cord blood (CB) from matched siblings (MSD) or unrelated donors (UD) in first complete remission (CR1) between 2000 and 2019 were included. Busulfan/Cyclophosphamide (BuCy) and BuCy/Melphalan (BuCyMel) were the most frequent combinations on which this analysis focused. The primary endpoint was leukemia-free survival (LFS). Multivariate analysis adjusting for differences between the conditioning regimens and risk factors influencing outcome was performed using the Cox's proportional hazards regression model. Results: 289 patients (56% male) transplanted at a median age of 1.2 years (IQR 0.9-1.6) after BuCy (164, 57%) or BuCyMel (125, 43%) were included. 184 (64%) patients received BM, 71 (24%) CB and 34 (12%) PBSC from UD (201, 70%) and MSD (88, 30%). In-vivo T-cell-depletion (TCD) was performed in 160 (58%, missing data 14) of the HSCTs with anti-thymocyte-globulin (ATG, 153) or alemtuzumab (7). Ex-vivo TCD was performed in 13 (5%, missing data 3) of the HSCTs. Graft-versus-host-disease (GvHD)-prophylaxis was Cyclosporin-A-based in 90% of the HSCTs. Median follow-up (FU) was 4.9 years (95% CI 3.9-5.5). After a median FU of 4 years, 4-y-LFS after BuCyMel (74.3%, 95% CI 65.1-81.4) was significantly better compared to BuCy (59.7%, 95% CI 51.2-67.2), hazard ratio (HR) 0.56 (95% CI 0.35-0.90, P=0.02). Overall survival (4-y-OS) after BuCyMel (77.2%, 95% CI 68.1-84.0) was significantly better compared to BuCy (66.6%, 95% CI 58.0-73.8), HR=0.58 (95% CI 0.35-0.97, P=0.04). No significant differences were found in the probability of relapse (4-y-RI (whole cohort) 26.2% (95% CI 21.0-31.7), HR of BuCyMel 0.59 (95% CI 0.34-1.02), P=0.06), non-relapse mortality (4-y-NRM (whole cohort) 7.8% (95% CI 5.0-11.4), HR of BuCyMel 0.49 (95% CI 0.19-1.24), P=0.13) and incidence of acute grade II-IV GvHD at day 100 (day-100-aGvHD II-IV (whole cohort) 36.8% (95% CI 31.2-42.5), HR of BuCyMel 0.59 (95% CI 0.35-1.01), P=0.06). Incidence of chronic GvHD (4-y-cGvHD (whole cohort)) was 9.8% (95%-CI 6.3-14.2). The donor type had no significant influence on the outcome. Conclusion: Bu-based conditionings of HSCT for infants with AML at high risk of relapse offer a high probability of cure. Conditioning with three alkylators (BuCyMel) resulted in better LFS and OS compared with two alkylators (BuCy) without significantly increasing the risk of both NRM and aGvHD. Future trials will evaluate the impact of the more recently introduced alkylator Treosulfan within the conditioning of HSCT in pediatric AML. Disclosures Peters: Amgen: Membership on an entity's Board of Directors or advisory committees, Other: Travel grants. Locatelli: Amgen: Membership on an entity's Board of Directors or advisory committees, Speakers Bureau; Novartis: Membership on an entity's Board of Directors or advisory committees, Speakers Bureau; Miltenyi: Speakers Bureau; Medac: Speakers Bureau; Jazz Pharamceutical: Speakers Bureau; Takeda: Speakers Bureau. Moraleda: Pfizer: Other: Educational Grants, Research Funding; Sanofi: Other: Educational Grants, Research Funding; MSD: Other: Educational Grants, Research Funding; ROCHE: Consultancy, Honoraria, Other: Educational Grants, Research Funding; Takeda: Consultancy, Honoraria, Other: Educational Grants, Research Funding; Sandoz: Consultancy, Honoraria; Novartis: Consultancy, Honoraria, Other: Educational Grants, Research Funding; Gilead: Consultancy, Honoraria, Other: Educational Grants, Research Funding; Jazz Pharmaceuticals: Consultancy, Honoraria, Other: Educational Grants, Research Funding; NovoNordisk: Other: Educational Grants, Research Funding; Janssen: Other: Educational Grants, Research Funding; Celgene: Other: Educational Grants, Research Funding; Amgen: Other: Educational Grants, Research Funding. Biffi: BlueBirdBio: Consultancy, Other: Advisory Board. Corbacioglu: Gentium/Jazz Pharmaceuticals: Consultancy, Honoraria.

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The Complexity of Interpreting Genomic Data in Patients with Primary and Secondary Acute Myeloid Leukemia (AML)

Blood ◽

10.1182/blood.v126.23.86.86 ◽

2015 ◽

Vol 126 (23) ◽

pp. 86-86

Author(s):

Aziz Nazha ◽

Ahmad Zarzour ◽

Tomas Radivoyevitch ◽

Hetty E. Carraway ◽

Jennifer S. Carew ◽

...

Keyword(s):

Acute Myeloid Leukemia ◽

Board Of Directors ◽

Cytogenetic Analysis ◽

Myeloid Leukemia ◽

Genetic Alterations ◽

The Cancer Genome Atlas ◽

Advisory Committees ◽

Recurrent Mutations ◽

The Impact ◽

Acute Myeloid

Abstract Background Acute myeloid leukemia (AML) is a complex, heterogeneous neoplasm characterized by the accumulation of complex genetic alterations that are responsible for the initiation and progression of the disease. Secondary AML (sAML) represents a progression from antecedent hematologic disorders such as myelodysplastic syndromes (MDS) or myeloprolifrative neoplasms (MPN). Certain acquired mutations have been reported to be specific for sAML when compared to primary AML (pAML), but many limitations exist when cytogenetic grouping or other parameters are taken into account. In addition, some mutations have been shown to impact survival in some studies, but not others. Methods We performed targeted deep sequencing on samples from bone marrow and peripheral blood of pts diagnosed with sAML and pAML and treated at our institution between 1/2003-1/2013. Additional data on pAML was added from The Cancer Genome Atlas (TCGA). A panel of 62 gene mutations described as frequently recurrent mutations in myeloid malignancies were assessed. Cytogenetic grouping was defined by CALGB/Alliance criteria. Differences were compared using Fisher's exact test and the Mann-Whitney U test for categorical and continuous variables, respectively. Overall survival (OS) was calculated from the time of diagnosis to last follow up or death. Results: A total of 496 pts included: 273 with pAML and 223 with sAML. Comparing pAML to sAML, pts were younger (median age 59 vs. 68 years, p<.001) and had a higher WBC at diagnosis (13.5 vs. 3.9 X 109/L, p<.001), respectively. Cytogenetic analysis showed significant differences: 58% of pAML pts had normal karyotype (NK) compared to 37% of sAML (p=.002), whereas 24% and 26% of sAML had intermediate risk (other than NK) and complex karyotype (> 3 abnormalities) compared to 11% and 16% for pAML (p< .001, .009), respectively. Mutations in ASXL1 (p<.001), JAK2 (p=.014), CBL (p=.05), BCOR (p=.02), STAG2 (p =.003), SF3B1 (p=.04), SRSF2 (p=.001 ), and U2AF1 (p=.03) were highly specific for the sAML phenotype, whereas mutations in NPM1 (p<.001 ), FLT3 (p< .001), DNMT3A (p<.001), and IDH2 (p=.02) were more specific for pAML. When the analysis was restricted to pts with NK cytogenetics, only ASXL1 (p<.001) remained specific for sAML and DNMT3A (p<.001) for pAML.Further, when the analysis was restricted to pts with unfavorable risk cytogenetics, only ASXL1 (p=.01) remained specific for sAML. No other mutations were specific for pAML. We then evaluated whether the mutations that were specific to each AML phenotype had an impact on OS. We observed different mutations that impacted OS in each phenotype: DNMT3A (HR 1.81, 95% CI 1.28-2.57, p<.001), TP53 (HR 3.1, 95% 1.74-5.53, p< .001), and SUZ12 (HR 3.18, 95% CI 1.01-10, p=.05) led to worse OS in pAML, whereas mutations in EZH2 (HR 2.12, 95% CI 1.07-4.21, p =.03), PRPF8 (HR 2.32, 95% CI 1.20-4.46, p=.01), and TP53 ( HR 2.92, 95% CI 1.69-5.04, p<.001) lead to worse OS in sAML. Different mutations had a different impact on OS when cytogenetic analysis was taken into account. Mutations in FLT3 (HR 2.15, 95% CI 1.37- 3.35, p<.001) and DNMT3A (HR 2.41, 95% CI 1.57-3.70, p<.001) led to worse OS in NK pAML, whereas none of the mutations impacted OS in NK sAML. Further, in pAML with unfavorable cytogenetics, BCOR (HR 2.41, 95% CI 1.57-3.70, p<.001) and TP53 (HR 2.41, 95% CI 1.57-3.70, p<.001) had led to worse OS, whereas BOCR (HR 2.95, 95% CI 1.03-8.50, p<.001), SF3B1 (HR .19, 95% CI .05-.82, p<.001), SUZ12 (HR .12, 95% CI .01-.99, p<.001),and TP53 (HR 1.9, 95% CI 1.09-3.46, p<.001) only impacted OS in sAML. Conclusion Clear genomic variations exist between sAML and pAML. Although some of these genomic changes are more specific to each phenotype in general, this specificity and the impact on OS differed for each cytogenetic subgroup, highlighting the complexity of interpreting genomic information in pts with AML and the need to incorporate both cytogenetic and molecular data in prognosis-driven treatment decisions. Disclosures Sekeres: TetraLogic: Membership on an entity's Board of Directors or advisory committees; Celgene Corporation: Membership on an entity's Board of Directors or advisory committees; Amgen: Membership on an entity's Board of Directors or advisory committees.

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The Impact of Diagnosis to Treatment Interval on the Outcome of Patients with Acute Myeloid Leukemia

Blood ◽

10.1182/blood-2019-124150 ◽

2019 ◽

Vol 134 (Supplement_1) ◽

pp. 2212-2212

Author(s):

Samah Nassereddine ◽

Kimberley Doucette ◽

Vanya Aggarwal ◽

Richard Amdur ◽

Imad A. Tabbara ◽

...

Keyword(s):

Acute Myeloid Leukemia ◽

Board Of Directors ◽

Myeloid Leukemia ◽

University Hospital ◽

Advisory Committees ◽

Disease Characteristics ◽

Treatment Interval ◽

Initiation Of Therapy ◽

The Impact ◽

Acute Myeloid

Introduction: Acute myeloid leukemia (AML) has historically been considered an oncologic emergency, requiring immediate intervention and initiation of therapy. Although urgency to initiate treatment has been debated, no guidelines exist to address the impact of diagnosis to treatment interval (DTI) in patients with AML. Recent FDA approvals have added treatment options using targeted therapy as monotherapy in older patients (e.g. - ivosidenib), or in combination with chemotherapy in younger patients (e.g.- midostaurin) in the newly diagnosed setting with improved outcomes. Unfortunately, results of molecular mutation testing often return several days after the initial diagnosis of AML has been made. While immediate induction is important to control disease and to minimize disease-related morbidity and mortality (Sekkers et al), molecular testing is becoming increasingly important for treatment decisions, and there may be benefit in waiting for these results. In addition, in 'real world settings', several barriers (e.g., lack of resources, correct diagnostic testing) often delay time to diagnosis, and initiation of therapy. We conducted a retrospective study in two academic centers in a major metropolitan area in the United States to evaluate the impact of DTI on the outcomes of patients with AML. Methods: We collected data from 196 patients who presented to George Washington University Hospital (120 patients) between June 2010 and July 2018 and Georgetown University hospital (76 patients) between January 2014 and December 2018. All patients were older than 18 years. Patients with acute promyelocytic leukemia and those who decided to pursue treatment elsewhere were excluded. Patients characteristics including age, gender, race, smoking past medical history and disease characteristics (Cytogenetics, FISH and NGS when available) were collected using retrospective chart review. Type of treatment received (low intensity vs high intensity), and the time from diagnosis to initiation of therapy were collected. We recorded mortality at day 30 and day 90. Multivariable logistic regression models were used to evaluate the association of DTI with mortality independently from patient age. Chi-square test was used to examine the association of 30- and 90-day mortality with DTI. Results: A total of 140 patients were used in the analysis, 71% of whom were treated within 5 days of diagnosis (DTI <1-5 days), 16% in 6-10 days, and 12% in >10 days. Incidence of 30-day mortality was 15%, 14%, and 0% (p=.24), while 90-day mortality was 28% 18%, and 13% for <1-5, 6-10, and >10 days respectively (p=.33). Neither association was statistically significant, and adjusting for age and type of therapy did not change the findings. Conclusion: Our data does not support that shorter DTI is associated with improved mortality regardless of age or type of therapy. Although there was no statistical significance, there was a numerical trend of improved mortality in patients with delayed DTI (6-10 days) compared to those with a DTI of <1-5 days. Larger prospective studies need to be conducted to investigate DTI in AML patients based on patient's age, disease characteristics, and treatment type. In particular, given the growing importance of knowing molecular mutations at diagnosis, used for both prognosis and incorporation of potential targeted agents, it will be important to understand how long we can safely wait to treat patients without affecting outcomes. Disclosures Lai: Jazz Pharma: Membership on an entity's Board of Directors or advisory committees; Jazz Pharma: Speakers Bureau; Astellas: Speakers Bureau; Daiichi-Sankyo: Membership on an entity's Board of Directors or advisory committees; Agios: Membership on an entity's Board of Directors or advisory committees.

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Impact of Sociodemographic and Clinical Factors on the Survival of Patients with Acute Myeloid Leukemia: A Multicenter Experience in Colombia, on Behalf of Acho's Renehoc-Pethema Investigators

Blood ◽

10.1182/blood-2021-150930 ◽

2021 ◽

Vol 138 (Supplement 1) ◽

pp. 3374-3374

Author(s):

Claudia Lucia Sossa ◽

Virginia Abello ◽

Angela María Peña ◽

Luis Antonio Salazar ◽

Guillermo Quintero Vega ◽

...

Keyword(s):

Acute Myeloid Leukemia ◽

Board Of Directors ◽

Myeloid Leukemia ◽

Research Funding ◽

The United States ◽

Advisory Board ◽

Clinical Factors ◽

Advisory Committees ◽

The Impact ◽

Acute Myeloid

Abstract Introduction: Acute myeloid leukemia (AML) is the most common type of acute leukemia in adults, accounting for almost 80 percent of the cases. Incidence of AML increases with age and it ranges from 3 to 5 cases per 100,000 persons in the United States. Advances in treatment have led to significant improvements in outcomes for younger patients, while prognosis in the elderly remains poor. There are different sociodemographic and clinical factors that have an impact on survival such as type of leukemia (secondary vs novo), low socioeconomic status, age, gender, health regimen, co-morbidities and performance status Objective: The aim of the study was to describe the impact of sociodemographic and clinical factors on survival of patients with AML in 11 health institutions from Colombia, from 2009 to June 2021. Methods: Population based on RENEHOC (online platform) and PETHEMA (Spanish Program for Hematology Treatments). Kaplan-Meier analysis was used to assess overall survival (OS) and Relapse-Free Survival global (RFS) of the different evaluated factors. Results: A total of 463 patients were included. The median age at diagnosis was 61 years (range, 19-90) and 50.5% were female. According to the FAB classification, 95 (26.6%), 84 (23.6%), and 53 (14.9%) of patients were classified as M2, M0 and M1, respectively. The cytogenetic risk was applied for 227 patients (57%), 135 (59.5%) were intermediate and 78 (34.4%) were high-risk. Secondary AML were 73 (18.2%) and these cases evolved from hematological malignancies in 38 cases (80.8%), the most common were myelodysplastic syndrome (n=16; 34%) and chronic myeloid leukemia (n=7; 50%). For induction therapy, 232 (59.7%) patients received 7+3 (cytarabine/idarubicin), 47 (11.7%) received Azacitidine (AZA) and 23 (5.7%) received FLUGA (Fludarabine/cytarabine low doses). Complete remission (CR) after induction was achieved in 53% of patients, 12% had partial remission, 20.3% had primary refractory AML. Twelve percent died during induction. The most common consolidation regimen was high dose cytarabine (HiDAC), 143 (35,6%) and 36 (9%) of patients received 1 and 2 cycles respectively. Seventy-two (51%) patients that achieved a CR relapsed, and 46 (69.7%) received second line therapy. The most common treatment was FLAG-IDA (27%), followed by best supportive care (23.8%). The response rate was 40% (CR:31.1%/PR:8.9%) with 16 (36.6%) patients being refractory to treatment. Five (11.1%) died during salvage therapy. Thirty-eight (21%) patients had a hematopoietic stem cell transplantation (HCT), 35 (92%) had allogeneic HCT and 3 (8%) autologous HCT, respectively. The median and 5-year OS for the whole population was 19 months and 27.6% (95%CI,19.7- 36.0). The median and 5-year RFS was 14 months and 21.8% (95%CI, 15.2 - 29.2), respectively (Figure 1). Sociodemographic and clinical factors such as age, ECOG PS, co-morbidies (Hypertension, diabetes, and chronic heart failure), AML subtype and leukocytosis at diagnosis were prognostic (Table 1). Conclusion: This is the first multicenter report analyzing real world data from AML patients in Colombia. Results confirm the impact of clinical factors: age, ECOG, secondary LMA on OS and RFS. Challenges includes low alloHSCT rate and low access to complete cytogenetic and molecular classification at diagnosis. Figure 1 Figure 1. Disclosures Sossa: Amgen: Research Funding. Abello: Dr Reddy's: Research Funding; Janssen: Honoraria; Amgen: Honoraria. Peña: Amgen: Research Funding. Salazar: Amgen: Research Funding. Sandoval-Sus: SeaGen, Janssen, MassiveBio, TG: Other: Advisory Board; BMS: Other: Advisory Board, Speakers Bureau. Montesinos: Celgene: Consultancy, Membership on an entity's Board of Directors or advisory committees, Research Funding, Speakers Bureau; Agios: Consultancy; Tolero Pharmaceutical: Consultancy; AbbVie: Membership on an entity's Board of Directors or advisory committees, Research Funding, Speakers Bureau; Glycomimetics: Consultancy; Astellas Pharma, Inc.: Consultancy, Honoraria, Other: Advisory board, Research Funding, Speakers Bureau; Forma Therapeutics: Consultancy; Daiichi Sankyo: Consultancy, Membership on an entity's Board of Directors or advisory committees, Research Funding, Speakers Bureau; Incyte: Membership on an entity's Board of Directors or advisory committees, Speakers Bureau; Janssen: Membership on an entity's Board of Directors or advisory committees, Research Funding, Speakers Bureau; Karyopharm: Membership on an entity's Board of Directors or advisory committees, Research Funding; Novartis: Membership on an entity's Board of Directors or advisory committees, Research Funding, Speakers Bureau; Pfizer: Membership on an entity's Board of Directors or advisory committees, Research Funding, Speakers Bureau; Sanofi: Membership on an entity's Board of Directors or advisory committees, Speakers Bureau; Teva: Membership on an entity's Board of Directors or advisory committees, Research Funding, Speakers Bureau; Stemline/Menarini: Consultancy.

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Donor Cell Acute Myeloid Leukemia after Transplant for Follicular Lymphoma

Blood ◽

10.1182/blood-2019-122932 ◽

2019 ◽

Vol 134 (Supplement_1) ◽

pp. 5697-5697

Author(s):

Lacey S. Williams ◽

Catherine E. Lai

Keyword(s):

Bone Marrow ◽

Acute Myeloid Leukemia ◽

Follicular Lymphoma ◽

Board Of Directors ◽

Myeloid Leukemia ◽

Donor Cell ◽

Cell Leukemia ◽

Advisory Committees ◽

Donor Cell Leukemia ◽

Acute Myeloid

Donor cell leukemia is postulated to account for up to 5% of all leukemia "relapses" after hematopoietic stem cell transplant (SCT), though in many cases this is the first leukemia diagnosis for the patient if their transplant was for non-leukemia primary diseases. The rarity of the condition and heterogeneity of disease create challenges in diagnosis and management. In the present case, donor cell leukemia (DCL) developed in a 68-year-old female after allogeneic SCT 18 years earlier for follicular lymphoma. Only one other case of DCL after transplantation for follicular lymphoma has been reported (Boulton-Jones et al., Bone Marrow Transplantation, 2005). Furthermore, this case is atypical in that the presentation occurred many years after transplantation, since very few cases of DCL occur more than 15 years after original transplant. Case In 1993, the patient was diagnosed with stage IIIA follicular lymphoma at age 50. She achieved a complete remission with CHOP (cyclophosphamide, doxorubicin, vincristine, and prednisone) for 4 years. She relapsed in 1998 and received treatment with fludarabine and mitoxantrone. In 1999, she enrolled in a toxitumomab clinical trial (NCT00268203) but discontinued therapy secondary to side effects. Due to persistent disease, she proceeded with SCT and received EPOCH-F (etoposide, prednisone, vincristine, cyclophosphamide, doxorubicin, and fludarabine) prior to allogeneic SCT from her brother in 2000 (6/6 HLA match), augmented with TH2 cells. She received graft versus host disease (GVHD) prophylaxis with cyclosporine, however her post transplant course was complicated by engraftment syndrome and gastrointestinal and skin GVHD. In 2019, she presented to hematology for evaluation of worsening chronic neutropenia and thrombocytopenia persistent for three years, noted during work-up for symptomatic cholelithiasis. Bone marrow biopsy revealed acute myeloid leukemia (AML) with a hypocellular marrow with 30% blasts and myelodysplasia related changes. Her cytogenetics showed 46XY, +1, der(1;7)(q10;p10)/47,sl,+8/46,XY. FISH analyses demonstrated deletion 7q31 D7S486 locus in 156/200 cells (78%). NGS panel showed IDH1 (VAF16%) and U2AF1 (VAF 26%) mutations. Based on cytogenetics and chimerism studies showing 100% donor, the patient was diagnosed with donor-derived AML secondary to allogeneic SCT from her brother. The brother currently has no known hematologic problems. The patient was treated with CPX-351 (liposomal cytarabine and daunorubicin) and achieved a complete remission, followed by consolidation with CPX-351. Given her complex cytogenetics and poor prognosis, the patient proceeded to non-myeloablative haploidentical peripheral blood SCT from her son, with post-transplant cyclophosphamide. She subsequently had complications of neutropenic fever and C. dificile colitis, with progressive colitis leading to her death on day 22 after SCT. Discussion Though cytogenetic and molecular studies along with functional status assist clinicians in treatment decisions for DCL patients, the benefits and risks of treatment remain difficult to balance for this unique subset of leukemia. Of patients that achieve remission for greater than 18 months, many undergo second allogeneic SCT, however a similar number of patients have remissions of at least 18 months treated with chemotherapy alone (Wiseman, Biology of Blood and Bone Marrow Transplantation, 2011). In 15 reported cases that went to SCT, approximately 50% lived longer than 12 months after their DCL diagnosis. Second allogeneic SCT is often favored after initial remission in patients with good performance status due to high risk for relapse. This case illustrates the challenge in management of donor cell leukemia, a rather rare entity with very few cases in the literature developing greater than 15 years after transplant. Limited robust evidence favoring a particular treatment supports the need for further prospective studies. Disclosures Lai: Agios: Membership on an entity's Board of Directors or advisory committees; Daiichi-Sankyo: Membership on an entity's Board of Directors or advisory committees; Jazz Pharma: Membership on an entity's Board of Directors or advisory committees; Jazz Pharma: Speakers Bureau; Astellas: Speakers Bureau.

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Phase I Study of Ixazomib with Conventional Chemotherapy in the Treatment of Acute Myeloid Leukemia in Older Adults

Blood ◽

10.1182/blood-2020-140584 ◽

2020 ◽

Vol 136 (Supplement 1) ◽

pp. 7-8

Author(s):

Philip C. Amrein ◽

Eyal C. Attar ◽

Geoffrey Fell ◽

Traci M. Blonquist ◽

Andrew M. Brunner ◽

...

Keyword(s):

Acute Myeloid Leukemia ◽

Board Of Directors ◽

Myeloid Leukemia ◽

Research Funding ◽

Remission Rate ◽

Conventional Chemotherapy ◽

Advisory Committees ◽

Secondary Aml ◽

Grade 3 ◽

Acute Myeloid

Introduction: Outcomes for acute myeloid leukemia (AML) among older patients has remained largely unchanged for decades. Long-term survival for patients aged >60 years is poor (median survival 10.5 months). Targeting the proteasome in AML is attractive, since leukemia stem cells have demonstrated sensitivity to proteasome inhibition in preclinical models, perhaps through down regulation of nuclear NF-KB (Guzman, Blood 2001). AML cell lines are susceptible to synergistic cytotoxicity when bortezomib, a proteasome inhibitor, is combined with daunorubicin and cytarabine. We have shown that adding bortezomib to standard treatment in AML results in a high remission rate, although grade 2 sensory neurotoxicity was noted in approximately 12% of treated patients. A newer generation proteasome inhibitor, ixazomib, is less frequently associated with neurotoxicity, and, therefore, was selected for combination with conventional chemotherapy in this phase I trial. The primary objective of this study was to determine the maximum tolerated dose (MTD) of ixazomib in combination with conventional induction and consolidation chemotherapy for AML. Herein are the initial results of this trial. Methods: Adults >60 years of age with newly diagnosed AML were screened for eligibility. Patients with secondary AML were eligible, including those with prior hypomethylating agent therapy for myelodysplastic syndromes (MDS). We excluded those with promyelocytic leukemia. There were 2 phases in this study. In the first phase (A), the induction treatment consisted of the following: cytarabine 100 mg/m2/day by continuous IV infusion, Days 1-7; daunorubicin 60 mg/m2/day IV, Days 1, 2, 3, and ixazomib was provided orally at the cohort dose, Days 2, 5, 9, and 12. Consolidaton or transplant was at the discretion of the treating physician in phase A. In the second phase (B), induction was the same as that with the determined MTD of ixazomib. All patients were to be treated with the following consolidation: cytarabine at 2 g/m2/day, days 1-5 with ixazomib on days 2, 5, 9, and 12 at the cohort dose for consolidation. A standard 3 + 3 patient cohort dose escalation design was used to determine whether the dose of ixazomib could be safely escalated in 3 cohorts (1.5 mg/day, 2.3 mg/day, 3.0 mg/day), initially in induction (phase A) and subsequently in consolidation (phase B). The determined MTD of ixazomib in the first portion (A) of the trial was used during induction in the second portion (B), which sought to determine the MTD for ixazomib during consolidation. Secondary objectives included rate of complete remission, disease-free survival, and overall survival (OS). Results: Thirty-six patients have been enrolled on study, and 28 have completed dose levels A-1 through A-3 and B1 through B-2. Full information on cohort B-3 has not yet been obtained, hence, this report covers the experience with the initial 28 patients, cohorts A-1 through B-2. There were 12 (43%) patients among the 28 with secondary AML, either with prior hematologic malignancy or therapy-related AML. Nineteen patients (68%) were male, and the median age was 68 years (range 61-80 years). There have been no grade 5 toxicities due to study drug. Three patients died early due to leukemia, 2 of which were replaced for assessment of the MTD. Nearly all the grade 3 and 4 toxicities were hematologic (Table). There was 1 DLT (grade 4 platelet count decrease extending beyond Day 42). There has been no grade 3 or 4 neurotoxicity with ixazomib to date. Among the 28 patients in the first 5 cohorts, 22 achieved complete remissions (CR) and 2 achieved CRi, for a composite remission rate (CCR) of 86%. Among the 12 patients with secondary AML 8 achieved CR and 2 achieved CRi, for a CCR of 83%. The median OS for the 28 patients has not been reached (graph). The 18-month OS estimate was 65% [90% CI, 50-85%]. Conclusions: The highest dose level (3 mg) of ixazomib planned for induction in this trial has been reached safely. For consolidation there have been no serious safety issues in the first 2 cohorts with a dose up to 2.3 mg, apart from 1 DLT in the form of delayed platelet count recovery. The recommended phase 2 dose of ixazomib for induction is 3 mg. Accrual to cohort B-3 is ongoing. Notably, to date, no grade 3 or 4 neurotoxicity has been encountered. The remission rate in this older adult population with the addition of ixazomib to standard chemotherapy appears favorable. Figure Disclosures Amrein: Amgen: Research Funding; AstraZeneca: Consultancy, Research Funding; Takeda: Research Funding. Attar:Aprea Therapeutics: Current Employment. Brunner:Jazz Pharmaceuticals: Membership on an entity's Board of Directors or advisory committees; Forty-Seven Inc: Membership on an entity's Board of Directors or advisory committees; AstraZeneca: Research Funding; Takeda: Research Funding; Celgene: Membership on an entity's Board of Directors or advisory committees, Research Funding; Novartis: Research Funding. Hobbs:Constellation: Honoraria, Research Funding; Novartis: Honoraria; Incyte: Research Funding; Merck: Research Funding; Bayer: Research Funding; Jazz: Honoraria; Celgene/BMS: Honoraria. Neuberg:Celgene: Research Funding; Madrigak Pharmaceuticals: Current equity holder in publicly-traded company; Pharmacyclics: Research Funding. Fathi:Blueprint: Consultancy; Boston Biomedical: Consultancy; BMS/Celgene: Consultancy, Research Funding; Novartis: Consultancy; Kura Oncology: Consultancy; Trillium: Consultancy; Amgen: Consultancy; Seattle Genetics: Consultancy, Research Funding; Abbvie: Consultancy; Pfizer: Consultancy; Newlink Genetics: Consultancy; Forty Seven: Consultancy; Trovagene: Consultancy; Kite: Consultancy; Daiichi Sankyo: Consultancy; Astellas: Consultancy; Amphivena: Consultancy; PTC Therapeutics: Consultancy; Agios: Consultancy, Research Funding; Takeda: Consultancy, Research Funding; Jazz: Consultancy. OffLabel Disclosure: Ixazomib is FDA approved for multiple myeloma. We are using it in this trial for acute myeloid leukemia.

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Epigenetic Activation of the pH Regulator MCT4 in Acute Myeloid Leukemia Exploits a Fundamental Metabolic Process of Enhancing Cell Growth through Proton Shifting

Blood ◽

10.1182/blood-2019-123604 ◽

2019 ◽

Vol 134 (Supplement_1) ◽

pp. 3765-3765

Author(s):

Cheuk-Him Man ◽

David T. Scadden ◽

Francois Mercier ◽

Nian Liu ◽

Wentao Dong ◽

...

Keyword(s):

Acute Myeloid Leukemia ◽

Cell Growth ◽

Board Of Directors ◽

Myeloid Leukemia ◽

Monocarboxylate Transporter ◽

Advisory Committees ◽

Hematopoietic Stem ◽

Equity Ownership ◽

Acute Myeloid

Acute myeloid leukemia (AML) cells exhibit metabolic alterations that may provide therapeutic targets not necessarily evident in the cancer cell genome. Among the metabolic features we noted in AML compared with normal hematopoietic stem and progenitors (HSPC) was a strikingly consistent alkaline intracellular pH (pHi). Among candidate proton regulators, monocarboxylate transporter 4 (MCT4) mRNA and protein were differentially increased in multiple human and mouse AML cell lines and primary AML cells. MCT4 is a plasma membrane H+and lactate co-transporter whose activity necessarily shifts protons extracellularly as intracellular lactate is extruded. MCT4 activity is increased when overexpressed or with increased intracellular lactate generated by glycolysis in the setting of nutrient abundance. With increased MCT4 activity, extracellular lactate and protons will increase causing extracellular acidification while alkalinizing the intracellular compartment. MCT4-knockout (MCT4-KO) of mouse and human AMLdid not induce compensatory MCT1 expression, reduced pHi, suppressed proliferation and improved animal survival. Growth reduction was experimentally defined to be due to intracellular acidification rather than lactate accumulation by independent modulation of those parameters. MCT4-KOmetabolic profiling demonstrated decreased ATP/ADP and increased NADP+/NADPH suggesting suppression of glycolysis and the pentose phosphate pathway (PPP) that was confirmed by stable isotopic carbon flux analyses. Notably,the enzymatic activity of purified gatekeeper enzymes, hexokinase 1 (HK1), pyruvate kinase M2 isoform (PKM2) and glucose-6-phosphate dehydrogenase (G6PDH) was sensitive to pH with increased activity at the leukemic pHi (pH 7.6) compared to normal pHi (pH 7.3). Evaluating MCT4 transcriptional regulation, we defined that activating histonemarks, H3K27ac and H3K4me3, were enriched at the MCT4 promoter region as were transcriptional regulators MLL1 and Brd4 by ChIP in AML compared with normal cells. Pharmacologic inhibition of Brd4 suppressed Brd4 and H3K27ac enrichment and MCT4 expression in AML and reduced leukemic cell growth. To determine whether MCT4 based pHi changes were sufficient to increase cell proliferation, we overexpressed MCT4 in normal HSPC and demonstrated in vivo increases in growth in conjunction with pHi alkalization. Some other cell types also were increased in their growth kinetics by MCT4 overexpression and pHi increase. Therefore, proton shifting may be a means by which cells respond to nutrient abundance, co-transporting lactate and protons out of the cell, increasing the activity of enzymes that enhance PPP and glycolysis for biomass generation. Epigenetic changes in AML appear to exploit that process by increasing MCT4 expression to enforce proton exclusion thereby gaining a growth advantage without dependence on signaling pathways. Inhibiting MCT4 and intracellular alkalization may diminish the ability of AML to outcompete normal hematopoiesis. Figure Disclosures Scadden: Clear Creek Bio: Consultancy, Equity Ownership, Membership on an entity's Board of Directors or advisory committees; Novartis: Other: Sponsored research; Editas Medicine: Consultancy, Equity Ownership, Membership on an entity's Board of Directors or advisory committees; Bone Therapeutics: Consultancy; Fog Pharma: Consultancy; Red Oak Medicines: Consultancy, Equity Ownership, Membership on an entity's Board of Directors or advisory committees; LifeVaultBio: Equity Ownership, Membership on an entity's Board of Directors or advisory committees; Magenta Therapeutics: Consultancy, Equity Ownership, Membership on an entity's Board of Directors or advisory committees; Agios Pharmaceuticals: Equity Ownership, Membership on an entity's Board of Directors or advisory committees; Fate Therapeutics: Consultancy, Equity Ownership.

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EZH2 Mutations and Impact on Clinical Outcome Analyzed in 1604 Patients with Acute Myeloid Leukemia

Blood ◽

10.1182/blood-2018-99-114421 ◽

2018 ◽

Vol 132 (Supplement 1) ◽

pp. 1528-1528

Author(s):

Sebastian Stasik ◽

Jan Moritz Middeke ◽

Michael Kramer ◽

Christoph Rollig ◽

Alwin Krämer ◽

...

Keyword(s):

Bone Marrow ◽

Acute Myeloid Leukemia ◽

Board Of Directors ◽

Myeloid Leukemia ◽

Research Funding ◽

Employment Equity ◽

Advisory Committees ◽

Mutational Status ◽

Equity Ownership ◽

Acute Myeloid

Abstract Purpose: The enhancer of zeste homolog 2 (EZH2) is a histone methyltransferase and key epigenetic regulator involved in transcriptional repression and embryonic development. Loss of EZH2 activity by inactivating mutations is associated with poor prognosis in myeloid malignancies such as MDS. More recently, EZH2 inactivation was shown to induce chemoresistance in acute myeloid leukemia (AML) (Göllner et al., 2017). Data on the frequency and prognostic role of EZH2-mutations in AML are rare and mostly confined to smaller cohorts. To investigate the prevalence and prognostic impact of this alteration in more detail, we analyzed a large cohort of AML patients (n = 1604) for EZH2 mutations. Patients and Methods: All patients analyzed had newly diagnosed AML, were registered in clinical protocols of the Study Alliance Leukemia (SAL) (AML96, AML2003 or AML60+, SORAML) and had available material at diagnosis. Screening for EZH2 mutations and associated alterations was done using Next-Generation Sequencing (NGS) (TruSight Myeloid Sequencing Panel, Illumina) on an Illumina MiSeq-system using bone marrow or peripheral blood. Detection was conducted with a defined cut-off of 5% variant allele frequency (VAF). All samples below the predefined threshold were classified as EZH2 wild type (wt). Patient clinical characteristics and co-mutations were analyzed according to the mutational status. Furthermore, multivariate analysis was used to identify the impact of EZH2 mutations on outcome. Results: EZH2-mutations were found in 63 of 1604 (4%) patients, with a median VAF of 44% (range 6-97%; median coverage 3077x). Mutations were detected within several exons (2-6; 8-12; 14-20) with highest frequencies in exons 17 and 18 (29%). The majority of detected mutations (71% missense and 29% nonsense/frameshift) were single nucleotide variants (SNVs) (87%), followed by small indel mutations. Descriptive statistics of clinical parameters and associated co-mutations revealed significant differences between EZH2-mut and -wt patients. At diagnosis, patients with EZH2 mutations were significantly older (median age 59 yrs) than EZH2-wt patients (median 56 yrs; p=0.044). In addition, significantly fewer EZH2-mut patients (71%) were diagnosed with de novo AML compared to EZH2-wt patients (84%; p=0.036). Accordingly, EZH2-mut patients had a higher rate of secondary acute myeloid leukemia (sAML) (21%), evolving from prior MDS or after prior chemotherapy (tAML) (8%; p=0.036). Also, bone marrow (and blood) blast counts differed between the two groups (EZH2-mut patients had significantly lower BM and PB blast counts; p=0.013). In contrast, no differences were observed for WBC counts, karyotype, ECOG performance status and ELN-2017 risk category compared to EZH2-wt patients. Based on cytogenetics according to the 2017 ELN criteria, 35% of EZH2-mut patients were categorized with favorable risk, 28% had intermediate and 37% adverse risk. No association was seen with -7/7q-. In the group of EZH2-mut AML patients, significantly higher rates of co-mutations were detected in RUNX1 (25%), ASXL1 (22%) and NRAS (25%) compared to EZH2-wt patients (with 10%; 8% and 15%, respectively). Vice versa, concomitant mutations in NPM1 were (non-significantly) more common in EZH2-wt patients (33%) vs EZH2-mut patients (21%). For other frequently mutated genes in AML there was no major difference between EZH2-mut and -wt patients, e.g. FLT3ITD (13%), FLT3TKD (10%) and CEBPA (24%), as well as genes encoding epigenetic modifiers, namely, DNMT3A (21%), IDH1/2 (11/14%), and TET2 (21%). The correlation of EZH2 mutational status with clinical outcomes showed no effect of EZH2 mutations on the rate of complete remission (CR), relapse free survival (RFS) and overall survival (OS) (with a median OS of 18.4 and 17.1 months for EZH2-mut and -wt patients, respectively) in the univariate analyses. Likewise, the multivariate analysis with clinical variable such as age, cytogenetics and WBC using Cox proportional hazard regression, revealed that EZH2 mutations were not an independent risk factor for OS or RFS. Conclusion EZH mutations are recurrent alterations in patients with AML. The association with certain clinical factors and typical mutations such as RUNX1 and ASXL1 points to the fact that these mutations are associated with secondary AML. Our data do not indicate that EZH2 mutations represent an independent prognostic factor. Disclosures Middeke: Janssen: Membership on an entity's Board of Directors or advisory committees, Research Funding; Abbvie: Membership on an entity's Board of Directors or advisory committees; Roche: Membership on an entity's Board of Directors or advisory committees. Rollig:Bayer: Research Funding; Janssen: Research Funding. Scholl:Jazz Pharma: Membership on an entity's Board of Directors or advisory committees; Abbivie: Other: Travel support; Alexion: Other: Travel support; MDS: Other: Travel support; Novartis: Other: Travel support; Deutsche Krebshilfe: Research Funding; Carreras Foundation: Research Funding; Pfizer: Membership on an entity's Board of Directors or advisory committees. Hochhaus:Pfizer: Research Funding; Incyte: Research Funding; Novartis: Research Funding; Bristol-Myers Squibb: Research Funding; Takeda: Research Funding. Brümmendorf:Janssen: Consultancy; Takeda: Consultancy; Novartis: Consultancy, Research Funding; Merck: Consultancy; Pfizer: Consultancy, Research Funding. Burchert:AOP Orphan: Honoraria, Research Funding; Bayer: Research Funding; Pfizer: Honoraria; Bristol Myers Squibb: Honoraria, Research Funding; Novartis: Research Funding. Krause:Novartis: Research Funding. Hänel:Amgen: Honoraria; Roche: Honoraria; Takeda: Honoraria; Novartis: Honoraria. Platzbecker:Celgene: Research Funding. Mayer:Eisai: Research Funding; Novartis: Research Funding; Roche: Research Funding; Johnson & Johnson: Research Funding; Affimed: Research Funding. Serve:Bayer: Research Funding. Ehninger:Cellex Gesellschaft fuer Zellgewinnung mbH: Employment, Equity Ownership; Bayer: Research Funding; GEMoaB Monoclonals GmbH: Employment, Equity Ownership. Thiede:AgenDix: Other: Ownership; Novartis: Honoraria, Research Funding.

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