Persistence of Cytogenetic Abnormalities at Complete Remission Is Not Prognostic for Relapse-Free or Overall Survival in Adult Patients with Acute Lymphoblastic Leukemia

Blood ◽  
2015 ◽  
Vol 126 (23) ◽  
pp. 1416-1416
Author(s):  
Nicholas J. Short ◽  
Hagop M. Kantarjian ◽  
Elias Jabbour ◽  
Susan O'Brien ◽  
Stefan Faderl ◽  
...  
Keyword(s):  
Overall Survival ◽  
Complete Remission ◽  
Research Funding ◽  
Residual Disease ◽  
Lymphoblastic Leukemia ◽  
Prognostic Significance ◽  
Adult Patients ◽  
Relapse Free Survival ◽  
Free Survival ◽  
Cytogenetic Abnormalities

Abstract Background: Cytogenetic abnormalities are identified at the time of diagnosis in approximately 80% of patients with acute lymphoblastic leukemia (ALL). In acute myelogenous leukemia (AML), the detection of persistent abnormal cytogenetics at complete remission (ACCR) is associated with shorter relapse-free survival (RFS) and overall survival (OS) compared to patients with normal cytogenetics at CR (NCCR). However, the incidence and prognostic significance of ACCR in adult patients with ALL is unknown. Methods: We evaluated 324 adult patients with ALL and abnormal cytogenetics at baseline who were treated on frontline induction chemotherapy protocols between 6/2001 and 3/2015 and achieved complete remission (CR) or CR without platelet recovery (CRp). Bone marrow specimens for cytogenetic and minimal residual disease (MRD) assessment were obtained at the time of CR. Cytogenetic abnormalities were classified according to standard conventions (Moorman et al., Blood 2007;109:3189-97). MRD by multi-parameter flow cytometry (MFC) was assessed with a sensitivity of 0.01% using a 15-marker, 4-color panel in the first half of the study period; subsequently a 6-color panel was used. Results: 272 patients (84%) had cytogenetic analysis performed at the time of remission and were evaluable for this analysis. Median age was 48 years (range, 16-84) and median WBC at presentation was 11.6 x109/L (range, 0.4-629.4 x109/L). A hyperCVAD backbone was used for induction in 237 patients (87%) and augmented BFM was used in 35 (13%). All patients with Philadelphia positive (Ph+) ALL were treated with a tyrosine kinase inhibitor added to the chemotherapy regimen. 245 patients (90%) had pre-B ALL, 14 (5%) had pre-T ALL and 13 (5%) had Burkitt or Burkitt-like leukemia. Cytogenetics at baseline were Ph+ in 119 (44%), hyperdiploid in 31 (11%), complex in 18 (7%), MLL rearranged in 16 (6%), hypodiploid in 9 (3%) and miscellaneous in 79 (29%). Median time to CR was 23 days (range 14 to 84 days). Among the 272 patients, ACCR was observed in 26 (9.6%). Baseline characteristics associated with ACCR were Ph+ ALL (62% of ACCR group vs. 42% of NCCR group, P=0.055) and longer mean time to CR (29.8 ± 15.6 days for ACCR group vs. 26.0 ± 9.7 days for NCCR group, P=0.07). Median RFS was 22.4 months (range, 12.3 months to not reached) for patients with ACCR vs. 47.7 months (range, 29.5 to 125 months) in those patients with NCCR (P=0.31). Median OS did not differ between the ACCR (98.7 months [range, 17.1 months to not reached]) and NCCR groups (67.3 months [range, 46.6 months to not reached], P=0.86). There was also not a significant difference in RFS or OS between the ACCR and NCCR groups when only Ph+ patients were evaluated. Among the 227 patients evaluable for MRD by MFC, MRD positivity at CR was observed in 78 patients (34%) and was highly associated with shorter RFS and OS (P<0.01 for both). The specificity of ACCR for detecting MRD (as assessed by MFC) was 43%, and there was overall poor correlation between these two methods for the detection of residual disease (P=0.47). When patients were stratified by MRD status as assessed by MFC, the presence of absence of persistent cytogenetic abnormalities did not add additional prognostic information (Fig. 1 and 2). Conclusions: There is poor association between MRD assessment by MFC and the presence or absence of cytogenetic abnormalities at CR in adult patients with ALL. Although ACCR has prognostic significance in AML, ACCR is not associated with adverse outcomes in ALL and therefore should not be used to guide prognostication or therapeutic decisions. Figure 1. Relapse-free survival of patients with and without cytogenetic abnormalities at CR, stratified by MRD status Figure 1. Relapse-free survival of patients with and without cytogenetic abnormalities at CR, stratified by MRD status Figure 2. Overall survival of patients with and without cytogenetic abnormalities at CR, stratified by MRD status Figure 2. Overall survival of patients with and without cytogenetic abnormalities at CR, stratified by MRD status Disclosures Faderl: Celgene Corp.: Other: Advisory Board. Burger:Pharmacyclics LLC, an AbbVie Company: Research Funding. Konopleva:Novartis: Research Funding; AbbVie: Research Funding; Stemline: Research Funding; Calithera: Research Funding; Threshold: Research Funding. Cortes:Pfizer: Consultancy, Research Funding; BMS: Consultancy, Research Funding; Teva: Consultancy, Research Funding; Novartis: Consultancy, Research Funding; ARIAD Pharmaceuticals Inc.: Consultancy, Research Funding.

scholarly journals Complete Hematologic and Molecular Response in Adult Patients With Relapsed/Refractory Philadelphia Chromosome–Positive B-Precursor Acute Lymphoblastic Leukemia Following Treatment With Blinatumomab: Results From a Phase II, Single-Arm, Multicenter Study

2017 ◽  
Vol 35 (16) ◽  
pp. 1795-1802 ◽  
Author(s):  
Giovanni Martinelli ◽  
Nicolas Boissel ◽  
Patrice Chevallier ◽  
Oliver Ottmann ◽  
Nicola Gökbuget ◽  
...  
Keyword(s):  
Overall Survival ◽  
Stem Cell ◽  
Residual Disease ◽  
Lymphoblastic Leukemia ◽  
Philadelphia Chromosome ◽  
Relapse Free Survival ◽  
Hematopoietic Stem ◽  
Free Survival ◽  
Disease Response ◽  
Minimal Residual

Purpose Few therapeutic options are available for patients with Philadelphia chromosome–positive (Ph+) B-precursor acute lymphoblastic leukemia (ALL) who progress after failure of tyrosine kinase inhibitor (TKI) −based therapy. Here, we evaluated the efficacy and tolerability of blinatumomab in patients with relapsed or refractory Ph+ ALL. Patients and Methods This open-label phase II study enrolled adults with Ph+ ALL who had relapsed after or were refractory to at least one second-generation or later TKI or were intolerant to second-generation or later TKIs and intolerant or refractory to imatinib. Blinatumomab was administered in 28-day cycles by continuous intravenous infusion. The primary end point was complete remission (CR) or CR with partial hematologic recovery (CRh) during the first two cycles. Major secondary end points included minimal residual disease response, rate of allogeneic hematopoietic stem-cell transplantation, relapse-free survival, overall survival, and adverse events (AEs). Results Of 45 patients, 16 (36%; 95% CI, 22% to 51%) achieved CR/CRh during the first two cycles, including four of 10 patients with the T315I mutation; 88% of CR/CRh responders achieved a complete minimal residual disease response. Seven responders (44%) proceeded to allogeneic hematopoietic stem-cell transplantation, including 55% (six of 11) of transplantation-naïve responders. Median relapse-free survival and overall survival were 6.7 and 7.1 months, respectively. The most frequent AEs were pyrexia (58%), febrile neutropenia (40%), and headache (31%). Three patients had cytokine release syndrome (all grade 1 or 2), and three patients had grade 3 neurologic events, one of which (aphasia) required temporary treatment interruption. There were no grade 4 or 5 neurologic events. Conclusion Single-agent blinatumomab showed antileukemia activity in high-risk patients with Ph+ ALL who had relapsed or were refractory to TKIs. AEs were consistent with previous experience in Ph– ALL.

scholarly journals Prognostic Impact of Kinase Mutations and Minimal Residual Disease in Core-Binding Factor Leukemia

Blood ◽  
2015 ◽  
Vol 126 (23) ◽  
pp. 3828-3828
Author(s):  
David Sanford ◽  
Jorge E. Cortes ◽  
Farhad Ravandi ◽  
Wei Qiao ◽  
Keyur P. Patel ◽  
...  
Keyword(s):  
Overall Survival ◽  
Research Funding ◽  
Residual Disease ◽  
Univariate Analysis ◽  
Prognostic Impact ◽  
Rt Pcr ◽  
Relapse Free Survival ◽  
Free Survival ◽  
Log Reduction ◽  
Binding Factor

Abstract Background Core-binding factor (CBF) acute myeloid leukemia (AML) is characterized by recurrent cytogenetic abnormalities t(8;21)(q22;q22) or inv(16)(p13q22)/t(16;16)(p13;q22), amenable for minimal residual disease (MRD) monitoring by quantitative reverse transcription polymerase chain reaction (RT-PCR). Kinase mutations (KIT, RAS, FLT3) have been reported to carry adverse prognostic implication. Promising results using FLAG-based treatment (fludarabine/Ara-C/G-CSF) in CBF leukemia in phase 2 [Borthakur G, Am J Hematol, 10, 89 (2014)] and phase 3 [Burnett AK, JCO, 27, 31 (2013)] clinical trials prompted us to review the prognostic impact of MRD evaluation and mutations. Methods The primary aim was to assess the prognostic impact of kinase-activating mutations (KIT, FLT3-TKD, FLT3-ITD, KRAS and NRAS) and MRD in CBF leukemia treated with FLAG-based regimens. Newly diagnosed patients were treated in 2 consecutive phase 2 clinical trials (clinicaltrials.gov identifier: NCT00801489) and received FLAG during induction (1 cycle) and consolidation (up to 6 cycles) in combination with either gemtuzumab (for 3 cycles) or idarubicin (for 2 cycles). Mutation analysis was performed at baseline on bone-marrow aspirates and MRD was measured on serial bone marrow aspirates using RT-PCR to detect RUNX1-RUNX1T1 and CBFB-MYH11 fusion transcripts, normalized to ABL1 transcript. The Kaplan-Meier method was used to estimate unadjusted overall survival (OS) and relapse-free survival (RFS). The Cox-proportional hazards model was used to estimate the association of covariates with OS and RFS. Landmark survival analysis was used to determine the association between OS/RFS and MRD, to account for time-dependent nature of this covariate. Results: One hundred and seven patients were included [t(8;21)=54, inv(16)=53]. Forty-eight were treated with FLAG + gemtuzumab and 59 were treated with FLAG + idarubicin. The 3 year OS and RFS for the cohort was 79% (95% CI, 71-89%) and 82% (95% CI, 74 - 91%) respectively with comparable outcomes with both regimens. The incidence of mutations in KIT, FLT3-ITD, FLT3-TKD and NRAS/KRAS was 13%, 7%, 10% and 38.5% respectively. In univariate analysis, the presence of mutations in KIT, FLT3 and NRAS/KRAS individually or together were not associated with OS or RFS. A 3-log or greater reduction in RT-PCR level at 1 month and 3-4 months was associated with improved RFS. A 3-log or greater reduction in RTPCR level at 6-9 months was also significantly associated with improved OS (HR 0.19, 95% CI 0.03 -1.0, p=0.05) and there was a trend towards improved OS with 3-log reduction at 1 month (HR 0.39, 95% CI 0.14 - 1.06, p=0.06). Conclusion: In contrast to some reports, mutations in KIT, FLT3 and RAS were not prognostic for RFS or OS in our study. Favorable outcomes using FLAG-based therapy in CBF leukemia may abrogate adverse impact of kinase mutations and this hypothesis needs to be clinically tested. The incidence of KIT mutations was slightly lower in our cohort in comparison to most previous reports, which may relate to differences in sensitivity of detection. Significantly, quantitative detection of MRD by PCR early on appears to be a broadly applicable predictor of relapse and may be the most relevant prognostic factor for clinical management of CBF leukemia patients. Table 1. Univariate analysis showing hazard of relapse for all patients HR 95% CI p-value Age 1.00 0.97 - 1.04 0.89 Performance status (ECOG 1,2 vs. 0) 3.59 1.3 - 9.95 0.01 Therapy related (Y vs. N) 0.38 0.05 - 2.93 0.36 CBF Type - [inv(16) vs. t(8;21)] 0.95 0.34 - 2.62 0.92 Treatment (FLAG-ida vs. FLAG-GO) 1.59 0.56 - 4.51 0.38 Mutated KIT (Y vs. N) 1.55 0.35 -6.91 0.56 FLT3-ITD (Y vs. N) 0.7 0.09 - 5.39 0.73 FLT3-TKD (Y vs. N) 2.07 0.46 - 9.32 0.34 RAS - NRAS/KRAS (Y vs. N) 0.79 0.24 - 2.63 0.7 Any mutation -KIT/FLT3/ RAS (Y vs. N) 1.17 0.42 - 3.22 0.76 MRD - 3 log reduction at 1 month (Y vs. N) 0.23 0.06 - 0.81 0.02 MRD - 3 log reduction at 3-4 months (Y vs. N) 0.18 0.05 - 0.61 <0.01 MRD - 3 log reduction at 6-9 months (Y vs. N) 0.29 0.06 - 1.41 0.12 MRD - negative at 6-9 months (Y vs. N) 0.3 0.06 - 1.47 0.13 Figure 1. Outcomes by mutation status (KIT or FLT3 or RAS). (a) Overall survival; (b) Relapse free survival. Figure 1. Outcomes by mutation status (KIT or FLT3 or RAS). (a) Overall survival; (b) Relapse free survival. Disclosures Cortes: Teva: Research Funding; Novartis: Consultancy, Research Funding; BerGenBio AS: Research Funding; Pfizer: Consultancy, Research Funding; BMS: Consultancy, Research Funding; Ariad: Consultancy, Research Funding; Astellas: Consultancy, Research Funding; Ambit: Consultancy, Research Funding; Arog: Research Funding; Celator: Research Funding; Jenssen: Consultancy.

scholarly journals Poor Outcomes with Hyper CVAD Induction for T-Cell Lymphoblastic Leukemia/Lymphoma

Blood ◽  
2015 ◽  
Vol 126 (23) ◽  
pp. 3762-3762 ◽  
Author(s):  
Vamsi K Kota ◽  
Amanda Redden Hathaway ◽  
Bijal D. Shah ◽  
Deniz Peker ◽  
Ling Zhang ◽  
...  
Keyword(s):  
Overall Survival ◽  
Clinical Trials ◽  
Board Of Directors ◽  
Research Funding ◽  
Lymphoblastic Leukemia ◽  
Cancer Center ◽  
Relapse Free Survival ◽  
Advisory Committees ◽  
Free Survival ◽  
Genetics Research

Abstract Background: T-cell acute lymphoblastic leukemia/lymphoma (T-ALL/LBL) in adults is an aggressive bone marrow malignancy that historically has a poor prognosis. Hyper-CVAD/methotrexate-cytarabine (hyper CVAD) regimen is a commonly used induction regimen following the protocol developed at MD Anderson Cancer center. Recent reports from Swedish Cancer Registry showed that relapse rates were much higher than expected with this regimen. We report our retrospective experiences across three different centers, Winship Cancer Institute of Emory University (Atlanta), University of Alabama Cancer Center (Birmingham) and Moffitt Cancer Center, (Tampa), with the use of this regimen for management of T-ALL/LBL. Methods: We conducted a retrospective chart review of all adult T-ALL/T-LBL cases at three large cancer centers between the years 2005-2015, treated at the physician's discretion. Data collected included patient demographics, tumor characteristics (white count at diagnosis, flow cytometry, FISH, cytogenetics, bone marrow involvement), treatment regimens and patient outcomes. Since hyper CVAD is a commonly used regimen outside of clinical trials, we focused our analysis on outcomes with this regimen. This regimen consisted of 4 courses of hyper-CVAD (fractionated cyclophosphamide, vincristine [VCR], doxorubicin, dexamethasone; the odd courses 1, 3, 5, 7); and 4 courses of MTX-Ara-C (methotrexate-cytarabine; the even courses 2, 4, 6, 8). CNS prophylaxis was given to all patients as per standard of care recommendations. All patients eligible for maintenance received 2 years of POMP (6 mercaptopurine, methotrexate, vincristine and prednisone) maintenance. Relapse-free survival (RFS) and overall survival (OS) were examined looking at medians and interquartile ranges of times to events. Kaplan Meier curves provided a graphical representation of the survival probability. Results: The final analysis included 95 adult patients with 64/95 (67%) patients receiving hyper-CVAD induction. Among the hyper-CVAD patients the median age at diagnosis was 30 (range 17-74). 71% of patients were male. Median white cell count (WBC) was 13.6/mm3 (1.7-500). Cytogenetic analysis revealed diploid in 36, complex (1 or more abnormalities in 16) and was not available in 12. WBC count was > 100,000/mm3 in 9 patients. 14 patients had mediastinal disease while 7 had CNS disease at diagnosis. Hyper-CVAD was the primary induction regimen in 56/64. Other patients either started on non-hyper CVAD induction prior to switching (n=3) or had asparaginase added to induction (n=5). The median number of cycles given as 7 (range 2-10) with 27(45%) patients receiving the planned 8 cycles. 37 patients did not complete 8 cycles due to stem cell transplant in remission (n=12), progressive disease (n=10) and unclear reasons (n=15). After induction therapy, remission status was unknown in 3 patients while 43/61 patients (70%) achieved remission. Maintenance with POMP was started in 21 patients that were in remission while 12 patients were taken to transplant without starting on maintenance. At the time of analysis, 23/64 (35%) patients are alive. The median relapse free survival was 387 days (12.9 months) and the median overall survival was 536 days (17.6 months). Excluding one patient lost to follow up, 44/63 (69.8%) relapsed. There was no difference in relapse versus non relapse patients in terms of median age (30 vs 33 years), median WBC at diagnosis (13.2 vs 13.6 mm3). Relapse rate was lower in patients with diploid karyotype (22/36, 61%) as compared to those with complex karyotype (14/16). Median survival in patients post relapse was 150 days. Only 9 patients were able to go for transplant after relapse with post transplant survival also being low (6 deaths). For the entire group, the two year survival was 35%. Conclusion: Our multi-institutional retrospective review shows that outcomes are poor across various centers in patients outside of clinical trials. This is the largest reported series of patients with adult T-ALL/T-LBL treated with hyper-CVAD outside of clinical trials. This data warrants investigation with newer agents to improve outcomes in this disease. Figure 1. Relapse free survival and overall survival in patients treated with hyper-CVAD (n=64) Figure 1. Relapse free survival and overall survival in patients treated with hyper-CVAD (n=64) Disclosures Kota: Leukemia Lymphoma Society: Research Funding; Pfizer: Membership on an entity's Board of Directors or advisory committees. Hathaway:OnQ Health: Research Funding. Shah:Celgene: Membership on an entity's Board of Directors or advisory committees, Speakers Bureau; Acetylon: Membership on an entity's Board of Directors or advisory committees; PLexus Communications: Honoraria; Pharmacyclics: Speakers Bureau; Spectrum: Membership on an entity's Board of Directors or advisory committees, Speakers Bureau; Bayer: Honoraria; Rosetta Genomics: Research Funding; Seattle Genetics: Research Funding. Jillella:Seattle Genetics, Inc.: Research Funding. Borate:Genoptix: Consultancy; Seattle Genetics: Research Funding; Gilead: Speakers Bureau; Alexion: Speakers Bureau; Novartis: Speakers Bureau; Amgen: Speakers Bureau.

scholarly journals Evaluating Outcomes of Adult Patients with Acute Lymphoblastic Leukemia Treated on the GMALL Protocol

Blood ◽  
2020 ◽  
Vol 136 (Supplement 1) ◽  
pp. 28-29
Author(s):  
Danielle Fredman ◽  
Yulia Volchek ◽  
Gabriel Heering ◽  
Keren Shichrur ◽  
Ronit Yerushalmi ◽  
...  
Keyword(s):  
Overall Survival ◽  
Research Funding ◽  
Blood Donors ◽  
Lymphoblastic Leukemia ◽  
Survival Rates ◽  
Disease Relapse ◽  
Relapse Free Survival ◽  
Free Survival ◽  
Car T ◽  
Matched Sibling

Background Chemotherapy based approaches still constitute an essential feature in the treatment paradigm of adult acute lymphoblastic leukemia (ALL). The German Multicenter Study Group (GMALL) is a well-established and commonly used protocol for ALL (Gökbuget 2012). Over the years evolving versions of the protocol have been developed with the aim of improving patient outcome (Apel 2014). In view of the recent advancements in the treatment of adult ALL we now analyzed our more recent data. Aims Assess the clinical outcomes of adult ALL patients treated on the GMALL protocol in real world settings, and establish prognostic parameters associated with long term survival and risk of relapse. Methods Retrospective analysis of all adult ALL patients who were treated with GMALL in our institution between the years 2008-2020. Demographic, clinical, cytogenetic, treatment, and transplant related data were collected using our institution's electronic medical records system. Baseline characteristics were evaluated by Fisher's exact test and Wilcoxon rank sum tests. Kaplan-Meier estimates were used to estimate overall survival (OS) and relapse-free survival (RFS). Hazard ratios and 95% confidence intervals were generated using a Cox proportional hazards model. Results The analysis comprised 81 evaluable patients with a median age of 36 years (range 18-73), 36% were adolescents and young adults (AYA). Forty-three were B-ALL (53%), 12 (15%) patients were Philadelphia chromosome positive ALL (Ph+ ALL), and 26 (32%) were T-ALL. Median duration of follow-up was 24.4 months (range 0.7-112.1 months), at the time of data analysis 51 patients (63.8%) were alive. Seventy patients (88%) attained a first remission (CR1) and 4 (5%) died during the first two induction phases. The 2-year and 5-year overall survival rates were 62% and 44%, respectively. Estimated 2-year and 5-year leukemia-free survival rates were 52% and 35%, respectively. Overall, disease relapse (31%), lethal infection (28%), and graft-versus-host disease (14%) accounted for most patient deaths. Of patients achieving CR1, 20 (29%) eventually relapsed after a median time of 9.8 months (range 1.1-69.3). Fifty-five patients (68%) underwent an allogeneic stem cell transplantation using matched sibling (47%), matched unrelated (31%), haploidentical (7%), partially mismatched (12%), and cord blood donors (3%). Of the 50 patients transplanted in CR1, 15 relapsed (30%) after a median time of 10.9 months (range 3.8-32.8). Multivariate analysis revealed that in terms of overall survival, increasing patient age was associated with inferior outcome [Hazard ratio (HR)=1.026, confidence interval (CI) 95%, 1.002-1.05, p=0.035) as was outcome for patients whose baseline cytogenetic analysis detected a higher number of clones (HR=2.69, CI 95%, 1.57-4.62, p=0.0002). T-ALL patients experienced longer survival compared with B-ALL (87 months versus 56 months, p=0.019) while patients transplanted using cord blood donors had inferior survival, 12.8 months, compared with matched sibling donors, 71.3 months, and fully matched unrelated donors, 73.4 months (p=0.001, and p=0.003, respectively). Relapse-free survival was significantly better in patients with T-ALL compared with B-ALL (90 months vs. 50 months, p=0.039), and in patients without t(12;21)(p13;q22) (75 months vs. 11.7 months, p=0.034). Gender, AYA status, extramedullary disease at diagnosis, initial white blood cell count, treatment delays, presence of MLL rearrangement, specific measurable residual disease modality used, GMALL risk category, and cytogenetic hyperdiploidy did not significantly impact on survival or disease relapse. Treatments for relapse following GMALL included blinatumomab (6), inotuzumab (3), nelarabine (3), and CAR-T (2). Conclusions While results are improving for patients treated on GMALL, a substantial patient segment still experiences relapse. It is conceivable that in the near future new novel therapeutic modalities for adult ALL involving the use of monoclonal antibodies and CAR-T cell therapy will help reduce relapse rates and further improve the current outcomes of patients treated on the GMALL protocol. Disclosures Avigdor: Takeda, Gilead, Pfizer: Consultancy, Honoraria; Janssen, BMS: Research Funding. Canaani:Abbvie: Consultancy, Honoraria, Research Funding.

Phase II Study of the Frontline Hyper-CVAD in Combination with Ofatumumab for Adult Patients (pts) with CD-20 Positive Acute Lymphoblastic Leukemia (ALL)

Blood ◽  
2015 ◽  
Vol 126 (23) ◽  
pp. 1295-1295 ◽  
Author(s):  
Koji Sasaki ◽  
Paul B. Koller ◽  
Hagop M. Kantarjian ◽  
Deborah A Thomas ◽  
Maria R. Khouri ◽  
...  
Keyword(s):  
Overall Survival ◽  
Complete Remission ◽  
Multiple Organ Failure ◽  
Research Funding ◽  
De Novo ◽  
Residual Disease ◽  
Progression Free Survival ◽  
Multiple Organ ◽  
Free Survival ◽  
Minimal Residual

Abstract Background: The hyper-CVAD regimen is an effective frontline regimen for de novo adult ALL. Expression of CD20 was identified as an adverse prognostic factor, associated with a higher incidence of relapse, lower 3-year complete remission duration (CRD) and lower 3-year overall survival (OS) rate. The addition of rituximab to the hyper-CVAD regimen in pts with CD20-positive ALL (≥20% expression by multicolor flow cytometry - FCI) improved outcome with 3-year CRD and OS rates by 68% and 65%, respectively. Ofatumumab (HuMax-CD20) targets a membrane proximal small-loop epitope on the CD20 molecule and was found to be more potent than rituximab in promoting complement-dependent cytotoxicity in vitro. Ofatumumab's safety and efficacy has been proven in chronic lymphocytic leukemia. Therefore a combination of the hyper-CVAD regimen and ofatumumab may be associated with better response rates, higher 3-year CRD and overall survival rates. Methods: Pts with newly diagnosed ALL and pts who received one prior course of chemotherapy received 4 courses of hyper-CVAD (fractionated cyclophosphamide, vincristine [VCR], doxorubicin, dexamethasone; the odd courses 1, 3, 5, 7); ofatumumab was given on courses 1 and 3, and 4 courses of MTX-Ara-C (methotrexate-cytarabine; the even courses 2, 4, 6, 8); ofatumumab was given on courses 2 and 4. This treatment would be followed by POMP (6-mercaptopurine, MTX, VCR, prednisone) maintenance therapy for approximately 30 months, interrupted by intensifications months 6, 7 and 18, 19 with MTX/Pegylated asparaginase and hyper-CVAD-ofatumumab. Central nervous system prophylaxis with MTX and ara-C was administered. When indicated local radiotherapy was administered in patients with bulky mediastinal disease Results: To date 37 pts with de novo ALL and 4 pts in complete remission (CR) previously treated (2 with prior cycle of hyper-CVAD, 1 post fludarabine-cytarabine based regimen, 1 with cyclophosphamide and dexamethasone) have received a median of 6 cycles (1-8) of therapy. Median age is 46 years (32-71). Median WBC at diagnosis was 5.4 x 109/L (1 -202 x 109/L). CD20 expression above 20% was found in 27 pts (66%), between 10 and 20% in 3 (7%) and below 10% in 11 (27%). 2 pts (5%) had concomitant CNS disease at diagnosis. Among the 34 pts with evaluable baseline cytogenetic analysis, 20 (49%) were abnormal. All but one pt (97%) achieved a CR after cycle 1 (4 pts were in CR at the start); 1 pt died of septic shock and multiple organ failure at day 21 of cycle 1. Thirty-eight (95%) pts achieved minimal residual disease (MRD) negativity as assessed by FCI; of whom 23 (64%) achieved MRD negativity after induction. Ten (27%) pts did not receive the full 8 planned courses of induction-consolidation; 16 (43%) pts are receiving maintenance in CR; 4 (11%) pts finished all treatment; 5 (%) pts were referred to allogeneic stem cell transplantation due to multiple cytogenetic abnormalities and delay in achieving negative MRD. Median time to neutrophil and platelet recovery for cycle 1 was 18 and 22 days after induction chemotherapy, respectively. Grade ≥ 3 toxicity included increase of LFT's in 13 pts (32%), increase of bilirubin in 7 (17%), nausea/vomiting in 4 (10%), mucositis in 3 (7%), neuropathy in 3 (7%), and thrombotic events in 1 (2%). Febrile neutropenia episodes during induction and consolidation cycles were reported at rates of 67% and 89%, respectively. With a median follow up of 15 months (1-45), 35 pts are alive; 6 pts relapsed and one had molecular relapse only. Six pts died: 1 at C1D22 of sepsis and intracranial bleed; 1 at C3D17 of sepsis and multiple organ failure; 1 at maintenance C16D35 of sepsis; 1 of relapse post ASCT; 1 post salvage therapy for minimal residual disease relapse; 1 of progressive disease after relapse. The 2-year PFS and OS rates were 68% and 87% respectively. Conclusion: The combination of hyper-CVAD with ofatumumab is safe and highly effective in pts with CD20-positive ALL. Table 1. Patient characteristics and outcome N (%)/Median [range] N=41 Age (yrs) 44 [22-71] Sex Male 25 (61) Female 16 (39) PS 0-1 38 (93) 2-3 3 (7) WBC (x 109/L) 5.4 [0.7-201.7] CNS disease positivity 2 (5) CD20 + (%) 1-10 9 (22) 10-20 3 (7) >20 27 (66) Pos 2 (5) CG Diploid 14 (34) Abnormal 20 (49) IM/ND 7 (17) Response CR 37/38 (97) CR after induction 37/38 (97) MRD at CR 23/36 (64) MRD overall 38/40 (95) Early death 1 (3) Figure 1. Progression-free survival and overall survival Figure 1. Progression-free survival and overall survival Disclosures Cortes: Teva: Research Funding; BerGenBio AS: Research Funding; Pfizer: Consultancy, Research Funding; Novartis: Consultancy, Research Funding; Ariad: Consultancy, Research Funding; BMS: Consultancy, Research Funding; Astellas: Consultancy, Research Funding; Ambit: Consultancy, Research Funding; Arog: Research Funding; Celator: Research Funding; Jenssen: Consultancy. Chahoud:American Society of Hematology (ASH): Other: 2015 HONORS Award recipient. Verstovsek:Incyte Corporation: Research Funding. Konopleva:Novartis: Research Funding; AbbVie: Research Funding; Stemline: Research Funding; Calithera: Research Funding; Threshold: Research Funding. O'Brien:Pharmacyclics LLC, an AbbVie Company: Consultancy, Research Funding.

scholarly journals Prognostic impact of complete remission with MRD negativity in patients with relapsed or refractory AML

2020 ◽  
Vol 4 (24) ◽  
pp. 6117-6126
Author(s):  
Nicholas J. Short ◽  
Hind Rafei ◽  
Naval Daver ◽  
Hyunsoo Hwang ◽  
Jing Ning ◽  
...  
Keyword(s):  
Overall Survival ◽  
Complete Remission ◽  
Cumulative Incidence ◽  
Residual Disease ◽  
Multiparameter Flow Cytometry ◽  
Prognostic Impact ◽  
Relapse Free Survival ◽  
Hematopoietic Stem ◽  
Free Survival ◽  
Refractory Aml

Abstract In relapsed/refractory acute myeloid leukemia (AML), the prognostic impact of complete remission (CR) and measurable residual disease (MRD) negativity is not well established. We retrospectively analyzed 141 patients with relapsed/refractory AML who received first salvage therapy and had MRD assessed by multiparameter flow cytometry at the time of response. Patients who achieved CR with full hematologic recovery as best response vs those with incomplete hematology recovery had lower cumulative incidence of relapse (P = .01) and better relapse-free survival (P = .004) but not overall survival (P = .15); a similar trend was observed in patients who achieved MRD negativity vs those who were MRD positive (P = .01, P = .05, and P = .21, respectively). By multivariate analysis, CR and MRD negativity were each independently associated with lower cumulative incidence of relapse (P = .001 and P = .003, respectively) and better relapse-free survival (P &lt; .001 and P = .02) but not overall survival. Patients who achieved CR with MRD negativity had the lowest rates of relapse and best survival (2-year overall survival rate, 37%), which was driven largely by lower rates of early relapse and an increased ability in this group to undergo hematopoietic stem cell transplantation (HSCT); however, post-HSCT outcomes were similar regardless of response to salvage chemotherapy. Overall, in patients with relapsed/refractory AML, CR with MRD negativity was associated with the best outcomes, supporting it as the optimal response in this setting.

Blast Percentage of Bone Marrow Aspirate on Day 14 of Induction Chemotherapy Predicts Adult Acute Lymphoblastic Leukemia Treatment Outcomes

2018 ◽  
Vol 139 (4) ◽  
pp. 220-227 ◽  
Author(s):  
Han-Seung Park ◽  
Dae-Young Kim ◽  
Eun-Ji Choi ◽  
Jung-Hee Lee ◽  
Je-Hwan Lee ◽  
...  
Keyword(s):  
Bone Marrow ◽  
Overall Survival ◽  
Acute Lymphoblastic Leukemia ◽  
Complete Remission ◽  
Treatment Outcomes ◽  
Induction Chemotherapy ◽  
Lymphoblastic Leukemia ◽  
Relapse Free Survival ◽  
Free Survival ◽  
Adult Acute Lymphoblastic Leukemia

The prognosis of adult acute lymphoblastic leukemia is much worse than that of pediatric acute lymphoblastic leukemia, even when patients achieve complete remission. Early response to treatment can be an important alternative indicator of treatment outcomes. The purpose of our current study was to identify the prognostic value of the blast percentage of the induction interim bone marrow, which might predict relapse-free survival and overall survival in patients with adult acute lymphoblastic leukemia. A retrospective analysis was performed on 80 adult patients diagnosed with Philadelphia chromosome-negative acute lymphoblastic leukemia from 1994 to 2011. Complete remission was observed in 75 (93.8%) patients after induction chemotherapy. On multivariate analysis, a reduction of blasts to a level of 5% or less in the induction interim bone marrow and CD20 positivity were significant prognostic predictors of relapse-free survival (hazard ratio, HR = 2.88, p = 0.006, and HR = 2.67, p = 0.010) and overall survival (HR = 2.10, p = 0.033, and HR = 2.39, p = 0.013). The blast percentage of the induction interim bone marrow may be a useful prognostic factor to predict outcome.

scholarly journals Structural Chromosomal Changes Are Common Manifestation of FLT3 ITD Relapse and Presence of Chromosomal Progression Is Independent of Normal Karyotype at Diagnosis

Blood ◽  
2016 ◽  
Vol 128 (22) ◽  
pp. 2868-2868 ◽  
Author(s):  
Melanie Rebechi ◽  
Wesley Hand ◽  
B. Douglas Smith ◽  
Ivana Gojo ◽  
Margaret M. Showel ◽  
...  
Keyword(s):  
Overall Survival ◽  
Research Funding ◽  
Excision Repair ◽  
Clonal Evolution ◽  
Relapse Free Survival ◽  
Free Survival ◽  
Cytogenetic Abnormalities ◽  
New Findings ◽  
Structural Abnormalities ◽  
Allelic Burden

Abstract FLT3 ITD mutations occur in both cytogenetically normal and abnormal AML. FLT3 ITD mutated AML is associated with genomic instability and clonal evolution (Gourdinet al., Cancer Genet 2014). The most common other molecular abnormality in FLT3 ITD AML, NPM1, has been shown to participate in DNA damage response and base excision repair but its role in clonal evolution in AML is poorly characterized (Polettoet al., Mol Biol of Cell 2014). We set out to describe the characteristics of clonal evolution in FLT3 ITD AML cases treated at Johns Hopkins Hospital (JHH) over the past 15 years to characterize clinical outcomes in these leukemias. 211 patients with FLT3 ITD AML were seen at JHH between 2000 and 2015, including newly diagnosed cases, and those referred for relapsed disease, with diagnostic and response information was available for 162 patients. 132 patients (81.4%) achieved remission, of which 66 subsequently relapsed (50%). 26 (16%) patients were refractory to therapy, 3 (1.8%) patients died during induction therapy, and 1 (0.6%) patient chose supportive care only. Characteristics at diagnosis are described in Table 1. Median relapse free survival was 1.07 year and median overall survival was 1.48 years (Table 2). Relapse free survival (RFS) and overall survival (OS) were longer for patients who were less than 60 years old (p=0.001 and p<0.0001 Log-rank test). Overall survival was longer for patients who were diagnosed in or after the year 2010 (p=0.0038). Patients who received a BMT had the longest relapse free (median 2.75yr, v 0.63 yr, p=<0.0001) and overall survivals (median 2.49 v 0.73 yrs, p<0.0001). RFS and OS did not appear to be dependent upon ITD length, cytogenetics, or allelic burden. However, the 5-year survival for the low allelic burden (<40 bp) patients was 35.6%, compared to 45.2% for the high allelic burden patients (>/=40 bp). Median RFS was nearly twice as long for patients with NPM1 mutations (median 2.11 v 1.06 yrs, p=NS). The 5-year overall survival for the NPM1 positive patients was 49.6%, when compared to 29.4% for NPM1 negative patients. The median allelic burden and ITD length at relapse (49% and 62bp) were similar to those at diagnosis (30% and 56.5bp) and most remained FLT3 ITD mutated at relapse (88%)(Table 3). 50% of relapsed patients were found to have new cytogenetic abnormalities (27/54). Of those with new findings, 26/27 (96%) of those cytogenetic changes were acquired structural abnormalities (26/27). 9/27 (33%) were acquired numerical abnormalities and 8/27 (30%) acquired both structural and numerical abnormalities. Those patients who acquired structural abnormalities had a median RFS of 0.77 years versus those who remained cytogenetically unchanged from diagnosis had a median RFS of 0.62 years(p=NS). Interestingly, patients with abnormal cytogenetics at diagnosis were not statistically more likely to acquire new cytogenetic abnormalities at relapse than patients with normal cytogenetics at diagnosis who relapsed (40% versus 54%, p=NS). Patients with NPM1 mutations at diagnosis appeared to acquire new cytogenetic abnormalities at relapse less often (5/15) than NPM1 negative patients (7/11)(33% versus 64%, p=NS), although this observation did not reach statistical significance (Fishers exact test). Patients who acquired cytogenetic abnormalities had a higher median allelic burden at diagnosis (67.5% versus 24%), although those without cytogenetic evolution had higher allelic burden at relapse (127.5% vs 38.5% median allelic burden). ITD lengths were similar for both groups at diagnosis (58bp and 56.5bp) but patients who acquired cytogenetic abnormalities also had longer median ITD lengths at relapse (67.5 bp versus 57.5 bp). These results suggest that FLT3 ITD AML is a heterogeneous disease with variable clinical outcome linked to age at diagnosis, NPM1 status, FLT3 ITD allelic burden, and transplantation status. Cytogenetic clonal evolution is common in FLT3 ITD AML, irrespective of karyotype at diagnosis and likely reflects ongoing DNA repair and replication deficiencies in the leukemic clone. Further characterization of this deficiency may reveal future therapeutic targets. Disclosures Smith: Celgene: Consultancy, Other: member of DSMB. Levis:Novartis: Consultancy, Honoraria, Research Funding; Millennium: Consultancy, Research Funding; Daiichi-Sankyo: Consultancy, Honoraria; Astellas: Consultancy, Honoraria, Research Funding.

scholarly journals Outcome modeling with CRLF2, IKZF1, JAK, and minimal residual disease in pediatric acute lymphoblastic leukemia: a Children's Oncology Group Study

Blood ◽  
2012 ◽  
Vol 119 (15) ◽  
pp. 3512-3522 ◽  
Author(s):  
I-Ming Chen ◽  
Richard C. Harvey ◽  
Charles G. Mullighan ◽  
Julie Gastier-Foster ◽  
Walker Wharton ◽  
...  
Keyword(s):  
Acute Lymphoblastic Leukemia ◽  
High Risk ◽  
Minimal Residual Disease ◽  
Residual Disease ◽  
Lymphoblastic Leukemia ◽  
Prognostic Significance ◽  
Relapse Free Survival ◽  
Full Cohort ◽  
Free Survival ◽  
Minimal Residual

As controversy exists regarding the prognostic significance of genomic rearrangements of CRLF2 in pediatric B-precursor acute lymphoblastic leukemia (ALL) classified as standard/intermediate-risk (SR) or high-risk (HR), we assessed the prognostic significance of CRLF2 mRNA expression, CRLF2 genomic lesions (IGH@-CRLF2, P2RY8-CRLF2, CRLF2 F232C), deletion/mutation in genes frequently associated with high CRLF2 expression (IKZF1, JAK, IL7R), and minimal residual disease (MRD) in 1061 pediatric ALL patients (499 HR and 562 SR) on COG Trials P9905/P9906. Whereas very high CRLF2 expression was found in 17.5% of cases, only 51.4% of high CRLF2 expressors had CRLF2 genomic lesions. The mechanism underlying elevated CRLF2 expression in cases lacking known genomic lesions remains to be determined. All CRLF2 genomic lesions and virtually all JAK mutations were found in high CRLF2 expressors, whereas IKZF1 deletions/mutations were distributed across the full cohort. In multivariate analyses, NCI risk group, MRD, high CRLF2 expression, and IKZF1 lesions were associated with relapse-free survival. Within HR ALL, only MRD and CRLF2 expression predicted a poorer relapse-free survival; no difference was seen between cases with or without CRLF2 genomic lesions. Thus, high CRLF2 expression is associated with a very poor outcome in high-risk, but not standard-risk, ALL. This study is registered at www.clinicaltrials.gov as NCT00005596 and NCT00005603.

scholarly journals Phase I Study of Ixazomib Added to Chemotherapy in the Treatment of Acute Lymphoblastic Leukemia in Older Adults

Blood ◽  
2020 ◽  
Vol 136 (Supplement 1) ◽  
pp. 41-42
Author(s):  
Philip C. Amrein ◽  
Karen K. Ballen ◽  
Kristen E. Stevenson ◽  
Traci M. Blonquist ◽  
Andrew M. Brunner ◽  
...  
Keyword(s):  
Overall Survival ◽  
Acute Lymphoblastic Leukemia ◽  
Complete Remission ◽  
Board Of Directors ◽  
Research Funding ◽  
Lymphoblastic Leukemia ◽  
Advisory Committees ◽  
Survival Estimate ◽  
Grade 3 ◽  
Experienced Grade

Introduction: While progress has been made in the treatment of childhood leukemia, the outlook for patients &gt;60 years of age with acute lymphoblastic leukemia (ALL) is poor with complete remission rates (CR) of approximately 60% and 3-year survivals (OS) of less than 15%. Intensified treatment in a later CALGB trial showed little improvement with a CR=61% and 5-year OS=6% (Stock, Cancer 2013). Ixazomib is an oral proteasome inhibitor, which has shown single agent activity and promising combination activity in pediatric ALL patients (Messinger, Blood 2012). We sought to assess the safety and tolerability, as well as early efficacy of adding ixazomib to a current MGH-DFCI/HCC multi-agent regimen for older adults with ALL. Methods: Patients aged 51 to 75 years of age with newly diagnosed B-ALL and T-ALL were screened for eligibility. Patients with mature ALL (including Burkitt's) were excluded. Patients with Philadelphia chromosome positive ALL (BCR-ABL1+) were eligible, and dasatinib was added to the chemotherapy on Day 10 for these patients. The chemotherapy treatment schedule from induction through maintenance is outlined in Table 1. A standard 3 + 3 patient cohort dose escalation design was used to determine the maximum tolerated dose (MTD) of ixazomib during induction for these patients, the primary objective of the trial. After consolidation I, patients in complete remission (CR) with a suitable donor were offered a hematopoietic stem cell transplantation (HSCT) as per institutional guidelines. Those not going to HSCT continued therapy as noted in the table. Results: There were 19 patients with B-ALL enrolled, none with T-ALL. Among these patients, 7 harbored BCR-ABL1 rearrangements. The median age was 65 years, 74% were male, and 90% had a performance status 0 or 1. The MTD was 2.3 mg of ixazomib, as 2 patients at 3.0 mg developed DLT's: a grade 3 peripheral neuropathy and a grade 5 acute kidney injury (Table 2). Grade 3 and 4 toxicities encountered at any time consisted mainly of grade 4 neutropenia in 13 patients and grade 4 thrombocytopenia in 12 patients. One patient experienced grade 3 neutropenia and 5 patients experienced grade 3 thrombocytopenia. Two patients with grade 2 neuropathy did not meet the definition of DLT. Among the 19 patients, 15 (79%, [95% confidence interval (CI), 54-94%]) achieved CR (14) or CRi (1), and 5 patients went on to HSCT. The median follow-up time was 2 years (range, 1-5) for 8 patients remaining alive. The 1-year overall survival estimate was 53% [95% CI, 29-72%], while the 2-year overall survival estimate was 47% [95% CI, 24-67%]. Conclusions: A dose of 2.3 mg of ixazomib in combination with induction chemotherapy among older patients with ALL was well-tolerated and associated with a promising rate of complete remission. Disclosures Amrein: Takeda: Research Funding; AstraZeneca: Consultancy, Research Funding; Amgen: Research Funding. Brunner:Celgene: Membership on an entity's Board of Directors or advisory committees, Research Funding; Takeda: Research Funding; AstraZeneca: Research Funding; Forty-Seven Inc: Membership on an entity's Board of Directors or advisory committees; Jazz Pharmaceuticals: Membership on an entity's Board of Directors or advisory committees; Novartis: Research Funding. Hobbs:Novartis: Honoraria; Celgene/BMS: Honoraria; Jazz: Honoraria; Constellation: Honoraria, Research Funding; Incyte: Research Funding; Merck: Research Funding; Bayer: Research Funding. Neuberg:Celgene: Research Funding; Pharmacyclics: Research Funding; Madrigak Pharmaceuticals: Current equity holder in publicly-traded company. Fathi:Takeda: Consultancy, Research Funding; Agios: Consultancy, Research Funding; PTC Therapeutics: Consultancy; Amphivena: Consultancy; Astellas: Consultancy; Daiichi Sankyo: Consultancy; Novartis: Consultancy; Newlink Genetics: Consultancy; Pfizer: Consultancy; Blueprint: Consultancy; Trillium: Consultancy; Kura Oncology: Consultancy; Forty Seven: Consultancy; Jazz: Consultancy; Boston Biomedical: Consultancy; BMS/Celgene: Consultancy, Research Funding; Kite: Consultancy; Trovagene: Consultancy; Amgen: Consultancy; Seattle Genetics: Consultancy, Research Funding; Abbvie: Consultancy. OffLabel Disclosure: MLN 9708, ixazomib is FDA approved for multiple myeloma. In this trial it is used to treat acute lymphoblastic leukemia.

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