De Novo Acute Leukemia Research Articles

Resilience Development Among Adult Patients With DeNovo Acute Leukemia: A Qualitative Study.

This study aimed to explore the development process of psychological resilience among adult patients with de novo acute leukemia. This study utilized a descriptive qualitative approach, employing a purposeful sampling method to select a sample of 15 newly diagnosed patients with acute leukemia (AL) who underwent their initial induction chemotherapy treatment at the Hematology Department of the First Affiliated Hospital of Zhejiang University School of Medicine, China. Semi-structured interviews were conducted with the selected patients. Content analysis methodology was used to analyze, summarize, and extract themes from the collected data. Three categories emerged-namely, (1) negative period, (2) adaptive response phase, and (3) growth transformation period. The negative period occurs during the initial diagnosis and throughout the treatment cycle. However, influenced by both internal and external protective factors, including personal characteristics and social support, individuals enhance their psychological resilience through emotional regulation, mental adjustment, and adaptive strategies vis-à-vis healthcare decision-making and disease management. Overall, psychological resilience development follows an upward spiral trajectory. This study identified that negative emotions and symptom clusters impede the development of patients' psychological resilience. Moreover, it revealed a substantial need for disease-related information among patients. Therefore, healthcare professionals should prioritize addressing the negative emotions of patients, early identification of protective factors, dynamic monitoring of symptom clusters, effective management, and provision of psychological counseling and interventions. Simultaneously, providing personalized, professional, and systematic disease-related information is vital for promoting psychological resilience development.

Clinical significance of EVI-1 gene expression and aberrations in patient with de-novo acute myeloid and acute lymphoid leukemia

BackgroundAcute leukemia is a common health problem in adults and children, however its exact molecular etiology is still unclear. MethodsThe expression of EVI-1 was assessed in the bone marrow of 178 de-novo acute leukemia patients (101 AML, 71 ALL and 6 MPAL), compared to 40 control subjects. EVI-1 gene aberrations were also assessed in 69 AML patients using Fluorescence in situ hybridization (FISH) technique. ResultsThe expression of EVI-1 was significantly lower in ALL patients compared to control [0.177 (0.002–15.189) vs 0.953 (0.179–1.68); respectively, P = 0.009]. There was no significant difference between AML patients and control group [0.150 (0.0–641) vs 0.953 (0.179–1.68); respectively, P = 0.082]. The sensitivity, specificity, AUC of EVI-1 in ALL were (80.3 %, 60 % and 0.778; respectively, P = 0.009), and (67.3 %, 60 %, 0.667; respectively P = 0.082) in AML patients. One patient showed EVI-1 gene rearrangement in a complex karyotype and four patients showed EVI-1 amplification in hyperdiploid karyotypes. All patients with BCR-ABL fusion were EVI-1 over-expressers (P = 0.010). AML patients with EVI-1 low expression were positively associated with t(8;21)(q22;q22)RUNX1:RUNX1T1 fusion, favorable recurrent translocation, and low genetic risk (P = 0.037, P = 0.023, and P = 0.013; respectively). There was a significant association between low EVI-1 expression and prolonged overall survival (OS) in AML patients, while there was no significant association with the disease-free survival (DFS) (P = 0.048 and P = 0.419). There was no significant impact of EVI-1 expression on OS and DFS rates in ALL patients. ConclusionEVI-1 expression could be a helpful diagnostic, prognostic, and predictive biomarker for acute leukemia especially in AML.

Pattern of Immunophenotypic Aberrant Expression in De-Novo Acute Leukaemia

Background: Aberrant expression (AE) of Acute Leukaemia (AL) is essential to confirm the diagnosis of AL patients whether it is biphenotypic/mix phenotypic AL or it is AL with AE. Objectives: This study is conducted to observe the diversity of aberrant immunophenotypic expressions among the patients of acute leukaemia with varying frequencies, to find out the correlation between aberrantly expressed immunophenotypic markers with different variety of French American British (FAB) sub classification of acute leukaemia and any correlation of clinical presentation of AL patients with aberrantly expressed immunophenotypic markers. Methodology: This cross-sectional observational study was carried out in the department of Haematology, BSMMU, Bangladesh on 50 patients from 14 to 65 years of age of both sex of newly diagnosed de- novo untreated AL patients from January 2017 to June 2018. Informed written consent & clinical history is taken and physical examinations were done in a predesigned data collection sheet. Then Bone marrow (BM) with peripheral blood sample for morphology and immunophenotyping were done in the laboratory of the Haematology department of BSMMU. After collection of data, these data were analysed for the final result. Result: In this study, 24 (48%) patients of de-novo Acute Leukaemia have Immunophenotypic aberrant expressions. Among them 12 (24%) patients were AML with AE, 9 (18%) patients were B ALL with AE, 3 (6%) patients were T ALL with AE and 2 (4%) patients were MPAL. In case of AML the most frequent Lymphoid aberrant marker is CD7 (12%), In B ALL the most frequent aberrant marker is CD5 (10%) and in T ALL the most frequent aberrant marker is CD10 (4%). Conclusion: In de-novo acute leukaemia, there is significant number of patients have aberrant expression which should be differentiated from biphenotypic/mix phenotypic AL for therapeutic and prognostic implications.

Therapy-related Acute Lymphoblastic Leukaemia has a Unique Genetic Profile Compared to De Novo Acute Lymphoblastic Leukaemia.

Background: Unlike therapy-related myeloid neoplasms, therapy-related acute lymphoblastic leukaemia (tr-ALL) is poorly defined due to its rarity. However, increasing reports have demonstrated that tr-ALL is a distinct entity with adverse genetic features and clinical outcomes.Methods: We compared the clinicopathological characteristics and outcomes of patients diagnosed with tr-ALL (n = 9) or de novo ALL (dn-ALL; n = 162) at a single institution from January 2012 to March 2021. The mutational landscapes of eight tr-ALL and 63 dn-ALL patients were compared from a comprehensive next-generation sequencing panel.Results: All tr-ALL patients had the B-cell phenotype. The most frequently mutated genes were IKZF1 (37%), CDKN2A (14%), SETD2 (13%), and CDKN2B (11%) in dn-ALL, whereas TP53 (38%) and RB1 (25%) mutations were most common in tr-ALL. tr-ALL patients did not show a statistically significant difference in overall survival (p = 0.70) or progression-free survival (p = 0.94) compared to dn-ALL patients.Conclusions: In this study, we determined the clinical and genetic profiles of Korean patients with tr-ALL. We found alterations in genes constituting the TP53/RB1 pathway are more frequent in tr-ALL. Due to the rarity of the disease, multi-institutional studies involving a larger number of patients are required in future study.

Nonhematologic neoplasia in biallelic BRCA2 mutated Fanconi anemia.

10041 Background: Fanconi anemia (FA) is a cancer predisposition disorder. Affected individuals do not tolerate conventional doses of chemotherapy or radiation well. Biallelic BRCA2 mutations cause a rare (̃3%) form of FA. Most patients with this subtype have a family history of breast cancer and die in early childhood. Optimal management remains uncertain. Herein, we report the world’s largest single center cohort of biallelic BRCA2 patients, with a focus on non-hematologic malignancies. Methods: The University of Minnesota’s prospectively maintained FA database was analyzed for data on biallelic BRCA2 mutated FA patients. IRB-approved consent was obtained for all subjects. Results: Twenty patients with biallelic BRCA2 were identified. Median age of FA diagnosis was 1.5 years (range: 0-16.2 years). All patients had a significant history of cancer in the family with breast cancer being particularly frequent (65%). Eight (40%) patients developed non-hematologic neoplasia before 18 years of age. These included 10 malignant tumors and 4 benign neoplastic lesions; 3 patients had more than one solid tumor (see Table). Surgical resection was attempted in all malignant tumors, dose reduced adjuvant chemotherapy was utilized in 5 cases and radiation in one case. Thirteen (65%) patients developed hematologic malignancies (AML=6, ALL=3, MDS=4), all without preceding marrow failure. Fourteen patients underwent allogeneic HCT. Eleven patients have died, 3 from solid tumors and 5 from leukemias. Nine patients are currently alive, of whom 3 are post-HCT. Only 4 (age range: 6.5-16.3 years) patients in the cohort remain free of any oncologic diagnoses. Conclusions: Patients with FA due to biallelic BRCA2 mutations have a unique phenotype with an extraordinarily high risk of early-onset de-novo acute leukemia and solid tumors, often both diagnosed in the same patient. They require extensive, lifelong cancer surveillance from an early age to optimize outcomes. Therapy for malignant diagnoses should aim to minimise exposure to genotoxic / crosslinking agents and radiation. BRCA2 mutation testing in family members and appropriate genetic counselling is essential. Additionally, a family history of BRCA2 mutated cancers should prompt FA testing in offspring with any relevant FA-related clinical findings. Nonhematologic neoplasia and therapy.[Table: see text]

Unorthodox Flowcytometric Scatter and Severe Bone Marrow Fibrosis in De Novo Acute Promyelocytic Leukaemia.

Unorthodox Flowcytometric Scatter and Severe Bone Marrow Fibrosis in De Novo Acute Promyelocytic Leukaemia.

A Phase II Non-Randomized Study to Evaluate the Efficacy of Single Dose Rasburicase (1.5mg) in Adult Acute Leukemia and High Grade Lymphomas with Established Tumor Lysis Syndrome

BACKGROUND Tumor lysis syndrome (TLS) refers to a constellation of metabolic derangements due to the breakdown of tumor cells.It is a medical emergency and is associated with significant morbidity and mortality. Hyperuricemia is a key manifestation of TLS, that can lead to renal insufficiency and trigger a vicious cycle of metabolic abnormalities. Rapid resolution of hyperuricemia is key to successful outcomes. Rasburicase is a recombinant form of enzyme urate oxidase, approved in patients with established TLS,which converts the uric acid to soluble allantoin. It acts rapidly, bringing down the levels in as less as 4 hours. The approved dose is 0.2 mg/kg/day for 5 days. While there is efficacy data to support the use of fixed low-dose (1.5-3 mg) rasburicase in the prophylactic setting,no such data exists in the therapeutic setting. Each 1.5 mg vial costs about 8,000 rupees (115 USD), the dose required for a 60 kg adult would be 12 mg, which equals to about 300,000 rupees (4340 USD) for 5 days. Given the cost constraints, most of our patients with established TLS receive only a single fixed dose of rasburicase at 1.5 mg as a standard of care. We have observed that even this lower dose is adequate to normalize the uric acid levels in a majority of them. We planned to prospectively evaluate the efficacy of single-dose rasburicase in patients with established TLS. METHODS We conducted a single centre phase II study and enrolled patients (>15 years) with de-novo acute leukemia and high-grade lymphoma with hyperuricemia(laboratory or clinical TLS) and ECOG PS ≤ 4. Patients with hemodynamic instability or neurological impairment were excluded. After enrollment, patients received rasburicase at a dose of 1.5 mg fixed-dose intravenous over 30 min. Patients were monitored daily either as an in- or outpatient. Blood samples to measure the renal function tests and electrolytes were collected at 4 hours, 24-h, 48-h, Day 3, Day 4, and Day 5. Blood samples were transported in heparinized tubes at room temperature and processed immediately. Additional 1.5 mg dose of rasburicase was given if the plasma uric acid level did not decline by at least 50% at 24 hours. Additional doses were also given at the clinician's discretion in case of rising uric acid levels on subsequent monitoring. The primary objective was to estimate the rate of plasma uric acid response (Defined as normalization of uric acid at 48 hours that is sustained till day 5). Secondary objectives were to assess the number of patients requiring additional doses of rasburicase, need for dialysis, mortality attributable to TLS and adverse events due to rasburicase. The sample size was calculated using Simon's two-stage design.52 patients were required to detect a Plasma UA response rate of 85% (Compared to 99% with the approved dose) with a type I error of 5% and power of 80%. Due to a higher than anticipated attrition rate, we enrolled 70 patients. Results: A total of 70 patients were enrolled in the study, 60 were analyzed for secondary and 53 for the primary endpoint (Fig 1). The baseline features are summarized.(Fig 1) Plasma uric acid normalized at 48 hours in 37/53 (70%) of the patients and became normal at day 5 in 46/53(87%) of the patients. The corresponding figures for the entire cohort were 68% and 82% respectively. Only 3 patients required hemodialysis. 11 patients were managed as outpatient, the remaining were admitted. 3 patients required ICU admission. 20 patients required additional doses of rasburicase, out of which 13 patients required 2 doses, 5 patients required 3 doses, 1 each required 4 and 5 doses. The total number of vials required in the study were 83 vials. In comparison, 2120 vials would have been required for a cohort of people weighing 60kgs. Hypersensitivity reaction, cardiac dysfunction, methemoglobinemia were not seen in any patient. 1 patient developed hemolysis post rasburicase. Other adverse events were fever(25%), vomiting(10%), abdominal pain(13%). All 60 evaluable patients were alive at the end the study. Conclusion: Lower dose of rasburicase is sufficient and cost-effective in established TLS. This strategy obviates the need for FDA approved higher doses. Disclosures No relevant conflicts of interest to declare.

Study of Isocitrate Dehydrogenase 1and 2 Mutations in Adult Egyptian Patients with Denovo Acute Myeloblastic Leukemia, Their Relation to Clinical Characteristics, FLT3/ITD and Nucleophosmin 1 Mutations and Impact on Treatment Outcome

Background: Acute myeloid leukaemia (AML) is a malignancy that is heterogeneous in nature characterized by genetic abnormalities some of which are established in the diagnosis and prognosis of the disease. An additional role for alterations in epigenetic mechanisms has been also highlighted in the pathogenesis of the disease. This may have a role in determining the disease outcome, impact the treatment decision and provide options for targeted therapies especially in patients who lack genetic aberrations. One of the modes of epigenetic dysregulation is mutation in genes encoding isocitrate dehydrogenase 1 and 2 that has been observed in AML with a higher incidence in patients with normal karyotype (NK).
 Aim of the work: The aim of this work was to study the frequency of IDH1 (R132) and IDH2 (R140Q, R172K) mutations in adult Egyptian patients with de novo acute myeloblastic leukemia (AML), their relation with clinical characteristics, other molecular markers (the internal tandem duplication (ITD)) mutation of FLT3 gene and NPM1 gene mutation) and impact on treatment outcome.
 Methods: Peripheral blood samples from 50 adult patients with denovo acute myeloid leukemia, admitted to the haematology unit at Alexandria Main University Hospital from February 2015 to February 2017, were used. The polymerase chain reaction-restriction fragment length polymorphism method (PCR-RFLP) was used for detection of IDH1 codon R132 and IDH2 codons (R140, R172) mutations on genomic DNA. PCR was used for detection of FLT3-ITD mutation on genomic DNA. PCR was used for detection of NPM1 mutation on RNA.
 Results: IDH 1and 2 mutations occurred in 30% of newly diagnosed AML patients and 47.6% of NK patients. Both mutations did not co-occur except in one case. IDH positive patients were significantly older than IDH negative patients (p=0.003). There was no statistically significant correlation between any of the clinical parameters and the IDH mutations. FAB-M2 was the most common FAB subtype among IDH positive patients. No correlation between IDH mutations and NPM1 or FLT3 could be demonstrated. IDH positive patients had significantly lower CR rates after induction chemotherapy than IDH negative patients (p=0.021).
 Conclusion: IDH1, 2 mutations are recurring genetic alterations in AML with a higher incidence in patients with normal karyotype and they may have an unfavorable impact on clinical outcome in adult AML patients.

Comorbidities Are Frequent in Older Patients with De Novo Acute Lymphoblastic Leukemia (ALL) and Correlate with Induction Mortality: Analysis of More Than 1200 Patients from GMALL Data Bases

Comorbidities Are Frequent in Older Patients with De Novo Acute Lymphoblastic Leukemia (ALL) and Correlate with Induction Mortality: Analysis of More Than 1200 Patients from GMALL Data Bases

Диагностическое значение С-реактивного белка как маркера инфекции у больных с впервые выявленными острыми миелоидными лейкозами

Диагностическое значение С-реактивного белка как маркера инфекции у больных с впервые выявленными острыми миелоидными лейкозами

Fludarabine, Melphalan and Alemtuzumab Conditioned Reduced Intensity (RIC) Allogeneic Hematopoietic Cell Transplantation for Adults Aged >40 Years with De Novo Acute Lymphoblastic Leukemia: A Prospective Study from the UKALL14 Trial (ISRCTN 66541317)

In the donor versus no donor analysis of the UKALL12/E2993 trial in adult acute lymphoblastic leukaemia (ALL), there was a significant improvement in overall survival (OS) and reduction in relapse in the donor arm. However the OS benefit did not extend to older patients in whom myeloablative allogeneic hematopoietic cell transplant (alloHCT) related mortality was 35% at 2 years and outweighed the reduction in relapse risk. The overall outcome of older patients in this trial was poor, with patients >40 and 50 years having 23% and 15% 5 year survival respectively. In our current UK National Cancer Research Institute UKALL14 study all patients >40 years in CR, regardless of Philadelphia (Ph+) status and other high risk factors, are considered "high risk" and recommended a reduced intensity conditioned (RIC) alloHCT with a matched sibling (sib) or 8/8 matched unrelated donor (MUD) after a 2 course induction and high dose methotrexate. The primary endpoint is event free survival (EFS). We report here the early outcome of 88 patients with at least day 100 follow up (FU) (median FU 18 months) who received RICalloHCT on trial.Conditioning was with fludarabine 30mg/m2 d -6 to -2, melphalan 140 mg/m2 d -2 and alemtuzumab 30mg d -2 to-1 (MUD) or d-1 (sib). Graft versus host disease (GVHD) prophylaxis was ciclosporin A only. Nine patients did not receive alemtuzumab as per protocol. Multilineage chimerism (MC) and minimal residual disease (MRD) were assessed 3 monthly post alloHSCT. Escalating doses of donor lymphocyte infusions (DLI) were given for T-cell mixed chimerism or MRD, starting dose 1 x 106 CD3 cells/kg, escalating by half log increments every 3 months.Of 511 registered patients, 306 were >40 years old; 127 of those have completed RIC allograft, 88 of whom have sufficient FU to report. Median age was 51.5 years (range 41 to 64). Donor was sib in 24 and MUD in 64 patients, respectively. Median WBC at diagnosis was 7 x 109/l (0.6-557). Forty one of 77 (53%) evaluable patients had high risk cytogenetics, 22 (25%) were Ph+. Twelve of 56 (21%) with MRD data were MRD +ve pre-alloHCT.Post-alloHCT, myeloid engraftment occurred in 86/88 patients at a median of 13 days, 2 had missing data. Acute graft versus host disease (GVHD) occurred at grade 1 in 30 patients (34%) and grade 2-3 in 8 patients (9%). Thirty patients developed chronic GVHD (34% of 87/88 patients surviving to D100), 13 limited and 17 extensive. Of 12 patients who suffered transplant-related mortality (TRM), 6 died of infection (one post-transplant lymphoproliferative disease), 4 of organ toxicity and 2 of GVHD. TRM was not associated with age or donor type. Sixteen patients relapsed at a median time of 317 days (range 110-1034). Of those, 9 (of 15 with data) had high risk cytogenetics (EFS, p=0.38) and 6 (of 11 with data) were MRD +ve pre-alloHCT (EFS, HR 3.35, p=0.047). Twenty seven patients in total received 67 DLI (median maximum dose 3 x 106 CD3 cells/kg): 15 for mixed chimerism, 4 for rising MRD and 8 for both. Five patients (19%) developed post-DLI GVHD at grade 1 (n=4) and grade 2 (n=1). MC data is available for 36 patients receiving alemtuzumab and is shown in figure 1 where dark grey bars represent full and light grey bars mixed chimerism, respectively. DLI are denoted by black dashes. Mixed chimerism was seen in 22 of 36 patients (61%) who received alemtuzumab and so far 26 of 36 have achieved full donor chimerism (median 9 months), 10 after DLI (38%). Figure 2 shows Kaplan Meier curves of OS 76% (64-84, 95% CI) and EFS 68% (55-77)at 18 months.This is the first prospective study of RIC alloHCT in older adults with ALL; these early results demonstrate its feasibility within a large, multicentre trial. T-cell mixed chimerism was common at 1st MC assessment but early data indicate that conversion to full donor chimerism with DLI is a safe and realistic possibility. The impact of mixed chimerism (and pre-emptive DLI) on relapse remain to be evaluated. Severe GVHD and TRM were relatively low, such that the EFS of chemotherapy then RIC alloHCT, albeit with short-term FU, may be higher than expected for chemotherapy alone in this age group. [Display omitted] [Display omitted] DisclosuresCopland:Novartis: Honoraria, Membership on an entity's Board of Directors or advisory committees, Research Funding; BMS: Honoraria, Membership on an entity's Board of Directors or advisory committees, Research Funding; Ariad: Honoraria, Membership on an entity's Board of Directors or advisory committees; Pfizer: Honoraria, Membership on an entity's Board of Directors or advisory committees. Fielding:Amgen: Consultancy, Honoraria.

Detection of Leukemic Stem Cells in Patients with De Novo Acute Myeloblastic Leukemia

ABSTRACT Aim: Defining the self-renewing [Thy1-, CD34 + , CD38-] LICs in AML cases before and after induction chemotherapy as a predictor for relapse and to determine how CSF1R (Fms) and CD34 markers affect the growth and survival of human leukemic cells in the CD38- Thy1- population. Methods: This study was carried out on 30 samples from the peripheral blood of adult patients with de-novo acute myeloid leukemia. The majority of the patients were monocytic AML Samples were sorted into four populations (Fms + CD34-, Fms + CD34 + , Fms-CD34+ and Fms-CD34-) according to the surface markers of the cells. Cells were cultured on mouse stromal cells transfected with a plasmid containing human CSF-1. Samples were cultured using Iscove's modified Dulbecc's medium (IMDM).The cultures were assessed for survival of leukemic cells in days. Results: The mean survival in days of the cells was 13.9 before chemotherapy and 14.1 after chemotherapy. The difference in growth was insignificant (p > 0.05). The Fms-CD34+ population in all but two samples tested had the longest survival time in culture. Conclusions: Our results suggest that leukemic stem cells may survive chemotherapy mainly due to their quiescence. Human CSF-1 was shown to increase the number of leukemic cells in co-culture with mouse stroma after 5 weeks. A novel leukemic stem cell (Fms-CD34+) has been identified and is the cell responsible for the growth and maintenance of the leukemic bulk. Disclosure: All authors have declared no conflicts of interest.

JAK-2V617F Mutation in Acute Leukemia (South Egypt Experience)

Aim: To search for JAK2V617F mutation in patients with acute myeloid and acute lymphoblastic leukemia in south Egypt. Study Design: JAK2V617F mutation detected by amplification refractory mutation system (ARMS) -PCR. Place and Duration of Study: Department of clinical pathology and department of medical oncology, South Egypt Cancer Institute, Assiut University, Assiut, Egypt, between December 2010 and December 2012. Method: We included 90 patients (58 men and 32 women; age range 2-67 years) with denovo acute leukemia (30 acute myeloid leukemia and 60 acute lymphoblastic leukemia), JAK-2 V617F mutation using ARMS-PCR was done for all the patients. Results: JAK-2 V617F mutation was absent in all of the studied patients. Conclusion: Our results confirm the finding published previously which reported that JAK2 V617F mutation is very rare or absent in acute leukemia.

Study of Correlation Between SFRP-1 and SFRP-2 Hypermethylation With Relapse, Complete Remission, Genetic Mutations of FLT3-ITD and NPM1 and Immunophenotypes of Leukemic Cells in Patients With De Novo Acute Myeloblastic Leukemia

Background: Acute myeloid leukemia (AML) is a clonal disorder of hematopoietic stem cells that is associated with the infiltration of blasts in the peripheral blood and bone marrow. In recent years, the role of epigenetic abnormalities such as promoter methylation of tumor suppressor genes, including secreted frizzled related proteins (SFRPs) family genes, has been shown in the pathogenesis of cancers. This study evaluates the correlation between SFRP-1 and SFRP-2 hypermethylation with genetic mutations of FLT3-ITD, NPM1 and immunophenotypes of leukemic cells. Methods: In peripheral blood from 43 patients with de novo AML, isolated DNA was treated with sodium bisulphite and analyzed by methylation-specific polymerase chain reaction (MSP). Fisher exact test and SPSS 21 were used for statistical data analysis. Results: SFRP-1 hypermethylation had significant association with CD34 (P = 0/045) and CD14 (P = 0/046) expression. There was no difference in the incidence of genetic mutations of FLT3-ITD and NPM1 between patients with and without SFRP hypermethylation. Conclusion: Based on these results, hypermethylation of SFRP-1 is associated with increased expression of CD34 and CD14 antigenes. However, further studies on a large group of patients are necessary to confirm our findings. J Hematol. 2014;3(2):34-42 doi: http://dx.doi.org/10.14740/jh154w Normal 0 false false false EN-US X-NONE FA

Establishment of an 11-Year Cohort of 8733 Pediatric Patients Hospitalized at United States Free-standing Children’s Hospitals With De Novo Acute Lymphoblastic Leukemia From Health Care Administrative Data

Acute lymphoblastic leukemia (ALL) accounts for almost one quarter of pediatric cancer in the United States. Despite cooperative group therapeutic trials, there remains a paucity of large cohort data on which to conduct epidemiology and comparative effectiveness research studies. We designed a 3-step process utilizing International Classification of Diseases-9 Clinical Modification (ICD-9) discharge diagnoses codes and chemotherapy exposure data contained in the Pediatric Health Information System administrative database to establish a cohort of children with de novo ALL. This process was validated by chart review at 1 of the pediatric centers. An ALL cohort of 8733 patients was identified with a sensitivity of 88% [95% confidence interval (CI), 83%-92%] and a positive predictive value of 93% (95% CI, 89%-96%). The 30-day all cause inpatient case fatality rate using this 3-step process was 0.80% (95% CI, 0.63%-1.01%), which was significantly different than the case fatality rate of 1.40% (95% CI, 1.23%-1.60%) when ICD-9 codes alone were used. This is the first report of assembly and validation of a cohort of de novo ALL patients from a database representative of free-standing children's hospitals across the United States. Our data demonstrate that the use of ICD-9 codes alone to establish cohorts will lead to substantial patient misclassification and result in biased outcome estimates. Systematic methods beyond the use of just ICD-9 codes must be used before analysis to establish accurate cohorts of patients with malignancy. A similar approach should be followed when establishing future cohorts from administrative data.

P-250 Nucleophosmin cytoplasmic and nucleus immunohistochemical cell positivity of bone marrow biopsy sections in AML and MDS patients

Background Nucleophosmin (NPM) is phosphoprotein in nucleolus and shuttles continuously between nucleus and cytoplasm. Major role of NPM is to mediate nuclear export of ribosome components to the cytoplasm and to control centrosome duplication and it also interacts with oncosupressors p53 and p19Arf thus controlling cell proliferation and apoptosis. NPM mutations are involved in pathogenesis of some AML cases. Introduction The abnormal mutated NPM1 protein shows an aberrant cytoplasmic localization in leukemic cells (NPMc), whereas the wild-type protein is mainly located in the nucleolus and on the nuclear membrane. Approximately one-third of cases of denovo acute myeloblastic leukemia (AML) carry mutations in the c-terminal region of NPM (NPM1) gene. NPM1 mutations are rare in myelodisplasia (MDS) but in some reports NPM mutations and NPMc cell bone marrow cell positivity were also found in MDS. Purpose Aim of the study were to analyze cell NPM immunohistochemical expression in nuclei (NPMn) and cytoplasm (NPMc) in bone marrow (BM) sections of 7 patients with de novo AML and 9 MDS patients. Materials and Methods Immunohistochemical procedures were performed on paraffin sections cut from B5-fixed/EDTA-decalcified BM biopsies. Sections were subjected to micro waving/antigen retrieval, pH9 and immunostained with anti-NPM monoclonal antibody (clone 376) using immuno alkaline phosphatase technique. NPMc and NPMn cell positivity between AML and MDS patients were statistically compared with Mann-Whitney and Chi-square tests. From patients informed consent was obtained. Results NPMn cell positivity was seen in 6/7 AML and in 8/9 MDS patients. NPMc was detected in 5/7 AML and in 8 out of 9 MDS patients. Percentages of NPMn of BM cells were higher in MDS than in AML patients with borderline statistical significance. NPMn immunoexpression above 30% of BM positive cells was more frequently (with statistical significance) observed in MDS than in AML patients (p< 0.05). Conclusions Higher NPMn cell positivity (above 30% of nucleated BM cells) in MDS is probably linked to higher number of normal BM cells in MDS. Lower NPMn cell positivity in AML is maybe associated to higher number of leukemic cells and also to NPM functional loss in progression and transformation of MDS to AML. NPMc was also observed in most of our AML and MDS patients. This finding is in a concordance with some recent reports also implicating that that NPM1 mutations may be also seen in MDS, but further studies are needed to analyze correlation of NPMc cell positivity and NPM1 mutations in MDS patients

Abstract 1301: Post translationally modified EVI1 regulates ΔNp63 to delay cell cycle progression and cell proliferation via the cyclin dependent kinase p21

Abstract Several lines of evidence suggest that specific transcriptional events are involved in cell cycle, proliferation and differentiation processes; however, their deregulation by proto-oncogenes are involved in the development of leukemia and tumors. One such proto-oncogene is Ecotropic Viral Integration site I (EVI1) which can differentially effect cell cycle progression and proliferation in cell types of different origin. The proto-oncogene EVI1 which localizes in chromosome 3 (3q26.2) is attracting considerable attention in the recent years because of its reported involvement in late stage chronic myeloid leukemia (CML), high risk myelodysplastic syndrome (both MDS and MDS-AML) and also in de-novo acute myeloid leukemias (AML). Studies also indicate that EVI1 is overexpressed in a subset of human colon cancers, ovarian cancers and that EVI1 might induce disease progression and/or sensitivity to chemotherapy. In this report we provide evidence of a pathway through which EVI1 inhibits cell cycle progression and cell proliferation in HT-29 colon carcinoma cells which was reported earlier to express high levels of the proto-oncogene EVI1. Our bio-informatics analysis and quantified chromatin immunoprecipitation data shows that EVI1 very strongly binds to ΔNp63 promoter element. Deletion mutant analysis revealed that EVI1 binds to ΔNp63 promoter element through its distal zinc finger domain. RQ-PCR and luciferase assay revealed that the binding of EVI1 to ΔNp63 down regulates its expression by ∼4.5 fold and that down regulation of ΔNp63 induces the expression of p21 in HT-29 cells which eventually delay cell cycle progression at G0/G1 phase. Concomitant knocking down of EVI1 with a specific siRNA or transfecting ΔNp63 in EVI1+ cells significantly rescued this phenotype, indicating the growth defect induced by ΔNp63 deficiency to be, at least in part, attributable to EVI1 function. We have reported earlier that EVI1 is post-translationally modified and the modified forms of EVI1 divergently regulate the target genes. Post-translational modification of proteins is a hallmark of signal transduction and it allows existing proteins to react rapidly to extra cellular events cascading to a total cellular response. Interestingly, here we show that EVI1 is phosphorylated and the unphosphorylated form of EVI1 failed to regulate ΔNp63 that eventually showed no change in cell cycle/cell proliferation pattern. Our findings for the first time identify a possible link between two diverse signal transduction pathways acting together in response to a post-translationally modified oncogene that eventually delays cell cycle progression and inhibits cell proliferation. Citation Format: {Authors}. {Abstract title} [abstract]. In: Proceedings of the 103rd Annual Meeting of the American Association for Cancer Research; 2012 Mar 31-Apr 4; Chicago, IL. Philadelphia (PA): AACR; Cancer Res 2012;72(8 Suppl):Abstract nr 1301. doi:1538-7445.AM2012-1301

Myeloablative Unrelated Cord Blood Transplantation From Grafts With Three HLA Antigen Mismatches Resulted in Superior Outcomes for Patients With De Novo Acute Leukemias

Myeloablative Unrelated Cord Blood Transplantation From Grafts With Three HLA Antigen Mismatches Resulted in Superior Outcomes for Patients With De Novo Acute Leukemias

Significance of Minimal Residual Disease (MRD) by Multiparameter Flow Cytometry (MFC) In Adults with De Novo Acute Lymphoblastic Leukemia (ALL) After Therapy with the Modified Hyper-CVAD Regimen

AbstractAbstract 2145The hyper-CVAD regimen is an effective frontline program for de novo adult ALL [Kantarjian, JCO 18:547, 2000; Kantarjian, Cancer 101:2788, 2004]. Intensive cycles of hyper-CVAD (fractionated cyclophosphamide, vincristine [VCR], doxorubicin, dexamethasone) alternate with high dose methotrexate (MTX) and cytarabine every 21 days for 8 courses, followed by maintenance therapy with POMP (6-mercaptopurine, MTX, VCR, prednisone) interrupted with early and late intensifications. The regimen was modified in 1999 in order to improve on the results. Induction chemotherapy was administered in a laminar air flow room for pts aged 60 years or older owing to high induction mortality rate (17%). Rituximab 375 mg/m2 (days 1 & 11 of hyper-CVAD, days 1 & 8 of MTX-cytarabine for 8 total doses) was given if CD20 expression was > 20% owing to association with increased propensity for relapse [Thomas D, Blood 113:6330, 2009]. CNS prophylaxis alternated intrathecal MTX day 2 with cytarabine day 7 of the first 3 courses for low CNS risk and first 4 courses for high CNS risk (in the absence of CNS disease). The maintenance phase was extended from 24 to 30 mos with modifications of the early and late intensifications (hyper-CVAD followed by MTX-L-asparaginase mos 6 & 7 and 18 & 19) in order to reduce incidence of late relapses. Newly diagnosed or primary refractory (1 course only) pts with Philadelphia chromosome negative B-lymphoblastic leukemia (n=126) were treated with this modified hyper-CVAD regimen without anthracycline intensification (pts age 30 years or less have been allocated to treatment with the pediatric-inspired augmented Berlin-Frankfurt-Muenster regimen since 2006). Median age was 43 yrs (range, 15–83). CD20 expression was noted in 49%. Overall CR rate of the group was 93%; the rate of MRD negativity by 4- or 6-color MFC (sensitivity of 0.01%) at the time of CR in 95 evaluable pts was 72%. Overall, MRD positivity by MFC at the time of CR was associated with a higher relapse rate (52% versus 21%, p=.01) and lower 3-yr CR duration rates (45% versus 78%, p=.01). The CD20 positive pts (n=57) who were treated with rituximab had a higher rate of MRD negativity by MFC at CR than their CD20 negative counterparts (81% versus 58%, p=.02). MRD positivity by MFC after hyper-CVAD and rituximab was associated with a significantly lower 3-yr CR duration rate (24% versus 82%, p=.002), but survival rates were not statistically different (27% versus 70%) likely due in part to deaths in CR in the older subset of the MRD-negative group. In contrast, for the CD20 negative subset, presence of detectable MRD by MFC at the time of CR was not associated a with lower 3-yr CR duration rate (58% versus 63%). Dectectable MRD by MFC at the time of CR, despite subsequent eradication with consolidation chemotherapy in the majority of patients, predicts for increased risk of disease recurrence. Strategies to improve the MRD negativity rate at the time of CR (e.g., addition of monoclonal antibodies directed at other lymphoblast antigens such as CD22 for the CD20 negative subset and use of the newer anti-CD20 monoclonal antibodies for the CD20 positive subset) may further improve outcome after frontline therapy with the modified hyper-CVAD regimens. Disclosures:Thomas: Novartis: Honoraria; Bristol-Meyer-Squibb: Honoraria; Pfizer:; Amgen: Research Funding. Off Label Use: Imatinib for de novo Philadelphia positive ALL. Dasatinib for de novo Philadelphia positive ALL. Rituximab for CD20 positive ALL and Burkitt leukemia/lymphoma. Nelarabine for de novo T-lymphoblastic leukemia/lymphoma.

Thymic Renewal and Anti-Leukemic Effect In Adults After Haploidentical Transplantation and Donor T Cell Suicide Gene Therapy

AbstractAbstract 833 Introduction:Hematopoietic Stem Cell Transplantation (HSCT) from partially HLA-matched (haploidentical) family donors represents a promising therapy for high-risk leukemia, but requires appropriate strategies to control the adverse reactions mediated by the partially incompatible, transplanted immune system. In a recent phase II study (TK007 study), we demonstrated that the infusion of donor lymphocytes transduced with the Herpes Simplex Virus Thymidine kinase (HSV-Tk) suicide gene allows to control Graft-versus-Host Disease (GvHD) and to rapidly provide an effective and polyclonal anti-infective T cell repertoire (Ciceri and Bonini et al., Lancet Oncology, 2009). Even though their engraftment is necessary to achieve these effects, HSV-Tkpos cells represent the minority of lymphocytes circulating in treated patients. Therefore, in the present study, we investigated the putative role of HSV-Tkpos cells in promoting thymic activity and T cell development from graft progenitors. Methods:Twenty-eight adult patients underwent haploidentical HSCT and infusion of purified suicide gene-modified donor T cells for high-risk hematologic malignancies in the TK007 study. Thymic function was investigated in a selected cohort of this study (n=14) and in a control group who underwent unselected T cell-replete haploidentical transplantation with an ATG-rapamycin-mycophenolate-based GvHD prophylaxis (n=31), after validation in healthy pediatric and adult controls. T cell subsets and the proportion of CD31+ recent thymic emigrants (RTEs) amongst CD4+ naïve T cells were measured by immunophenotypic analysis. Single joint T cell Receptor Excision Circles (sjTREC) were quantified by qPCR. Thymic output was correlated with thymic volume, as assessed by CT scans. Post-transplantation pathogen-specific immune response was quantified by ELISpot. Alloreactivity against leukemic blasts was studied by mixed lymphocyte cultures. Results:Post-transplantation recovery of naïve CD45RA+CD62L+ T cells occurred in patients treated with gene modified T cells, reaching values of healthy controls in approximately one year. At the time of immune reconstitution (median 76 days after HSCT, defined as CD3+ cells > 100/ml peripheral blood), 76.5% of circulating T cells did not carry the HSV-Tk suicide gene, and the CD4+ naïve subset was largely comprised of cells recently originated from the thymus (90.5±3.2%). This observed frequency of CD31+ RTEs in these patients was significantly higher than that measured in the same patients before HSCT (60.7±6%, p=0,0087) or in patients analyzed 90 days after T cell-replete haploidentical HSCT (31.0±6.3%, p<0.0001), suggesting a direct role of the infused HSV-Tkpos cells in promoting thymopoiesis. Accordingly, CT scans documented an increase in thymic volume following HSV-Tkpos cell add-backs. The newly generated HSV-Tkneg T cells granted full immune competence against infectious agents, which was not compromised in those patients in whom the suicide gene was activated to control GvHD (n=11). Finally, besides promoting thymic renewal, HSV-Tkpos also displayed a direct antitumor effect, as demonstrated by their recognition of leukemic blasts in experimental cultures. Consistent with the observed ex vivo alloreactivity of the gene-modified cells, relapse mortality at 3 years was 19% (95% CI 0–43) for de-novo acute leukemia, and in two of the treated patients repeated HSV-Tkpos cell infusions drove in vivo selection of immunoresistant leukemic variants with genomic loss of the mismatched HLA haplotype (Vago et al., New Engl J Med, 2009). Conclusions:These data show that the infusion of suicide gene-modified T cells prompts the renewal of thymic activity, which contributes to the recovery of a polyclonal T cell repertoire protective against pathogens. Contextually, the infused transduced cells mediate also a direct antitumor effect through their recognition of allogeneic determinants on leukemic cells. A phase III clinical trial (TK008 study) to assess the efficacy of HSV-Tkpos cells in the context of haploidentical HSCT for leukemia started in 2010 in Italy, and is currently expanding to multiple centers throughout Europe. Disclosures:Bonini:MolMed S.p.A.: Consultancy.