Impaired Left Ventricular Ejection Fraction Induces "Very Early Pre-Diagnostic" Hemopoietic Modifications in Myeloid Leukemia Patients

Background: There is strong association between clonal hematopoiesis of undetermined prognosis (CHIP) and coronary artery disease (CAD) development. Indeed, ischemic heart disease is a leading cause of congestive heart failure (CHF) in western society. CH induces not only enhanced risk for myeloid malignancies, but also significant cardiovascular morbidity in elderly patients (pt). Pt with impaired ejection fraction (EF) and clinical manifestation of heart failure frequently initiates systemic pro-inflammatory state [SPS] characterized by interleukin-6 (IL6) and tumor necrosis factor alpha (TNF-α) upregulation. Previous studies suggest that such an inflammatory state is capable of sustaining and/or accelerating hemopoietic clonal selection/dominance. How these CHF induced inflammatory changes affect "peripheral blood cell count composition' in pt with suspected CHIP is unknown. However, modifications in peripheral blood count data "months before hemopoietic malignancy diagnosis" may inform association between clonal dynamics and hemopoietic output under CHF stress. The primary objective of our study was to investigate effect of heart failure in "pre- AML diagnosis" peripheral blood count data to detect "early" hemopoietic modifications induced by CHF. Methods: After IRB approval, AML pt diagnosed with and without CHF were selected for analysis. Given possible differential inflammatory effect between pt exhibiting CHF with and with low EF, we analyzed peripheral blood cell count in pt with "echocardiographically confirmed" EF <> 50% and those pt with and without clinically documented CHF [cdCHF]. Descriptive statistics was performed for categorical and continues variable with Chi-square and t-test. SAS software was used for analysis. Results: 27/152 (17.7%) and 125/152 (82.2%) pt developed or not EF <50%. Median age was 71.1 years (y) v 61.2 y, in pt with and without EF<50%, p=<0.0001. Aging was negatively correlated with EF, [R= -0.25, p=0.001]. Median age was 73 y v 61 y, for pt with and without cdCHF, p=0.001. 100% and 82% of pt were male among those with and without EF <50%. In pt who had or did not have EF <55% Favorable (fav), Intermediate (Int) and unfavorable (unfav) ELN-2017 subgroups were 3.23% vs 13.6%; 42% vs 46%; and 55% vs 40%, p=0.07. To address our main hypothesis that CHF induces "early pre-diagnostic AML' hemopoietic modifications, CBC data at 6 and 12 months (m) before AML onset in pt with and without EF<50% v those with and without cdCHF was extracted. At 12 m prior AML diagnosis, EF<> 50% detected differential expression for WBC [p=0.07], Hemoglobin [p=0.002], platelets [p=0.05] and absolute lymphocyte count (ALC) [p=0.006] [Fig 1, panel A, C, I, K]. Similarly, EF <>50% at 6 m prior AML diagnosis detected differential expression for platelets [p=0.01], ALC [p=0.04] [Fig 1, panel D, J, L]. In contrast, cdCHF detected only differential hemoglobin at 12 m [p=0.01]. Conclusions: CHF induces quantitative count defects 6 and 12 m before AML diagnosis. Changes are characterized by WBC, hemoglobin, platelets and ALC decline that are directly correlated with objective left ventricular EF impairment, but not with only clinical CHF. Our study adds body of evidence to support the role of CHF with low EF as "hemopoietic cell extrinsic stressor'. CHF associated with low EF seems to be prerequisite for hemopoietic stress in hosts with already initiated clonal hematopoiesis. Our findings have important experimental implications, especially for studies that seek to understand how cell extrinsic stressors facilitate clonal progression. Figure 1 Figure 1. Disclosures No relevant conflicts of interest to declare.

Absolute Lymphocyte Count Predicts Immune-Related Adverse Events in Patients With Non-Small-Cell Lung Cancer Treated With Nivolumab Monotherapy: A Multicenter Retrospective Study

BackgroundAmong patients with advanced non-small-cell lung cancer who were treated with nivolumab monotherapy, the association of peripheral blood count data (at baseline and 2 weeks after treatment initiation) with the early onset of immune-related adverse events (irAEs) and treatment efficacy has not been clearly established. This study aimed to identify peripheral blood count data that may be predictive of the development of nivolumab-induced irAEs in a real-world clinical setting.Materials and MethodsThis multicenter observational study retrospectively evaluated consecutive patients with advanced non-small-cell lung cancer undergoing nivolumab monotherapy in the second- or later-line setting between December 2015 and November 2018 at the National Cancer Center Hospital and Keio University Hospital in Japan. The primary endpoint was the association between peripheral blood count data and irAEs during the 6-week study period. Receiver operating characteristic curve and multivariable logistic regression analyses were performed.ResultsOf the 171 patients evaluated, 73 (42.7%) had ≥1 irAE during the first 6 weeks following treatment initiation. The median time to irAEs from the initiation of nivolumab was 15 (interquartile range: 13–28) days. Receiver operating characteristic curve analyses revealed that the optimal cut-off values of the absolute lymphocyte count, neutrophil-to-lymphocyte ratio, and lymphocyte-to-monocyte ratio 2 weeks after treatment initiation for early irAE onset were 820, 4.3, and 2.2, respectively. In multivariable logistic regression analyses, absolute lymphocyte count >820 at 2 weeks after treatment initiation was significantly associated with an increased risk of early onset of any irAE. In contrast, no significant association was observed for the neutrophil-to-lymphocyte ratio (>4.3) or the lymphocyte-to-monocyte ratio (>2.2) at 2 weeks following treatment initiation.ConclusionsThe absolute lymphocyte count >820 at 2 weeks following nivolumab initiation predicts early onset of irAEs during a 6-week study period. Routinely available absolute lymphocyte count, which is measured after the initiation of nivolumab, may be useful for identifying patients at risk of early onset of irAEs.

Quantitative Modeling of Ineffective Hematopoiesis in Myelodysplastic Syndrome Patients Yields Distinct Clinical Phenotypes and Can Identify a State of Disease Predictive of Loss of Response to Azacitidine

Background: The implementation of genomic data from myelodysplastic syndrome (MDS) patients into clinical practice requires its association with MDS disease activity. However, the determination of a genotype-phenotype correlation in MDS where the disease phenotype is ineffective hematopoiesis, is not straightforward. Part of the problem may be that disease activity reflected by a change in blast count, a change in a peripheral blood count, or the acquisition of a new cytogenetic abnormality does not currently provide any information about the likely dynamics of hematopoietic progenitors underlying this change. Being able to reliably infer a change in the early hematopoietic progenitor compartment of MDS patients where the disease clone likely resides that can account for the phenotype of ineffective hematopoiesis is an important step in the development of a tool to measure disease activity over time. We aim to apply a quantitative model of hematopoiesis based on parameters known to affect hematopoietic progenitor population dynamics, including rate of self-renewal, rate of proliferation, rate of differentiation, and rate of apoptosis. The mathematical formulation based on delay-differential equations has been successfully used to model the peripheral blood counts of CML and cyclic neutropenia. The goal is to identify unique MDS disease states based on the parameters described in the model, and to correlate these with both genotype and clinical outcomes. Methods: MDS patients with IPSS intermediate-2/high diagnosed during the period 2010-2017 at the London Health Science Centre had their bone marrow aspirate and biopsy data at diagnosis, laboratory data while on treatment with azacitidine and following disease progression, and transfusion history collected. The time-dependence of the peripheral blood counts for each patient were modeled using a delay-differential equation (Colijn and Mackey, 2005), with parameters representative of rates of proliferation, self-renewal, differentiation, and apoptosis of the stem cell and progenitor compartments. The model was integrated with MATLAB's dde23 routine and the model parameters were fit to the peripheral blood counts using gradient descent for the constrained non-linear least squares problem. The patients were separated into two clusters using the k-means clustering of all the model parameters using the city-block distance measure. The number of clusters were determined using the Calinski-Harabasz criterion. Results: Seventy-seven patients with a diagnosis of IPSS intermediate-2/high risk MDS were included in the analysis. Model fitting of the peripheral blood count data of 1000 simulated healthy patients whose blood count parameters were within their respective normal ranges over time yielded baseline variability of hematopoietic kinetic parameters (Figure 1). Two main groups of MDS patients could be identified from model fitting: MDS 1 and MDS 2, both of which could be best distinguished from the simulated healthy patients based on the parameter for the rate of megakaryocytic differentiation. MDS 1 and MDS 2 also had distinct parameters for the rates of hematopoietic progenitor proliferation, describing two different phenotypes of disease activity. The red blood cell count of a representative patient in MDS 1 is shown in Figure 2, where application of the Akaike information criterion identified the most likely time point when the hematopoietic kinetic parameters accounting for the peripheral red blood cell count changed after initiation of azacitidine. This time point preceded proven disease progression by 40 days. Conclusion: Parameterization of hematopoiesis with a model that can infer the kinetics of hematopoietic compartments in the bone marrow provides a powerful tool for measuring ineffective hematopoiesis in MDS patients. The resulting kinetic parameters can identify distinct groups of MDS patients based on the phenotype of their disease. The next step would be to correlate the different kinetic parameters distinguishing these groups to their disease genotypes using next-generation sequencing. On an individual patient level, these parameters can identify the most likely time when the disease phenotype changes. The development of a dynamic score predicting the change in disease activity based on hematopoietic kinetic parameters derived from peripheral blood count data over time is ongoing. Disclosures No relevant conflicts of interest to declare.

Correlation Between Peripheral Blood Counts and Day 14 Bone Marrow Biopsy in Acute Myeloid Leukemia during Induction Chemotherapy

Background Current NCCN guideline recommends that a bone marrow sample be performed 7-10 days (day 14 bone marrow) after completion of induction therapy in newly diagnosed acute myeloid leukemia (AML). However, the value of day 14 bone marrow has been questioned due to the invasive nature of the procedure and lack of specificity pertaining to complete remission in cases of borderline blasts count and cellularity. We examined peripheral blood count and bone marrow from day 0 to day 14, to see if a reduction of peripheral blood correlated and predicted the day 14 bone marrow morphologic changes and complete remission (mCR). Methods We did 10 years retrospective review between year 2004 and 2013 at the Henry Ford Hospital, on patients who had newly diagnosed AML and day 14 bone marrow biopsy. The majority of patients underwent "7+3" or a "7+3"-like regimen for induction chemotherapy. Firstly, we evaluated the relationship of change of peripheral blood count from day 0 to day 14 with blast percentage and cellularity of bone marrow. Spearman correlations coefficients were computed for each pair of characteristics. Peripheral blood count includes neutrophil (ANC), monocyte, white blood cells (WBC), blast, hemoglobin and platelet. Secondly, we investigated the possible correlation of mCR to peripheral blood and bone marrow changes, using binary univariate logistic regression. mCR as defined by blast percentage <5, absolute neutrophil (ANC) >1000/mm3, platelets>100,000/mm3. Thirdly, we explored differences in peripheral blood counts on day 14 among three bone marrow groups, those with blast percentage <5, 5-20, >20. Results A total of 200 patients were reviewed and 56 patients met the inclusion criteria. Decrease of ANC/WBC correlated with decrease of bone marrow blast/cellularity from day 0 to day 14 (ANC: Blast P ≤ 0.05; ANC: cellularity P ≤ 0.05; WBC: blast P ≤ 0.001, WBC: cellularity P ≤ 0.01). In other words, a larger reduction in ANC/WBC correlated with larger reduction in both blast and cellularity in bone marrow. However, this correlation with bone marrow change was not found in peripheral blast, monocyte, hemoglobin and platelet. We also found that with increasing age, there was less reduction from day 0 to day 14 in bone marrow blast and cellularity. Bone marrow blast and cellularity on day 14 is strongly associated with mCR (P<0.01), the reduction of blast (43.7 +/- 22.86, Odds ratio 1.03 (1.01, 1.06), P=0.012) and cellularity (66.21 +/- 29.98, Odds ratio 1.03 (1.01, 1.05), P=0.003) from day 0 to 14 is also predictive for mCR. Interestingly, there is a trending effect that the reduction of ANC from day 0 to 14 may predict mCR, but it is not statistically significant (Odds ratio 1.22 (1.02, 1.66), P=0.097). The reduction of WBC is not associated with mCR. Furthermore, peripheral blood counts on day 14 are similar among 3 bone marrow groups, those of blast percentage <5, 5-20, and >20% on day 14. Conclusion ANC/WBC decrease from day 0 to day 14 correlated with the decrease in bone marrow blast count and cellularity, and can be used as a predictor for bone marrow change on day 14, but the level of day 14 peripheral blood findings are similar among 3 bone marrow groups (blast percentage <5, 5-20, and >20% on day 14), so it could not be used to predict the level of bone marrow change. Our data confirmed that the significant decrease of bone marrow blast percentage and cellularity from day 0 to 14 predicts mCR. Decrease of ANC from day 0 to 14 may also predict mCR although it is not statistically significant. A larger sample size can be studied in the future to further explore the possibility of using peripheral blood to predict bone marrow changes and mCR. Summary Our data demonstrates a significant reduction of ANC on day 14 after induction therapy in newly diagnosed AML, which correlates with a decrease in bone marrow cellularity and blast percentage. However, a statistically significant association with blast percentage pertaining to mCR was not obtained. In conclusion, while the current findings do not justify replacement of day 14 bone marrow for predicting mCR, further large scale studies are indicated. Disclosures No relevant conflicts of interest to declare.

Gene Mutations in MDS Associating with Peripheral Blood Count Abnormalities

Recent data suggested that low levels of mutated myeloid genes could be detected in the peripheral blood of individuals with normal peripheral blood counts. While testing for MDS-related molecular abnormalities is not justified in individuals without a cytopenia, appreciating the linkage between abnormal peripheral blood counts and specific myeloid gene mutations would support the need for genetic testing. Furthermore, we found that approximately 50% of practicing hematologists and oncologists do not send MDS bone marrow specimens for conventional cytogenetic testing (Craig, et al. Leuk Res 2011), and even fewer order gene mutation profiling, despite the informative potential of results for diagnosis, prognosis and therapy. Hence, there is a gap in recognizing when to order genetic testing in MDS. To address this, bone marrow aspiration cells from patients with morphologically and clinically confirmed MDS were examined for genomic mutations by conventional cytogenetics and targeted next generation sequencing (NGS). Sequencing covered mutations in the following genes: TET2, SF3B1, ASXL1, DNMT3A, SRSF2, RUNX1, NRAS, ZRSR2, EZH2, ETV6, TP53, CBL, NPM1, JAK2, U2AF1, IDH1, KRAS, IDH2, FLT3, PTPN11, and SETBP1. The average depth of NGS was 10,000x and mutant allele frequency was >5%. Association between genomic mutations and peripheral blood counts were evaluated using the Kruskal-Wallis test. 147 patients with WHO-defined MDS were included in this study. 12/147 (8%) had very good cytogenetic risk disease, 104/147 (71%) were good risk, 22/147 (15%) were intermediate risk, 4/147 (3%) were poor risk, and 5/147 (3%) were very poor risk. Anemia was significantly associated with SF3B1 mutations (P=0.0017), while higher hemoglobin values were significantly associated with SRSF2 mutations (P=0.0051). Macrocytosis was associated with SF3B1 (P<0.0001) and ZRSR2 (P=0.0382) mutations. Thrombocytopenia (<100x109 /L) was associated with mutations in SRSF2 (P=0.0148), TP53 (P=0.0005), or U2AF1 (0.0434). Higher platelet counts were found in patients with SF3B1 mutations (P<0.0001). Higher total white blood cell counts (P<0.0001) and higher absolute neutrophil counts (P<0.0001) were noted in patients with SF3B1 mutations. Absolute monocyte counts were higher in patients with NRAS (P=0.0237) and SF3B1 (P=0.0122) mutations. TET2 mutations were associated with lower percentage of bone marrow blasts (P=0.0032). While patients with TP53 mutations tended to have higher IPSS-R score (P=0.0017), patients with SF3B1 mutations tended to have lower IPSS-R score (P=0.0133). Overall, patients with TP53 mutations were more likely to present with higher risk disease by IPSS-R than patients without TP53 mutations. In patients with MDS, certain myeloid gene mutations significantly associated with peripheral blood count abnormalities (Table 1). Genetic testing of bone marrow samples is warranted in MDS patients showing abnormal peripheral blood counts. Table 1. Summary of Significant Associations Between Peripheral Blood Count Abnormalities and Myeloid Gene Mutations in Patients with MDS. Peripheral Blood Count Abnormality Genetic Mutation Anemia SF3B1 Higher Hemoglobin SRSF2 Macrocytosis SF3B1, ZRSR2 Thrombocytopenia (<100x109 /L) SRSF2, TP53, U2AF1 Higher Platelet Count SF3B1 Higher Total WBC count SF3B1 Higher Absolute Neutrophil Count (ANC) SF3B1 Higher Absolute Monocyte Count (AMC) SF3B1, NRAS Lower % BM blasts TET2 Lower IPSS-R score SF3B1 Higher IPSS-R score TP53 Disclosures Cogle: OXiGENE: Research Funding.

Preoperative Peripheral Blood Count in Breast Carcinoma: Predictor of Prognosis or a Routine Test

Background.Peripheral blood count is the first investigation to be done in every patient before surgery. As strong relationship exists between cancer and immune response of the body, clinical stage at presentation and altered hematological parameters can influence the progression of cancer and vice versa.Settings and Design.It is a case control study of total 50 cases (35 cases of carcinoma breast and 15 cases of benign breast disease).Methods.A case control study was carried out; 35 cases of breast cancer patients were taken prior to surgery and chemotherapy with 15 cases of benign breast disease as control. Clinical staging according to the tumor, node, and metastasis classification (TNMc) was done and was correlated with complete blood count (CBC).Results.All the cancer patients were females with overall mean age of47.96±13.84years. Amongst all altered blood parameters, correlation of absolute lymphocytic count (pvalue 0.001) with TNMc staging was found significant. Particularly, decrease in absolute leucocytic count was observed with increase in stage of breast carcinoma.Conclusions. The stage-specific mean values of absolute lymphocytic counts of preoperative breast cancer patients can be used as an economical tool to know the evolution of disease.