End Of Induction Chemotherapy Research Articles

MIR4435-2HG as a possible novel predictive biomarker of chemotherapy response and death in pediatric B-cell ALL.

Introduction: Although B-cell acute lymphoblastic leukemia (B-cell ALL) survival rates have improved in recent years, Hispanic children continue to have poorer survival rates. There are few tools available to identify at the time of diagnosis whether the patient will respond to induction therapy. Our goal was to identify predictive biomarkers of treatment response, which could also serve as prognostic biomarkers of death, by identifying methylated and differentially expressed genes between patients with positive minimal residual disease (MRD+) and negative minimal residual disease (MRD-). Methods: DNA and RNA were extracted from tumor blasts separated by immunomagnetic columns. Illumina MethlationEPIC and mRNA sequencing assays were performed on 13 bone marrows from Hispanic children with B-cell ALL. Partek Flow was used for transcript mapping and quantification, followed by differential expression analysis using DEseq2. DNA methylation analyses were performed with Partek Genomic Suite and Genome Studio. Gene expression and differential methylation were compared between patients with MRD-/- and MRD+/+ at the end of induction chemotherapy. Overexpressed and hypomethylated genes were selected and validated by RT-qPCR in samples of an independent validation cohort. The predictive ability of the genes was assessed by logistic regression. Survival and Cox regression analyses were performed to determine the association of genes with death. Results: DAPK1, BOC, CNKSR3, MIR4435-2HG, CTHRC1, NPDC1, SLC45A3, ITGA6, and ASCL2 were overexpressed and hypomethylated in MRD+/+ patients. Overexpression was also validated by RT-qPCR. DAPK1, BOC, ASCL2, and CNKSR3 can predict refractoriness, but MIR4435-2HG is the best predictor. Additionally, higher expression of MIR4435-2HG increases the probability of non-response, death, and the risk of death. Finally, MIR4435-2HG overexpression, together with MRD+, are associated with poorer survival, and together with overexpression of DAPK1 and ASCL2, it could improve the risk classification of patients with normal karyotype. Conclusion: MIR4435-2HG is a potential predictive biomarker of treatment response and death in children with B-cell ALL.

Optimal index for detecting splenic involvement on 18F-fluorodeoxyglucose positron emission tomography/computed tomography imaging in diffuse large B-cell lymphoma.

Accurate clinical staging is important in diffuse large B-cell lymphoma (DLBCL) to adapt to optimal therapy. Splenic involvement of DLBCL has been recently more detectable with the advancement of a diagnostic scan by 18F-fluorodeoxyglucose (FDG) positron emission tomography (PET)/computed tomography (CT). Our clinical question is whether splenic involvement was adequately diagnosed by FDG-PET/CT imaging. This retrospective study aimed to determine the optimal index for evaluating splenic involvement in patients with DLBCL. Patients with newly diagnosed DLBCL who were examined with FDG-PET/CT at diagnosis and the end of induction chemotherapy (EOI) was enrolled. The splenic involvement with the splenic FDG uptake value higher than that of the liver at diagnosis or with the decrease of splenic uptake at EOI by visual evaluation was evaluated as positive. The calculative evaluation of splenic involvement, based on the data of standardized uptake value (SUV) of the spleen, used maximum SUV (SUVmax), mean SUV (SUVmean), spleen total lesion glycolysis (spleen TLG), and spleen length. A change in each index following induction chemotherapy was expressed as an index. Receiver operating characteristic analysis was used to set the cutoff value for each index. This study included 52 patients. Spleen TLG (0.904) showed the best accuracy, followed by SUVmax (0.885) and SUVmean (0.885), among the 5 indexes for splenic involvement at diagnosis. Splenic involvement was predicted with a higher accuracy level (0.923) when selecting the cases with values higher than the cutoff level on both spleen TLG and SUVmax. The decision at EOI was more suitable by selecting both positive cases of ∆ TLG and ∆ SUVmax. Obtaining both the positive spleen TLG and SUVmax is recommended at diagnosis to predict splenic involvement. The assessment by ∆ spleen TLG and ∆ SUVmax seems to be optimal.

Serum IgG and IgA level in children with acute lymphoblastic leukaemia and its relation with outcome in induction chemotherapy

Background: Immunosuppression in children with Acute Lymphoblastic Leukaemia (ALL) escalates vulnerability to severe infectious complications which leads to higher morbidity and mortality rates among patients. Immunoglobulins are important part of defence mechanism of the body contributing to the humoral immunity. Of all the immunoglobulins, IgG and IgA represents most common type of antibody in blood circulation and provides most long-lived antibody-based immunity against invading pathogens. In earlier years, studies have shown that, serum immunoglobulins are found to be decreased during chemotherapy and this reduction is related with severe sepsis and death in patients. Early identification of immune status can be much useful for assessment of severity and better risk stratification of the patients. Objective: Evaluation of serum IgG and IgA levels in children with ALL and its relationship with sepsis in induction phase of chemotherapy. Method: This prospective observational study was conducted in the Departments of Paediatric Haematology & Oncology and Department of General Paediatrics, Bangabandhu Sheikh Mujib Medical University, Dhaka. During January 2022 to December 2022, a total 60 paediatric patients of newly diagnosed ALL were included as study population. As control, 30 patients were included in this study from General paediatrics and Paediatric Haematology & Oncology, BSMMU to compare baseline immunoglobulin levels with the study group. Complete history and physical examination of all patients were undertaken, and all prior reports were collected. Serum IgG and IgA level assay was done before starting chemotherapy and at the end of induction chemotherapy in the study group. Patients diagnosed with ALL received chemotherapy modified UK-ALL 2003 protocol. History and data of any event of sepsis, along with the symptoms of complications were taken from all patients during the course of induction chemotherapy. Results: The mean age of the cases were 5.49±3.15 (mean ± SD) years, which ranged from 1.9 to 15 years. Among the cases, 41 patients (68.3%) were male and 19 (31.7%) females. Seven (11.7%) subjects expired during induction chemotherapy. In comparison to the control group the mean IgG level in the study group was lower at baseline and even lower at the end of induction and it was statistically significant (p<0.05). The mean IgG level was low in patients with septic events in comparison with the patients with no septic events. Difference of mean of IgG between septic and aseptic patients was significant only at the end of induction chemotherapy (p<0.05). The mean IgA level was low in study group in comparison with the control group and it was statistically significant (p<0.05) only at the end of induction chemotherapy. The mean IgA level was low in patients with septic events in comparison with the patients with no septic events. Difference of mean of IgA between septic and aseptic patients was significant (p<0.05). Based on the receiver-operator characteristic (ROC) curves of change of S. IgG, with a cut off value 50% decreased from baseline having 68.8% sensitivity and 29.7% specificity for prediction of sepsis. Considering change of S. IgA with a cut off value 50% decreased from baseline having 67.6% sensitivity and 27.5% specificity for prediction of sepsis. Conclusion: In our study, the mean IgG and IgA level of the cases were low in comparison to the control group. The mean IgG and IgA level of the patients were lower who had infectious complications, and it was more marked after induction chemotherapy. Therefore, evaluation of immunoglobulin profiles is recommended to be considered in patients with ALL in further studies.

Flow cytometric and cytomorphological definition of remission achievement in children with B-lineage acute lymphoblastic leukemia

The achievement of remission at the end of induction (EOI) chemotherapy in patients with acute lymphoblastic leukemia (ALL) is the key parameter of treatment effectiveness evaluation. The aim of the study – defining complete remission by multicolor flow cytometry (MFC) and bone marrow (BM) cytomorphology (CM) at the EOI chemotherapy in children with B-lineage ALL. The study was approved by the Independent Ethics Committee and the Scientific Council of the Dmitry Rogachev National Medical Research Center of Pediatric Hematology, Oncology and Immunology. The study included patients of “ALL-MB 2008” and “ALL-MB 2015” trials for whom minimal residual disease (MRD) was evaluated by MFC at the EOI simultaneously with CM BM investigation. Less than 5% blasts in BM and MRD < 1% were established as the remission achievement criteria for CM and MFC respectively. The study group included 1498 children aged from 1 to 18 years (median age was 4 years and 11 months) with B-cell precursor ALL. The overall concordance of MFC and CM was found to be 96.1% (1440 of 1498 patients). In 36 (2.4%) children with MRD ≥ 1%, M1 BM status was observed. In contrast, in 22 (1.5%) patients with M2/M3 BM status by CM, MRD value was below 1%. Treatment outcome was analyzed in 522 patients of “ALL-MB 2008” trial. Children with M2/M3 BM, as well as with MRD ≥ 1% demonstrated dramatically inferior outcome, in comparison to those who achieved remission. The presence of at least one of the mentioned criteria (M2/M3 status by CM or MRD ≥ 1% by MFC) defined a group of 23 (4.4%) patients with very low event-free survival (34.9%, standard error 11.0%) and very high cumulative incidence of relapse (56.4%, standard error 12.0%). For the evaluation of remission achievement, MFC and CM should be applied simultaneously at the EOI. High leukemic burden found by any of these methods is the clear definition of induction failure. MRD detection at the EOI should be implemented in any modern treatment protocol as an obligatory stage of treatment response monitoring and final risk group stratification. Considering the crucial importance of the MRD detection results, this study must be performed only in the reference laboratories of the study groups.

Cancer Genomic Profiling and Minimal Residual Disease Monitoring By Cell-Free DNA Sequencing in Pediatric Leukemia

Introduction: Cell-free DNA (cfDNA) sequencing has been reported as a promising non-invasive tool for detecting cancer and monitoring treatment response. We sought to evaluate the potential of a cfDNA-based strategy for detecting diverse classes of somatic mutations relevant to pediatric leukemia and cancers. Methods: Plasma samples collected at diagnosis from 135 acute lymphoblastic leukemia (ALL) and 34 acute myeloid leukemia (AML) patients were evaluated, including 114 B-ALL and 21 T-ALL. We also studied diagnostic plasma samples from 38 solid tumor and 19 brain tumor patients, and plasma collected from 12 patients with B-ALL at days 15, 22 and end of induction chemotherapy (EOI). Plasma cfDNA extraction and library preparation were performed with the NucleoSnap cfDNA kit and ThruPLEX Tag-Seq HV kit, respectively. Next-generation sequencing was performed using a capture panel covering 355 pediatric cancer genes (including noncoding regions covering hotspots of structural variation) and 8,103 heterozygous population polymorphisms. We developed analytic approaches for de novo detection of all types of somatic mutations, including focal copy number alterations, rearrangements, and large chromosomal abnormalities. Whole-genome sequencing (WGS) was also performed for 10 cfDNA samples from leukemia. Data were compared with corresponding whole-genome, exome and transcriptome tumor cell sequencing data at diagnosis. Results: At diagnosis, plasma cfDNA yield was higher for leukemias than for solid and brain tumors (median, 142 ng/ml, 7.16 ng/ml, and 7.07 ng/ml, respectively. The average coverages of leukemia cfDNA sequencing were 790X by capture panel post error suppression and 69X by WGS. We found that 100% cases of leukemia at diagnosis had detectable circulating tumor DNA (ctDNA) in plasma cfDNA, and the median ctDNA purity was 77%, comparable to primary tumor purity from diagnostic sequencing. Overall, our panel covered 86% somatic variants present in the tumor samples. Of those covered events, capture-based cfDNA sequencing detected 98% SNVs/indels, 95% focal copy gains/losses, 100% internal tandem duplications, 95% chromosomal translocations, and 99% aneuploidy. In addition, capture-based sequencing identified cfDNA-specific variants such as NRAS/KRAS SNVs and a IKZF1 deletion that were subclonal in plasma cfDNA. Of those uncovered events, 85% were structural variants with their breakpoints in intronic/noncoding regions, and cfDNA WGS identified all somatic events present in the 10 sequenced tumor samples. To detect minimal residual disease (MRD) in B-ALL patients during induction, we increased cfDNA sequencing depth for low VAF events, and the detection limit was 0.4% for SNV/indel and structural variations. Compared to the MRD results from flow cytometry, somatic mutations were detected in 7/8 MRD-positive and 1/4 MRD-negative patients on day 15, 3/4 MRD-positive patients on day 22, and 0/2 MRD-positive patients at EOI. We also sequenced cfDNA from peripheral blood and bone marrow plasma for 2 B-ALL patients on day 0, day 15, and EOI, with comparable ctDNA purity and dynamics observed between the two compartments. In a patient with concurrent ALL and neuroblastoma (NBL) who experienced NBL relapse four months after the primary diagnosis, cfDNA genomic profiling identified ctDNA derived from ALL (52% of total plasma cfDNA), primary NBL (20%), and relapsed NBL (10%), suggesting that genetic variations of multiple tumors could be detected in a single cfDNA sample. Conclusion: Our study has demonstrated the utility of cfDNA sequencing to identify both sequence and structural somatic mutations in childhood acute leukemia. This approach will be useful to monitor disease, as well as providing a non-invasive diagnostic approach.

Combination of Selinexor with BTK Inhibitor for Central Nervous System Diffuse Large B-Cell Lymphoma, Possible Mechanisms and Therapeutic Potential Exploration

Background: Primary central nervous system lymphoma (PCNSL) is a rare aggressive extra-nodal non-Hodgkin lymphoma (NHL) of which over 90% are diffuse large B-cell lymphoma (DLBCL). High-dose methotrexate (HD-MTX)-based regimens are the dominant therapy for newly diagnosed PCNSL, but the patients' complete remission rate (CRR) is merely about 50%. Bruton tyrosine kinase (BTK), a critical kinase in the B cell receptor (BCR) signaling pathway, contributes to the degradation of FOXO3a and promotes abnormal B cell proliferation. Recent studies revealed that BTK inhibitors (BTKi) play a role in various B cell lymphomas, including DLBCL, and have also shown promising efficacy in PCNSL. However, the clinical management of PCNSL is still challenging for its limited treatment options and poor prognosis, especially when patients developed acquired resistance to BTKi. Selinexor (KPT-330) is a first-ever oral small molecule Exportin-1 (nuclear output protein XPO1) inhibitor with a molecular weight of 443.31 Da, which can efficiently cross the blood-brain barrier. Currently Selinexor was found to promote the aggregation of FOXO3a and could synergistically inhibit PI3K/AKT and NF-κB pathways with BTKi to overcome acquired BTKi resistance. To investigate the therapeutic potential of Selinexor and BTKi in PCNSL, we examined the combination both in DLBCL cells and A20 transplantation mice, and further explored the clinical efficacy in PCNSL patients. Methods and Results: ABC-DLBCL cell lines (OCI-LY3 and OCI-LY10) were treated with Selinexor for 48 hours. Western blot analysis showed that Selinexor inhibited NF-κB, P-STAT3, and NFATc1 signaling pathways in DLBCL in vitro. Combining Selinexor(1μM) with ICP-022(2μM), a BTKi, resulted in more notable inhibition of the above tumor signaling pathways. A20 murine B-cell lymphoma transplantation models were divided into a control group, Selinexor monotherapy group, ICP-022 monotherapy group, and combination group. Tumor volume was measured after 30 days (Figures 1A), and the number of CD4+ T cells and CD8+ T cells and the corresponding cellular expression of PD-1 and TIM-3 in the spleen and tumor tissues of mice were detected. The results showed that the tumor volume in the combination group was minimized, and the number of CD4+ T cells and CD8+ T cells in spleens and tumors in this group was significantly increased, while PD-1 and TIM-3 expression was downregulated (Figures 1B-C). Based on these results, a prospective, open-label, single-arm, multicenter study was conducted with MSZ regimen (MTX, BTKi, Selinexor) for the treatment of PCNSL (Trial Registration Number: ChiCTR2200062154). Newly diagnosed primary and secondary central DLBCL patients (18-80 years old) received a 6-cycle MSZ regimen (HDMTX 3.5 g/m 2 3-h infusion d1, Zanubrutinib 160 mg Bid po, Selinexor 40 mg Biw po, 3 weeks per cycle) and evaluated by MRI/PET. 5 patients (2 GCB-DLBCL, 3 ABC-DLBCL) were enrolled, with a median age of 65 years (range: 54-73 years), 100% achieved metabolic remission (Figure 2A) and maintained long-term efficacy. 4 patients achieved early deep remissions of over 75% reduction with 1 cycle of treatment, and 1 patient had a complete remission after 2 cycles of treatment (Figures 2B). 3 patients chose radiation therapy as consolidation after the end of induction chemotherapy. 2 others were on maintenance therapy with Selinexor combined with Zanubrutinib, one of them has completed the two-year maintenance treatment and maintained sustained remission till now. Only 1 patient experienced several grade 3 adverse events (AEs) including anemia, decreased white blood cell and platelet counts, and elevated alanine aminotransferase.1 patient developed mild renal insufficiency, which recovered 6 months after the end of treatment. Patients were generally well-tolerated and there were no treatment-related deaths. Conclusion: This is the first report describing that Selinexor combined with BTKi can synergistically inhibit the DLBCL tumor signaling pathway and repairing the immune microenvironment. Correspondingly, in treatment of central DLBCL patients, the novel therapeutic strategy of MSZ regimen has achieved impressive results, with a CRR of 100%. Most patients attained early and rapid deep remissions with durable efficacy. This study provides theoretical support and preliminary clinical data for the combined application of Selinexor and BTK inhibitors.

Survival outcomes in pediatric patients with metastatic Ewing sarcoma who achieve a rapid complete response of pulmonary metastases.

11535 Background: Twenty-five percent of patients with Ewing Sarcoma (EWS) have metastatic disease at diagnosis, most commonly in the lungs. Our objectives were to compare overall (OS) and pulmonary disease-free survival (PDFS) between patients with metastatic EWS at diagnosis who achieve rapid complete response (RCR), defined as radiographic resolution of all pulmonary nodules at the end of induction chemotherapy, and those with residual pulmonary nodules after induction chemotherapy (non-RCR). Methods: This multi-center, retrospective cohort study included children under 20 years of age with metastatic EWS treated from 2007-2020 at 19 institutions participating in the Pediatric Surgical Oncology Research Collaborative. Chi-square tests were conducted for differences among groups, and p < 0.05 was considered significant. Kaplan-Meier curves were generated for OS and PDFS. Cox regression was performed for OS, controlling for whole lung irradiation (WLI), extrapulmonary metastases, and age. Results: Among 153 patients with metastatic EWS at diagnosis, 61 (40%) achieved RCR, and 87 (57%) did not (5 unknown). The median number of pulmonary nodules was 3.5 in the RCR vs 5 in the non-RCR groups (p = 0.02), while bilateral disease was present in 44 (72%) RCR vs 75 (86%) non-RCR patients (p = 0.03). Pulmonary relapse occurred in 58 (38%) patients, including 18 (29%) in the RCR and 36 (41%) in the non-RCR groups (p = 0.14). Factors associated with pulmonary relapse in the univariate analysis include median age [15 years (IQR: 12-17) with pulmonary relapse vs 12 years (IQR: 9-16) without (p = 0.03)] and extrapulmonary metastases at diagnosis [24 (41%) patients with pulmonary relapse vs 26 (27%) patients without pulmonary relapse (p = 0.05)]. WLI was performed in 100 patients and was not associated with a reduction in pulmonary relapse (p = 0.93). Complete surgical clearance of pulmonary disease was attempted in 29 (19%) patients, including 17 of the patients who met the criteria for RCR. On Kaplan-Meier analyses, 5-year PDFS did not significantly differ based on RCR (67%) vs. non-RCR (53%, p = 0.13), or WLI (61%) vs. no WLI (54%, p = 0.32). However, 5-year OS did vary significantly between patients with RCR and WLI (85%), RCR without WLI (55%), non-RCR with WLI (60%), and non-RCR without WLI (25%; p < 0.01). In Cox regression analysis, RCR was associated with improved OS after controlling for WLI, extrapulmonary metastases, and patient age (HR 0.51, p = 0.03). Conclusions: Patients with EWS who had pulmonary metastases at diagnosis had improved OS if they achieved RCR and received WLI, despite having no significant differences in rates of pulmonary relapse. Further research is needed to determine whether clearance of pulmonary disease achieved through surgical metastasectomy provides a comparable survival benefit and if any subsets of patients have a reduced risk of pulmonary relapse after resection.

Rituximab with high-dose methotrexate is effective and cost-effective in newly diagnosed primary central nervous system lymphoma

Induction chemotherapy based on high-dose methotrexate is considered as the standard approach for newly diagnosed primary central nervous system lymphomas (PCNSLs). However, the best combination chemotherapeutic regimen remains unclear. This study aimed to determine the efficacy and toxicities of rituximab with methotrexate (R-M regimen). Consecutive 37 Chinese patients receiving R-M regimen as induction chemotherapy were retrospectively identified from January 2015 to June 2020 from our center in eastern China. Fourteen patients receiving rituximab plus methotrexate with cytarabine (R-MA regimen) at the same period were identified as the positive control group. The response rates, survival, toxicities, length of hospital stay (LOS), and cost were compared. Compared with the R-MA regimen, the R-M regimen showed comparable response rate and survival outcomes, but had fewer grade 3–4 hematological toxicities, shorter LOS, lower mean total hospitalization cost and lower mean total antibiotic cost. Complete remission at the end of induction chemotherapy and ECOG > 3 were independent prognostic factors for overall survival. In conclusion, R-M regimen is an effective and cost-effective combination treatment for PCNSLs, which warrants further evaluation in randomized trials.

AML-317 Long-Term Follow-Up of Acute Promyelocytic Leukemia: Experience From Clinical Hematology Department of Casablanca

Acute promyelocytic leukemia (APL) accounts for about 5-10% of all AML cases, its incidence is about 0.1/100,000. The present study was designed to analyze the clinicopathologic features and outcomes in APL. This is a retrospective descriptive study based on medical records and follow-up of APL patients from 2003 to 2021. It includes all patients diagnosed with APL at the Casablanca Hematology Department. The diagnosis was genetically confirmed by detecting the PML-RAR fusion gene or demonstrating the t(15;17). A total of 94 patients with APL were seen between November 2003 and July 2021 in our department. Median age at presentation was 34 years (range, 1-69 years). The gender ratio was 0.7 (40 men and 54 women). Patients from the northwest region of Morocco, which is dominated by Casablanca, accounted for 47 percent of all patients, followed by 15% from the north and 11% from the east. The median duration of symptoms before presentation was 32 days (range, 2-240 days). At the time of presentation, 51 (60%) of the patients had disseminated intravascular coagulation (DIC). The performance status was 1 in 72% of the cases. The hemorrhagic grade was 36% of stage 2. High-risk, intermediate-risk, and low-risk were seen in 32%, 55%, and 13% of patients, respectively. PML-RAR data was available for 34 patients (36%) and karyotyping data for 85 patients (91%). Except for 15 patients (16%) who died at diagnosis, all 79 patients who were followed up on received chemotherapy: 63 patients (78.8%) received APL protocol and 18 patients (19.8%) Pethema. At the end of induction chemotherapy, 68 patients (86%) achieved complete hematologic remission, while 11 patients (14%) died. 3 patients relapsed after maintenance treatment including 2 cases of neurological relapse and one case of bone marrow relapse, all died. At 4 years, the event-free survival and overall survival rates were 62% and 62%, respectively. Early death remains the major reason for treatment failure. Retrospective studies have reported an early death rate of 7.2-21.1%. In our population, it represents 16%. APL has progressed from a fatal disease to one that is highly curable in the last decade.

Implications of undernutrition in children with acute lymphoblastic leukaemia during induction therapy – experience from a developing country

Introduction: Undernutrition is an important prognostic factor in children with acute lymphoblastic leukaemia (ALL) and higher incidences of mortality are reported during induction remission in severely undernourished children. This study was conducted to assess the prevalence and implications of malnutrition among ALL children during induction therapy. Methods: All children ≤18 years diagnosed and treated for ALL at our institution, between June 2010 to July 2016 were included in this retrospective cohort study. Nutrition was assessed by body mass index-forage z-scores calculated using World Health Organization’s Anthro (<5 years) and Anthro-Plus Software (≥5 years). Children with a z-score of <-2 standard deviation (SD) were classified as undernourished. All events and outcomes were compared between undernourished and adequately nourished children. Results: A total of 72 children were included in this study. Nineteen (26.4%) were undernourished at the time of diagnosis. Twenty-eight (38.8%) children had significant weight loss. Sixty-seven of them attained remissions by the end of induction chemotherapy. Five children who died had significant weight loss. Children with significant weight loss during induction phase had a higher risk of developing complications such as febrile neutropenia, pneumonia, mucositis, and drug interruptions. Those with a deteriorating nutritional status had a higher chance of poor treatment outcome (p=0.05, CI=95%). Conclusion: It is important to assess and monitor the nutrition status of children and timely nutritional intervention is essential. A simple, cost effective nutritional intervention that will decrease morbidity and mortality associated with the disease must be devised.

Assessment of Baseline Nutritional Status, Vitamin B12, and Folate Levels in Patients with Acute Leukemia and Their Effect on Initial Treatment Outcome: A Prospective Observational Study

Abstract Introduction Poor nutrition is a common finding in patients with acute leukemia, affecting disease progression, treatment outcome, and survival. Overall nutritional status and micronutrients status evaluation may be an important step in management of acute leukemia. Objective The objective of this study was to investigate baseline nutritional status, vitamin B12, and folate levels in patients with acute leukemia at the time of admission before starting chemotherapy and their initial treatment outcome. Materials and Methods This was a prospective observational study. We assessed the pretreatment nutritional status of 73 patients by body mass index (BMI), serum vitamin B12 using a two-step chemiluminescent microparticle immunoassay, and serum folate using electrochemiluminescence by Cobas e411 analyzer before initiation of induction chemotherapy and evaluated for treatment response at the end of induction chemotherapy. Results Out of a total of 73 patients, 51 (69.8%) completed induction chemotherapy, 36 (49.3%) showed complete remission, and 15 (20.5%) were in incomplete remission. Of the remaining 22 (30.1%) patients, 11 (15.1%) died due to toxicity during therapy. The mean values of baseline BMI, serum vitamin B12, and folate was 20.46 kg/m2, 956.04, and 13.52 ng/mL, respectively. There was no significant association between vitamin B12 (p-value = 0.609) and folate (p-value = 0.404) deficiency and the response to treatment. Conclusion Baseline nutritional status, serum vitamin B12, and folate levels have no significant role in induction outcome in response to treatment, including mortality in patients with acute leukemia.

Efficacy and safety of obinutuzumab for the first-line treatment of follicular lymphoma: a subgroup analysis of Chinese patients enrolled in the phase III GALLIUM study.

Backgrounds:GALLIUM is a global phase III study that demonstrated significant improvements in progression-free survival (PFS) for obinutuzumab plus chemotherapy (G-chemo) vs. rituximab plus chemotherapy (R-chemo) in previously untreated patients with follicular lymphoma (FL). This study aimed to report the results of a subgroup of patients in China.Methods:Patients were randomized to G-chemo or R-chemo. Responders received maintenance therapy for 2 years or until disease progression. The primary endpoint was investigator (INV)-assessed PFS. Secondary endpoints included the overall response rate (ORR) and complete response rate (CRR) at the end of induction chemotherapy, overall survival (OS), and safety.Results:Overall, 58 patients with FL were randomized to the G-chemo (n = 25) and R-chemo arms (n = 33). The INV-assessed PFS rate at 3 years was 81.8% in the G-chemo arm, vs. 70.2% in the R-chemo arm (hazard ratio 0.35; 95% confidence interval: 0.09–1.34; P = 0.1120). The INV-assessed CRRs (without positron emission tomography [PET]) in these arms were 24.0% and 21.2%, respectively, whereas the ORRs were 80.0% and 90.9%, respectively. INV-assessed CRR-PET was 52.6% in the G-chemo, vs. 60.9% in the R-chemo. Median OS was not reached in either arm. Grade 3 to 5 adverse events were more frequent in the R-chemo arm (97.0% vs. 88.0%).Conclusions:The results of this subgroup analysis were consistent with those of the global population, and they suggest that G-chemo has a positive benefit–risk profile in patients from China with FL.Trial registration:ClinicalTrials.gov, No. NCT01332968.

Dexamethasone Pharmacokinetics Following Standard and Short Dosing Schedules in Patients on the UKALL2011 Trial

Dexamethasone (Dex) is a key component of ALL therapy, with glucocorticoid sensitivity strongly linked to prognosis. However, it also contributes to both short and long term toxicities. The UKALL 2011 trial (ISRCTN64515327) investigated a shorter schedule of Dex as part of randomisation 1 (R1) (10mg/m2 x 14 days vs 6mg/m2 x 28 days), in an attempt to bring about a more rapid cytoreduction whilst limiting toxicities associated with long term steroid exposure. There are limited data regarding Dex pharmacokinetics, however large variability has been reported in children being treated for ALL (Yang et al. 2008).To investigate Dex pharmacokinetics in the context of the UKALL2011 randomised dex dosing and scheduling, blood samples were collected up to 8h post oral administration of Dex on one of the first three days, and one of the last three days of induction chemotherapy. Plasma Dex levels were analysed using a fully validated tandem reverse phase LC-MS method, and non-compartmental pharmacokinetic analysis was performed using Pheonix WinNonlin.Pharmacokinetic parameters from day one sampling are shown in the table below. Exposure, as defined by AUC0-12h, and Cmax were significantly higher on the short arm (n=72) compared to the standard arm (n=53) (p=<0.0001 for both). However, there was substantial overlap between the two arms, with a number of patients on the standard arm exhibiting higher exposures than those on short therapy, despite having a longer duration of treatment, and vice versa. This variation is displayed in the greater than 20-fold variation in AUC0-12h values observed on the two arms (short: 69.1-1,606; standard: 38.3-1,009 hr*ng/mL). When AUC values were extrapolated to the duration of Dex therapy on short and standard arms, patients on the standard arm had a significantly larger overall exposure compared to those on the short arm (short: 16,318 (14,177-19,568) vs. standard: 22,570 (18,012-25,550) hr*ng/mL, median (95% CI) p=0.01).Early response data would indicate a trend towards a higher Dex exposure (AUC) in patients with a day 8 bone marrow blast count <5% versus those patients with a day 8 blast count >5 % (595.3 (458.5-843.7) vs 441.7 (387.5-552.1) hr*ng/mL, median (95% CI) p=0.0006). However, there was no statistical difference between the two randomisation arms in terms of day 8 blast count (p=0.2). Pharmacokinetic profiles also differed between the two days of treatment, with AUC0-12h being significantly higher at the end of induction chemotherapy (n=52, study day 1: 562.5 (435.7-756.5); study day 2:794.5 (648.7-1041) hr*ng/mL, (median (95% CI) p=0.0003).The UKALL 2011 R1 found no statistical difference in terms of steroid related toxicity or MRD response between short and standard Dex dosing. The data generated from patients recruited to the pharmacology sub-study shows considerable variation in Dex pharmacokinetics and suggest that pharmacokinetic variability may be a more important factor than variation in dosing regimen on the two arms of the randomisation. Furthermore, a significantly higher cumulative exposure of patients on the standard arm suggests that in a drug treatment with markedly variable pharmacokinetics, duration of therapy may be more important in terms of the likely impact on clinical response and toxicity. [Display omitted] DisclosuresNo relevant conflicts of interest to declare.

Prevention of Dysbiosis Complications with Autologous Fecal Microbiota Transplantation (auto-FMT) in Acute Myeloid Leukemia (AML) Patients Undergoing Intensive Treatment (ODYSSEE study): First Results of a Prospective Multicenter Trial

Introduction. There is a growing body of evidence highlighting the possible interactions between the microbiota and cancer. However, little is known about the consequence on the microbiota of the intensive chemotherapy in patients with AML. Indeed, intensive treatments of AML are known to negatively impact gut microbiota composition; it is measured by a deep shutdown of diversity indices (eg. Simpson), also called dysbiosis. Decrease in microbiota diversity may impact the immune system and may have consequences on the outcome of AML patients. Therefore, development of strategies to manipulate the gut microbiota may minimize treatment-related complications and potentially improve outcomes. With this background, we developed a single arm prospective phase I/II multicenter trial (ClinicalTrials.gov Identifier: NCT02928523) aiming to evaluate use of auto-FMT in AML patients treated with intensive chemotherapy and antibiotics.Patients and methods. For this purpose, at the time of admission and AML diagnosis, patients were requested to donate stools that were screened according to standard recommendations. If deemed appropriate according to protocol criteria, stools were conditioned, processed with a patented diluent, and stored frozen until transplantation performed after recovery from aplasia and before the second course of chemotherapy. The auto-FMT inoculum was administered as an enema, and was prepared for each individual patient according to standardized and reproducible processes developed by the sponsor of the trial. The primary endpoint was the recovery of microbiota diversity and correction of dysbiosis after auto-FMT. The microbiome diversity and richness were measured at baseline (prior to induction chemotherapy), after induction chemotherapy, and around 10 days post-auto-FMT. Microbiome restoration was assessed at the genus and species level, on the basis of metagenomic results obtained for the 3 sequential samples. Illumina TruSeq Nano Prep kit was used for sequence-library preparation and samples were sequenced on HiSeq 2500 2x125bp, 40 million reads/sample. Secondary objectives included monitoring of the immune system, safety and feasibility of auto-FMT, and a set of parameters exploring the impact of auto-FMT on different patient-related outcomes (clinical status and recovery).Results. At time of this planned intermediate analysis, 35 AML patients eligible for intensive induction chemotherapy (intermediate and unfavorable karyotype) with a median age of 53 (range, 23-67) years were screened. The current interim results concern the 9 patients who fulfilled all criteria for inclusion and were able to proceed to auto-FMT after intensive induction therapy (“3+7” induction or equivalent). Prior to the start of induction chemotherapy, the mean baseline Simpson index (measured at genus level) was 0.836 (95%CI, 0.755-0.987). At the end of induction chemotherapy, a highly significant decrease of -0.519 ([-0.677, -0.361], p<.001) was observed, highlighting the deleterious impact on the gut microbiome of intensive chemotherapy and the multiple antibiotics received during induction. Per protocol, these patients were able to receive an auto-FMT prior to receiving their subsequent consolidation chemotherapy. Auto-FMT was well tolerated, only one serious adverse event was reported: a case of E. Coli infection which resolved after appropriate antibiotherapy. After auto-FMT, the Simpson index returned back to baseline level (difference=0.023 ([-0.135, 0.181], p=0.776), and virtually identical results were obtained when Simpson was measured at species level. The ongoing immunomonitoring of these 9 patients suggested data correlated with the dysbiosis correction.Conclusions. This first multicenter prospective trial reached its primary endpoint in all analyzed cases thus far, and established the capacity of auto-FMT to correct dysbiosis and restore a normal microbiota in AML patients receiving intensive induction chemotherapy and wide-spectrum antibiotics. Correlations with clinical and immune parameters that may influence AML outcome are currently being analyzed and will be presented. The apparent modulation of the immune system through microbiota restoration is a promising venture in the treatment of AML patients warranting further investigations. (The trial was funded by MaaT Pharma whose product was tested in this protocol). DisclosuresMohty:Sanofi: Honoraria, Speakers Bureau. Recher:Celgene, Sunesis, Amgen, Novartis: Research Funding; Novartis, Celgene, Jazz, Sunesis, Amgen: Consultancy. Plantamura:Maat Pharma: Employment. Lehert:Maat Pharma: Consultancy, Honoraria, Membership on an entity's Board of Directors or advisory committees, Research Funding, Speakers Bureau. Doré:Maat Pharma: Consultancy, Honoraria, Membership on an entity's Board of Directors or advisory committees, Research Funding, Speakers Bureau.

Response and Survival in Newly Diagnosed Multiple Myeloma Patients Treated with Cybord Regimen Using Generic Bortezomib — Data from Two Centres from India

Background: The standard of care for patients with newly diagnosed multiple myeloma is induction chemotherapy using novel agents followed by autologous stem cell transplantation, if eligible. In resource limited countries, generic drugs have allowed wider access to novel agents. There is limited data on the outcome of patients treated with induction therapy with generic novel agents. Hence we evaluated the clinical outcomes of patients with newly diagnosed multiple myeloma initiated on a common induction therapy consisting of Cyclophosphamide - Bortezomib - Dexamethasone (CyBorD) using generic Bortezomib at two centres in India.Objectives: The objective of the study was to evaluate (i) response to treatment (ii) progression free survival and (iii) overall survival in patients with MM who were treated with CyBorD regimen using generic Bortezomib as the first line of treatment.Methods: We retrospectively analyzed data of all patients with newly diagnosed multiple myeloma treated with a uniform induction therapy of CyBorD during the study period from January 2012 to June 2016 at two tertiary care centres in India. A total of 195 patients were included. All received Bortezomib 2mgIV/SC on days 1,8 15 and 22; Cyclophosphamide 300mg/m2 IV/Oral on days 1, 8, 15 and 22; Dexamethasone 40 mg IV/Oral on days 1-4 and then weekly once. All drug dosages were prescribed as per the NCCN guideline. All drugs were given on a 28 day cycle and repeated for four cycles. The response to treatment and progression of disease were defined according to the IMWG criteria. Statistical analysis was done in SPSS version 20. Continuous variables were represented as mean (SD) and categorical variables as percentages. Survival analysis was computed by Kaplan -Meier method.Results: The median age of patients was 58 years (range - 23 to 78 years). The proportion of females was 28.72%. The distribution of patients under International Staging System (ISS) I, II and III (n=157) were 24.84%, 28.66% & 46.5% respectively. The median number of CyBorD cycles were 4 (range 2 to 7). Five patients did not have assessment done at the end of induction chemotherapy. Of the remaining 190 patients, the proportion of patients with VGPR (very good partial response) or more, PR (partial response) and stable or progressive disease were 57.9%, 32.1% and 10% respectively. Following treatment with CyBorD, 123 (63.1%) received maintenance Bortezomib while 54 patients (27.69%) underwent an autologous stem cell transplant. On follow up, 59 patients (31.05%) had evidence of disease progression. The mean progression free survival (PFS) was 36.4 (95% CI 31.2-41.6) months and the mean overall survival (OS) was 48.95 (95% CI 45.86-52.05) months (Fig 1). The proportion of Grade III or higher non-hematologic and hematologic toxicity was 32.9% and 8.8% respectively. Peripheral neuropathy (n=22; 11.28%) was the major toxicity seen in our study. Among the 195 patients, 31 (15.90%) died at a median follow up of 21.7 months. The average expenditure for 16 weeks of treatment with generic Bortezomib is US$ 1137.6 USD compared to US$ 9850 for the innovator.Conclusion: Treatment with CyBorD is an effective regimen in newly diagnosed MM patients. The regimen appears tolerable with manageable toxicities and at affordable costs in a resource limited setting.Figure1- Overall survival (OS) of the patients: The mean overall survival (OS) was 48.95 (95% CI 45.86-52.05) months [Display omitted] DisclosuresSrivastava:Bayer Healthcare, Shire, Novo Nordisk, Roche Genentech, LFB: Other: Educational grants / Advisory Board / Grants Review / Data Monitoring Committee, Research Funding.

Detection of circulating immunosuppressive cytokines in malignant pleural mesothelioma patients for prognostic stratification

BackgroundNo data on circulating biomarkers for the prognostic stratification of Malignant Pleural Mesothelioma (MPM) patients are available. We prospectively explored the prognostic role of circulating monocyte and cytokine levels and their dynamic change during chemotherapy. Patients and MethodsMPM patients receiving a first line treatment based on a platinum compound plus pemetrexed were eligible. Blood samples were collected at the baseline and at the end of induction chemotherapy. CCL-2, IL-10 and TGF-β levels in plasma were quantified by Enzyme-Linked Immunosorbent Assay (ELISA); white blood cells, monocytes and platelets were evaluated by blood count test. ResultsThirty-one patients were included in the study. Median overall survival (OS) was 12.13 months versus 9.6 months in patients with lower and higher monocytes count, respectively (p value = 0.02). We further stratified patients according to a combined score based on the association of IL-10, TGF-β levels and monocytes count. High combined score was associated with shorter OS and PFS in univariate and multivariate analysis. Chemotherapy induced an increase in monocytes, IL-10, but not TGF-β levels. ConclusionThe prognostic value of circulating levels of multiple immunosuppressive cytokines and inflammatory cells should be confirmed in a wider validation set of MPM patients.

Frequency of Infectious Mortality at the End of Induction Chemotherapy in Acute Lymphoblastic Leukemia and Lymphoma Patients: Findings From a Tertiary Care Cancer Center.

Background and objectiveIn low- and low-to-middle-income countries (LMICs), the incidence of treatment-related mortality (TRM) in patients with acute lymphoblastic leukemia (ALL) and lymphoblastic lymphoma (LBL) is up to 52%. This study aimed to determine the mortality rate at the end of the induction phase of the treatment among patients with ALL and lymphoma at a tertiary care cancer center.MethodsThis retrospective study analyzed outcomes after induction chemotherapy in pediatric patients with acute leukemia and lymphoma at a tertiary care cancer center from January 2015 to December 2016. Information regarding demographics, clinical characteristics, and laboratory investigations were extracted and reviewed.ResultsOf the total 160 patients, 110 were males, and the mean age of the sample was 4.6 +2.8 years. B-cell leukemia (pre-B-ALL) was diagnosed in 84% (n=134), while 10% (n=6) had acute T-cell leukemia (pre-T-ALL) and 6% (n=10) had lymphoma. Sixteen patients (10%) died within the defined induction period, with 14 deaths occurring due to infections and two deaths resulting from chemotherapy-related toxicity.ConclusionBased on our findings, there is a significant prospect of mortality from infections during induction chemotherapy in patients with pediatric hematological malignancies.

Utility and feasibility of a six-color multiparametric flow cytometry for measurable residual disease analysis in plasma cell myeloma in resource-limited settings with 5-year survival data.

Treatment of multiple myeloma (MM) has evolved over decades with the introduction of novel therapeutic strategies. Response rates has significantly improved; however, there is a need for more sensitive techniques to study the residual disease other than conventional means. We evaluated the feasibility and utility of a two-tube six color multiparametric flow cytometry (MFC) assay for measurable residual disease (MRD) detection in MM patients on treatment. Pretitrated cocktails containing antibodies against CD38, CD138, CD45, CD19, CD56, CD81, CD27, and cytoplasmic kappa and lambda light chains were used in the combination of two tubes and were acquired on a flow cytometer. Limit of detection was determined through dilution and spiking experiments with a limit of 0.01%. Of the 62 patients screened, 58 patients were included in the final study cohort (day 100 postautologous stem cell transplant and at the end of induction chemotherapy). Twenty-eight patients (48%) revealed the presence of MRD in bone marrow on MFC (median = 0.12, range = 0.01-5.89%). Out of 28 MFC-MRD positive patients, only 16 patients showed M band on immunofixation-electrophoresis (IFE) (MRD+/IFE+, 57%), and rest of them were IFE negative (MRD+/IFE-, 42%). Patients with MRD positive status at the end of induction chemotherapy or day 100 posttransplant had an inferior overall survival (P = 0.009) and progression-free survival (P = 0.0002) than those with MRD negativity. We have demonstrated the impact of MRD testing in MM using MFC with a long follow-up data, suggesting its routine incorporation in monitoring the disease independent of the immunofixation status.

Measurable Residual Disease Assessment and Allogeneic Transplantation as Consolidation Therapy in Adult Acute Lymphoblastic Leukemia in Colombia

IntroductionDetectable minimal residual disease (MRD) after therapy for acute lymphoblastic leukemia (ALL) is the strongest predictor of hematologic relapse. The objective of the study was to assess disease-free survival (DFS) and overall survival (OS) of patients with ALL according with MRD status at the end of induction therapy in a Colombian population. Patients and MethodsWe assessed a retrospective cohort to compare DFS and OS in adults with de novo ALL according to MRD status at the end of induction chemotherapy, and the type of postinduction consolidation strategy used. ResultsA total of 165 adults with ALL were included in the MRD part of the study, 73 patients in the MRD-negative group and 92 in the MRD-positive group. Median DFS for the MRD-positive group was 11 months (95% confidence interval, 11.7-22.2) and was not reached for the MRD-negative group (P < .001). At 3 years, DFS was 18% and 55%, respectively (P < .001). The median OS for MRD-positive patients was 16 months (95% confidence interval, 8.8-23.15) and was not reached in the MRD-negative group. At 3 years, OS was 26% and 51% for the former and latter group, respectively. Among subjects who did not receive a transplant, median DFS was 21 months for MRD-negative patients and 9 months for MRD-positive patients (P < .001). The median DFS was not reached in either group, whereas 3-year DFS was 64% for MRD-negative and 70% for MRD-positive patients who underwent transplantation in first remission (P = .861). ConclusionMRD status at the end of induction is an independent prognostic factor for DFS and OS in adult ALL. Allogeneic transplantation in first remission could overcome the adverse prognostic impact of MRD.

Minimal Residual Disease Assessment and Allogeneic Transplantation As Consolidation Therapy in Acute Lymphoblastic Leukemia

Minimal Residual Disease Assessment and Allogeneic Transplantation as Consolidation Therapy in Acute Lymphoblastic Leukemia Abstract Introduction: Detectable minimal residual disease (MRD) after therapy for acute lymphoblastic leukemia (ALL) is the strongest predictor of hematologic relapse (1-4). Colombian reports of adults with ALL showed poor survival rates, the median OS was 12 months and the median PFS was only 7 months (5,6). Most reports from Colombia as well as Latin America did not include patients that had a transplant as an initial consolidation strategy and used MRD as prognostic factor. (7-9). The objective of the study was to assess progression free survival (PFS) and overall survival (OS) of patients with ALL according with MRD status at end of induction therapy. Methods: A retrospective cohort comparing PFS and OS in adults with de novo ALL, according to the MRD status at the end of induction chemotherapy, and the type of post-induction consolidation strategy used. This research work had the endorsement of the ethics and research committees of the institutions where it was carried out. Results: Were included 165 adults with ALL in the MRD investigational group, the basal characteristics of the population are described in table 1.There were 73 patients in the MDR negative group and 92 in the MDR positive group. Median PFS for the MRD positive group was 11 months (CI 95% 11.7 - 22.2), and not reached for the MRD negative group (p&amp;lt;0.001). At three-years PFS was 18% and 55 %, respectively (p&amp;lt;0,001). Fig 1. The median OS for MRD positive patients was 16 months (CI 95%, 8.8 - 23.15) and was not reached in the MRD negative group. At three-years, OS was 26 % and 51 % for the former and latter group, respectively. Fig 2. Among subjects that were not transplanted, median PFS was 21 months for MRD negative and 9 months MRD positive patients (p&amp;lt;0.001). Fig 3A. Median of PFS was not reached in either group, whereas 3-year PFS was 64% for MRD negative and 70% for MRD positive patients when transplantation in first remission was used (p=0.861). Fig 3B. For the patients with only chemotherapy for consolidation treatment, the median OS were 16 months (IC 95% 11.32 to 20.67) for MRD positive, and 27 months IC 95% (20.91 to 33.09) in negative MRD. (p=0.004). The 3-year OS 34% for MRD negative and 22% for MRD positive patients. Fig 4A. The individuals with allogeneic transplantation during first remission overcome de risk of death in the positive MRD status. The median OS were 16 months for positive MRD and transplantation and not reached in negative MRD group, The 3 year OS were 74% for MRD negative and 49% for MRD positive patients. (p=0.187). Fig 4B. Multivariate analysis At multivariate analysis, the Negative MRD status and transplantation in first remission were associated with better PFS and OS, in these patients with ALL de novo, Table 2. Conclusion: MRD status at end of induction is an independent prognostic factor for PFS and OS in adult ALL. Allogeneic transplantation in first remission may overcome the adverse prognostic impact MRD. This is the first report that verifies the impact of MRD, on progression free survival and overall survival in the Colombian population. Disclosures No relevant conflicts of interest to declare.