11q23 Abnormalities Research Articles

The adverse impact of ecotropic viral integration site-1 (EVI1) overexpression on the prognosis of acute myeloid leukemia with KMT2A gene rearrangement in different risk stratification subtypes.

AML patients with KMT2A-MLLT3 and other 11q23 abnormalities belong to the intermediate and high-risk level groups, respectively. Whether the poor prognostic value of Ecotropic Viral Integration site-1 (EVI1) overexpression suits either the subtypes of KMT2A-MLLT3 or Non-KMT2A-MLLT3 AML patients (intermediate and high risk group) needs to be further investigated. We retrospectively analyzed the clinical characteristics of 166 KMT2A-r and KMT2A-PTD AML patients. For the Non-KMT2A-MLLT3 group, patients in the EVI1-high subgroup had shorter OS and DFS and higher CIR than those in the EVI1-low subgroup (p=.027, p=.018, and p=.020, respectively). Additionally, both KMT2A-MLLT3 and Non-KMT2A-MLLT3 patients who received chemotherapy alone had poorer prognosis than patients who also received allogeneic hematopoietic stem cell transplant (allo-HSCT) regardless of their EVI1 expression level (all p < .001). For transplanted patients with KMT2A-MLLT3 or Non-KMT2A-MLLT3 rearrangement, the EVI1-high subgroup had worse prognosis than the EVI1-low subgroup (all p < .05). The 2-year CIR of the KMT2A-MLLT3 and Non-KMT2A-MLLT3 groups with high EVI1 expression was high (52% and 49.6%, respectively). However, for patients with low EVI1 expression, the 2-year CIR of transplanted patients with KMT2A-MLLT3 and Non-KMT2A-MLLT3 was relatively low. Our study showed that for the Non-KMT2A-MLLT3 group, the EVI1-high group had shorter OS and DFS than the EVI1-low group. High EVI1 expression showed an adverse effect in AML with KMT2A rearrangement in different risk stratification subtypes. For the EVI1-high patients with non-KMT2A-MLLT3 rearrangement, other novel regimens towards relapse should be taken into consideration.

CYTOGENETIC ANALYSIS OF MYELODYSPLASTIC SYNDROME PATIENTS WITH COMPLEX KARYOTYPE IN NORTHEASTERN BRAZIL

Cytogenetic abnormalities occurs in almost half of myelodysplastic syndrome (MDS) patients and are considered to be the most important prognostic factor for survival, so they have been included in the International Prognostic Scoring System (IPSS) since 2007. Complex karyotype (CK) is defined as more than or equal to 3 independent chromosomal abnormalities at the same metaphase and is an independent poor prognostic factor, usually associated with a shorter median overall survival and propensity toward malignant transformation. From January 2008 through June 2022, 1744 patients with suspected or diagnosed hematological neoplasms (including MDS/AML) who had a bone marrow evaluation and concurrent conventional karyotype were identified. Karyotyping was successfully performed on 1167 (67%) of 1744 patients. In total, 914 (54%) with an adequate karyotypic analysis carried out a diagnosis of myelodysplastic syndrome. Among the cases, 9,7% were classified as complex karyotype. Del(5q)/-5 was identified in 52% of patients with complex karyotype, followed by chromosome 11 and chromosome 7 as well as chromosome 17 abnormalities, accounting for 38%, 23% and 23%, respectively. Besides, complex karyotype patients with translocations and derivation involvements, accounted for 28% and 14%, respectively. It is likely that pathogenetic mechanisms in del(5q) may involve hemizygous mutations or haploinsufficiency and be modified by additional somatic lesions affecting genes on other chromosomes. This report shows that the presence of deletion 5q may be the first step to the development of complex karyotype and is a determinant key of the genetic and genomic complexity and clonal hierarchy in MDS with 5q abnormalities.

MDS-450 Impact of Number of Cells Harboring Deletion 5q Abnormality by Conventional Cytogenetics in Isolated Deletion 5q Myelodysplastic Syndromes

Isolated del 5q myelodysplastic syndrome (MDS) is defined as presence of del 5q +/- one additional chromosomal abnormality without excess myeloblasts. Lenalidomide (len) is current standard of care for those patients. The impact of percentage of cells (number of metaphases) harboring del 5q by karyotype is not known. We examined our cohort of isolated del 5q MDS patients at Moffitt Cancer Center. We assessed baseline characteristics, response to len, and outcomes based on % of cells/metaphases harboring del 5q using G-banding "conventional cytogenetics clone size." We divided patients into 2 groups based on number of cells harboring del 5q, those with <50% i.e less than 10 out 20 metaphases and 50-100% (10 or more out of 20 metaphases). We identified 142 isolated del 5q MDS patients. Baseline characteristics of the whole cohort was similar to what has been previously described in the literature. Patients with >50% metaphases harboring del 5q had more severe anemia (Hgb < 8.0 g/dl) (30% versus 13%) (p=0.05). Among patients who were treated with len (n=100), 50% achieved a response. There was a trend for higher response rate among patients with >50% del 5q metaphases with (42/80) 53% response rate compared to (8/20) 40% among those with <50%. (p=0.32). There was no difference in presence of TP53 somatic mutation based on % of metaphases harboring del 5q. There was a non-statistically significant trend for better overall survival among patients with >50% cells with detected del 5q compared to those with <50%, median OS 57 mo versus 35 mo, p=0.90. The number of cells harboring del 5q among isolated del 5q MDS patients using regular karyotyping "clone size by conventional cytogenetics" correlated with severity of anemia, trend for better response to len and trend for better overall survival. Those findings should be further confirmed in larger cohort of patients.

Chromosome 1q21 aberrations identify ultra high-risk myeloma with prognostic and clinical implications.

Numerical abnormalities of chromosome 1q (+1q21) are common in patients with newly diagnosed multiple myeloma (MM) but their prognostic impact remains a matter of debate. In addition, the impact of the number of copies of 1q21 is not known. We analyzed 912 consecutive patients with symptomatic MM to evaluate the prognostic implications of +1q21 and of their copy number variations, as assessed by FISH. At the time of initial diagnosis, 249 (27.3%) patients had +1q21, of which 150 (16.4%) had 3 copies and 99 (10.9%) had 4 or more copies. Presence of +1q21 was associated with advanced ISS stage (p=.003), concurrent presence of other cytogenetics aberrations and advanced R-ISS stage (p < .001). Patients with +1q21 had inferior PFS (median 34 vs. 20 months, p < .001) and OS (median 75 vs. 44 months, p < .001) but the copy number of 1q21 had no additional prognostic impact. In multivariate analysis, adjusting for R-ISS, age, treatment and HDM, +1q21 remained an independent prognostic factor both for PFS (p < .001) and OS (p=.008). The detrimental prognostic effect of +1q21 was more profound in R-ISS-3 patients, identifying a subgroup with OS of just 16 months (vs. 46 for R-ISS-3 without +1q21, p < .001). We further validated our findings in an independent cohort of 272 patients. In conclusion, the presence of +1q21 is associated with more advanced disease, inferior PFS, and OS but especially patients with R-ISS-3 disease and +1q21 have a very poor outcome comprising an ultra-high-risk group.

A Favorable Outcome With CPX-351 Liposome (Vyxeos) in the Management of A Sporadic Monosomy 7 Myelodysplastic Syndrome Related Acute Myeloid Leukemia

Introduction: Although Acute Myeloid Leukemia (AML) has been associated with several environmental factors, in some patients the evolution to AML is preceded by myelodysplastic syndrome (MDS). We report a case of 63-year-old male who was diagnosed with sporadic monosomy 7 MDS/AML who achieved good response to treatment with CPX-351 (Vyxeos) induction chemotherapy. Case information: A 63-year-old male initially presented to the ED for further evaluation of pancytopenia that was discovered incidentally during a routine office visit. Further evaluation revealed his blast count was elevated with presence of Auer rods, myelocytes and basophilia. He was admitted for further work-up of pancytopenia with suspicion being for MDS/AML and bone marrow biopsy for flow cytometric evaluation of the bone marrow was strongly suggestive of acute myeloid leukemia, with morphology suggesting a predisposing MDS. Subsequent molecular cytogenetic [FISH] report confirmed -7/7q abnormality in 80% of nuclei with loss of 1 copy of chromosome 7. The following week, patient was initiated on CPX–351 [Vyxeos; daunorubicin and cytarabine liposome for injection]. Bone marrow biopsy following induction chemotherapy showed 11 to 12% of CD34 positive myeloid blasts with abnormal myeloid maturation, representing notable improvement with greater than 50% reduction in his blast count. Conclusion: Sporadic monosomy 7 MDS/AML that arises without evidence of germline genetic predisposition and in the absence of other predisposing medical conditions or treatments is an uncommon subset of AML. Vyxeos induction chemotherapy may be an excellent option in the management of sporadic monosomy 7 MDS/AML.

Prediction of MYCN Amplification, 1p and 11q Aberrations in Pediatric Neuroblastoma via Pre-therapy 18F-FDG PET/CT Radiomics.

PurposeThis study aimed to assess the predictive ability of 18F-FDG PET/CT radiomic features for MYCN, 1p and 11q abnormalities in NB.MethodOne hundred and twenty-two pediatric patients (median age 3. 2 years, range, 0.2–9.8 years) with NB were retrospectively enrolled. Significant features by multivariable logistic regression were retained to establish a clinical model (C_model), which included clinical characteristics. 18F-FDG PET/CT radiomic features were extracted by Computational Environment for Radiological Research. The least absolute shrinkage and selection operator (LASSO) regression was used to select radiomic features and build models (R-model). The predictive performance of models constructed by clinical characteristic (C_model), radiomic signature (R_model), and their combinations (CR_model) were compared using receiver operating curves (ROCs). Nomograms based on the radiomic score (rad-score) and clinical parameters were developed.ResultsThe patients were classified into a training set (n = 86) and a test set (n = 36). Accordingly, 6, 8, and 7 radiomic features were selected to establish R_models for predicting MYCN, 1p and 11q status. The R_models showed a strong power for identifying these aberrations, with area under ROC curves (AUCs) of 0.96, 0.89, and 0.89 in the training set and 0.92, 0.85, and 0.84 in the test set. When combining clinical characteristics and radiomic signature, the AUCs increased to 0.98, 0.91, and 0.93 in the training set and 0.96, 0.88, and 0.89 in the test set. The CR_models had the greatest performance for MYCN, 1p and 11q predictions (P < 0.05).ConclusionsThe pre-therapy 18F-FDG PET/CT radiomics is able to predict MYCN amplification and 1p and 11 aberrations in pediatric NB, thus aiding tumor stage, risk stratification and disease management in the clinical practice.

MECOM gene overexpression in pediatric patients with acute myeloid leukemia

Background Acute myeloid leukemia (AML) is characterized by blocked or aberrant differentiation of hematopoietic stem cells. The MECOM gene overexpression in hematopoietic progenitors induces myeloid differentiation block, resulting in increased self-renewal and survival of these transformed progenitors. However, its exact role in AML remains unclear. We aimed to estimate the prevalence of MECOM overexpression among pediatric AML patients, and assess its impact on clinical outcome. Patients and Methods Real-time quantitative polymerase chain reaction and Livak method (2ΔΔCt) were used to determine relative MECOM expression level among 243 pediatric patients with AML. MECOM overexpression was considered if the cumulative relative expression was above 1 (2-ΔΔCt) and was designated as MECOMpos . Results Of 243 AML patients tested 57(23.5%) demonstrated MECOMpos . Patients with MECOMpos had significantly lower median age. The frequency of MECOMpos was significantly higher among AML patients with 11q23 abnormalities, complex karyotypes and among high- and intermediate-risk groups compared to low-risk group (p = .014). MECOMpos patients had significantly lower overall survival (OS) (38.7 vs. 78.9%, p < .001), event-free survival (EFS) (37.3% vs. 68.4%, p < .001), and had higher cumulative incidence of relapse (49.5% vs. 23.5%, p = .002) at 36 months compared to MECOMneg patients. Multivariate analysis revealed that MECOMpos was an adverse prognostic factor for OS (hazards ratio (HR) = 2.11, 95% confidence interval (CI) 1.24–3.60, p = .006) and EFS (HR= 1.71, 95% CI 1.07–2.75, p = .025). The logistic regression model showed that MECOMpos was an independent prognostic factor regardless of minimal residual disease status post first induction therapy in the intermediate-risk group (odds ratio 2.89; 95% CI 1.19–6.57, p = .018). Conclusion The aberrant MECOM gene expression is an adverse prognostic factor, especially in patients without previously known cytogenetic risk factors. Our results suggest the potential benefit from pretreatment screening for MECOM gene overexpression in newly diagnosed AML patients for better risk stratification and treatment adjustment.

The retinoic acid receptor co-factor NRIP1 is uniquely upregulated and represents a therapeutic target in acute myeloid leukemia with chromosome 3q rearrangements

Aberrant expression of Ecotropic Viral Integration Site 1 (EVI1) is a hallmark of acute myeloid leukemia (AML) with inv(3) or t(3;3), which is a disease subtype with especially poor outcome. In studying transcriptomes from AML patients with chromosome 3q rearrangements, we identified a significant upregulation of the Nuclear Receptor Interacting Protein 1 (NRIP1) as well as its adjacent non-coding RNA LOC101927745. Utilizing transcriptomic and epigenomic data from over 900 primary samples from patients as well as genetic and transcriptional engineering approaches, we have identified several mechanisms that can lead to upregulation of NRIP1 in AML. We hypothesize that the LOC101927745 transcription start site harbors a context-dependent enhancer that is bound by EVI1, causing upregulation of NRIP1 in AML with chromosome 3 abnormalities. Furthermore, we showed that NRIP1 knockdown negatively affects the proliferation and survival of 3qrearranged AML cells and increases their sensitivity to all-trans retinoic acid, suggesting that NRIP1 is relevant for the pathogenesis of inv(3)/t(3;3) AML and could serve as a novel therapeutic target in myeloid malignancies with 3q abnormalities.

The retinoic acid receptor co-factor NRIP1 is uniquely upregulated and represents a therapeutic target in acute myeloid leukemia with chromosome 3q rearrangements

Aberrant expression of Ecotropic Viral Integration Site 1 (EVI1) is a hallmark of acute myeloid leukemia (AML) with inv(3) or t(3;3), which is a disease subtype with especially poor outcome. In studying transcriptomes from AML patients with chromosome 3q rearrangements, we identified a significant upregulation of the Nuclear Receptor Interacting Protein 1 (NRIP1) as well as its adjacent non-coding RNA LOC101927745. Utilizing transcriptomic and epigenomic data from over 900 primary samples from patients as well as genetic and transcriptional engineering approaches, we have identified several mechanisms that can lead to upregulation of NRIP1 in AML. We hypothesize that the LOC101927745 transcription start site harbors a context-dependent enhancer that is bound by EVI1, causing upregulation of NRIP1 in AML with chromosome 3 abnormalities. Furthermore, we showed that NRIP1 knockdown negatively affects the proliferation and survival of 3q-rearranged AML cells and increases their sensitivity to all-trans retinoic acid, suggesting that NRIP1 is relevant for the pathogenesis of inv(3)/t(3;3) AML and could serve as a novel therapeutic target in myeloid malignancies with 3q abnormalities.

Clinical Features and Cytoreduction Therapy in Children with Newly Diagnosed Acute Myeloid Leukemia and Hyperleukocytosis

Background Hyperleukocytosis is observed in 5% to 20% of patients with newly diagnosed acute myeloid leukemia (AML) and is associated with an increased risk of early complications and mortality. While being used frequently in patients with AML and hyperleukocytosis, the clinical utility of leukapheresis has not been conclusive. Low-dose chemotherapy has also been used recently as a cytoreduction method in these patients, but the data are limited.Objectives: To describe and compare the clinical and laboratory characteristics, early adverse events, and outcomes of children with newly diagnosed AML and hyperleukocytosis according to cytoreductive methods; leukapheresis, low dose chemotherapy (cytarabine), or no intervention.Methods: We studied patients with newly diagnosed AML treated on three multi-institutional St. Jude protocols, AML97, AML02, and AML08, between 1997 and 2017. Hyperleukocytosis was defined as white blood cell (WBC) counts of 100 x 10 9/L or higher at diagnosis. The decision of cytoreductive treatment was made as the discretion of the treating physician. Leukoreduction was used in the AML97 and AML02 studies, and cytarabine (100mg/m 2/dose every 12 hours) was the first choice for AML08 study. We reviewed baseline clinical characteristics and laboratory data (complete blood cell counts [CBC], chemistries, coagulation) and adverse effects (grade 3 or higher on neurologic, renal, respiratory, and hemorrhagic complications based on Common Terminology Criteria for Adverse Events) from diagnosis to day 14 of protocol-based chemotherapy. Cairo-Bishop criteria was used for laboratory/clinical tumor lysis syndrome. The time from the first CBC to administration of protocol-based chemotherapy was calculated.Results: A total of 49 patients were identified: 8 patients in AML97, 19 in AML02, and 22 in AML08) (Table). The age at diagnosis was 10.8 years with a median initial WBC count of 157.6 x 10 9/L; CNS (CNS 2, 3 or traumatic lumbar puncture with blasts) was seen in 29 (59.2%) cases. FAB M4 or M5 subtype was found in 30 patients (61.2%), 11q23 abnormalities in 15 (30.6%) and inv(16) in 8 (16.3%). In regards to leukoreduction method, 16 patients received leukapheresis (14 patients in AML97/02 and 2 in AML08), 18 cytarabine (all in AML08) and 1 hydroxyurea (in AML08); 14 did not receive leukoreduction (13 patients in AML97/02 and 1 in AML08). Leukapheresis was used more often in patients with higher diagnostic WBC counts (218.7 x 10 9/L) than those treated with cytarabine (152.9 x 10 9/L) or without intervention (127.3 x 10 9/L) (P<0.001). The decrease of WBC counts (%) before and after intervention was more pronounced among patients treated with cytarabine than those treated with leukapheresis (75% vs. 48.5%, P=0.03). When decreases in WBC counts were evaluated from the first CBC to the initiation of protocol therapy, cytarabine treatment was associated with more decreases in WBC counts from baseline (84.8%) than leukapheresis (46.7%) or no intervention (1.8%) (P<0.001). Patients who received cytarabine intervention had a longer median time from the first CBC to initiation of protocol therapy (95.2 hours) compared to those who received leukapheresis (28.1 hours) and no intervention (20.4 hours) (P<0.001). No early deaths were observed from the time of diagnosis to two weeks after initiation of protocol chemotherapy, and no statistically significant differences were noted in the incidences of neurologic, pulmonary, renal, hemorrhagic events, or laboratory/clinical tumor lysis syndrome among these three groups.Conclusion: Low-dose cytarabine treatment appears to be a safe and effective mean of cytoreduction for patients with AML and hyperleukocytosis. Further studies are needed to determine if this approach is preferable among patients treated with contemporary treatment. [Display omitted] DisclosuresPui: Adaptive Biotechnologies: Membership on an entity's Board of Directors or advisory committees; Novartis: Other: Data Monitoring Committee.

Impact of Specific Adverse Cytogenetic Features on Outcomes after Allogeneic Hematopoietic Cell Transplantation in Myelodysplastic Syndrome with Very Poor Risk Cytogenetics: A Study from the Chronic Malignancies Working Party of EBMT

INTRODUCTIONMyelodysplastic Syndrome (MDS) is a heterogenous disease which is almost incurable without an allogeneic hematopoietic cell transplantation (allo-HCT). Within the revised international scoring system (R-IPSS), MDS with poor and very poor cytogenetics have a much worse outcome after allo-HCT. The very poor cytogenetic subgroup refers to patients harboring more than 3 abnormalities and is therefore a highly heterogenous group. We have shown in acute myeloid leukemia (AML) that beyond complex karyotype, specific adverse cytogenetic features such as 7q abnormalities (abn7q), 5q abnormalities (abn5q), 17p abnormalities (abn17p) and monosomal karyotype (MK) worsen the outcomes after allo-HCT. We have therefore retrospectively reviewed MDS with very poor cytogenetics and studied the impact of adverse cytogenetic features on outcomes after transplant. METHODSWe selected MDS patients who underwent allo-HCT between 2001 and 2018 from a matched related or unrelated donor, for whom a full cytogenetic report was available in the EBMT registry. We then stratified them according to the presence of abn7q, abn5q, abn17p, MK and the number of abnormalities (≤5, 6-9 and ≥10). Graft-versus-host disease (GvHD) and relapse-free survival (GRFS) was defined as survival without grade II-IV acute GvHD, extensive chronic GvHD or relapse. RESULTSA total of 154 patients were identified in the registry. One hundred twenty-three patients (81%) had MDS with excess of blasts and 4 (3%) had secondary AML. Median age was 59 years (interquartile range (IQR), 51-64) and the median follow-up was 38 months (95% confidence interval (CI), 34-60). The time from diagnosis to allo-HCT was a median of 6 months (IQR, 4-8). Two thirds of patients received a reduced-intensity conditioning regimen (N = 103, 67%) and 87 patients had a matched unrelated donor (57%). Almost all patients were in first complete remission at time of transplant (N= 149, 97%). Regarding specific cytogenetic features, 87 patients had abn7q (57%), 99 abn5q (64%), 59 abn17p (38%) and 120 MK (78%) with considerable overlap between groups.The 2-year overall survival (OS) and progression-free survival (PFS) was 34% (95% CI 26-42%) and 24% (95% CI 17-31%), respectively. The 2-year cumulative incidence of relapse and non-relapse mortality (NRM) was 59% (95% CI 51-67%) and 18% (95% CI 12-24%), respectively. The cumulative incidence of grade II-IV acute GvHD and chronic GvHD was 33% (95% CI 25-40%) and 44% (95% CI 36-53%) by day 100 and 2 years respectively. The 2-year GRFS was 12% (95% CI 6-17%). The presence of abn5q was associated with a significantly decreased PFS of 17% (95% CI 9-25%) versus 36% (95% CI 23-49%); p=0.05) and GRFS (6% (95% CI 1-11%) versus 23% (95% CI 11-34%); p=0.04). The presence of abn7q was associated with significantly increased NRM (25% (15-34%) versus 9% (2-16%); p=0.02) which did not translate into OS. There were no specific cytogenetic features that had an independent impact on the cumulative incidence of relapse, but age over 55 years did increase the relapse risk (<55: 45% (95% CI 31-59%); 55-65: 65% (95% CI 54-77%); >65: 66% (95% CI 50-83%); p=0.03). A continuous effect was also observed (per decade increase: HR=1.24, 95%CI 1.02-1.52; p=0.03). Patients with an interval of more than 6 months from diagnosis to allo-HCT had almost double the OS (45% (95% CI 32-58%)) compared to patients with an interval less than 6 months (27% (95% CI 17-37%); p=0.04), however a continuous effect was not observed. CONCLUSIONMDS with very poor cytogenetics according to R-IPSS is a very bad group with dismal outcomes after allo-HCT. Within this high-risk group, specific adverse cytogenetic features such as the number of abnormalities, abn7q, abn5q, abn17p or MK did not stratify outcomes further, except for abn5q which was associated with a decreased PFS. Our results might be explained in part by the low number patients and by the over-representation of adverse features within this cohort. Despite that, advancing age was associated with increased relapse. Whilst allo-HCT remains the best therapeutic option for this very high-risk patient group, efforts should focus on post-transplant preemptive intervention strategies to prevent relapse. DisclosuresByrne: Incyte: Honoraria. Schroeder: Celgene: Honoraria, Other: Travel support, Research Funding. Blaise: Jazz Pharmaceuticals: Honoraria. Hayden: Jansen, Takeda: Other: Travel, Accomodation, Expenses; Amgen: Honoraria. Scheid: Janssen: Consultancy, Honoraria, Membership on an entity's Board of Directors or advisory committees; BMS: Consultancy, Honoraria, Membership on an entity's Board of Directors or advisory committees, Research Funding; Amgen: Consultancy, Honoraria, Membership on an entity's Board of Directors or advisory committees; Takeda: Honoraria, Membership on an entity's Board of Directors or advisory committees, Research Funding; Abbvie: Honoraria; Roche: Consultancy; Novartis: Honoraria, Membership on an entity's Board of Directors or advisory committees. Yakoub-Agha: Jazz Pharmaceuticals: Honoraria.

Preclinical Evaluation of a Novel Orally Bioavailable Menin-MLL Interaction Inhibitor, DSP-5336, for the Treatment of Acute Leukemia Patients with MLL-Rearrangement or NPM1 Mutation

Background: The 11q23 abnormalities involving mixed lineage leukemia (MLL) gene are frequently found in adult and pediatric patients with acute leukemia. MLL rearrangements (MLL-r) are often associated with a poor prognosis and show poor response to currently available therapies, thus developing more effective therapy is urgently required. The leukemogenic activity of MLL fusion proteins, the products of the chimeric genes of MLL and its fusion partners generated by MLL-r, is critically dependent on direct interaction with MENIN, the product of the MEN1 gene. Interaction of MLL fusion proteins with MENIN plays an important role to enhance the proliferation and to block the differentiation of hematopoietic cells by maintaining high expression of hematopoietic stem cell program genes, such as HOXA9 and MEIS1. It has also been reported that the MENIN interaction with wild-type MLL, is required to induce HOXA9 and MEIS1 expression and also crucial for the development of acute leukemia with nucleophosmin (NPM1) mutations. Therefore, the MENIN-MLL interaction inhibitor is expected to have anti-leukemogenic activity against acute leukemia with MLL-r or NPM1 mutation by suppressing the expression of HOXA9 and MEIS1 and inducing terminal differentiation.Results: We generated DSP-5336, a novel, potent, and orally bioavailable MENIN-MLL interaction inhibitor for the treatment of acute leukemia patients with MLL-r or NPM1 mutation. DSP-5336 directly bound to the MENIN protein (Kd = 6.0 nM) and inhibited the MENIN-MLL interaction (IC 50 = 1.4 ± 0.058 nM). DSP-5336 selectively inhibited the cell growth of human leukemia cell lines including MV-4-11, MOLM-13, KOPN-8, and OCI-AML3 (IC 50 = 10, 15, 31 and 15 nM, respectively). These DSP-5336-sensitive cell lines possess a MLL-r or NPM1 mutation. On the other hand, DSP-5336 did not affect the cell growth of human leukemia cell lines such as HL-60, MOLT-4, and Reh (IC 50 > 10 μM), which do not have MLL-r or NPM1 mutations. In a mouse xenograft model using MV-4-11 cells, which express MLL-AF4, DSP-5336 exhibited a significant antitumor activity at the doses of 25 mg/kg and 50 mg/kg, administered twice daily (BID) for 20 days. There were no dose related changes in general condition or body weight. The effects of DSP-5336 on the expression of MENIN-MLL-regulated genes and differentiation marker genes were evaluated using MV-4-11 cells as pharmacodynamics markers in vitro and in vivo. In both cases, DSP-5336 significantly reduced the gene expression of MEIS1 and HOXA9, representative leukemic genes regulated by the MENIN-MLL complex. On the contrary, DSP-5336 significantly increased the gene expression level of ITGAM, a terminal differentiation marker.The efficacy of DSP-5336 was further assessed in acute leukemia patient samples and in mouse AML models. DSP-5336 strongly inhibited blast colony formation and changed the gene expression of the pharmacodynamics markers (HOXA9, MEIS1 and ITGAM ) in an AML patient sample carrying the MLL-AF6 fusion. In patient-derived xenograft (PDX) model with NPM1 mutation, human CD45 positive cells in peripheral blood progressively decreased during and beyond the 28 day period of DSP-5336 administration at doses of 25, 50, and 100 mg/kg BID and achieved a complete remission with no relapse at the doses of 50 and 100 mg/kg BID. At these three dose levels, DSP-5336 also induced a significant prolongation of survival compared to the vehicle control. Similarly, in a PDX model with MLL-AF4, DSP-5336 induced complete remission and significant prolongation of survival at the doses of 100 mg/kg BID compared to the vehicle control. In mouse AML models wherein MLL-ENL- or MLL-AF10-transduced bone marrow cells are transplanted in syngeneic mice, DSP-5336 induced a significant prolongation of survival at the doses of 200 mg/kg once daily (QD) compared to the vehicle control and the standard chemo therapy (cytarabine+daunorubicin) group.Summary: DSP-5336 has a potential as an antitumor drug that provides survival advantages in acute leukemia patients with MLL rearrangement or NPM1 mutation. Currently, a Phase 1/2 clinical study of DSP-5336 is planned in AML and ALL patients. DisclosuresEguchi: Sumitomo Dainippon Pharma: Current Employment. Shimizu: Sumitomo Dainippon Pharma: Current Employment. Kato: Sumitomo Dainippon Pharma: Current Employment. Furuta: Sumitomo Dainippon Pharma: Current Employment. Kamioka: Sumitomo Dainippon Pharma: Current Employment. Ban: Sumitomo Dainippon Pharma: Current Employment. Ymamoto: Sumitomo Dainippon Pharma: Current Employment. Yokoyama: Sumitomo Dainippon Pharma: Research Funding. Kitabayashi: Sumitomo Dainippon Pharma: Research Funding.

Frequency, variations, and prognostic implications of chromosome 14q32 deletions in chronic lymphocytic leukemia

The clinical implications of deletions within chromosome 14q32 in CLL pathogenesis remain unclear. We examined the frequency of 14q32 deletions among CLL cases by karyotype and FISH, categorized the variation using genomic microarray, and assessed the prognostic impact by time-to-first-treatment (TTFT) analysis. A 14q32 abnormality was detected in 35 % (245/698) of cases, with the majority containing a 5′ partial telomeric 14q32 deletion. These deletions within the IGH variable region (35/40) ranged from 236 kb to 1.4 Mb involving FAM30A, ADAM6, LINC00226, and LINC00221. The 214 kb minimum deleted region implicated in CLL pathogenesis encompassed LINC00221. Cases with a 14q32 deletion had a shorter median TTFT compared to cases with a sole deletion/nullisomy 13q, a good prognostic indicator, and longer than cases with a sole deletion of 11q or 17p, conferring an unfavorable prognosis. This investigation underscores the importance of comprehensive testing to apprehend the implications of 14q32 deletions in CLL.

Molecular Landscape and Clinical Features of Acute Myeloid Leukemia (AML) with Complex Karyotype (CK)

Molecular Landscape and Clinical Features of Acute Myeloid Leukemia (AML) with Complex Karyotype (CK)

Advanced Forms of the Myeloproliferative Neoplasms Are Associated with Chromosomal Abnormalities Involving 1q and 12q: Implicating MDM2 and MDM4 in Disease Progression

Inevitably patients (pts) with myeloproliferative neoplasms (MPNs) including polycythemia vera (PV) and essential thrombocythemia (ET) progress to more advanced forms of myelofibrosis (MF) and acute myeloid leukemia (AML). Loss of TP53 function plays a critical role in cancer biology yet, the MPNs are characterized predominately by wild type (WT) TP53 (Rampal et al, PNAS, 2014;111: 5401-10). The major protein regulators of TP53 are MDM2 and MDM 4. TP53 activity has been reported to be down-regulated in MPNs due to overexpression of MDM2 (Lu et al, Blood, 2012;120:3098-3105, Nakatake et al, Oncogene, 2012: 311: 323-33). Since the gene for MDM4 is located on chromosome 1q and the gene for MDM2 is located on chromosome 12q, we hypothesized that cytogenetic abnormalities involving these locations might lead to disease progression This hypothesis is supported by the recent observation that mice engineered to possess JAK2 V617F and lack TP53 are prone to develop AML as compared to JAK2 V617F+ mice with WT TP53 (Rampal et al, PNAS, 2014:111:5401-10). Gain of 1q (+1q) in the form of jumping translocations in pts with MPN was previously reported to be associated with transformation to AML (Najfeld et al, Br.J. Haematol., 2010; 151: 285-291).These studies were extended to 362 MPN pts enrolled in 5 different MPN-RC clinical trials involving pts with ET or PV (222), MF and MPN -Blast Phase (MPN-BP)(140) and 989 pts with MPNs, ET(177), PV (400), MF (385) and MPN-BP(27) who were studied at the Icahn School of Medicine at Mount Sinai (ISMMS) between 1986 and June 2017. 92 pts in the various MPN-RC trials (25.4%) and 344 (34.7%) of the pts from ISMMS were chromosomally abnormal. Among the abnormalities, 23 pts in the MPN-RC trials had either +1q/dup(1q)(n=16) or rearrangements of 12q (n=7) (6.3% of the total pts and 25.0% of the chromosomally abnormal pts). Similarly, the most frequently observed chromosomal abnormality at ISMMS associated with disease progression, either as a sole abnormality or as a subclone with other chromosomal abnormalities, was gain of 1q, identified in 59 pts (6.0% of total, 17.4% of the abnormal pts). Gain of 1q was observed in three forms: 1) as an unbalanced translocation with the breakpoint at 1q21. 2) a duplication of 1q region and/or 3) as a jumping +1q translocation. The most frequent unbalanced translocation identified was +der(9)t(1;9)(q21;q12) (24%) resulting in three copies of 1q and 3 copies of 9p. Rearrangement of 12q most frequently involved balanced translocations and/or inv(12q) with 50% of these pts having a breakpoint at 12q15 where the gene for MDM2 is located. Gain of 1q/dup(1q) and rearrangements of 12q were mutually exclusive with the exception of one patient with a translocation between chromosomes 1 and 12 [der(12)t(1;12)(q24;q15)]. Among PV/ET pts enrolled in MPN-RC trials, 1.3% (3/222) had +1q and 0.0% (0/222) had 12q abnormalities, while 11% (15/140) of pts enrolled in MF and MPN-BP treatment protocols had +1q and 5% (7/140) had 12q abnormalities. These findings indicate that +1q and structural abnormalities of 12q are associated with more advanced forms of MF and MPN-BP (p<0.001). In both, the MPN-RC and the ISMMS data bases, 42 cases with +1q and 13 cases with 12q abnormalities were identified where the driver mutational status was known. The JAK2 V617F mutation was observed in 83.3% (35/42)of pts with +1q while 23.1% (3/13) pts with 12q abnormalities were JAK2 V617F+.These data indicate that gain of 1q but not 12q abnormalities are associated with the JAK2 V617F mutation (p<0.001). In a limited number of pts (n=10) we were able to monitor the chronological acquisition of 1q and 12q abnormalities. The 1q abnormalities occurred 5-7 years following the initial cytogenetic evaluation of PV pts and the proportion of cells with gain of 1q increased over time being present in 100% of cells over the next 4-5 years of observation. By contrast, 12q abnormalities occurred exclusively in MF pts as the sole abnormality and appeared in 90-100% of the examined cells at presentation. In 5 MF pts with +1q, qPCR demonstrated upregulation of MDM 4 mRNA transcripts (86%) when compared to 5 pts without +1q. These data suggest that MPN disease progression is associated with specific chromosomal abnormalities that result in up regulation of MDM2 or MDM4 which further down-regulate p53 .These data provide the rationale for the use of MDM2/MDM4 antagonists as a means of halting MPN disease progression. DisclosuresMascarenhas:CTI Biopharma: Research Funding; Novartis: Other: DSMB member , Research Funding; Merck: Research Funding; Incyte: Other: Clinical Trial Steering Committee , Research Funding; Promedior: Research Funding; Janssen: Research Funding.

Potential Prognostic Significance of Patterns of Deletion (13q) in Plasma Cell Myelomas—Reappraisal of a Perennial Bone of Contention

AbstractDeletion 13q is recommended in the initial cytogenetic workup of myeloma patients. The patterns of this abnormality have been shown to have differential prognostic value. The presence of monosomy 13 is associated with a significantly poor progression-free survival, while interstitial deletion 13q is associated with significant improvement in the overall survival. We analyzed the patterns of 13q abnormalities on fluorescent in situ hybridization (FISH) assay results in myeloma patients. Deletion 13q abnormalities were observed in 38% (55 of 138) of the myeloma patients. Ten (18%) and 44 (80%) patients showed interstitial deletion and terminal deletion, respectively. One had a mosaic of both the patterns. Nine of the ten patients with interstitial deletions were males. For terminal deletion 13q, there appeared to be a slight female predilection, with a male to female ratio of 0.83:1. Half of the patients with deletion 13q had coexistent cytogenetic abnormalities. We suggest a baseline FISH for deletion 13q and specification of the type of abnormality (terminal vs. interstitial) in patients with myeloma. Based on our observation in conjunction with the available literature, further studies in a large cohort of patients with survival data are warranted to clearly delineate the role of deletion 13q in myeloma.

How to Treat High-Risk Myeloma at Diagnosis and Relapse.

Survival in multiple myeloma has improved greatly during the past 2 decades, but this change has primarily benefited patients who have standard-risk disease. Patients with high-risk disease remain a challenge to diagnose and treat. To improve their clinical outcomes, it is imperative to develop tools to readily identify them and to provide them with the most effective available treatments. The most widely used stratification system, the revised International Staging System, incorporates serum β-2 microglobulin, albumin, lactate dehydrogenase, and high-risk chromosomal abnormalities [del(17p), t(4;14), and t(14;16)]. Recent updates have included mutational status and chromosome 1q abnormalities. Plasma cell leukemia, extramedullary disease, circulating plasma cells, renal failure, and frailty are also associated with poor outcome. The treatment approach for a newly diagnosed patient with high-risk multiple myeloma should include induction therapy, autologous stem cell transplantation if appropriate, and maintenance therapy. Triplet therapy with a proteasome inhibitor, immunomodulatory drug, and steroid, with or without an anti-CD38 antibody, should be considered for induction, along with a proteasome inhibitor and/or immunomodulatory drug for maintenance. Aiming for a deep and sustained response is important. Similar principles apply at relapse, with close monitoring of response, especially extramedullary disease and active management of side effects, so that patients can continue therapy and benefit from treatment. Immune-based therapies, including autologous CAR T-cell-based therapies and bispecific antibodies, show promising activity in relapsed disease and are being actively explored in earlier disease settings. As the prognosis for high-risk disease remains poor, the future goal for this patient group is to develop specific clinical trials to explore novel approaches and therapies efficiently.

Erythroleukemia: an Update

Acute erythroleukemia (AEL) is a rare form of acute myeloid leukemia recognized by erythroblastic proliferation. Many controversies remain around diagnosis influencing prognostic and therapeutic implications relating to this unique leukemia subset. The 2016 WHO classification includes more clear and restrictive diagnostic criteria for AEL. Primary acute erythroid leukemia is associated with complex and high-risk karyotypes including chromosomes 5q and 7q abnormalities. Mutational data shows that AEL is characterized by far lower NPM1 and FLT3-ITD mutation rates and higher mutational rates in TP53 compared with other AML subtypes. Hypomethylating agents have shown therapeutic value in AEL. In this article, we discuss the evolving diagnostic concepts of erythroleukemia, genomics, clinical outcome, and promising therapeutic targets through an appraisal of the current literature.

Chromosomal Abnormalities in 478 Children With Acute Myeloid Leukemia: Clinical Characteristics and Treatment Outcome in a Cooperative Pediatric Oncology Group Study—POG 8821

AbstractWe determined the type and frequency of chromosomal aberrations in leukemic cells of 478 children diagnosed with acute myeloid leukemia and enrolled in the Pediatric Oncology Group study 8821. Of the 478 cases, 109 (22.8%) had normal karyotypes. Chromosomal abnormalities of 280 patients (58.6%) were classified into subgroups: 11q23 abnormalities (n = 88, 18.4%), t(8;21) (n = 56, 11.7%), t(15;17) (n = 55, 11.5%), inv(16)/t(16;16) (n = 28, 5.9%), trisomy 8 alone (n = 10, 2.1%), monosomy 7 (n = 9, 1.9%), non–Down-associated trisomy 21 alone (n = 7, 1.5%), and rare recurrent chromosomal translocations (n = 27, 5.6%). The remaining 89 patients (18.6%) had miscellaneous clonal abnormalities. Overall, 84.9% of the children achieved a complete remission; the 4-year event-free survival (EFS) estimate was 33.8% ± 2.4%. Remission rates were significantly higher (96.4%,P = .011) for patients with t(8;21) and inv(16)/t(16;16) but significantly lower (74.5%, P = .022) for those with t(15;17). The 4-year survival rate for all patients was 43.5% ± 2.4%; for those with an inv(16)/t(16;16), 75.0% ± 8.6%; a normal karyotype, 53.8% ± 4.9%; a t(8;21), 51.6% ± 7.3%; a t(15;17), 39.8% ± 6.9%; and an 11q23 abnormality, 32.9% ± 5.1%. Four-year EFS estimates for patients with inv(16)/t(16;16) (58.2% ± 10.9%,P = .007), t(8;21) (45.1% ± 7.7%,P = .014), or normal karyotypes (43.1% ± 5.0%,P = .012) were higher than the 4-year EFS estimate for all patients, but EFS estimates for patients with t(15;17) (19.6% ± 8.0%, P = .033) or 11q23 abnormalities (23.8% ± 4.8%, P = .0013) were lower. EFS estimates did not differ significantly among 11q23 subgroups. Limited analysis suggested that patients with inv(16) can be salvaged better following relapse than those with t(8;21). Thus, patients with an inv(16)/t(16;16) may have high survival rates when treated with chemotherapy alone.

Immunophenotypic and Genotypic Features, Clinical Characteristics, and Treatment Outcome of Adult Pro-B Acute Lymphoblastic Leukemia: Results of the German Multicenter Trials GMALL 03/87 and 04/89

In contrast to childhood acute lymphoblastic leukemia (ALL), the cell-biological features, clinical characteristics, and treatment outcome of CD10− pro-B ALL have not yet been determined in larger series of adult patients. Therefore, we studied 57 adult patients with newly diagnosed pro-B ALL (median age, 30 years) enrolled in two consecutive German multicenter ALL studies (03/87 and 04/89). Extensive immunophenotypic characterization of leukemic blasts could be performed on all patients, whereas adequate cytogenetic data were available in 33 cases and molecular studies in 18 cases, using reverse transcription-polymerase chain reaction to detect MLL-AF-4 transcripts. Twenty-two patients demonstrated a t(4;11)(q21;q23) and/or MLL-AF-4 rearrangements, and 6 patients had other structural abnormalities, including a t(9;22)(q34;q11) (N = 2). Nine patients had a normal karyotype. Patients with 11q23 abnormalities tended to be younger (median age, 29 years) and were characterized by male predominance (64%), hyperleukocytosis (median leukocyte count, 168 × 109/L), and a frequent coexpression of CD65s (64%) as compared with patients with other cytogenetic abnormalities or a normal karyotype. Twelve of 16 (75%) pro-B ALL patients in study 03/87 and 30 of 41 (73%) in study 04/89 achieved a complete remission (CR). Sixteen of 30 patients in study 04/89 remain in continuous CR (CCR) in contrast to only 2 of 12 patients in study 03/87. Interestingly, all 7 patients treated with high-dose cytarabine and mitoxantrone as consolidation in study 04/89 remain alive and leukemia-free. One patient in study 03/87 and 8 in study 04/89 underwent autologous (N = 2) or allogeneic (N = 7) bone marrow transplantation (BMT). The median remission duration was 420 days for patients in study 03/87 and has not yet been reached in study 04/89. The median survival time of all pro-B ALL patients was 571 days in study 03/87 and 747 days in study 04/89. Among the 22 patients with a t(4;11) and/or MLL-AF-4 rearrangements, 17 achieved a CR and 8 are still in CCR, of whom 4 underwent an allogeneic BMT. Remission duration and overall survival did not differ significantly between pro-B ALL patients with 11q23 abnormalities and those with a normal karyotype or other structural abnormalities. These data indicate that intensification of postremission treatment may improve the prognosis of adult pro-B ALL, including patients with a t(4;11).© 1998 by The American Society of Hematology.