German Multicenter Study Group For Adult ALL Research Articles

Evaluation of Minimal Residual Disease (MRD) and MRD-Based Treatment Decisions in Ph/BCR-ABL Negative Adult Acute Lymphoblastic Leukemia (ALL): Experience from the German Multicenter Study Group for Adult ALL (GMALL)

Abstract Detectable MRD during chemotherapy is considered to be the most important prognostic factor in ALL. Pts with molecular failure (MolF) have a poorer overall survival (OS), inferior remission duration (RD) and poorer prognosis even after stem cell transplantation (SCT) compared to pts with molecular CR (MolCR) (Gokbuget et al, Blood 2012: 120(9): 1868). Little is known however on the outcome of pts with MRD results not fitting in the above categories e.g. MRD low positive and on the impact of additional treatments in pts with MolF. We report an expanded cohort of pts treated according to protocol 07/03 (within the trial or in GMALL registry). MRD was tested by real-time PCR of clonal TCR and Ig gene rearrangements in a reference laboratory (Kiel). The analysis refers to molecular response in ‘wk 16‘ after induction/1st consolidation and to molecular relapse (MolR) later than wk 16 (all definitions see table). The GMALL recommended referral of MolF and MolR pts to SCT in CR1. The median age of 2061 pts with Ph-neg ALL (1484 trial, N=577 registry) was 34 (16-65) yrs. Pts 625 (59%)/1857 pts had a MolCR and196 (18%) MolF. In addition 7% were MRDneg and 16% MRDpos - both not fulfilling the criteria of MolCR or MolF (definitions see table). Results for OS at 5 yrs (MolCR vs MolF vs MRDneg vs MRDpos) were 83% vs 43% vs 78% vs 68% resp. and for RD 80% vs 38% vs 76% vs 56% resp. Differences were significant (p In 196 MolF pts OS and RD from wk16 onward was 43% and 38% at 5 yrs resp. 121 (62%) MolF pts received SCT in ongoing 1st CR. The SCT rate in MolF pts increased from 54% (2003-2009) to 72% (2010-2016)(p=.008). OS and RD for non-SCT vs SCT pts was 28% vs 53% (p Out of 196 MolF pts, 19 relapsed shortly after wk 16, 2 pts were withdrawn, 1 pt died in CR and data were missing in 6 pts. Of the remaining 168 pts, 52 received immediate SCT (31%), whereas 115 pts received consolidation. Data on molecular response after the next 1-3 cycles or after SCT were available for 142 pts. In B-prec ALL (N=95) and T-ALL (N=47) the MolCR rate was 34% and 43% resp. for non-SCT approaches, whereas 75% and 71% resp. achieved a Mol CR after immediate SCT (table). However, the OS with immediate SCT vs later SCT was 34% (N=52) vs 63% (N=69) at 5 yrs resp (p=.002) and the corresp. RD was 42% vs 66% (p=.001) resp. Furthermore, pts with next consolidation leading to molCR had a superior OS (76% at 5yrs) vs those who did not (44% at 5yrs) (p=.02). A similar difference was seen for RD (60% vs 36% resp.; p=.08). In addition 102 pts with MolR during/after chemo were observed (median time to MolR: 18 mo). OS and RD from MolR onwards were 51% and 35% at 5 yrs. 38 pts were transplanted in ongoing 1st CR. OS w/o and with SCT was 37% vs 71% (p=.001) resp. with corresp. RD of 5% vs 70% (p Important conclusions for future MRD based therapy can be drawn from this large adult ALL cohort: 1) a similar poor prognostic impact of MolF and MolR is underlined; 2) it is demonstrated that pts with any detectable MRD (MRDpos) have an intermediate prognosis and require regular follow-up MRD testing; 3) SCT offers an advantage in MolF and MolR pts, however 4) evidence was provided that later SCT (i.e. in better molecular status) could be superior to immediate SCT; 5) compliance with MRD testing and SCT in MolF increased over time; 6) many MolF pts relapsed quickly; 7) additional chemotherapy offered limited chances to achieve a MolCR, but 8) promising MolCR rates were observed for targeted therapies. For future optimisation of MRD based therapy, logistics for decisions have been implemented earlier in the GMALL trial 08 in order to avoid rapid relapses. A first stratification takes place already after induction and targeted therapies are recommended in all MolF pts before SCT. Download : Download high-res image (209KB) Download : Download full-size image Disclosures Rollig: Janssen: Research Funding; Bayer: Research Funding. Kneba: AbbVie: Consultancy, Honoraria, Other: travel support, Research Funding; F. Hoffmann-LaRoche: Consultancy, Honoraria, Other: travel support, Research Funding; Gilead: Consultancy, Honoraria, Other: travel support, Research Funding; Janssen-Cilag: Consultancy, Honoraria, Other: travel support, Research Funding; Mundipharma: Consultancy, Honoraria, Other: travel support, Research Funding.

Prognostic Value of the Immunological Subtypes of Adolescent and Adult T-Cell Lymphoblastic Lymphoma; an Ultra-High-Risk Pro-T/CD2(-) Subtype.

Simple SummaryT-cell lymphoblastic lymphoma (T-LBL) is extremely rare and aggressive with no practical risk model defined. Considering the controversies over the prognostic value of T-LBL immunological subtypes, we re-evaluated 49 subsequent adult T-LBL patients treated according to the German Multicenter Study Group for Adult Acute Lymphoblastic Leukemia protocols, with 85.7% with complete remissions. To the best of our knowledge, this is the largest study of T-LBL diagnosed by flow-cytometry of the material obtained by fine-needle aspiration biopsy. We show that (1) CD2 status and age are powerful independent prognostic factors influencing overall survival and the risk of treatment failure; (2) the early/pro-T/CD2(−) subtype is associated with extremely poor outcomes; and (3) poor outcomes in ETP vs. non-ETP are strikingly consistent with the pro-T CD2(−) subtype. The lack of CD2 expression in T-LBL emerges as a new marker of an ultra-high-risk of treatment failure. We show here that ETP is a non-uniform entity, where the outcome depends on the CD2 status.(1) Background: T-cell lymphoblastic lymphoma (T-LBL) is extremely rare and highly aggressive, with no practical risk model defined yet. The prognostic value of T-LBL immunological subtypes is still a matter of controversy. (2) Methods: We re-evaluated 49 subsequent adult T-LBL patients treated according to the German Multicenter Study Group for Adult Acute Lymphoblastic Leukemia (GMALL) protocols, 05/93 (n = 20) and T-LBL 1/2004 (n = 29), 85.7% of which achieved complete remission (CR). (3) Results: The 5/10-year overall survival (OS) and event-free survival (EFS) were 62%/59% and 48%/43%, respectively. In 96% of patients, flow cytometry analyses defining the WHO 2008 immunophenotypes were available. Cortical, early/pro-T/CD2(−), early/pre-T/CD2(+), and mature subtypes were identified in 59.5%, 19%, 15%, and 6.5% of patients, respectively. Overall, 20% of patients had the early T-cell precursor (ETP)-LBL immunophenotype, as proposed by the WHO 2017 classification. For the early/pro-T/CD2(−) subtype, the five-year OS and EFS were 13% and 13%, while for all the other, non-pro-T subtypes, they were 69% and 67%. By multivariate analysis, only CD2(−) status and age > 35 years emerged as strong, independent factors influencing OS and EFS, while the risk of CR failure was influenced by age only (>35 years). (4) Conclusions: ETP was non-significant for OS, unless an ultra-high-risk pro-T/CD2(−) subtype was concerned.

Chemotherapy Delays Are Associated with Inferior Outcome in Acute Lymphoblastic Leukemia: A Retrospective Study from a Tertiary Cancer Center in South India

Abstract Background Treatment protocols for acute lymphoblastic leukemia (ALL) have evolved over time to give excellent cure rates in children and moderate outcomes in adults; however, little is known how delays in chemotherapy affect long-term survival. Objectives To find the association of delays during different treatment phases on the survival outcomes. Materials and Methods Data from 149 ALL cases treated between 2009 and 2015 were retrospectively analyzed. Treatment course in commonly used protocols was divided into three phases—induction, consolidation (postremission), maintenance, and also a combined intensive phase (induction plus consolidation) for the purpose of analysis, and delay in each phase was defined based on clinically acceptable breaks. Analysis was done to find the impact of treatment delay in each phase on the survival outcomes. Results The median age was 12 years (range, 1–57). Multi-center Protocol-841 (MCP-841) was used for 72%, German Multicenter Study Group for Adult ALL (GMALL) for 19%, and Berlin, Frankfurt, Muenster, 95 protocol (BFM-95) for 9% of patients. Delay in induction was seen in 52%, consolidation in 66%, and during maintenance in 42% of patients. The median follow-up was 41 months, and 3-year survival outcomes for the entire cohort were event-free survival (EFS)—60%, relapse-free survival (RFS)—72%, and overall survival (OS)—68%. On univariate analysis, delay in induction adversely affected EFS (hazard ratio [HR] = 1.78, p = 0.04), while delay in intensive phase had significantly worse EFS and RFS (HR = 2.41 [p = 0.03] and HR = 2.57 [p = 0.03], respectively). On separate analysis of MCP-841 cohort, delay in intensive phase affected both EFS (HR = 3.85, p = 0.02) and RFS (HR = 3.42, p = 0.04), whereas delay in consolidation significantly affected OS with (HR = 4.74, p = 0.04) independently. Conclusion Treatment delays mostly in intensive phase are associated with worse survival in ALL; attempts should be made to maintain protocol-defined treatment intensity while adequately managing toxicities.

Molecular Subgroups of T Cell Acute Lymphoblastic Leukemia in Adults Treated According to GMALL Protocols

Molecular Subgroups of T Cell Acute Lymphoblastic Leukemia in Adults Treated According to GMALL Protocols

Systematic Review of the Burden and Treatment Patterns of Adult and Adolescent Acute Lymphoblastic Leukemia in India: Comprehending the Challenges in an Emerging Economy

BackgroundIn the present systematic literature review, we sought to describe the burden and treatment practices of adult acute lymphoblastic leukemia (ALL) in India, which reflect the realities and outcomes in a middle-income country. Materials and MethodsWe conducted a search for reported studies using terms such as “adult ALL,” “epidemiology,” and “treatment” in the Medline, Embase, Cochrane, and other database sources. We obtained 249 articles and 18 conference abstracts reported until December 2019. A total of 40 studies were selected to qualitatively summarize the data. ResultsThe proportion of ALL among adult patients diagnosed with acute leukemia at reporting institutions from 16 Indian studies ranged from 7.3% to 57.8%. Most studies were performed in Northern India (n = 12), had a male preponderance (range, 57%-80%), and had a predominance of B-ALL (range, 65.2%-75.9%). The treatment protocols used for ALL included MCP-841, BFM (Berlin-Frankfurt-Münster)-90, chemotherapy plus a tyrosine kinase inhibitor, GMALL (German Multicenter Study Group for Adult Acute Lymphoblastic Leukemia), and hyper-CVAD (cyclophosphamide, vincristine, doxorubicin, dexamethasone). The complete remission rates and median overall survival for these protocols ranged from 46.7% to 91.4% and 7 to 46 months, respectively. The overall relapse rates were 24.3% to 57.1% within median time of 9 to 24 months, with bone marrow the most frequent relapse site. After relapse, most patients had chosen palliative therapy (range, 78.7%-96.0%). The major treatment-related toxicities included neutropenia, myelosuppression, and infection. ConclusionsThe results from Indian studies on adult ALL are heterogeneous, reporting a diverse incidence and poor overall outcomes using varied non-contemporaneous treatment protocols adapted from the developed world. A comprehensive countrywide approach to diagnosis, treatment, and follow-up and the potential incorporation of novel therapies could improve the prognosis and outcomes of adult ALL in India.

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

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

Adults with Philadelphia chromosome-like acute lymphoblastic leukemia frequently have IGH-CRLF2 and JAK2 mutations, persistence of minimal residual disease and poor prognosis.

Philadelphia-like B-cell precursor acute lymphoblastic leukemia (Ph-like ALL) is characterized by distinct genetic alterations and inferior prognosis in children and younger adults. The purpose of this study was a genetic and clinical characterization of Ph-like ALL in adults. Twenty-six (13%) of 207 adult patients (median age: 42 years) with B-cell precursor ALL (BCP-ALL) were classified as having Ph-like ALL using gene expression profiling. The frequency of Ph-like ALL was 27% among 95 BCP-ALL patients negative for BCR-ABL1 and KMT2A-rearrangements. IGH-CRLF2 rearrangements (6/16; P=0.002) and mutations in JAK2 (7/16; P<0.001) were found exclusively in the Ph-like ALL subgroup. Clinical and outcome analyses were restricted to patients treated in German Multicenter Study Group for Adult ALL (GMALL) trials 06/99 and 07/03 (n=107). The complete remission rate was 100% among both Ph-like ALL patients (n=19) and the "remaining BCP-ALL" cases (n=40), i.e. patients negative for BCR-ABL1 and KMT2A-rearrangements and the Ph-like subtype. Significantly fewer Ph-like ALL patients reached molecular complete remission (33% versus 79%; P=0.02) and had a lower probability of continuous complete remission (26% versus 60%; P=0.03) and overall survival (22% versus 64%; P=0.006) at 5 years compared to the remaining BCP-ALL patients. The profile of genetic lesions in adults with Ph-like ALL, including older adults, resembles that of pediatric Ph-like ALL and differs from the profile in the remaining BCP-ALL. Our study is the first to demonstrate that Ph-like ALL is associated with inferior outcomes in intensively treated older adult patients. Ph-like adult ALL should be recognized as a distinct, high-risk entity and further research on improved diagnostic and therapeutic approaches is needed. (NCT00199056, NCT00198991).

Significant Improvement Of Outcome In Adolescents and Young adults (AYAs) Aged 15-35 Years With Acute Lymphoblastic Leukemia (ALL) With a Pediatric Derived Adult ALL Protocol; Results Of 1529 AYAs In 2 Consecutive Trials Of The German Multicenter Study Group For Adult ALL (GMALL)

▪Several groups have reported results from smaller series of AYAs with ALL. Outcomes with so-called protocols for adults were generally inferior compared to so-called pediatric protocols. The GMALL protocols were originally based on pediatric BFM protocols and have been consecutively optimized for adults since 1981. We report the results of two recent protocols 05/93 (Goekbuget et al, Blood 98(11):802a, 2001) and 07/03 (Goekbuget et al, Blood 110(11):12a, 2007). In study 07 high risk (HR) pts were identified by one of the factors: B-lin with WBC>30.000, late CR (>3 wks), pro-B, early T, mature T, MLL1/AF4/t(4;11). Pts without risk factors were standard risk (SR) and those with BCR-ABL/t(9;22) very high risk (VHR). HR/VHR pts were candidates for SCT in CR1. The major innovations in study 07 were: intensified, shortened induction with dexamethasone instead of prednisone, PEG-asparaginase (ASP) instead of native ASP, intensified first consolidation, 6x HDMTX/ASP during consolidation, matched unrelated SCT for HR/VHR pts without sibling donor and SCT indication in pts with persistent MRD. After amendments in trial 07 pts partly also received intensified PEG-ASP, rituximab in CD20+ ALL and imatinib in Ph+ ALL.Overall, 1529 of 3060 (50%) pts recruited into both trials were aged between 15-35 yrs. 642 pts from 94 centres were recruited to study 05 and 887 pts from 130 centres to study 07. Patient characteristics were similar for both trials. 70% had B-Lin and 30% T-ALL (61% c/preB, 9% proB, 7% early T, 6% mature T, 17% thy T) with no significant differences across age subgroups (15-17,18-25 and 26-35 yrs). Allocation to SR, HR and VHR was 51%, 35% and 14%. VHR incidence increased from 3%, 11% to 19% in age groups (p<.0001).The CR rate increased in studies 05 to 07 from 88% to 91% (p=.001), most prominently within the age range of 26-35 yrs (86% to 90%;p=.001) (table). The OS increased from 46% to 65% (p<.0001) (significant in all age groups). Remission duration (RD) at 5 yrs increased from 49% to 61% (p=.0001), most prominently within the age range of 26-35 yrs (46% vs 59%; p=.005). OS improved from study 05 to study 07 in B-Lin (45% vs 66%; p<.0001) and T-ALL (47% vs 63%; p=.0007) overall and in subgroups as c/pre B (50% vs 68%;p<.0001), pro B (45% vs 67%;p=.05), mature T (19% vs 61%; p=.005) and thymic T (59% vs 70%;p=.09) but to a lesser extent in early T (35% vs 48%;p>.05). OS increased in SR (58% to 74%; p<.0001), HR (24% to 58%; p<.0001) and VHR (36% vs 55%;p=.0003).Table 1Results of Induction and Overall Outcome in GMALL-Studies 05/93 and 07/0305/9307/03Total15-1718-2526-35Total15-1718-2526-35Evaluable64210625238488753458376CR88%91%88%86%91%94%91%90%ED3%1%3%3%4%0%3%6%Failure9%8%8%11%5%6%5%4%RD at 5y49%52%50%46%61%60%62%59%OS at 5y46%57%45%42%65%73%69%60%15% vs 43% of all CR pts underwent SCT in CR1 in studies 05 and 07. The proportion of SCT increased from 22% to 68% (p<.0001) in HR and from 62% to 73% (p<.0001) in VHR in studies 05 vs 07. The OS after SCT improved from 36% to 68% (p<.0001), mainly due to a decrease of TRM from 34% to 12% (p<.0001).In trial 07 MRD in week 16 (after consolidation I) was tested in 353 pts. The proportion of molecular failure (MRD>0.01%) was 26% with no differences across age groups. OS was 90% in pts with mol. CR vs 53% in mol. failure (p<.0001). Amendments in study 07 led to further improvement with an OS of 71% in 274 pts aged between 15-35 yrs treated according to the final protocol version.We present here results of the so far largest cohort of AYA ALL pts treated according to pediatric-derived adult ALL protocols. Outcomes have significantly improved and reached a 73% OS in pts aged 15-17 yrs. Intensified treatment with ASP, MTX and targeted therapies as rituximab and imatinib and MRD based stratification have contributed to the improvement in study 07. SCT led to improved OS in HR and VHR ALL. Obviously, there is no indication for SCT in CR1 in young SR pts with an OS of 74%. Future GMALL studies will attempt to optimize further the combination of pediatric approaches and targeted therapies in adults.Supported by Deutsche Krebshilfe 70-2657-Ho2 and partly BMBF 01GI 9971. Disclosures:Off Label Use: RItuximab in ALL.

Low Expression Of BCL11B Predicts Poor Overall Survival In Adult Standard Risk T-ALL

▪ IntroductionAlthough risk stratification, detection of minimal residual disease (MRD) and implementation of novel therapeutic agents have improved outcome in acute lymphoblastic leukemia (ALL), survival in adult T-ALL patients still remains unsatisfactory. Therefore, new prognostic markers and potential therapeutic targets are warranted. BCL11B, a key player in normal T-cell development, has recently gained interest due to its high mutation rate (9-16%) in T-ALL. We investigated the frequency of BCL11B mutations, expression levels and the prognostic value in a large uniformly treated cohort of adult T-ALL. Patients and methodsWe analyzed bone marrow (BM) samples of 201 adult T-ALL patients sent to the reference laboratory of the German Multicenter Study Group for Adult ALL (GMALL). BCL11B expression was determined in 195 patients by qRT-PCR, BCL11B mutations were assessed in 178 patients by Sanger sequencing of exon 4 (including all 6 zink finger [ZF] domains). Low expression of BCL11B was defined by expression levels in the lowest quartile (BCL11Blow), high expression by levels in the three remaining quartiles (BCL11Bhigh). Samples had previously been characterized for expression of BAALC, IGFBP7, MN1, WT1, GATA3, ERG as well as for the mutations status of NOTCH1, WT1, and TCR rearrangements. Clinical data were available for 169 patients enrolled on the GMALL trials. We generated BCL11B associated gene expression profiles (GEP) derived from an independent set of 86 T-ALL patients enrolled in the Microarrays Innovations in LEukemia multicenter study. ResultsBCL11B was aberrantly expressed in adult T-ALL with significantly higher expression levels in thymic compared to early T-ALL (0.6 vs. 0.3, P=0.01). Expression of genes associated with a prognostic impact (BAALC, IGFBP7, ERG) or/and T-cell stage dependent expression profile (GATA3, IGFBP7) showed that BCL11Blow (n=49) had higher MN1 (1.6 vs, 0.3, P=0.01), IGFBP7 (1.3 vs. 0.5, P=0.02), and lower GATA3 expression (2.1 vs. 5.7, P<0.01) compared to BCL11Bhigh patients (n=146). This maturation stage specific expression of BCL11B was stressed by a higher rate of TCR rearrangement in BCL11Bhigh patients (73% vs. 27%, P=0.005) and further underlined by the BCL11B derived GEP linking low BCL11B to an immature molecular signature characterized by high expression of BAALC, IGFBP7, FLT3, CD34. Regarding clinical characteristics, low BCL11B expression was associated with a poor prognosis (5-year overall survival (OS): low 35% (n=40) vs. high 53% (n=129), P=0.02) in the overall T-ALL cohort. In the standard risk group of thymic T-ALL (n=102), BCL11Blow identified patients with an unexpected poor outcome (5-year OS: 20%, n=18) compared to BCL11Bhigh (62%, n=84, P<0.001). In addition, BCL11Blow thymic T-ALL patients showed a lower remission rate (5 years: 38% vs. 72%, P=0.02).BCL11B mutations were found in 24 of the 178 (13.5 %) T-ALL patients. In 9 patients, mutations resulted in frame shifts, whereas the remaining, except for a single one, missense mutations were located in the ZF domains: three resulting in introduction of a stop codon. BCL11B mutations were enriched in the mature immunophenotype (thymic: 20%, mature: 8%, early: 3%, P=0.03). No differences were observed in mRNA levels for BAALC, IGFBP7, MN1, WT1, GATA3, ERG, but patients with BCL11B mutations were less frequently assigned to the BCL11Blow group compared to those with high expression (5% vs. 95%, P=0.02). Regarding the clinical characteristics, BCL11B mutations had no prognostic impact regarding OS, neither in the total T-ALL cohort (5-year OS: 56% vs. 48%, n.s.) nor in the thymic T-ALL subgroup (5-year OS: 65% vs. 51%, n.s). ConclusionOur data confirmingly show a high frequency of BCL11B mutations (13.5%) in the so far largest cohort of adult T-ALL patients. As loss of function mutations were restricted to functional ZF domains and recurrently occurred in thymic T-ALL, these data stress a potential pathogenetic role of BCL11B as T-cell specific transcription factor. Importantly, low expression was associated with poor prognosis; in particular in the standard risk group of thymic T-ALL, BCL11Blow is a novel marker that identifies patients with an unacceptable poor prognosis. These findings might help to improve risk stratification in a significant proportion of adult T-ALL patients, which fail to standard therapy despite the favourable immunophenotypic characteristics. Disclosures:No relevant conflicts of interest to declare.

Allogeneic Stem Cell Transplantation In Adults With High Risk Acute Lymphoblastic Leukemia (ALL) In 1. Remission (CR1): Promising, But Strongly Influenced By ALL Subtypes

Stem cell transplantation (SCT) has contributed to improved overall survival particularly in high risk adult ALL patients and the indication for SCT is a matter of ongoing discussion. We report the results obtained over a period of 18 years in a large center. Patients received first line treatment according to three consecutive trials of the German Multicenter Study group for Adult ALL (GMALL) and risk stratification was performed accordingly. In the most recent trial patients with high risk and very high risk factors are candidates for allogeneic stem cell transplantation (SCT) in CR1 from matched sibling or unrelated donors. The risk factors are: very high risk (VHR): Philadelphia chromosome positive ALL (Ph+ALL); high risk group (HR) of B-lineage ALL (HR-B): leukocytes > 30/nl at diagnosis and/or delayed CR > 3 weeks (other B) or pro B-ALL and of T-lineage ALL (HR-T): early-T-All and mature T-ALL. In addition standard risk patients were candidates for SCT in case of molecular failure or molecular relapse (SR-Mol). 106 high risk ALL patients in CR1 underwent allogeneic SCT between 1995 and 2012 at our center. Median age was 38 years (17 – 67). 40/106 patients had Ph+ALL (VHR), 57/106 patients were HR patients (HR-B n = 32: pro-B-ALL n = 15, other B n = 17; HR-T n = 25: early T n = 17, mature T n = 4, thymic n = 4). 9/106 patients belonged to the SR-Mol group. Stem cell donors were matched related donors (MRD) in 42 patients and compatible unrelated donors in 64 patients. The conditioning regimen was 12 Gy TBI ± Cyclophosphamide or VP16 in 86 patients, other n = 1, and in patients > 55 years 8 Gy TBI + Fludarabine (n = 5) or Fludarabine + Busulfan (n = 14). ATG as GvHD and rejection prophylaxis was given since 5/2005 in all patients with unrelated SCT and in reduced intensity conditioning regimens (RIC). Results60/106 (57 %) patients with high risk ALL transplanted in CR1 are alive, 46/106 (43 %) patients are dead. The median follow-up of the surviving patients is 64 months (5 – 172). Causes of death were leukemia in 16/106 patients (15%) and transplant-related mortality (TRM) in 30/106 patients (28%), mainly infections ± GvHD (n = 24), secondary malignancies (n = 2) and other (n = 4). In Ph+ALL 19/40 patients (47 %) are alive in CR (CCR), 12/40 are dead due to TRM and 9/40 due to leukemia. In HR-B ALL 23/32 patients (71 %) are in CCR, 8/32 are dead due to TRM and 1/32 due to leukemia. In HR-T ALL 11/25 patients (44 %) are in CCR, 10/25 died due to TRM and 4/25 due to leukemia. In SR-Mol patients 7/9 patients (77 %) are in CCR, 2/9 died due to leukemia. Probability of survival (OS) for all patients at 96 months is 0.48, probability of disease free survival (DFS) at 96 months is 0.47, probability of TRM at 96 months is 0.34. OS was 0.50 for patients with myeloablative conditioning (MAC) (n = 86) and 0.38 for patients with RIC (n = 19), n.s. OS was different for the 4 risk groups: VHR 0.42, HR-B 0.67, HR-T 0.27, SR-Mol 0.74, but not significant (0.095). DFS: VHR 0.42, HR-B 0.68, HR-T 0.24, SR-Mol 0.76 (0.041) and TRM: VHR 0.34, HR-B 0.26, HR-T 0.58, SR-Mol 0. (0.026). In HR-B OS was better for pro-B-ALL than other B-lineage (0.73.vs. 0.66, resp.). OS was lower in early-T-ALL (0.24). In mature T-ALL 3/4 patients are dead, in thymic ALL 1/4 patients. In ConclusionLong term survival and probably cure can be reached in high risk ALL patients after allogeneic stem cell transplantation in CR1. OS in pro-B-ALL and B-lineage-HR-ALL patients is better than in Ph+ALL or in HR-T-ALL due to lower relapse rate and lower TRM. Whether the quality of remission before allogeneic SCT could be improved in Ph+ALL and HR-T-ALL, has to be studied. Allogeneic SCT in SR with molecular failure or relapse show promising data, though in a small patient cohort. For all patients the TRM-rate due to GvHD and infection has to be improved due to better supportive care. Disclosures:No relevant conflicts of interest to declare.

FAT1 Expression and Mutation Status In Adult Acute Lymphoblastic Leukemia

IntroductionFAT1 belongs to the FAT protocadherin family, a drosophila homologous gene involved in development processes. Recently, FAT1 gained large interest as it is mutated in various cancers. Besides the known function of cell-cell interaction and polarity, FAT1 loss of function mutations have been linked to dysregulation of the WNT pathway in solid tumors. In acute lymphoblastic leukemia (ALL), aberrantly high expression of FAT1 was claimed to be associated with inferior outcome in pediatric B-lineage ALL. Herein, we investigated the yet unknown frequency and relevance of FAT1 expression and mutation in a large, homogenously treated cohort of adult ALL patients. Patients and MethodsWe investigated FAT1 expression in diagnostic bone marrow (BM) samples of 112 T-ALL, 122 B-lineage ALL, and additional 63 early T-cell precursor (ETP) ALL patients by real time (RT)-PCR. Patients were enrolled in trials of the German Multicenter Study Group for Adult ALL (GMALL) and outcome was investigated for patients into GMALL trials 06/99 and 07/03. Using the T-cell line BE13 as reference, we defined patients with FAT1 expression higher than BE13 as FAT1pos (0.01-38.5) and patients with a lower expression as FAT1neg (<0.01). We additionally examined peripheral blood (PB), BM, CD34+-, CD3+-cells from healthy donors. FAT1mutation status was investigated in 68 T-ALL patients. For mutation analyses customized biotinylated RNA oligo pools (SureSelect, Agilent) were used to hybridize the targeted regions, followed by 76-bp paired-end sequencing on an Illumina Genome Analyzer IIx platform. ResultsNormal hematopoietic cells including unselected BM cells, CD34+-progenitors, or CD3+ T-cells from healthy donors lacked FAT1 expression (<0.01) with the one exception of a CD34+-sample (0.03). In contrast, ALL samples aberrantly expressed FAT1: 32% of B-lineage ALL (0.01-38.5) and 54% of T-ALL cases (0.01-31.2) showed elevated FAT1 expression, with a lower frequency in the immature ETP-ALL subgroup (17%; 0.01-15.2). FAT1 expression was associated with a more mature immunophenotype (T-ALL: thymic 74%, mature 45%, early 4%, p<0.001; B-lineage ALL: pre B-ALL 57%, common ALL 26%, pro B-ALL 9%, p=0.04). No significant differences between FAT1pos and FAT1neg patients were observed regarding age and sex. FAT1pos T-ALL patients more frequently showed a white blood cell count (WBC) >30.000/µL at diagnosis compared to FAT1neg T-ALL patients (78% vs. 42%, p<0.01). Whereas no negative prognostic impact was observed for FAT1 expression in B-lineage ALL or T-ALL with respect to overall survival or remission duration, lack of FAT1 expression was associated with primary resistance to induction therapy in T-ALL (T-ALL: FAT1neg 12%, FAT1pos 0%, p=0.04). In addition, we found an unexpected high rate of FAT1 mutations (exclusively missense mutations) with 8 of 68 T-ALL patients (12%). The mutation spectrum, mainly located in the cadherin domains, was similar to the distribution of FAT1 mutations in solid tumors. No difference were observed between FAT1 mutated (FAT1mut) and FAT1 wild-type patients (FAT1wt) with regard to sex, age, WBC, and presentation of antigens associated with an early differentiation stage. FAT1 mutations were more frequent in early T-ALL (3/12, 25%) and in thymic T-ALL (5/41, 12%) than in T-ALL patients with a mature immunophenotype (0/15, 0%). FAT1 expression was more common in FAT1wt T-ALL compared to FAT1mut T-ALL patients (50% vs. 25%). ConclusionThis first comprehensive analysis on FAT1 in a large cohort of adult patients with ALL shows a high frequency of FAT1 expression. Higher FAT1 expression occurred in ALL patients with more mature immunophenotype linking FAT1 to cell-cell adhesion and polarity, thymic homing and interaction with the BM niche. This yet unreported high mutation rate of 12 % in adult T-ALL makes FAT1 to one of the most frequently mutated genes in T-ALL. The link of inactivating FAT1 mutations to aberrant activation of the WNT pathway, as reported in solid tumors, might allow the development of refined treatment options. In summary, these data make FAT1 a promising candidate for disease monitoring, risk stratification and development of targeted therapies. Disclosures:Krebs:Illumina: Honoraria. Greif:Illumina: Honoraria.

Moderate Intensive Chemotherapy Including CNS-Prophylaxis with Liposomal Cytarabine Is Feasible and effective in Older Patients with Ph-Negative Acute Lymphoblastic Leukemia (ALL): Results of a Prospective Trial From the German Multicenter Study Group for Adult ALL (GMALL)

Abstract 1493 Few older ALL pts are entered into prospective trials and data on characteristics and outcome are scarce. The GMALL started a prospective trial in older ALL (>55 yrs) in 2003. In Ph-neg ALL a prephase (Dexa, Cyclo, MTX i.th.) was followed by induction I (Dexa, VCR, Idarubicin), induction II (Cyclo, AraC), alternating consolidation with IDMTX (d 1,15) ×3, VM26/AraC ×2, reinduction (VCR, Ida, Cyclo, AraC) and maintenance (MP, MTX) up to 2 yrs. In CD20+ ALL Rituximab ×8 was added. CNS-prophylaxis consisted of i.th. triple combination (MTX, AraC, Dexa) ×4 during induction, ×8 during consolidation/maintenance. The original protocol (group 1) was amended to optimize CNS prophylaxis and consolidation (group 2). I.th. therapy was then performed with liposomal cytarabine, 3x during induction, 3x during consolidation. IDMTX dose was increased from 500 to 1000 mg/m 2 and native E.coli ASP (10.000 U/m 2 ) was added on d2 and d16 of IDMTX. VM26/AraC was replaced by IDAraC (1000 mg/m 2 d1,3,5). In a further amendment the original i.th. prophylaxis was reinserted until final analysis of liposomal AraC became available. Furthermore, after induction, one cycle with pegylated ASP (500 U/m 2 ) (PEG-ASP) was scheduled to evaluate feasibility in older pts (group 3). Results of induction were compared for groups 1–3; outcome analysis was restricted to 1–2 due to still short follow-up for group 3. 268 pts with a median age of 67 (55–85) yrs treated in 94 hospitals were evaluable (180, 43 and 45 pts in groups 1, 2 and 3 resp.). 39% were aged 55–65 yrs, 51% 66–75 yrs and 10% above 75 yrs. 67% had c/pre-B-ALL, 18% pro-B-ALL and 15% T-ALL. WBC was >30/nL in 27%. Poor ECOG status (≥2) before (ECOGb) or after (ECOGa) onset of ALL was described in 7% or 38% resp. 78% had any comorbidity and 9% had a Charlson score (ChS) ≥3. No significant differences were detected between groups 1–3. Overall 76% (N=203) achieved CR after induction, 14% experienced early death (ED) and 10% did not achieve CR. In groups 1–3 CR rates were 72%, 86% and 82% resp. and ED rates 18%, 0% and 11% resp. (p=.03). CR rates were 84%, 74% and 52% in three age groups (p=.002) with ED rates of 7%, 14% and 37% resp. (p=.0004). Immunophenotype and WBC ( 30.000) correlated with CR but not ED rate. ECOGb 0–1 vs ≥2 correlated with CR (82% vs 33%;p Overall survival (OS) at 5 yrs was 23%; 33% at 2 yrs for group 1 and 52% for group 2 resp. (p=.01). Mortality in CR was 6% and 15% of the pts were withdrawn in CR. Probability of continuous complete remission (CCR) was 32% at 5 yrs, 42% and 43% at 2 yrs for group 1 and group 2 resp. (p=>.05). Age (42% vs 37% vs 8%;p=.0007), WBC (43% vs 15%;p With this age adapted regimen a favorable CR rate was achieved in a large patient group with a median age of 67 yrs. CR was increased (86%) and mortality was decreased (0%) significantly with liposomal cytarabine compared to triple i.th. prophylaxis during induction, since the latter probably induced more bone marrow toxicity. Reduced ED contributed considerably to improved OS. Moderate intensive consolidation was feasible and ASP, including PEG-ASP, was well tolerated. Age was correlated with outcome and 75 yrs appears to be the upper limit for this regimen. General condition was an additional highly relevant prognostic factor whereas comorbidity, measured by Charlson score was associated with ED but not with OS. These results encourage further treatment optimisation in older ALL pts, including those with comorbidities, based on comprehensive diagnostics, geriatric assessment, MRD evaluation, intensified consolidation, use of ASP, dose-reduced stem cell transplantation and integration of new, targeted drugs. Disclosures: Goekbuget: Medac: Consultancy, Research Funding, Speakers Bureau; Novartis: Research Funding; BMS: Research Funding; Genzyme: Research Funding; Mundipharma: Research Funding, Speakers Bureau; Glaxo: Research Funding, Speakers Bureau; Micromet/AMGEN: Consultancy; Sigma Tau: Consultancy. Off Label Use: Liposomal cytarabine in prophylaxsis of CNS relapse in ALL.

Substantially Improved Outcome of Adult Burkitt Non-Hodgkin Lymphoma and Leukemia Patients with Rituximab and a Short-Intensive Chemotherapy; Report of a Large Prospective Multicenter Trial

AbstractAbstract ▪667▪This icon denotes a clinically relevant abstract Aim.The aim of this study was to prove in a large prospective multicenter trial the tolerance and efficacy of short-intensive chemotherapy combined with the antibody Rituximab directed against CD20 for patients with Burkitt Non-Hodgkin lymphoma (B-NHL) and Burkitt leukemia (B-L). Background.In adult Burkitt lymphoma/leukemia with short-intensive chemotherapy regimen - mostly derived from pediatric protocols - a complete remission (CR) rate of 83% and an overall survival (OS) of 62% (both weighted mean) could be achieved. Further intensification of chemotherapy apparently did not improve the overall outcome. This was the rationale to integrate the monoclonal anti-CD20 antibody Rituximab in B-NHL / leukemia patients with a CD20 expression of >90%. Patients and Methods.363 adult patients (229 B-NHL and 134 B-L), 15 years or older (without age limit) were recruited from 98 centers in the German Multicenter Study Group for Adult Acute Lymphoblastic Leukemia (GMALL) B-ALL/NHL 2002 protocol, initiated in 8/2002 until 06/2011. Median age of the Burkitt lymphoma cohort was 40 years (16–79) and for the Burkitt leukemia cohort 47 years (16–85). CNS involvement was observed in 6% / 18%. In the Burkitt lymphoma cohort, 6% had mediastinal tumor, 53% had stage III/IV and IPI>2 of 35%. Treatment.The treatment consisted of 6 five-day chemotherapy cycles with high-dose methotrexate (HD-MTX) 1500 mg/m2 (total 6 doses), high-dose cytosine arabinoside (HD-AraC) 2000 mg/m2 (total 4 doses), cyclophosphamide, etoposide, ifosphamide and corticosteroids, and a triple intrathecal therapy (MTX, AraC, Dexa). Elderly patients >55 years received reduced drug doses (500 mg/m2), particularly no C-cycles with HD-AraC among other drugs. Rituximab was given d ⦵1 before each cycle and twice at 4 week intervals thereafter, for overall 8 doses. Total treatment duration was 28 weeks (figure 1). [Display omitted] Results.CR rate in B-NHL patients was 91% (182/229) and 86% (162/182) in B-L patients. For the B-NHL cohort the results were excellent with an OS of 88%, and a progression-free survival (PFS) of 83% at >7 yrs, with no significant difference in OS for adolescents 15-≤25 yrs with 91%, adults 26-’55 yrs with 91% or elderly >55 yrs with 80%. In Burkitt leukemia the OS for adolescents was also very promising with 90%, for adults OS was 71%, but inferior for elderly patients with 46%. Therefore two cycles C, including high dose AraC, were added for older patients in an amendment. Prognostic factors.In B-NHL patients the age adapted International Prognostic Index (aIPI) was the only significant prognostic factor for OS (p = 0.02) whereas in B-L patients the factors age 15-≤25, 26-≤55 and >55 yrs (p = 0.0007) and a lower platelet count <25000/μl (p = 0.01) had an adverse influence on OS. Major toxicity grade III/IV was less pronounced in B-NHL than in B-L, neutropenia 64% vs. 68%, mucositis 31% vs. 54% and infections 23% vs. 49%. Neurotoxicity was low in both cohorts. Conclusion.In the largest prospective trial for adult Burkitt NHL/leukemia, overall survival and progression-free survival could be substantially improved by a combination of short-intensive chemotherapy with Rituximab with manageable toxicity. Even with lower doses of HD-MTX outcome of B-NHL was excellent in all age groups, including elderly. Disclosures:No relevant conflicts of interest to declare.

Overall Outcome of Relapsed Acute Lymphoblastic Leukemia Can Be Improved by Stem Cell Transplantation and Early Treatment in Stage of Molecular Relapse

Abstract 250Survival of adult ALL has improved over the past decade to >50% with contemporary, risk adapted, targeted treatment strategies. However, published results of relapsed ALL are poor. In 4 retrospective studies with 1494 patients (pts) the CR rate after first salvage therapy was 40% and the long-term survival was only 6% including stem cell transplantation (SCT) (Thomas et al 1999, Tavernier et al 2007, Fielding et al 2007, Oriol et al, 2010).1638 patients with newly diagnosed ALL were included in studies 06/99 and 07/03 of the German Multicenter Study Group for Adult ALL (GMALL). 547 patients with first hematologic relapse (HemRel) were evaluable for a retrospective analysis (378 chemotherapy, 169 post SCT). Median age was 33 (15–55) yrs. 432 pts had early (< 18 mo of 1st remission duration) and 115 late relapse. Salvage therapy was given according to physicians’ choice and results are available in part of the pts. The aim was to achieve a CR and to perform SCT. Molecular relapse (MolRel) defined by standard criteria (Brüggemann et al, Leukemia, 2010) as reappearance of minimal residual disease (MRD) above 10-4 after prior molecular CR and measured by quantitative PCR of individual IgH/TCR rearrangements was detected in 43 pts.Response to salvage was evaluable in 224 pts with Ph-neg ALL with bone marrow (BM) relapse (no CNS involvement) during/after chemotherapy. The CR rate after first salvage was 42% and significantly inferior in early vs late relapse (36% vs 58%; p=.003). In early relapse the most frequently used regimens were FLAG-IDA (N=38; 42% CR) or a combination of HDAC/HDMTX/VP16/VCR/DEXA (N=38; 29% CR) in B-lineage and CLAEG (N=16; 19% CR) in T-lineage. In late relapses most frequently induction was repeated (N=30; 90% CR). In pts with failure after 1st salvage (N=82) the CR-rate after 2nd salvage was 33%. In relapse after SCT (N=48) the CR rate after 1st salvage was 23%.Median overall survival after relapse was 8.4 months and survival at 5 yrs 24%. Survival was significantly inferior in relapse post-SCT versus relapse on chemotherapy (15% vs 28%; p<.0001) and in BM±other vs CNS±other vs isolated extramedullary relapse (23% vs 27% vs 47%; p=.02).Prognostic factors for survival were analysed in 291 pts with Ph-neg ALL and BM relapse (no CNS involvement) on chemotherapy. Survival was superior in late vs early relapse (43% vs 22%; p<.0001), in pts aged 15–25 yrs vs 26–45 yrs vs 46–55 yrs (38% vs 28% vs 12%; p<.0001) and in pts with CR compared to failure/PR after 1st salvage (47% vs 13%; p<.0001). 75% of evaluable pts received SCT in any stage after relapse. Their survival at 5 yrs was 38% vs 0% without SCT (p<.0001). Survival was significantly better if SCT was performed in CR after 1st salvage vs later CR vs no CR (56% vs 39% vs 20%;p<.0001).Of pts with MolRel (N=43) 26% remained untreated, 19% received specific salvage therapy and in 55% first-line treatment was continued without modification. 11% (N=5) remained in CCR, 30% (N=13) underwent SCT in 1st CR and 58% (N=25) developed HemRel. Median remission duration without SCT in CR1 was 92 d until HemRel and no pt was in continuous CR after 3.5 yrs. Survival after 5 yrs was significantly superior in pts with SCT in CR1 (N=13; 100%) compared to those without (N=30; 24%) (p=.0006). Overall survival after 5 yrs was significantly superior after MolRel (45%) compared to HemRel (22%) (p=.003).Survival of pts with relapse during/after chemotherapy was 28% in the GMALL trials and superior compared to published data. Outcome after relapse was not uniformly poor but depended on prognostic factors such as age and time to relapse. The most important prognostic factor, however, was response to first salvage therapy, being very poor in early relapse. These pts suffer from chemorefractory disease and are candidates for experimental, targeted approaches. Improved overall outcome was mainly an effect of a high rate of SCT (75%) which was possible due to stringent donor search (related/unrelated) at diagnosis of relapse. Survival was significantly better if SCT was performed in CR. For the first time it could be demonstrated that outcome after molecular relapse is superior to outcome after hematologic relapse and this result underlines the relevance of MRD follow-up testing. Further improvement should therefore be achievable by early detection of molecular relapse, stratified relapse treatment, experimental approaches in early relapse and rapid transplant realisation with optimised procedures. Disclosures:No relevant conflicts of interest to declare.

PEG-Asparaginase Intensification In Adult Acute Lymphoblastic Leukemia (ALL): Significant Improvement of Outcome with Moderate Increase of Liver Toxicity In the German Multicenter Study Group for Adult ALL (GMALL) Study 07/2003

AbstractAbstract 494Several randomised pediatric trials have demonstrated that intensification of Asparaginase (ASP) treatment in ALL can contribute to improved outcome. In adult ALL few data are availabe and optimal ASP preparation, schedule and intensity with respect to efficacy and tolerability have to be defined. The optimisation of ASP treatment is therefore an essential aim of the GMALL.Treatment: Induction treatment of the ongoing study 07/2003 consists of dexamethasone, vincristine, daunorubicine, pegylated asparaginase (PEG-ASP) (phase I), mercaptopurine, cyclophosphamide and cytarabine (phase II) as previously described (Brueggemann et al, Blood 2006: 107; 1116). During the study the dose for PEG-ASP was increased from 1000 to 2000 U/m2 in induction and from 500 to 2000 U/m2 in consolidation (combined with HDMTX and MP) for pts aged between 15 and 55 years. 1 application for high risk and 7 applications for standard risk (SR) were scheduled during the first year and the aim was improvement of overall survival (OS) and remission duration (RD).Patients: From more than 100 centers in Germany 1226 pts with a median age of 35 (15-55) yrs were evaluable. 826 pts were treated with 1000 U/m2 (cohort 1) and 400 pts with 2000 U/m2 (cohort 2) and both groups were comparable regarding major entry criteria. The analysis was restricted to pts who received one of the scheduled PEG-ASP doses during induction.Outcome: CR rate after induction was 91% vs 91% in cohort 1 and 2 resp., with comparable rates for early death (4% vs 5%) and failure (5% vs 4%). Data on molecular response (MRD below 10−4) after induction are available in a subset and showed no difference between both cohorts after induction (79% vs 82%).OS after 3 years was improved in cohort 2 (60% vs 67%; p>.05). The positive effect was specifically evident in SR patients (N=407 vs 190) with respect to OS (68% vs 80%; p=.02) and RD (61% vs 74%; p=.02). It was demonstrated in younger pts (15-45 yrs) (71% vs 82%; p=.02) and older pt (45-55 yrs) (56% vs 74%; p>.05). Excellent results were achieved in young adults (15-25 years) with respect to OS (77% vs 86%; p>.05) and RD (60% vs 78%; p>.05).Toxicity: The analysis of toxicity was focused on grade III-IV events during induction with potential correlation to PEG-ASP (764/382 pts in cohort 1/cohort 2)). Incidences are as follows: GOT or GPT (30%/30%), bilirubine (10%/16%), thrombosis (5%/5%) and hypersensitivity (<1%/<1%). In a subset of pts additional AEs were assessed as amylase (5%/13%), lipase (23%/15%) and glucose (10%/12%). Significantly less toxicity was observed during consolidation cycles.Bilirubine °III/IV occurred median 16d after PEG-ASP during phase II of induction. In univariate analysis it was correlated to dose (10% vs 16%; p=.004), age <> 45 yrs (11% vs 17%; p=.005), BMI <> 30 (12% vs 18%; p=.04) and rituximab application (11% vs 18%; p=.009). Hepatomegaly, infections or imatinib application had no significant effect. In multivariate analysis dose and age remained independent significant prognostic factors. Bilirubine increase during induction was associated with treatment delays and inferior prognosis. Conclusions:This is the largest cohort of adult ALL treated with PEG-ASP. Due to prolonged activity fewer applications are required which is a pre-requisite for realisation of ASP intensification in the context of an intensive multidrug chemotherapy for adult ALL. Although CR rate and molecular CR were not significantly improved PEG-ASP intensification was associated with an improved OS and RD. The improvement was specifically evident in SR pts treated with up to 7 doses of PEG-ASP. Overall intensified PEG-ASP was feasible. The rate of grade III-IV bilirubine elevation increased after dose escalation and led to treatment delays in individual pts which were prognostically relevant. It would be an important goal to identify parameters to predict severe ASP related toxicity. Further intensification of ASP by additional applications would be of interest.Supported by Deutsche Krebshilfe 70–2657-Ho2 and partly BMBF 01GI 9971 and Medac GmbH. Disclosures:Goekbuget: Medac: Consultancy, Research Funding, Speakers Bureau. Hoelzer: Medac: Speakers Bureau.

Prognostic Impact of Different High Risk Features in Allogeneic Stem Cell Transplantation for Acute Lymphoblastic Leukemia in First Complete Remission.

Abstract 2303Poster Board II-280 Introduction:In acute lymphoblastic leukemia (ALL) specific clinical and biological features confer high relapse risk and inferior overall survival (OS) after treatment with conventional chemotherapy alone. The differential prognostic impact of these high risk features after treatment with allogeneic hematopoietic stem cell transplantation (HCT) has not been well studied. Patients and Methods:79 adult ALL patients in first complete remission (CR) received allogeneic HCT at our center between 1995 and 2008. All patients were high or very high risk according to German Multicenter Study Group for Adult ALL (GMALL) criteria. Median age was 36 years (range: 17-68). Patients received high-dose conditioning consisting of 12 Gy total body irradiation ± etoposide ± cyclophosphamide (n=69, 87%) or reduced intensity conditioning (RIC) consisting of fludarabine/busulfan/ATG (n=10, 13%) and HSCT from related (n=34, 43%) or unrelated (n=45, 57%) donors. Bone marrow (n=17, 22%) or peripheral blood stem cells (n=62, 78%) were given. Graft-versus-host-disease prophylaxis was CSA/MTX for high-dose conditioning or CSA/MMF for RIC. Results:Patients were classified as high risk or very high risk due to Philadelphia chromosome-positive disease (Ph+) (n=30, 38%), leukocytosis>30/nl at diagnosis in B-ALL (n=25, 23%), late response to induction therapy in B-ALL (>week 4) (n=13, 16%), early or mature T-ALL (n=13, 16%), pro-B-ALL/t(4;11) (n=8, 10%), persistence of minimal residual disease (MRD) (>week 16) (n=8, 10%) or complex aberrant karyotype (n=6, 8%). 57 patients (72%) presented with one high risk feature, whereas 20 patients (25%) and 2 patients (3%) presented with two or three features, respectively. Currently, after a median follow-up of 56 months (7-169) 49 patients (62%) remain alive. Projected OS of the whole cohort at 1, 2 and 5 years was 78%, 70% and 55% and leukemia-free survival was 77%, 66% and 55%. Cumulative incidence of non-relapse mortality (NRM) and relapse mortality (RM) at 5 years was 23% and 18%, respectively. In multivariate Cox regression analysis, a non-significant trend for inferior OS was seen for patients with early or mature T-ALL (hazard ratio (HR): 2.03 (95%CI: 0.92-4.52), p=0.082), whereas no differential effect on OS, NRM or RM was seen for any other high risk feature (Table 1). In additional analyses, inferior OS (HR 1.81 (95%CI: 1.02-3.29), p=0.043) and increased RM (HR 2.17 (95%CI 1.16-4.05), p=0.015) was observed for patients with more than one high risk feature. Conclusions:In summary, this single center study on allogeneic HCT in high risk ALL found a negative prognostic trend for early or mature T cell immunophenotype. No differential prognostic impact on OS, NRM and RM was seen for other high risk features as defined by GMALL criteria, however this conclusion is limited by the low patient number in some of the subgroups. Overall survival for the whole cohort was 55% at 5 years, with inferior OS and higher RM being observed in patients with more than one high risk feature.Table 1Prognostic impact of GMALL high risk criteria for outcome after allogeneic HCT in adult ALL in CR1. Shown are results from multivariate Cox regression analysis. Other variables included in the analysis were patient age, gender, year of HCT, time from diagnosis to transplantation, conditioning regimen, stem cell source and donor type.OSNRMRMpnHR (95%CI)pHR (95%CI)pHR (95%CI)Ph+ ALL301.51 (0.76-3.00)0.241.08 (0.42-2.79)0.881.96 (0.63-6.09)0.25Leukocytes 30/nl (B-ALL)250.76 (0.34-1.69).511.19 (0.44-3.18)0.730.48 (0.11-2.21)0.35Late CR (B-ALL)131.08 (0.46-2.50)0.850.84 (0.24-2.90)0.781.93 (0.58-6.43)0.28Early/mature T-ALL132.03 (0.92-4.52)0.0822.36 (0.84-6.65)0.101.29 (0.28-5.90)0.74Pro-B-ALL/t(4;11)80.54 (0.13-2.24)0.390.52 (0.07-3.90)0.520.04 (0.00-100.51)0.42Persistent MRD80.74 (0.18-3.08)0.670.62 (0.08-4.71)0.651.16 (0.15-8.99).89Complex aberrant61.45 (0.44-4.78)0.540.82 (0.11-6.18)0.841.35 (0.17-10.59)0.78>1 high risk feature221.81 (1.02-3.29)0.0431.78 (0.82-3.86)0.142.17 (1.16-4.05)0.015 Disclosures:No relevant conflicts of interest to declare.

Matched Unrelated Donor Allogeneic Stem Cell Transplantation in High Risk Acute Lymphoblastic Leukemia (ALL) After a Preparative Regimen of Hyperfractionated Total Body Irradiation and High-Dose Etoposide – A Feasibility Study within the German Multicenter Study Group for Adult ALL.

Abstract 3389Poster Board III-277 Introduction:The optimal preparative regimen for allogeneic hematopoietic stem cell transplantation (alloHCT) using matched unrelated donors (MUD) for adult patients (pts) with acute lymphoblastic leukemia (ALL) in first complete remission (CR1) is currently undefined. There is some evidence from one comprehensive retrospective comparative analysis that a higher dose of hyperfractionated total body irradiation (fTBI) or the use of high-dose etoposide instead of cyclophosphamide is able to reduce the leukemic relapse risk of adult pts transplanted in second CR from HLA-identical sibling donors (ISD) (Marks, DI et al. J Biol Blood Marrow Transplant 12: 438-453, 2006). Purpose:Within the framework of the German multicenter study group for adult ALL (GMALL) protocols 06/1999 and 07/2003, the combination of 12 Gy fTBI + 120 mg/kg cyclophosphamide is the standard preparative regimen for MUD alloHCT in CR1. In these protocols, a preparative regimen of 12 Gy fTBI + 60 mg/kg etoposide before ISD alloHCT in CR1 has shown particular promising results compared to 12 Gy fTBI + cyclophosphamide. Therefore, this pilot study tested the feasibility of the12 Gy fTBI + etoposide regimen for MUD alloHCT in CR1 adult ALL pts. Patients and methods:In the GMALL protocol 07/2003, alloHCT is generally performed after the first consolidation therapy according to predefined prognostic disease features indicating a high relapse risk for pts up to the age of 55 years (yrs). This study prospectively included 20 consecutive (very) high-risk pts (median age: 39 [range 17 to 55] yrs) from two major GMALL transplant centers, who underwent alloHCT using MUD between 01/07 and 03/09. TBI was applied in 2 daily fractions of 2 Gy on 3 consecutive days (days -6 to -4) followed by etoposide on day -3 (alloHCT on day 0). For prophylaxis of acute graft-versus-host disease (GvHD), 3 × 20 mg/kg antithymocyte globuline was given on days -3 to -1 and ciclosporin combined with prednisone thereafter. Results:Neutrophil reconstitution > 0.5/nL was reached after a median of 18 (range 12 to 32) days and self-sustaining platelet counts > 20/nL were attained after a median of 25 (range 13 to 36) days. The cumulative incidence of grades I – IV acute GvHD reached 64 %. Three pts. (15 %) developed acute GvHD > grade II. The cause-specific non-relapse mortality (NRM) incidences at 3, 12 and 24 months are 5 %, 18 %, and 22 % (4/20 pts), respectively. Causes of NRM were infections (2 pts), graft failure and toxic epidermiolysis (1 patient each). The cause-specific leukemic relapse incidence reaches 18 % (3/20 pts) after 12 and 24 months. Two pts were successfully rescued by a 2nd alloHCT after leukemic relapse. After a median follow-up period of 22 months for the 15 surviving pts, the 2-year overall survival estimate is 73 % (95 % confidence limits: 47 % - 89 %). Conclusions:This pilot study demonstrates that the preparative regimen of fTBI + etoposide before MUD alloHCT is feasible in CR1 adult high-risk ALL pts after intensive induction and consolidation courses as applied in the GMALL protocol 07/2003. The comparatively low relapse rate in high-risk ALL pts further supports that the substitution of cyclophosphamide by etoposide leads to better disease control and may thereby improve transplant outcome in this setting. Based on these results, a prospective study comparing fTBI in combination with either etoposide or cyclophosphamide appears justified. Disclosures:No relevant conflicts of interest to declare.

New Definition of Treatment Response in Adult Acute Lymphoblastic Leukemia (ALL): Use of Molecular Markers for Minimal Residual Disease (MRD).

Abstract 90▪FN2▪This icon denotes an abstract that is clinically relevant.Response to treatment measured by cytologic bone marrow evaluation has been so far the most important prognostic factor in adult ALL, and cytological complete remission (cyCR) and relapse (cyREL) are accepted endpoints for clinical trials. However, measurement of MRD is a more sensitive approach for assessment of response. In the past decade it has been confirmed that MRD is an independent, strong prognostic factor in ALL. The most widely applied method is based on quantative PCR evaluation of individual rearrangements of TCR and Ig genes. Methodology, interpretation and definitions are highly standardised and confirmed in different labs (e.g. van der Velden et al, Leukemia, 2007). Therefore it is essential to define and validate MRD based response criteria – namely complete molecular/complete MRD response (molCR), molecular failure/MRD persistence (molFAIL) and molecular relapse/MRD relapse (molREL) - as endpoints for clinical trials.Since 1999 the German Multicenter Study Group for Adult ALL (GMALL) has conducted two consecutive studies (GMALL 06/99 and 07/2003) with a risk and MRD adapted treatment strategy and prospective MRD evaluation. 1489 evaluable pts (15–55 y) with Ph-negative standard (SR) and high risk (HR) ALL have been included so far. MRD evaluation as described above has taken place in central labs. For analysis of molCR MRD evaluation was restricted to pts with cyCR (prerequisite: at least one marker with sensitivity and quantitative range of minimum 10−4 for negative results). MolCR was defined as negative MRD status after induction therapy. MolREL was defined as reappearance of MRD above 10−4 after achievement of molCR.MolCR after induction: The overall cyCR rate was 89% with differences between SR and HR (92% vs 84%;p<.0001) and age < vs >35 yrs (90% vs 86%;p=.01) but not B vs T-lineage (89% vs 88%). As expected the molCR was lower (69%) in 479 evaluable pts. Significant differences were seen between SR vs HR (77% vs 46%;p<.0001) and B vs T-lineage (63% vs 79%;p=.0005). The most rapid decrease of MRD was observed after induction phase I (34% molCR) and phase II (69%), whereas the effect of first consolidation was limited (72%) indicating a progressive selection of chemotherapy resistant leukemic clones. MolCR evaluation was also used to assess treatment modifications such as asparaginase intensification or addition of rituximab to induction therapy.Prognostic impact of molCR:SR pts were scheduled for chemotherapy. Those with molCR had a superior overall survival (OS) when compared to molFAIL (67% vs 38%;p<.0001) which was mainly due to a lower relapse rate (RR) (26% vs 59%;p<.0001) leading to better remission duration (RD) (57% vs 29%;p<.0001). MolFAIL pts had a better OS with SCT in CR1 than without (60% vs 27%;p=.09).All HR pts were scheduled for SCT in CR1. OS was superior for MolCR vs MolFAIL (66% vs 42%; p=.003). The RR was higher for molFAIL vs molCR on chemotherapy (66% vs 18%;p=.04) and after SCT (34% vs 11%;p=.04). Even after SCT pts with molCR had a better OS (75% vs 58%; p=.03).MolREL: The incidence and outcome of molREL was evaluated in 432 pts with MRD tests during and after treatment. 36 molREL without additional extramedullary relapse were observed. The OS was 36% and the probability of cyREL was 82% with median of 75 d from molREL to cyREL. All pts not treated at molREL relapsed (N=12). Only 1/11 (9%) pts who were transferred to SCT in cyCR1 after additional treatment, including experimental drugs, relapsed compared to 21/25 (84%) pts without SCT in cyCR1 (p<.0001).Overall these data show in the largest cohort of adult ALL pts with MRD analysis reported so far, the proof of principle for molecular response evaluation. In a study with high cyCR rate it allows to detect differences between subgroups and treatment approaches and thereby refines the evaluation of treatment efficacy. It is a clinically relevant endpoint since molFAIL is associated with significantly poorer RD and OS even after subsequent SCT. Detection of molFAIL and molREL identifies pts with resistance to conventional drugs and the need for targeted, experimental drugs and SCT in cyCR1 before occurrence of cyREL. Molecular response evaluation with standardised methods provides new refined endpoints for future trials, including pivotal trials with new drugs with the major advantage of early decision points and strong correlation to clinical outcome.Supported by Deutsche Krebshilfe 702657Ho2 and BMBF 01GI9971/8 Disclosures:No relevant conflicts of interest to declare.

Fine Needle Aspiration Biopsy with Flow Cytometry Is a Reliable Method for Defining Immunophenotype of Prognostic Value in T Lymphoblastic Lymphoma.

Abstract 3928Poster Board III-864 Background and aimIn contrast to T lymphoblastic leukemia (T-ALL), there is a little data on the incidence and prognostic value of immunologic subtypes of adult T lymphoblastic lymphoma (T-LBL) as the use of flow cytometry in the absence of leukemia may be problematic. Our aim was to define immunophenotype of T-LBL and T-ALL in 51 consecutive patients by use of the flow cytometry (FCM) of tissue aspirates if peripheral blood (PB) and bone marrow (BM) were uninvolved. We also evaluated prognostic value of immunophenotype and clinical features of adult patients treated on uniform ALL protocol. MethodsBetween 1997 and 2006, 51 adult patients with T-LBL/ALL were treated according to the GMALL (German Multicenter Study Group for Adult ALL) 05/93 and T-LBL/2004 protocols (D.Hoelzer et al., Blood 2002; 99:4379). Immunophenotype was determined by specimen immunohistochemical staining and by FCM of cellular suspension obtained from lymph nodes (n=22), skin tumors (n=2) or mediastinal mass (n=9) by fine needle aspiration biopsy (FNAB), as well as of BM (n=6), PB (n=7) and pleural fluid (n=5). Disease subtype was defined according to WHO 2008 classification. Pro-T: cCD3+, CD7+, CD2-, CD1a-, CD34+/-; pre-T: cCD3+, CD7+, CD2+, CD1a-, CD34+/-; cortical T: cCD3+, CD7+, CD2+, CD1a+, CD34-, CD4+, CD8+; medullary T: cCD3+, sCD3+, CD7+, CD2+, CD1a-, CD34-, CD4+ or CD8+. Recognition of pan-T-cell CD antigens (pTAg) expression included: CD1a, CD2, cCD3, sCD3, CD4, CD5, CD7, CD8 and CD10, CD16&CD56, CD56, CD13, CD15, CD33. ResultsPatients (pts) characteristics: ALL (BM+ >20%): 37%, LBL: 63%, age < 35: 80%, males: 75%, median WBC: 22 G/L, Hb: 13.6 g/dl, plt: 267 G/L, mediastinal mass (MM): 92%, primary CNS+: 10%, PS 0-1: 60%, LDH > normal: 69% of pts. Immunophenotype: pro-T: 20%, pre-T: 12%, cortical: 51%, medullary: 12%, blastic plasmacytoid dendritic cell neoplasm with skin manifestation: 6% of pts. Number of pTAg present: 0-3: 39%, and 4-7: 61% of pts. Most frequently expressed pTAg were: CD7: 86%, CD5: 78%, CD2: 69%, CD1a: 47%, and CD56: 59%. Myeloid markers: CD13/33/15 were expressed in 14%/23%/10% of pts. Complete and partial remission (mostly residual MM) rate was 75% and 21%. With a median follow up for surviving patients of 62 months, 5 yr overall (OS) and disease-free (DFS) survival (95%C.I.) was 45% (31%; 59%) and 46% (32%, 60%), respectively. 5 yr OS for pts with CD2 and more than 3 pTAg present was 61% and 63% compared to 7% and 19% for pts without CD2 and 3 or less pTAg, (p=0.004 and 0.025) respectively. CD1a expression was favorable but of unconfirmed significance (p=0.09). On Cox's analysis of clinical features, only PS and LDH were predictive for OS and DFS and only expression of CD2 among immunophenotypic variants was significant for OS (p=0.004) and DFS (p=0.004). ConclusionCombined use of fine needle aspiration biopsy and flow cytometry is a reliable method for defining immunologic subtype of lymphoblastic lymphoma. In a prospective evaluation of 51 consecutive T-LBL/ALL patients treated on GMALL protocols, expression of CD2 antigen – mostly consistent with cortical and pre-T subtypes, and presence of more than 3 pTAg along with PS less than 2 and normal LDH were predictive for favorable outcome. Disclosures:No relevant conflicts of interest to declare.

PEG-Asparaginase in Adult Acute Lymphoblastic Leukemia (ALL): Efficacy and Feasibility Analysis with Increasing Dose Levels

Asparaginase (ASP) has a unique role in the treatment of ALL, and several pediatric studies have demonstrated that modifications of schedule, preparation and dose of ASP may have an impact on overall outcome. The optimisation of ASP treatment is therefore an important aim of the German Multicenter Study Group for Adult ALL (GMALL). In 1999 a pilot trial for adult ALL was started (GMALL 06/99), followed by the ongoing main trial 07/2003. Induction comprised dexamethasone, vincristine, daunorubicine and i.th. methotrexate. One dose of pegylated ASP (PEG-ASP) 1000 U/m2 (500 U/m² if > 55yrs) was given instead of 7 doses of 5000 U/m2 native E.coli asparaginase (ASP) given over 14 days in previous GMALL studies. In consolidation one dose PEG-ASP (500 U/m2) replaced one dose of E.coli ASP (10000 U/m2) in combination with high-dose methotrexate (1500 U/m²) and mercaptopurine. ASP activity was above 100 U/l at day 10 in 80% of the pts after 1000U/m2 and in only 42% after 500 U/m2. Based on this correlation between dose and duration of activity in study 07/2003 (amendment II in 12/2006) the dose for PEG-ASP was increased to 2000 U/m2 in induction and consolidation for pts < 55 yrs and to 1000 U/m2 for pts > 55 yrs in order to improve treatment efficacy. Details of the protocol have been reported (Brüggemann, Blood 2006: 107;1116).Patients: 959 pts with a median age of 36 yrs are evaluable. 8% (N=82) were older than 55 yrs. Clinical characteristics were representative for adult ALL and similar in the cohorts. 766 pts were treated before the amendment with 1000 U/m2 (cohort 1) and 117 pts after the amendment with 2000 U/m2 (cohort 2), with the respective reductions for pts > 55yrs. 76 pts did not receive ASP in induction due to various reasons (cohort 3).Efficacy: In cohort 1 and 2 91% and 90% achieved CR after induction (80% in cohort 3). Data on molecular response, defined as MRD below 10 −4,after induction are available in a subset of both cohorts. There is a trend towards earlier and higher molecular CR rate in cohort 2 (82% after induction) compared to cohort 1 (70%). Survival after 1 yr is similar in cohort 1 (79%) compared to cohort 2 (77%) and inferior in cohort 3 (66%). Probability of continuous CR after 1 year shows a trend to improvement with 87% in cohort 2 vs 77% in cohort 1.Toxicity in induction: Toxicity reported here is focused on potentially ASP related oIII–IV (WHO scale) events. 676 pts are evaluable for cohort 1 and 107 pts for cohort 2. Incidences for both cohorts are as follows: GOT or GPT (30%/27%), bilirubine (12%/14%), thrombosis (5%/2%), bleeding (2%/0%) and hypersensitivity (1%/1%). Details on adverse events of all degrees are available in a subset of pts showing an increase of any WHO grade in 81% for bilirubine, 80% for GPT, 52% for amylase, 29% for lipase and 51% for glucose. Data on substitution of clotting factors were available in 84 and 61 pts: 73% vs 93% required substitution (25%/12% FFP, 37%/46% ATIII concentrate and 37%/42% both).Conclusions: This is the largest cohort of adult ALL pts treated with PEG-ASP so far. Overall intensified PEG-ASP was feasible in the context of intensive multidrug induction. Coagulation disturbances occurred frequently and substitution was extensive, but bleeding or thrombosis were rare events. Although substitution of clotting factors was clinically effective it remains open whether it is clinically necessary. The rate of severe hepatotoxicity was stable after dose escalation however lead to significant treatment delays in individual pts. Lab value changes e.g. liver occured in a large proportion of pts; it remains open to what extent they are clinically relevant and require interruption of further chemotherapy. It would be an important goal to identify parameters to predict severe ASP related toxicities e.g. by pharmacogenomics. The molecular CR rates after dose escalation are promising and will hopefully turn out into an improved overall survival.Supported by supported by Deutsche Krebshilfe 70-2657-Ho2 and partly BMBF 01GI 9971 and Medac GmbH