Acute Myeloid Leukemia Cases Research Articles

Acute myeloid leukemia with RAM immunophenotype: A new underdiagnosed entity.

Acute myeloid leukemia (AML) with RAM immunophenotype is a distinct subtype of AML, as described by the Children's Oncology Group (COG), with characteristic morphological and immunophenotypic properties. It is characterized by strong CD56 expression with dim to negative CD45, HLA-DR, and CD38 expression. It is an aggressive leukemia with a poor response to induction chemotherapy and/or frequent relapses. Seven cases with the characteristic RAM immunophenotype were identified in this retrospective analysis of newly diagnosed pediatric AML cases from January 2019 to December 2021. Herein, we have critically analyzed their clinical, morphological, cytochemical, immunophenotyping, cytogenetic, and molecular profiles. The patients were traced and followed for their current disease and treatment status. Of 302 cases of pediatric AML (age <18 years), seven cases (2.3%) with the distinct RAM phenotype were observed, with age ranging from 9 months to 5 years. Two patients were misdiagnosed earlier as small round cell tumor because of the strong CD56 positivity and the absence of leukocyte common antigen (LCA), but they were later correctly identified as granulocytic sarcoma. The bone marrow aspirate showed blasts with unusual cohesiveness and clumping with nuclear moulding, mimicking non-hematologic malignancies. Flow cytometry revealed blasts with low side scatter, dim to negative CD45 and CD38, negative cMPO, CD36, and CD11b; moderate to bright CD33, CD117, and bright CD56. The Mean fluorescence intensity (MFI) of CD13 expression was significantly lower as compared to the internal controls. Cytogenetic and molecular studies did not show any recurrent abnormalities. Reverse transcription polymerase chain reaction for CBFA2T3-GLIS2 fusion was performed in 5/7 cases, with one positive result. On clinical follow-up, two patients were refractory to chemotherapy. Six of the seven cases had succumbed to death (duration of survival: 3-343 days after initial diagnosis). AML with RAM immunophenotype, a distinct form of pediatric AML with a poor prognosis, may pose a diagnostic challenge if presented as a soft tissue mass. A comprehensive immunophenotypic evaluation, including stem cell and myeloid markers, is critical for an accurate diagnosis of myeloid sarcoma with the RAM-immunophenotype. Our data demonstrated weak CD13 expression as an additional immunophenotypic finding.

Vincristine induced peripheral neuropathy in children undergoing chemotherapy for acute lymphoblastic leukaemia during induction

Background: Vincristine is an anticancer agent administered to all children with acute lymphoblastic leukemia (ALL), and peripheral neuropathy is the major dose-limiting toxicity of this therapy. As cure rates of childhood ALL exceeds 80%, therefore treatment-related toxicities need to be reduced. Thus, the aim of this study was to determine the prevalence and risk factors of vincristine-induced peripheral neuropathy (VIPN) in children with ALL undergoing induction chemotherapy. Methods: A case-control study was conducted from September 2017 to August 2018 in the Department of Paediatric Haematology and Oncology at Bangabandhu Sheikh Mujib Medical University, Dhaka, Bangladesh. Eighty newly diagnosed ALL and 35 acute myeloid leukemia (AML) cases aged 5 to 17 years with no pre-existing neurological abnormality were recruited. To assess the peripheral neuropathy, we used pediatric-modified total neuropathy score and National Cancer Institute- Common Terminology Criteria for Adverse Events (NCI-CTCAE), version-04 grade. Results: Among ALL patients, 29.2% developed peripheral neuropathy compared to 10% in AML control group (P=0.04). Higher proportion (57.1%) of peripheral neuropathy was found in age below 10 years (P&lt;0.001). There was no significant association of peripheral neuropathy with sex and body mass index of the patients. Conclusion: Almost 3 in 10 patients developed VIPN during the induction therapy which is significantly higher in age below 10 years compared to ≥ 10 years.

Impact of Frailty Assessment on The Outcome of Acute Myeloid Leukemia in Elderly Patients

Acute myeloid leukemia (AML) is the most common type of acute leukemia in adults. The incidence of AML increases with age. According to the Surveillance, Epidemiology, and End Results Program, over 57% of new cases of AML occur in adults aged 65 years or above (65–74 years: 23.7%; 75–84 years: 22.8%; and >84 years: 10.6%).

Abstract LB122: Arima-HiC sequencing accurately detects clinically-relevant structural variants in pediatric leukemia samples

Abstract Genetic structural variants (SVs), especially those leading to gene fusions, are well-known oncogenic drivers. These SVs can produce overexpression or loss-of-function of certain genes, or generate chimeric fusion proteins. Thus, they serve as important disease biomarkers across several cancers and can also represent therapeutically targetable alterations. Detecting these SVs at a gene-level resolution can be challenging with lower resolution karyotyping approaches, or even RNA sequencing approaches, due to difficulties with culture, sample stability, low transcript abundance, or low-quality RNA. In addition, the ability of fluorescence in situ hybridization (FISH) techniques to detect gene fusions is limited by the targeted nature of these assays as they depend heavily on the design and selection of each probe. Here we use a novel method, Arima-HiC sequencing, that utilizes DNA to evaluate 12 pediatric leukemia samples and determine this assay’s effectiveness in detecting clinically-relevant SVs. We first selected 5 archived (cryopreserved) pediatric acute myeloid leukemia (AML) samples (archival period range: 1-4 years) known to be either fusion-positive (n=3) or fusion-negative (n=2) via prior clinical genetic testing (i.e., chromosomes, FISH, and/or microarray). All samples underwent Arima-HiC sequencing. Briefly, chromatin digestion, end-labeling, and proximity ligation were performed prior to DNA purification per the Arima-HiC protocol. Purified DNA was next prepared as a short-read sequencing library and sequenced on a HiSeq X. The raw reads were aligned and deduplicated, and SVs were called using HiC-Breakfinder software. For a discovery set, we then additionally selected 7 pediatric leukemia samples—6 precursor B-cell acute lymphoblastic leukemias (ALL) and 1 AML—for Arima-HiC sequencing (as above). These cases had undergone standard-of-care cytogenetic (karyotyping, FISH, microarray) and/or molecular (targeted cancer NGS sequencing panel) testing clinically, and a genetic driver/known gene fusion had not been identified. Using Arima-HiC sequencing, we identified the clinically-relevant SV in each of our 3 fusion-positive AML cases, consistent with the original diagnostic cytogenetic finding (n= 1 RUNX1-RUNX1T1 fusion, 1 CBFB-MYH11 fusion, and 1 CBFA2T3-GLIS2 fusion). The 2 fusion-negative AML cases were also negative for structural gene fusions by HiC data. In our discovery sample set, Arima-HiC sequencing was able to find clinically-relevant SVs that were not previously detected in 3 of 6 samples: a KMT2A-MLLT10 fusion was found in an AML case, and a ZNF384-EP300 fusion was found in each of 2 ALL cases. A ABHD17B-PTK2B fusion was found in another ALL case, although ABHD17B may be a novel partner PTK2B and is undergoing validation. Rearrangements involving KRAS and EGFR were detected in the final two ALL cases, and are also undergoing validation. Overall, this study demonstrates how Arima-HiC sequencing can provide diagnostic value in pediatric leukemia specimens via the identification of clinically relevant SVs. Citation Format: Anthony Schmitt, Shadi Melnyk, Kristin Sikkink, Lisa Lansdon, Tomi Pastinen, Erin Guest, Midhat Farooqi. Arima-HiC sequencing accurately detects clinically-relevant structural variants in pediatric leukemia samples [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2023; Part 2 (Clinical Trials and Late-Breaking Research); 2023 Apr 14-19; Orlando, FL. Philadelphia (PA): AACR; Cancer Res 2023;83(8_Suppl):Abstract nr LB122.

Treating low- and intermediate-risk acute promyelocytic leukemia with and without chemotherapy: A comparison in a tertiary care center.

Acute promyelocytic leukemia (APL) comprises approximately 10% of acute myeloid leukemia (AML) cases. Both options of treatment (ATRA-ATO and ATRA-chemotherapy) were discussed with patients with low- and intermediate-risk APL, pros and cons explained in details, and treatment regimen selected after getting informed written consent. Total 71 patients were included in the study; among these patients, 3 were negative for both FISH for t (15,17) and RT-PCR for promyelocytic leukemia retinoic acid receptor alpha, and 36 patients with APL had white blood cell count at diagnosis >10 × 109/l. Total 30 patients with newly diagnosed as low- and intermediate-risk-APL fulfilled all inclusion criteria, treated and followed for a minimum period of 2 years up to June, 2016. Fifteen patients liked to be treated with all-trans retinoic acid (ATRA) and arsenic trioxide (ATO), while rest of the 15 patients preferred treatment with ATRA and chemotherapy. Combination of ATRA and ATO is equally effective, less toxic, and more feasible in comparison to ATRA and chemotherapy for patients with low- and intermediate-risk APL and is a viable option for this subset of patients, especially in countries with limited resources.

Abstract 4009: Discovery of PLM-102, a highly potent 3rd generation FLT3 inhibitor, in drug-resistant FLT3-ITD-TKD mutated acute myeloid leukemia

Abstract Mutations of the FMS-like tyrosine kinase 3 (FLT3) gene occur in approximately 25 ~ 30% of all acute myeloid leukemia (AML) cases and FLT3-ITD mutations are associated with a particularly unfavorable prognosis, with an increased risk of relapse and shorter overall survival (OS) compared with AML patients without the mutation. Even though multiple FLT3 inhibitors are in various stages of clinical evaluation, resistance to FLT3 inhibitors resulting from acquired point mutations in tyrosine kinase domain (TKD) have limited the sustained efficacy of treatments. Among them, a “gatekeeper” mutation (F691L) is resistant to most available FLT3 inhibitors. Here, we show the efficacy and mechanism of PLM-102, developed an orally available and highly selective small molecule, in overcoming drug-resistant FLT3-ITD-TKD mutations as a strong candidate of the 3rd generation of FLT3 inhibitor. PLM-102 displays extraordinary potency of enzyme inhibitory activities of all FLT3 WT/mutants including F691L with IC50 values of &amp;lt;1 nM. In FLT3-ITD-positive cell lines (MV4-11, MOLM-13, MOLM-14, Ba/F3-ITD-D835Y, Ba/F3-ITD-F691L), PLM-102 shows about 18~25-fold higher anti-proliferative activities than Gilteritinib. Also, PLM-102 potently inhibited the phosphorylation of FLT3 and its downstream signaling pathways, and induced apoptosis as evidenced by PARP-cleavage and caspase-3 activation. Moreover, in AML-related xenograft mouse models (MV4-11, MOLM-14, Ba/F3-ITD-D835Y, Ba/F3-ITD-F691L), once-daily oral dose of PLM-102 significantly suppressed the tumor growth and achieved complete tumor regression. In addition, the outstanding efficacy of our compound has been confirmed in large tumor xenograft models. These results are very encouraging because large tumors have a limited blood supply and high interstitial fluid pressure, leading to a poor absorption of anticancer drugs. Pharmacokinetics of PLM-102 displayed higher bone-marrow exposure indicating better target engagement and benefits in the clinical translation in AML. In conclusion, PLM-102 is a promising therapeutic candidate for the FLT3-ITD-mutated AML as well as the acquired resistance to current FLT3 inhibitors. Citation Format: Jin-Hee Park, Jae-Seon Lee, Su-jin Oh, So-Deok Lee, Yong June Choi, Keon Wook Kang, Miran Moon, Soo Yeon Jang, Myung Jin Kim, Yong-Chul Kim. Discovery of PLM-102, a highly potent 3rd generation FLT3 inhibitor, in drug-resistant FLT3-ITD-TKD mutated acute myeloid leukemia. [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2023; Part 1 (Regular and Invited Abstracts); 2023 Apr 14-19; Orlando, FL. Philadelphia (PA): AACR; Cancer Res 2023;83(7_Suppl):Abstract nr 4009.

Abstract 3804: Linear PVT1 isoforms and circPVT1 regulate DNA damage response and immunological pathways in acute myeloid leukemia and have a potential role in the crosstalk between leukemic cells and the tumor microenvironment

Abstract The human Plasmacytoma Variant Translocation 1 (PVT1) gene encodes for 176 linear (PVT1, lncipedia.org) and 29 circular isoforms (circPVT1, www.circbase.org). The most common isoform of circPVT1 is 410bp and is a product of back-splicing containing the whole exon 2 of PVT1 in a closed loop-like structure (hsa_circ_0001821). PVT1 and circPVT1 have oncogenic roles in several tumor types and can contribute to the suppression of anti-tumor immune responses. Our study aims to investigate whether and how PVT1 isoforms and circPVT1 promote an aggressive phenotype in acute myeloid leukemia (AML) and are involved in the crosstalk between leukemic and immune cells. Six out of the 14 PVT1 isoforms expressed by white blood cells and lymphnodes (noncode.org) were detected in a panel of AML cell lines along with circPVT1. Downregulation (KD) of groups of linear isoforms (based on sequence homology) or of circPVT1 by antisense-oligonucleotides (ASOs) in the t(8;21) KASUMI-1 and the NPM1-mut OCI-AML3 cells induced an impairment of leukemia cell growth especially when all the 6 linear isoforms were silenced by ASO combination, in both cell lines, under normoxia and hypoxia mimicking the bone-marrow microenvironment. Interestingly circPVT1-KD induced apoptosis in OCI-AML3 cells. Moreover, MYC protein expression decreased by ASO combination or circPVT1_KD in OCI-AML3 under normoxia and in KASUMI-1 under hypoxia. To further investigate the biological consequences of PVT1/circPVT1-KD, we performed RNAseq. Analysis on AML cell lines revealed that downregulation of PVT1 and, especially circPVT1, altered the expression of genes involved in RNA transport and degradation, as expected for a long non-coding genes, but also in DNA damage response (DDR) and immunological pathways, as also confirmed by transcriptomic data of primary AML cases and proteomic analysis of both cell lines. Based on these novel findings, we tested the downregulation of PVT1/circPVT1 in combination with inhibition of ATM or ATR, key DDR transducers. Interestingly, circPVT1-KD sensitized OCI-AML3 to ATM (71% vs 95% live cells) or ATR (75% vs 90% live cells) inhibitors. PVT1 and circPVT1 expression was also detected at the level of cell-free RNA in primary AML samples, the latter showing higher levels. We then analyzed extracellular vesicles (EVs) from AML peripheral blood and healthy subjects. EVs from patients were larger, increased in number and expressed higher levels of myeloid lineage markers. Finally AML EVs had more circPVT1 cargo. In conclusion, we uncovered novel potential roles of PVT1 isoforms and circPVT1 in the DDR and in the tumor microenvironment that pave the way for novel therapeutic combinations. Citation Format: Martina Ghetti, Lorenzo Ledda, Ivan Vannini, Eugenio Fonzi, Maria Teresa Bochicchio, Tristan Cardon, Andrea Ghelli Luserna di Rorà, Matteo Paganelli, Chiara Servili, Francesco Fabbri, Sabina Marianini, Giovanni Marconi, Michela Rondoni, Roberta Chicchi, Rino Biguzzi, Francesco Lanza, Michel Salzet, Giovanni Martinelli, Giorgia Simonetti. Linear PVT1 isoforms and circPVT1 regulate DNA damage response and immunological pathways in acute myeloid leukemia and have a potential role in the crosstalk between leukemic cells and the tumor microenvironment. [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2023; Part 1 (Regular and Invited Abstracts); 2023 Apr 14-19; Orlando, FL. Philadelphia (PA): AACR; Cancer Res 2023;83(7_Suppl):Abstract nr 3804.

Abstract 3332: Reference materials for the development of assays for the detection of measurable residual disease in acute myeloid leukemia

Abstract The detection of Minimal Residual Disease (MRD) in Acute Myeloid Leukemia (AML) can present a challenge because it can require detecting just several malignant cells within thousands - if not millions - of normal cells. AML is a rare form of cancer that affects blood and bone marrow cells, and AML accounts for ~2 % of all cancer deaths in the United States with a 5-year relative survival rate of ~30 %. Early diagnosis of AML is crucial in determining targeted treatment plans that allow for better prognosis. At that point, tracking the response of AML to a therapy and monitoring for a future relapse becomes important. While nearly half of AML cases contain mutations in either NPM1 or FLT3, nearly half of AML cases appear to have driver mutations in other genes. One of the major challenges associated with the development and validation of assays for MRD in AML is the absence of cell-based reference materials that feature diverse mutations that may be encountered clinically. To begin to address this concern, we developed full process cell-based reference materials that contain a number of mutations, including nucleophosmin (NPM1) c.860_863dup, an FMS-like tyrosine kinase 3 (FLT3) internal tandem duplication (ITD), and SNVs in IDH1 and IDH2. We formulated them at concentrations down to 1 in 100,000 in a background of normal leukocytes. Mutations were quantified by digital PCR assays as well as by a targeted Next Generation Sequencing (NGS) panel. We also prepared similar reference materials in a circulating cell-free DNA (ccfDNA) format and analyzed them similarly. Using digital PCR, we were able to detect the expected mutations in extracted DNA - although reference materials with mutations present in fewer than 1 in 1,000 cells were difficult to analyze using an input of 50 ng of gDNA per sample. Similarly, error corrected NGS data of this gDNA and ccfDNA became challenging to analyze when the mutation-containing cells were present at fewer than 1 in 1,000 cells due to the low frequency of the mutations. Overall, we have generated cell-based and ccfDNA-based reference materials for the development and validation of assays for the detection of MRD in AML. While our own assays were unable to reliably detect the mutations at the lowest concentrations, these materials should be of use for assay developers who are trying to push and establish the sensitivities of their assays. Citation Format: Rajula Elango, Matthew G. Butler, Ojaswee Dahal, Jayanthi Ramprakash, David Merriam, Yves Konigshofer, Russell K. Garlick. Reference materials for the development of assays for the detection of measurable residual disease in acute myeloid leukemia [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2023; Part 1 (Regular and Invited Abstracts); 2023 Apr 14-19; Orlando, FL. Philadelphia (PA): AACR; Cancer Res 2023;83(7_Suppl):Abstract nr 3332.

Optical Genome Mapping in Routine Cytogenetic Diagnosis of Acute Leukemia

Cytogenetic aberrations are found in 65% of adults and 75% of children with acute leukemia. Specific aberrations are used as markers for the prognostic stratification of patients. The current standard cytogenetic procedure for acute leukemias is karyotyping in combination with FISH and RT-PCR. Optical genome mapping (OGM) is a new technology providing a precise identification of chromosomal abnormalities in a single approach. In our prospective study, the results obtained using OGM and standard techniques were compared in 29 cases of acute myeloid (AML) or lymphoblastic leukemia (ALL). OGM detected 73% (53/73) of abnormalities identified by standard methods. In AML cases, two single clones and three subclones were missed by OGM, but the assignment of patients to cytogenetic risk groups was concordant in all patients. OGM identified additional abnormalities in six cases, including one cryptic structural variant of clinical interest and two subclones. In B-ALL cases, OGM correctly detected all relevant aberrations and revealed additional potentially targetable alterations. In T-ALL cases, OGM characterized a complex karyotype in one case and identified additional abnormalities in two others. In conclusion, OGM is an attractive alternative to current multiple cytogenetic testing in acute leukemia that simplifies the procedure and reduces costs.

Analysis of 7 cases of pediatric acute myeloid leukemia with DEK-NUP214 fusion gene

Objective: To investigate the clinical features, treatment regime, and outcome of pediatric acute myeloid leukemia (AML) with DEK-NUP214 fusion gene. Methods: The clinical data, genetic and molecular results, treatment process and survival status of 7 cases of DEK-NUP214 fusion gene positive AML children admitted to the Pediatric Blood Diseases Center of Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Sciences from May 2015 to February 2022 were analyzed retrospectively. Results: DEK-NUP214 fusion gene positive AML accounted for 1.02% (7/683) of pediatric AML diagnosed in the same period, with 4 males and 3 females. The age of disease onset was 8.2 (7.5, 9.5) years. The blast percentage in bone marrow was 0.275 (0.225, 0.480), and 6 cases were M5 by FAB classification. Pathological hematopoiesis was observed in all cases except for one whose bone marrow morphology was unknown. Three cases carried FLT3-ITD mutations, 4 cases carried NRAS mutations, and 2 cases carried KRAS mutations. After diagnosis, 4 cases received IAE induction regimen (idarubicin, cytarabine and etoposide), 1 case received MAE induction regimen (mitoxantrone, cytarabine and etoposide), 1 case received DAH induction regimen (daunorubicin, cytarabine and homoharringtonine) and 1 case received DAE induction regimen (daunorubicin, cytarabine and etoposide). Complete remission was achieved in 3 cases after one course of induction. Four cases who did not achieved complete remission received CAG (aclarubicin, cytarabine and granulocyte colony-stimulating factor), IAH (idarubicin, cytarabine and homoharringtonine), CAG combined with cladribine, and HAG (homoharringtonine, cytarabine and granulocyte colony-stimulating factor) combined with cladribine reinduction therapy, respectively, all 4 cases reached complete remission. Six patients received hematopoietic stem cell transplantation (HSCT) after 1-2 sessions of intensive consolidation treatment, except that one case was lost to follow-up after complete remission. The time from diagnosis to HSCT was 143 (121, 174) days. Before HSCT, one case was positive for flow cytometry minimal residual disease and 3 cases were positive for DEK-NUP214 fusion gene. Three cases accepted haploid donors, 2 cases accepted unrelated cord blood donors, and 1 case accepted matched sibling donor. The follow-up time was 20.4 (12.9, 53.1) months, the overall survival and event free survival rates were all 100%. Conclusions: Pediatric AML with DEK-NUP214 fusion gene is a unique and rare subtype, often diagnosed in relatively older children. The disease is characterized with a low blast percentage in bone marrow, significant pathological hematopoiesis and a high mutation rate in FLT3-ITD and RAS genes. Low remission rate by chemotherapy only and very high recurrence rate indicate its high malignancy and poor prognosis. Early HSCT after the first complete remission can improve its prognosis.

Polymorphisms of the DNA repair genes (APE1, XPD, and RAD51) and the risk of developing cytogenetic abnormalities in a cohort of Egyptian patients with newly diagnosed AML

Abstract Background Genetic alterations of the DNA repair genes might decrease the efficiency of DNA repair mechanisms and increase susceptibility to cancers such as acute myeloid leukemia (AML). Objectives The purpose of the present study was to detect the association of APE1Asp148Glu; rs1130409, XPD Lys751Gln;rs13181 &amp; RAD51 G135C;rs1801320 polymorphisms with the risk of developing abnormal cytogenetics in a sample of newly diagnosed AML Egyptian patients. Methods: The target genetic polymorphisms were determined by polymerase chain reaction and restriction fragment length polymorphism (PCR –RFLP) in 101 AML blood samples comprising 70 cases with normal cytogenetics and 31 cases with abnormal cytogenetics. Results: The genotypic variants of APE1Asp148Glu; rs1130409 polymorphism (T/G,G/G,T/G+G/G) were significantly associated with cytogenetic abnormalities than normal cytogenetics in the studied de novo AML cases {P-0.022,OR:3.463,95%CI:1.199-10.002;P-0.042,OR:3.85,95%CI:1.049-14.124;P-0.01,OR:3.568,95%CI:1.299-9.797}, respectively. The combined APE1 mutants (T/G+G/G) were more likely to be associated with t(15;17){P-value0.02,OR:10.08,95%CI:1.23-82.41}. The association of XPD Lys751Gln combined mutants (A/C+C/C) and RAD1 G135C(G/C+C/C) in AML cases with abnormal cytogenetics were not significantly different from those with normal cytogenetics. Conclusions: APE1Asp148Glu; rs1130409 polymorphism in AML may be associated with the development of favourable cytogenetic abnormalities, especially t(15; 17) .This association might affect AML prognosis but further large sample studies including AML cases with adverse cytogenetics should be performed.

Allogeneic hematopoietic stem cell transplantation in acute leukemia patients with the SET-NUP214 fusion gene: Efficacy and survival analysis

Objective: To investigate the clinical efficacy of allogeneic hematopoietic stem cell transplantation (allo-HSCT) for patients with acute leukemia who are positive for the SET-NUP214 fusion gene (SET-NUP214+AL). Methods: This was a retrospective case series study. Clinical data of 18 patients with SET-NUP214+AL who received allo-HSCT in the First Affiliated Hospital of Soochow University and Soochow Hongci Hematology Hospital from December 2014 to October 2021 were retrospectively analyzed to investigate treatment efficacy and prognosis. The Kaplan-Meier method was used for survival analysis. Results: Of the 18 patients, 12 were male and 6 were female, and the median age was 29 years (range, 13-55 years). There were six cases of mixed phenotype acute leukemia (three cases of myeloid/T, two cases of B/T, one case of myeloid/B/T), nine cases of acute lymphoblastic leukemia (ALL) (one case of B-ALL and eight cases of T-ALL), and three cases of acute myeloid leukemia. All patients received induction chemotherapy after diagnosis, and 17 patients achieved complete remission (CR) after chemotherapy. All patients subsequently received allo-HSCT. Pre-transplantation status: 15 patients were in the first CR, 1 patient was in the second CR, 1 was in partial remission, and 1 patient did not reach CR. All patients were successfully implanted with stem cells. The median time of granulocyte and platelet reconstitution was +12 and +13 days, respectively. With a median follow-up of 23 (4-80) months, 15 patients survived, while 3 patients died. The cause of death was recurrence of SET-NUP214+AL after transplantation. After allo-HSCT, 5 patients relapsed. The estimated 3-year overall survival (OS) and relapse-free survival (RFS) rates were 83.3%±15.2% and 55.4%±20.7%, respectively. Among the 15 patients who achieved CR before transplantation, there was no significant difference in OS and RFS between haploidentical HSCT and matched sibling donor HSCT (all P>0.05). Conclusions: Allo-HSCT can improve the prognosis and long-term survival rate of patients with SET-NUP214+AL. Disease recurrence is the most important factor affecting long-term survival.

Computational analysis of a microRNA signature for poor prognosis suggests a microRNA-controlled stemness pathway in paediatric acute leukaemia.

Esperanza-Cebollada E., et al. found a group of 24 microRNAs, to be differentially expressed between two groups of paediatric acute myeloid leukaemia (AML) cases with distinct outcomes. The main target of this microRNA signature is SOCS2, a gene that controls stemness. The results of this study may open doors for further investigation of the role for microRNAs in poor prognostic paediatric AML. Commentary on: Esperanza-Cebollada et al. A miRNA signature related to stemness identifies high-risk patients in paediatric acute myeloid leukaemia. Br J Haematol 2023;202:96-110.

Characteristics and clinical outcomes of patients with acute myeloid leukemia with inv(3)(q21q26.2) or t(3;3)(q21;q26.2).

Acute myeloid leukemia (AML) with inv(3)(q21q26.2)/t(3;3)(q21;q26.2) has a very poor prognosis. Determinants of clinical outcomes and optimal treatment remain uncertain. We retrospectively reviewed 108 cases of AML with inv(3)/t(3;3) and evaluated clinicopathological characteristics and clinical outcomes: 53 newly diagnosed (ND) AML and 55 relapsed/refractory (R/R) AML. Median age was 55 years. White blood cell (WBC) count ≥20x109/L and platelet count ≥140x109/L was observed in 25% and 32% of ND patients, respectively. Anomalies involving chromosome 7 were identified in 56% of patients. The most frequently mutated genes were SF3B1, PTPN11, NRAS, KRAS and ASXL1. In ND patients, the composite complete remission (CRc) rate was 46% overall; 46% with high-intensity treatments and 47% with lowintensity treatments. The 30-day mortality was 14% and 0%, with high- and low-intensity treatment, respectively. In R/R patients, the CRc rate was 14%. Venetoclax based-regimens were associated with a CRc rate of 33%. The 3-year overall survival (OS) was 8.8% and 7.1% in ND and R/R patients, respectively. The 3-year cumulative incidence of relapse was 81.7% overall. Older age, high WBC, high peripheral blast count, secondary AML and KRAS, ASXL1, DNMT3A mutations were associated with worse OS in univariable analyses. The 5-year OS rates were 44% and 6% with or without hematopoietic stem cell transplantation in CR1, respectively. AML with inv(3)/t(3;3) is associated with low CR rates, very high risk of relapse and dismal long-term survival. Intensive chemotherapy and hy pomethylating agents provide similar rates of remission and patients achieving CR benefit from hematopoietic stem cell transplantation in first CR.

Expression of DR4, DR5, FAS, Caspase-8 and, DDIAS Genes in AML Patients.

Acute myeloid leukemia (AML) is the most common acute leukemia in adults and accompanies a worse survival. In this study, gene expression levels of 5 key players of apoptosis, including DR4, DR5, FAS, caspase 8, and DNA damage-induced apoptosis suppressor (DDIAS), have been evaluated in AML patients compared with controls, aiming to evaluate their possible role and prognostic impact. This cross-sectional study was performed in the Cancer Molecular Pathology Research Center, Mashhad University of Medical Sciences. A total of 30 newly diagnosed AML cases as well as 30 healthy controls enrolled in the study. Real-time polymerase chain reaction was used to evaluate the expressions of DR4, DR5, FAS, DDIAS, and caspase 8 genes in cases and controls. Other necessary data, including cytogenetic findings, mutations, French-American-British (FAB) classification, and survival, were retrieved from hospital records and by direct contact with patients. Statistical analysis was done by SPSS software. When appropriate, the Mann-Whitney U, Pearson's correlation, and the t tests were utilized. Overall survival (OS) was estimated using the Kaplan-Meier method. The expression of all evaluated genes, including DDIAS (0.89 ± 0.20), DR4 (0.67 ± 0.24), DR5 (0.72 ± 0.24), FAS (0.70 ± 0.25), and Caspase 8 (0.77 ± 0.20) were significantly decreased in AML patients compared with the controls (P < 0.001). Patients with the t (16;16) or inv (16) expressed significantly higher amounts of the FAS gene and those with FLT3 mutation exhibited lower expression of caspase 8. Expression of the evaluated genes showed no significant effect on survival. The expression of DR4, DR5, FAS, and caspase 8 seems to be decreased in AML. Lower expression of these molecules may aid AML cells in avoiding apoptosis because they are involved in the initiation of apoptosis, making them potential targets for treatment.

Smoking status in acute myeloid leukemia is associated with worse overall survival and independent of prior nonhematopoietic malignancies, cytogenetic abnormalities, and WHO category

Acute myeloid leukemia (AML) is an aggressive hematopoietic malignancy with several patient- and disease-associated variables known to impact prognosis. Tobacco smoking is an environmental factor associated with a greater incidence of AML, but there have been limited studies that evaluated smoking toward overall survival. We retrospectively searched for AML cases and collected clinical and diagnostic data for each case. We also used an independent next-generation sequencing (NGS) data set to assess for a distinct mutational signature associated with smoking. When stratified by smoking status, there was a greater number of males, patients aged ≥60 years, and patients with ≥2 comorbidities within the smoking category (P<.05). Survival analysis demonstrated decreased survival probability in the smokers, male smokers, smokers with 1 other comorbidity, and smokers without a prior history of nonhematopoietic malignancy (P<.05) as compared to nonsmokers. Smoking was associated with a decrease in survival within the World Health Organization categories of AML, not otherwise specified (AML NOS; P=.035) and AML with recurrent genetic abnormalities (AML RGA; P=.002). Multivariate analysis showed that patients who were smokers had a greater hazard ratio than nonsmokers after adjusting for the other covariates. Our findings demonstrated that smoking was independently associated with decreased overall survival after adjusting for other potentially confounding factors. In addition, our results suggest that a mutational signature can be recognized using NGS data in a subset of AML patients who smoke.

Case report: Sustained complete remission with ivosidenib in a patient with relapsed, IDH1-mutated acute leukemia

Older patients with acute lymphoblastic leukemia (ALL) have a poor prognosis, with a 5-year overall survival rate of only 10%–20%. This is attributable to patient comorbidities, poor performance status, and high-risk disease biology. The prognosis for patients with relapsed/refractory (R/R) disease remains poor, particularly for patients who are not candidates for therapies targeting CD19 or CD22. Additional treatment options are needed for these patient populations. The patient presented here is a 76-year-old man diagnosed with precursor B-cell ALL with aberrant expression of myeloid markers and lacking significant CD19 or CD22 expression. A 3-year remission was achieved with one cycle of CVP (cyclophosphamide, vincristine, and prednisone) followed by 22 months of maintenance DOMP (dexamethasone, vincristine, methotrexate, and 6-mercaptopurine) prior to relapse. He was then treated with one cycle of salvage CVP, which was complicated by a stroke resulting in hemiparesis. Next-generation sequencing (NGS) was performed on the relapsed bone marrow, which revealed the presence of an R132H mutation in the isocitrate dehydrogenase 1 (IDH1) gene. He was subsequently treated with the IDH1 inhibitor ivosidenib and remained in a second remission for nearly 1 year. IDH1 mutations are present in up to 14% of acute myeloid leukemia (AML) cases but are also seen more rarely in ALL, particularly in cases involving aberrant expression of myeloid markers. Ivosidenib has demonstrated efficacy in patients with IDH1-mutated AML but has not been extensively studied in other hematologic malignancies. This case demonstrates the role of NGS in revealing treatment options in patients with otherwise limited available therapies.

Comparison of DNA Sequencing and Multispecific Monoclonal Antibody (Msmab-1) based Immunohistochemical Detection of IDH1/2 Mutation in Acute Myeloid Leukemia Cases.

Background: The IDH1/2 mutation is an important epigenetic modifier involved in the pathogenesis of AML. It is associated with variable prognosis in AML cases. Lack of proper molecular diagnostic infrastructure and high cost limits the routine use of PCR with sequencing as routine diagnostic methodology. The aim of this study was to find the prevalence of IDH mutation in AML cases using both PCR with sequencing and Immunohistochemistry method.&#x0D; Methods: We evaluated 60 patients registered at KGMU, Lucknow for diagnosis and treatment of AML. PCR followed by sequencing was done. IHC staining of the IDH1/2 mutation was performed on all cases using bone biopsy or clot section (in cases of pediatric AML cases).&#x0D; Results: Out of the total 60 patients of AML 4(6.7%) patients had IDH1R312 mutation and 5(8.3%) Patients had IDH2R172 mutation. IDH2 R140 mutation was not detected in any sample. On immunohistochemistry analysis 10 cases showed positive staining against anti IDH1/2 mutant (R132/R172) antibody, clone MsMab-1 with a sensitivity of 77.8% and specificity of 94.1%.&#x0D; Conclusion: IHC could be an alternative method to direct Sanger sequencing for IDH1/2 mutation detection in AML cases. However, the antibody used in the study is not effective for individual assessment of IDH1 and IDH2 mutation.&#x0D; Keywords: Immunohistochemistry, Sanger sequencing, IDH1/2 Mutation, Acute Myeloid Leukemia

Unexpected diagnosis in not so usual clinical scenarios: Acute promyelocytic leukemia – A tertiary care hospital experience

Background: Acute promyelocytic leukemia (APL) is a distinct subtype of Acute myeloid leukemia (AML) with arrest in maturation of cells of myeloid series in bone marrow. PML-RARA fusion resulting from t(15;17) translocation forms the genetic basis of this haematological malignancy. Introduction of specific differentiating targeted therapy i.e. All-trans retinoic acid (ATRA) have remarkably improved the outcome of this previously dreaded AML. Aims and Objective: The current study presents five cases of Acute promyelocytic leukemia with unusual presentations followed by effective treatment to revert their adverse outcome. Materials and Methods: In this retrospective evaluation of Acute Myeloid leukemia cases, five cases were included from duration of November 2019 to November 2021. The diagnosis of AMLs was made according to EGIL 1998/WHO 2016 guidelines. Peripheral blood (PB) and bone marrow aspirate (BMA) were stained with Giemsa and cytochemistry included myeloperoxidase (MPO) and periodic acid-schiff (PAS). Results: Five color flowcytometric analyses were performed on BMA and PB samples. Chemotherapy was administered in the patients and follow-up was done. 03/05 patients faced mortality due to rapid disease progression. Conclusion: The fast track clinical course from presentation to the outcome of APL is dreadful for the treating clinician and the heamatopathologist. Cytomorphology and Cytochemistry are as important in rapid recognition of APL as Immunophenotyping and Cytogenetics for establishing accurate diagnosis.

Oncogenic FLT3 internal tandem duplication activates E2F1 to regulate purine metabolism in acute myeloid leukaemia

Oncogene FLT3 internal tandem duplication (FLT3-ITD) mutation accounts for 30 % of acute myeloid leukaemia (AML) cases and induces transformation. Previously, we found that E2F transcription factor 1 (E2F1) was involved in AML cell differentiation. Here, we reported that E2F1 expression was aberrantly upregulated in AML patients, especially in AML patients carrying FLT3-ITD. E2F1 knockdown inhibited cell proliferation and increased cell sensitivity to chemotherapy in cultured FLT3-ITD-positive AML cells. E2F1-depleted FLT3-ITD+ AML cells lost their malignancy as shown by the reduced leukaemia burden and prolonged survival in NOD-PrkdcscidIl2rgem1/Smoc mice receiving xenografts. Additionally, FLT3-ITD-driven transformation of human CD34+ hematopoietic stem and progenitor cells was counteracted by E2F1 knockdown. Mechanistically, FLT3-ITD enhanced the expression and nuclear accumulation of E2F1 in AML cells. Further study using chromatin immunoprecipitation-sequencing and metabolomics analyses revealed that ectopic FLT3-ITD promoted the recruitment of E2F1 on genes encoding key enzymatic regulators of purine metabolism and thus supported AML cell proliferation. Together, this study demonstrates that E2F1-activated purine metabolism is a critical downstream process of FLT3-ITD in AML and a potential target for FLT3-ITD+ AML patients.