5-year EFS Research Articles

Age, Tumor Characteristics, and Treatment Regimen as Event Predictors in Ewing: A Children's Oncology Group Report.

Purpose. To associate baseline patient characteristics and relapse across consecutive COG studies. Methods. We analyzed risk factors for LESFT patients in three randomized COG trials. We evaluated age at enrollment, primary site, gender, tumor size, and treatment (as randomized). We estimated event-free survival (EFS, Kaplan-Meier) and compared risk across groups (log-rank test). Characteristics were assessed by proportional hazards regression with the characteristic of interest as the only component. Confidence intervals (CI) for RR were derived. Factors related to outcome at level 0.05 were included in a multivariate regression model. Results. Between 12/1988 and 8/2005, 1444 patients were enrolled and data current to 2001, 2004, or 2008 were used. Patients were with a median age of 12 years (0–45), 55% male and 88% Caucasian. The 5-year EFS was 68.3% ± 1.3%. In univariate analysis age, treatment, and tumor location were identified for inclusion in the multivariate model, and all remained significant (p < 0.01). Since tumor size was not collected in the last study, the other two were reanalyzed. This model identified age, treatment, tumor location, and tumor size as significant predictors. Conclusion. Age > 18 years, pelvic tumor, size > 8 cms, and chemotherapy without ifosfamide/etoposide significantly predict worse outcome. AEWS0031 is NCT00006734, INT0091 and INT0054 designed before 1993 (unregistered).

Developing a prognostic model for localized Ewing sarcoma family of tumors: A single institutional experience of 224 cases treated with uniform chemotherapy protocol.

Data on patients with localized Ewing sarcoma family of tumors (ESFT) who have received a uniform chemotherapy protocol are minimal. This is a single institutional review of patients with ESFT treated between June 2003 and November 2011. 224/374 (60%) patients with ESFT presented with localized disease; median age was 15 years (range: 0.1-55). Ninety-nine patients underwent surgery of which 50 received adjuvant radiotherapy; 80 patients received radical radiotherapy following neoadjuvant chemotherapy. At median follow-up of 40.2 months (range: 1.3-129), 5-year EFS, OS, and local-control-rate, were 36.8 ± 3.6%, 52.4 ± 4.3%, and 63 ± 4.3%, respectively. In multivariate analysis, tumor diameter > 8 cm (P = 0.03), symptom duration > 4 months (P = 0.04), and WBC > 11 × 10(9) /L (P = 0.003) predicted inferior EFS; spine/abdomino-pelvic primary (P = 0.009) and WBC > 11 × 10(9) /L (P = 0.003) predicted inferior OS. Tumor size > 8 cm (P = 0.03) and radical radiotherapy as local treatment (P = 0.01) predicted inferior local-control-rate. Prognostic hazard models for EFS and OS based on significant prognostic factors suggested that patients with combination of ESFT of spine/abdomino-pelvic region and baseline WBC > 11 × 10(9) /L had inferior OS (hazard ratio 4.44, P < 0.001) while patients with combination of ESFT with symptom duration > 4 months, tumor diameter > 8 m and baseline WBC > 11 × 10(9) /L had inferior EFS (hazard ratio 3.89, P = 0.002).

Hidden DNA Copy Number Alterations and Mutations in IKZF1, TP53, CRLF2 and JAK2 Genes Are Associated with a Poor Prognosis in B-Progenitor Acute Lymphoblastic Leukemia

Background: In B-progenitor acute lymphoblastic leukemia (B-ALL) the identification of additional genetic alterations associated with treatment failure is still a challenge.Aims: 1.To identify genomic gains and losses in B-ALL at the time of diagnosis and to correlate these abnormalities with the genetic characteristics and the patients outcome. 2.To assess the prevalence and prognostic impact of genetic lesions in IKZF1, TP53, CRLF2, IL7R, PAX5, JAK2 and LEF1 genes in B-ALL.Methods: A total of 215 B-ALL patients were eligible for this study. 115 (53.5%) had less than <18 years. In all cases oligonucleotide microarrays (aCGH) were carried out. For genetic gain and losses analysis, the NimbleGen CGH 12x135K array (Roche) was used. The data analysis was performed with GISTIC and aCGHweb software. In 118 of these cases (65 children and 53 adults), an integrative analysis of aCGH and NGS was performed to identify genetic lesions in genes associated with B-ALL: JAK2 (Exon 12-Exon 16), PAX5 (E2-E3), LEF1 (E2-E3), CRLF2 (E6), IL7R (E5), IKZF1 (E2-E8) and TP53 (E4-E11). The 454 GS Junior system (Roche) was used. The variant analysis was performed using Amplicon Variant Analyzer (AVA-Roche 454) and Sequence Pilot (JSI Medical Systems) software.Results: DNA copy number aberrations (CNAs) were observed in 96.5% of cases. Gains on chromosomes 4 (10%), 6 (10%), 10 (12%), 14 (13%), 21 (31%) and X (18%) were more common in children, whereas losses in 7p (13%) and 9p21 (24%) were frequent in adults. In children, gains on chromosomes 6, 10, 14q, 17, 18, 21 and X were associated with longer overall survival (OS) while loss on 7p and 17p were associated with shorter OS in adults (Table 1).The integrative analysis of aCGH and NGS showed that 60% of patients carried at least one alteration (deletion and/or mutation) in the seven genes analyzed. Focal deletions were common in IKZF1, CRLF2, PAX5, and LEF1 genes while broad deletions were more frequent in TP53, JAK2 and IL7R. Forty-one percent of patients harbored IKZF1 alterations (IKZF1+), 22.9% in PAX5, 18.6% in JAK2 and 11% had TP53 or CRLF2 alterations. LEF1 and IL7R genomic lesions were only present in 4.2% and 2.5% of the B-ALL, respectively. JAK2 and CRLF2 mutations were associated (p=0.01). Moreover abnormalities in IKZF1+ were associated with alterations in JAK2 (p=0.004), TP53 (p=0.04) and PAX5 (p=0.03).The presence of alterations was most frequent in high-risk (HR) B-ALL (38% vs 18%, p=0.02), although 8% low-risk (LR) childhood patients showed genetic alterations. Fourteen B-ALL patients carried mutations in TP53, CRLF2 and/or JAK2 genes: all of them were Ph-, and 11 were classified as HR. Of note, 3 cases were children. In the HR group the presence of mutation in TP53, CRLF2 and/or JAK2 was related to a shorter OS (3-year OS: 56% vs. 36%; P=0.034) and event-free survival (3-year EFS: 56% vs. 11%; P<0.002) (Figure 1), due to an increased cumulative incidence of relapse (3-year CIR: 38% vs. 88%; P<0.004).The presence of IKZF1 alterations stratified HR-Ph- B-ALL cases. Thus HR-Ph- patients with normal IKZF1 were associated with longer EFS compared to HR-Ph- B-ALL IKZF1+ (3-year EFS: 60% vs. 33%; P=0.005) (Figure 2). The presence of IKZF1 deletion was associated with shorter EFS (89% vs. 67%, P= 0.04) and increased CIR (3-year CIR: 12% vs. 33%; P=0.05) in children.Summary/Conclusions: CNAs are frequent in B-ALL and are associated with genetic subtype, age and overall survival. The integrative analysis by aCGH and NGS techniques demonstrated that alterations in IKZF1 gene and mutations in TP53, CRLF2 and/or JAK2 genes could stratify high-risk Ph- B-ALL patients.Subvention:FP7/2007-13, Nº306242-NGS-PTL; HUS272U13, JCyL,Consejería de Educación; BIO/SA31/13 Gerencia Regional de Salud, SACYL, SpainTable 1DNA copy number aberrations (CNAs) associated with overall survival in 215 B-ALL patientsAssociationCNAnMedian (months)P valueShort overall survival7p-ChildrenAdults1961396150.0517p-ChildrenAdults12576940.029+19ChildrenAdults351421Not reached100.00122q+ChildrenAdults261214Not reached7<0.0001Longoverall survival+6ChildrenAdults26197Not reached7<0.0001+10ChildrenAdults25196Not reached70.001+14qChildrenAdults26188Not reached4<0.0001+17ChildrenAdults24177Not reached600.012+18ChildrenAdults25187Not reachedNot reached<0.000121q+ChildrenAdults473116Not reached8<0.0001XChildrenAdults522725Not reached9<0.0001 [Display omitted] [Display omitted] DisclosuresNo relevant conflicts of interest to declare.

Improved Outcome with ATRA-Arsenic Trioxide Compared to ATRA-Chemotherapy in Non-High Risk Acute Promyelocytic Leukemia – Updated Results of the Italian-German APL0406 Trial on the Extended Final Series

▪Background: We recently showed that the combination of ATRA and arsenic trioxide (ATO) is at least not inferior and possibly superior to standard ATRA and chemotherapy (CHT) in the front-line management of low/intermediate risk APL (Italian-German APL 0406 trial; Lo-Coco et al., NEJM 2013). We report herein on the extended and final series of 276 patients (162 were in the previous report) with the last case being enrolled into the study in January 2013.Methods: The APL0406 study was a prospective, open-label, randomized intergroup trial conducted by the Italian GIMEMA and the German SAL and AMLSG study groups. Eligible patients were adults aged 18-<71 years with newly diagnosed, genetically confirmed, non-high-risk (WBC≤10x109/L) APL. Patients were randomized to receive the ATO+ATRA combination originally developed by the MD Anderson Cancer Center group, or the Italian AIDA2000 protocol (Estey et al., Blood 2006 and Lo-Coco et al., Blood 2010). Patients in the ATRA-ATO arm received ATO 0.15/kg plus ATRA 45 mg/m2 daily until CR, then ATO 5 days/week, 4 weeks on 4 weeks off, for a total of 4 courses and ATRA 2 weeks on and 2 weeks off for a total of 7 courses. Patients in the ATRA-CHT arm received the standard AIDA (ATRA+Idarubicin) induction followed by 3 cycles of anthracycline-based consolidation together with ATRA and low dose CHT and ATRA for maintenance. The primary study objective was EFS at 2 years.Results: A total of 254 patients were evaluable for response to induction. CR was achieved in 122/122 (100%) in the ATRA-ATO versus 128/132 (97%) in the ATRA-CHT arm (P=0.12). Four patients died during induction in the ATRA-CHT arm. After a median follow-up of 36 months (range 1-75 months), the 2-year EFS was 98% and 84.9% in the ATRA-ATO and ATRA-CHT groups respectively (P= 0.0002), The 2-year cumulative incidence of relapse (CIR) rate was 1.1% and 9.4%, respectively (P=0.005) and, finally, the 2-year overall survival (OS) rate was 99.1% vs. 94.4% (P=0.01) for ATRA-ATO vs ATRA-CHT, respectively.Conclusions: The data on this extended cohort demonstrate a significantly augmented survival benefit coupled to a higher antileukemic efficacy provided by ATRA-ATO as compared to ATRA-CHT, in low/intermediate risk APL. These results further support ATRA-ATO as the new standard of care in this clinical setting. [Display omitted] DisclosuresPlatzbecker:Teva: Honoraria. Off Label Use: Presentation includes off-label use of arsenic trioxide (ATO) in front-line management of APL. ATO is currently approved in treatment of relapsed APL in the US and Europe. Breccia:Bristol Myers Squibb: Consultancy; Novartis: Consultancy. Fiedler:TEVA: Travel reimbursement for meeting attendance Other. Lübbert:Cephalon / TEVA: Travel support Other. Link:TEVA: Consultancy, Speakers Bureau. Radsak:Celgene: Research Funding. Döhner:TEVA: Research Funding. Schlenk:TEVA: Research Funding, Speakers Bureau. Lo-Coco:TEVA: Honoraria; Lundbeck: Honoraria.

Clofarabine in Combination with High-Dose Cytarabine and Liposomal Daunorubicin in Pediatric AML: Results of a Phase 1B Combination Study By the ITCC Consortium

Introduction: Relapsed/refractory pediatric AML has a poor prognosis. Chemotherapy using FLAG plus liposomal daunorubicine (FLAG-DNX) followed by stem-cell transplantation (SCT) is currently considered the standard in 1strelapse in Europe (Kaspers, JCO 2013), and ~results in ~40% survival. FLAG is based on potentiation of high-dose cytarabine (Ara-C) by fludarabine (Flu) by increasing Ara-CTP levels. Clofarabine (CLO) is a novel purine nucleoside analog, designed to have improved efficacy.Methods: We initiated a phase 1B study using a '3x3 design’ to define the optimal dose of CLO, replacing Flu in FLAG-DNX. Dosages consisted of Ara-C 2gr/m2/day (day 1-5), with escalation of DNX from 40 to 60 mg/m2/day (day 1, 3 and 5), and CLO from 20, 30 to 40 mg/m2/day (day 1-5) in 4 dose-levels (DL). At day 6 intrathecal Ara-C was administered. Patients with early 1st relapse, refractory 1st relapse and 2nd relapse of AML were eligible. Responding patients received a consolidation with CLARA-DNX or treated by investigator discretion. DL 5 was open for patients with early 1st relapse only, and dose-escalated DNX to 80 mg/m2. MTD was the primary endpoint. At the MTD the cohort was expanded to 10 patients. Hematologic DLTs were defined as count recovery in responding pts >42 days. Overall response rate (ORR) was defined as: partial remission (PR, 50% reduction BM blasts), no evidence of leukemia (NEL, <5% blasts, no regeneration), complete remission with insufficient recovery (CRi, platelets below 80/μl and neutrophils below 1000/μl) and complete remission (CR). Morphology was centrally reviewed by the AML-BFM SG in Hannover. The study is registered in the Dutch Trial Registry (nr. 1880), and was open in 14 ITCC/I-BFM-sites.Results: DL 1-4 accrued 29 AML patients (≥2nd relapse, n=8; refractory 1st relapse, n=11; early 1strelapse, n=10). Patients were treated at dose-level (DL) 1, n=4; 2, n=3; 3, n=12 (split in 3A and 3B); 4, n=10. Twelve patients had been transplanted prior to enrollment. In total 38 CLARA-DNX courses were administered. Median age was 8.8 years, 18 patients were male, median WBC at enrollment 8.7x10.9/l. 26 SAEs were reported, consisting of febrile neutropenia (n=14), typhlitis (n=1), lung-infection fungal (n=3), lung-infection bacterial (n=2), candida sepsis (n=1), streptococcal sepsis (n=2), rash (hand-foot skin reaction) (n=1), and tumor lysis/capillary leak syndrome (n=1), cardiovascular failure (n=1) and vomiting (n=1). Other grade 3-4 AEs reported consisted of abdominal pain, nausea and vomiting, diarrhea, anorexia. blood pressure changes, DIC, rash and renal failure. Three pts had bilirubin elevation (>2.5xULN, max 61 µmol/l); 8 transaminitis (> 100 U/l; max. 998U/l), 1 elevated creatinine (83µmol/l) and 1 renal failure, 5 low potassium (<3 mmol/l) and 3 low sodium (<130mmol/l). At DL 3A, DLTs (fungal infection) halted dose-escalation. Detailed analysis showed subclinical fungal infections prior to enrollment. A protocol amendment was issued requiring screening patients with CT-scan and serum-galactomannan. After enrolling DL3B this appeared to be safe (1 DLT of Candida sepsis out of 6 patients). One DLT occurred at dose-level 4 (sepsis). Time to recovery of peripheral blood values in patients with CR/CRi was median 30 days for neutropenia and 26 days for platelets.Considering outcome, the ORR was 59% in the 26 pts evaluable for response. In the 11 pts with refractory 1st relapse after FLAG the ORR was 38%. In the expansion cohort (10 pts in DL4) there was 1 CR, 7 CRi, 1 PR, and 1 early death. 18 pts were transplanted post clofarabine treatment (1 HLA-id, 13 MUD, 1 MFD, 2 haplo, 1 unkown). The median follow-up time of the 9 survivors was 16 months. The 1-year overall survival was 48±9%, and the 1-year EFS was 33±9%.Five patients were recruited in DL5. Two DLTs occurred in 2 pts, i.e. a severe pseudomonas cellulitis and a Gram-negative sepsis, and hence this cohort was closed.Conclusions: The RP2D of CLO in a CLARA/DNX course in relapsed/refractory pediatric AML is 40 mg/m2 combined with DNX 60 mg/m2 and Ara-C 2 gr/m2, excluding patients with evidence of prior subclinical fungal infection. This combination resulted in a high response rate in the expansion cohort. We observed responses in 38% of patients refractory to FLAG. This regimen therefore has greater anti-leukemic potential than FLAG.Acknowledgment: This study was financially supported by Sanofi, and by the KiKa-foundation grant nr. 26. DisclosuresZwaan:Sanofi: Research Funding. Off Label Use: Clofarabine is off-label for AML, and so is Daunoxome.

MEK Inhibition Is a Promising Therapeutic Strategy for MLL-Rearranged Infant ALL Patients Carrying RAS Mutations

Background: Acute Lymphoblastic Leukemia (ALL) in infants is characterized by a high incidence (~80%) of chromosomal rearrangements of the Mixed Lineage Leukemia (MLL) gene, fusing the N-terminal portion of MLL to the C-terminal region of one of its translocation partner genes. MLL-rearranged infant ALL patients are challenged by a very poor prognosis (i.e. 30-40% 5-year EFS), hence the need for better risk stratification and improved therapeutic solutions is evident. We recently screened a relatively large cohort (n=109) infant ALL patients (all enrolled in INTERFANT treatment protocols) for the presence of KRAS and NRAS mutations and found that the incidence of such mutations ranges between 14-24%, depending on the type of MLL translocation. Moreover, these mutations were found to represent independent predictors of exceedingly poor prognosis; patients carrying RAS mutations essentially stand no chance in surviving their malignancy, as all RAS mutation-positive MLL-rearranged infant ALL patients deceased within 3 years from diagnosis.Aims: Here we aimed to identify a therapeutic strategy to improve the prognosis of MLL-rearranged infant ALL patients carrying RAS mutations.Methods: For this, 8 small molecule inhibitors against different RAS-pathway components were selected and initially tested for anti-leukemic activity against the MLL-rearranged ALL cell lines SEM and RS4;11 (RASwt) and KOPN8 (RASmut) using MTS cell viability assays. Next, primary MLL-rearranged infant ALL samples (n=20) all carrying MLL translocation t(4;11) (giving rise to the MLL-AF4 fusion protein) either with (n=6) or without (n=14) RAS mutations were exposed to these inhibitors in MTT cytotoxicity assays. In addition, we assessed the RAS activity in RAS mutated and wild-type MLL-rearranged infant ALL cells, and performed immunoblotting analysis of downstream MEK and ERK both in the absence and presence of the MEK inhibitors.Results: We found that the MEK inhibitors MEK162, Selumetinib and Trametinib effectively reduced the viability of KOPN8 cells (RASmut), whereas SEM and RS4;11 cells (RASwt) largely remained unaffected. In line with this, MLL-AF4+ infant ALL patient samples carrying RAS mutations were significantly more sensitive to these MEK inhibitors when compared with patients carrying wild-type RAS genes: LC50 values for MEK162 were 0.04 vs. 26.9 µM (p<0.01), for Selumetinib 0.04 and 23.7 µM (p<0.01), and for Trametinib 0.01 vs. 26.5 µM (p<0.01), respectively. Furthermore, the presence of RAS mutations in primary MLL-rearranged infant ALL samples was associated with significantly increased RAS activity, as determined by immunoprecipitation of GTP-bound RAS. Remarkably, however, enhanced RAS activation did not manifest itself in the form of increased phosphorylation of the downstream ERK protein, while a slight increase of MEK phosphorylation was observed. Yet, MEK inhibitor exposure in both KOPN8 and SEM cells resulted in nearly complete abrogation of ERK phosphorylation, without affecting total ERK protein levels, suggesting that the loss of ERK activation plays an important role in the observed anti-leukemic effects. Furthermore, MEK162 and Selumetinib seemed to induce accumulation of phosphorylated MEK, while MEK phosphorylation was hardly affected by Trametinib. Interestingly, a subgroup of patient samples (n=5) with wild-type RAS also showed sensitivity towards MEK inhibition, similar to the primary cells with RAS mutations. However, this observation could not be explained by increased RAS activation, nor by the phosphorylation levels of either MEK or ERK.Conclusions: Our data show that MEK inhibition represents a promising therapeutic approach for MLL-rearranged infant ALL patients carrying additional RAS mutations. Furthermore, the mechanism of action provoked by these MEK inhibitors seems to involve abrogation of ERK phosphorylation, but the initial level of ERK phosphorylation did not correlate with MEK inhibitor sensitivity, and has no predictive value. Currently we are in the process of testing the efficacy of the above mentioned MEK inhibitors in vivo using a xenograft mouse model, while further elucidation of the molecular mechanisms underlying the anti-leukemic effects of these inhibitors in MLL-rearranged ALL cells is in progress. DisclosuresNo relevant conflicts of interest to declare.

PT-11 * THALAMIC TUMORS IN CHILDREN: THE CURRENT ROLE OF SURGERY IN A MULTIMODAL TREATMENT APPROACH

Thalamic tumors are rare neoplastic lesions usually of glial lineage representing about 2- 5% of all pediatric brain tumors. We report on our experience in the management of thalamic tumors in children and analyze the current role of surgery in a multimodal treatment approach. We retrospectively reviewed the medical charts of all children treated at our institution for a thalamic tumor since March 1992. Neuroimaging data were reviewed for anatomic location, contrast enhancement, solid and cystic components, and extent of resection. Tumors primarily localized in the basal ganglia, hypothalamus, pineal gland and optic pathway were excluded. All histologic specimens were reexamined for the study by one neuropathologist. From 1992 to 2014, 36 children with a thalamic tumor were identified. The median age at diagnosis was 9.2 (range 1-19) years with a male:female ratio of 1:1. Tumors were unilateral in 29 and bilateral in 7 patients. Histology was pilocytic astrocytoma (PA, WHO I) in 10 patients, astrocytoma WHO II or glioma NOS in 7 patients, glioma WHO III or IV in 17, and atypical teratoid rhabdoid tumor (ATRT) in 2 patients. Surgery consisted of a GTR in 6, STR in 9, PR in 9, and biopsy in 12 patients. 22/26 WHO II-IV tumors were irradiated and all WHO III and IV tumors received adjuvant chemotherapy. 3/10 patients with PA received chemotherapy. 5-year OS for the whole cohort was 56.2 ± 8.6% and 5-year EFS was 47.6 ± 8.7%. For the 2 patients with ATRT and the 10 with PA the 5-year OS was 100% versus 36.1 ± 10.1% for the remaining patients. Gross total tumor removal is recommended for PA. In unilateral non-pilocytic tumors the attempt at extensive resection should be decided on individually since most tumors will be candidates for adjuvant treatment. Bilateral thalamic tumors should initially be biopsied.

Abstract A42: miR34a: A valuable indicator of differential outcome of Ewing sarcoma patients with complex functions

Abstract The identification of reliable indicators of prognosis, which may allow the stratification of patients according to different risk at diagnosis isan important aspect of translational research in Ewing sarcoma (ES). In this paper, we validated our previous evidence showing how expression of miR34a in ES tumor samples at diagnosis was signficantly associated with tumor progression (Nakatani F. J Pathol 2012). Here we analyzed a different series of speciments derived from very controlled and homogeneously treated non-metastatic ES patients, and we compared evaluation of miR34a by RT-PCR using frozen samples with that obtained by in situ hybridization on paraffin-embedded samples . The median follow-up of the 109 EWS patients was 90 months (range 9 to 241 months). 68 patients (63%) remained continuously free of disease and 41 (38%) relapsed. Expression of miR34a was evaluated by qRT-PCR using TaqMan miRNA assay kit and/or by in situ hybridization ISH optimization kit from Exiqon. High expression of miR34a was significantly related to better EFS and OVS : 5-year EFS was 74% for the 55 patients with high expression of miR34a and was 51% for the 54 patients with low expression (p = 0.004); 5-year OVS was 83% in high-expressors and 58% in low-expressors . By multivariate Cox regression analysis, the value of low miR-34a expression as well as of non-total necrosis and high LDH were all confirmed as independent risk factors associated with poor outcome. miR34a was also evaluated by ISH on TMA. miRNA expression by ISH correlates with that obtained by RT-PCR (r=0.59, p&amp;lt;0.0001, Spearman test). Although not significant, high expression of miR34a evalutated on tissue microarray still shows an association with better outcome (p=0.19). Expression of miR34a inversely correlated with expression of cyclin D1 mRNA, as well as with Ki-67 labelling. In contrast positive association was observed with YY1, a transcription factor that regulates a dazzling list of genes and whose role in malignancy is complex and has just started to emerge. The value of miR34a as predictor was higher than that of these specific targets, indicating a more complex relationship with tumor malignancy. Citation Format: Katia Scotlandi, Maria Teresa Marino, Andrea Grilli, Piero Picci, Alessandra Carè, Claudio Tripodo, Stefano Ferrari. miR34a: A valuable indicator of differential outcome of Ewing sarcoma patients with complex functions. [abstract]. In: Proceedings of the AACR Special Conference on Pediatric Cancer at the Crossroads: Translating Discovery into Improved Outcomes; Nov 3-6, 2013; San Diego, CA. Philadelphia (PA): AACR; Cancer Res 2013;74(20 Suppl):Abstract nr A42.

Second Malignancies after Adjuvant Radiotherapy for Early Stage Breast Cancer: Is There an Increased Risk with the Addition of Regional Radiotherapy?

to the Allred abstract showing the benefit of ET to be limited to ER+ DCIS, the “post-Allred era” was defined as December 1, 2003, to December 31, 2009. EFS was defined as survival plus freedom from local, regional, or distant relapse and contralateral breast cancer. Results: ET was used in 404/2061 (19.6%) patients treated with BCS plus RT. Median follow-up time was 9.0 years. The median age of patients treated with compared to without ET, was 52.5 vs. 57.1 years, (p Z 0.02). There was no significant difference in grade or tumor size between the ET vs. no ET groups. In the pre-NSABP B24 era, 0.3% (1 of 353) of patients received ET, compared to 26.2% (390 of 1486) in the post-NSABP B24 era (p < 0.001). Among 404 patients who received ET, 1-year and 4-year actuarial rate of ET continuation was 76% and 55%, respectively. Fortyeight percent of patients filled 80% of the anticipated number of ET pills over the given 5-year period. Of the 1034 patients in the post-Allred era, 497 (48%) had ER+, 123 (12%) had ER-, and 414 (40%) had unknown ER status. ET was used in 30% of ER+ cases, 2% of ER-negative cases and 19% of unknown ER cases. On Cox regression analysis, ETwas associated with improved EFS (HR Z 0.44; 95% CI Z 0.20-0.96; p Z 0.04) after adjusting for age at diagnosis, tumor size, final margin status, grade, and ER status; 5-year EFS was 97.3% vs. 94.5% for patients treated with ET vs. without ET (p Z 0.03). Conclusions: The use of ET in DCIS patients treated with BCS and RT increased significantly in the province after publication of the NSABP B24 study. ER+ disease in the post-Allred era and younger age at diagnosis were associated with increased rate of ET use. Approximately half the patients took 80% of the anticipated 5 years of ET. ET was associated with improved EFS, which confirms the generalizability of the NSABP B24 data at a population level for clinical practice and policy. Author Disclosure: A. Lo: None. P.T. Truong: None. E.S. Wai: None. A. Nichol: None. L. Weir: None. C. Speers: None. M. Hayes: None. S. Tyldesley: None.

Predictors of survival after resection of children with hepatoblastoma: A single Asian center experience

AimThe aim of this study is to investigate and identify the predictors associated with the prognosis of patients with hepatoblastoma (HB). MethodsWe retrospectively reviewed 112 children with HB (58 female, 54 male) managed in our institution between May 1st, 2001 and January 30th, 2012. Prognostic factors were evaluated using Kaplan–Meier curves and Cox proportional hazards models. ResultsFor the entire cohort of 112 patients, the overall median survival was 83.5 months, and the 5-year EFS and OS rates were 57.1% and 63.4%, AFP<100 or >1000 (ng/ml)(HR:2.454, P = 0.013), multifocality (HR:2.852, P = 0.012), vascular invasion (HR:2.272, P = 0.026), metastases (HR:2.654,P = 0.005) and PRETEXT stage (HR:2.817, P = 0.005) were associated with an adverse prognosis in the univariate and multivariable adjusted analysis. Based on these findings, a prognostic scoring system was developed that allotted one point each for these factors. Patients with HB could be stratified into 3 distinct prognostic groups (median and 5-year EFS, respectively): 0 points (105.1 months, 94.1%), 1–2 point (85.8 months, 60.2%), and 3–4 points (31.8 months, 13.5%) (P < 0.001). ConclusionsWe have confirmed the HB prognostic factors associated with survival in the Asian population and established a simple prognostic scoring system.

Challenges in the local treatment of large abdominal embryonal rhabdomyosarcoma.

Embryonal rhabdomyosarcoma is the most common pediatric soft tissue sarcoma. The best local treatment in large, nonmetastatic primary unresected nongenitourinary embryonal rhabdomyosarcoma of the abdomen (LARME) is however unclear. We analyzed patients with LARME treated in four consecutive CWS trials. All diagnoses were confirmed by reference reviews. Treatment included multiagent chemotherapy and local treatment of the primary tumor with surgery and/or radiotherapy. The impact of primary debulking surgery (PDS) also was studied. One hundred patients <21years with a median age of 4years had LARME. Sixty-one of them had a tumor >10cm in diameter at diagnosis. PDS was performed in 19 of 100 children. The outcomes of patients with PDS were similar to those of the other patients. In 36 children, the tumor was resected after induction chemotherapy; 60 RME were irradiated. The toxic effects of radiochemotherapy were not significantly increased compared with the nonirradiated patients. With a median follow-up of 10years, the 5-year EFS and OS were 52±10 and 65±9%, respectively. Significant risk factors in multivariate analysis were age >10years; no achievement of complete remission; and inadequate secondary local treatment, defined as incomplete secondary resection or no radiation. Children with LARME have a fair prognosis, despite an often huge tumor size and unfavorable primary site, if the tumors can either be resected or irradiated following induction chemotherapy. PDS was only performed in a small subgroup. Radiation performed concomitantly with chemotherapy did not increase the acute toxicity significantly.

Allogeneic haematopoietic SCT for natural killer/T-cell lymphoma: a multicentre analysis from the Asia Lymphoma Study Group

Eighteen patients (men=14; women=4) with natural killer (NK)/T-cell lymphomas (CR1, N=9; CR2, N=7; PR, N=1; progressive disease, N=1) undergoing allogeneic haematopoietic SCT (HSCT) (myeloablative, N=14; reduced intensity, N=4) were analyzed. With a median follow-up of 20.5 months, the 5-year OS was 57% and 5-year EFS was 51%. The use of the SMILE regimen pre-HSCT was the most important positive prognostic indicator, resulting in significantly superior OS and EFS (P<0.01). Acute GVHD had a significant negative impact on OS (P=0.03). CR1 and CR2 patients had similar survivals, but all patients who were not transplanted in remission died. Chronic GVHD, International Prognostic Index, disease stage, primary sites of involvement, conditioning regimen and source of HSC did not affect survival. Although allogeneic HSCT leads to reasonable survival for NK/T-cell lymphoma patients, results need to be compared with those in patients receiving L-asparaginase-containing regimens. Novel prognostic models incorporating biomarkers, such as circulating EBV DNA, are needed to identify high-risk patients who may benefit from allogeneic HSCT.

Hyperfractionated Accelerated Radiotherapy (HART) with maintenance chemotherapy for metastatic (M1–3) Medulloblastoma – A safety/feasibility study

Background and purposeTo evaluate feasibility and toxicity of Hyperfractionated Accelerated Radiotherapy (HART) 1.24Gy b.i.d. followed by chemotherapy for M1–3 Medulloblastoma (MB). The aim of HART was to use hyperfractionation to improve therapeutic ratio combined with acceleration to minimise tumour cell repopulation during radiotherapy (RT). Materials and methodsBetween February 2002 and May 2008, 34 eligible patients (22 male, 12 female) aged 3–15years (median 7) with metastatic MB (M1–9; M2–3, M3–22) received HART with a craniospinal radiotherapy (CSRT) dose of 39.68Gy followed by 22.32Gy boost to the whole posterior fossa and 9.92Gy metastatic boosts. The 8th and subsequent patients received vincristine (VCR) 1.5mg/m2 weekly×8 doses over 8weeks starting during the 1st week of RT. Maintenance chemotherapy comprised 8 six-weekly cycles of VCR 1.5mg/m2 weekly×3, CCNU 75mg/m2 and cisplatin 70mg/m2. ResultsMedian duration of HART was 34days (range 31–38). Grade 3–4 toxicities included mucositis (8), nausea (10), anaemia (5), thrombocytopaenia (2), leucopaenia (24). With 4.5-year median follow-up, 3-year EFS and OS were 59% and 71%, respectively. Of 10 relapses, 1 was outside the central nervous system (CNS), 1 posterior fossa alone and 8 leptomeningeal with 3 also associated with posterior fossa. ConclusionHART with or without VCR was well tolerated and may have a place in the multi-modality management of high-risk MB.

Busulfan-containing conditioning regimens are optimal preparative regimens for autologous stem cell transplant in patients with diffuse large B-cell lymphoma

We retrospectively examined the outcomes of 56 patients with diffuse large B-cell lymphoma (DLBCL) who underwent autologous stem cell transplant (ASCT) with BEAM/BEAC (carmustine, etoposide, cytarabine, melphalan/cyclophosphamide) or busulfan (Bu)-containing conditioning regimens. The Bu group had lower disease-related mortality and more frequent achievement of complete remission (CR) after ASCT from partial remission (PR) or refractory status before ASCT compared with the BEAM/BEAC group. The estimated 2-year EFS (59.3% vs. 15.0%) and overall survival (OS) (70.2% vs. 42.0%) in pre-ASCT rituximab-exposed patients with DLBCL were higher in the Bu group. In patients with high-risk DLBCL exposed to rituximab with first remission, the Bu group had better EFS (p = 0.004) and OS (p = 0.053) rates, while survival rates for relapsed/refractory patients did not differ between groups. Bu regimens are highly effective for preparing patients with DLBCL with previous exposure to rituximab for ASCT, especially in high-risk patients who achieved a first remission.

Clinical analysis and prognostic significance of haemophagocytic lymphohistiocytosis-associated anaplastic large cell lymphoma in children

Haemophagocytic lymphohistiocytosis (HLH) has been rarely described in children treated for an anaplastic large-cell lymphoma (ALCL). We evaluated the incidence, the clinical and histological characteristics and the prognosis of HLH associated-ALCL. The medical, biological, cytological and histological data of patients treated for ALK-positive ALCL in the paediatric department of a single institution between 1975 and 2008 were analysed and assessed for HLH according to diagnosis criteria of the Histiocyte Society. Data concerning a series of 50 consecutive children with ALCL were reviewed. HLH-associated ALCL was observed in 12% of the patients. Lung involvement was significantly more frequent in HLH-associated ALCL patients than in the group without HLH (P=0·004), as well as central nervous system (CNS) and bone marrow involvement (P=0·001 and P=0·007 respectively). The histological subtype in children with HLH-associated ALCL did not differ from that of the group without HLH. There was no significant difference between the two groups in 5-year EFS and OS (P=0·91 and P>0·99 respectively). In conclusion, HLH is not rare in paediatric ALCL. Despite a high incidence of visceral, CNS and bone marrow involvement, HLH does not seem to exert a significant impact on outcome in children treated for ALCL.

High number of additional genetic lesions in acute myeloid leukemia with t(8;21)/RUNX1-RUNX1T1: frequency and impact on clinical outcome

t(8;21)/RUNX1-RUNX1T1-positive acute myeloid leukemia (AML) is prognostically favorable; however, outcome is heterogeneous. We analyzed 139 patients with t(8;21)/RUNX1-RUNX1T1-positive AML (de novo: n=117; therapy-related: n=22) to determine frequency and prognostic impact of additional genetic abnormalities. All patients were investigated for mutations (mut) in ASXL1, FLT3, KIT, NPM1, MLL, IDH1, IDH2, KRAS, NRAS, CBL and JAK2. Sixty-nine of 139 cases (49.6%) had 1 mutation in addition to RUNX1-RUNX1T1, and 23/139 (16.5%) had ⩾2 additional mutations. Most common were KITmut (23/139; 16.5%), NRASmut (18/139; 12.9%) and ASXL1mut (16/139; 11.5%). FLT3-ITD, FLT3-TKDmut, CBLmut, KRASmut, IDH2mut and JAK2mut were found in 2.9-5.0%. Additional chromosomal abnormalities (ACAs) were found in 97/139 (69.8%). Two-year overall survival (OS) was 73.4% in 111 intensively treated patients. KITD816mut negatively impacted on OS in de novo AML (2-year OS: 59.1% vs 82.0%, P=0.03), ASXL1mut on EFS (de novo AML: 20% vs 59.1%, P=0.011; total cohort: 28.6% vs 56.7%, P=0.021). Sex chromosome loss was favorable (2-year EFS: 66.9% vs 43.0%, P=0.031), whereas +8 was adverse on EFS (2-year EFS: 26.7% vs 55.9%, P=0.02). In conclusion, t(8;21)/RUNX1-RUNX1T1-positive AML shows a high frequency of additional genetic alterations. Investigation for KITD816 and ASXL1mut combined with investigation of ACAs is recommended in t(8;21)/RUNX1-RUNX1T1-positive AML because of the prognostic significance of these parameters.

Minimal Disseminated Disease in Pediatric Non-Hodgkin Lymphoma

clinical parameter such as mediastinal, visceral or skin involvement for risk stratification, the 3 yrs PFS was 58% for patients with clinical highrisk features vs 88% for standard risk patients. Thus the combination of MDD and antibody titer represents a new prognostic indicator that may be considered in the design of new ALCL trials. Lymphoblastic T-cell lymphoma (T-LBL) and T-cell lymphoblastic leukemia (T-ALL) are often considered to be part of a spectrum of a single disease. The malignant cells in T-ALL and T-LBL are morphologically indistinguishable, and immunophenotype as well as genetic abnormalities of the cells are similar. The sensitive and specific methodologies used for MRD monitoring in T-ALL, such as PCR amplification of specific genetic abnormalities and clonal IG/TCR gene rearrangement, but also flow cytometric analysis can be used to detect sub-microscopic disseminated disease also in patients with T-LBL. The very first data on the prognostic impact of minimal disease at diagnosis, evaluated by flow cytometry, was reported recently by Coustan-Smith et al. in 99 pediatric T-LBL patients [4]. Submicroscopic disease was detected in 72% of BM studied (71/99). In most of the patients a PB sample at diagnosis was also studied and every patient with detectable disease in the BM had also detectable disease in blood (r=0.86, p<0.0001). Using a cut-off level of 1%, the 2-year EFS was 68% for patients with higher levels of disease dissemination versus 91% for those with lower levels. These results indicate that flow-cytometric assay, that is at least 100-fold more sensitive than morphology, could allow a better stratification of patients for therapeutic purposes. The overall scenario indicates that similar approaches used for MRD studies in ALL may be applied to analyze MDD-MRD in NHL patients. These studies are limited in solid tumors by the different nature of the primary disease compare to ALL, which implies availability of unfixed bioptic material.

Reduced intensity conditioning in allogeneic stem cell transplantation for AML with Down syndrome

Allogeneic hematopoietic stem cell transplantation (HSCT) has not been widely used in patients with acute myeloid leukemia (AML) and Down syndrome (DS) due to fear of transplantation-related toxicity. A retrospective analysis of the outcome of allogeneic HSCT was conducted in 15 patients with AML and DS. The five patients transplanted with the reduced intensity conditioning (4 in complete remission (CR) and 1 in non-CR) had a significantly better survival rate than 10 patients transplanted with a conventional conditioning (4 in CR and 6 in non-CR) (3-year EFS (95% confidence interval): 80.0% (20.4-96.9%) vs. 10.0% (0.6%-35.8%), P = 0.039).

Plasma Imatinib Trough Level Is a Predictor For 3-Month Early Molecular Response In New CP CML Patients

BackgroundRecent studies have demonstrated that measurements of BCR-ABL1 transcript levels at 3 and 6 months were able to identify high-risk patients treated with IM. However, the value of early molecular response has not been fully defined. New European Leukemia Net (ELN) recommendations concluded that a single measurement of BCR-ABL1 transcripts level after 3 months of treatment is not sufficient to define failure necessitating a change of treatment. The aim of this study was to identify predictive factors for an achievement of 3-month EMR. For the purpose, we explored contributing factors including trough plasma concentrations of IM, precise IM dose schedule. Additionally, in the same population, prognostic implications of 3- month EMR were analyzed. MethodsBetween December 2009 and June 2012, 102 patients with newly diagnosed CP CML were enrolled. They started IM (400 mg/day) therapy without prior treatment except hydroxyurea or anagrelide and molecular responses were monitored using qRT-PCR assay with 3 month intervals, and then 6 month intervals after achieving major molecular response (MMR). All qRT-PCR tests were performed in a single laboratory (Cancer Research Institute, The Catholic University of Korea, Seoul, Korea). Measurements of IM plasma concentrations were performed on day 29. ResultsA total of 102 newly diagnosed CP CML patients (including 61 men and 41 women) were analyzed. With a median age of 41 years (range, 18-75 years), the distribution of low, intermediate and high Sokal risk scores were 42%, 42% and 16%, respectively. All patients, except one patient who showed less than complete hematologic response, were evaluable for molecular analyses at 3 months. Day 29 trough IM level data were available from 99 patients. The median trough concentrations of IM were 1,252 (range, 439-3,491) and cut-off IM levels for Q1 and Q4 quartiles were 958 and 1767 ng/mL on day 29, respectively.Univariate analyses revealed that age of ≥ 40 years (P = 0.046), high Sokal risk (P = 0.066), high Euro risk (P = 0.004), increased platelet count (P = 0.028), increased blast percentage (0.023), and large spleen size (P = 0.046) were potential predictive factors for no achievement of 3-month EMR. In addition, plasma IM trough level of ≤ Q1 quartile on day 29 was associated with no achievement of 3-month EMR. After adjusting for factors affecting achievement of 3-month EMR on univariate analyses, multivariate analyses showed that large spleen size (RR of 0.79, P = 0.030) was predictor for no achievement of 3-month EMR and patients in ≤ Q1 of plasma IM trough level on day 29 had a lower 3-month EMR, compared with those in Q2-4 (RR of 15.61, P = 0.005).To evaluate the prognostic value of 3-month EMR in our cohort, we analyzed CCyR at 6 months, MMR at 12 months, and the 3-year CI of CCyR, MMR, and UMRD. In addition, the 3-year EFS, FFS, and PFS were also assessed. In patients with BCR-ABL1 ≤10% at 3 months, significantly higher rates of CCyR at 6 months (79% vs 13%, P < 0.001) and MMR at 12 months (54% vs 10%, P = 0.014) were observed, compared with that of patients with BCR-ABL1 >10%. They also had significantly better 3-year CI of CCyR (100% vs 63.0%, P<0.001) and MMR (100% vs 30.4%, P = 0.001), EFS (62.2% vs 26.3%, P = 0.002), and FFS (89.6% vs 73.7%, P = 0.044). However, there were no significant differences in 3-year PFS. ConclusionsThis study analyzed various factors, such as baseline biological characteristics, adherence to IM, IM dose intensity, pharmacokinetics. It provides predictors for 3-month EMR and re-confirmed the prognostic significance of 3-month EMR. The considering of IM plasma concentrations for 3-month EMR should be needed in the clinical decision of changing therapy at this time point. Further clinical investigations in a larger patient population with longer follow-up are needed. Disclosures:No relevant conflicts of interest to declare.

ABT-737 Restores Prednisolone Sensitivity In Early T-Cell Precursor Acute Lymphoblastic Leukemia With High MEF2C Expression

BackgroundEarly T-cell precursor-acute lymphoblastic leukemia (ETP-ALL) has been identified as high-risk subtype of pediatric T cell acute lymphoblastic leukemia (T-ALL). ETP-ALL is characterized by lack of expression of CD1a and CD8, weak or absent expression of CD5 and aberrant expression of myeloid and hematopoietic stem cell markers, such as CD13, CD33, CD34 and CD117. Because conventional chemotherapy is not fully effective for this subtype, potential therapeutic target should be explored. Here, we assessed gene expression pattern of the transcriptional factors related to differentiation of lymphoid and myeloid cells in ETP-ALL to determine the potential therapeutic target for this particular subtype. Patients and MethodsThirty-one patients with T-ALL treated in Kyoto Prefectural University of Medicine and affiliated hospitals were classified in ETP-ALL or non- ETP ALL based on the results of surface marker analysis by FACS. To compare the gene expression pattern of transcriptional factors related to differentiation of myeloid and lymphoid cells in ETP-ALL with those in non-ETP-ALL, real time RT-PCR (RQ-PCR) was performed to determine expression level of C/EBPa, ID2, NOTCH1, LYL1, IL7R, LMO2, MEF2C, PU.1, and FLT3 in primary leukemic cells from twenty-one patients with T-ALL (ETP-ALL: 9, non ETP-ALL: 12) based on the availability of appropriate RNA. To assess the relationship between high MEF2C expression and prednisolone (PSL) /Bcl2 inhibitor (ABT-737) sensitivity, cell proliferation of Jurkat (not expressing MEF2C) and Loucy (expressing MEF2C) cells cultured with serial concentration of PSL and/or ABT-737 was measured with the WST-1 assay to determine the 50% growth inhibitory concentration (IC50) of these agents. BaF3 cells expressing MEF2C (BaF3-MEF2C) was also generated using retrovirus gene transduction system (MSCV) and cultured with serial concentration of PSL/ABT-737 to determine the IC50 of PSL/ABT-737. Apoptosis was determined by Annexin V/PI staining. Viability of primary leukemic blasts of ETP-ALL and non-ETP-ALL, which were co-cultured with murine stromal cell(MS-5 cell) and treated with PSL and/or ABT-737, was also determined by Annexin V/PI staining. ResultsThirty-one patients diagnosed with T-ALL were classified in ETP-ALL (N=10) or non- ETP ALL (N=21). Although 5 patients in ETP-ALL experienced induction failure (IF), none of the patients in non-ETP-ALL experienced IF (p<0.05). The 5-year EFS in ETP-ALL was significantly inferior than that in non-ETP-ALL ( 40±15.5% vs 76.1±9.2%, log-rank p<0.05). However, the 5-year OS was not significantly different in two groups (67±15.7% in ETP-ALL vs 81±8.5% in non-ETP ALL). RQ-PCR analysis determined that MEF2C and FLT3 was expressed more in ETP-ALL than in non-ETP ALL (MEF2C: p=0.039, FLT3: p=0.014). Because MEF2C augments Bcl2 activity to inhibit the apoptosis, we explored whether high expression of MEF2C was associated with PSL poor response and Bcl2 inhibitor restored the sensitivity to PSL. Combination treatment of PSL and ABT-737 resulted in the significant reduction of IC50 of PSL in Loucy cell (combination index, CI: 0.39). In addition, apoptotic cells increased when Loucy cells were treated with PSL (25mM) in combination with ABT-737 (10nM) compared to be treated with PSL (25mM) alone. In contrast, combination treatment did not reduce significantly IC50 of PSL in Jurkat cell (CI: 1.12). The combination treatment of PSL and ABT-737 also resulted in the significant reduction of IC50 of PSL in BaF3-MEF2C compared to BaF3 cells. Finally, treatment of ABT-737(10nM) in combination with PSL (50 or 200 mM) reduced viability of primary leukemic blasts of ETP-ALL with high expression of MEF2C more profoundly than the treatment of PSL (50 or 200 mM) alone. ConclusionsThese findings suggest that high expression of MEF2C is associated with PSL poor response and Bcl2 inhibitor restores PSL sensitivity in ETP-ALL in vitro. Thus, Bcl2 inhibitor might be therapeutic option for ETP-ALL with high expression of MEF2C. Disclosures:No relevant conflicts of interest to declare.