Diagnosed Acute Myeloid Leukemia Pts Research Articles

Evaluation of Neddylation and Apoptosis-Related Gene Expression in Patients with Acute Myeloid Leukemia

Introduction Regulated cell death (RCD) is a process commonly dysregulated in patients (pts) with acute myeloid leukemia (AML), resulting in the survival of genetically unstable cells. Apoptosis, as the best-known form of RCD, interacts with neddylation, a process that contributes to tumorigenesis and apoptosis resistance. Aims This study was conducted to determine the expression of the selected genes involved in the neddylation pathway and to assess their clinical importance along with selected interacting proapoptotic genes. In addition, we correlated the expression levels of these genes with known prognostic factors in AML and determined their impact on the survival of AML pts. Methods The expression of selected proapoptotic genes BIK, BAX, BAK, BCL2L11, BBC3 , PMAIP1 CASP3, CASP7, and neddylation-related genes: CUL1, CUL2 , CUL4A, CUL5, CUL7, CUL9, NEDD8 was determined in duplicates in bone marrow samples of newly diagnosed AML pts. Real-Time PCR was carried out using the TaqMan chemistry and the QuantStudio7 thermal cycler (Applied Biosystems-Thermo Fisher Scientific). Gene expression was normalized using reference genes selected by the Normirazor tool. The normalization was performed by ∆Ct = Ct (reference) - Ct (mRNA of interest). This approach results in higher values for higher mRNA expression. Differential expression analysis was performed using a Welch t-test. Kaplan-Meier method with the log-rank test was used to assess overall survival (OS). Results In a prospective study, we included 40 newly diagnosed AML pts (mean age 62; range 26-87) with a median (m) follow-up of 6.7 months (95% CI: 4.5-9.1). High-risk AML was present in 52.5%, intermediate-risk in 32.5%, and low-risk in 15% of pts, according to European LeukemiaNet (ELN) 2022 risk stratification. NPM1 mutation was present in 23%, whereas FLT3 ITD or TKD mutation in 25% of pts. Intensive treatment was introduced in 43% of pts, while 25% were treated with azacitidine+venetoclax. Non-intensive treatment with azacitidine in monotherapy was administered to the remaining pts. BAK expression was detected in 70%, BIK in 98%, while expression of the other genes was found in all pts. In the high-risk group, we detected lower expression of both proapoptotic BAX (fold change - FC=0.7, p=0.01) and BIK gene (FC=0.4, p=0.01), as well as lower expression of CUL9 (FC=0.7, p=0.03). Accordingly, in pts with NPM1 mutation we revealed upregulation of BIK (FC=6.1, p=0.001), and CUL9 (FC=1.6, p=0.01). Whereas pts with FLT3 mutation had lower expression of proapoptotic BBC3 (FC=0.5, p=0.01), and neddylation-related CUL1 (FC=0.6, p=0.01). In cases of initial bone marrow blasts infiltration above median value (>49%) BCL2L11 CUL5 , NEDD8 and PMAIP1were downregulated ( p=0.001-0.02), while CUL7 ( p=0.00) and CASP3 ( p=0.04) were upregulated. Patients with initial white blood cell count >20 G/l had lower expression of BCL2L11 ( p=0.005), and CUL4A ( p=0.02), while higher expression of CASP7 ( p=0.04). The mOS in the study cohort was not reached. OS was longer in pts with higher (> -2.061, cutoff was determined with CutOff Finder) BAX expression (log-rank: p=0.03) [Figure 1]. The mOS was not reached in this group, whereas the mOS in pts with lower BAX expression was 1.3 months (95% CI: 0.6-1.3). In univariate Cox regression analysis, higher BAX expression (HR 0.31, 95%CI: 0.11-0.84, p=0.022), higher albumin level (HR 0.13, 95%CI: 0.04-0.41, p=0.0004), and intensive treatment (HR 0.18, 95%CI: 0.04-0.69, p=0.012) were factors influencing the outcome. In the multivariate model for OS, higher expression of BAX (HR 0.03, 95%CI: 0.003-0.33, p=0.004) retained its significant protective effect in the context of established prognostic factors [Table 1]. Conclusions To our knowledge, we were the first to evaluate such a complex spectrum of neddylation and apoptosis-related genes in AML. We revealed dysregulation of these genes in AML. Our data indicate that upregulation of BAX at the diagnosis is associated with longer OS. Moreover, we reported significantly lower BAX expression in ELN high-risk group. Thus, indicating BAX may be a potential prognostic factor in AML. Our preliminary results did not prove significant differences in the effect of neddylation gene expression levels on the prognosis of AML patients. As studies are emerging on the potential of neddylation-targeted therapies, we are conducting further research to verify the effect of neddylation on AML.

Assessment of SIRT1-SIRT7 and TP53 Genes Expression in Patients with Acute Myeloid Leukemia

BACKGROUND Sirtuins ( SIRTs) are a family of histone deacetylases with 7 representatives ( SIRT1-7), which affect cell survival and metabolism. They influence gene expression by interacting with histones and transcription factors, or directly modulate pathways associated with cell survival, for instance by downregulating p53, thus potentially contributing to cancerogenesis. On the other hand, SIRTs may function as tumor suppressors depending on cellular context. While the role of SIRTs expression is widely discussed in solid neoplasms, they have not been comprehensively evaluated in acute myeloid leukemia (AML) yet. AIMS To investigate the prognostic importance of initial SIRTs expression in AML patients (pts) and its relationship with the expression of TP53. METHODS The study included 40 newly diagnosed AML pts (19 women, 21 men), with a mean age of 62 years (range: 26-87). Low-, intermediate- or high-risk AML according to European LeukemiaNet (ELN) 2022 stratification was diagnosed in 6 (15%), 13 (32.5%), and 21 (52.5%) of pts respectively. The expression of SIRT1-7 and TP53 was examined by real-time PCR using the TaqMan chemistry and the QuantStudio7 thermal cycler (Applied Biosystems-Thermo Fisher Scientific). The reference genes were selected using GeNorm and NormFinder. The mRNA levels were normalized by the formula ∆Ct = Ct(reference) - Ct(particular mRNA). Group comparisons were performed using Welch's t-test. Pearson correlation evaluated the relationship between individual gene expression. Overall survival (OS) was assessed by the Kaplan-Meier method with the log-rank test. Cox proportional hazard regression of clinical factors and genes expression for predicting OS was performed. RESULTS FLT3 ITDor TKD mutations were present in 10 (25%) of pts, NPM1 in 9 (23%), and IDH1 or IDH2 in 6 (15%). 14 (35%) of the study group were diagnosed with AML with myelodysplasia-related cytogenetic abnormalities, AML progressed from myelodysplastic syndrome, or therapy-related AML (secondary AML, sAML). Standard induction chemotherapy was given in 42.5% of pts, 25% were treated with azacitidine+venetoclax (Aza+Ven), and other non-intensive therapies were administered to 32.5%. SIRT4 expression was detected in 92.5% of pts, while expression of the other genes studied was found in all pts. There were no differences in SIRT 1-7 expression in terms of ELN2022 risk stratification. However, TP53 was downregulated in the high-risk group (fold change - FC=0.6, p=0.004). In pts with FLT3 mutation, SIRT7 was downregulated (FC=0.8, p=0.07), while in both NPM1 and IDH1/2 mutated groups, we showed upregulation of TP53 (FC=1.5, p=0.03, and FC=1.5, p=0.001, respectively). Moreover, in older pts (>60 years old) TP53 was downregulated (FC=0.7, p=0.02). In sAML group SIRT3 and TP53 were downregulated (FC=0.7, p=0.08, and FC=0.7, p=0.05, respectively). Significant positive correlations were shown between the expression of individual SIRTs, and it was most strongly expressed between SIRT2 and SIRT6 (r=0.85, p=0.00), SIRT2 and SIRT7 (r=0.81, p=0.00), and SIRT6 and SIRT7 (r=0.76, p=0.00). The median follow-up was 6.7 months (95% CI: 4.5-9.1). The median OS in the study cohort was not reached. There were no significant differences in treatment response or OS considering each SIRT expression level. However, pts with higher TP53 expression (> median) presented longer OS (median OS not reached vs 5.8 months (95% CI:1.3-5.8, p=0.05) [Figure 1]. In the multivariate Cox proportional hazard model for OS, upregulation of TP53 (HR 0.25, 95%CI: 0.08-0.60, p=0.01), age (HR 1.06, 95%CI: 1.01-1.12, p=0.03), as well as initial albumins (HR 0.01, 95%CI: 0.00-0.07, p=0.01), and LDH levels (HR 1.00, 95%CI: 1.00-1.01, p=0.01) were factors influencing the outcome [Table 1]. CONCLUSIONS The expression of SIRTs in AML presented no evident impact on treatment outcome. However, our study revealed that higher TP53 expression was associated with longer OS. Moreover, TP53 upregulation was found in pts with certain mutational profiles, while downregulation in the elderly and those with sAML. The analysis indicates that SIRTs expression may also vary markedly depending on the clinical and molecular context. The expression of individual SIRTs is closely correlated with each other, but these preliminary results did not show their direct relationship with TP53 expression. Further studies on SIRTs are needed to assess their impact on AML.

Combination of Venetoclax and Azacytidine As First-Line Induction Therapy for Acute Myeloid Leukemia in Patients Younger Than 60 Years: A Tertiary Care Center Experience from Our Low Middle Income Country

INTRODUCTION: Anthracycline- and cytarabine-based “7+3” induction chemotherapy has been the frontline treatment option for acute myeloid leukemia (AML) in the non-elderly and fit patient population. Sixty percent of these patients (pts) achieve Complete remission (CR). However, an estimated 30-40% of pts relapse (Tara L. Lin & Livio Pagano et al., Expert Review of Hematology, 2021). In addition, based on a large US database study and studies from India, the “7+3” regimen is associated with high rates of induction mortality, intensive care unit (ICU) admission, and duration of hospital stay. BCL2 inhibition with venetoclax has been a new paradigm for the treatment of AML. Herein, we present our institutional experience in treating AML in pts younger than 60 years (yrs) old with a combination of venetoclax (ven) and azacytidine (aza). METHODS: We conducted a retrospective review of patients aged 18-60 who were newly diagnosed with AML between May 2020 and May 2023, and in this study, we included all pts, who met the WHO criteria for AML, did not have APML, had no prior history of treatment for other malignancies, and had not received prior induction treatment. Pts received aza 75 mg/m2 on days 1-7 and ven, which escalated from 100 to 200 to 400 mg on days 1-3. Ven continued at 400 mg without posaconazole or 100 mg with posaconazole from days 4-28, and bone marrow aspiration and biopsy were performed after day 28. Patients who achieved morphological remission without count recovery had up to 14 days off therapy before subsequent cycles. Non-responders received up to 1-2 additional cycles. Post-response (defined as a complete remission [CR] ), and patients with measurable residual disease (MRD) negative by multiparameter flow cytometry (MFC) with the residual blast cutoff being < 0.1% proceeded to further cycles. The primary objective of the study is to focus on the induction mortality rate and complete remission in younger, newly diagnosed AML pts who received aza and ven in the induction period. Responses to induction and subsequent post-remission therapy were recorded. RESULTS: A total of 17 patients with AML aged ≥ 18 years and ≤60 years were treated with a combination of aza and ven from May 2020 to May 2023. The median patient age was 47 yrs (interquartile range [IQR]: 30-56 yrs, 52.9% age <50 yrs ), and 52.9% of the pts were males. According to the European Leukemia Network (ELN) guidelines for 2022, using FISH and next-generation sequencing (NGS), 5 out of 17 pts (41.2%) were categorized as having favorable risk, 3 out of 17 patients (17.6%) were categorized as having intermediate risk, and 9 out of 17 pts (41.2%) were categorized as having adverse risk. During their inpatient stay, none of the pts required renal replacement therapy (RRT), and 1 out of 17 (5.8%) pts required mechanical ventilation. The dose of ven was 400 mg in 8 out of 17 patients (47%). One pt was on sertraline and received 200mg of ven. The remaining pts (8/17) received 100 mg of ven with posaconazole, which reduced the cost of the treatment to 50%. The median pretreatment white cell count (WCC) was 11.49 x 10^9/L (IQR: 6.25 to 39.74 x 10^9/L). The platelet count took a median of 31 days to recover above 50 x 10^9/L (IQR: 28-43 days), while the median time for the absolute neutrophil count (ANC) to recover above 1 x 10^9/L was 52 days (IQR: 47-60 days). 11 out of 17 (64%) of our patients achieved complete remission (CR1) after the first cycle. Additionally, 5 out of 17 (29.4%) were MRD-negative when compared to a large US study database and an Indian study (see table1). The median duration of hospital stay was 16 days (IQR: 10-20 days), and the induction mortality rate was 1/17 (5.8%) (see table1). This death occurred in a patient with adverse risk. CONCLUSIONS: The response to induction therapy with venetoclax and azacytidine in young adults with AML was similar to the standard “7+3” induction therapy, with around 64% of pts achieving CR after the first cycle. The median duration of hospital stay, frequency of ICU admission, and especially induction mortality have been lower than the “7+3” regimen. BCL2 inhibition has indeed resulted in a paradigm shift in the treatment of AML. Therefore, it may be the right time to consider the combination of ven and aza as the standard first-line induction therapy for all pts with AML.

T-Cells Immune Cluster Analysis Using Cytof Identifies Unique Patient Subgroups with TP53 Mutation and Predicts Complete Remission (CR) in Patients with Acute Myeloid Leukemia (AML) Receiving Venetoclax Plus Hypomethylating Agent Therapy

Introduction The advent of venetoclax (VEN) based chemotherapy has revolutionized the treatment of elderly acute myeloid leukemia (AML), with improvement in remission rates from historical 10%-20% to 60%-70%. However, remission duration is short-lived in patients (pts) with high-risk AML with consequent dismal outcome. As our knowledge of genomic landscape of AML expands and more immunotherapies become available, exploration of the immune tumor microenvironment (TME) of AML may allow identification of subsets of pts that may benefit from immune based therapy. We conducted an investigator initiated prospective study to evaluate TME of pts receiving VEN plus hypomethylating agent (HMA; azacitidine or decitabine) combination. We hypothesize that these pts will cluster into immune-infiltrated vs. immune-depleted sub-types by high-definition immune cell profiling. Methods In 26 newly diagnosed AML pts, who were planned to receive VEN plus HMA therapy, we isolated bone marrow (BM) and peripheral blood (PB) derived mononuclear cells (MC) by density gradient centrifugation and cryopreserved. We performed CyTOF (cytometry time-of-flight) analysis to study their immune signatures. Thawed cells were labeled with metal-conjugated antibodies that bind CD33, CD196, CD19, CD127, CD11b, CD4, IgD, CD11c, CD14, CD56, CD123, TCRgd, CD185/CXCR5, CD45RA, CD27, CD28, CD66b, CD183 (CXCR3), CD161, CD45RO, CD197 (CCR7), CD8a, CD25, CD3, CD20, CD38, HLA-DR, CD194 (CCR4), CD57, CD16 and CD45. We performed a Rphenograph clustering on 25 paired BMMC and PBMC samples (one patient only had PBMC) to create 35 unique clusters for each ( Figure 1). Then we broke down the distribution of cluster by two different groupings: pts with TP53 mutation (m) and those who achieve complete remission. Statistical significance of clusters calculated using t-test. We performed Pearson correlation test on the paired BMMC and PBMC samples to assess correlation between BMMC and PBMC samples. Results Baseline characteristics The median age of the pts was 74 years (range, 53-88), and 17 (65%) pts were male. Ten (37%) pts had secondary AML, and 12 (46%) pts had ELN adverse risk disease (n=6; TP53m). There was no significant difference in median age (p= >0.99), proportion of pts with secondary AML (p= 0.64), acute myelomonocytic leukemia (p= 0.14) white blood cell count (WBC) ≥ 100 (10 9/L) (p= >0.99), and frequency of commonly occurring co-mutations ( ASXL1 [p=0.35]), FLT3 ITD [p=0.54], splicing [p=0.29], IDH1/2 [p=0.28], DNMT3A [p=0.29], NPM1 [p=0.29], TET2 [p=0.35]) in TP53m and TP53 wild-type group. Response 12/20 (60%) evaluable pts achieved complete remission with or without count recovery (CR/CRi). There was no significant difference in median age (p= 0.06), proportion of pts with secondary AML (p= 0.16), therapy related AML (p= 0.60) WBC ≥ 100 (10 9/L) (p= 0.40), and frequency of commonly occurring mutations ( TP53 [p=0.60], ASXL1 [p > 0.99]), FLT3 ITD [p=0.54], splicing [p > 0.99], IDH1/2 [p=0.60], DNMT3A [p=>0.99], NPM1 [p=0.61], TET2 [p >0.99]) in CR/CRi and no-CR/CRi group. CyTOF analysis and Rphenograph clustering on 25 paired BMMC and PBMC samples We found significant clustering with high expression of B-cell activated (cluster 2; p= 0.005), NK cell rich (cluster 1; p= 0.005, cluster 35; p= 0.0009), CD8 T-cells (cluster 31; p= 0.01) and CD4 effector cells (cluster 17; p= 0.005) phenotype among TP53m AML ( Table 1). Among pts who achieved CR/CRi, significant clustering with low expression of B-cell activated (cluster 29; p= 0.01), CD8 cytotoxic (cluster 14; p= 0.01) CD4 activated (cluster 21; p= 0.03) phenotypes observed. Correlation between BMMC and PBMC clustering Among clusters which showed significance for a particular phenotype, we performed Pearson correlation (R 2) and observed strong correlation between BMMC and PBMC samples clustering in cluster 1 (R 2 = 0.99), cluster 2 (R 2 = 0.95), cluster 17 (R 2 = 0.96), cluster 21 (R 2 = 0.99) and cluster 29 (R 2 = 0.93). Conclusion In this single institutional study using CyTOF analysis we have identified novel clustering with immune- infiltrated phenotype among pts with TP53m AML and conversely immune-depleted phenotype among AML pts who responded to VEN plus HMA. Moreover, we found strong correlation in CyTOF analysis conducted from BMMC and PBMC samples. Future studies with larger sample size needed to validate our findings.

Selinexor in Combination with Venetoclax and Azacitidine for Newly Diagnosed (ND) Unfit Acute Myeloid Leukemia (AML): A Multicenter, Open-Label Prospective Study

Introduction: Acute myeloid leukemia (AML) predominantly affects the elderly, with a median age at diagnosis around 68 years (Bhansali, 2023). Due to existing or potential comorbidities and frailty, many patients are unable to undergo conventional intensive chemotherapy at the time of diagnosis. The combination of venetoclax with azacytidine has shown improved clinical response rates of 64% with a median overall survival of 14.7 months (DiNardo, 2020). However, subgroup data demonstrated no significant benefits in the Chinese population, in pts with poor risk, or in those with TP53 mutations. Therefore, managing AML in elderly or unfit pts remains a significant challenge. Selinexor has shown promising tolerability and clinical activity in AML through various phase 1/2 trials. The triple regimen of selinexor, venetoclax, and azacytidine (SAV) has demonstrated favorable results in AML pts with severe co-morbidities in real-world settings. To further evaluate its efficacy and safety, we have designed a prospective study (NCT05736965) to assess the SAV regimen for ND AML pts who are ineligible for intensive therapy. Methods: To report the efficacy and safety of ND AML pts ineligible for intensive chemotherapy, treated with a triple regimen from 6 sites. The study enrolled pts who were unfit for intensive chemotherapy, ≥75 years, had significant comorbidities, an Eastern Cooperative Oncology Group Performance Status (ECOG PS) of ≥3, organ dysfunction, or had abandoned intensive chemotherapy. The primary study objectives were the complete response (CR)/complete response with incomplete count recovery (CRi) rate and overall response rate (ORR). Responses were assessed according to the ELN2022 criteria. Pts received the following treatment regimen: Selinexor 60mg on days 3, 10, and 17; Azacitidine 75mg/m2 on days 1-3, 8-9, and 15-16; Venetoclax 100mg on day 1, 200mg on day 2, and 400mg on days 3 to 14. Each treatment cycle lasted for 28 days. Pts who achieved CR, CRh, or CRi, as per the center's treatment guidelines, were eligible for transplantation at any time point. Remaining pts continued to receive the SAV regimen until disease progression or intolerable toxicity. Results: From March 2023 to the data cutoff on June 10, 2023, a total of 20 pts were enrolled in the study, of which 16 had de novo or therapy-related AML, and 4 had secondary AML with a history of myelodysplastic syndrome. Table 1 displays the baseline characteristics and responses of the newly diagnosed AML pts. The median age of the 20 pts was 64 years (range: 28-80), and the majority of them had high-risk disease: 12/20 (60%) had intermediate-risk, and 8/20 (40%) had adverse-risk according to the ELN 2022 criteria. Additionally, 4/20 (20%) of the pts had therapy-related AML, 6/20 (30%) were aged ≥75 years, 12/20 (60%) had ≥2 high-risk molecular mutations, and a significant proportion had high blast counts. All pts completed at least 1 cycle of treatment (range: 1-4). Specifically, 1patient completed 4 cycles, 2pts completed 3 cycles, and 7pts completed 2 cycles. The remaining 10pts have just completed their first cycle of treatment and evaluation. With the exception of one patient with disease progression (PD), all other pts are still undergoing treatment. As the treatment duration extends, the depth of remission in pts may further deepen. The CR/CRi rates and ORR across the ELN 2022 risk groups for all pts, intermediate-risk group, and adverse-risk group were as follows: 80% (16/20) and 90% (18/20), 75% (9/12) and 91.7% (11/12), 87.5% (7/8) and 87.5% (7/8), respectively. In comparison, the VIALE-A data showed a CR/CRi rate of 52.9% for adverse-risk pts, indicating a higher remission rate observed in this study. As of now, 3 pts were MRD-negative. The reported adverse events of grade 3 or higher occurring in ≥10% of pts in the triple regimen were thrombocytopenia (35%), neutropenia (35%), and infections (15%). The most frequently reported adverse events of Grade 1-2 included anemia, nausea, fatigue, anorexia, and hyponatremia. All adverse events could be managed and improved through dose adjustments and supportive treatment. Conclusions: The SAV regimen has been found to be safe and effective, with encouraging complete response (CR) rates in newly diagnosed AML pts, especially in adverse risk patients. Further trial enrollment and correlative analysis are currently underway to thoroughly observe the efficacy and safety of the SAV regimen.

Venetoclax Plus Azacitadine for Middle Aged and Elderly Patients with Newly Diagnosed Acute Myeloid Leukemia: Interim Analysis of a Prospective, Multicenter, Single-Arm, Phase 2 Trial

Background: “7+3” induction is the standard regimen in newly diagnosed young patients (pts) with acute myeloid leukemia (AML) fit for intensive chemotherapy with 60-80% complete remission rate. However, middle aged and elderly pts may experience more severe complications during induction therapy and overall survival is shorter than that of younger pts. Recently, venetoclax with azacitadine as induction therapy was approved as the first line therapy for pts with aged more than 75 years or unfit pts with composite complete remission (CRc) of 60-70%. We hypothesize that venetoclax with azacitadine as induction therapy in fit middle aged and elderly pts may have similar CRc rate and less complications. This study aims to evaluate the safety and efficacy of venetoclax plus azacitadine as induction therapy in fit middle aged and elderly newly diagnosed AML pts. Methods: This is an interim analysis of an ongoing phase 2 clinical trial (NCT05471700) of a planned 40 untreated AML pts aged 45-65 who were fit for intensive chemotherapy according to Ferrara Criteria. In cycle 1, pts received azacitadine 75mg/m2/day on d1-7 and venetoclax escalated from 100mg to 200mg to 400mg until 28-day cycle was finished. For pts with FLT3-ITD positive, sorafenib was optional administered at a dose of 400mg twice daily. Bone marrow assessments were performed on d28. Pts who achieved CRc (defined as complete remission[CR] and CR with incomplete hematologic recovery[CRi]) with intermediate or adverse risk groups received 1 or 2 cycles of consolidation with venetoclax plus azacitadine or center-specific cytarabine-based consolidation. Allogeneic stem cell transplantation (HSCT) was performed if a donor was available. Pts in favorable risk gruop received 3 to 4 cycles of center-specific intermediate or high dose cytarabine-base consolidation. Non-responders or pts who achieved partial remission received 1 more cycle of venetoclax plus azacitadine. Who could not get CRc after 2 cycles of induction would be withdrawn from the study. The primary objective is to determine the CRc rate. The secondary objective is safety, MRD negative rate, duration of remission (DOR), the rate of allo-HSCT, event free survival (EFS), and overall survival (OS). The endpoint is to show that venetoclax plus azacitadine is not inferior to “3+7” induction in fit pts with newly diagnosed AML aged 45-65. Results: From 10/9/2022 to 6/30/2023, a total of 32 pts was enrolled to this study, comprising 18 males and 14 females. There were 27 (84%) pts with de novo AML, 2(6%) pts were secondary AML, 3 pts (9.4%) were therapy-related AML. Median age was 58 years (range, 45-64 years). There were 2(6%), 14(44%) and 16(50%) pts were in the favorable, intermediate and adverse risk group, respectively. The baseline patient characteristics are summarized in Table 1. Outcome data were updated as of June 30, 2023, for a median follow-up of 2.2(0.2-8.8) months. Among 27 evaluable pts, 21(77.8%) achieved CRc with 11(40.8%) in CR and 10(37.0%) in CRi, 2(7.4%) achieved PR in cycle1, while 23(85.2%) achieved CRc with 14(51.9%) in CR and 9(33.3%) in CRi, 4(14.8%) got induction failure after 2 cycles(Figure 1). A total of 16 (61.5%) pts got MRD negative among the pts with CRc after cycle1, and 17 (65.4%) after cycle2. CRc rate after 2 cycles in ELN2017 favorable, intermediate, adverse risk group was 100%, 83.3% and 85.0%, respectively, and MRD negative rate was 100%, 88.9% and 55.6%, respectively. The regimen was well tolerated. No mortality occurred during induction therapy. The most common non-hematological grade 3/4 AE were febrile neutropenia (n=13, 40.6%)，followed by pneumonia (n=3, 9.4%).Sepsis occurred in 1 (3.1%) pt. With a median follow-up of 2.2(0.2-8.8) months, the median remission duration, EFS and OS have not been reached. Conclusions: Preliminary results indicate that venetoclax plus azacitadine as an induction regimen for fit middle aged and elderly pts with newly diagnosed AML is promising with high CRc and low toxicity. Recruitment of adults with newly diagnosed aged 45-65 AML pts for this trial is ongoing.

The Presence of Somatic Mutations on Specific Pathways Such As Chromatin Modifier, Spliceosome, and Myeloid Transcription Factor at Diagnosis Was Found to Have Benefit from Allogeneic Hematopoietic Stem Cell Transplantation (HCT) in 1,228 Patients with Acute Myeloid Leukemia in First Complete Remission (CR1)

Introduction Allogeneic stem cell transplant (HCT) brings survival benefit to certain subgroups of acute myeloid leukemia (AML) patients, although it may not be suitable for all cases. Decision for HCT referral is based on the ELN risk grouping, which classifies pts into favorable, intermediate, and adverse risk categories. While HCT is recommended for pts in the intermediate and adverse risk, those in the favorable risk are deferred to receive HCT. However, currently, there is a lack of data directly demonstrating benefits of HCT in specific mutation groups. Patients and Method In this retrospective study, out of 1477 newly diagnosed AML pts 1,228 pts achieved CR1 and had undergone baseline next-generation sequencing (NGS) at diagnosis from January 1997 to January 2020. The data were collected from five different centers located in Toronto, Vancouver, and Montreal, Canada, as well as Hwasun and Seoul, South Korea. NGS was performed in each institution with each institution's standard targeted sequencing panel. To assess the effectiveness of HCT, particular attention will be given to the time from achieving complete remission 1 (CR1) to HCT. To handle immortal time bias, the Mantel-Byar method was used to depict outcomes during the follow-up period. Kaplan-Meier curves were avoided as they can introduce immortal bias, considering the period of time before treatment as part of the treatment arm. Instead, the MBT and landmark methods were employed to address this issue. Allogeneic HCT was treated as a time-dependent variable to prevent immortal bias. Gene mutations were grouped into 6 biologic pathways, including DNA methylation, chromatin modifiers, cohesion complex, activated signaling, tumor suppressor, spliceosome, and myeloid transcription factor (TF) mutations. In the multivariate (MVA) analysis, any mutations with a frequency of >5% were included as well as TP53 which has very grave prognosis. The primary objective of this study is to identify specific groups of AML pts who can derive significant benefits from receiving HCT in CR1, treating HCT as a time-dependent (td) covariate in the analysis. Statistical analyses were conducted using EZR version 1.41. Results The median duration of follow-up among survivors after achieving CR1 was 22.6 months (range: 1-217.9 months). Among the 593 pts, who underwent allogeneic HCT in CR1, the HCT group was composed of younger pts, with a median age of 50 years compared to 56 years in the non-HCT group (p < 0.001). Also, there were fewer pts with NPM1 mutation in the HCT group, accounting for 20.7% compared to 32.4% in the non-HCT group (p < 0.001). Apart from these characteristics, the two groups were similar in other parameters. The 2-year overall survival (OS) was higher in the HCT group, at 66.4%, compared to 54.6% in the non-HCT group (p < 0.0001). Similarly, the 2-year RFS was higher in the HCT group, with a rate of 64.8%, compared to 52.1% in the non-HCT group (p =1.82e-15). Furthermore, HCT as a time-dependent covariate was found to be favorable (Hazard ratio [HR] 0.76, 95% C.I. [0.63-0.91]; p=0.003), as demonstrated in the Simon-Makuch plot (p = 0.003). In the MVA, HCT as a time-dependent covariate retained its favorable impact on RFS (HR 0.67, [0.56-0.82]; p<0.0001). The MVA showed several prognostic factors besides HCT such as NPM1 and CEBPA mutations as favorable factors for RFS, being classified under the European Leukemia Network (ELN) favorable risk group. Conversely, FLT3-ITD, DNMT3A, IDH1, KIT, and TP53 mutations, monosomal karyotype, age > 60 years, and white blood count (WBC) at diagnosis > 55,600/mm^3 were associated with worse RFS. In terms of RFS, the greatest benefit of HCT was observed in the pts having mutations in ASXL1 (HR 0.34 [0.15-0.78]), BCOR (HR 0.29 [0.14-0.61]), IDH1/2 (HR 0.62 [0.42-0.92]), and RUNX1 (HR 0.17 [0.08-0.40]) but no significant benefit in those with KRAS (HR 1.59), NRAS (HR 1.21), PTPN11 (HR 1.23), and WT1 (HR 1.30). According to the biological pathway of somatic mutations, the greatest benefit of HCT in terms of RFS was observed in pts with mutations in the chromatin modifier (HR 0.37 [0.22-0.62]), spliceosome (HR 0.32 [0.16-0.65]), and myeloid TF pathway (HR 0.52 [0.34-0.79]). Conclusion Allogeneic HCT exerts a greater benefit on RFS in AML pts with mutations in the chromatin modifier, spliceosome, and myeloid TF pathways. Further study is warranted to replicate this finding.

P392: PHARMACOLOGICAL INHIBITION OF SYK CONFERS ANTI-PROLIFERATIVE AND NOVEL ANTI-TUMOR IMMUNE RESPONSES IN AML

Background: Spleen tyrosine kinase (SYK) acts as a key integrator of signals from cell surface receptors containing an immunoreceptor tyrosine-based activation motif to boost cellular proliferation. In acute myeloid leukemia (AML), SYK serves as a relay to an oncogenic transcriptional regulatory network linked to NPM1, HOXA9 and MEIS1. The selective, orally bioavailable SYK inhibitor entospletinib (ENTO) has demonstrated clinical activity and tolerability in HOXA9/MEIS1-driven AML. ENTO is currently being investigated in a global Phase 3 trial, AGILITY (NCT05020665), in combination with intensive induction/consolidation chemotherapy in patients (pts) with treatment-naive NPM1-mutated (NPM1m) AML. Lanraplenib (LANRA) is a next-generation SYK inhibitor with similar potency and selectivity to ENTO but with more favorable pharmacologic properties that is currently being evaluated in combination with gilteritinib in pts with relapsed or refractory FLT3-mutated AML (NCT05028751). Aims: To investigate the effects of ENTO and LANRA in T-cell responses in AML. Methods: All pt-derived bone marrow (BM) and peripheral blood samples were obtained in accordance with IRB (OHSU#004422) approval. Results from gene expression profiling studies (RNA sequence [RNA-seq]) in bone marrow/peripheral blood mononuclear cells (MNCs) derived from 152 pts with AML, for which matching NPM1 status and ex vivo sensitivity to ENTO was available, previously published by Tyner et al (2018), were reanalyzed using trimmed mean of M values normalization and differential expression using edgeR. ENTO/LANRA sensitivity was assessed ex vivo after 72 hours in culture at 37°C by MTS assay. T-cell functional assays were performed by culturing MNCs with anti-CD3 and treating with ENTO or LANRA, singly and in combination with anti-PD1. CD3+ T-cell proliferation as measured by Ki67 expression and pSYK activation were assessed by quantitative single-cell immunofluorescence microscopy. Six formalin-fixed, paraffin-embedded BM biopsies from newly diagnosed AML pts were assessed for spatial expression of mRNA using a digital spatial profiling method. Results: In AML, mutations in NPM1 with co-expression of HOXA9/MEIS1 at baseline predicted anti-proliferative activity to ENTO in ex vivo drug sensitivity studies. Accordingly, treatment of leukemic cells with either ENTO or LANRA inhibited SYK auto-phosphorylation in a dose-dependent manner. Pathway analysis of archival RNA-seq data from pts enrolled in the Leukemia and Lymphoma Society BEAT AML Master Protocol (NCT03013998 [BAML-16-001-S6]) revealed gene expression signatures at baseline associated with the observed sensitivity to ENTO, including significant enrichment in the expression of genes associated with leukemogenesis, myeloid differentiation and immune regulation. This was supported by T-cell functional studies, which demonstrated that ENTO and LANRA, singly as well as in combination with anti-PD1, could restore T-cell proliferation in primary AML pt samples that exhibited suppression. Lastly, Cancer Transcriptome Atlas analysis on archival BM biopsies obtained from these AML pts showed a strong correlation between immune checkpoint response and gene expression associated with immune pathway signaling. Summary/Conclusion: Inhibition of SYK is a promising therapeutic approach in NPM1m AML. Our studies illustrate that ENTO and LANRA may restore T-cell proliferation in a subset of AML pts with dysfunctional T-cell responses, suggesting a novel mechanism of action. Additional studies are required to fully understand the mechanism of SYK-mediated antitumor immune responses in AML.

P506: ACHIEVEMENT OF MEASURABLE RESIDUAL DISEASE CLEARANCE IS A STRONGER PREDICTOR OF PATIENT OUTCOME THAN TREATMENT INTENSITY IN NEWLY DIAGNOSED PATIENTS WITH ACUTE MYELOID LEUKEMIA

Background: Modern therapy for acute myeloid leukemia (AML) can consist of either intensive or low-intensity regimens selected based on patient (pt) age/comorbidities. Measurable residual disease (MRD) has emerged as a strong independent prognostic factor in AML. It is unknown whether pts who achieve similar levels of MRD clearance experience comparable outcomes irrespective of treatment intensity. Aims: To establish the relative prognostic contribution of treatment intensity and MRD status on overall survival (OS) and relapse-free survival (RFS) in newly diagnosed AML pts who have achieved a first response. Methods: We conducted a retrospective chart review to identify non-CBF, non-APL AML pts treated at our institution between 2010 and 2021 with intensive (IA; int/high-dose cytarabine + anthracycline-based, without venetoclax) or low-intensity (Lo + VEN; low-dose cytarabine/hypomethylating agent-based, with venetoclax) regimens who had achieved CR/CRi/MLFS and undergone MRD testing by multiparameter flow cytometry at time of first response. Differences in baseline pt characteristics were evaluated using the Chi-square or Wilcoxon-Mann-Whitney tests for categorical and continuous variables, respectively. The Kaplan-Meier method was used to estimate median OS and RFS, with pts censored at the time of stem cell transplantation (SCT). Multivariate analysis was performed using a Cox proportional hazards model. Results: We identified 635 pts meeting inclusion criteria. Baseline characteristics are shown in Table 1. Compared to the IA-treated pts (n=385), pts treated with Lo + VEN (n=250) were significantly older, more likely to be male, less likely to achieve MRD clearance, and more likely to be classified as adverse risk by ELN 2017. The SCT rate in the Lo + VEN cohort was half that of the IA cohort (25% vs 50%). Median OS was 51m, 24.6m, 15m, and 9.9m in the IA MRD(-), Lo + VEN MRD(-), IA MRD(+), and Lo + VEN MRD(+) groups, respectively. Median RFS was 27.8m, 15.4m, 7.3m, and 5.2m in the IA MRD(-), Lo + VEN MRD(-), IA MRD(+), and Lo + VEN MRD(+) groups, respectively. Pts within the same MRD category (+ or -) had significantly higher OS and numerically higher RFS if treated with IA versus Lo + VEN. When the analysis was restricted to pts aged ≥ 60 years (n=56 in IA, n=239 in Lo + VEN; Fig. A-B), the differences within MRD categories did not reach statistical significance (median OS NR in IA MRD(-) vs 24.6m in Lo + VEN MRD(-), p=0.08; median OS 13m in IA MRD(+) vs 10.6m in Lo + VEN MRD(+), p=0.50; median RFS NR in IA MRD (-) vs 15.4m in Lo + VEN MRD(-), p=0.07; median RFS 25.1m in IA MRD(+) vs 5.3m in Lo + VEN MRD(+), p=0.24). The SCT rate was 29% (87/295) in the age ≥ 60 cohort. Given the confounding effect of unbalanced pt characteristics between the IA and Lo + VEN cohorts, we performed a multivariate analysis on the full population (n=635) taking into consideration the effects of age, treatment intensity, MRD status, and ELN category on OS and RFS (all significant by univariate analysis). In the multivariate analysis for OS, ELN adverse risk was the strongest predictor (HR 2.09, p<0.001), followed by MRD(+) status (HR 1.68, p<0.001), while treatment intensity and age were not significantly predictive. For RFS, ELN adverse risk (HR 2.31, p<0.001) and MRD(+) status (HR 1.98, p<0.001) were also the only two significant predictors. Image:Summary/Conclusion: In newly diagnosed AML patients, MRD status at time of first response and ELN risk are stronger predictors of pt outcome than intensity of therapy received.

Prognostic Impact of Morphological Cellularity in Early Assessment Bone Marrow Biopsy after 7+3 Induction in Patients with Acute Myeloid Leukemia

Background:Blast clearance in early assessment bone marrow biopsy (BMBx) is well studied as a potential prognostic factor for newly diagnosed acute myeloid leukemia (AML) patients (pts). However, prognostic impact of morphological cellularity in early assessment BMBx remains unclear.Methods:We retrospectively identified newly diagnosed AML pts, treated at University Hospitals Seidman Cancer Center between 2003 and 2016, who underwent early assessment BMBx after median of 13 days (range: 12 - 17) from initiation of 7+3 induction chemotherapy. Eventual outcome of induction was defined per Cheson criteria. Risk groups were determined by combining cytogenetic and molecular data based on the National Comprehensive Cancer Network guidelines. Overall survival (OS), calculated from date of diagnosis, and relapse free survival (RFS), calculated from date of first complete remission (CR), were estimated by the Kaplan-Meier method and compared by the log-rank test. Risk factors identified as having statistical significance on univariate Cox proportional hazards analysis (p<0.05) were selected for multivariate analysis.Results: We screened 501 newly diagnosed AML pts and identified 183 AML pts who meet our inclusion criteria for analysis. Median age at diagnosis was 58.3 (range: 25.8 - 76.2). Patient and treatment characteristics are listed in Table 1.After analyzing different cut-off points, ≥10% morphological cellularity in early assessment BM biopsy yielded greatest differential in OS and RFS. Therefore optimal and suboptimal response cohorts were defined as <10% and ≥10% cellularity in early assessment BMBx, respectively. One hundred (55%) pts had optimal and 72 (39%) pts had suboptimal response. Eleven (6%) pts were unclassifiable because cellularity was not mentioned as a numerical value (Figure 1). In the optimal response cohort; 5 (2%) pts underwent second induction after early assessment BMBx and 95 (98%) pts were observed, with CR rate of 80% and 86%, respectively. Among 13 (14%) pts who didn't achieve CR after observation, 12 pts underwent second induction, with CR rate of 25%, and 1 pt died before second induction. In the suboptimal response cohort; 40 (56%) pts underwent second induction after early assessment BMBx and 29 (40%) pts were observed, with CR rate of 70% and 59%, respectively. Twelve (41%) pts who didn't achieve CR after observation underwent second induction, with CR rate of 42%. Overall 50 (69%) pts in the suboptimal response cohort and 88 (88%) pts in the optimal response cohort ultimately achieved CR after either first or second induction.Among observed patients, who did not receive early 2nd induction, ≥10% cellularity in early assessment BMBx was reliable as a predictive tool for CR (specificity 83%, negative predictive value 86%) but it was not reliable as a predictive tool for no-CR (sensitivity 48%, positive predictive value 41%).Median follow-up of pts was 28 months since diagnosis. Two-year OS for pts with optimal and suboptimal response at early assessment BMBx was 59.9% (CI 50.1% - 71.5%) and 33.3% (CI 23.4% - 47.3%), respectively (p= 0.001) (Figure 2A). When we censor pts at their first transplant to remove effect of transplant on survival curves, 2-year OS for pts with optimal and suboptimal response at early assessment BMBx was 77.8% (CI 65.7% - 92.0%) and 44.6% (CI 27.1% - 73.4%), respectively (p= 0.003) (Figure 2B). Two-year RFS for pts with optimal and suboptimal response at early assessment BMBx was 49.5% (CI 39.6% - 61.9%) and 29.9% (CI 19.6% - 45.6%), respectively (p= 0.015) (Figure 2C). On univariate analysis, poor-risk group by cytogenetic and molecular data, hemoglobin (<8.8 g/dL), secondary AML, >5% blast and ≥10% cellularity at early assessment BMBx showed statistically significant correlation with OS (Table 2). On multivariate analysis, only poor-risk group and ≥10% cellularity at early assessment BMBx remained to be statistically significant predictors of OS.Conclusions:In our cohort of pts with AML, ≥10% morphological cellularity in early assessment BMBx provided strong independent predictive value for OS, whereas >5% blast was not an independent risk factor. Our findings indicate that ≥10% cellularity in early assessment BMBx can be part of overall risk stratification tools and the definition of hypoplasia should include <10% cellularity when considering early assessment biopsies. [Display omitted] DisclosuresCooper:Novartis: Research Funding. Caimi:Incyte: Equity Ownership; Celgene: Speakers Bureau; Seattle Genetics: Equity Ownership; Abbvie: Equity Ownership. Malek:Celgene: Speakers Bureau; Takeda: Membership on an entity's Board of Directors or advisory committees, Speakers Bureau; Sanofi: Membership on an entity's Board of Directors or advisory committees. De Lima:Pfizer: Membership on an entity's Board of Directors or advisory committees; Celgene Corporation: Research Funding.

Maximal Tolerated Dose of the BCL-2 Inhibitor Venetoclax in Combination with Daunorubicin/Cytarabine Induction in Previously Untreated Adults with Acute Myeloid Leukemia (AML)

Maximal Tolerated Dose of the BCL-2 Inhibitor Venetoclax in Combination with Daunorubicin/Cytarabine Induction in Previously Untreated Adults with Acute Myeloid Leukemia (AML)

Clinical and Prognostic Implications of PTPN11 Mutations in Acute Myeloid Leukemia (Alliance)

Clinical and Prognostic Implications of PTPN11 Mutations in Acute Myeloid Leukemia (Alliance)

Factors Associated with Clinical Outcomes after Venetoclax-Based Combination Therapy in Acute Myeloid Leukemia and High-Grade Myeloid Neoplasms

Background Outcomes of older patients (pts) with acute myeloid leukemia (AML) ineligible for intensive chemotherapy (IC) remain poor with an overall survival (OS) of &amp;lt;12 months (mo). The combination of venetoclax (ven) and azacitidine (aza) for such newly diagnosed AML pts in the confirmatory VIALE-A trial demonstrated an improvement in OS compared with aza alone. However, this trial excluded pts with prior hypomethylating (HMA) therapy, as well as pts with relapsed/refractory (R/R) disease. Therefore, the outcomes of those pts remain unknown. We thus investigated the outcomes of pts treated with ven-based therapy in the newly diagnosed and R/R settings. Methods Pts diagnosed with AML or high-grade myeloid neoplasms (MN) between 2/2018 - 5/2020 who completed at least one cycle of ven-based therapy were included. Clinical data were collected and targeted next generation sequencing evaluating a panel of ~80 genes commonly mutated in myeloid malignancies was performed. Responses were assessed using the IWG criteria, and OS was calculated from cycle one day one until the date of last follow-up/death. Categorical variables were compared using Fisher's exact test. Univariable and multivariable Cox- and logistic-regression were used to assess factors associated with response and OS. Results Fifty pts were prescribed ven at our center, and eight were excluded as they received less than one full cycle of therapy. Of the 42 pts included, the majority (91%) had AML and 9% had high-grade R/R MDS or CMML. Median age at diagnosis was 66 years (28-88) and 23 pts (55%) were female. Per ELN risk stratification, most (81%) pts had poor, 14% had intermediate, and 5% had favorable-risk disease. Forty percent had de novo-, 52% had secondary/therapy-related AML (t-AML) and 8% had R/R MN. Twenty one (50%) pts received venetoclax for newly diagnosed AML, and of those nine (43%) had prior HMA therapy. Of the other 21 (50%) pts who received venetoclax in the R/R setting, 10 (48%) received prior HMA therapy. Median duration of prior HMA therapy was 6 cycles (1-24). Ven was given in combination with HMA, low dose cytarabine (LDAC), or IC in 35 (83.3%), 6 (14.3%), and 1 (2.4%) pt respectively. Forty pts were evaluable for response. Complete response (CR) or CR with incomplete count recovery (CRi) rate was 47.5%. CR/CRi rates were significantly different based on ven combination (IC&amp;gt; HMA &amp;gt; LDAC, p=.001), AML status (de novo &amp;gt; t-AML &amp;gt; s-AML, p=.025), ELN risk and cytogenetic group (favorable &amp;gt; intermediate &amp;gt; poor, p=.001 and p=.004 respectively). CR/CRi rates were lower for pts receiving prior HMA, p=.012. CR/CRi rates were higher for pts with FLT3 (p=.040) and NPM1 mutations (p=.04). There was a trend for lower CR/CRi for pts with TP53 mutations, p=.095. [Table 1] Newly diagnosed vs R/R disease status, number of mutations (≤3 vs &amp;gt;3), and prior treatment with IC for AML had no impact on CR/CRi rates. There was no difference in median OS (mOS) between newly diagnosed vs R/R pts: 10.9mo vs 9.5mo respectively, p=.61. OS was significantly different based on response (CR vs CRi vs MLFS/PR vs PD with mOS not reached, 13.2, 9.5, and 2.3 mo respectively, p&amp;lt;.001. OS was longer for pts with de-novo AML&amp;gt; t-AML&amp;gt; s-AML with mOS of 15.6, 10.9, and 2.8 mo respectively, p=.007. Lastly, mOS was significantly shorter for pts with prior HMA exposure vs not at 5.0 vs 15.6 mo respectively, p=.003. [Figure 1] Multivariable analysis (MVA) for response demonstrated ELN cytogenetic intermediate vs high risk to be the only factor associated with CR/CRi, p=.004. MVA for OS showed prior HMA exposure and ELN poor cytogenetic risk to be the only two factors associated with shorter OS, p=.022 and p=.007 respectively. Conclusions In summary, this study of real world outcomes with ven combination therapy in AML has revealed disease features predictive of clinical outcomes. Remarkably, we observed no difference in response rates or OS between pts with newly diagnosed AML or R/R disease, which may be in part reflective of a population with high disease risk less likely to respond to upfront therapy. Additionally, we identify in a MVA disease factors predictive of response to therapy such as ELN cytogenetic risk and prior HMA exposure, the latter of which was not previously evaluated in clinical trials. Together, these observations highlight the clinical potential of ven combinations for R/R AML, as well as the need for novel therapeutic strategies to overcome the poor outcomes of pts with prior HMA exposure. Disclosures Patel: Celgene: Consultancy, Speakers Bureau; DAVA Pharmaceuticals: Honoraria; France Foundation: Honoraria; Agios: Consultancy.

A Phase I/II Trial of CPX-351 + Palbociclib in Patients with Acute Myeloid Leukemia

A Phase I/II Trial of CPX-351 + Palbociclib in Patients with Acute Myeloid Leukemia

Outcomes of Venetoclax-Based Regimens Compared with Hypomethylating Agents (HMA) Alone or 7+3 in Elderly Patients with Newly Diagnosed Acute Myeloid Leukemia (AML): A Single Center Retrospective Analysis

Outcomes of Venetoclax-Based Regimens Compared with Hypomethylating Agents (HMA) Alone or 7+3 in Elderly Patients with Newly Diagnosed Acute Myeloid Leukemia (AML): A Single Center Retrospective Analysis

Phase I Trial of Escalating Doses of the Bcl-2 Inhibitor Venetoclax in Combination with Daunorubicin/Cytarabine Induction and High Dose Cytarabine Consolidation in Previously Untreated Adults with Acute Myeloid Leukemia ( AML)

Phase I Trial of Escalating Doses of the Bcl-2 Inhibitor Venetoclax in Combination with Daunorubicin/Cytarabine Induction and High Dose Cytarabine Consolidation in Previously Untreated Adults with Acute Myeloid Leukemia ( AML)

Hypomethylating Agent and Venetoclax Combination Yields Comparable Outcomes to CPX-351 in Newly Diagnosed Acute Myeloid Leukemia

Hypomethylating Agent and Venetoclax Combination Yields Comparable Outcomes to CPX-351 in Newly Diagnosed Acute Myeloid Leukemia

Impact of Leukapheresis and Time to Chemotherapy on Outcomes of Newly Diagnosed Patients (pts) with Acute Myeloid Leukemia (AML) Presenting with Hyperleukocytosis: An Analysis from a Large International Patient Cohort

Impact of Leukapheresis and Time to Chemotherapy on Outcomes of Newly Diagnosed Patients (pts) with Acute Myeloid Leukemia (AML) Presenting with Hyperleukocytosis: An Analysis from a Large International Patient Cohort

Results of a Phase 2, Open-Label Study of Idarubicin (I), Cytarabine (A) and Nivolumab (Nivo) in Patients with Newly Diagnosed Acute Myeloid Leukemia (AML) and High-Risk Myelodysplastic Syndrome (MDS)

Results of a Phase 2, Open-Label Study of Idarubicin (I), Cytarabine (A) and Nivolumab (Nivo) in Patients with Newly Diagnosed Acute Myeloid Leukemia (AML) and High-Risk Myelodysplastic Syndrome (MDS)

Intra-Tumor Heterogeneity in Acute Myeloid Leukemia (AML): Results from a Real Life Cohort

Context. AML is an oligoclonal disease. Intratumoral genetic heterogeneity (ITH) is pervasive in cancers and has often been linked to poor outcome. Except in patients (pts) with complex karyotypes (Bochtler, J Clin Oncol 2013), the clinical relevance of ITH remains unknown in AML. We assessed ITH in a real-life AML cohort.Methods. Since Nov 2015, all newly diagnosed AML pts at our institution were analyzed by targeted sequencing with a 60-gene myeloid panel at an average depth of 815X. Variant Allele Frequencies (VAF) were adjusted for copy number variation to estimate Cancer Cell Fractions (CCFs) and rank mutations by decreasing CCFs. Mutations were segregated into different clones when distant by >10% CCF. Ancestral (as opposed to secondary) mutations are defined as those belonging to the first clone (Figure). We could next derive for each pt the total number of clones and the ITH index, defined as the ratio of secondary to ancestral mutations (according to Turajlic, Cell 2018).Results. We studied 201 consecutive AML pts (median age 67 years, secondary AML 24%). The median number of mutations was 4 (range 0-12). Clonal heterogeneity (>1 clone) was found in 71% of pts with a median of 2 clones per pt (range 1-5). 140 pts received intensive chemotherapy (IC), 50 hypomethylating agents (HMA) and 11 best supportive care (BSC) only.Signaling (FLT3, NRAS, KRAS, KIT, JAK2, CBL, CSF3R, BRAF, NF1, PTPN11, RIT1, CALR and MPL, 60%), DNA methylation (DNTM3A, TET2, IDH1/2, 54%), NPM1 (29%), spliceosome (U2AF1, SRSF2, SF3B1, ZRSR2, PRPF8, 27.9%) and tumor suppressors (PHF6, TP53, WT1, 27.4%) were the most frequently mutated pathways. ELN 2017 risk category was favorable, intermediate, adverse and not evaluable in 35%, 27%, 35% and 3% of pts respectively. Increasing ITH was associated with a higher number of clones (p=0.001) and of mutations (p<0.001). ITH was greater in pts with at least one mutation in histone modifiers (ASXL1, ASXL2, EZH2, KMT2A-PTD KMT2D, KDM6A, p=0.0004), cohesin (STAG2, RAD21, SMC3, SMC1A, CTCF, p=0.0018) or signaling (p=0.002) genes but was not affected by the presence of mutations in DNA methylation or spliceosome, tumor suppressor genes, transcription factors (RUNX1, CEBPA, ETV6, GATA2) or co-activators (BCOR, BCORL1, EP300, CREBBP), all p>0.05. ITH was not different among ELN 2017 risk categories (p=0.15). ITH was independent of age, WBC count and type of AML (secondary vs de novo), all p>0.2.There was no significant difference in the number of mutations (p=0.12), clones (p=0.58) or ITH indexes (p=0.38) according to IC/HMA/BSC treatment strategies. We next performed a preliminary analysis of the prognostic impact of ITH in the 140 pts treated with IC (median age 58y), with a median follow-up of only 12.5 months. 117 (84%) pts achieved CR and 32 (23%) were transplanted in first CR. Median event-free survival (EFS) was 18.7 vs 8.0 months in pts with adv and non-adv ELN risk, respectively (p=0.016). In univariate analyses, DNA methylation (p=0.04) and spliceosome (p=0.007) mutations were the two pathways predicting adverse outcome. The number of mutations (p=0.6) or of clones (p=0.8) had no impact on EFS. Pts with fewer secondary than ancestral mutations (ITH <1, ‘ITH low’ group, n=64 [46%]) had a median EFS of 13.6 months vs 19.8 months in the 76 (54%) pts with ITH index ≥1 (‘ITH high’ group, p=0.067). In a multivariate Cox model accounting for age, log(WBC), ELN risk, AML type (secondary vs de novo), presence of DNA methylation and spliceosome mutations and ITH, ITH-high was identified as a significant predictor of improved EFS (HR=0.54, p=0.03), independently of older age (HR=1.02, p=0.07), adv ELN risk (HR=2.4, p=0.005) and higher WBC count (HR=1.27, p=0.004). Censoring at transplant in first CR did not affect this result. In 14 pts who relapsed after a median of 12.9 months since diagnosis with paired NGS at relapse, the number of clones significantly decreased at relapse (p=0.046).Conclusion. Our results confirm that most AMLs are oligoclonal. Surprisingly, higher ITH is not related to older age or secondary AML. Our preliminary results suggest that lower ITH translates into shorter EFS in pts treated with IC. Longer follow-up and/or increased pt numbers are warranted to determine whether NGS-based assessments of clonal heterogeneity can improve AML risk stratification. [Display omitted] DisclosuresFenaux:Otsuka: Honoraria, Research Funding; Jazz: Honoraria, Research Funding; Janssen: Honoraria, Research Funding; Celgene: Honoraria, Research Funding.