The Diagnostic Utility of Mutational Analysis in Patients with Suspected Myeloid Neoplasms, a Single Institution Experience

Abstract Introduction Molecular abnormalities in primary myeloid diseases have been well described. Some of these molecular alterations are nearly pathognomonic for specific diseases such as JAK2 V617F and CALR, whereas others are more generally associated with myeloid disorders, though they may have prognostic significance. Commercially available panel testing screen for multiple genetic alterations simultaneously and are used increasingly for diagnostic and prognostic purposes. We sought to evaluate the clinical utility of panel testing in primary myeloid disorders and to evaluate the impact on diagnosis and management. Methods Patients who presented to the MDS/MPN clinic between February, 2015 and May, 2016 were included in the study if a Genoptix Myeloid Molecular Panel (MMP) was submitted and resulted. The MMP tests for 40 recurrently mutated genes in myeloid malignancies using next generation sequencing. It includes genes involved with RNA splicing, epigenetics, transcription factors, cohesion complex, activated signaling, and others. Primary diagnosis (if determined), and rationale for testing (diagnostic, diagnosis in question, or prognostic) at the time the test was ordered was recorded. Charts were reviewed to determine if a diagnosis was made or if there was a change in diagnosis, prognosis, or management as a result of the MMP. Results 40 patients had a resulted MMP. The primary diagnoses at presentation were: ICUS (8), MDS (18), MF (7), CMML (2), MPN-U (2), MDS/MPN (1), and multiple diagnoses (2). Of the 40 patients that were evaluated, 35 patients had at least one reported mutation. 5 MMPs (12.5%) resulted in a change in diagnosis. 2 patients diagnosed with MPN-U at presentation were found to carry CSF3R mutation consistent with a diagnosis of chronic neutrophilic leukemia. 3 additional patients had an original diagnosis of MDS with fibrosis; however, 2 of these patients had a MPL mutation and third had a CALR mutation consistent with myelofibrosis. Of prognostic significance, 5 of the 18 patients with MDS (27.8%) were found to harbor TP53 mutations. Of these, 4 (22.2%) patients were previously classified as having low risk disease by IPSS, 2 (11.1%) of which had deletion 5q as their only cytogenetic abnormality. Altogether, 8 (20%) patients had a drastic change in diagnosis or prognosis. In 4 (10%) patients, this resulted in a change in management as follows: of the 2 patients that had a diagnosis of CNL, 1 was enrolled on a clinical trial involving a JAK2 inhibitor; 1 of the 2 patients with a history of MDS changed to MF by the identification of a CALR mutation was treated with a JAK2 inhibitor; and 2 of the patients with low risk MDS were referred for transplant evaluation due to the presence of a TP53 mutation where transplant would otherwise not be indicated. Conclusions: In this small series, we find that the MMP can aid in making an accurate diagnosis and has prognostic significance particularly in the following patient populations: MDS with fibrosis, MPN-U, and young patients with low-risk MDS who may benefit from closer monitoring and early referral for transplant evaluation. Confirmation of these observations merits prospective evaluation for a larger number of patients. Disclosures Shammo: novartis: Consultancy, Honoraria, Research Funding, Speakers Bureau; celgene: Consultancy, Honoraria, Research Funding, Speakers Bureau; incyte: Consultancy, Honoraria, Research Funding, Speakers Bureau; alexion: Consultancy, Honoraria, Research Funding, Speakers Bureau.

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Impact of Minimal Residual Disease in Transplant Ineligible Myeloma Patients: Results from the UK NCRI Myeloma XI Trial

Blood ◽

10.1182/blood.v128.22.245.245 ◽

2016 ◽

Vol 128 (22) ◽

pp. 245-245 ◽

Cited By ~ 6

Author(s):

Ruth Mary de Tute ◽

Andy C Rawstron ◽

David A Cairns ◽

Charlotte Pawlyn ◽

Faith E Davies ◽

...

Keyword(s):

Minimal Residual Disease ◽

Research Funding ◽

Residual Disease ◽

Prognostic Significance ◽

Continuous Variable ◽

Powerful Predictor ◽

Qualitative Variable ◽

The Impact ◽

Minimal Residual ◽

Support Research

Abstract Introduction. Minimal residual disease (MRD) is a powerful predictor of outcome in multiple myeloma (MM). We have previously demonstrated, in transplant eligible patients, that the level of MRD as a continuous variable independently predicts both PFS and OS, with approximately a one year median OS benefit per log depletion (J Clin Oncol 2013; 31:2540-7 and Blood 2015; 125:1932-5). The impact of MRD also appears to be independent of therapy received. There is more limited data on the applicability of MRD assessment in transplant ineligible patients, largely as a consequence of low rates of CR historically within this patient cohort. Patients and Methods. In this analysis we have assessed the impact of MRD on PFS amongst patients treated within the non-intensive arm of the NCRI Myeloma XI trial. Patients were randomised between thalidomide (CTDa) and lenalidomide (RCDa) based induction therapies with responding patients being subsequently randomised to maintenance with lenalidomide monotherapy, or no further therapy. Bone marrow aspirates were obtained at the end of induction and this analysis represents a subset of 297 patients (median age 74 years). MRD was assessed using flow cytometry (sensitivity 10-4) with a minimum of 500,000 cells evaluated with six-colour antibody combinations including CD138/CD38/CD45/CD19 with CD56/CD27 in all cases and CD81/CD117 in additional cases as required. Results. Overall MRD-negativity was demonstrated in 41/297 (13.8%). When considered according to induction therapy received 25/154 (16.0%) of patients randomized to RCDa were MRD-negative compared to 16/143 (10.8%) of those randomized to CTDa (p=0.24; Fisher's exact test). MRD-negativity was associated with a significant outcome advantage as the median PFS was 34 months versus 18 months for MRD-positive patients (p<0.0001, HR 0.44 [95% confidence interval (CI 0.29-0.67)]). This effect was noted in both RCDa (median PFS 17m v 32m; p=0.001, HR 0.41 [95%CI 0.23-0.69]) and CTDa (median PFS 19m v 34m; p=0.03, HR 0.49 [95%CI 0.26-0.95]). When the impact of MRD was assessed according to induction regimen the outcome of MRD-negative and MRD-positive patients was similar with both regimens (see figure). The impact of MRD was also assessed as a continuous variable across 5 logs of residual disease. Sequential improvements in outcome with each log reduction were demonstrable. Median PFS for the following disease levels; <0.01%, 0.01 - <0.1%, 0.1% - <1%, 1% - <10% and >/=10% were 34, 26, 16, 14 and 9 months respectively (p<0.0001). This pattern was demonstrable in both RCDa and CTDa treated patients (p<0.0001 for both). Multivariate analysis confirmed the independent predictive value of MRD both as a qualitative and continuous quantitative variable (p<0.0001 for both). In both instances achieving an immunofixation-negative CR was not a significant prognostic variable when included in the model with MRD. Conclusions. We would conclude that MRD is a powerful predictor of outcome in transplant ineligible patients and is a meaningful therapeutic goal in this patient group. In contrast to conventional CR it retains independent prognostic significance both as a quantitative and qualitative variable. This data further supports the role of MRD as a primary endpoint and surrogate marker for survival in future clinical trials. Figure. Figure. Disclosures Rawstron: Janssen: Research Funding; BD Biosciences: Other: Remuneration; Gilead: Consultancy, Honoraria, Research Funding; GlaxoSmithKline: Honoraria; Genzyme: Honoraria; AbbVie: Honoraria; Roche: Honoraria; Celegene: Honoraria. Pawlyn:Celgene: Consultancy, Honoraria, Other: Travel Support; Takeda Oncology: Consultancy. Davies:Janssen: Consultancy, Honoraria; Celgene: Consultancy, Honoraria; Takeda: Consultancy, Honoraria. Kaiser:Amgen: Consultancy, Honoraria; Celgene: Consultancy, Honoraria, Research Funding; Janssen: Honoraria; Takeda: Consultancy; Bristol-Myers Squibb: Consultancy, Other: Travel support; Chugai: Consultancy. Jones:Celgene: Honoraria, Research Funding. Cook:Janssen: Consultancy, Honoraria, Research Funding, Speakers Bureau; Glycomimetics: Consultancy, Honoraria; Takeda: Consultancy, Honoraria, Research Funding, Speakers Bureau; Amgen: Consultancy, Honoraria, Research Funding, Speakers Bureau; Bristol-Myers Squibb: Consultancy, Honoraria; Sanofi: Consultancy, Honoraria, Speakers Bureau; Celgene: Consultancy, Honoraria, Research Funding, Speakers Bureau. Jenner:Janssen: Consultancy, Honoraria, Other: Travel support, Research Funding; Celgene: Consultancy, Honoraria, Research Funding; Novartis: Consultancy, Honoraria; Amgen: Consultancy, Honoraria, Other: Travel support; Takeda: Consultancy, Honoraria, Other: Travel support. Drayson:Abingdon Health: Equity Ownership, Membership on an entity's Board of Directors or advisory committees. Jackson:MSD: Consultancy, Honoraria, Speakers Bureau; Celgene: Consultancy, Honoraria, Other: Travel support, Research Funding, Speakers Bureau; Roche: Consultancy, Honoraria, Speakers Bureau; Amgen: Consultancy, Honoraria, Speakers Bureau; Janssen: Consultancy, Honoraria, Speakers Bureau; Takeda: Consultancy, Honoraria, Other: Travel support, Research Funding, Speakers Bureau. Morgan:Celgene: Consultancy, Honoraria, Research Funding; Takeda: Consultancy, Honoraria; Bristol Meyers: Consultancy, Honoraria; Janssen: Research Funding; Univ of AR for Medical Sciences: Employment. Owen:Celgene: Consultancy, Honoraria, Research Funding; Takeda: Honoraria, Other: Travel support; Janssen: Consultancy, Other: Travel support.

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Detection of 13q14 Deletion by FISH Is Not Sufficient to Define a Group of Good Prognosis Patients with Chronic Lymphocytic Leukemia.

Blood ◽

10.1182/blood.v114.22.2332.2332 ◽

2009 ◽

Vol 114 (22) ◽

pp. 2332-2332

Author(s):

Virginie Eclache ◽

Vincent Levy ◽

Fanny Baran-Marszak ◽

Remi Letestu ◽

Florence Cymbalista

Keyword(s):

Prognostic Markers ◽

Prognostic Significance ◽

Genetic Alterations ◽

Large Cohort ◽

Fish Analysis ◽

Prognostic Impact ◽

Trisomy 12 ◽

Conventional Cytogenetics ◽

The Impact ◽

13Q Deletion

Abstract Abstract 2332 Poster Board II-309 Deletion of a 13q14.3 region is by far the most common genomic alteration in CLL. In a large cohort of CLL patients, the presence of deletion 13q as sole anomaly detected by FISH was predominantly found in Binet stage A CLL and associated with a favorable outcome (Dohner et al., N Engl J Med 2000). Further studies have evidenced some heterogeneity among CLL cases with 13q deletion, such as the size of the clone carrying the deletion, the existence of mono versus biallelic deletions, and the presence of other concomitant genetic aberrations. Therefore, we aimed at analysing the impact of this heterogeneity on the prognostic value of 13q14 deletion (del13q) in CLL. Patients and methods In a cohort of 329 previously untreated newly diagnosed stage A CLL, we detected del13q by FISH in 172 patients (52%) using the D13S319 probe. Conventional cytogenetics was performed in the 105 cases with del13q followed in our institution. The other important prognostic markers ( ZAP70, IgVH, CD38, proliferation markers) and clinical progression were also available for all patients. Results We first studied the large cohort of stage A patients and found that deletion 13q had no prognostic impact on PFS. When considering more specifically the presence of deletion 13q as sole anomaly (n=143), PFS was not significantly different from that of patients with no aberration detected by FISH analysis (del 13q, del11q, del17p and trisomy 12) (n=98). Moreover, the distribution of prognostic factors (ZAP70, sTK, mutational status, CD38 expression, lymphocytosis) was not statistically different among these two groups. We aimed at deciphering further these del13q cases through analysis of the percentage of deleted cells, the presence of mono versus biallelic deletions, and the presence of additional aberrations as detected by FISH and conventional cytogenetics in the 105 del13q cases followed in our institution. The size of the del13q clone, as reflected by the percentage of del13q cells by FISH, was highly variable, ranged from 7 to 90 %, and had no prognostic significance on PFS. Monoallelic deletions were present in 77 cases, fully biallelic deletions in 9 cases, and concomitant bi and monoallelic deletions in 19 cases. The 9 cases with biallelic deletions had a significantly shorter PFS and were associated with other unfavorable prognostic markers. As biallelic deletions are most likely to represent progression from monoallelic cases, it is understandable that no clear prognostic impact was evidenced between cases with monoallelic deletions and with concomitant variable amount of bi and monoallelic deleted cells. Twenty cases (20 monoallelic and 6 biallelic) were further studied by array-CGH. Minimal deleted region (MDR) was included in all deletions but the size of the deletion was variable and in most cases much larger than MDR. Among the 6 bi allelic cases, one of the deletions was restricted to the MDR in all cases, pointing out to the importance of the level of miRNA expression. Additional aberrations were found in 44/105 del13q cases. In 17 patients, one or more alterations were detected by FISH techniques : del11q (n=8), trisomy 12 (n=8) or del17p (n=5). By conventional cytogenetic all these aberrations were also detected, as well as other rare ones in 16 additional cases, either isolated or associated in a complex karyotype in 5 cases. Presence of additional aberrations had a significant unfavourable impact on PFS, even when excluding del11q, del17p and tri12, and considering the non recurrent aberrations that were detected by conventional cytogenetics only. Conclusion Presence of 13q deletion should not be considered as a good prognostic marker by itself among stage A patients. Moreover, del13q cases are highly heterogeneous, and the presence of deletion 13q should not be interpreted without considering both alleles or the presence of concomitant genetic alterations. Disclosures: No relevant conflicts of interest to declare.

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Clinical “MUTATOME” Of Myelodysplastic Syndrome; Comparison To Primary Acute Myelogenous Leukemia

Blood ◽

10.1182/blood.v122.21.518.518 ◽

2013 ◽

Vol 122 (21) ◽

pp. 518-518 ◽

Cited By ~ 1

Author(s):

Hideki Makishima ◽

Thomas LaFramboise ◽

Bartlomiej P Przychodzen ◽

Kenichi Yoshida ◽

Matthew Ruffalo ◽

...

Keyword(s):

High Risk ◽

Lower Risk ◽

Research Funding ◽

Somatic Mutations ◽

Low Risk ◽

Myelogenous Leukemia ◽

Clonal Architecture ◽

Ras Family ◽

Definition Of ◽

The Impact

Abstract Chromosomal aberrations and somatic mutations constitute key elements of the pathogenesis of myelodysplastic syndromes (MDS), a clonal hematologic malignancy characterized by cytopenias, a dysplastic bone marrow and propensity to clonal evolution. Next generation sequencing (NGS) enables definition of somatic mutational patterns and clonal architecture as a discovery platform, and for clinical applications. We systematically applied NGS to 707 cases of MDS and MDS-related disorders. 205 cases (low-risk MDS: N=78, high-risk MDS: N=42, MDS/MPN: N=48 and sAML: N=37) were tested by whole exome sequencing (WES). For validation in an additional 502 patients (low-risk MDS: N=192, high-risk MDS: N=104, MDS/MPN: N=111 and sAML: N=95), targeted deep NGS was applied for 60 index genes which were most commonly affected in the cohort analyzed by WES. For NGS data analysis a statistical pipeline was developed to focus on: i) identification of the most relevant somatic mutations, and ii) minimization of false positive results. We studied serial samples from 21 exemplary informative patients. We also compared somatic mutational patterns to those seen in primary AML TCGA cohort (N=201). Given the size of the cohort, there was, for example, a 87% chance of seeing mutations at a frequency of 1% and a 98% of seeing those with a frequency of 2%. While focusing on the most common events, we observed 1117 somatic mutations in 199 genes. The 88 genes mutated mutated in >1% of cases with MDS carried 388 mutations in MDS+sAML (2.5/case), 128 in MDS/MPN (2.7/case) and 398 in pAML (2.0/case). The average number of mutations per case increased during progression (2.2 in lower-risk, 2.8 in higher-risk MDS, 3.4 in sAML). In MDS, the 30 most frequently affected genes were present at least once in 70% of patients. The 30 most frequently mutated genes in MDS/MPN were mutated in 82% of patients. Individual mutations were also sub-grouped according to their function. When we compared three MDS subcategories (lower-risk, higher-risk MDS and sAML) in a cross-sectional view, RTK family, RAS family, IDH family and cohesin family mutations were more frequently detected in the sAML group than in the MDS group. In contrast, the frequency of the DNMT family, TET2 and ASXL family gene mutations did not increase in frequency in the sAML cohort. In addition to better definition of mutational patterns of known genes, we have also defined new mutations, including in the RNA helicase family and the BRCC3pathway. Clonal architecture analysis indicates that mutations of TET2, DNMT3A, ASXL1, and U2AF1 most likely represent ancestral/originator events, while those of the IDH family, RTK family and cohesin family are typical secondary events. Establishment of mutational patterns may improve the precision of morphologically-based diagnosis. The comparison between MDS-related diseases (MDS+sAML) and pAML revealed a notably different mutational pattern suggestive of a distinct molecular derivation of these two disease groups. While RTK, IDH family and NPM1 mutations were more frequently observed in the pAML cohort, mutations of SF3B1 and SRSF2, were more common in MDS+sAML. With regard to the connections between individual mutation combinations, RTK mutations were strongly associated with DNMT, but not with RAS family mutations in the pAML cohort, while the mutual association between TET2 and PRC2 family, cohesin family and RUNX1were encountered in the MDS+sAML cohort. Individual mutations may have prognostic significance, including having an impact on survival, either within the entire cohort or within specific subgroups. In the combined MDS cohort, TP53 family mutations were associated with a poor prognosis (HR; 3.65, 95%CI; 1.90-7.01, P<.0001) by univariate analysis. Similar results were found for mutations in TCF4(HR; 7.98, 95%CI; 1.58-10.1, P<.0007). Such an individual approach does not allow for assessment of the impact of less common mutational events. In conclusion, our study continues to indicate the power of NGS in the molecular analysis of MDS. MDS and related disorders show a great deal of pathogenetic molecular overlap, consistent with their morphologic and clinical pictures, but also distinct molecular differences in mutational patterns. Some of the specific mutations are pathognomonic for specific subtypes while some may convey a prognostic rather than discriminatory value. Disclosures: Makishima: Scott Hamilton CARES grant: Research Funding; AA & MDS international foundation: Research Funding. Polprasert:MDS foundation: Research Funding.

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PD-L1 and PD-L2 Genetic Alterations Define Classical Hodgkin Lymphoma and Predict Outcome

Blood ◽

10.1182/blood.v126.23.176.176 ◽

2015 ◽

Vol 126 (23) ◽

pp. 176-176

Author(s):

Margaretha GM Roemer ◽

Ranjana H Advani ◽

Azra H. Ligon ◽

Yasodha Natkunam ◽

Robert A Redd ◽

...

Keyword(s):

Board Of Directors ◽

Research Funding ◽

Early Stage ◽

Prognostic Significance ◽

Genetic Alterations ◽

Genetic Alteration ◽

Newly Diagnosed ◽

Advisory Committees ◽

Therapy Regimen ◽

Clinical Risk

Abstract Introduction. Classical Hodgkin Lymphomas (cHL) include small numbers of malignant Reed-Sternberg (RS) cells within an extensive but ineffective inflammatory/immune cell infiltrate. In cHL, chromosome 9p24.1 alterations increase the abundance of the PD-1 ligands, PD-L1 and PD-L2, and their further induction via JAK2-STAT signaling. PD-1 ligands engage the PD-1 receptor on T-cells and induce PD-1 signaling and T-cell exhaustion. Tumor cells expressing PD-1 ligands on their surface utilize the PD-1 pathway to evade an effective immune response. In recent pilot studies, PD-1 blockade was associated with high response rates and durable remissions in relapsed/refractory cHL. The unique composition of cHL limits its analysis with high throughput genomic assays. Therefore, the precise incidence, nature and prognostic significance of PD-L1 and PD-L2 alterations in cHL remain undefined. Herein, we utilize a recently developed fluorescence in situ hybridization (FISH) assay to characterize 9p24.1/PD-L1/PD-L2 alterations in a cohort of 108 newly diagnosed cHL patients (pts) who were uniformly treated with StanfordV (a combined modality therapy regimen) and have longterm followup. Methods. Pts were characterized as Ann Arbor early stage I/II favorable risk (ES-F), early stage unfavorable risk (bulk ≥ 10cm or ≥ .33 mediastinal dimension and/or B symptoms) (ES-U) or advanced stage III/IV (AS). ES-F pts received 8 weeks of Stanford V and 30 Gy involved field radiation (IFR); ES-U and AS pts received 12 weeks of Stanford V and 36 Gy IFR to initial sites > 5 cm. FISH was performed on formalin-fixed paraffin-embedded diagnostic biopsy specimens using bacterial artificial chromosome probes which covered CD274/PD-L1 (labeled with spectrum orange) and PDCD1LG2/PD-L2 (labeled with spectrum green) and a control centromeric probe (spectrum aqua-labeled CEP9, from 9p11-q11). Malignant RS cells were identified by their nuclear morphologic features and 50 RS cells/case were analyzed. Nuclei with a target:control probe ratio of at least 3:1 were defined as amplified (amp), those with a probe ratio of more than 1:1 but less than 3:1 were classified as relative copy gain, and those with a probe ratio of 1:1 but more than 2 copies of each probe were defined as polysomic for chromosome 9p. In each case, the percent and magnitude of disomy, polysomy, copy gain and amp were noted. In accordance with clinically approved diagnostic criteria, cases were classified by the highest observed level of 9p24.1 alteration. Specifically, cases with polysomy lacked copy gain or amp and cases with copy gain lacked amp. Immunohistochemical staining for PD-L1/PAX5 was performed as previously described and PD-L1 expression in PAX5 dim+ malignant RS cells and PAX5- infiltrating normal cells was assessed separately. Results. Almost all newly diagnosed cHL pts in this series had concordant alterations of the PD-L1 and PD-L2 loci; disomy was found in only 1% (1/108), polysomy in 5% (5/108), copy gain in 56% (61/108) and amp in 36% (39/108) of study pts. There was a correlation between intensity of PD-L1 protein expression and relative genetic alterations in this series. Two additional pts had translocations of PD-L1 or PD-L2 (2%, 2/108). We next assessed the association between specific types of PD-L1/PD-L2 alterations, clinical risk factors and outcome. Overall, the progression-free survival (PFS) was significantly lower for AS pts compared to ES-F/U pts (p=0.017). A model of PFS for the cHL pts by genetic alteration indicated that PFS was also significantly lower for pts with amp (p=0.02). Consistent with these findings, the incidence of 9p24.1 amp increased by clinical risk group: ES-F, 24%; ES-U, 34%; and AS, 50% (p=0.024, Kruskal-Wallis test). Therefore, we fit a full model of clinical and genetic factors including B-symptoms, bulk, stage and amp. Despite the association of amp with increased clinical risk groups, the genetic alteration further delineated PFS in the multivariate model (p=0.075). Conclusions. PD-L1/PD-L2 alterations are a defining feature of cHL with rare polysomy and more frequent copy gain and amp. There is an increased incidence of amp in pts with AS disease and a highly significant association of PD-L1/PD-L2 amp with PFS. These findings underscore the importance of genetically defined PD-1 mediated immune evasion in cHL and provide a rationale for the efficacy of PD-1 blockade in this disease. Disclosures Rodig: Perkin Elmer: Membership on an entity's Board of Directors or advisory committees; BMS: Research Funding. Shipp:BMS: Membership on an entity's Board of Directors or advisory committees, Research Funding; Bayer: Membership on an entity's Board of Directors or advisory committees, Research Funding; Sanofi: Research Funding; Gilead: Consultancy; Merck: Membership on an entity's Board of Directors or advisory committees.

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Targeting the Inflammatory Niche in MDS By Tasquinimod Restores Hematopoietic Support and Suppresses Immune-Checkpoint Expression in Vitro

Blood ◽

10.1182/blood-2021-150455 ◽

2021 ◽

Vol 138 (Supplement 1) ◽

pp. 2596-2596

Author(s):

Manja Wobus ◽

Ekaterina Balaian ◽

Uta Oelschlaegel ◽

Russell Towers ◽

Kristin Möbus ◽

...

Keyword(s):

Bone Marrow ◽

Mrna Expression ◽

Immunohistochemical Staining ◽

Research Funding ◽

Fold Increase ◽

Low Risk ◽

Hematopoietic Stem ◽

Healthy Donors ◽

The Impact

Abstract Introduction Myelodysplastic syndromes (MDS) belong to the most common hematological neoplasms in the elderly population, characterized by ineffective hematopoiesis, peripheral cytopenia and the risk of transformation into acute myeloid leukemia. There is increasing evidence that an aberrant innate immune response and a proinflammatory bone marrow (BM) microenvironment play a critical role in the pathogenesis of MDS. The alarmin S100A9, a key player for regulation of inflammatory responses, has been shown to be elevated in MDS patients. It directs an inflammatory cell death (pyroptosis) by increased NF-kB mediated transcription and secretion of proinflammatory, hematopoiesis-inhibitory cytokines and production of reactive oxygen species. Tasquinimod (TASQ, Active Biotech) is a novel, oral small molecular drug with S100A9 inhibitory activity and it is currently investigated in a phase Ib/IIa trial in relapsed/refractory multiple myeloma (NCT04405167). TASQ has demonstrated anti-angiogenic, antitumor and immunomodulatory properties in a broad range of preclinical solid tumor models; however, little is known about its effects in myeloid malignancies. Aim We investigated the role of S100A9 in cellular models of MDS and the potential of TASQ to target S100A9 within the MDS stroma in vitro. Methods Immunohistochemical staining of S100A9, CD271+ mesenchymal stromal cells (MSCs), CD68+ macrophages and CD66b+ neutrophils in BM tissues from MDS patients and healthy donors was performed with multiplex immunohistochemistry and analyzed with the VECTRA imaging system. MSCs from patients with either low-risk MDS, CMML or age-adjusted healthy donors were exposed to S100A9 (1.5µg/ml) in the presence or absence of TASQ (10µM). Subsequently, TLR4 downstreaming molecules such as IRAK1, gasdermin and NF-kB-p65 were analyzed by Western blot. Moreover, the mRNA expression of further proinflammatory molecules (IL-1b, IL-18, caspase1) and PD-L1 was quantified by real-time PCR. To study the impact on the hematopoietic support, MSCs were pre-treated for one week with S100A9 ± TASQ before CD34+ hematopoietic stem and progenitor cells (HSPCs) were seeded on the stromal layer. The colony formation (CAF-C) was analyzed weekly followed by a CFU-GEMM assay in methylcellulose medium. Additionally, PD-1 mRNA expression was quantified in cocultured HSPCs. Results Immunohistochemical staining of BM tissue demonstrated S100A9 expression mainly by CD66b+ neutrophils and with less extent by CD68+ macrophages. In line with this, we could not detect relevant S100A9 mRNA expression in cultured MDS or healthy MSCs in vitro. Exposure of MDS and healthy MSCs with S100A9 induced TLR4 downstream signalling as demonstrated by increased expression of IRAK1 and NF-kB-p65. We further detected a higher expression of gasdermin, an inductor of pyroptosis, in S100A9 exposed MSCs. Addition of TASQ abolished these effects and inhibited the expression of the mentioned proteins, indicating an alleviation of inflammation. Furthermore, we detected a 2-fold increase of mRNA expression of the proinflammatory cytokines IL-1b and IL-18 as well as a 5-fold increase of their activator caspase 1 in MSCs after treatment with S100A9, which could be prevented by TASQ. Interestingly, PD-L1 as a potential downstream target was induced by S100A9 by 2.5-fold and could be suppressed by TASQ to about 50%. To evaluate the impact on the hematopoietic support of MSCs, we analysed MSC/HSPC cocultures after treatment with S100A9. We observed a decreased number of cobblestone area forming cells (CAF-C) as well as reduced numbers of colonies (CFU) in a subsequent clonogenic assay, indicating a disturbed hematopoietic support by S100A9 treated MSCs. Interestingly, both the number of CAF-C and CFU could be increased by TASQ pre-treatment. Finally, the PD-1 expression in co-cultured HSPCs was regulated in the same way as its ligand in treated MSCs, nominating this interaction as a potential target of S100A9/TASQ in the MDS BM. Conclusion In summary, we provide evidence that the pathological inflammasome activation in the myelodysplastic bone marrow can be rescued by TASQ at least in part by inhibition of the S100A9 mediated TLR4 downstream signalling including NF-kB-p65 transcription and PD-L1 expression. These effects result in an improved hematopoietic support by MSCs, suggesting a potential efficacy to improve cytopenia in low-risk MDS patients. Disclosures Balaian: Novartis: Honoraria. Törngren: Active Biotech: Current Employment. Eriksson: Active Biotech: Current Employment. Platzbecker: AbbVie: Honoraria; Takeda: Honoraria; Celgene/BMS: Honoraria; Novartis: Honoraria; Janssen: Honoraria; Geron: Honoraria. Röllig: Novartis: Honoraria, Research Funding; Jazz: Honoraria; Janssen: Honoraria; Bristol-Meyer-Squibb: Honoraria, Research Funding; Amgen: Honoraria; AbbVie: Honoraria, Research Funding; Pfizer: Honoraria, Research Funding; Roche: Honoraria, Research Funding.

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Mutations Highly Specific for Secondary AML Are Associated with Poor Outcomes in Patients with NPM1-Mutated ELN Favorable Risk AML

Blood ◽

10.1182/blood-2021-150759 ◽

2021 ◽

Vol 138 (Supplement 1) ◽

pp. 686-686

Author(s):

Onyee Chan ◽

Najla Al Ali ◽

Hammad Tashkandi ◽

Austin Ellis ◽

Somedeb Ball ◽

...

Keyword(s):

Board Of Directors ◽

Research Funding ◽

Univariate Analysis ◽

Prognostic Significance ◽

Cancer Center ◽

Cell Transplant ◽

Intermediate Risk ◽

Advisory Committees ◽

Secondary Aml ◽

The Impact

Abstract Background: NPM1 is commonly mutated in acute myeloid leukemia (AML) and represents a distinct entity under the WHO 2016 classification. It is one of the few mutations that can potentially support favorable risk by European LeukemiaNet (ELN) 2017 criteria. Mutations that are highly specific for secondary AML including SRSF2, SF3B1, U2AF1, ZRSR2, ASXL1, EZH2, BCOR, and STAG2 (sMut) (Lindsley et al.) have been shown to confer poor prognosis. The impact of these mutations on NPM1-mutated AML warrants further investigation. Objective: In this study, we explore the outcomes in patients with NPM1-mutated AML. Methods: This was a retrospective study of NPM1-mutated AML patients who were diagnosed and treated at the Moffitt Cancer Center from 2013 to March 2021. Inclusion was restricted to NPM1-mutated patients with mutation analysis (NGS) performed at diagnosis (n=159). Kaplan-Meier, univariate, and multivariate analyses were performed. Results: Among 159 patients (78M/81F, median age 63 years at diagnosis), 80.5% had de novo AML. By ELN 2017 criteria, 63.5% (101/159) had favorable risk, 27.7% (44/159) had intermediate risk, and 8.2% (13/159) had adverse risk disease. Almost 90% had intermediate risk cytogenetics at the time of diagnosis. Common co-mutations included DNMT3A (47.2%), FLT3-ITD (35.8%), TET2 (26.4%), IDH1 (17.6%), FLT3-TKD (15.1%), and IDH2 (13.8%). sMut comprised 19.5% (31/159) of patients and 20.8% (21/101) of those with ELN favorable risk. In patients with treatment response data, those with sMut never achieved CR/CRi in 35.7% (10/28) compared to 17.2% (22/128) of patients without sMut (p=0.038). The overall survival (OS) was 43.7 months with a median follow up of 35.5 months. Patients with sMut had worse OS compared to those without sMut (14.7 months vs 57.6 months, p=0.011). Among patients with favorable risk disease, OS was 11.6 months compared to not reached for those with sMut and without sMut, respectively (p<0.0001). Univariate analysis showed sMut and allogeneic hematopoietic cell transplant (HCT) significantly impacted OS (sMut: HR 3.48, 95% CI: 1.80-6.72, p<0.001; HCT: HR 0.17, 95% CI: 0.07-0.44, p<0.001). Multivariate regression using covariates including age, AML type, sMut, and HCT confirmed their prognostic significance on survival (sMut: HR 2.40, 95% CI: 1.17-4.93, p=0.017; HCT: HR 0.26, 95% CI: 0.08-0.56, p=0.002). Conclusions: Our findings suggest NPM1-mutated AML patients with sMut have significantly worse prognosis despite being classified primarily as favorable risk by ELN 2017 at diagnosis. This may have treatment implications altering the need for and/or timing of HCT. These findings should be assessed prospectively and validated in independent datasets. Figure 1 Figure 1. Disclosures Hussaini: Adaptive: Consultancy, Honoraria, Speakers Bureau; Stemline: Consultancy; Amgen: Consultancy; Seattle Genetics: Consultancy; Celegene: Consultancy; Decibio: Consultancy; Guidepoint: Consultancy; Bluprint Medicine: Consultancy. Talati: AbbVie: Honoraria; Pfizer: Honoraria; Astellas: Speakers Bureau; BMS: Honoraria; Jazz: Speakers Bureau. Kuykendall: Incyte: Consultancy; Novartis: Honoraria, Speakers Bureau; Protagonist: Consultancy, Research Funding; Celgene/BMS: Honoraria; Abbvie: Honoraria; Blueprint: Honoraria; Pharmaessentia: Honoraria. Padron: Blueprint: Honoraria; Incyte: Research Funding; Kura: Research Funding; Stemline: Honoraria; Taiho: Honoraria; BMS: Research Funding. Sallman: Shattuck Labs: Membership on an entity's Board of Directors or advisory committees; Syndax: Membership on an entity's Board of Directors or advisory committees; Magenta: Consultancy; Takeda: Consultancy; Kite: Membership on an entity's Board of Directors or advisory committees; Bristol-Myers Squibb: Membership on an entity's Board of Directors or advisory committees, Speakers Bureau; Incyte: Speakers Bureau; Novartis: Consultancy, Membership on an entity's Board of Directors or advisory committees; Intellia: Membership on an entity's Board of Directors or advisory committees; AbbVie: Membership on an entity's Board of Directors or advisory committees; Agios: Membership on an entity's Board of Directors or advisory committees; Aprea: Membership on an entity's Board of Directors or advisory committees, Research Funding. Sweet: Novartis: Honoraria, Membership on an entity's Board of Directors or advisory committees; Astellas: Consultancy, Membership on an entity's Board of Directors or advisory committees; Gilead: Membership on an entity's Board of Directors or advisory committees; Bristol Meyers Squibb: Honoraria, Membership on an entity's Board of Directors or advisory committees; AROG: Membership on an entity's Board of Directors or advisory committees. Komrokji: Novartis: Consultancy, Honoraria, Membership on an entity's Board of Directors or advisory committees; Geron: Consultancy; BMSCelgene: Consultancy, Membership on an entity's Board of Directors or advisory committees, Speakers Bureau; Acceleron: Consultancy; AbbVie: Consultancy; Jazz: Consultancy, Speakers Bureau; Taiho Oncology: Membership on an entity's Board of Directors or advisory committees; PharmaEssentia: Membership on an entity's Board of Directors or advisory committees. Lancet: AbbVie: Consultancy; Celgene/BMS: Consultancy; Daiichi Sankyo: Consultancy; ElevateBio Management: Consultancy; Millenium Pharma/Takeda: Consultancy; BerGenBio: Consultancy; Jazz: Consultancy; Agios: Consultancy; Astellas: Consultancy.

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Symptom Burden in "Low Risk PV" Frequently Is Problematic and May Justify Earlier Intervention with Cytoreductive Therapy: An MPN-QOL Study Group Study

Blood ◽

10.1182/blood-2020-134583 ◽

2020 ◽

Vol 136 (Supplement 1) ◽

pp. 47-48

Author(s):

Ruben Mesa ◽

Heidi E. Kosiorek ◽

Alessandra Carobbio ◽

Tiziano Barbui ◽

Amylou C. Dueck

Keyword(s):

Board Of Directors ◽

Research Funding ◽

Treatment Guidelines ◽

Symptom Burden ◽

Low Risk ◽

Study Group ◽

Advisory Committees ◽

Specific Symptom ◽

Hemorrhagic Events ◽

The Impact

Background: Historical treatment guidelines for the myeloproliferative neoplasm, polycythemia vera (PV), have generally not recommended cytoreductive therapy for "low risk" PV (age <60 and no prior thrombo-hemorrhagic events (TH)) on the hypothesis that decreasing the risk of TH events is the only goal of therapy for PV. The MPN-QOL Study Group has previously reported on the presence of PV associated symptoms, sometime severe, in PV including "low risk" PV patients. Recently, data from the ongoing "Low PV" interventional trial of RoPEG Interferon (INF) vs. Phlebotomy alone suggests an advantage in symptom control and event free survival in "low risk" PV patients treated on the RoPEG INF cytoreductive arm (LBA EHA 2020). Given this latter trial might alter the approach to managing "low risk" PV patients we sought to assess the symptom burden (with or without cytoreductive treatments) in that population. Methods: MPN patient data was collected prospectively amongst an international cohort of PV patients including symptom burden, demographics, and disease features collected by IRB approved de-identified survey questionnaires (N=2,017, of which 698 had PV). We analyzed data from a subgroup consistent with "low risk PV" (age <60, no prior thrombo-hemorrhagic events). All participants completed the MPN-specific symptom burden questionnaire (MPN-SAF TSS [MPN-10]) and had no prior history of splenectomy. Surveyed symptoms on the MPN-10 included the patient's perceptions of common MPN-related symptoms and overall quality of life (QOL) on a 0 (absent) to 10 (worst imaginable) scale. Results: A total of 211 "low risk" PV patients were identified, of which 140 (66.4%) had received some form of cytoreductive therapy (hydroxyurea = 54%; pegylated interferon = 44%; and anagrelide = 2%), with those patients not on cytoreductive therapy being statistically significantly younger (M=48.2±8.74 years vs. M=50.6±7.41 years), having a shorter duration of an MPN diagnosis (M=4.6±4.82 years vs. M=6.7±6.00 years), and higher hemoglobin (M=16.9±3.26 vs. M=15.2±2.37), higher hematocrit (M=50.6±9.83 vs. M=45.5±7.10), higher leukocyte (M=10.8±4.25 vs. M=7.5±4.72), and higher platelet counts (M=508.1±317.19 vs. M=327.8±190.52) at the time of MPN symptom assessment (Table 1). The entire cohort was quite symptomatic with 87% (n=184/211) of patients endorsing fatigue, but overall the PV patients on cytoreduction were more symptomatic (mean MPN-10 of 24.7 (cytoreduction) vs 18.5 (no cytoreduction) p=0.01) with significantly higher levels of fatigue (p=0.04), bone pain (p=0.04), fever (p=0.001) and weight loss (p=0.04) in cytoreductive group (Table 2). Conclusions: "Low risk" PV patients are frequently symptomatic, and an unselected series from the MPN-QOL Study Group demonstrates significant symptomatic unmet needs in this population potentially supporting the need and potential benefit of cytoreductive therapy. "Low risk" PV patients (even before the impact of the Low PV Study is realized) also have frequently been receiving cytoreductive therapies, even though they have not been included in treatment guidelines, and typically have higher symptom burden despite lower counts, are older, and have longer duration of MPNs. Drivers of the decision to use cytoreductive therapy was not captured, but it is possible longer duration of disease, higher symptom burden, intolerance of phlebotomy might all be contributing factors. These results show there is both unmet need, and frequent heterogeneity amongst "low risk" PV patients, the final results of the Low PV Study are anticipated with great interest. Disclosures Mesa: Novartis: Consultancy; LaJolla Pharmaceutical Company: Consultancy; Samus Therapeutics: Research Funding; Sierra Oncology: Consultancy; Genentech: Research Funding; Incyte: Research Funding; AbbVie: Research Funding; CTI BioPharma: Research Funding; Promedior: Research Funding; Bristol Myers Squibb: Research Funding. Barbui:Italfarmaco: Membership on an entity's Board of Directors or advisory committees; Novartis: Membership on an entity's Board of Directors or advisory committees; AOP: Membership on an entity's Board of Directors or advisory committees.

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Development of Predictive Biomarker and Optimal Treatment Strategy with FLT3 Inhibitors in Acute Myeloid Leukemia

Blood ◽

10.1182/blood-2019-127610 ◽

2019 ◽

Vol 134 (Supplement_1) ◽

pp. 1418-1418

Author(s):

Jeong Hui Kim ◽

Yasuhiko Harada ◽

Yuichi Ishikawa ◽

Naomi Kawashima ◽

Marie Nakashima ◽

...

Keyword(s):

Research Funding ◽

Therapeutic Strategy ◽

Inhibitory Effect ◽

Genetic Alterations ◽

Molecular Characteristics ◽

Inhibitory Effects ◽

Npm1 Mutation ◽

Growth Inhibitory ◽

Flt3 Inhibitors ◽

The Impact

【Background】Recently, FLT3 inhibitors are approved for FLT3 mutated AML patients and other FLT3 inhibitors are also in clinical development. Since the target selectivity and the inhibitory activity of FLT3 inhibitors are varied, it is required to establish a therapeutic strategy in consideration of their characteristics. Most FLT3 mutated AML cells co-express wild type (Wt)-FLT3, and we previously demonstrated that FLT3 ligand (FL) stimulation attenuated the inhibitory effect of FLT3 inhibitors through the activation of Wt-FLT3 in Wt- and ITD-FLT3 co-expressing cells; however, little is known about this inhibitory mechanism in recently developed FLT3 inhibitors. In this study, we aimed to clarify the efficacy and characteristics of four FLT3 inhibitors including the impact of FL on AML cell lines and primary patients cells, and to identify biomarkers for drug selection and prediction of their efficacy. 【Methods】We examined the growth inhibitory effects of midostaurin, quizartinib, gilteritinib and FF-10101 at various concentrations of FL in ITD-FLT3 expressing 32D cells, Wt- and ITD-FLT3 co-expressing 32D cells,and FL and Wt-FLT3 co-expressing 32D cells. The inhibitory effects of these four FLT3 inhibitors were also examined in 87 primary AML cells with or without FLT3 mutationin vitro, and the correlation between their efficacy and clinical and molecular characteristics including genetic alterations and FLT3-ITD allelic ratio (ITD-AR) were investigated. Moreover, characteristics of residual AML cells after the treatment with FLT3 inhibitors were also examined in patient-derived xenografts (PDX) -AML model. 【Results】The inhibitory effect of FLT3 inhibitors was significantly impaired by FL stimulation dose dependently in all inhibitors except for midostaurin in Wt- and ITD-FLT3 co-expressing 32D cells. In FL and Wt-FLT3 co-expressing cells, GI50 value of gilteritinib was higher than that in ITD-FLT3 solo-expressing cells, and the similar tendency was observed with quizartinib. We examined the Growth inhibitory effects of these inhibitors in 33 FLT3 mutated and 54 FLT3 un-mutated primary AML cells. In primary cells, midostaurin showed lower selectivity to FLT3 mutation compared with other inhibitors. Subsequently, the correlation between the efficacy of FLT3 inhibitors and ITD-AR was examined. RNA or DNA based ITD-AR was not related to the growth inhibitory effect of FLT3 inhibitors except for gilteritinib in FLT3-ITD mutated patient cells; the GI50 value of gilteritinib in AML cells with RNA based ITD-AR-low were significantly higher than those in RNA based ITD-AR-high (P=0.036) (Figure).Moreover, FLT3-ITD cells with mutated NPM1 tend to have higher GI50values for all of FLT3 inhibitors, irrespective of ITD-AR. In AML-PDX treated with quizartinib or gilteritinib, FLT3-ITD-AR in residual AML cells was lower than that of non-treated cells, suggesting that co-expression level of Wt-FLT3 is related to the response to FLT3 inhibitors in vivo. 【Conclusions】FL affected the efficacy of FLT3 inhibitors in Wt- and ITD-FLT3 co-expressing cells, and the inhibitory effects on ITD-FLT3 and FL-Wt-FLT3 pathway were different among FLT3 inhibitors. Furthermore, NPM1 mutation and RNA based ITD-AR might be predictive biomarkers for the efficacy of FLT3 inhibitors in FLT3-ITD positive AML. The appropriate therapeutic strategy based on the characteristics of each inhibitor is necessary. Disclosures Ishikawa: Bristol-Myers Squibb: Honoraria; Abbvie GK.: Honoraria; Kyowa Hakko Kirin Co., Ltd.: Honoraria; Celgene Co., Ltd.: Honoraria. Goto:Celgene Co., Ltd.: Honoraria; Novartis Pharma Co., Ltd.: Honoraria; JCR Pharmaceuticals Co., Ltd.: Honoraria; Takeda Pharmaceutical Co., Ltd.: Honoraria. Ozawa:Pfizer Japan Inc.: Honoraria; Novartis: Honoraria; Kyowa-Hakko Kirin: Honoraria; Astellas Pharma Inc.: Honoraria. Kiyoi:Zenyaku Kogyo Co., Ltd.: Research Funding; Nippon Shinyaku Co., Ltd.: Research Funding; Eisai Co., Ltd.: Research Funding; Chugai Pharmaceutical Co., Ltd.: Research Funding; Sumitomo Dainippon Pharma Co., Ltd.: Research Funding; Takeda Pharmaceutical Co., Ltd.: Research Funding; Astellas Pharma Inc.: Honoraria, Research Funding; Otsuka Pharmaceutical Co.,Ltd.: Research Funding; FUJIFILM Corporation: Research Funding; Pfizer Japan Inc.: Honoraria; Kyowa Hakko Kirin Co., Ltd.: Research Funding; Daiichi Sankyo Co., Ltd: Research Funding; Bristol-Myers Squibb: Research Funding; Perseus Proteomics Inc.: Research Funding.

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Prevalence and Clinical Implications of N-RAS Mutations in Childhood AML – A Report From the Children's Oncology Group.

Blood ◽

10.1182/blood.v114.22.3115.3115 ◽

2009 ◽

Vol 114 (22) ◽

pp. 3115-3115

Author(s):

Jason N. Berman ◽

Robert B. Gerbing ◽

Lillian Sung ◽

Kristen Miller ◽

Jessica A. Pollard ◽

...

Keyword(s):

Signal Transduction ◽

High Risk ◽

Prognostic Significance ◽

Low Risk ◽

Signal Transduction Pathways ◽

Free Survival ◽

Ras Mutations ◽

Significant Difference ◽

Pediatric Aml ◽

The Impact

Abstract Abstract 3115 Poster Board III-52 Mutations in the RAS proto-oncogenes are frequent in acute myeloid leukemia (AML) and serve as prototypic Class I lesions, initiating key downstream hyper-proliferative signal transduction pathways. N-RAS mutations (N-RASmut) are common in AML, occurring in 10-20% of adult and pediatric AML patients; however their prognostic significance in both adults and children remains disputed. Due to a frequent association with a normal karyotype, delineating the impact of these mutations on outcome may enable appropriate risk-adapted therapeutic approaches. Here, we report on the incidence and prognostic significance of N-RASmut in a cohort of 825 pediatric AML patients treated on 2 recent co-operative group studies, CCG-2961 and COG AAML03P1. In total, of the 825 children with de novo AML who underwent N-RAS mutational analysis, 86 (10%) were positive. Gender, age, race, presence of hepatosplenomegaly and FAB subtype were comparable between patients with and without N-RASmut. There was no statistically significant difference between those with and without N-RASmut with respect to specific chromosome class. FLT3/Internal tandem duplications (FLT3/ITD) were less common in those with N-RASmut (2% vs. 9%, p=0.03). In contrast, nucleophosmin (NPM) mutations were more common in those with N-RASmut (13% vs. 5%, p=0.02). Overall, N-RASmut showed a significant correlation with low risk AML (CBF, CEBPαa, or NPM, p=0.04) and an inverse relationship with high risk disease (-5/5q- or -7, FLT3/ITD/high allelic ratio, p=0.007). Patients with N-RASmut had similar complete remission (CR) rates following two courses of induction chemotherapy compared with non-mutated patients (79% vs. 79%, p=0.92). Those in CR had a similar relapse rate regardless of the presence of N-RASmut (RR 39% vs. 36%, p=0.97). Five year event free survival (EFS) and overall survival (OS) from study entry were also comparable, however N-RASmut patients demonstrated a marked increase in overall treatment related mortality (TRM) (21% vs. 14%, p=0.03), which was maintained when high and low risk patients were excluded (22% vs. 11%, p=0.05). Evaluation of TRM in CCG-2961 compared with COG AAML03P1 demonstrated that increased TRM in N-RASmut was only seen in patients treated on CCG-2961 and TRM was primarily due to invasive fungal and gram negative infections. Interestingly, for patients treated on CCG-2961, who received interval compressed intensive induction therapy, this increase in TRM correlated with a decrease in both OS and disease free survival from CR. Remission specimens from patients with N-RASmut were negative for the mutation, demonstrating that an increased infectious risk could not be attributed to a host polymorphism. We found N-RASmut did not contribute to increased disease recurrence in pediatric AML. Our findings indicate that N-RAS mutations do not identify a high risk population, however, as such mutations lead to downstream activation of signal transduction pathways, they may identify a target for directed therapy. Disclosures No relevant conflicts of interest to declare.

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Outcomes and Management of Red Blood Cell Transfusions in Multiple Myeloma Patients Treated with Daratumumab

Blood ◽

10.1182/blood.v126.23.3571.3571 ◽

2015 ◽

Vol 126 (23) ◽

pp. 3571-3571 ◽

Cited By ~ 5

Author(s):

Ajai Chari ◽

Toshihisa Satta ◽

Amit Tayal ◽

Sundar Jagannath ◽

Hearn Jay Cho ◽

...

Keyword(s):

Multiple Myeloma ◽

Research Funding ◽

Single Agent ◽

Cell Phenotype ◽

Institutional Research ◽

Panel Testing ◽

Antiglobulin Test ◽

Positive Direct ◽

The Impact ◽

Transfusion Reactions

Abstract Background Daratumumab (DARA) is a human IgG1 kappa monoclonal antibody that targets cells expressing CD38, which is highly expressed in multiple myeloma (MM) cells. In the phase 2 MMY2002 (Sirius) trial, treatment with single agent DARA resulted in a 29% overall response rate, with a median PFS of 3.7 months in heavily pretreated MM patients (Lonial S. J Clin Oncol. 2015; 33(suppl): abstrLBA8512). However, CD38 is also expressed on red blood cells (RBCs) and DARA binding to RBCs results in pan-reactivity on RBC panel testing using an indirect antiglobulin test (IAT). Recently, it was reported that treating RBCs with dithiothreitol (DTT) removes DARA to allow for accurate antibody testing (Chapuy CI, et al. Transfusion. 2015;55(6pt2):1545-1554) but also denatures Kell antigen in the process. To date, little is known about the impact of DARA interference with IAT on the outcomes of patients requiring packed RBC (PRBC) transfusions. Methods The frequencies of PRBC transfusions and any transfusion-related adverse events from all 124 patients treated on the Sirius study were obtained from the clinical database as of the data cut off of January 9th, 2015. Although details of transfusions were not prospectively collected, surrogate outcomes of transfusion reactions within 4 weeks of the transfusion were analyzed including change in hemoglobin (Hb), elevated bilirubin, fever, and hypotension. In addition, we evaluated IAT results and transfusion outcomes of the 8 patients treated at our institution. Results During the study, 47 patients received 147 transfusions with a total of 235 units of PRBCs. To date, no transfusion-related reactions were noted. Of the 47 patients, 8 patients were treated at our institution. One patient showed multiple alloantibodies (anti-E, -K, -Jkb, -Fya, -Fy3, -S, Knops) on IAT prior to DARA. This individual and 6 others agglutinated all RBCs on panel testing with weak reactivity at the antihuman globulin phase of testing. Reactivity was enhanced by gel testing compared to reactivity in low ionic strength saline and was unaffected by enzymatic treatment with ficin. Six out of 7 patients had a negative autocontrol. The one patient with a positive autocontrol had a weakly positive direct antiglobulin test with IgG. Six out of these 7 patients with panagglutinin had a positive result on the first IAT after initiation of DARA, ranging from 7 to 175 days (median 49). One patient did not have an IAT after initiation of DARA. A total of 9 leuko-reduced, irradiated, phenotypically matched RBCs were given to 3 patients during DARA treatment, and additional 9 units were given to 3 patients after DARA completion while their IATs remained positive. All transfusions resulted in an appropriate rise in Hb (median 1.0 g/dL, range 0.5-2.7) without any associated transfusion reactions. None of the patients made new unexpected RBC alloantibodies while receiving phenotypically matched RBCs. Conclusion For the 7 patients at our site with IAT testing after DARA treatment, all demonstrated pan-reactivity on RBC panel testing. Treatment with DTT removes this interference but also denatures Kell antigen in the process. Most hospitals do not use DTT as part of routine immunohematology workups; therefore, we recommend obtaining a red cell phenotype prior to initiating DARA treatment and providing phenotypically matched blood thereafter to avoid resultant difficulties in new alloantibody identification and delays in providing compatible PRBCs. Based on a database query of all 124 patients as well as all patients at our site, PRBC transfusions did not appear to be associated with complications. In a MM patient population that will frequently require PRBC transfusion, blood bank and hematologist/oncologist awareness of these findings is important to minimize errors or delays in providing compatible PRBCs. Disclosures Chari: Novartis: Consultancy, Research Funding; Millennium/Takeda: Consultancy, Research Funding; Celgene: Consultancy, Membership on an entity's Board of Directors or advisory committees, Research Funding; Onyx: Consultancy, Research Funding; Biotest: Other: Institutional Research Funding; Array Biopharma: Consultancy, Other: Institutional Research Funding, Research Funding. Jagannath:Celgene: Honoraria; BMS: Honoraria; MERCK: Honoraria; Novartis Pharmaceuticals Corporation: Honoraria; Janssen: Honoraria. Catamero:Celgene: Honoraria, Other: Lecturer; Onyx: Other: Lecturer; Millennium/Takeda: Other: Lecturer. Verina:Celgene: Other: Lecturer. Doshi:Janssen: Employment. Feng:Janssen: Employment. Uhlar:Janssen: Employment. Khan:Janssen: Employment. Ahmadi:Janssen: Employment. Voorhees:Millennium/Takeda and Novartis: Honoraria; Array Biopharma, Bristol-Myers Squibb, Celgene, GlaxoSmithKline, and Oncopeptides: Consultancy; Celgene, GlxoSmithKline, and Oncopeptides: Research Funding.

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