11q23 Abnormalities Research Articles

Survival Improvement in Therapy Related Myeloid Neosplasm ? a Single Center Analysis of 428 Patients

Therapy-related acute myeloid leukemia/myelodysplastic syndrome (t-AML/MDS) arise after cytotoxic chemotherapy and/or radiotherapy administered for a prior neoplasm and have a dismal outcome (median survival of 8 months in the largest series published including 306 patients (pts), Smith, Blood 2003). Recent registry data suggested a continued increase in survival in AML (Derolf, Blood 2009) and we wondered whether this was also observed in the setting of t-AML/ MDS.All pts with a t-AML/MDS diagnosed and/or treated for their prior neoplasm at Gustave Roussy Cancer Center between July 1986 and 2016 were included in this retrospective study. Data regarding pts' demographics, primary diagnosis and treatment, latency time, cytogenetic, treatment and outcome were collected. The diagnosis of t-AML/MDS was based on the WHO 2016 classification. t-AML were classified based on cytogenetic results as favorable, intermediate and adverse according to international classification, t-MDS based on IPSS score as favorable (Low, Int-1) and adverse (Int-2 and High).428 pts were analyzed. The median age at diagnosis of t-AML/MDS was 56.4 years with a female predominance (60%). 224/428 (52.3%) pts had t-AML, 204/428 (47.7%) t-MDS. The most common primary malignancies were breast cancer (24%), non-Hodgkin lymphoma (15%), Hodgkin lymphoma (HL) (9%) and ovarian cancer (9%). Occurrence of t-AML/MDS following HL represented 26.6% of t-AML/MDS cases between 1986-96 comparing to 4 % between 2006-16 whereas breast cancer rose from 16% to 45%. Prior treatments included chemotherapy alone in 137/428 pts (32%), radiotherapy alone in 61 pts (14%) and both in 230 pts (54%).At diagnosis of t-AML/MDS, 295 pts (69%) were in complete remission (CR) of their prior neoplasm, 29 (7%) had a stable and 104 (24%) a progressive disease. Median interval between primary cancer and t-AML/MDS was 5 years (4.3 and 5.7 years for t-AML and t-MDS respectively, (p=0.03)). Furthermore, delay to develop t-AML/MDS after radiotherapy alone was longer compare to chemotherapy or both (6.1, 5.1 and 4.3 years, respectively (p=0.0087)). In the t-AML subgroup, 47% of pts presented unfavorable cytogenetic (including complex karyotype (20%) and 11q23 abnormalities (16.9%)), 26% intermediate and 26% favorable cytogenetic (core binding factor mutations (12.7%), t(15;17) (13.3%)). In the t-MDS subgroup, 78% of pts were considered adverse; complex karyotype, chromosome 7 and 5 abnormalities were found in 40.8%, 46.7% and 28.9% respectively. Pts received intensive chemotherapy (including 41 allografts), low dose chemotherapy (including 74 treatments with hypomethylating agents) and best supportive care in 42%, 24% and 34% respectively.The median overall survival (OS) was 10.6 months and the 5-year survival was 19.1% (Figure 1A). The 5-year OS of patients in CR of their prior neoplasm was 25.5% compared to 3.65 and 0% for pts with progressive and stable disease, respectively (p<0.001). 5-year OS was not statistically different between t-AML and t-MDS subgroups (23.3% vs 13.5%) and between hematologic or oncologic malignancies as primary diagnosis (12.6% vs 21.1%). Pts with favorable risk t-AML had better 5-year survival compared with patients with intermediate or unfavorable risk disease (55.5% vs 20% vs 12.1% respectively, p<0.001). In addition, favorable t-MDS was associated with better 5-year OS compared to adverse t-MDS (34.9% vs 6.6%, p<0.001). We next compared OS of pts diagnosed for their t-AML/MDS after or before July 2001. A trend for better OS for pts diagnosed in the last 15 years was observed (21.5% vs 15.1%, p=0.39). Interestingly outcome of t-AML patients with favorable subtype significantly improved over the last 15 years (68.8% vs 25%, p=0.03, Figure 1B) which was not the case for other cytogenetic subgroups and for t-MDS, especially pts with adverse prognosis (4.6% vs 3.9%, p=0.92). Pts who received allograft had a trend for better OS in the last 15 years (52.8% vs 21.5% p=0.2).t-AML/MDS are still associated with a low 5-year OS (19.1%) but our results are upper than previous publications. However, a significant improvement of survival in favorable t-AML was observed during the past 30-years, with a trend for pts who benefit from allograft. In addition to improve treatment for t-MDS pts, detection of the disease at the earliest stage is a real challenge to improve their survival. [Display omitted] DisclosuresNo relevant conflicts of interest to declare.

Decitabine Followed By Clofarabine, Idarubicin, and Cytarabine (DAC-CIA) in Relapsed/Refractory Acute Myeloid Leukemia (AML)

Background: Patients with relapsed/refractory AML have dismal outcomes with currently available chemotherapy regimens. Preclinical and clinical evidence suggests that the use of hypomethylating agents such as decitabine prior to standard chemotherapy may be synergistic (Benton et al. BJH 2014, Qin et al. CCR 2007; Scandura et al. Blood 2011).Methods: Patients aged ≥18 to 65 years with relapsed/refractory AML (up to salvage 2) were enrolled in this investigator-initiated trial (NCT01794702). Other eligibility criteria included ECOG PS 0-2 and adequate organ function. Chemotherapy regimen consisted of Induction cycle with decitabine (20 mg/m2 IV days 1-5), clofarabine (15 mg/m2 IV days 6-9), idarubicin (10 mg/m2 IV days 6-8), and cytarabine (1 gm/m2 IV days 6-10). Consolidation cycle consisted of decitabine (20 mg/m2 IV days 1-5), clofarabine (15 mg/m2 IV days 6-8), idarubicin (8 mg/m2 IV days 6-7), and cytarabine (1 gm/m2 IV days 6-8).Results: Fifty-Fourpatients (female, n=16) have been treated. Median age was 44 years (range 20-66). Majority of the patients (29/54, 54%) were in salvage 1. Cytogenetics were diploid (n=25), complex (n=15), CBF (n=5), 11q23 abnormality (n=2), trisomy 8 (n=2), inv 3 (n=2), misc (n=3). Six patients had a TP53 mutation and 6 patients had an NRAS mutation. Seven patients had NPM1 mutation. No patient had a FLT3 ITD or D835 mutation. Median number of cycles administered was 1 (range 1-3). Grade 3 mucositis was seen in 2 patients and grade 3 transaminitis in 8 patients. Thirty-three patients had one or more infections. Early deaths occurred in 4 (7%) patients within 4 weeks, and 8 (15%) patients within 8 weeks.Twenty six (48%) patients achieved CR/CRi (Table 1). Median time to CR was 42 days. An additional 3 patients had a >50% decrease in bone marrow blast count (bone marrow response) and an additional 3 patients had aplastic/hypoplastic marrow at the end of induction. Patients younger than 40 years had a significantly increased likelihood of achieving a CR/CRp/CRi (71% vs. 33%, p = 0.01) (Table 2). Eighty percent of patients with CBF AML and 64% of patients with diploid cytogenetics achieved a CR/CRp/CRi. CR rate in patients with complex cytogenetics was 20%.Twenty-five (46%) patients underwent allo-SCT (20 CR/CRp/CRi, 2 with 50% marrow blast reduction, 3 with aplastic/hypoplastic marrow). 13/21 (62%) patients younger than 40 years of age were able to undergo allo-SCT as compared to 12/33 (36%) of patients 40 years of older (p = 0.09).Ten patients have relapsed (including six after allo-SCT). Twenty patients are alive (13 after stem cell transplant, 1 is still on study, 4 are receiving further salvage regimens after DAC-CIA failure, 2 lost to follow-up). Median survival of the entire group is 6.0 months (figure 1).Conclusions: The sequential treatment of decitabine followed by chemotherapy is safe and effective with a CR/CRp/CRi rate of 48% and with 25/54 (46%) patients able to proceed to an allo-SCT. [Display omitted] [Display omitted] [Display omitted] DisclosuresJain:Novartis: Consultancy, Honoraria; Pfizer: Consultancy, Honoraria, Research Funding; Servier: Consultancy, Honoraria; Incyte: Research Funding; Genentech: Research Funding; Celgene: Research Funding; Seattle Genetics: Research Funding; Novimmune: Consultancy, Honoraria; Pharmacyclics: Consultancy, Honoraria, Research Funding; Infinity: Research Funding; ADC Therapeutics: Consultancy, Honoraria, Research Funding; Abbvie: Research Funding; BMS: Research Funding. Jabbour:ARIAD: Consultancy, Research Funding; Pfizer: Consultancy, Research Funding; Novartis: Research Funding; BMS: Consultancy. Daver:Kiromic: Research Funding; BMS: Research Funding; Pfizer: Consultancy, Research Funding; Sunesis: Consultancy, Research Funding; Otsuka: Consultancy, Honoraria; Ariad: Research Funding; Karyopharm: Honoraria, Research Funding. DiNardo:Novartis: Other: advisory board, Research Funding; Daiichi Sankyo: Other: advisory board, Research Funding; Abbvie: Research Funding; Celgene: Research Funding; Agios: Other: advisory board, Research Funding. Konopleva:Reata Pharmaceuticals: Equity Ownership; Abbvie: Consultancy, Research Funding; Genentech: Consultancy, Research Funding; Stemline: Consultancy, Research Funding; Eli Lilly: Research Funding; Cellectis: Research Funding; Calithera: Research Funding. Cortes:ARIAD: Consultancy, Research Funding; BMS: Consultancy, Research Funding; Novartis: Consultancy, Research Funding; Pfizer: Consultancy, Research Funding; Teva: Research Funding.

The Novel BET Inhibitor PLX51107 Has In Vitro and In Vivo Activity Against Acute Myeloid Leukemia

Background:Acute myeloid leukemia (AML) has very poor long-term survival with traditional therapies. AML has a diverse pathogenesis and likely represents multiple different diseases. Various epigenetic effector proteins are altered in AML by mutation, over-expression, or compartmental displacement and these changes maintain transcriptional programs important for leukemogenesis. The bromodomain and extra-terminal domain (BET) proteins, including BRD2, BRD3 and BRD4, play roles in many cellular functions important to leukemogenesis, such as super-enhancer function, transcriptional elongation, histone acetylation and cell cycle progression. In particular, AML cells depend on BRD4 for expression of the pro-survival proteins MYC and BCL2. BRD4 has therefore become an attractive target for novel therapeutics. PLX51107 is a novel BET inhibitor with a unique binding mode in the acetylated lysine binding pocket of BRD4 that differentiates it from other compounds under investigation. Our group has previously shown this compound to have antineoplastic activity in models of aggressive B cell malignancies. We have now investigated the anti-leukemic properties of PLX51107 in both in vitro and in vivo models of AML.Results:PLX51107 treatment potently reduced viability and proliferation of the human AML cell lines MV4-11, MOLM-13, OCI-AML3, and Kasumi-1, with IC50 of 0.17, 1.8, 0.2 and 0.2 μM, respectively. We then evaluated the in vitro activity of PLX51007 in primary human AML samples. PLX51107 inhibited the proliferation of primary human AML cells co-cultured with HS5 stromal cells. For nearly all samples tested (n=9), the IC50 of PLX51007 was less than 1 μM (average = 0.41 μM, range 0.039 - 1.5 μM). Notably, PLX51107 showed efficacy across a broad range of AML risk groups, including samples with adverse risk features such as 11q23 abnormalities and FLT3-ITD mutations. In comparison, for the same AML samples, the average IC50 for JQ1 was 0.71 μM (range 0.02 - 3.3 μM) and for cytarabine was 3.5 μM (range 0.33 to >10 μM). Furthermore, PLX51107 treatment reduced the clonogenicity of primary AML cells. Following incubation of AML cells in 1 μM PLX51107, there was significantly decreased colony formation (p<0.05) in drug-free, cytokine-supplemented methylcellulose media.We next examined the efficacy of PLX51107 in vivo, utilizing luciferase labeled MV4-11 AML cells xenotransplanted into NOD / SCID / IL2rgnull (NSG) immunodeficient mice. Daily oral dosing with 20 mg/kg PLX51107 resulted in prolonged survival (median 47 days) compared to vehicle treated control animals (median 30 days, p< 0.001). Weekly measurement of bioluminescence showed decreased disease burden in PLX51107 treated mice. In addition, human peripheral blood CD45 / CD33 double positive cells were significantly decreased in treated animals. Histologic analysis conducted at day 16 showed decreased leukemic burden in the bone marrow of the PLX51107 treated animals. In addition, examination of tissues from moribund mice at time of euthanasia demonstrated fewer leukemia cells in the spleen, liver and bone marrow.Conclusions:Collectively, our results show pre-clinical activity of PLX51107 in AML, supporting further development of this compound in clinical trials for relapsed or refractory myeloid malignancies. We are currently working to define downstream targets of PLX51107 action and developing patient derived AML xenografts to further characterize the in vivo effects of PLX51107. DisclosuresWalker:Gilead Sciences: Research Funding. Bhatnagar:Karyopharm: Research Funding.

Characteristics and Outcomes of Older Patients with Secondary AML According to Treatment Approach

BACKGROUND: Advanced age, AML arising from an antecedent hematologic disorder (AHD), and therapy-related AML (t-AML) are well established risk factors associated with poor outcome in AML. This subgroup of AML has been associated with lower rates of complete remission (CR) and shorter disease-free survival compared with de novo AML in younger patients (pts), when using standard therapy. Developing newer strategies to improve outcomes in this subgroup of pts is therefore a critical unmet need. Establishing baseline metrics from which to evaluate newer approaches is important. We sought to review our own experience with pts treated with different therapies at our institution to establish this baseline.METHODS: We retrospectively reviewed pts aged 60-75 years with newly diagnosed AML treated at our institution from 1990-2015 with one or more of the following characteristics: history of prior MDS, CMML, MPN, or aplastic anemia, the diagnosis of t-AML, or AML with karyotypic abnormalities characteristic of MDS as defined by the WHO. The pts were grouped into 5 study cohorts based on their treatment regimen: 1) High-dose Ara-C based intensive chemotherapy (HiDAC), 2) Hypomethylating agents (HMA)/HMA combinations, 3) Low-dose Ara-C combinations (LDAC), 4) Liposomal Ara-C:Daunorubicin (CPX-351), and 5) Other investigational agents (INV). Pts’ karyotypes were divided into 4 categories: adverse karyotype (complex: defined by >2 chromosomal abnormalities, Del 5/5q, Del 7/7q, 11q, 3q abnormality); diploid karyotype, intermediate karyotype (karyotype other than adverse or diploid); and unknown/not available. Endpoints included complete response (CR) rate/CR with low platelets (CRp) and 8-week mortality rates. Both univariate and multivariate analyses were performed to examine the relationships between disease characteristics and outcomes (CR, Overall survival).RESULTS: We evaluated a total of 931 pts with newly diagnosed AML meeting these criteria of age and secondary AML (s-AML). The baseline characteristics of pts in each group are summarized in table 1. The median age was 68 (60-75) years. Most pt characteristics were well balanced across the 5 treatment groups. Karyotyping was performed in 89% of the pts: 57.5% belonged to adverse risk profile and 31% belonged to intermediate risk profile (excluding diploid). The overall CR/CRp rates for the entire group was 39.5%. CR/CRp rates were lower in the HMA (36%) and INV (16%) groups compared to HiDAC (46%), CPX (45%) and LDAC (43%). Eight week mortality rate for the entire group was 20%: HiDAC (23%), HMA (12%), CPX (10%), LDAC (19%), and INV (27%). The median OS for the entire group was 6 months and by each treatment regimen is shown in Figure 1. There was a significant difference in OS between the 5 treatment groups. Pts receiving less intensive regimens [HMA + LDAC] had a superior median OS compared to those receiving HiDAC-based regimens (6.9 vs. 5.4; P=0.002, Figure 2). There was no difference in median survival in pts treated with CPX compared with conventional lower-intensity approaches (HMA + LDAC) (p=0.75). In the multivariate analysis, age >70yrs, adverse karyotype, and prior treatment for AHD were associated with a decreased OS. Similarly, use of HMA/INV treatment, adverse/intermediate risk karyotype, history of prior treatment for AHD were associated with lower CR rates.CONCLUSIONS: The outcomes of older pts with newly diagnosed s-AML are poor and reflective of their advanced age and poor-risk karyotype. Various treatment approaches have been attempted to improve outcomes. Lower-intensity approaches such as HMA and LDAC-based regimens have response rates similar to HiDAC regimens, but are associated with lower early mortality and improved overall survival. While the investigational liposomal formulation CPX-351was associated with favorable CR rates and low early mortality, the median OS was similar to pts treated with low intensity therapy. The unsatisfactory outcomes using other investigational agents in the INV group underscores the need for more effective therapies for these patients. [Display omitted] [Display omitted] [Display omitted] DisclosuresKantarjian:BMS, Pfizer, Amgen, Novartis: Research Funding. Konopleva:Reata Pharmaceuticals: Equity Ownership; Abbvie: Consultancy, Research Funding; Genentech: Consultancy, Research Funding; Stemline: Consultancy, Research Funding; Eli Lilly: Research Funding; Cellectis: Research Funding; Calithera: Research Funding. DiNardo:Celgene: Research Funding; Abbvie: Research Funding; Novartis: Other: advisory board, Research Funding; Daiichi Sankyo: Other: advisory board, Research Funding; Agios: Other: advisory board, Research Funding. Jain:Celgene: Research Funding; Infinity: Research Funding; ADC Therapeutics: Consultancy, Honoraria, Research Funding; Novimmune: Consultancy, Honoraria; Incyte: Research Funding; Abbvie: Research Funding; Novartis: Consultancy, Honoraria; Servier: Consultancy, Honoraria; Pfizer: Consultancy, Honoraria, Research Funding; Genentech: Research Funding; Pharmacyclics: Consultancy, Honoraria, Research Funding; BMS: Research Funding; Seattle Genetics: Research Funding. Wierda:Acerta: Research Funding; Novartis: Research Funding; Gilead: Research Funding; Abbvie: Research Funding; Genentech: Research Funding. Cortes:ARIAD: Consultancy, Research Funding; BMS: Consultancy, Research Funding; Novartis: Consultancy, Research Funding; Pfizer: Consultancy, Research Funding; Teva: Research Funding.

Cytogenetic Abnormalities May Predict Transformation to Acute Myeloid Leukemia in Polycythemia Vera Patients

Introduction: Cytogenetic abnormalities can be detected in about 20% of patients with polycythemia vera (PV) at initial diagnosis. The accumulated risk for acute myeloid leukemia (AML) transformation from PV has been estimated to be 2.3-14.4% at 10 years. Risk factors for AML transformation suggested in other studies include older age, abnormal karyotype and high leukocyte count. The purpose of this study is to evaluate the association of cytogenetic abnormalities with AML transformation in PV.Methods: We searched the database at our institution for patients with a diagnosis of PV during Jan. 1994 to Apr. 2015. Demographic data, clinical presentations and follow-up, and laboratory data including karyotype before and after AML transformation were collected. Bone marrow morphology, especially evidence of myelodysplasia, myelofibrosis and blast percentage were evaluated.Results: A total of 317 patients with a diagnosis of PV were identified. 36 (11%) patients progressed to AML (Group A), including 15 who presented in chronic phase and 21 in blast phase. The median interval from the diagnosis of PV to AML transformation was 97 months (range, 11 - 331 months). For comparison, 50 patients with similar demographic features during the same time interval but no evidence of AML transformation were also included in the study (Group B). The age of patients in both groups was comparable (median age: 57 vs. 54 years, p=0.2791). All patients were positive for JAK2 V617F mutation. The main therapies for patients with chronic phase PV included phlebotomy, hydrea, and tyrosine kinase inhibitors in a small subset of patients. There was no significant difference of treatments among the patients in groups A and B.Karyotype at chronic phase of PV was available in 15 patients in Group A and all 50 patients in Group B. Eleven (73%) patients in Group A showed an abnormal karyotype in chronic phase. The most common chromosomal abnormalities were trisomy 1q (n=6, 40%), including 4 (27%) patients with [+1, der(1;7)(q10;p10)] resulting in trisomy 1q and del(7q); and complex karyotype (n=3, 20%). Del(20q) and +8 was uncommon, only detected in 1 patient each. In Group B, 11 (22%) patients had an abnormal karyotype, which was much less frequent compared with Group A. No patients in Group B showed a complex karyotype or trisomy 1q; instead, del(20q) (n=6, 55%), +9 and/or +8 (n=5, 45%) were the most common chromosomes abnormalities detected.The median follow-up was 10 years in Group A and 14.5 years in Group B. At the time of AML transformation, 35 (97%) patients in Group A showed an abnormal karyotype, including 21 (58%) patients with a complex karyotype, 22 patients with -5/del(5q) and/or -7/del(7q) and 10 (28%) with trisomy 1q [8 with +1, der(1;7)]. Among the 15 patients who had karyotypic information during the chronic phase, 4 (27%) patients showed clonal evolution and 7 (47%) acquired new unrelated abnormal clones when AML transformation occurred.Morphologically, 15 patients in Group A had sequential bone marrow evaluation from chronic phase to blast phase, 14 (93%) patients developed myelofibrosis and 7 (47%) patients showed multilineage dysplasia during the chronic phase. At the time of AML transformation, 35 (97%) patients showed myelodysplasia. In Group B, 5 (10%) patients developed myelodysplasia and 31(62%) developed myelofibrosis in follow-up bone marrow samples.Conclusion: Cytogenetic abnormalities are associated with AML transformation in PV patients. Patients with an abnormal karyotype, especially with abnormalities of trisomy 1q [+1,der(1;7)(q10;p10)] or a complex karyotype, are at highest risk to develop clonal evolution or acquire new myelodysplasia-related clones [like -5/del(5q) and/or -7/del(7q)] or develop myelodysplasia and transform into AML. On the other hand, cytogenetic abnormalities, such as del(20q), +8 and/or +9, although commonly detected in PV, are associated with a low risk for myelodysplasia and AML transformation. Surveillance for cytogenetic abnormalities is helpful in the risk assessment of AML transformation in PV patients. DisclosuresNo relevant conflicts of interest to declare.

Clinical Impact of KMT2C and SPRY4 Expression Levels in Intensively Treated Younger Adult Acute Myeloid Leukemia Patients

Background:Recent publications suggest important roles of lysine methyltransferase 2C (KMT2C, located on 7q) and sprouty 4 (SPRY4, located on 5q) as candidate genes in leukemogenesis of acute myeloid leukemia (AML). The prognostic impact of the gene expression levels (ELs) of both genes on outcome in AML patients (pts) is currently unclear.Aim:To evaluate the prognostic impact of KMT2C and SPRY4 expression in correlation to clinical characteristics and genetic abnormalities assessed at diagnosis in a cohort of intensively treated adult AML pts.Methods: We retrospectively studied 268 AML pts (median age, 48 years; range, 17-60 years) who had been enrolled on 2 AML SHG trials (0295 and 0199, n=148; only normal cytogenetics pts (CN)) and the SAL-AML2003 trial (n=120; only abnormal cytogenetics pts (CA)). Acute promyelocytic and core-binding factor leukemia pts were excluded. Type of AML was de novo in 235 (88%), secondary in 19 (7%) and therapy-related in 14 (5%) of the 268 pts. Regarding baseline characteristics, CN pts had significantly higher white blood counts (WBC; p=0.001) and blast cells in peripheral blood (p=0.02) as compared to CA pts; all other factors were comparable. Cytogenetic analyses could be performed in 263 (98%) of the 268 pts. Cytogenetic risk classification according to ELN guidelines was intermediate-II in 55 (47%) and adverse in 63 (53%) of the CA pts, respectively. Abnormalities (abn) of 5q were present in 21 (18%) and abn of 7q in 16 (14%) of the CA pts. NPM1 and FLT3-ITD were analyzed in 145 (98%) of the CN pts. Of those, 59 (41%) were only NPM1 positive (pos), 12 (8%) were only FLT3-ITD pos, 34 (23%) were double pos and 40 (28%) were double negative (neg).KMT2C and SPRY4 ELs, normalized to ABL1and log2-transformed for analysis, were measured in triplets on cDNA obtained at diagnosis by RT-qPCR. Based on cDNA availability, KMT2C ELs could be analyzed in 143 (97%) of the CN and in all of the 120 CA pts, respectively. SPRY4 ELs could be measured in 30 (21%) of the CN and 107 (89%) of the CA pts, respectively.Results: KMT2C ELs were significantly lower in CN pts with de novo as compared to secondary AML (p= 0.02), whereas there was no difference in CA pts. No significant association was found for SPRY4 and type of AML. KMT2C ELs were significantly lower in FLT3-ITD pos as compared to FLT3-ITD neg CN pts (p=0.046), whereas there was no difference for SPRY4 ELs between the two groups (p=0.57). In addition, there was a significantly lower KMT2C expression in CN pts with intermediate-I risk as compared to NPM1 pos / FLT3-ITD neg pts (p=0.01). Regarding CA pts, there was no difference of KMT2C or SPRY4 ELs in adverse as compared to intermediate-II risk pts (p=0.08; p=0.20, respectively). When focusing on specific subgroups, KMT2C ELs were significantly lower in abn7q CA pts as compared to those without abn7q (p=0.002), whereas there was no difference of SPRY4 ELs in CA pts with or without abn5q (p=0.27). In univariate analysis higher SPRY4 ELs showed a significant favorable impact on relapse-free (RFS, p=0.03) and a trend towards a beneficial impact on overall survival (OS, p=0.06) for CA patients. A similar effect for KMT2C was not observed (RFS, p=0.96; OS, p=0.92). In subgroup analyses of pts with adverse risk cytogenetics, there was no impact of KMT2C or SPRY4 ELs on RFS (p=0.73; p=0.39) or OS (p=0.49; p=0.46), respectively. The same was true for FLT3-ITD pos CN pts (RFS, p=0.73; p=0.37; OS, p=0.91; p=0.36, respectively). In multivariate analyses on RFS and OS in CA pts including age, gender, KMT2C and SPRY4 ELs, logarithm of WBC, blast cells in bone marrow and cytogenetic risk group as variables, only higher age (OS, Hazard ratio (HR),1.28 per 10 years; 95%-confidence interval (CI): 1.02-1.59; p=0.03) and complex karyotype as compared to intermediate-II risk cytogenetics (RFS, HR: 2.25; 95%-CI: 1.20-4.22; p=0.01; OS, HR: 2.97; 95%-CI: 1.65-5.35; p<0.001) had an adverse impact. An effect of KMT2C or SPRY4 on RFS (p=0.84; p=0.16) or OS (p=0.85; p=0.45) was not found in the multivariate setting. In addition, in a multivariate model on CN pts (risk class according to NPM1 and FLT3-ITD mutational status instead of cytogenetic risk class) neither KMT2C nor SPRY4 had an impact on RFS (p=0.13; p=0.39, respectively) or OS (p=0.36; p=0.56, respectively).Conclusions:Lower KMT2C and SPRY4 ELs are associated with distinct genetic risk groups. An impact on prognosis was evident in univariable analyses for SPRY4 but not for KMT2C ELs in CA pts. DisclosuresKayser:Novartis: Consultancy. Platzbecker:Amgen: Honoraria, Research Funding; Novartis: Honoraria, Research Funding; TEVA Pharmaceutical Industries: Honoraria, Research Funding; Janssen-Cilag: Honoraria, Research Funding; Celgene Corporation: Honoraria, Research Funding. Heuser:Tetralogic: Research Funding; Novartis: Consultancy, Research Funding; Celgene: Honoraria; Bayer Pharma AG: Research Funding; Pfizer: Research Funding; Karyopharm Therapeutics Inc: Research Funding; BerGenBio: Research Funding. Thiede:AgenDix: Employment, Other: Ownership.

Analysis of Genomic Aberrations and Its Impact on Survival in Patients with Chronic Lymphocytic Leukemia (CLL) at the William Beaumont Hospital Cancer Center

CONTEXTChronic Lymphocytic Leukemia (CLL) is a clonal proliferation of small mature B-cell lymphocytes diagnosed clinically when the peripheral blood clonal B lymphocyte count is persistently >5,000/mcL with distinctive immunological markers defined by co-expression of CD5 and CD23 with additional expression of CD19, CD20 (weak) with weak surface immunoglobulin expression, usually IgM heavy chain. Expression of CD79b and FMC7 is typically negative to weakly positive. With the recent advancement in cancer genetics and the continued understanding of the transforming events in CLL, the importance of the various somatic genomic aberrations has been well documented. Multiple studies have shown the clinical implications of these aberrations in terms of their prognostic and predictive relevance in clinical practice and these genomic aberrations are usually assessed clinically by cytogenetic analysis and FISH.OBJECTIVEWe proposed this study to determine the incidence of the genomic aberrations in the CLL patients diagnosed at the Rose Cancer Treatment Center of the William Beaumont Hospital between 2010 and 2015 and to determine their impact on survival among the patients diagnosed during the study period. STUDY DESIGNA retrospective review of all the patients diagnosed with CLL between 2010 and 2015 at the Rose Cancer Treatment Center was conducted with the assistance of the staff in the William Beaumont cancer registry office. We determined the demographic variables and analyzed the incidence of CLL among the subjects diagnosed within the study period. Data analysis was performed using SPSS 21 and Kaplan-Meier curves were plotted for survival analysis and log rank (Mantel-Cox) was used to compare these curves. 12-Month and 36-Month overall survival rates were analyzed by actuarial method. The distribution of the various genomic aberrations was determined using descriptive statistical analysis. RESULTSA total of 151 patients were identified at the Rose Cancer Center of the William Beaumont Hospital during the study period. The median age at diagnosis was 74 years (range 38-101) of which 90 were male (59.6%) and 61 female (40.4%). One-hundred and twenty-four (82.1%) patients were white, six patients (4.0%) were African American, two patients (1.3%) were Asian and nineteen (12.6%) patients declined to identify their race.Analysis of cytogenetic distribution showed that, twenty patients (13.2%) had normal cytogenetic, eleven patients (7.3%) had del(13q) alone, eight (5.3%) had both del(13q) and del(11q), four patients (2.6%) had del(13q) plus trisomy 12 aberrations, ten (6.6%) patients had del(13q) and other karyotypes (TP53, RB1, trisomy 1q, del(6q23), unmutated IGHV). Thirteen patients (8.6%) had trisomy 12 abnormality, five patients (3.3%) had del(11q), three patients (2.0%) had del(17p), twenty-five patients (16.6%) had complex cytogenetic abnormalities and fifty-two (34.4%) patients cytogenetic were not checked (see Fig.1). The median follow-up duration for the cohort was 22.5 months (range 0 to 70 months). The survival rates at 12 months and 36 months for the cohorts based on cytogenetic are described in table 1 and fig.2.CONCLUSIONOur study showed that majority of our patients (34.4%) did not have their cytogenetics checked at diagnosis, patients with del(13q) abnormality alone had the most favorable 36-Month overall survival rate and those with del(17p) fared worst with the most unfavorable outcome followed by patients with complex cytogenetic abnormalities. Presence of del(13q) with either del(11q) or trisomy 12 abnormalities appeared to ameliorate their poor and intermediate adverse prognostic effects, respectively. [Display omitted] [Display omitted] [Display omitted] DisclosuresNo relevant conflicts of interest to declare.

Interaction with the DNA Binding Domain of MLL and a Small Molecular Drug Induces Proteolysis of MLL-Fusion Proteins and Ablates Leukemic Stem Cell Activity

IntroductionLeukemias harbouring 11q23 abnormalities causing mixed-lineage leukaemia gene (MLL) rearrangements are associated with poor clinical outcomes. Despite being an aggressive leukaemia, the MLL rearranged infant ALL has among the lowest mutation rates reported for any cancer. This means that to improve survival for patients with this aggressive leukaemia we need drugs that target the abnormal proteins produced by the MLL fusion gene or that interact with the abnormal MLL fusion protein to shut down the cellular machinery that drives these leukemias. Indeed, targeting MLL fusion dependent gene pathways has become a major focus.Our previous studies have shown that inhibition of MLL-fusions, in a conditional mouse model of MLL-ENL driven acute myeloid leukaemia, resulted in a block in self-renewal of the leukemic cells and ablated the leukaemia in the mice. This led us to hypothesise that if, we could achieve pharmacological inactivation of the MLL fusion proteins, we could achieve improved clinical outcomes. To achieve this, we set out a drug screening programme in acute leukaemia with the aim to discover drugs that can inactivate MLL-fusion oncoproteins.ResultsOur drug discovery pipeline screened clinical approved drugs for their ability to inhibit the function of the MLL fusion protein. This lead to the discovery of a drug that interacts with the DNA binding domain within the MLL fusion protein. This interaction destabilises the MLL fusion protein so that the fusion protein gets degraded within 24 hours of addition of the drug. So far, we have shown that we can inhibit and induce the degradation of MLL-AF9, MLL-AF6 and MLL-AF4 (and WT MLL) in the human MLL rearranged cell lines (THP-1, SHI-I and MV4-11), in primary immortalized cells in which the MLL-AF9 is overexpressed from a lentiviral backbone and in patient derived leukemic samples.Inactivation/degradation of the MLL fusion protein should shut down the cellular machinery that drives these leukemias. It is well established that MLL-fusions lead to abhorrent upregulation of its target genes HOXA9, MEIS1 and c-MYB. Treatment of MLL rearranged cells resulted in the downregulation of these MLL-fusion target genes within 24hrs of addition of the drug. Furthermore, Gene Set Enrichment Analysis of drug treated MLL-AF9 cells showed strong negative enrichment to various published MLL fusion target gene sets. Inactivation of MLL fusion protein should also result in block in self-renewal as we have previously shown in our conditional mouse model. Indeed, Gene Set Enrichment Analysis showed negative enrichment to published Leukemic Stem Cell gene set. To analyse the impact of drug treatment on self-renewal, we used a well-established self-renewal assay, whereby self-renewal is assessed by their ability to form colonies derived from single cells in methylcellulose. While treatment had no significant impact on the colony formation of CD34 positive cord blood progenitors, the drug was able to block the colony formation ability of MLL rearranged cell lines while only slowing a slight reduction in in the colony numbers of non MLL rearranged cell lines.ConclusionOverall, the data indicates that we may have discovered a new targeted treatment for MLL rearranged leukemia, which shows excellent clinical properties. We have successfully generated Patient Derived Xenografts (PDX) models and we are currently testing this drug to verify its effectiveness in the treatment on PDX. We will include this data in our presentation. DisclosuresNo relevant conflicts of interest to declare.

Spindle cell lipoma adherent to the digital nerve in the palm.

Dear sir, Spindle cell lipoma, a solitary, slowly growing subcutaneous tumor, mainly in the posterior neck, shoulder girdle, upper back predominantly in men in the fifth to seventh decades. It can arise in other areas of the body. Johnson et al. reported a spindle cell lipoma in the orbital region; Toker et al. reported in the breast; Suster et al. reported in the gastrointestinal tract and Eckert et al. reported in the upper arm. Spindle cell lipomas are typically placed encapsulated in sub cutis, while occasionally they are poorly demarcated and can extend in to the dermis or underlying tissues. No case of spindle cell lipoma in the palm adherent to digital nerve has been reported in the literature. Here, we present a rare case of spindle cell lipoma adherent to the digital nerve in the palm. A 43 years old male patient was admitted to our clinic for further examination of the mass occurring in his right palm 24 months ago and hypoesthesia of radial side of the third finger for 3 months. A physical examination revealed 4 cm × 3 cm subcutaneous mass in the right palmar area. Ultrasonography revealed well circumscribed and low-echo 4 cm × 3 cm mass in the subcutaneous region of the palm. Furthermore, heterogenous signal intensity on all pulse sequences was showed by magnetic resonance imaging. A fine needle biopsy reported a spindle cell lipoma. At exploration, there was a well-circumscribed mass, connected to the digital nerve. (Fig.​(Fig.1a)1a) The multi lobulated 34 mm diameter mass was yellowish-white on its cut surfaces, had a firm texture, and was clearly demarcated from the adjacent tissues by a thin fibrous capsule The patient had no recurrence in 46 months follow-up. Fig. 1 a. Peroperative view of the spindle cell lipoma and the digital nerve b. Spindle cells in non-lipogenic areas are CD34 positive. (CD34; Original magnification X200) Spindle cell lipoma is a benign tumor distinguished by the replacement of mature adipocoyte by collagen forming spindle cells. It is a mixture of short spindle cells, adipocytes, and ropey collagen bundles, sometimes with a myxoid stroma. The differential diagnosis includes dermatofibrosarcoma protuberance, angiomyofibroblastoma, nodular fasciitis and myxoid liposarcoma [1]. Lipoblasts, fat necrosis, and fat with atrophic changes are important to the differential diagnosis of liposarcoma and spindle cell lipoma. There was co-expression of CD34, bcl-2, and vimentin in the spindle cells. (Fig. 1b). Tardio also reported that co-expression of CD34 and bcl-2 was common in atypical adipocytic tumors in a recent study [2]. Spindle cell lipoma is most closely related to pleomorphic lipoma in terms of demographics and presenting location. Cytogenetically, most spindle cell and pleomorphic lipomas show common 16q or 13q abnormalities [3]. Some authors have reported on the intra dermal origin which presents with different clinical or morphological features such as, widespread anatomical distribution, female predilection and an infiltrative pattern. Also, Mounasamy et al. have reported single case of spindle cell lipoma of palm [4]. Definitive diagnosis of spindle cell lipoma is crucial to recognize that this is a benign tumor and avoid misdiagnosing the lesion as a myxoid liposarcoma. The treatment of option for spindle cell lipoma is a complete local excision and its recurrence is extremely rare.

Changes in cytogenetics and molecular genetics in acute myeloid leukemia from childhood to adult age groups.

To obtain better insight into the biology of acute myeloid leukemia (AML) in various age groups, this study focused on the genetic changes occurring during a lifetime. This study analyzed the relation between age and genetics from birth to 100 years in 5564 patients with de novo AML diagnosed from 1998 to 2012 (1192 patients from nationwide pediatric studies [AML Berlin-Frankfurt-Münster studies 98 and 2004] and 4372 adults registered with the Munich Leukemia Laboratory). The frequencies of cytogenetic subgroups were age-dependent. Favorable subtypes (t(8;21), inv(16)/t(16;16), and t(15;17)) decreased in general from the pediatric age group (2 to < 18 years; 33%) to the oldest groups (<5% for > 70 years; P < .0001). Unfavorable cytogenetics (-7/del(7), -5/del(5q) or 5p, inv(3)/t(3;3), t(6;9), complex karyotype, 12p, 17p, and 11q23/mixed-lineage leukemia aberrations, excluding t(9;11)) were frequent (42%) in infants (<2 years), had a low frequency in children and young adults (<22%), and increased in frequency up to 36% in patients older than 85 years (P = .01). This was even more significant for complex karyotypes (P ≤ .0001), which also showed a strong increase in the absolute age-specific incidence with age. Interestingly, the frequency of 11q23 abnormalities decreased from infants to older patients. The proportion of clinically relevant molecular aberrations of CCAAT/enhancer binding protein α, nucleophosmin (NPM1), and NPM1/fms-related tyrosine kinase 3-internal tandem duplication increased with age. Altogether, with the exclusion of infants, a significant decrease in the proportion of favorable cytogenetic subtypes and an increase in unfavorable cytogenetics were observed with increasing age. These findings indicate different mechanisms for the pathogenesis of AML; these different mechanisms also suggest directions for etiological research and contribute to the more unfavorable prognosis with increasing age. Cancer 2016;122:3821-3830. © 2016 American Cancer Society.

Post-Transplant Outcomes in High-Risk Compared with Non–High-Risk Multiple Myeloma: A CIBMTR Analysis

Conventional cytogenetics and interphase fluorescence in situ hybridization (FISH) identify high-risk multiple myeloma (HRM) populations characterized by poor outcomes. We analyzed these differences among HRM versus non-HRM populations after upfront autologous hematopoietic cell transplantation (autoHCT). Between 2008 and 2012, 715 patients with multiple myeloma identified by FISH and/or cytogenetic data with upfront autoHCT were identified in the Center for International Blood and Marrow Transplant Research database. HRM was defined as del17p, t(4;14), t(14;16), hypodiploidy (<45 chromosomes excluding -Y) or chromosome 1 p and 1q abnormalities; all others were non-HRM. Among 125 HRM patients (17.5%), induction with bortezomib and immunomodulatory agents (imids) was higher compared with non-HRM (56% versus 43%, P < .001) with similar pretransplant complete response (CR) rates (14% versus 16%, P .1). At day 100 post-transplant, at least a very good partial response was 59% in HRM and 61% in non-HRM (P = .6). More HRM patients received post-transplant therapy with bortezomib and imids (26% versus 12%, P = .004). Three-year post-transplant progression-free (PFS) and overall survival (OS) rates in HRM versus non-HRM were 37% versus 49% (P < .001) and 72% versus 85% (P < .001), respectively. At 3 years, PFS for HRM patients with and without post-transplant therapy was 46% (95% confidence interval [CI], 33 to 59) versus 14% (95% CI, 4 to 29) and in non-HRM patients with and without post-transplant therapy 55% (95% CI, 49 to 62) versus 39% (95% CI, 32 to 47); rates of OS for HRM patients with and without post-transplant therapy were 81% (95% CI, 70 to 90) versus 48% (95% CI, 30 to 65) compared with 88% (95% CI, 84 to 92) and 79% (95% CI, 73 to 85) in non-HRM patients with and without post-transplant therapy, respectively. Among patients receiving post-transplant therapy, there was no difference in OS between HRM and non-HRM (P = .08). In addition to HRM, higher stage, less than a CR pretransplant, lack of post-transplant therapy, and African American race were associated with worse OS. In conclusion, we show HRM patients achieve similar day 100 post-transplant responses compared with non-HRM patients, but these responses are not sustained. Post-transplant therapy appeared to improve the poor outcomes of HRM.

48 - A Variant of inv(3)(q21q26.2) or t(3;3)(q21;q26.2) (MECOM) Rearrangement in AML

Acute myeloid leukemia with inv(3)(q21q26.2) or t(3;3)(q21;q26.2) is a distinct entity recognized by the WHO Classification of Tumors of Haematopoietic Tissue as an aggressive disease with short survival. EVI1 overexpression in AML with 3q rearrangements is frequently driven by its new proximity to an enhancer of the GATA2 gene. We report the cytogenetic analysis of a bone marrow aspirate from a 77 year old man with AML. Karyotype analysis of bone marrow cell G banded metaphases revealed a subtle abnormality in 3q26.2. Analysis with a FISH probe encompassing the entire MECOM (MDS1 and EVI1 complex) locus on chromosome 3q26.2 revealed that this rearrangement was actually an insertion of MECOM into the other chromosome 3 homologue at 3p24 to produce ins(3;3)(p24;q26.2q26.2). The rearrangement was not apparent in a previous karyotype analysis when his disease was described as CMML; its appearance marked the change to a very aggressive form of AML to which he unfortunately succumbed within a few months. The “formerly known as EVI1 locus” actually harbours two transcription start sites and thus has now been renamed MECOM for “MDS1 and EVI1 complex locus” gene. MECOM harbours both a hematopoietic stem cell factor that blocks both myeloid cell differentiation and apoptosis, and a chromatin remodelling activity that promotes cell quiescence and likely contributes to chemotherapy resistance. Both functions present potential targets for therapy. Discussion is underway whether the presence of inv(3)(q21q26.2) or t(3;3)(q21;q26.2) should be used to diagnose AML regardless of blast count and whether other 3q abnormalities such as t(3;12)(q26;p13) EV1/ETV6 fusion or t(3;21)(q26;q22) RUNX1/EVI1 fusion should be classed together in this category. There are likely more chromosome variants of MECOM to be recognized as the function of this locus is better understood.

Complex chromosomal rearrangements leading to MECOM overexpression are recurrent in myeloid malignancies with various 3q abnormalities.

Chromosomal rearrangements involving 3q26 are recurrent findings in myeloid malignancies leading to MECOM overexpression, which has been associated with a very poor prognosis. Other 3q abnormalities have been reported and cryptic MECOM rearrangements have been identified in some cases. By fluorescence in situ hybridization (FISH) analysis, we investigated 97 acute myeloid leukemia/myelodysplastic syndrome patients with various 3q abnormalities to determine the role and the frequency of the involvement of MECOM. We identified MECOM rearrangements in 51 patients, most of them showed 3q26 involvement by chromosome banding analysis (CBA): inv(3)/t(3;3) (n = 26) and other balanced 3q26 translocations (t(3q26)) (n = 15); the remaining cases (n = 10) showed various 3q abnormalities: five with balanced translocations involving 3q21 or 3q25; two with homogenously staining region (hsr) on 3q; and three with other various 3q abnormalities. Complex rearrangements with multiple breakpoints on 3q, masking 3q26 involvement, were identified in cases with 3q21/3q25 translocations. Furthermore, multiple breaks were observed in two cases with t(3q26), suggesting that complex rearrangement may also occur in apparently simple t(3q26). Intrachromosomal gene amplification was another mechanism leading to MECOM overexpression in two cases with hsr on 3q. In the last three cases, FISH analysis revealed 3q26 involvement that was missed by CBA because of metaphases' suboptimal quality. All cases with MECOM rearrangements showed overexpression by real-time quantitative PCR. Finally, MECOM rearrangements can occur in patients with 3q abnormalities even in the absence of specific 3q26 involvement, underlining that their frequency is underestimated. As MECOM rearrangement has been associated with very poor prognosis, its screening should be performed in patients with any 3q abnormalities.

Allogeneic Hematopoietic Stem Cell Transplantation in Acute Myeloid Leukemias: Prognostic Significance of Complex Karyotype Including del(5q), -7, del(7q) Abnormalities

Aim. To evaluate the prognostic significance of the complex karyotype including del(5q), -7, del(7q) abnormalities in acute myeloid leukemia (AML) after allogeneic hematopoietic stem cell transplantation (allo-HSCT). Materials &amp; Methods. Forty-four AML patients with chromosome 5 and/or 7 abnormalities (22 women and 22 men, aged from 1.2 to 67 years, median 31.2 years) were examined. Analysis of overall (OS) and event-free survival (EFS) predictors after allo-HSCT in patients with different clinical, transplant and cytogenetic characteristics was performed. Results. Prior to allo-HSCT, the complex karyotype (with three or more chromosomal abnormalities) was observed in 19 (43 %) patients, the monosomal karyotype was in 8 (18 %) patients. Univariate analysis demonstrated that OS and EFS differed in patients from different age groups (&gt; 18 vs. &lt; 18 years; p = 0.01 and p = 0.05, respectively), with different disease status at transplantation (1 remission vs. other clinical status; p = 0.1 and p = 0.008, respectively), with and without complex karyotype (СК- vs. CK+; p = 0.05 and p = 0.002, respectively), with and without monosomal karyotype (МК- vs. MK+; p = 0.009, only for EFS), and with different stem cells source (bone marrow vs. other source; p = 0.03 only for OS). Multivariate analysis confirmed that age of 18 years and more (p = 0.02 and p = 0.01, respectively), active disease at allo-HSCT (p = 0.04 and p = 0.005, respectively), complex karyotype (p = 0.04 и p = 0.0008, respectively) and stem cell source other than bone marrow (p = 0.02 only for OS) were independent predictors of OS and EFS deterioration. Conclusion. The study demonstrates that chromosome 5 and/or 7 abnormalities as a part of the complex karyotype is high-risk factor in AML patients undergoing allo-HSCT (unlike the monosomal karyotype), that requires the special therapeutic approach.

Перестройки хромосомного района 11q23 при острых миелоидных лейкозах у детей

Aim. To study characteristics of 11q23 involvement, agespecific differences in the incidence of these chromosomal markers in acute myeloid leukemias (AML) in children, and to determine their prognostic significance in patients treated according to the protocols applied in leading Russian pediatric hematological clinics. Methods. The chromosomal analysis of bone marrow and peripheral blood cells has been performed prior to initiation of treatment in 395 children with primary AML aged from 0 to 16 years. The patients were treated in pediatric hematological clinics of Moscow and Moscow Region and in Yekaterinburg District Children's Hospital No. 1. Clinical outcomes of 300 followed-up pediatric patients treated with similar modern therapy protocols were analyzed to evaluate the prognostic impact of 11q23/MLL abnormalities. To determine the incidence of 11q23/MLL rearrangements in AML of different age groups, we examined not only children, but also adult patients (n = 212). Results. In AML, the frequency of changes in the 11q23 region exceeded 40 % in children aged from 0 to 2 years. The frequency decrease with age and in patients over 40 years it was only 2 %. Significant heterogeneity of changes in karyotypes with 11q23/MLL rearrangements was observed: both various translocations with different regions of other chromosomes, and 11q23 deletions were detected. In addition, a great variability of numerical and structural additional chromosomal abnormalities was observed. The 10-year relapse-free survival rates (30.4 ± 6.7 %) and overall survival rates (35.1 ± 7.0 %) in AML with changes in the 11q23 region (n = 61) were significantly lower than those in patients from the intermediate risk group (n = 103): 48.9 ± 5.8 % and 43.8 ± 7.5 %, respectively (p = 0.035). The data are close to those in the high-risk group (n = 44): 35.9 ± 8.1 % and 38.3 ± 7.6 %, respectively. The study failed to confirm the published data that t(9; 11) is a more favorable prognostic factor, and that t(6; 11) and t(10; 11) are less favorable ones than all other 11q23 translocations. Our results did not confirm a negative prognostic effect of additional chromosome abnormalities associated with 11q23 rearrangements. Conclusion. Pediatric AML patients with 11q23 abnormalities should be included in a high-risk group if therapy is performed according protocols applied in leading hematological centers of Russia.

Therapy-related myeloid neoplasms in children and adolescents.

BackgroundThis retrospective study aimed to characterize and analyze the outcome of therapy-related myeloid neoplasms (t-MNs) in children and adolescents.MethodsThe medical records of 16 patients under 21 years of age at the time of t-MN diagnosis were reviewed.ResultsThe median patient age was 11.5 years (range, 1.6–20.4 yr). Twelve patients had therapy-related acute myeloid leukemia, 3 patients had myelodysplastic syndrome, and 1 patient had chronic myelomonocytic leukemia. The median latency period was 29 months (range, 11–68 mo). Fourteen patients had cytogenetic aberrations, 8 of whom had an 11q23 abnormality. Of the 13 patients treated with curative intent, 12 patients received myeloid-type induction therapy that led to complete remission (CR) in 8 patients. Nine patients underwent allogeneic transplantation; 4 patients did not undergo transplantation due to chemotherapy-related toxic death (N=3) or parental refusal (N=1). The 5-year overall survival and event-free survival of the 13 patients treated with a curative intent were 46.2% and 30.8%, respectively. For the 9 patients who underwent allogeneic transplantation, the 5-year event-free survival was 66.7%.ConclusionA significant proportion of young patients with t-MNs can experience long-term survival, and allogeneic transplantation plays a key role for attaining cure in these patients.

The first case of acute myeloid leukemia with solitary t(6;7)(p21.3;p22) passenger translocation that developed at relapse after allogeneic hematopoietic stem cell transplantation in a patient with a normal karyotype at the initial diagnosis.

TO THE EDITOR: Translocations involving chromosome 7 rarely occur in AML and to date, nine cases with t(7;21) (p22;q22) involving ubiquitin specific peptidase 42 (USP42) at 7p22 and runt-related transcription factor 1 (RUNX1) at 21q22 have been reported as recurrent, semi-cryptic aberrations in AML. AML is associated with 5q abnormalities and hyperploidy [1,2,3,4,5,6,7]. In terms of t(6;7), this abnormality was reported in three AML cases as a mainline abnormality included in complex chromosomal abnormality [8,9,10]. We report here a case of AML with a solitary t(6;7)(p21.3;p22) passenger translocation that developed at relapse after allogeneic hematopoietic stem cell transplantation (HSCT) in a patient with a normal karyotype at the initial diagnosis.

Recurrent Genetic Abnormalities Are Reflected in Phenotype at Diagnosis in Pediatric Acute Myeloid Leukemia: A Report from the Children's Oncology Group Protocol AAML0531

Background: Acute myeloid leukemia (AML) is a heterogeneous disease with high genomic and phenotypic complexity. Although a relationship between phenotype and t(15;17) is recognized, the effect of other genotypic abnormalities on phenotype remains to be elucidated.Objective: To explore the relationships between genotypic and phenotypic abnormalities in diagnostic specimens in pediatric AML.Methods: Of 1022 newly diagnosed pediatric patients with de novo AML enrolled on protocol AAML0531, 769 satisfied three criteria for this study: (1) submission of a blood or bone marrow sample for multidimensional flow cytometry (MDF) at diagnosis, (2) consent to blood bank specimen testing and (3) leukemia comprising >10% of non-erythroid cells by MDF. The diagnostic AML tumor population was identified by gating on CD45 vs log-SSC. A fifteen-dimensional immunophenotypic expression profile (IEP) was defined by computing mean fluorescent intensities, antigen intensity coefficient of variations, and light scatter characteristics of each leukemia without analyst imposed cut-offs.Unsupervised hierarchical clustering was performed to mathematically cluster patients with similar IEPs. The underlying karyotypic and mutational profile of each patient was compared to the IEPs to identify clusters of patients with relationships between phenotype and identifiable genetic abnormalities. Supervised bagged tree-based models were used to quantify the importance of each cell-surface antigen in identifying these clusters. Levene's test was used to assess the homogeneity of mean cell-surface antigen expression for important markers.Results: Analysis of hierarchical clustering results revealed 7 immunophenotypic clusters (A-G) of patients with relationships between IEP and 4 common genetic abnormalities (Figure 1).Cluster A and Cluster B were both strongly associated with the t(8;21) karyotype (Figure 1). 54/62 patients in Cluster A (87%) and 24/26 patients in Cluster B (92%) were positive for t(8;21). The most important cell-surface antigens in identifying patients with the Cluster A associated phenotype were dim CD33, expression of CD56, expression of CD34 and expression of HLA-DR. The mean antigen expression of these markers was significantly more homogenous for patients in Cluster A compared to all other patients for CD33 (p = 0.02), CD34 (p < 0.01) and HLA-DR (p<0.01). Mean expression of CD56 was notably more heterogeneous (p = 0.40) but positive in 91% of patients in this cluster. The most important cell-surface antigens in identifying the Cluster B associated phenotype were dim CD13, expression of CD34, expression of HLA-DR and dim CD33. The mean expression of these markers was significantly more homogeneous for patients in Cluster B compared to all other patients (all p values <0.01). In contrast to Cluster A, CD56 MFIs were negative for patients in Cluster B. Collectively, 72% of all patients with t(8;21) segregated into Cluster A (50%) or Cluster B (22%).Cluster C was strongly associated with chromosome 16 abnormalities (Figure 1). Of patients in this cluster, 50/55 (91%) were positive for inv(16)/t(16;16). The mean high-expression of CD13 was the most important antigen in identifying patients with this phenotype, and patients in Cluster C had more consistent mean CD13 expression compared to all other patients (p<0.01). 53% of all patients with chromosome 16 abnormalities comprised this cluster.Cluster D was strongly associated with 11q23 abnormalities (Figure 1). Of patients in this cluster, 105/135 (78%) were positive for 11q23 translocations. The most discriminating markers in identifying these patients were dim-to-negative CD34 and dim-to-negative CD117. 69% of all patients with 11q23 abnormalities comprised this cluster.Clusters E, F and G were associated with FLT3 ITD mutations (Figure 1). Of patients in these clusters, 44%, 49% and 53% were positive for FLT3 ITD mutations. Cumulatively, 63% of all patients with FLT3 ITD mutations were grouped into one of these three clusters.Conclusion: Hierarchical clustering algorithms identify IEPs associated with common genetic abnormalities in pediatric AML, providing insight into the consistent dysregulation of cell-surface gene product expression in patients with common genetic abnormalities. Further analysis may reveal that IEPs can identify patients otherwise classified as good or standard risk that will have a poor outcome. [Display omitted] DisclosuresVoigt:Hematologics Inc.: Employment. Brodersen:Hematologics Inc.: Employment. Menssen:Hematologics Inc.: Employment. Loken:Hematologics Inc.: Equity Ownership.

Quantification of Acute Lymphoblastic Leukemia Clonotypes in Leukapheresed Peripheral Blood Progenitor Cells Predicts Relapse Risk Following Autologous Hematopoietic Cell Transplantation

BackgroundAlthough multiple studies have shown superiority of allogeneic hematopoietic cell transplantation (alloHCT) over autologous hematopoietic cell transplantation (autoHCT) for patients with "high-risk" acute lymphoblastic leukemia (ALL), these findings may be explained, in part, by contamination of the peripheral blood progenitor cell (PBPC) leukapheresis product by residual leukemic cells in patients undergoing autoHCT.MethodsWe retrospectively evaluated minimal residual disease (MRD) via next-generation sequencing (NGS) (Adaptive Biotechnologies, S. San Francisco, CA) in the PBPC leukapheresis products from 32 ALL patients who underwent autoHCT. All patients had "high-risk" ALL, as defined by B-lineage disease with WBC at diagnosis >30,000/uL; high-risk cytogenetics including t(9;22), t(4;11), other 11q23 abnormalities, or monosomy 7; or primary refractory disease.Peripheral hematopoietic cell mobilization consisted of cytarabine 2000mg/m2 IV every 12 hours (16,000mg/m2 cumulative) concurrent with etoposide 40mg/kg cumulative by continuous IV infusion over 4 days. The autoHCT conditioning consisted of 1320cGy total body irradiation (TBI) given in 11 fractions from day -8 to -5, etoposide 60mg/kg IV on day -4, and cyclophosphamide 100mg/kg IV on day -2. Tyrosine kinase inhibitors (TKI) were allowed for patients with Philadelphia chromosome-positive (Ph+) B-ALL. Seven patients (22%) participated in a multi-institutional trial in which the PBPC graft underwent ex vivo complement-mediatedpurging using monoclonal antibodies against CD9/CD10/CD19/CD20 for patients with B-lineage disease, or against CD2/CD3/CD4/CD5/CD8 for patients with T-lineage disease.Kaplan-Meier curves were generated using GraphPad Prism (GraphPad Software, La Jolla, CA) and statistical differences assessed via Log-Rank and Wilcoxon analyses, with a p-value of <0.05 considered significant.ResultsTwenty-eight patients (88%) had diagnostic bone marrow samples with quantifiable immunoglobulin or T cell receptor (Ig/TCR) gene rearrangements suitable for MRD quantification in the PBPC collections. Twelve (38%) patients had Ph+ B-ALL, 12 (38%) had Ph-neg B-ALL, and 4 (14%) had T-cell ALL. The majority of patients were male, in first complete remission, and autografted between 2000-2009, with a median age at autoHCT of 32 (range 19-55).With a median follow-up of 41 months (range 3-217), median relapse-free survival (RFS) and overall survival (OS) for the entire cohort are 3.2 and 4.2 years, respectively. At 5 years post-autoHCT, 42% of patients remain alive and relapse-free.Of the 28 diagnostic bone marrow specimens, 21 (75%) had rearrangements in more than 1 immunoreceptor locus (Figure 1A). A total of 73 rearrangements were identified across all patients. Clonal Ig heavy chain (IGH) sequences with complete VDJ rearrangement were the most commonly identified rearrangement, present in 17 of 28 patients (61%) and representing 30 of the 73 (41%) total rearrangements.When stratified by graft MRD burden, the median RFS for patients with MRD detectable at a level ≥10-6 (n=13) was 6.5 months, and has not been reached for patients without detectable MRD above this threshold (n=15; p=0.0005; Figure 1B). Ex vivo antibody-based purging failed to eradicate leukemia cells from the PBPC collections of 3 patients with detectable MRD who received a purged graft (Figure 1C), all of whom ultimately relapsed.Of the Ph+ cohort, 6 (50%) had detectable MRD in the PBPC graft. Two (33%) of these patients were not treated with a TKI; 1 relapsed at 4 months post-autoHCT and the other died from non-relapse mortality. Of the 4 Ph+ patients with detectable MRD who received a TKI, 2 (50%) remain long-term relapse-free survivors. Of the 6 patients without MRD who were treated with a post-autoHCT TKI, 5 (83%) remain relapse-free.ConclusionWe demonstrate that the NGS-based immunosequencing platform identifies ALL MRD in leukapheresed PBPC collections. The presence of MRD in the autograft strongly predicts relapse, with only 15% RFS in patients harboring ≥10-6 MRD at stem cell collection versus 73% in patients with undetectable MRD. The absence of MRD in PBPC may thus identify a subset of "high-risk" patients likely to achieve long-term remissions without alloHCT. TKI therapy for patients with Ph+ B-ALL may also, in some cases, abrogate the need for alloHCT, even with quantifiable MRD prior to high-dose therapy. [Display omitted] DisclosuresDamon:Atara: Consultancy; Sunesis: Research Funding; Sigma-Tau: Research Funding; McGraw-Hill: Patents & Royalties: Book Chapter. Andreadis:McGraw Hill: Honoraria; Novartis: Consultancy; Cellerant: Consultancy; Pharmacyclics: Honoraria. Olin:Daiichi-Sankyo: Research Funding. Kong:Adaptive Biotechnologies: Employment, Equity Ownership. Faham:Adaptive Biotechnologies: Employment, Equity Ownership.

Impact of Hypomethylating Agent Therapy in Myelodysplastic Syndromes with Chromosome 3 Abnormalities

Background In myelodysplastic syndromes (MDS), abnormalities of chromosome 3 (i.e. inversion 3 (inv(3)), translocation 3q (t(3q)), or deletion 3q (del(3q)) represent a poor-risk karyotype in the Revised International Prognostic Scoring System (IPSS-R). In acute myeloid leukemia (AML) patients with 3q abnormalities, patients with inv(3)/t3;3 represented the most unfavorable group with a median overall survival (OS) of 10.3 months (Lugthart et al., 2010). We previously presented a single institution experience regarding outcomes of MDS patients with chromosome 3 abnormalities. Here, we sought to further define outcomes of chromosome 3 abnormalities in MDS and address the impact of hypomethylating agents (HMA) on outcome in multiple institutions.Patients and Methods Patients were identified through the MDS Clinical Research Consortium and were included if they had a WHO diagnosis of MDS, MDS/myeloproliferative neoplasm (MPN), therapy related MDS (t-MDS), or AML (20-30% myeloblasts) and had any karyotypic abnormality involving chromosome 3. Data analyzed included baseline demographics, disease characteristics, IPSS/IPSS-R scores, treatment and outcome. Responses to HMA therapy were evaluated using International Working Group (IWG) 2006 criteria. Kaplan-Meier estimates were used for overall survival.Results A total of 413 patients were identified with a median age at diagnosis of 67 years. WHO classification was as follows: 9% RA/RARS, 12% RCMD, 26% RAEB-1, 31% RAEB-2, 2% MDS/MPN, 7% MDS Unclassified, 13% AML; 34% had t-MDS. Overall, 97% of patients were higher risk by IPSS-R (i.e., intermediate to very high risk) with a median blast % in bone marrow of 8%. Distribution of cytogenetic abnormalities were inv(3) (10%), del(3q) (12%), t(3q) (18%), monosomy 3 (22%), 3p abnormalities (22%), and other chromosome 3 changes (17%). Median OS for the cohort was 12.0 months (95% C.I. 10.8 to 13.9 months) and 31% of patients without AML transformed to AML. IPSS-R was predictive of median OS across subgroups (P < 0.00001). The specific cytogenetic abnormality was predictive for survival (P < 0.00001) with median OS for t(3q) 19 months, inv(3) 13 months, del(3q) 13 months, 3p 10 months, monosomy 3 9 months, and other 3 abnormalities 11 months. There was no survival difference between patients with translocations of 3q21 versus 3q26 (median OS 18 months versus 18.6 months, P = 0.96). Patients with an isolated chromosome 3 abnormality had significantly improved OS (25.1 months versus 10.9 months (P < 0.00001). Complex karyotype (>/= 3 abnormalities) was observed in 74% of patients and was associated with decreased OS (11 months versus 21 months, P < 0.00001). Of patients who received HMA therapy (48%), the overall response rate was 46% (17% hematological improvement (HI), 7% PR, 20% CR, 2% marrow CR (CRm) with stable disease in 23%). Median OS with and without HMA was 15.5 months versus 8.4 months (p=0.038). In int-2/high risk patients by IPSS, HMA treated patient had a median OS of 14.0 months versus 7.6 months for patients not treated with HMAs (P = 0.005) with no benefit for HMAs in lower-risk patients (median OS 24.5 months with HMA versus 38.7 months without; P =0.41). Cox regression modeling with HMA therapy, IPSS and clinical site confirmed the HMA OS benefit in higher-risk patients (HR 0.69; 95% CI 0.53-0.89; P = 0.005), but showed decreased OS in lower-risk patients (HR 2.0; 95% CI 1.03-3.92; P = 0.04). Allogeneic transplantation was performed in 18% (n=75) of patients, with median OS of 18 months versus 10 months in non-transplanted patients (P < 0.00001).Conclusion In this large cohort of patients with MDS and oligoblastic AML associated with chromosome 3 abnormalities, survival was heterogeneous but overall poor, with isolated chromosome 3 abnormality and t(3q) patients having a more favorable OS than patients with other chromosome 3 anomalies. MDS patients with 3p changes have poor outcomes. Although some patients with chromosome 3 respond to HMA therapy, the overall survival remains poor and novel approaches are needed. DisclosuresSekeres:Amgen: Membership on an entity's Board of Directors or advisory committees; TetraLogic: Membership on an entity's Board of Directors or advisory committees; Celgene Corporation: Membership on an entity's Board of Directors or advisory committees. Steensma:Amgen: Consultancy; Celgene: Consultancy; Incyte: Consultancy; Onconova: Consultancy. Lancet:Boehringer-Ingelheim: Consultancy; Kalo-Bios: Consultancy; Pfizer: Consultancy; Seattle Genetics: Consultancy; Celgene: Consultancy, Research Funding; Amgen: Consultancy. List:Celgene Corporation: Honoraria, Research Funding. Komrokji:Incyte: Consultancy; Celgene: Consultancy, Research Funding; Novartis: Research Funding, Speakers Bureau; Pharmacylics: Speakers Bureau.