AML Protocols Research Articles

Twenty-year follow up on the importance of diagnostic cytogenetics on outcome in children treated as per UKMRC AML protocol

Twenty-year follow up on the importance of diagnostic cytogenetics on outcome in children treated as per UKMRC AML protocol

CT-282 Case Report: Successful Management of Severe Veno-Occlusive Disease after Allogeneic Stem Cell Transplantation Using a Transjugular Intrahepatic Portosystemic Shunt

Veno-occlusive disease (VOD), also called sinusoidal obstruction syndrome (VOD/SOS), of the liver is a complication of allogeneic bone marrow or peripheral stem cell transplantation and is known to be an unpredictable, life-threatening complication with high mortality. We report here a case of a 24-year-old male patient who was diagnosed in 2019 at Gustave Roussy institute with AML. The patient was treated with the AML protocol 3+7 in December 2019 with a complete cytologic response and a positive MRD. Leukemia relapse was observed in September 2020, treated by gemtuzumab ozogomycin and cytarabine with a negative MRD. A successful allogeneic bone marrow transplantation from an HLA-matched pheno-identical related donor was conducted on December 22, 2020, using a myeloablative conditioning regimen. The patient was always controlled by a daily blood test and controlled blood transfusions, and a weekly repeated Doppler ultrasound examination did not indicate a high-risk profile of VOD. However, 12 days post transplant, the patient's condition deteriorated with the appearance of abdominal ascites, weight gain of 6 kg (per base 76 kg), and liver cytolysis with ASAT 72 UI/L, ALAT 86 UI/L, and normal bilirubin. Worsening cytolysis was observed, with ASAT 659 UI/L, ALAT 557 UI/L, and normal bilirubin. A Doppler ultrasound found 5 positive criteria of VOD (hepatomegaly, portal dilation, enlargement of the gall bladder wall, splenomegaly, ascites, decrease in the diameter of the subhepatic veins). Defibrotide was initiated. The patient's condition worsened and was refractory to medical therapy. Transjugular intrahepatic portosystemic shunting (TIPS) was performed 13 days after transplantation without technical complications in any case. The median hepatic venous pressure gradient prior to the procedure was 20 mmHg with a drop to 12 mmHg. An abdominal CT scan showed an under hepatic hematoma with hemorrhagic syndrome. Ascites puncture with abdominal drain installation was done. In summary, following TIPS, the patient showed clinical improvement, and VOD resolved subsequently with a complete remission post allogeneic transplant.

Outcomes of Chronic Myelomonocytic Leukemia (CMML) after Hypomethylating Agent (HMA) Failure

Outcomes of Chronic Myelomonocytic Leukemia (CMML) after Hypomethylating Agent (HMA) Failure

Allogeneic Stem Cell Transplantation Has Limited Benefit in Older Patients with Mixed Phenotype Acute Leukemia

Mixed phenotype acute leukemia (MPAL) is a high risk leukemia that has markers of both myeloid and lymphoid lineage. The role of hematopoietic stem cell transplantation (alloHSCT) remains uncertain especially in the older population. We sought to evaluate the outcomes of our cohort of MPAL patients who were transplanted, including older adults unfit for MAC compared with the outcomes of patients who were consolidated with chemotherapy only. <b>Methods:</b> 74 patients aged 18 years or older, at the Princess Margaret Cancer Centre between January 1, 2000 and December 31, 2018 were evaluated. <b>Results:</b> Among the 74 MPAL patients included in this study, 59 (79%) received induction. Complete remission (CR) was achieved in 47 (79%) treated patients. 25 of 36(80%) achieved a CR using ALL protocols, while 9 of 23 (39%) achieved a CR using AML protocols. Consolidation treatment post CR was split, with 24(51%) receiving chemotherapy followed by an alloHSCT and 23 (49%) receiving chemotherapy only. In the alloHSCT group, RIC was used in 20 (81%) patients while MAC was used in four younger patients. The median age of the transplant cohort was 50 years with a median OS of 21 months. In the chemotherapy only group, the median age was 57 with a median OS of 18 months. Univariate analysis demonstrated no difference in outcomes in terms of age, induction chemotherapy, donor source, and conditioning intensity. The sole predictor of poor OS on univariate analysis was acute graft versus host disease (aGVHD) with a hazard ratio of 3.3 (95% CI 0.9-11). In total, 12 patients (50%) had aGVHD with a median OS of 16 months. However, when Grade 1/2 and Grade 3/4 aGVHD were compared, median OS was not reached in patients with G1/2, compared with an OS of 11 months in those patients with G3/4 aGVHD. Post-transplant relapses occurred solely in the RIC group and occured early. Although, there were no relapses in the MAC group, the non-relapse mortality (NRM) was 75% compared to 18% in the RIC group. The 3 year OS and relapse free survival (RFS) for the entire cohort was 30% and 32%, respectively. When comparing those who had undergone alloSCT and those who received chemo alone, survival in the two groups were similar with a 3 year OS of 29% vs 32% and the 3 year RFS at 29% and 34%, respectively. Subgroup analysis between the two groups was performed for patients with specific poor prognostic factors (older age, complex cytogenetics, higher WCC, conditioning regimen used), but results showed no significant survival differences. <b>Conclusions:</b> Older patients with MPAL have an inferior prognosis and worse outcomes with alloHSCT compared with those of younger adults or children. Despite the increase in access to alloHSCT and an expanding pool of alternative donors, outcomes with RIC remain similar to consolidation with chemotherapy alone. There may be some evidence to suggest that the graft versus leukemia effect can be harnessed to improve outcomes in selected patients.

Allogeneic Stem Cell Transplantation Has Limited Benefit in Older Patients with Mixed Phenotype Acute Leukemia

Allogeneic Stem Cell Transplantation Has Limited Benefit in Older Patients with Mixed Phenotype Acute Leukemia

Predicting Induction Toxicity with 7+3: Analysis of SWOG Trial S1203

Background: Prior work has shown that multivariable models can have reasonably high accuracy in predicting early deaths (deaths within 28 days of starting induction, defined as treatment-related mortality [TRM]) following intensive AML chemotherapy. These models can be used to derive a TRM score reflective of the probability of TRM with intensive AML therapy, and such scores can be used to make informed treatment decisions and as explicit eligibility criteria in AML protocols. The degree to which non-fatal toxicities can be predicted is unknown. It is also not known which patient characteristics are most strongly associated with occurrence of non-fatal toxicities following induction chemotherapy. Here, we examined these questions using data from the most recent SWOG Phase III with a 7+3 arm.Patients and Methods: We analyzed 260 eligible patients randomized to the 7+3 arm SWOG trial S1203 who received the first cycle of protocol therapy. 7+3 was per contemporary standard when the trial was opened in 2012: 100mg/m2 cytarabine on days 1-7 and 90mg/m2daunorubicin on days 1-3. Toxicities were reported using CTCAE version 4.0. We used logistic regression models to model toxicity incidence and evaluated the predictive accuracy of the models with the area under the receiver operating characteristic curve (AUC). We note that AUC of 0.5 is what would be expected with random chance or using a coin flip to make a decision, while an AUC of 1 denoted perfect prediction. We evaluated the following baseline covariates (modeled quantitatively unless otherwise specified): age at study registration, gender, Zubrod performance status (0-1 versus 2-3), pre-study white blood cell counts (WBC), pre-study platelets, pre-study marrow blasts, secondary vs. de novo AML, cytogenetic risk, and NPM1+ and FLT3-ITD- versus other NPM1/FLT3-ITD status. For toxicities with lower incidence, the number of covariates included in multivariable models was proportionate to one covariate per 10-15 patients with a toxicity. Toxicities were reported using the contemporary CTCAE version 4.0. Only toxicities observed during the first cycle of induction are analyzed below.Results: We evaluated the incidence grade 3 or higher thrombocytopenia (n=180, 70%), infection (n=166, 64%), anemia (n=159, 61%), neutropenia (n=145, 56%), lymphopenia (n=92, 35%), electrolyte abnormalities (n=66, 25%), liver abnormalities (n=37, 14%), cardiovascular abnormalities (n=20, 8%), constitutional symptoms (n=19, 7%), skin abnormalities (n=18, 7%), mucositis (n=17, 7%), GI tract abnormalities (n=16, 6%), pulmonary abnormalities (n=14, 5%), pain (n=13, 5%), endocrine abnormalities (n=12, 5%), bleeding (n=12, 5%), neurologic abnormalities (n=10, 4%), nausea/vomiting (n=7, 3%), kidney abnormalities (n=4, 2%).In univariate models no individual covariate was a strong predictor of toxicity. Only 3 pairs of toxicity/covariate had an AUC > 0.65 [indicating modest predictive ability]: older age predicting increased risk of endocrine abnormalities (OR=1.08 [per year], p=0.06, AUC=0.67), higher baseline WBC predicting increased risk for bleeding (OR=1.26 per 1,000, p=0.36, AUC=0.67), and higher baseline HGB predicting increased risk of neurologic toxicity (OR=1.33 per g/dL, p=0.10, AUC=0.69).As incidence allowed, we evaluate multivariable models. Multivariable models had increased AUC compared to univariate models, but no multivariable model had an AUC larger than 0.70.Conclusion: These findings indicate that with the baseline covariates evaluated, we have a poor ability to predict commonly occurring grade 3 and higher toxicities that occur during the first cycle of 7+3 induction therapy for AML. These findings support the claim that randomization is necessary to compare toxicities between standard and investigational regimens. Moreover, assuming that trial eligibility criteria are often stringent in an attempt to minimize the occurrence of treatment toxicities in study participants, the lack of strong association between individual baseline characteristics and toxicities could be used to argue for less-stringent study inclusion criteria.Support: NIH/NCI grants CA180888 and CA180819 [Display omitted] DisclosuresWalter:Aptevo Therapeutics, Inc: Consultancy, Other: Clinical Trial Support, Research Funding; Amphivena Therapeutics, Inc: Consultancy, Other: Clinical Trial Support, Research Funding; Covagen AG: Consultancy, Other: Clinical Trial Support, Research Funding; Seattle Genetics, Inc: Consultancy, Other: Clinical Trial Support, Research Funding; Pfizer, Inc: Consultancy; Amgen Inc: Other: Clinical Trial Support, Research Funding; Actinium Pharmaceuticals, Inc: Other: Clinical Trial support , Research Funding; Boehringer Ingelheim Pharma GmbH & Co. KG: Consultancy.

Effects of intensive induction and consolidation chemotherapy with idarubicin and high dose cytarabine on minimal residual disease levels in newly diagnosed adult precursor-B acute lymphoblastic leukemia.

An intensive induction regimen, consisting of idarubicin and high dose cytarabine, was assessed in 19 adult patients, median age 44 years, with newly diagnosed precursor-B acute lymphoblastic leukemia (ALL). Patients achieving a complete response (CR) were given an attenuated consolidation course. The primary endpoints were induction death rate and incidence of serious non-hematological toxicity. Grades 3–4 diarrhoea occurred in 47% of patients during induction. Two patients (11%) died during induction therapy, and 2 were withdrawn due to resistant disease or prolonged marrow hypoplasia. Fifteen patients achieved CR (79%), but levels of minimal residual disease (MRD) after induction were comparable with those previously observed using a modified pediatric protocol. Overall survival at 5 years was 36.8% while leukemia-free survival was 44.1%. An intensive AML protocol used in adults with ALL resulted in substantial toxicity and provided similar levels of cytoreduction to conventional ALL protocols, without improving long-term outcomes.

Massive Thrombosis of the Right Atrium Extended to the Superior Vena Cava at the Diagnosis of Acute Myeloid Leukemia.

Introduction. Venous thromboembolic disease is a common complication found in 8% of patients with acute myeloid leukemia. The location at the right atrium is exceptional. These last fifty years, only 6 cases of thrombosis of the atrium in the diagnosis of acute myeloid leukemia were published on PubMed search engine. Case Presentation. 35-year-old farmer, who had been admitted by emergency department for superior vena cava syndrome and had a hyperleukocytic AML with complex karyotype associated with a significant thrombosis of the right atrium, extended all along the superior vena cava. He has been treated by the 2011 AML protocol using low molecular weight heparin and died from respiratory distress. Conclusions. If thrombosis is common in AML, the location in right atrium is rare. Its management requires surgery that is sometimes difficult to achieve.

MRD-Based Strategy without Myeloablative Transplantation for AML in Children

Background. For the purpose of increasing survival rate and minimizing early and late toxicities, we conducted a clinical study of an individualized treatment of AML in children between Jun/2002 and September/2014. Minimal residual disease (MRD)-based stratification was employed in this study, and patients in the high-risk group underwent allogeneic hematopoietic stem cell transplantation (HSCT) following reduced-intensity conditioning (RIC). This study was following our previous studies of a basic research on MRD in 1990s, and an early multi-center study between Feb/1999 and May/2002 [Miyamura T, et al. IJH 79: 243-249, 2004].Methods. The main eligibility criteria were as follows: children with newly diagnosed de novo AML (excluding FAB M3), and with written informed consent obtained by the patients' guardians and the patients if aged 16 years or more. The main exclusion criteria were children with organ failure, and with uncontrolled infections. The treatment consisted of one induction chemotherapy and 5 courses of consolidation chemotherapy originating from the AML99 protocol [Tsukimoto I, et al. JCO 27: 4007-4013, 2009]. Patients with Down syndrome were treated with a dose-reduced protocol.WT1 mRNA in PB, WT1 mRNA in BM, and chimeric-gene mRNA in BM were measured as MRD markers by quantitative RT-PCR. MRD was assessed at every hematopoietic recovery after course of chemotherapy. Patients were categorized into 5 groups: (a) non-complete remission (non-CR; blast cells >= 5% in BM) after the induction therapy, (b) MRD positive after 1st consolidation therapy, (c, d) MRD negative after 1st consolidation, and (e) patients without any MRD markers available. The patients whose MRD became negative after the 1st consolidation were divided into two: (c) reemerging MRD after 2nd consolidation or later, and (d) continuously negative for MRD. Patients in categories (a), (b) and (c) underwent allogeneic RIC-HSCT (with one exception of myeloablative conditioning (MAC)). HLA-haploidentical HSCT was performed for the patients in (a). MRD monitoring was finished with a negative result for MRD after the last course of consolidation in the group of (d).Results. Enrolled patient number was 35. A median age at diagnosis was 2 years old (range; 2 months - 20 years old). Three patients were stratified in the group of (a), 12 in (b), 4 in (c), 10 in (d), and 6 in (e). Eighteen patients (51.4%) underwent allogeneic HSCT. Five-year EFS (5y-EFS) was 77.9+/-7.4%, and 5y-OS was 86.0+/-6.6%, with 7.0 years of an median observation period (range; 0.7-12.6 years). Among non-Down syndrome patients (n = 29), 5y-EFS was 77.7+/-8.1%, and 5y-OS was 87.5+/-6.9%. RIC seemed to work, as resulted in a 5y-EFS 75.4+/-12.6% (2 relapses and 1 non-relapse mortality) and a 5y-OS 77.9+/-14.1% in all patients who underwent HSCT (excluding group (a)).Discussion. It has already reported that the AML99 protocol, which did not employ MRD-based stratification, resulted in a 5y-EFS 61.6% and a 5y-OS 75.6%. Although direct comparison of our presenting strategy and the AML99 protocol cannot be carried out mainly because ours was conducted one decade later and time-event data was missing in the AML99 report for log-rank test, our strategy may contribute to shortening the treatment period and increasing the 1st continuous CR rate. In addition, RIC potentially contributes to reducing late complications [Shimizu M, et al. BMT 47: 141-142, 2012]. In the AML99 study 18.1% (41/227) received allogeneic MAC-HSCT in 1st CR, and 32.2% relapsed in total [2]. Therefore, RIC-HSCT in the present study seems to be comparable with those of MAC-HSCT.Conclusion. Our strategy of MRD-based stratification and RIC-HSCT for childhood AML may provide a promising platform for further study. DisclosuresNo relevant conflicts of interest to declare.

Description and Management of Accelerated Phase and Blast Crisis in 21 CML Pediatric Patients

Introduction: Philadelphia-positive chronic myelogenous leukemia (CML) is a rare disease in children and constitutes approximately 3-5% of all childhood leukemias. With tyrosine kinase inhibitors (TKI), the frequency of accelerated phase (AP) or blast crisis (BC) is remarkably reduced, estimated to 1% to 1.5% per year in adults compared with more than 20% per year in the pre-TKI era. But no data are available among children.Purpose: We described the characteristics, the treatment and the outcome of 21 children with CML, who evolved in accelerated phase and/or blast crisis under TKI.Results: From 2001 to april 2015, 415 European patients were enrolled in the CML pediatric database. Twenty-one patients (5.1%), in chronic phase (CP) treated by TKI, presented AP or BC.The median age of AP/BC cohort was 13.2 years (range: 4.5-16.9 years) with a sex ratio M/F at 2. At CML diagnosis, 15 patients (71%) had high risk Sokal Score with a median score of 1,4 (range: 0,16-2,4). All patients harbored t(9;22)(q34;q11) but one had a complex translocation t(1;9;22)(q12;q34;q11) and another one presented additional inv(3)(q21q26). Imatinib was the first line TKI for all patients. Before AP or BC, only five patients (24%) obtained a complete cytogenetic response (CCyR) and three achieved MMR. For incomplete molecular response or progression to accelerated phase, 8 patients (38%) were switched to dasatinib. Median duration of TKI before AP or BC was 11 months (range: 3 months-56.5 months). Six patients evolved to AP with a median interval of 8.7 months (range: 1 months-24 months), leading to blast crisis for 4 patients with a median time of 3.5 months (range: 0.3-5.4 months). Among the 2 patients remaining in AP, imatinib was increased for one and the other was switched for dasatinib, all before hematopoietic stem cells transplantation (HSCT). One patient died of post-transplant complication and the other one is still alive in complete molecular response without TKI. Nineteen patients presented BC, including 4 after AP. Thirteen patients (62%) presented ALL, five (24%) AML and one a bi phenotypic leukemia. Central nervous system (CNS) was involved for two patients with ALL, one isolated, one combined. At AP or BC, nine patients (43%) presented new additional cytogenetic abnormalities. Eighteen patients with BC were treated according to AML or ALL protocols, combined with second generation TKI for twelve patients. Only one patient underwent preparative regimen, without intensive chemotherapy before HSCT. Ten patients reached complete remission. Four patients died before HSCT, by progressive disease for 2 and by fatal infection for 2. Overall, 15 patients in BC were transplanted. Before HSCT, median molecular response was 0.2% (range: 0-29%) and only four patients had a complete molecular response. After transplant, seven patients received second generation TKI. Four patients died, including three related to transplant toxicity. Thirteen patients were alive, but one with ALL BC relapsed 26 months post-transplant and was waiting for second HSCT. With a median follow-up of 4.4 years, 4-year overall survival was 59% (66% for ALL BC versus 40% for AML BC).Conclusion: Incidence of AP/BC after imatinib for CP CML is at 5%, in the CML pediatric database. Despite second generation TKI, combined with HSCT, outcome remains poor. Post-transplant indication of TKI is heterogenic. Recommendations would be useful for practice. [Display omitted] DisclosuresSuttorp:Novartis, Bristol Meyer Squib: Honoraria, Membership on an entity's Board of Directors or advisory committees, Research Funding.

FLT3, NPM1 and CEBPA Mutations in 195 Children with Acute Myeloid Leukemia in Argentina

Background: Mutations of FLT3, NPM1 and CEBPA are found in 25 to 35% of adult-AML. These mutations correlate with outcome, especially in AML with normal karyotype. There are few reports concerning the incidence and prognostic significance of these mutations in childhood-AML and there is no data from Argentina.Objectives: To describe the prevalence of FLT3, NPM1 and CEBPA mutations and to analyze the prognostic impact in the outcome in our setting.Methods: Samples from 195 children treated with AML protocols were retrospectively analyzed. The mean age at diagnosis was 6.8 [0.0-17.9] years, including 65 patients younger than 2 years of age. FAB subtypes were M2: 18%, M3: 15%, M4: 12%, M5: 34%, M6: 3%, M7: 10%, while 16 cases (8%) disclosed an ambiguous lineage immunophenotype. Genetic abnormalities of AML cases were characterized by cytogenetic analysis (97%) and/or RT-PCR for AML1-ETO, CBFB-MYH11, PML-RARA, MLL-AF4, MLL-AF9, MLL-ENL and MLL-AF10 fusion transcripts (95%). The distribution of the genetic abnormalities was: AML1-ETO: 11%, PML-RARA: 15%, CBFB-MYH11: 6%, MLL/11q23: 23%, other abnormalities: 25% and normal karyotype: 16%. Detection of NPM1 and CEBPA mutations was performed by Gene-scanning; FLT3-ITD and FLT3-TKD were studied by RT-PCR and RFLP respectively. Positive cases were further characterized by sequencing analysis.Results: The prevalences of the studied mutations were: FLT3-ITD: 10.3%, FLT3-TKD: 8.2%, NPM1mut: 4.6% and CEBPAmut: 2.1%. Within the group of AML with normal karyotype the incidences were: FLT3-ITD: 12.5%, FLT3-TKD: 6.3%, NPM1mut: 25.0% and CEBPAmut: 12.5%. The mean age for each subgroup was: FLT3-ITD: 14 years, FLT3-TKD: 9 years, NPM1mut: 12 years and CEBPAmut: 12 years. Simultaneous presence of FLT3-ITD and NPM1 mutations was detected in 2 cases while 1 patient disclosed both FLT3-TKD and CEBPAmut. FLT3-ITD and FLT3-TKD showed significant association with the presence of PML-RARA (p<0.00001 and p=0.055 respectively). Eight out of nine patients with NPM1mut and 4/4 patients with CEBPAmut were AML with normal karyotype. The FAB subtypes more frequently observed for each subgroup were: FLT3-ITDmut: M3 (n:10/20; p<0.00001), FLT3-TKDmut: M5 (n:8/16; p=n.s.), NPM1mut: M2 (n:4/9; p=0.062) and CEBPAmut: M2 (n:3/4; p=0.019). The mean ages of patients with FLT3-ITDmut, NPM1mut and CEBPAmut were significantly higher (p<0.00001, p=0.006 and p=0.033, respectively). FLT3-TKD was the only mutation detected in 5/45 (11%) of patients younger than 1 year of age. The five-years leukemia-free survival probabilities (pLFS) and standard error (SE) were: Total AML: 49 (4)%, FLT3-ITDmut:68 (12)%, FLT3-TKDmut:46 (17)%, NPM1mut: 75 (15)%, CEBPAmut: 100 (0)% and NPM1mut/CEBPAmut/FLT3-ITDneg: 83 (15)% (p<0.00001). The pLFS (SE) of patients with normal karyotype and FLT3-ITDneg and NPM1mut or CEBPAmut was 88 (12)% (p=0.066).Conclusions: This is the first report of the frequencies of FLT3, NPM1 and CEBPA mutations in childhood AML in our country. The incidences of NPM1mut and CEBPAmut were significantly higher in AML with normal karyotype. Our data confirm the favorable prognosis of AML with NPM1mut/FLT3-ITDneg and CEBPAmut/FLT3-ITDneg genotypes, especially in cases with normal karyotype. The present results support the notion that this group should be considered as a new AML subset with better outcome. This group of AML patients with better outcome could be included in the standard risk group, thus avoiding intensive treatments and related toxicity. DisclosuresNo relevant conflicts of interest to declare.

Anthracycline Type during Induction Associated with Outcome in Pediatric t(8;21) and Inv(16) AML

Background. The core-binding factor AMLs, t(8;21)(q22;q22), AML1-ETO or RUNX1-RUNX1T1 and inv(16)(p13q22), CBFB–MYH11, are considered as favorable risk factors in AML with superior event-free survival (EFS) and overall survival (OS). However, within the AML protocol from the Nordic society of pediatric hematology/oncology (NOPHO) from 2004 we observed a decrease in EFS for t(8;21) AML.Material. We analyzed all children with t(8;21) or inv(16) treated on NOPHO-AML 93 and NOPHO-AML 2004 from Denmark, Finland, Iceland, Norway, and Sweden from 1993 to 2013 and patients from countries later joining the NOPHO-AML 2004 protocol; Estonia (2004), Hong Kong (2007), Belgium and the Netherlands (2010). The choice of anthracycline during induction changed from two courses including doxorubicin (75 mg/m2 in each course), Dox-Dox, in the NOPHO-AML 93 to idarubicin (36 mg/m2) and mitoxantrone (30 mg/m2), Ida-Mitox, in NOPHO-AML 04. After the observation of a decrease in EFS in patients with t(8;21) in late 2010 it was recommended to give fludarabine, cytarabine, and DaunoXome (liposomal daunorubicin 180 mg/m2) as second induction to patients with t(8;21); Ida-DNX.Results. From 1993 to 2013 a total of 90 children, median age 9.1 years range 1-16, with t(8;21) AML were treated with Dox-Dox (n=25), Ida-Mitox (n=41), and Ida-DNX (n=24). Hematopoietic stem cell transplantation was given to 10 patients (11%), mostly with sibling donors in the NOPHO-AML 93 protocol (n=7). A reduction of the 3-year EFS was noted in patients treated with Ida-Mitox (41%) compared with Dox-Dox (64%). Those treated with Ida-DNX had significantly higher 3-year EFS of 87% (Figure). The events in t(8;21) AML on Ida-Mitox were relapses (n=20), death in CR1 (n=2), and secondary malignancy (n=2). The salvage rate for relapsed t(8;21) patients remained high and the overall favorable OS did not change significantly (Figure). From 1993 to 2013 a total of 58 children with inv(16) AML were treated with Dox-Dox (n=18) and Ida-Mitox (n=40). No significant changes in EFS (72% vs. 65%) or OS (89% vs. 79%) were observed for patients with inv(16).Conclusion. Despite the overall favorable survival in t(8;21) the present study suggests that the choice of anthracycline during induction may be of major importance for the EFS in t(8;21) AML. Idarubicin and mitoxantrone during induction was associated with an inferior EFS compared with doxorubicin in t(8;21) AML. DaunoXome combined with fludarabine and cytarabine seemed to be particular effective during induction therapy in t(8;21) AML. [Display omitted] [Display omitted] DisclosuresNo relevant conflicts of interest to declare.

Sorafenib Is Contributing to Salvage Chemotherapy and Is Effective Given Alone for Maintenance in AML FLT3 ITD Patients Relapsing Post Allo Hematopoietic Stem Cell Transplantation

Normal karyotype AML patients with FLT3 ITD have a higher risk of relapse than those lacking this mutation (Estey EH, Am J Hematol. 2013). Our comparative genomic hybridization study (77 patients) showed that AML cases with as compared to those without FLT3 ITD had significantly lower number of amplifications or deletions (number of total CNV aberrations: 18±4 vs 51±8, p=0.003). The latter observation in concert with that of others (Thiede, Blood 2002) suggest that FLT3 ITD mutation if present in normal karyotype patients is a key player in the pathogenesis of leukaemia and targeting this mutation may be used successfully in FLT3 ITD positive patients relapsing post HSCT.This was also the case in the two patients presented in this study.Patient UPN 952, male, 53 years old, AML M4 (FAB), normal karyotype, received alloHSCT in 2 CR after completion of two lines of remission induction therapies (first: DA3+7 (Daunorubicin, Ara-C), HAM, high dose Ara-C; second: ICE (IDA, Ara-C, VP-16)) and then promptly transplanted. He relapsed 56 days after transplantation.Patient UPN 938, female, 50 years old, AML, normal karyotype, received as an induction DA 3+7, and for consolidation HAM and high dose Ara-C and completed only one course of the maintenance therapy and transplanted in CR.Both cases were transplanted from unrelated donors (10/10 HLA A, B, C, DR and DQ alleles matched), they received myeloablative conditioning (i.v. Busulfan and Cyclophosphamide) and Cyclosporin A as GvHD prophylaxis. At relapse they received salvage chemotherapy tailored to their biological performance (UPN 938 having Age Adjusted Charlson Comorbidity Index 3 received FLAG and UPN 952 with the index 9, ECOG 3, DA2+5). Both cases received in addition Sorafenib (two times 400 mg per day). The response was prompt and the marrow was free from blasts beginning from 11 day post chemotherapy. UPN 952 received as a maintenance only one course of 6-TG with low dose of Ara-C. Due to the substantial comorbidity and liver toxicity WHO3 further chemotherapy treatment was terminated. The patient was left only on Sorafenib (2 times 200 mg per day). UPN 938 was receiving the maintenance therapy (AML protocol) in 6 – 8 weeks intervals based on low dose Ara-C with 6TG or DNR and also Sorafenib (2 times 200 mg per day).In both cases FLT3 signalling pathway (FLT3 Pathway Mutation PCR Array, SABiosciences, Qiagen) revealed a lack of any additional mutation at the check points in FLT3, KRAS, HRAS, NRAS, MEK1, PIK3CA, BRAF and PTEN genes. UPN 938 had in addition to FLT3 ITD mutation c.1807_1808insATGAATATGATCTCAAAT (p.K602_W603insYEYDLK) insertion which relevance was not so far describe. Sorafenib resistance mutations were not found.The patients were on Sorafenib for 8 (UPN 938) and 9 months (UPN 952).The course of UPN938 was uncomplicated. The second case showed mild aGvHD symptoms evolving into cGvHD (skin lesions and dry eye) slowed down with rapamicine.Up to now the patients are in CR and free from FLT3 ITD. The main observation points:- Sorafenib with chemotherapy tailored to the biologic performance of patients contributes to the efficient salvage in patients with relapsing FLT3 ITD positive AML post HSCT and is also effective given alone as a maintenance.- Side effects were seen in one out of two patients likely associated with the blocking of VEGFR signalling transmission (hand foot skin rash, von Willebrandt factor activity – 388%).Conclusion: 1.The use of multikinase inhibitor (Sorafenib) contributes effectively to salvage therapy in FLT3+ AML patients relapsing post alloHSCT2.Sorafenib given alone is able to maintain long-lasting remission3.Side effects are individually dependentSupported by NBiR CellsTherpy grant and Byer Health Care DisclosuresNo relevant conflicts of interest to declare.

Outcome of children with relapsed acute myeloid leukemia following initial therapy under the AML99 protocol.

The outcomes of children with relapsed acute myeloid leukemia (AML) are known to be poor, but remain obscure. We retrospectively analyzed 71 patients who had relapsed following first-line treatment under the AML99 protocol. We investigated the time and site of recurrence, response to re-induction therapy, and performance of hematopoietic stem cell transplantation (HSCT) in relapsed cases, and performed a multivariate analysis to identify prognostic factors. The 5-year overall-survival (OS) rate after relapse was 37 %. Of 71 patients, three died without any anti-leukemic therapy and two underwent allogeneic HSCT. The remaining 66 patients received re-induction chemotherapy, and 33 (50 %) achieved second CR (CR2). Twenty-two of 25 (88 %) late relapse patients and 11 of 41 (27 %) early relapse patients achieved CR2 (P < 0.001). Twenty-nine CR2 cases and 35 non-CR2 cases underwent allogeneic HSCT. The 5-year OS rate was significantly higher in patients who underwent HSCT in CR2 than those in non-CR2 (66 vs. 17 %, P < 0.000001). Multivariate analysis indicated that early relapse (P < 0.05) and the positivity of the FMS-like tyrosine kinase 3--internal tandem duplication (P < 0.05) were adverse prognostic factors for survival. In conclusion, the etiology of relapsed pediatric AML needs to be elucidated and effective chemotherapy should be administered to obtain CR2.

Case Report of FLT3-ITD–Positive AML Patient 11 Years After Living Donor Liver Transplantation

With the increasing number of long-term survivors of living donor liver transplantation, the occurrence of secondary cancer is sometimes reported. Solid tumors such as lymphomas are mainly observed. However, only 8 cases of leukemia have been reported so far. For patients younger than 15 years old, leukemia developed in 4 within 3 years after the liver transplantation, whereas acute lymphoblastic leukemia developed in only 1 patient. This is the first case report of a patient in whom FLT3-ITD–positive acute myeloid leukemia (AML) developed more than 10 years after living donor liver transplantation for congenital biliary atresia. AML developed in a 14-year-old boy 11 years after living donor liver transplantation from his father. The patient received the transplant at the age of 3 years and was treated with tacrolimus and methylprednisolone for transplant rejection. Eleven years posttransplantation, he visited the hospital with general malaise and anemia. Blood tests revealed an elevated white blood cell count of 60,100/μL, and the patient was diagnosed with AML. Chromosome analysis revealed a t(6; 9) (p23 q34) translocation; moreover, genetic testing revealed a FLT3-ITD–positive mutation. We started treatment in accordance with the Tokyo Children's Cancer Study Group AML99 protocol. With chemotherapy treatment, the patient achieved complete remission. After chemotherapy, we performed stem cell transplantation from his father. Other patients were reported in relatively early stages after liver transplantation, but our case was more than 10 years posttransplantation. The association with the onset of congenital bile duct atresia and leukemia is still not clear, but we consider the possibility that long-term immunosuppressive drugs contribute to developing leukemia.

Purine Analogues Based Induction Regimen Followed By Allo-HSCT Is An Effective Treatment Modality Of Philadelphia Chromosome-Positive Acute Myeloid Leukemia-Retrospective Analysis Of Polish Adult Leukemia Group (PALG)

Abstract Background Philadelphia chromosome positive acute myeloid leukemia (AML Ph+) is a rare hematological malignancy with dismal prognosis. It comprises 1-2% of all cases with AML. Overall survival (OS) of AML Ph+ patients (pts) is around 6 months irrespective of the treatment modalities. The best treatment option has not been clearly determined. Material and methods We present a retrospective, multicenter analysis of AML Ph+ cases diagnosed in last 12 years in Poland. We searched our onsite registries for the pts diagnosed with AML without preceding history of chronic myeloproliferative neoplasm. All the pts had Ph chromosome present in the classic GTG cytogenetics performed at the time of diagnosis of AML. Patients with biphenotypic acute leukemias were excluded from the analysis. To our knowledge, this analysis covers the biggest group of pts with AML Ph+. Results During the 12 years period, 17 adult pts with de novo AML Ph+ were identified among 1221 newly diagnosed AML pts in 13 hematological departments cooperating in PALG clinical trials. The overall incidence with de novoAML Ph+ among all AML patients was 1,39%. Clinical characteristics The AML Ph+ group consisted of 11 men and 6 women with the median (Me) age of 36 years old (range 18-70 y). The median WBC count (25,3 G/L), peripheral blood basophiles percentage (0,5%) and Hgb level (9.2 g/dl) at diagnosis in AML Ph+ did not differ significantly compared to that reported for AML of all types (WBC 13,4 G/L; Baso 0,3%; Hgb 8,5 g/dlL respectively). However, the AML Ph+ group had a higher PLT count at diagnosis than AML Ph- patients (108 vs 43,6 G/L, p50 G/L p&lt;0.0001) and a higher leukemic infiltration of bone marrow (78% vs 58%; p&lt;0.02). Splenomegaly, hepatomegaly and lymphadenopathy as assessed by physical examination were similarly common in AML Ph+ and Ph−. The majority of AML Ph+ were diagnosed as M2 (47%) and M4 (29%) according to FAB classification. The M0 and M1 FAB subtypes consisted equally of 12%. In nearly all cases of AML Ph+ the blasts expressed CD13, CD33, CD34 and CD117. Bone marrow cytogenetic results at diagnosis were available for all 17 pts. The t(9;22) was the sole chromosome abnormality in 11 cases. Six AML Ph+ cases exhibited additional aberrations besides t(9;22) and 5 cases had at least 1 extra abnormal related clone. One variant t(9;14;22) was also observed occurring as the sole chromosomal abnormality. Treatment Response and Outcome: All but two AML Ph+ pts received standard induction chemotherapy according PALG AML protocols (DA-6 pts; DAC-8 pts and DAF-1 pt) (Holowiecki J; JCO 2012). One patient received FLAG-Ida induction regimen and one low-dose Ara-C. Five pts underwent allogeneic stem cell transplantation (allo-SCT). After first course of induction therapy 8/16 pts (50%) achieved the complete remission (CR) and one patient died early. The CR rate in pts who received more intensive first induction regimen with purine analogues (PNA) (DAC; n=8, DAF; n=1 or FLAG-IDA; n=1) was higher than in the standard DA group (70% vs 16,7% respectively; p=0.056). All 7 patients who did not respond to first induction course received second induction cycle (CLAG-M-6 pts, and DAC +imatinib (IM) − 1 patient). The overall CR rate was 75% and is the highest published in the literature. The only factors associated with higher probability of CR achievement after one course of induction were WBC &gt;50 G/L (p=0.032) and more intensive induction therapy with PNA (p=0.034) in univariate analysis. The median OS of all patients with AML Ph+ was 7,1 months (mo). Higher (&gt;100 G/L) PLT count, achievement of CR and allo-SCT were associated with longer OS in univariate analysis (p=0.037; p=0.045 p&lt;0.01 respectively). However, in multivariate analysis the only factors that influenced OS were CR achievement (HR 10,6; 95%CI: 1.18-86.33; p=0.034). Five out of 17 pts received off label IM at different points of treatment course. Surprisingly, IM had no significant impact on OS in our group. Conclusions AML Ph+ has an aggressive clinical course and short OS. More intensive induction regimens with purine analogs increase response to treatment and make CR rate comparable to AML Ph -. The CR achievement and allo-SCT play a pivotal role in long term survival of AML Ph+ patients. Disclosures: Off Label Use: Imatinib in Ph+AML.

High frequency of streptococcal bacteraemia during childhood AML therapy irrespective of dose of cytarabine

High-dose cytarabine has been associated with a high frequency of viridans group streptococcal (VGS) bacteraemia. VGS bacteraemia causes considerable morbidity and mortality. The Nordic Society of Paediatric Haematology and Oncology (NOPHO)-AML protocols use higher cumulated doses of cytarabine and more chemotherapy series (n = 6) than other protocols with the potential increased risk of severe VGS infections. Medical records of all Danish children enrolled on the NOPHO-AML-2004 protocol between January 2004 and September 2011 (n = 45) were retrospectively reviewed and all febrile episodes were registered. Following 236 courses of chemotherapy, 112 positive blood cultures were registered. VGS were found in 38% of all positive blood cultures. Infectious episodes with VGS resulted in more days of fever and intravenous antibiotic therapy compared with infections caused by other microorganisms. VGS were involved in 45% of all episodes categorized as sepsis (n = 51) and in 67% of life-threatening bloodstream infections (n = 9). Penicillin resistance was found in 40% of the VGS strains. No significant difference was observed in the proportion of VGS isolated following courses with low-dose cytarabine versus courses with high-dose cytarabine. VGS were the most commonly isolated pathogens causing the most severe infections and the majority of life-threatening infections. A substantial proportion of the strains were resistant to penicillin. The high rate of VGS seemed independent of high-dose cytarabine but was more likely caused by the intensive chemotherapy treatment leading to severe mucositis and neutropenia.

Outcome in 146 patients with paediatric acute myeloid leukaemia treated according to the AML99 protocol in the period 2003–06 from the Japan Association of Childhood Leukaemia Study

The acute myeloid leukaemia (AML) 99 trial conducted previously in Japan for the treatment of de novo paediatric AML showed excellent results, with a 5-year overall survival (OS) and event-free survival (EFS) of 75·6% and 61·6%, respectively. To examine reproducibility of these results in another cohort, the outcome of 146 newly diagnosed AML paediatric patients prospectively registered in the Japan Association of Childhood Leukaemia Study (JACLS) from 2003 to 2006 was compared to that of 240 patients in the original AML 99 clinical trial. The 5-year EFS and OS achieved in the new cohort was 66·7±4·0% and 77·7±8·0% respectively, which were comparable to those obtained in the original AML 99 clinical trial, although less frequent core-binding factor (CBF) AML (29·5% vs. 37%) and an almost equal frequency of allogeneic haematopoietic stem cell transplantation (allo-HSCT) during first complete remission (16·5% vs. 19%) were observed. The 5-year EFS in patients with a normal karyotype (NK) (n=35, 54·9±15·1%) was inferior in the present cohort when compared to the original AML99 trial. This study confirmed the excellent outcome of the original AML99 protocol.

Lineage switch in childhood acute leukemia: An unusual event with poor outcome

Although rarely, switches between lymphoid and myeloid lineages may occur during treatment of acute leukemias (AL). Correct diagnosis relies upon confirmation by immunophenotyping of the lineage conversion and certification that the same cytogenetic/molecular alterations remain despite the phenotypic changes. From a total of 1,482 AL pediatric patients, we report nine cases of lineage conversion (0.6%), seven from lymphoid (four Pro-B, two Pre-B, one Common) to myelo-monocytic, and two from myeloid (bilineal, with myeloid predominance) to Pro-B. Eight patients were infants. Switches were suggested by morphology and confirmed with a median of 15 days (range: 8 days-6 months) from initiation of therapy. Of note, in five cases switches occurred before day 15. Stability of the clonal abnormalities was assessed by cytogenetic, RT-PCR/Ig-TCR rearrangement studies in all patients. Abnormalities in 11q23/MLL gene were detected in seven cases. Treatment schedules were ALL (two pts), Interfant-99 (five pts) and AML (two pts) protocols. Despite changing chemotherapy according to the new lineage, all patients died. Our findings support the association of lineage switches with MLL gene alterations and the involvement of a common lymphoid B-myeloid precursor. New therapies should be designed to address these rare cases. Possible mechanisms implicated are discussed.

NUP98-NSD1 Fusion Gene Is Strongly Associated with a Poor Prognosis in Pediatric Acute Myeloid Leukemia: A Study of the Japanese Childhood AML99 Cooperative Study Group

Abstract 1475 Background:Acute myeloid leukemia (AML) is a complex disease caused by mutations, deregulated gene expression, and epigenetic modifications of genes leading to increased proliferation and decreased differentiation of hematopoietic progenitor cells. In hematological malignancies with 11p15 translocations, the nucleoporin 98-kDa (NUP98) protein regulates nucleocytoplasmic transport of protein and RNA. More than 20 different chromosomal rearrangements involving NUP98 have been identified. The cryptic translocation t(5;11)(q35;p15.5), which creates a fusion gene between the NSD1 and the NUP98. The NUP98-NSD1 fusion gene has been associated with a deletion of the long arm of chromosome 5, del(5q), in pediatric AML patients. Recently, NUP98-NSD1 was identified in childhood AML by fluorescence in situ hybridization (FISH) with subtelomeric probes. However, the frequency and clinical impact of NUP98-NSD1 in pediatric AML remain uncertain. Methods:To estimate the frequency and clinical impact of the NUP98-NSD1 in pediatric AML, we examined the NUP98-NSD1 fusion transcript in a consecutive series of 157 newly diagnosed AML patients enrolled in the AML99 protocol in Japan clinical trial. Total RNA extracted from the leukemia cells of the patient at diagnosis was reverse transcribed to cDNA. The PCR was performed using the primer sets for detection of NUP98-NSD1. The PCR amplification was performed with a DNA thermal cycler followed by direct sequencing with an ABI PRISM 310 Genetic Analyzer. We also examined somatic mutations of the FLT3, KIT, WT1, NPM1, NRAS, KRAS and MLL genes, which are prevalent in AML, in these AML patients with NUP98-NSD1. Results:In the current study, we identified the NUP98-NSD1 by RT-PCR followed by direct sequencing in 6 (3.8%) out of 157 AML patients, and clustered significantly in the cytogenetically normal AML subgroup (6/33, 18.2%). Significant differences between patients with and without NUP98-NSD1 were observed in 4-year OS (33.3% versus 80.0%), and EFS (33.3% versus 69.2%). NUP98-NSD1 was highly seen in males (5 males and 1 female). The statistical differences between patients with and without NUP98-NSD1 was not significant in age (median: 7 years [range: 2–15 years] versus 6 years [range: 0–15 years]), and the initial WBC count (median: 115.9 × 109/L [range: 9.0–329 × 109/L] versus 51.8 × 109/L [range: 1.0–621 × 109/L]). Interestingly, NUP98-NSD1 was observed in 4 patients with normal karyotype, and was observed in 2 patients with del(9q). NUP98-NSD1 could not be identified by conventional G-banding technique in any cases. Patients with NUP98-NSD1 had any mutation of FLT3 -ITD (66.7%), WT1 (50%), KIT (16.7%) or RAS (33.3%). Furthermore, NUP98-NSD1 was frequently found in M4 or M5 patients according to FAB classification. Conclusions:We identified the NUP98-NSD1 in 6 out of 157 AML patients, and clustered significantly in the cytogenetically normal AML subgroup. Patients with NUP98-NSD1 had any FLT3 -ITD, WT1, KIT or RAS mutations. These results suggest that simultaneous occurrence of FLT3 -ITD, WT1, KIT mutations and RAS aberrations in NUP98 -related leukemia may be associated with poor prognosis. The NUP98-NSD1 was not identified by conventional G-banding technique, confirming that this translocation can exist as the only cytogenetic alteration. Therefore, FISH and RT-PCR analyses for NUP98-NSD1 fusion gene is recommended at the onset of disease in larger series of AML patients presenting an apparently normal karyotype, del(9q) or del(5q) to gain insight into the actual incidence and clinical features of patients with t(5;11)(q35;p15.5). Disclosures:No relevant conflicts of interest to declare.