Acute Myelogenous Leukemia Patients Research Articles

Antifungal treatment duration in hematology patients with invasive mold infections: an untold story

Abstract Background Limited data exist on when and how to stop antifungal treatment (AFT) in immunocompromised patients with invasive mold infections (IMI). Methods This is a retrospective multi-center study on adult patients with acute myelogenous leukemia (AML) and proven/probable IMI (01.01.2010-31.12.2022) in three University Hospitals. The primary objective was to describe AFT duration and adaptation. Secondary objectives were to investigate the reasons for AFT adjustments and prolongation. Results Seventy-one patients with 73 IMI were identified; 51 (71.8%) had an allogeneic hematopoietic cell transplant (HCT). Most infections were invasive aspergillosis (IA, 49/71, 69%), followed by mucormycosis (12, 16.9%), and other IMI (12, 16.9%); there were two mixed infections. Treatment duration was 227 days (IQR:115.5-348.5). There was no difference in AFT duration between patients with IA and non-IA IMI (P:0.85) or by center (P:0.92). Treatment was longer in patients with an allogeneic HCT versus not (P:0.004). Sixteen (22.5%) patients had no therapy modifications. In 55 (77.5%) patients 2 (median; IQR:1-3; range:1,8) changes were observed. There were 182 reasons leading to 165 changes, associated with clinical efficacy (82/182, 44.5%), toxicity (47, 25.8%), and logistical reasons (22, 12.1%); no reason was documented in 32 (18.8%) changes. AFT was continued beyond day-90/day-180 in 59 (83%)/39 (54.9%) patients, respectively, mostly due to persistence of immunosuppression. Conclusions AFT in AML patients with IMI is longer than recommended by guidelines and frequently associated with treatment adjustments due to variable reasons. More data and better guidance are required to optimize AFT duration and secondary prophylaxis administration according to immunosuppression.

Donor KIR2DL1 Allelic Polymorphism Influences Posthematopoietic Progenitor Cell Transplantation Outcomes in the T Cell Depleted and Reduced Intensity Conditioning Setting

The majority of established KIR clinical assessment algorithms used for donor selection for hematopoietic progenitor cell transplantation (HPCT) evaluate gene content (presence/absence) of the KIR gene complex. In comparison, relatively little is known about the impact of KIR allelic polymorphism. By analyzing donors of T cell depleted (TcD) reduced intensity conditioning (RIC) HPCT, this study investigated the influence on post-transplant outcome of 2 polymorphic residues of the inhibitory KIR2DL1. The aim of this study was to expand upon existing research into the influence of KIR2DL1 allelic polymorphism upon post-transplant outcome. The effects of allele groups upon transplant outcomes were investigated within a patient cohort using a defined treatment protocol of RIC with TcD. Using phylogenetic data, KIR2DL1 allelic polymorphism was categorized into groups on the basis of variation within codons 114 and 245 (positive or negative for the following groups: KIR2DL1*002/001g, KIR2DL1*003, KIR2DL1*004g) and the identification of null alleles. The influence of these KIR2DL1 allele groups in hematopoietic progenitor cell transplantation (HPCT) donors was assessed in the post-transplant data of 86 acute myelogenous leukemia patients receiving RIC TcD HPCT at a single center. KIR2DL1 allele groups in the donor significantly impacted upon 5-year post-transplant outcomes in RIC TcD HPCT. Donor KIR2DL1*003 presented the greatest influence upon post-transplant outcomes, with KIR2DL1*003 positive donors severely reducing 5-year post-transplant overall survival (OS) compared to those receiving a transplant from a KIR2DL1*003 negative donor (KIR2DL1*003 pos versus neg: 27.0% versus 60.0%, P = .008, pc = 0.024) and disease-free survival (DFS) (KIR2DL1*003 pos versus neg: 23.5% versus 60.0%, P = .004, pc = 0.012), and increasing 5-year relapse incidence (KIR2DL1*003 pos versus neg: 63.9% versus 27.2%, P = .009, pc = 0.027). KIR2DL1*003 homozygous and KIR2DL1*003 heterozygous grafts did not present significantly different post-transplant outcomes. Donors possessing the KIR2DL1*002/001 allele group were found to significantly improve post-transplant outcomes, with donors positive for the KIR2DL1*004 allele group presenting a trend towards improvement. KIR2DL1*002/001 allele group (KIR2DL1*002/001g) positive donors improved 5-year OS (KIR2DL1*002/001g pos versus neg: 56.4% versus 27.2%, P = .009, pc = 0.024) and DFS (KIR2DL1*002/001g pos versus neg: 53.8% versus 25.5%, P = .018, pc = 0.036). KIR2DL1*004 allele group (KIR2DL1*004g) positive donors trended towards improving 5-year OS (KIR2DL1*004g pos versus neg: 53.3% versus 35.5%, P = .097, pc = 0.097) and DFS (KIR2DL1*004g pos versus neg: 50.0% versus 33.9%, P = .121, pc = 0.121), and reducing relapse incidence (KIR2DL1*004g pos versus neg: 33.1% versus 54.0%, P = .079, pc = 0.152). The presented findings suggest donor selection algorithms for TcD RIC HPCT should consider avoiding KIR2DL1*003 positive donors, where possible, and contributes to the mounting evidence that KIR assessment in donor selection algorithms should reflect the conditioning regime protocol used.

Racial Disparities in Telemedicine Uptake during the COVID-19 Pandemic among Patients with Hematologic Malignancies in the United States

Background: The COVID-19 pandemic impacted healthcare visit trends, transitioning care to utilize telemedicine. We aimed to investigate if the uptake in telemedicine during pandemic was equitable across racial groups for patients with hematologic malignancies. Methods: Using the nationwide Flatiron Health electronic health record (EHR)-derived de-identified database we analyzed patients with diagnosis of acute myelogenous leukemia (AML), diffuse large B-cell lymphoma (DLBCL), follicular lymphoma (FL), mantle cell lymphoma (MCL), chronic lymphocytic leukemia (CLL) or multiple myeloma (MM). Patients were categorized into treatment types within lines of therapy: outpatient (oral therapy and outpatient infusions combined with oral therapy) vs. inpatient treatments (chemotherapy, cellular therapy). Monthly visit rates were calculated as the number of visits (telemedicine or in-person [in-clinic treatment administration, vitals, and/or labs]) per active patient per 30-day standardized month. We used time-series forecasting methods on pre-pandemic monthly visit rate data (March 2016 - February 2020) to estimate projected counterfactual monthly visit rates between March 2020 - February 2021.Telemedicine uptake was descriptively analyzed over time (t). Results: We included 18,924 active patients (2,394 Black and 16,530 White) and 884,504 visits (117,673 Black and 766,831 White). 4,053 AML, 3,468 diffuse large B cell lymphoma, 1,943 follicular lymphoma, 2,151 mantle cell lymphoma, 5,926 chronic lymphocytic leukemia and 7,752 myeloma patients. Black patients had no significant reductions in in-person visit rates throughout the pandemic period compared to the projected rates. Conversely, White patients experienced an 18% (95% PI 9.9% - 25%) lower rate of in-person visits for outpatient therapy during the early pandemic (March - May 2020) (actual monthly visit rate 1.61; projected visit rate 2.0 [95% CI 1.8-2.2]). Telemedicine uptake was significantly higher for White patients compared with Black patients for all diseases and treatment categories between March 2020-February 2021 (t = 9.5, p < 0.01), AML inpatient (t = 2.4, p = 0.04), MM outpatient (Figure 3C) (t = 6.0, p < 0.01) and MM inpatient treatment categories (Figure 3D) (t = 2.3, p = 0.04). Conclusions: White patients had significantly higher telemedicine uptake compared with Black patients for all treatment categories. These findings challenge healthcare systems to direct efforts toward reducing the gap in healthcare access.

Estimation of Serum TLR-9,TNF-α, and IL-6 Levels in the Iraqi Patients Diagnosed as Acute Myelogenous Leukemia

Acute myelogenous leukemia (AML) is a varied group of biological and clinical diseases. It is distinguished by the fast proliferation of aberrant cells in the bone marrow, which interferes with normal blood cell formation. Several studies demonstrated that cytokines released by leukemic cells in an autocrine or paracrine manner influence the proliferation of AML cells. Our study aimed to assess serum levels of TLR-9, TNF-α and, IL-6 in patients of AML. The study was done via the ELISA Technique. The results show a highly significant difference in all parameters in Patients and control. The correlation between immunological parameters using the Pearson correlation coefficient for patients showed that there is a weak correlation between TLR-9 and TNF- α, IL-6 with P-values of 0.47 and 0.23 respectively. This may indicate the complex environment of inflammation. However, there was a strong correlation between TNF- α and IL-6 with a P-value (0.001). This indicates that the secretion of these cytokines was high in patients. All immunological parameters of patients were evaluated using the receiver operating characteristic (ROC) curve to demonstrate that any one of them is a useful tool for identifying and tracking inflammation. The ROC curve's findings revealed that all parameters have good sensitivity and specificity for detecting inflammation and disease activity in AML patients. According to the current study, AML was related to higher levels of TLR-9, TNF-α, and, IL-6 may be affected the prognosis of the disease, increase the risk of the disease progression, and may be used as a biomarker to target AML cells.

Financial Trends of AML Patients over the Past Decade

Background: Over the past 30 years, the incidence of acute myelogenous leukemia (AML) has progressively increased across the globe, and until recently, therapeutic options were primarily limited to the standard “7 + 3” cytotoxic chemotherapy. The economic burden associated with the management of AML has steadily increased and significantly escalated with the introduction of new targeted therapies. To our knowledge, there are very few studies that have looked at the major drivers of cost in AML treatment over the past decade and how they have evolved. Methods: We conducted a retrospective review with IRB approval of all the medical costs associated with the initial course of chemotherapy, administered in the hospital setting, in newly diagnosed AML patients at the Georgia Cancer Center (GCC) from 2011 to 2022. All medical costs were obtained through the accounting system at Augusta University Medical Center (AUMC) using the Patient Billing Department. Every direct cost from the patient's first to last day of hospitalization during which they received induction was included. Results: A total of 183 patients were identified. Patients were excluded for the following reasons: 3 patients left to receive induction elsewhere, and 2 patients left against medical advice for unclear reasons. A total of 178 newly diagnosed AML patients fit the above criteria during this period with a median age of 61 years. The median length of stay (LOS) of these 178 patients was 30 days. Between 2011 to 2016, 71 patients were treated and had a median age of 65 years, while 107 patients were treated between 2017 to 2022 with a median age of 57 years. Major drivers of total direct cost were identified which included inpatient bed (~40%), medications (~20%), blood bank products (~15%), and lab tests (~14%). Medication costs were further reviewed with breakdown as follows: chemotherapy (~3%), antibiotics (~10%), and all other medications (~7%). These medication costs were based on 340B pricing. The average and median direct costs from the above categories were compared from 2011-2016 to 2017-2022 (Table 1). The 2017-2022 group had significantly lower median and average bed cost, blood bank product cost, and overall total cost. The LOS was also noted to be shorter in the 2017-2022 group. We then analyzed the subset of patients (n=64) who received standard induction chemotherapy and excluded patients who required reinduction (n=8) or who died during induction (n=13). The same trends were identified in this subset analysis. AML patients with FLT3 mutations, which consisted of 41 of the total 178 patients, were of particular interest given the increased number of targeted therapies that have been approved since 2017. This was investigated further by comparing the direct average and median costs of the categories noted above between the 2011-2016 group with 11 FLT3+ AML patients to the 2017-2022 group with 30 FLT3+ AML patients (Table 2). The average and median medication costs, including chemotherapy, antibiotics, and all other medications, were higher in the 2017-2022 group. This resulted in the total direct cost being higher in the 2017-2022 group despite having lower blood bank and inpatient bed costs. Conclusion: Over the past decade, many significant changes have occurred in several of the driving factors associated with the cost of AML therapy. Still, there has been a decrease in length of stay, inpatient bed costs, blood bank costs, and overall total costs from 2017-2022 compared to 2011-2016. In the subset of FLT3+ AML patients, there was a shift in the financial landscape with an increase in medication costs that influenced the overall cost. It is likely that the economic impact from this will continue to grow as novel therapies become more available and the number of patients being treated continues to increase.

High Progression-Free Survival with Low Relapse Rates after Double-Unit Cord Blood Transplantation in Patients with High-Risk AML

Background : Double-unit cord blood transplantation (dCBT) is standard therapy for patients with acute myelogenous leukemia (AML) who do not have suitable adult donors. We & others have reported low relapse rates & high progression free survival (PFS) in dCBT recipients suggesting robust CB-derived graft-versus-leukemia effects. However, the efficacy of dCBT in high-risk AML as determined by ELN genetic risk & pre-transplant minimal residual disease (MRD) status has not been performed to date. Methods : All consecutive adult patients with AML who received first dCBT with intermediate intensity conditioning (Cy50/ Flu150/ Thio10/ TBI400) between 2014-2022 were analyzed. GVHD prophylaxis was with either Cyclosporine-A (CSA)/ Mycophenolate Mofetil (MMF) or CSA/MMF/Tocilizumab on an institutional protocol. Results : 63 patients (pts) (median age 49 years, range 23-63) were eligible for analysis (Table); 42 (67%) were CMV seropositive, 31 (49%) had non-European ancestry, & median HCT-CI was 2 (range 0-6). Most (n = 55, 87%) were in CR1, 5 (8%) in CR2, & 3 were relapsed or primary refractory at transplant (5-9% blasts). By ELN2022 genetic risk criteria, 8 pts had favorable, 29 intermediate, & 20 adverse risk AML (6 were missing ELN status). Of the 60 pts in CR, 36 were MRD- & 18 MRD+ by multicolor flow cytometry (6 had unknown/ indeterminate MRD status). Sixty-one of 63 pts engrafted for a 60-day cumulative incidence of 98% (95%CI:81-100). The median follow-up of survivors was 58 months (range 8-104 months). The 1- & 3-yr incidences of transplant-related mortality (TRM) were 13% (95%CI: 5.9-22) & 18% (95%CI: 9.6-29), respectively. The 1- & 3-year relapse incidences were 3.2% (95%CI: 0.6-9.9) & 8.6% (95%CI: 3.1-18), respectively. The 1- & 3-year OS were 87% (95%CI: 79-96) & 82% (95%CI:72-92) respectively, whereas the 1- & 3-year PFS were 84% (95%CI: 76-94) & 73% (95%CI: 63-85), respectively. When stratified by ELN2022 genetic risk, the 3-year relapse incidence was 0% in favorable, 10% (95%CI: 2.5-25) in intermediate & 13% (95%CI: 2-36%) in adverse risk AML patients. Pts with favorable risk AML had a 3-year PFS of 88% (95%CI: 67-100); the 3-year PFS was similar in patients with intermediate [68% (95%CI: 53-88)] or adverse [67% (95%CI: 48-93)] risk AML (Figure 1A). When stratified by MRD status, the 3-year relapse incidence was 8.4% (95%CI:2.1-20) in MRD- & 13% (95%CI: 1.9-34) in MRD+ patients. The 3-year PFS was similar in patients with AML in CR who were MRD- 80% (95%CI: 68-94) or MRD+ 76% (95%CI: 57-100), whereas all 3 relapsed/ refractory patients died of TRM (Figure 1B). Of 4 TP53-mutated AML patients, one relapsed, one died of TRM, & two are alive in remission. Conclusions: While retrospective, our findings highlight the low relapse rates & promising PFS in adult AML patients, including those with high risk features such as adverse-risk ELN genetic risk &/ or MRD positivity supporting robust CB-derived graft-versus-leukemia (GVL) effects. This observation, together with the mitigation of TRM in recent years due to the optimized transplant practices in adult dCBT (see Politikos et al, ASH 2023), makes intermediate intensity dCBT an attractive strategy for AML patients with a suitable dCB graft & high-risk disease. Our findings warrant prospective multi-center investigation with correlative studies to elucidate the biology of CB-derived GVL.

Platelet Factor 4 Binds to Low-Density Lipoprotein Receptor to Block Leukemic Stem Cell Expansion and Recurrence

Healthy hematopoietic stem cells (HSCs) reside in highly specialized microenvironments within the bone marrow, commonly referred to as niches. HSC activity is tightly regulated by various cellular and molecular niche constituents that ensure healthy hematopoiesis. However, through the accumulation of mutations, hematopoietic stem and progenitor cells can give rise to leukemia-initiating cells or leukemic stem cells (LSCs), which play a vital role in the onset, progression, and treatment outcome of acute myelogenous leukemia (AML). In AML, the expansion of the leukemic clone is associated with impaired healthy hematopoiesis, resulting in severe anemia, thrombocytopenia, and immunodeficiency, which can lead to severe morbidity. Current therapeutic options mainly eliminate the bulk of leukemic cells but do not efficiently target LSCs, leading to the high rates of relapse seen in AML patients. Recent studies suggest that LSCs hijack and alter the healthy bone marrow niche to better support their maintenance and proliferation. Understanding how LSCs interact with the bone marrow microenvironment is crucial for eradicating LSCs and preventing AML relapse. Our previous work showed that platelet factor 4 (PF4), a chemokine stored in platelet alpha-granules and secreted by bone marrow megakaryocytes, can induce quiescence in healthy myeloid-biased HSCs ( Nature Medicine 2014; Developmental Cell 2018). Here, we investigate the regulation of malignant LSCs by PF4 using mouse and human AML models. In an aggressive mouse AML model, MLL-AF9, our results show that recombinant PF4 blocks the proliferation of phenotypic LSCs (Lineage − IL7Rα − Sca1 − MLL-AF9-GFP + c-Kit high CD34 + FcγRII/III high) in vitro (70% reduction; P=0.0279). Strikingly, cell cycle analyses revealed that in vivo, both LSCs and bulk AML proliferation are significantly inhibited 24 hours post-PF4 (80 mg/kg) injection, resulting in a significantly lower leukemic burden. By contrast, Pf4 -/- mice exhibited rapid AML disease progression via increased LSC proliferation. Furthermore, using a genetic mouse model ( Pf4-Cre; iDTR) where PF4-secreting megakaryocyte cells can be depleted in vivo in leukemic mice, our results revealed that megakaryocyte depletion led to poor AML survival due to accelerated disease progression (Log-rank P<0.0017). These results demonstrate that megakaryocyte-derived PF4 can directly regulate the proliferation of leukemia cells. Interestingly, our results indicate that AML drives striking alterations in bone marrow megakaryocytes, including a lower frequency, reduced cell maturation, and reduced secretion of PF4 (~80% reduction, P<0.0001) compared to healthy controls. Accordingly, PF4 levels are reduced in the serum of myelodysplastic syndrome patients where hyperproliferative malignant cells are found alongside dysplastic megakaryocytes. To assess whether recombinant PF4 can alter the course of AML relapse in a preclinical experimental setting, we treated moribund leukemic mice with the chemotherapeutic drug Cytarabine followed by 3 daily I.V. injections of PF4 (80 mg/kg) or saline. Strikingly, this short treatment with PF4 preferentially reduced the frequency of LSCs in vivo during the relapse phase of AML (75% reduction; P=0.05). Furthermore, mice transplanted with MLL-AF9 AML cells that were pre-treated with Cytarabine and PF4 in vitro had prolonged overall survival (Log-rank P<0.0132) compared to Cytarabine alone. Importantly, two of six mice had no detectable AML up to 150 days post-transplantation. Finally, single-cell RNA sequencing experiments revealed that PF4 signals through Low-Density Lipoprotein Receptor (LDLR) on LSCs, whose expression is significantly upregulated upon Cytarabine treatment, during the relapse phase. Functional studies with fluorescently labeled low-density lipoprotein (LDL) confirmed that PF4 limits LSC uptake of LDL via LDLR to block LSC proliferation ( P=0.0044), suggesting an important role for PF4 in AML metabolism. Altogether, our studies reveal an unknown function for PF4 in AML and highlight PF4's potential as an effective adjuvant therapy in preventing AML relapse by inhibiting the recurrence of chemotherapeutic-resistant LSCs.

High Expression Level of MMP7 and Mir-489-3p/MMP7 Axis Associates with Venetoclax Resistance in Acute Myelogenous Leukemia

The BCL2 inhibitor venetoclax used to treat acute myelogenous leukemia (AML). Although this has been a promising therapeutic option for patients with AML, many of these patients develop resistance and relapsed disease. Matrix metalloproteinases (MMPs) were demonstrated to have important implications in the progression and invasiveness of many malignant disorders. In contrast, the biological significance of these molecules in AML is not clear. We determined the levels of MMP-7 in the bone marrow of 76 patients with AML. 70 bone marrow donors served as normal controls. The level of MMP-7 was significantly higher in the AML than in the normal controls. MMP-7 levels were significantly lower in the AML patients who achieved a complete remission (CR) than in those who did not. Through in vitro studies, we observed that MMP7 levels were elevated in AML cell lines (U937, THP-1) and in Venetoclax-resistant AML cell lines (U937R, THP-1R) and that downregulation of MMP7 could enhance Venetoclax efficacy in U937R and THP-1R cells. Our in vitro and in vivo investigations show that miR-489-3p was downregulated in Venetoclax-resistant AML cell lines and promoting level of miR-489-3p expression can directly suppressing MMP-7 expression. Pharmacological inhibition of miR-489-3p markedly reversed the effects of Venetoclax-resistant upon AML proliferation and metastasis. Thus, our study suggests that MMP-7 is an essential factor in AML, and regulator the miR-489-3p/MMP7 axis may be a novel treatment strategy for overcoming Venetoclax resistance in AML.

Myeloablative Fractionated Busulfan Conditioning Regimen with Chidamide in Patients with AML/MDS Less Than Complete Remission

Introduction Pre-transplant leukemic load significantly impacts relapse and long-term survival in patients with acute myelogenous leukemia (AML) and myelodysplastic syndrome (MDS). A prolonged duration of busulfan administration was reported as a safe myeloablative option with less toxicity and allows the addition of epigenetic agents, like chidamide, which may be synergistic with conditioning chemotherapy and may further improve disease control. Meanwhile, Pre-conditioning busulfan may play a priming role in enhancing the sensitivity of tumor cells to the following conditioning therapy. Here we report the safety and preliminary efficacy of chidamide and fractionated busulfan regimen in patients with AML or MDS who could not clear leukemia cells before transplantation. Methods We enrolled AML or MDS patients with residual or active disease after at least one line of standard therapy. Eligible patients received fractionated busulfan at a total dose of 12.8 mg/kg within 2 weeks. The first two doses of busulfan (1.4 mg/kg IV each) were administered on days -14 and -13. The rest of the busulfan was given on days -7 to -4. Fludarabine and cytarabine were given on days -7 to -3. Chidamide 30 mg twice weekly was given from day -14 to + 3. Peripheral stem-cell were used as grafts harvested from HLA-matched sibling donors (MSD), matched unrelated donors (MUD), or haploidentical donors (HID). Post-transplantation acute graft versus host disease (GVHD) prophylaxis consisted of cyclophosphamide on day +3 to +4, and cyclosporine started on day +5. For HID transplant recipients, mycophenolate mofetil was added from day +5 to day +35. Follow-up examinations were scheduled at +1, +2, +3, +4, +6, +9, +12, +18, and +24 months post-transplant. Donor lymphocyte infusion was not administered prophylactically in this trial. Results Twenty-six patients with de novo AML (n=19), secondary AML transformed from MDS (n=4), or MDS-EB2 (n=3) were enrolled with a median age of 48 years (range, 23~65 years). Patient and disease characteristics are summarized in Table 1. Nineteen patients had adverse risk karyotype according to European LeukemiaNet risk stratification. They received MSD (n=7), MUD (n=2), or HID (n=17) HSCT. Pre-transplant tests revealed that 14 of the patients had MRD (n=14, blast cells＜5% in the bone marrow), and 12 had active disease (blast cells ≥5%, including 4 who had blast cells ≥20%). The median pre-transplant blast cells were 7.5%. All patients successfully finished scheduled conditioning. Neutrophils and platelets engrafted at a median of 13 days (range,11-18 days) and 16 days (range, 11-53 days) post-transplant, respectively. All patients reached MRD negative with full donor chimerism at day +30. Cumulated incidence of grade II to IV and grade III to IV acute GvHD were 12.5% and 5.3% respectively. The median follow-up time was 13 months (2-45.5 months). For the whole cohort, the estimated 1-year progression free survival (PFS) and overall survival (OS) were 59.1% and 69.0% (Figure-1A). For patients with MRD+ or active disease, estimated 1-year PFS are 77.1% and 45.5%, respectively (Figure-1B), and estimated 1year OS of these two groups of patients are 87.5% and 63.6%, respectively (Figure-1C). Three patients died from pulmonary infections (2 with COVID-19 and 1 with cytomegalovirus) in CR at 5.8, 6.9, and 11.5 months post-transplant. The incidence of non-relapse mortality at 6 months and 1 year post-transplant was 4.8% and 16.3% respectively (Figure-1D). Conclusion Fractionated-busulfan based myeloablative conditioning regimen with chidamide confers survival advantage and good tolerance in acute leukemia and MDS patients with residual or active disease.

Investigating Racially Induced Metabolic and Genomic Signatures Mediating Inferior Survival in African Americans with Acute Myelogenous Leukemia

Background: African American (AA) patients experience worse survival outcomes compared to other patients with acute myelogenous leukemia (AML), independent of socioeconomic and molecular factors. 1 Indeed, our group previously demonstrated inferior survival in AA associated with the proxy for (1) genomic instability and (2) suggestion for inability to achieve protein damaging threshold among concurrent mutations. 2 In study expansion, we have confirmed worse overall survival (OS) for AA patients, and detected rapid attrition of AA patients, soon after diagnosis and therapy initiation. Given high incidence of cardiometabolic complications in AA patients, this prompted us to investigate the link between deranged metabolism and clinical outcomes. Additionally we explored nucleotide modifications that influence leukemogenesis in AA patients. In previous data, obesity correlated with poor outcomes for patients with acute promyelocytic leukemia (APL), but not in other AML, including in the CALGB cohort. 3-5 Interestingly, obesity is linked to 1) FTO/IRX3 pathways that block hematopoietic stem cell differentiation, and 2) oxidative stress, which may induce DNA damage favoring C>A and G>T nucleotide changes 6,7 and aberrant bone marrow microenvironment 8. Methods: We conducted retrospective analysis of 272 AML patients from Baylor TX, Georgetown DC, and Washington Hospital Center DC, including demographic and clinical variables (age, sex, race, BMI, comorbidities, smoking, treatments, and outcomes). APL patients were excluded. For patients with NGS data, mutation frequencies were annotated by ethnicity and prioritized by ELN 2022 classification. Chi-square and t-test evaluated differences in categorical and continuous variables respectively. Logistic binary regression was used to detect predictors for racial induced survival. SAS software was used. Results: Our expanded cohort has 272 AML patients, with 43 AA and 229 non-AA. AA patients showed worse OS than non-AA patients (Fig 1; 149 days vs 605 days, p=0.01). There were not any AA patients with favorable risk ELN 2022 disease status. Neither ELN 2022 risk groups nor presence of MDS-like mutations differentiated worse outcomes for AA patients, so we opted to examine the effect of obesity among AA and non-AA patients with intermediate and high risk AML (given no favorable risk AA patients in our cohort). Mean BMI for our AA patients was 28, with AA patients with BMI>28 showing significantly worse OS (Fig 1; 67 days vs 198 days, p=0.001), which was not present for non-AA patients. Metabolic derangement with high total cholesterol (p=0.02) and LDL (p=0.04) also segregated with worse OS for AAs (n=8 with cholesterol data), but not for other races. Nucleotide changes C>A and G>T characteristic of oxidative stress were overrepresented in AA patients with high BMI suggestive of clinical trend (33% vs 11%, p=0.06). Conclusion: Metabolic derangement in BMI and lipids correlated with inferior outcomes for AA patients only, supporting a unique pathobiology of highly aggressive AML that afflicts AA patients. Only AA patients demonstrated preference for C>A and G>T nucleotide changes, a hallmark of oxidative stress, also linked to obesity. These negative impacts support further mechanistic studies, and may present therapeutic strategies to improve metabolism, reduce oxidative stress, and suppress FTO/IRX3 pathways to induce myeloid differentiation. Figure 1: Inferior Survival For African American Patients Differentiated by BMI>28

AML-391 WHO and ICC 2022 Cytogenetic Abnormalities Defining Acute Myelogenous Leukemia (AML) Myelodysplasia-Related in First-Line Decitabine in Unfit AML Patients

AML-391 WHO and ICC 2022 Cytogenetic Abnormalities Defining Acute Myelogenous Leukemia (AML) Myelodysplasia-Related in First-Line Decitabine in Unfit AML Patients

POSTER: AML-391 WHO and ICC 2022 Cytogenetic Abnormalities Defining Acute Myelogenous Leukemia (AML) Myelodysplasia-Related in First-Line Decitabine in Unfit AML Patients

POSTER: AML-391 WHO and ICC 2022 Cytogenetic Abnormalities Defining Acute Myelogenous Leukemia (AML) Myelodysplasia-Related in First-Line Decitabine in Unfit AML Patients

UCHMC 1812: A phase 1b trial of CPX-351 plus gemtuzumab ozogamicin for relapsed/refractory acute myeloid leukemia.

7024 Background: Gemtuzumab ozogamicin (GO) is effective in favorable-risk acute myelogenous leukemia (AML), while its activity is limited in higher-risk AML in part due to multi-drug resistance (MDR) mechanisms, particularly P-glycoprotein efflux pumps. CPX-351 provides a survival benefit in secondary AML, a disease characterized by high MDR activity. The objective of this trial is to utilize CPX-351 as a bulk cytoreduction agent, to first reduce the high MDR leukemia clones, followed by sequential treatment with GO in a more favorable leukemia environment. Methods: This was a multicenter phase Ib trial of CPX-351 plus GO in relapsed/refractory (R/R) AML patients with standard 3+3 dose escalation design (NCT03904251). Cohort A was treated with CPX-351 100 u/m2 on days 1, 3, and 5 plus GO 3 mg/m2 (max 4.5 mg) on day 7. Cohort B was treated with the same regimen plus an additional dose of GO 3 mg/m2 on day 4. The primary endpoint was the maximum tolerated dose (MTD), defined as < 2 dose limiting toxicities (DLTs) in the highest dose cohort. Secondary endpoints were IWG complete remission (CR) rate at day 28-42, liver veno-occlusive disease (VOD) rate diagnosed by the Baltimore criteria, and time of hematologic recovery (defined as ANC > 1000/uL and platelet count > 100,000/uL). Patients were enrolled at 4 University of California Hematologic Malignancies Consortium (UCHMC) centers: UC Los Angeles, UC San Francisco, UC Davis, and UC Irvine. Results: Thirteen participants were enrolled. The median age was 63 years (range 29-75). Eleven had relapsed disease, and two had refractory disease. Most received one prior line of therapy (n = 9). Seven had ELN 2022 adverse-risk disease at initial diagnosis, and two had intermediate-risk disease. The MTD was not reached. DLTs were observed in 1/6 participants in cohort A (grade 3 rash), and 1/6 participants in cohort B (grade 5 intracranial hemorrhage in the setting of severe thrombocytopenia). There were no cases of liver VOD. Of 12 evaluable participants, 4 achieved CR (33%), of whom 3 were negative for measurable residual disease by multiparametric flow cytometry, and 1 one achieved partial remission. The median age of responders was 30 years (range 28-65). The median time to return of normal hematopoiesis in those who achieved remission was 37 days (range 36-43). Three participants received allogeneic hematopoietic cell transplant (alloHCT) following investigational therapy: one remains in remission 34 months post-transplant, one died of infectious complications shortly after alloHCT, and one relapsed at day +60. Conclusions: CPX-351 plus two doses of GO 3 mg/m2 is a feasible treatment with acceptable toxicity and reasonable marrow recovery kinetics. However, only three participants went on to curative alloHCT. Further evaluation for efficacy in a larger patient population is needed to determine the utility of this regimen in R/R AML. Clinical trial information: NCT03904251 .

Allogeneic transplantation in acute myelogenous leukemia: a comprehensive single institution's experience.

Debates on the role and timing of allogeneic hemtopoietic stem cell transplantation (HSCT) in acute myelogenous leukemia (AML) have persisted for decades. Time to transplant introduces an immortal time and current treatment algorithm mainly relies on the European LeukemiaNet disease risk classification. Previous studies are also limited to age groups, remission status and other ill-defined parameters. We studied all patients at diagnosis irrespective of age and comorbidities to estimate the cumulative incidence and potential benefit or disadvantage of HSCT in a single center. As a time-dependent covariate, HSCT improved overall survival in intermediate- and poor-risk patients (hazard ratio =0.51; P=0.004). In goodrisk patients only eight were transplanted in first complete remission. Overall, the 4-year cumulative incidence of HSCT was only 21.9% but was higher (52.1%) for patients in the first age quartile (16-57 years old) and 26.4% in older patients (57-70 years old) (P<0.001). It was negligible in patients older than 70 years reflecting our own transplant policy but also barriers to transplantation (comorbidities and remission status). However, HSCT patients need to survive, be considered eligible both by the referring and the HSCT physicians and have a suitable donor to get transplantation. We, thus, comprehensively analyzed the complete decision-making and outcome of all our AML patients from diagnosis to last followup to decipher how patient allocation and therapy inform the value of HSCT. The role of HSCT in AML is shifting with broad access to different donors including haploidentical ones. Thus, it may (or may not) lead to increased numbers of allogeneic HSCT in AML in adults.

DNA Damage Response-Related Proteins Are Prognostic for Outcome in Both Adult and Pediatric Acute Myelogenous Leukemia Patients: Samples from Adults and from Children Enrolled in a Children's Oncology Group Study.

The survival of malignant leukemic cells is dependent on DNA damage repair (DDR) signaling. Reverse Phase Protein Array (RPPA) data sets were assembled using diagnostic samples from 810 adult and 500 pediatric acute myelogenous leukemia (AML) patients and were probed with 412 and 296 strictly validated antibodies, respectively, including those detecting the expression of proteins directly involved in DDR. Unbiased hierarchical clustering identified strong recurrent DDR protein expression patterns in both adult and pediatric AML. Globally, DDR expression was associated with gene mutational statuses and was prognostic for outcomes including overall survival (OS), relapse rate, and remission duration (RD). In adult patients, seven DDR proteins were individually prognostic for either RD or OS. When DDR proteins were analyzed together with DDR-related proteins operating in diverse cellular signaling pathways, these expanded groupings were also highly prognostic for OS. Analysis of patients treated with either conventional chemotherapy or venetoclax combined with a hypomethylating agent revealed protein clusters that differentially predicted favorable from unfavorable prognoses within each therapy cohort. Collectively, this investigation provides insight into variable DDR pathway activation in AML and may help direct future individualized DDR-targeted therapies in AML patients.

Mitotic recombinatory evolution in acute leukemia

A cohort of leukemia cases is presented with ancillary testing that includes microarray studies, karyotyping, FISH, and RNA sequencing to illustrate clonal evolution. Common evolution etiology with each case is apparent homologous mitotic recombination (HMR). The cohort includes: four cases of Pre B-cell acute lymphoblastic leukemia (B-ALL) with a single translocation derivative (19)t(1;19)(q23.3;p13.3), an acute myelogenous leukemia (AML) case with a paracentric inversion of 11q13.3q23 in both homologues confirmed as a rare KMT2A-MAML2 gene fusion, and a transplant patient in AML relapse with a t(6;11)(6q27;q23) and evolution to an additional derivative 6 chromosome. The PBX1-TCF3 fusion in the t(1;19) B-ALL subgroup has long been associated with clones that show either the balanced translocation (∼25%) or the unbalanced single derivative 19 (∼75%). Evidence from the CMAs and FISH is consistent with HMR initiating at either the PBX1 translocation breakpoint or at a more proximal long arm site that mediates the evolution to the unbalanced form. This is contrary to the previous assumptions of either nondisjunction duplication of the normal homologue with loss of the translocation derivative 1 or an original trisomy 1 that loses the translocation derivative 1. Relapse from an unrelated transplant donor created unique allele dosage ratios in the microarray of the AML patient with the t(6;11) KMT2A-AFDN fusion. An HMR-based evolution initiation site proximal to the 6q27 AFDN fusion gene is evident in the microarray of chromosome 6, the known oncogenic fusion derivative. The HMR selection driver in both AML cases is very likely associated with the DNA doubling of the oncogenic fusions in 6q and 11q, respectively. Since the oncogenic derivatives in the 1;19 cases are clearly the retained derivative 19, selection for the HMR clonal evolution in 1q is apparently based on the known proliferative advantage of extra copies of 1q in B-ALL and other malignancies. Although selection-based HMR can effectively initiate at any site proximal to a driver gene fusion, it appears that the translocation breaksite is common for many translocations. In addition, evidence from HMR evolution related distal 11q mutations, numerous unbalanced CCND1/IGH translocations, and the double MAML2/KMT2A presented in this study suggest that a recombinatorial "hot spot" exists near the CCND1 gene in many rearrangements or mutations within 11q.

High expression level of the FTH1 gene is associated with poor prognosis in children with non-M3 acute myeloid leukemia.

Acute myelogenous leukemia (AML) is a disease that severely affects the physical health of children. Thus, we aimed to identify biomarkers associated with AML prognosis in children. Using transcriptomics on an mRNA dataset from 27 children with non-M3 AML, we selected genes from among those with the top 5000 median absolute deviation (MAD) values for subsequent analysis which showed that two modules were associated with AML risk groups. Thus, enrichment analysis was performed using genes from these modules. A one-way Cox analysis was performed on a dataset of 149 non-M3 AML patients downloaded from the TCGA. This identified four genes as significant: FTH1, RCC2, ABHD17B, and IRAK1. Through survival analysis, FTH1 was identified as a key gene associated with AML prognosis. We verified the proliferative and regulatory effects of ferroptosis on MOLM-13 and THP-1 cells using Liproxstatin-1 and Erastin respectively by CCK-8 and flow cytometry assays. Furthermore, we assayed expression levels of FTH1 in MOLM-13 and THP-1 cells after induction and inhibition of ferroptosis by real-time quantitative PCR, which showed that upregulated FTH1 expression promoted proliferation and inhibited apoptosis in leukemia cells. In conclusion, high expression of FTH1 promoted proliferation and inhibited apoptosis of leukemic cells through the ferroptosis pathway and is thus a potential risk factor that affects the prognosis of non-M3 AML in children.

Shorter duration of venetoclax administration to 14 days has same efficacy and better safety profile in treatment of acute myeloid leukemia

Venetoclax (VEN) is now widely used in the treatment of acute myelogenous leukemia (AML) in elderly patients who are not eligible for intensive remission induction therapy. Prolonged myelosuppression, increased incidence of infection, and long duration of hospital stay were major concerns for VEN treatment cases, and we thought that shortening the duration of VEN administration during induction therapy might solve these problems. Thirteen newly diagnosed AML patients who underwent VEN+azacitidine (AZA) induction therapy from March 2021 to June 2022 at Kushiro Rosai Hospital were analyzed retrospectively. The median age was 79 (range, 68–86) years, and 8 of the patients (61.5%) were classified as high risk according to the ELN 2017 risk stratification. Eight patients received VEN for 14 days (VEN14 group), and 5 patients received VEN for 28 days (VEN28 group). The composite complete remission (CRc) rate was 76.9% in total, and the CRc rates in the VEN14 and VEN28 groups were almost the same (75.0% and 80.0%, respectively). The median overall survival (OS) was not reached in the VEN14 group and was 254 days in the VEN28 group. The median event-free survival (EFS) was not reached in the VEN14 group and was 178 days in the VEN28 group. The VEN14 group might have a possibility to reduce febrile neutropenia (37.5% vs. 80%) and reduce the duration of hospital stay (median, 21.5 vs. 31 days) compared with the VEN28 group. VEN14 produced the same CRc rate and survival rate, safer profile, and shorter duration of hospital stay than VEN28.

CD4+ T-Cell Subsets in Aplastic Anemia, Myelodysplastic Syndrome, and Acute Myelogenous Leukemia Patients: a Comparative Analysis.

Systematic and comparative studies on CD4+ T-lymphocytes in aplastic anemia (AA), myelodysplastic syndrome (MDS), and acute myelogenous leukemia (AML) are scarce. This study aimed to investigate the importance of CD4+ T-cells in bone marrow (BM) failure. The proportions of Th1, Th2, Th17, and Treg cells in peripheral blood mononuclear cells (PBMCs) were examined by flow cytometry (FCM). The mRNA expression levels of transcription factors were measured using real-time PCR. The proportions of Th1, Th17 cells, and Th1/Th2 in the AA group were higher, whereas Th2 and Tregs were lower compared to controls. The proportions of Th17 and Treg cells accompanied by RORγt, and Foxp3 expression were significantly higher in the MDS group. The proportions of Th1, Th17, and Th1/Th2 were higher, whereas Th2 cells and GATA3 expression were significantly lower in MDS-multilineage dysplasia group, than in control group. The proportions of Th1, Th17, and Th1/Th2 were lower in MDS-excess blasts, and AML groups, than in controls, whereas that of Th2 and Treg cells accompanied by GATA3, and Foxp3 expression were significantly higher. Imbalance in CD4+ T-cell subsets may play a critical role in the pathogenesis and BM failure in the investigated diseases.

208. Clinical outcomes of empirical versus pre-emptive broad spectrum antifungal therapy in patients with acute myelogenous leukemia receiving antimold prophylaxis

Abstract Background Since antimold prophylaxis has been widely used in induction chemotherapy for acute myelogenous leukemia (AML), it should be re-evaluated whether broad spectrum antifungal therapy should be empirically used in prolonged febrile neutropenia. Therefore, we compared clinical outcomes of empirical versus pre-emptive antifungal therapy in patients with AML receiving antimold prophylaxis. Methods From September 2016 to December 2020, all adult AML patients (≥ 18 years) receiving antimold prophylaxis who had febrile neutropenia for ≥ 4 days during induction or re-induction chemotherapy at Seoul National University Hospital were retrospectively reviewed. They were classified into the empirical group (therapeutic broad spectrum antifungal agents had been used without evidence of invasive fungal infection [IFI]) or the pre-emptive group (antimold prophylaxis had been maintained until the emergence of IFI’s evidence). We compared clinical outcomes between the two groups after propensity score matching. Results A total of 229 chemotherapy episodes, 36 in the empirical group and 193 in the pre-emptive group, were analyzed. In the pre-emptive group, broad spectrum antifungal therapy was administered in 45 (23.3%) episodes. After 1:3 matching with age, gender, induction or re-induction chemotherapy, and worst qSOFA score at febrile neutropenia, incidence of proven or probable IFI (0/36 [0%] in the empirical group vs. 5/97 [5.2%] in the pre-emptive group, P=0.323) and all-cause mortality (3/36 [8.3%] in the empirical group vs. 4/97 [4.1%] in the pre-emptive group, P=0.388) were not different between the two groups. Conclusion Clinical outcomes of empirical versus pre-emptive broad spectrum antifungal therapy were comparable in patients with AML receiving antimold prophylaxis. Broad spectrum antifungal therapy could be delayed until the emergence of evidence of IFI, in the current era of antimold prophylaxis. Disclosures All Authors: No reported disclosures.