Involvement In Acute Myeloid Leukemia Research Articles

P110CUX1 promotes acute myeloid leukemia progression via regulating pyridoxal phosphatase expression and activating PI3K/AKT/mTOR signaling pathway.

As an evolutionarily conserved transcription factor, Cut-like homeobox 1 (CUX1) plays crucial roles in embryonic and nervous system development, cell differentiation, and DNA damage repair. One of its major isoforms, p110CUX1, exhibits stable DNA binding capabilities and contributes to the regulation of cell cycle progression, proliferation, migration, and invasion. While p110CUX1 has been implicated in the progression of various malignant tumors, its involvement in acute myeloid leukemia (AML) remains uncertain. This study aims to elucidate the role of p110CUX1 in AML. Our findings reveal heightened expression levels of both p110CUX1 and pyridoxal phosphatase (PDXP) in AML cell lines. Overexpression of p110CUX1 promotes AML cell proliferation while inhibiting apoptosis and differentiation, whereas knockdown of PDXP yields contrasting effects. Mechanistically, p110CUX1 appears to facilitate AML development by upregulating PDXP expression and activating the PI3K/AKT/mTOR signaling pathway. Animal experimental corroborate the pro-AML effect of p110CUX1. These results provide experimental evidence supporting the involvement of the p110CUX1-PDXP-PI3K/AKT/mTOR axis in AML progression. Hence, targeting p110CUX1 may hold promise as a therapeutic strategy for AML.

Myeloid sarcoma with RBM15::MRTFA (MKL1) mimicking vascular neoplasm.

Extramedullary involvement of acute myeloid leukemia (AML), aka myeloid sarcoma, is a rare phenomenon in acute megakaryoblastic leukemia with RBM15:: MRTFA(MKL1) fusion, which might mimic non-hematologic malignancies. A 7-month-old infant presented with leukocytosis, hepatosplenomegaly, multiple lymphadenopathies, and a solid mass in the right thigh. Initially, the patient was diagnosed with a malignant vascular tumor regarding the expression of vascular markers from the biopsy of the right thigh lesion that was performed after the inconclusive bone marrow biopsy. The second bone marrow biopsy, which was performed due to the partial response to sarcoma treatment, showed hypercellular bone marrow with CD34 and CD61-positive spindle cell infiltration and > 20% basophilic blasts with cytoplasmic blebs. RNA sequencing of soft tissue biopsy revealed the presence of RBM15::MRTFA(MKL1) fusion. Based on these findings, myeloid sarcoma/AML with RBM15::MRTFA(MKL1) fusion diagnosis was made. AML with RBM15::MRTFA(MKL1) fusion can initially present as extramedullary lesions and might cause misdiagnosis of non-hematologic malignancies.

Exclusion of Acute Myeloid Leukemia Patients with Central Nervous System Involvement from Clinical Trials: An Analysis of the National Institutes of Health Clinical Trials Registry from 2012 to 2022

Introduction: Central nervous system (CNS) involvement in acute myeloid leukemia (AML) can be successfully treated with intrathecal chemotherapy and carries debatable prognostic impact. However, patients with CNS involvement are commonly excluded from clinical trials at an unknown rate. We systematically evaluated exclusion criteria of AML clinical trials based on CNS involvement and determined associations with clinical trial characteristics. Methods: The National Institutes of Health Clinical Trials Registry was searched for interventional adult AML trials between 2012 and 2022 that were phase 1, 2, or 3 and relevant trial characteristics were extracted. Results: 1,270 trials were included in the analysis with 790 trials (62.1%) explicitly excluding CNS involvement. There was no significant change in rates of CNS exclusion over the past decade. CNS exclusion was higher in trials that included the non-transplant population compared to trials exclusive to the transplant population (66.9% vs. 43.8%, p < 0.01). Non-transplant trials were also more likely to exclude patients with a history of or ambiguous timing of CNS involvement (p < 0.01). Phase 3 trials were associated with more liberal definitions of CNS exclusion (history or ambiguous timing) as compared to phase 1 and 2 trials that had higher rates of excluding patients with only active CNS involvement (p < 0.01). Conclusion: A majority of AML clinical trials, particularly in the non-transplant setting, exclude patients with CNS involvement. Many of these trials, most notably phase 3 trials, exclude patients not only with active but also with any history of CNS involvement. Further research is needed to determine optimal management of these patients in order to increase representation in large clinical trials.

MiR-454-3p promotes apoptosis and autophagy of AML cells by targeting ZEB2 and regulating AKT/mTOR pathway

ABSTRACTBackgroundmiR-454-3p is considered to have a crucial role in cancer progression, but the potential involvement in acute myeloid leukemia (AML) remains unclear.MethodsExpression of miR-454-3p and ZEB2 mRNA and protein were quantified in AML cell lines. Cells were transfected with miR-454-3p inhibitor or mimic and cell growth was assessed by colony formation and CCK-8 assays and the cell cycle, apoptosis and autophagy were investigated by Western blotting, flow cytometry, immunofluorescence and 3-methyladenine (3-MA) treatment.ResultsmiR-454-3p expression was attenuated in AML cells. miR-454-3p overexpression attenuated cell growth and stimulated cell cycle arrest, apoptosis and autophagy. Dual-luciferase reporter assays and bioinformatics analysis showed that AML progression was inhibited when miR-454-3p regulated ZEB2, an effect confirmed by rescue assays. 3-MA reduced the autophagy-inducing effect of ZEB2 knockdown and indicated that autophagy induced apoptosis. miR-454-3p downregulated p-mTOR/p-AKT levels in AML cells.ConclusionThe novel role of miR-454-3p as a tumor inhibitor in AML via regulation of the ZEB2/AKT/mTOR axis was demonstrated, indicating miR-454-3p as a potential new molecular target for AML.

Extramedullary involvement in pediatric myeloid leukemia: challenges of diagnosis and treatment. Clinical cases and a literature review

The problem of extramedullary (EM) involvement in acute myeloid leukemia (AML) in children is of considerable relevance since its pathogenesis remains understudied and the impact on prognosis is still unclear. The variability of tissue and organ involvement depends on immunophenotypic, cytogenetic, and molecular features of myeloid cells and can cause difficulties in diagnosis, thus making it necessary to combine imaging and laboratory tools for timely and accurate diagnosis of EM disease. The prognostic significance of EM involvement has not been established unequivocally, thus the need for intensification of chemotherapy, as well as for allogeneic hematopoietic stem cell transplantation in first remission, remain debatable. The results of target therapy in EM AML are encouraging and may reduce the risk of AML relapse. This article describes the clinical features of EM AML in children and reviews the diagnostic approaches as well as the advantages and limitations of existing laboratory and imaging methods. The molecular features of EM AML, current treatment options and prognosis have also been analyzed. The patients' parents gave their consent to the use of their children's data, including photographs, for research purposes and in publications.

Central Nervous System Specific Characteristics and Outcomes in Acute Myeloid Leukemia Patients with Neurologic Involvement

Introduction: Rates of leukemic central nervous system (CNS) involvement in acute myeloid leukemia (AML) are lower than in acute lymphoblastic leukemia, with estimates ranging from about 1.1% - 32%, based largely on differences in lumbar puncture (LP) screening protocols. Although risk factors for CNS AML and the prognostic implications are widely documented, the CNS specific characteristics and outcomes with intrathecal (IT) therapy have not been previously reported. Methods: We retrospectively identified patients at The Mount Sinai Hospital with CNS AML, defined as having leukemic blasts in the cerebral spinal fluid (CSF), as identified by flow cytometry or cytology, or as having atypical immature myeloid cells in the CSF with either concerning imaging findings or neurologic symptoms. Patients with neurologic symptoms with imaging findings suggestive of CNS disease, but no CSF diagnosis, were excluded. Patient, disease, and treatment-related variables were summarized by the median and range; categorical variables were summarized by n (%). The Kaplan-Meier method was used to estimate the median times to event for outcomes including CSF blast clearance and overall survival (OS). Results: A total of 25 patients were identified with CNS AML, with a median age of 57 years and 52% male. Seventy-six percent of patients had de novo AML, 20% AML secondary to myeloproliferative neoplasm or myelodysplastic syndrome, and 4% (n=1) had acute promyelocytic leukemia. Baseline characteristics previously associated with CNS AML were frequently observed, including monocytic differentiation (28%), elevated LDH (84%), and WBC >100K (36%). The most common karyotype abnormality was trisomy 8 (32%) with 46% having a normal karyotype and 24% having a complex karyotype. The most common mutations were FLT3 (56%), TET2 (32%), NPM1 (32%), and SRSF2 (20%) (Table 1). Of the 25 patients, 56% had CD34+ blasts and 44% had atypical myeloid cells in the CSF accompanied by either imaging findings or neurologic symptoms; 40% of all patients had imaging findings concerning for leukemic infiltration. Fifty-six percent of patients were diagnosed with CNS disease before or during induction, whereas 44% were diagnosed at time of relapse. Neurologic symptoms were reported in 76% of patients, with headache being the most common (36%), followed by vision changes (24%), radicular pain (16%), and hearing loss/tinnitus (12%). Other neurologic symptoms recorded include vertigo, seizure, hemorrhage and altered mental status. Systemic AML therapy received during or immediately after CNS diagnosis was 7+3 (56%), 7+3+midostaurin (16%), hypomethylating agent (HMA) + venetoclax (12%), HMA monotherapy (12%), and all-trans retinoic acid + idarubicin (4%). Eighty-four percent of patients received at least one dose of IT methotrexate, 52% at least one dose of IT cytarabine, and 40% at least one dose of both. The median number of IT doses received was 4 with a range of 0-31. Twelve percent of patients received 1 dose, 38% received between 2-5 doses, 25% received 6-10 doses, 12% 11-15 doses, 12% 15+ doses, and 4% received no intrathecal therapy. Of the 23 patients that had repeat LPs, 96% achieved CSF clearance with a median number of IT doses before clearance of 1 (range 0-9) and a median time to CSF clearance of 3.79 weeks (95% CI 2.14 to 5.29) (Figure 1). Of those patients who had CSF clearance, 16% of patients (n=4) had CSF relapse with concurrent bone marrow relapse. All 4 of these patients were FLT3+. Of the 18 patients with baseline neurologic symptoms at time of CNS diagnosis, 56% had improvement in original symptoms, 33% had no improvement, and 11% had no clear documentation of clinical symptoms post-IT therapy. The median overall survival after CNS diagnosis was 6.53 months (4.1-Not Reached) for patients diagnosed before/during induction and 3.55 months (2.75-Not Reached) for patients diagnosed at relapse. Discussion: In the present study, IT therapy was shown to be rapidly effective in clearing blasts and atypical myeloid cells from the CSF. Furthermore, neurologic symptoms improved in a majority of patients that received IT therapy. Lastly, a minority of patients had CSF relapse which were all accompanied by BM relapse. Prospective clinical trials and multi-center retrospective cohort studies with greater sample size are needed to further fill the gaps in treatment and outcomes for AML patients with CNS disease. Figure 1View largeDownload PPTFigure 1View largeDownload PPT Close modal

Incidence and Characteristics of Central Nervous System Involvement in Adult Acute Myeloid Leukemia Patients

Features of central nervous system (CNS) involvement in acute myeloid leukemia (AML) are not well-defined. Unlike acute lymphoblastic leukemia, there are limited guidelines for the use of intrathecal chemotherapy with induction for AML, and institutional practices vary. Unfortunately, AML patients with CNS involvement often have worse outcomes compared to those without CNS involvement (Del Principe et al., 2018; Rozovski et al., 2015). It is important to better understand the incidence and predictive clinical and features of CNS involvement in AML to identify patients for diagnostic testing and intrathecal chemotherapy. This retrospective analysis evaluated the incidence and characteristics of CNS involvement in adult AML patients at our institution.CNS screening is recommended for AML patients with specific characteristics, including CNS symptoms, monocytic phenotype, FLT3-internal tandem duplication gene mutation, and hyperleukocytosis (>100,000 white blood cells per microliter). Treatment recommendations for CNS involvement include intrathecal methotrexate, intrathecal cytarabine, or a combination of both.In this IRB-approved retrospective study, medical records were analyzed from the University of Kansas Medical Center from years 2015-2020. Patients were selected by searching the electronic medical record for adult AML patients who received a diagnostic lumbar puncture. Characteristics of interest included presence of CNS symptoms, monocytic phenotype, FLT3 mutation, and hyperleukocytosis. Characteristics that prompted CNS screening were recorded for each patient. Additional data collection included next-generation sequencing (NGS), cytogenetic results, and whether CNS screening occurred during an initial diagnosis or during an AML relapse. Lastly, the number of intrathecal chemotherapy doses was recorded for each patient.The incidence of CNS involvement was determined by dividing the number of newly diagnosed AML CNS-positive patients by the total number of newly diagnosed AML patients. Screening detection rates were determined by dividing the number of CNS-positive patients with each characteristic by the total number that received a lumbar puncture. The percentage of CNS-positive patients with each characteristic was determined by dividing the number with each specific characteristic by the total number of CNS-positive patients. The number of intrathecal chemotherapy doses required for CNS clearance was determined using data only from patients that achieved CNS clearance.Forty-eight patients met current guidelines for CNS screening; 25 were CNS-positive and 23 were CNS-negative (overall screening detection rate of 52%). The incidence of CNS involvement among all newly diagnosed adult AML patients was 3.24%. Screening detection rates were 58% for patients with 3 characteristics, 60% for 2 characteristics, 45% for CNS symptoms, and 30% for monocytic phenotype. Not enough patients presented with the FLT3 mutation or hyperleukocytosis in isolation to calculate accurate detection rates. The CNS-positive group consisted of 28% with 3 characteristics, 24% with 2 characteristics, 20% with CNS symptoms, 12% with monocytic phenotype, 4% with FLT3 mutation, 4% with hyperleukocytosis, and 36% were screened during a relapse rather than at initial diagnosis. Two patients were CNS-positive without any of our characteristics of interest (screened due to extramedullary involvement at presentation and the other was screened as part of pre-transplant evaluation). Seventeen patients achieved CNS clearance with 41% requiring 1 dose of intrathecal chemotherapy, 35% requiring 2 doses, and 24% requiring more than 2 doses. NGS and cytogenetic results did not reveal any additional associations.This data indicates that current AML CNS screening guidelines appear to properly identify a patient population at risk for CNS involvement. At our institution, 52% of screened patients were CNS-positive. This analysis also revealed a diverse distribution of characteristics among AML patients with CNS involvement, and patients commonly presented with multiple risk factors. These results emphasize the need for ongoing research to further delineate CNS involvement risk factors in AML. This data will be used for current policy analysis at our institution and potentially prospective studies to better evaluate outcomes for AML patients with CNS involvement. [Display omitted] DisclosuresLin: AbbVie, Aptevo Therapeutics, Astellas Pharma, Bio-Path Holdings, Celgene, Celyad, Genentech-Roche, Gilead Sciences, Incyte, Jazz Pharmaceuticals, Novartis, Ono Pharmaceutical, Pfizer, Prescient Therapeutics, Seattle Genetics, Tolero, Trovagene: Research Funding.

Hemorrhagic Eye Involvement in Acute Myeloid Leukemia

Purpose: Through an observation, we focus on the ocular hemorrhagic manifestations during AML and the role of the ophthalmologist in the management of this condition. Methods: We report the case of a 14-year-old boy whose hemorrhagic ocular involvement was indicative of an AML. Results: This patient with no known history was sent for an ophthalmology consultation for a sudden decline in bilateral visual acuity associated with a bilateral periorbital ecchymosis. The interrogation found an effort of vomiting preceding the ocular symptoms and a notion of purpuric spots on the lower limbs 3 months ago. Distance visual acuity has been rated at 1/10 on the right and counts the fingers on the left. Examination of the anterior segment mainly revealed periorbital ecchymosis and diffuse bilateral subconjunctival hemorrhage. Fundus analysis revealed bilateral diffuse retinal hemorrhage, premacular retro-hyaloid hemorrhage on the right and macular hemorrhage on the left. An emergency blood count showed anemia with hemoglobin (Hb) level of 5.5g/dL and thrombocytopenia at 15,000/µL. Hyperleukocytosis at 126420/µL with monocytes at 84700/µL and neutrophils at 3312/µL. The patient was immediately referred to a hematologist and an oncologist. The investigations and the myelogram made it possible to make the diagnosis of acute myeloid leukemia. Conclusions: Although the ophthalmologist plays a secondary role in the treatment of leukemia, he must be able to recognize the eye symptoms indicative of systemic disease and collaborate with hematologists and oncologists in the follow-up and management of patients.

Long Non Coding RNA BALR2-CDK6 Axis Influences Cell Differentiation and Metabolic Status of Acute Myeloid Leukemia

Purpose: Non-coding RNA (ncRNAs) genes are at least as frequent as protein-coding genes in the human genome; however, our knowledge on their function is still preliminary. Long ncRNAs are arbitrarily defined as transcripts that are over 200 nucleotides in length, and demonstrate great heterogeneity in their molecular mechanisms. Their emerging role as new players in cancer development and therapy response is widely supported by several scientific reports, and we recently found the LncRNA BALR-2 expression significantly correlated with a decreased response to prednisone treatment in B-cell precursor acute lymphoblastic leukemia (Bcp_ALL). Given its association with mixed lineage leukemia (MLL) rearrangements in Bcp-ALL, we investigated BALR-2 involvement in acute myeloid leukemia (AML) leukemogenic pathways.Methods: We retrospectively analyzed by RQ-PCR bone marrow samples of 132 children with de novo AML harboring different genetic abnormalities (CBF,MLL, and NUP98 rearrangements, FLT3-ITD , other rare translocations and patients without any recurrent molecular abnormality) diagnosed between 2002-2014 in one of the AIEOP centers and treated according to AML-2002/01 protocol. We correlated the expression of BALR-2 with patient event-free survival (EFS) and gene expression profile (GEP, HTA affymetrix 2.0). Using gene set and single sample enrichment analysis (GSEA, ssGSEA), we compared the gene expression signatures of patients with either high (4th quartile) or low expression (1st+2nd+3rd quartiles) of BALR-2. SHI-1 cell line was used to perform in vitro experiments aimed at examining the function of BALR2.Results: The expression of BALR-2 was found higher in all AML samples as compared with those collected from healthy volunteers. Moreover, we did not find any correlation between BALR-2 expression and any specific genetic abnormality. We subdivided patients by using BALR-2 expression quartiles and found that that patients with higher BALR-2 expression (4th quartile, n=32) had worse, although not statistically significant, EFS when compared to that of patients allocated to the 1st+2nd+3rd quartiles (n=100; EFS= 53% versus 61%). We discovered that the 4th quartile was enriched for patients who did not reach complete remission (CR) after induction therapy (28% vs 12%, p=0.03). Supervised clustering analyses of GEP performed in 58 samples showed that cases belonging to the 4th quartile (n=18) clustered separately from the remaining quartiles (n=40), irrespectively of the underlining genetic abnormality shown by these patients. In particular, we found that 57 coding and 12 non-coding RNAs were significantly differentially expressed (Fold Change|2|, p<0.01), and CDK6 , being chromosomally adjacent to BALR2, was overexpressed in the 4th quartile. We further investigated this putative BALR2-CDK6 relationship and found a positive correlation between BALR-2 and CDK6 expression in the whole cohort analyzed (Pearson correlation>0.7, p<0.05). We silenced BALR-2 in vitro and found this induces lower CDK6 mRNA and protein levels, as well as phospho-RB, its direct target. In line with what seen in Bcp-ALL, BALR2-CDK6 knockdown decreased cell proliferation, increased apoptosis, and sensitivity to etoposide treatment. Of note, BALR-2 depletion increased myelomonocytic differentiation, as evidenced by CD11 and PU.1 markers, both of which are Runt-related transcription factor (RUNX1 ) targets. In agreement with studies demonstrating that CDK6 acts as RUNX1 inhibitor, we found that additional 81 RUNX1 target genes showed marked down-regulation in patients with high BALR-2-CDK6 expression. Through ssGSEA, an aberrant regulation of processes regulating mitochondrial mass and activity was found in patients with the 4th quartile of BALR-2 expression (p<0.05).Conclusions: Taken together, our data suggest that BALR-2 expression is associated with worse outcome in AML. Furthermore, our data suggest a cis-regulatory transcriptional relationship between BALR-2 and CDK6, which, in turn, antagonizes RUNX1 and enhances myeloid differentiation. Lastly, in vitro approaches are ongoing to define the mitochondrial signaling events involved in BALR-2's ability to alter the metabolic status in AML, which in turn could lead to novel approaches for inducing anti-leukemic effects. DisclosuresNo relevant conflicts of interest to declare.

Extramedullary Involvement in Acute Myeloid Leukemia. A Single Center Ten Years' Experience.

The incidence, risk factors, and prognostic significance of extramedullary involvement (EMI) in adult patients with acute myeloid leukemia (AML) have not been established yet. This study analyzed clinical and biological characteristics, the impact on prognosis, and the cumulative incidence of EMI in a monocentric retrospective series. All adult patients diagnosed with AML observed in our institution between January 2010 and December 2017 were included in the analysis.Overall, 346 AMLs were analyzed. The incidence of EMI was 11% (38 patients). The involved sites were: skin (66%), central nervous system (CNS) (23%), pleura (7%), lymph nodes (5%), peritoneum (2%), spleen (2%), pancreas (2%), breasts (2%) and bones (2%). Most patients (91%) had only one EMI site, while 9% had multiple sites affected at the same time. Twenty-four (63%) patients showed signs of EMI at presentation, while extramedullary relapse occurred in 10 patients (26%); 4 patients had EMI both at presentation and relapse.EMI had a significantly higher frequency in patients with monocytic and myelo-monocytic leukemia subtypes (p<0,0001), CD117-negative (p=0,03) at flow cytometry analysis, MLL rearrangements (p=0.001), trisomy 8 (p=0,02).An analysis regarding treatment, overall survival (OS), and disease-free survival (DFS) was performed only on the 28 patients who experienced EMI at the onset of their disease; one EMI patient receiving best supportive care was excluded from OS analysis. The other 27 patients were treated with: conventional chemotherapy (21 patients), hypomethylating agents (5 patients), and low dose cytarabine (1 patient); 8 patients only (28.5%) received an allogeneic stem cell transplantation (allo-HSCT). After induction therapy, complete remission (CR) rate was 22%, with a median DFS of 7.4 months. The median OS of all 27 EMI patients was 11.6 months (range 2–79); this resulted significantly longer for the 8 EMI patients who undergone allo-HSCT than those (19 patients) who did not receive this procedure (16.7 vs. 8.2 months respectively, p=0.02).Univariate and multivariate analyses showed that undergoing allo-HSCT and achieving CR were the main positive prognostic factors for our population’s survival (p<0,0001).This study confirms the poor prognosis for EMI patients. Allo-HSCT, applicable however only in some cases, seems to have a crucial role in these patients’ therapeutic approach, being associated with a better prognosis.

S2624 Liver Injury in Acute Myeloid Leukemia

INTRODUCTION: Hepatic involvement in acute myeloid leukemia (AML) is rare and associated with a high mortality rate. Given the potential hepatotoxicity of chemotherapy, treating patients with hepatic dysfunction requires administering attenuated doses or delaying therapy resulting in possible worse outcome. We report a case of a patient with elevated transaminases at the time of diagnosis of AML in whom treatment with attenuated dose chemotherapy was promptly started. CASE DESCRIPTION/METHODS: A 66-year-old male with no pertinent history came to the emergency room with neck fullness and right sided tooth pain associated with a 10lb weight loss. On admission he was febrile to 100.4F, vitals otherwise normal. Laboratory results revealed leukocytosis with WBC 138.8 (abs neutrophil count 1.4 Thou/mL and 25 Thou/mL of blasts), Hb 11.9, Hct 37.2, PLT 16,000. A CT neck showed right 2nd molar infection and lytic lesions of the maxilla. A peripheral flow cytometry and bone marrow biopsy were consistent with AML. The LFTs showed T bili 1.2, AST 163, ALT 138, ALP 114. Further workup including, abdominal ultrasound, viral hepatitis, ANA and anti-smooth muscle antibody were unremarkable. On day 2, T bili 3.2, AST 524, ALT 587, ALP 169. At this time, it was thought that the transaminitis was secondary to AML and induction chemotherapy with cytarabine and daunorubicin (50% reduction) was started. On day 7 of chemotherapy, the transaminases improved to normal limits indicating the liver injury was reversible and secondary to AML (Figure 1). Unfortunately, our patient did not achieve remission and died 35 days after admission. DISCUSSION: Although liver infiltration by AML is rare, it should be considered early. It usually presents with elevated LFTs in a mixed hepatocellular and cholestatic pattern. In addition to our case, there are several case reports suggesting AML as an etiology of elevated LFTs. Definitive diagnosis relies on liver biopsy which can be difficult to obtain in the presence of coagulopathy. The improvement of transaminases after initiating chemotherapy and negative work-up for other etiologies suggests that AML is the cause of hepatitis. Prompt initiation of chemotherapy in AML patients is of utmost importance. Studies suggest that semi intensive dosing or delays in chemotherapy initiation result in decreased survival and higher mortalities. It is important to recognize AML as a possible, and potentially reversible, cause of hepatic dysfunction in order to prevent treatment delays and poor outcomes.Figure 1.: Level of transaminases throughout admission. Dashed orange line corresponds to the time that chemotherapy was initiated.Table 1.: Laboratory, imaging and treatment findings in eight previous studies reporting liver involvement in AML

The diagnostic and prognostic value of MRI in central nervous system involvement of acute myeloid leukemia: a retrospective cohort of 84 patients

ABSTRACT Objective: To assess the diagnostic and prognostic value of magnetic resonance imaging (MRI) in Acute Myeloid Leukemia (AML) complicated with central nervous system leukemia (CNSL). Methods: A total of 84 patients with AML and confirmed of CNSL from January 2010 to September 2019 were selected and underwent MRI scan. We retrospectively analyzed their MRI findings, summarized the imaging features of AML central infiltration, and assessed the guiding significance of MRI on diagnosis and prognosis of this disease. Results: A total of 52 patients (61.90%, 52/84) had abnormal MRI findings, of which 31 cases clearly indicated intracranial infiltration of leukemia. Among the 31 patients, the most common site of infiltration is parenchyma (19/31). Most MRI of these patients showed multiple lesions with low T1 signal and high T2 signal, which were more obvious on enhanced scan. Sensitivity of MRI in diagnosing AML central infiltration was 36.90%. Despite of its low sensitivity, it still had superior diagnostic value on some patients with false-negative CSF. The median disease-free survival (DFS) and overall survival (OS) time of patients with MRI clearly indicated central invasion were 4 and 9 months, respectively. But there was no significant difference in survival analysis compared with MRI negative patients (including abnormal but non-invasive). Conclusion: MRI manifestation of central infiltration in AML patients has certain characteristic findings, which is helpful to improve the diagnostic efficiency. Prognosis of MRI positive patients is relatively worse than that of MRI negative patients however there is no siginificant difference.

Acute Myeloid Leukemia with High Risk Features: Routine Central Nervous System Evaluation May be Beneficial

Objective : Central nervous system (CNS) involvement is a known phenomenon of acute lymphoblastic leukemia. However little is known about the incidence of CNS involvement in acute myeloid leukemia (AML) as routine lumbar punctures are not done if patients are asymptomatic at diagnosis. Our practice has been to obtain lumbar puncture (LP) at or after complete remission (CR) for patients that present with any one of the following high risk features;hyperleukocytosis with WBC &gt;10,000 or blastic crisis, extramedullary disease,monocytic differentiation. Methods: We reviewed our leukemia database at Mayo Clinic to determine the incidence of CNS involvement in patients with high risk features after due IRB approval. We also compared baseline demographic characteristics, blood counts, cytogenetic risk groups, presence of extramedullary disease, relapse rate ,transplant rate and overall survival (OS) among patients with and without CNS involvement. OS estimates were calculated by Kaplan-Meier curves and log-rank testing using JMP v.13. Results: 298 patients with AML were identified with presence of at least 1 risk factor for CNS involvement. The results of LP were only available for 126 (42%) patients. The overall incidence of CNS involvement was 12% (15/126, figure 1). Among the patients with positive disease 3 had CSF examination at diagnosis prior to CR due to the presence of CNS myeloid sarcoma (n=2) and ambiguous lineage myeloid leukemia and were excluded from further evaluation. The incidence of CSF involvement at CR1 was 9.7% (12/123). All patient with CNS positive disease received intrathecal chemotherapy with alternating cytarabine and methotrexate until they cleared their blast and additional 2-4 treatments as per treating physician's discretion .The CNS positive and negative patients were compared and did not show any statistical difference in age, gender, presence of extramedullary disease ,cytogenetic risk group, relapse rate and transplant rate as shown in table1. Molecular data was not available in most of the patients and hence was not included for analysis. The median OS was significantly lower among patients with CNS involvement compared to absence of CNS involvement but was not statistically significant likely due to small sample size (3.9 vs12.8 years (p=0.2), figure 2). The overall CNS relapse rate in patients who did not have a LP done at CR was 5.8%(10/172). Conclusions : CNS evaluation should be done in AML patients with high risk features before declaring CR. CNS disease portends overall a poor prognosis with impaired overall survival and high relapse rate. However the sample size was small and true incidence of CNS disease will need routine diagnostic LP in all high risk patients. Disclosures Patnaik: Stem Line Pharmaceuticals.: Membership on an entity's Board of Directors or advisory committees. Al-Kali:Astex Pharmaceuticals, Inc.: Research Funding.

Internally quenched fluorogenic substrates with unnatural amino acids for cathepsin G investigation

Cathepsin G is one of four members of the neutrophil serine protease family and constitutes an important biological target in various human inflammatory diseases, such as chronic obstructive pulmonary disease, acute respiratory distress syndrome and cystic fibrosis. Many studies have been focused on determining its biological roles, the latest ones concerning its involvement in acute myeloid leukemia, and as such, multiple chemical and biochemical tools were developed to investigate cathepsin G. Nevertheless, most of them lack selectivity or sensitivity and therefore cannot be used in complex systems. Here we present the development of an optimal cathepsin G Internally Quenched Fluorescence (IQF) substrate that incorporates unnatural amino acids causing the increase of its selectivity toward neutrophil elastase and potency in in vitro studies.

Primary and Secondary Central Nervous System Involvement in Acute Myeloid Leukemia

Introduction: Central Nervous System involvement (CNSi) in patients with Acute Myeloid Leukemia (AML) rarely occurs. It is not well characterized clinically and lacks standardized treatments. Patients and methods: A retrospective analysis of 77 consecutive AML patients with primary and secondary CNSi during 2004-2016 was performed in eight Polish haematological centres. Results: 77 patients (38 with primary CNSi-AML) were included. Median age was 44 years in both groups. Elevated lactate dehydrogenase activity was found in the majority of subjects. Patients in primary CNSi-AML group more often had myelomonocytic and monoblastic AML subtypes (68.4%) compared to secondary CNSi AML (43.5%) (p=0.039). There were no differences between both groups in the number of leukocytes or the proportion of blast cells rates in peripheral blood or bone marrow at AML diagnosis. There were also no statistically significant differences between both groups in the incidence of cytogenetic or molecular abnormalities. In both groups, CNSi was most frequently found in the cerebrospinal fluid and the most common neurological symptom was headache. The following manifestations were more frequent in secondary than in primary CNSi-AML: lower extremity weakness (38.46% vs. 13.16%; p=0.023), paraesthesia (38.46% vs. 13.16%; p=0.023), motor deficits (31.58% vs. 10.53%; p=0.047), and asymmetry of reflexes (26.32% vs. 2.7%; p=0.007). Median pleocytosis was also significantly higher in secondary than in primary CNSi-AML: 27 (IQR 2-146) vs. 2 (IQR: 1-12; p=0.004). Both groups had rather short Overall Survival (OS), with a median of 16.6 months (9.9-NA) for patients with primary CNSi-AML and 15.4 months (10.1-21.1) for patients with secondary CNSi. Conclusion: Patients with CNSi AML were relatively young, having high lactate dehydrogenase activity and high rates of the myelomonocytic and monoblastic/monocytic AML subtypes. The advisability of undertaking CNS examination and prophylaxis in patients with such characteristics thus merits further reassessment.

Discrepant Mutational Composition between Myeloid Sarcoma and Bone Marrow Leukemia Revealed through Targeted Next Generation Sequencing

Introduction:Myeloid sarcoma (MS) is the involvement of acute myeloid leukemia (AML) cells in extramedullary tissues, whose mechanism remains to be further elucidated. How MS affects AML prognosis at a molecular level is also an open question. This unexplained tropism of leukemic blasts to extramedullary tissues is likely caused by the combination of genetic and epigenetic aberrations. Our study investigated the paired samples of myeloid sarcoma tissue and bone marrow (BM) at diagnosis in perspective of elucidating specific genetic abnormalities that underpin the ectopic homing of MS cells.Methods:A 62-patient cohort of pathologically-proven MS diagnosed between 2005-2018 was systemically reviewed. Histomorphology and immunophenotypes of all cases were reviewed by the hematopathologist. Cytogenetic karyotyping in BM cells was carried out with conventional G-banding method. Twenty-five cases of extramedullary presentation at initial diagnosis were further interrogated with next generation sequencing. DNA was extracted from formalin-fix-paraffin-embedded (FFPE) tissue using an error-avoiding reagent against formaldehyde-caused artificial single nucleotide changes (QIAGEN GeneRead). Mutations in 54 genes associated with myeloid disorders were analyzed in Illumina MiSeq sequencer along with the TruSight Myeloid Sequencing Panel. FLT3-ITD in bone marrow was detected by Sanger sequencing. Of these, 16 patients' paired samples (16 FFPE tissue and 16 BM tissue) were analyzed in comparison.Results:MS occurred concomitantly with leukemic marrow in 21 patients, without bone marrow disease in 2 patients, and resulted from transformation of MPN or MDS/MPN in 2 patients. The median age of diagnosis is 45 years (range 17-72 years), and the male to female ratio is 1.28. Twenty patients received standard treatment with systemic chemotherapy, and nine patients underwent subsequent allogeneic transplantation. The median overall survival was 31.6months ± 20.83 months with a median follow up of 28 months. Cytogenetic patterns included 9 patients with normal karyotypes, 5 with complex changes and 4 with a core-binding factor aberration. The median of mutation numbers in MS was three (range 0- 5) per case. In agreement with prior reports, the most common molecular abnormality in MS was NPM1 (11/25, 44%), followed by FLT3-ITD (7/25, 28%) and DNMT3A (6/25, 24%). The coexisting genetic alterations in the BM from patients without evident AML in morphology or immunophenotypic analyses, suggesting a role for clonal hematopoiesis in the BM. All of the cases with RUNX1-RUNX1T1 translocation harbored KIT mutation. Nineteen out of 25 cases (76%) had a mutation in the genes of receptor tyrosine kinase (RTK)- RAS pathway. In MS-BM paired samples, additional driver mutations in the MS samples included DNMT3A, IDH1, ASXL1, KRAS, CBL, NPM1, KIT and U2AF1. Conversely, one patient's BM PTPN11 mutation was lost in his MS lesion. For more details, the cytogenetic changes, mutational profile and the variant allele frequency were summarized in Figure 1.Conclusion:Interestingly, additional driver mutations were identified in the MS samples compared to the BM counterparts, suggesting that a comprehensive characterization of AML heterogeneity might need the mutational profiling of the coexisting MS. AML patients with MS infers a negative prognosis and were treated with frontline allogeneic stem cell transplantation whenever possible in this study. Consistent with prior report, this study showed a higher incidence of genetic alteration of NPM1, FLT3-ITD and DNMT3A in MS along with an enrichment of RTK-RAS signaling pathway mutations. Functional study is needed to delineate the biology underlying the ectopic homing of these commonly mutated genes in AML.(Figure legend)Molecular signature of 25 patients with myeloid sarcoma. Highlight in red represents pathologic mutation, highlight in blue represents mutation of unknown significance. [Display omitted] DisclosuresNo relevant conflicts of interest to declare.

"Secondary Ocular Involvement in Acute Myeloid Leukemia– M0: A Rare Case Report"

"Secondary Ocular Involvement in Acute Myeloid Leukemia– M0: A Rare Case Report"

Upregulation of long non-coding RNA MALAT-1 confers poor prognosis and influences cell proliferation and apoptosis in acute monocytic leukemia

Metastasis-associated lung adenocarcinoma transcript 1 (MALAT-1), a long non-coding RNA, has been documented to be a new prognostic marker and gene regulator in several types of cancer, but its potential involvement in acute myeloid leukemia (AML) remains unclear. This study investigated the expression and functional role of MALAT-1 in AML. MALAT-1 expression was assessed by real-time quantitative PCR. After lentiviral-mediated MALAT-1 knockdown, the proliferation of AML cells was determined by CCK-8 and colony formation assays. Cell cycle progression and apoptosis were evaluated by flow cytometry and the expression of caspase-3, −8 and −9 was assessed by western blot analysis. We found that MALAT-1 expression in patients with acute monocytic leukemia (M5) was significantly increased when compared with that of healthy controls, and the overall survival of M5 patients with high MALAT-1 expression was markedly reduced when compared with the overall survival of patients with low MALAT-1 expression. The analysis of cellular experiments showed that MALAT-1 silencing decreased the proliferation of M5 cells (U-937 and THP-1), inhibited cell cycle progression and increased apoptosis. Taken together, these findings suggest that high MALAT-1 expression is closely associated with poor prognosis in M5 patients and may play a role in leukemia cell proliferation and apoptosis, and may serve as a promising theranostic marker.

Clinical outcome and efficacy of current anti-leukemic therapy for leptomeningeal involvement in acute myeloid leukemia.

We investigated risk factors and outcome in acute myeloid leukemia (AML) patients with leptomeningeal involvement. Medical records of patients with non-promyelocytic AML at Seoul National University Hospital from January of 2000 to November of 2013 were reviewed. Leptomeningeal involvement was defined as the presence of atypical or malignant hematopoietic cells in the cerebrospinal fluid. Among 775 patients with AML, 141 patients (18.2%) underwent cerebrospinal fluid examination. Leptomeningeal involvement of AML, confirmed in 38 patients (4.9%), was associated with high white blood cell count and high level of lactic. There were seven patients in the favorable risk group (19.4%), 21 in the intermediate risk group (58.3%), and eight in the adverse risk group (22.2%). Twenty-eight patients (85.7%) developed leptomeningeal involvement during relapse status or refractory status. Thirty-one patients (81.6%) received intrathecal chemotherapy, and whole-brain and/or craniospinal radiotherapy was conducted in 10 patients (27.0%). The rate of complete remission after induction chemotherapy was 63.2%. Median overall survival was 9.9months. Radiotherapy and complete remission after the first induction chemotherapy were associated with longer overall survival. Leptomeningeal involvement in acute myeloid leukemia is rare, but relatively common in relapsed status or refractory status. Craniospinal radiotherapy and complete remission after induction chemotherapy were found to favorable prognostic factors.

Whole exome sequencing reveals de novo pathogenic variants in KAT6A as a cause of a neurodevelopmental disorder

Neurodevelopmental disorders (NDD) are common, with 1-3% of general population being affected, but the etiology is unknown in most individuals. Clinical whole-exome sequencing (WES) has proven to be a powerful tool for the identification of pathogenic variants leading to Mendelian disorders, among which NDD represent a significant percentage. Performing WES with a trio-approach has proven to be extremely effective in identifying de novo pathogenic variants as a common cause of NDD. Here we report six unrelated individuals with a common phenotype consisting of NDD with severe speech delay, hypotonia, and facial dysmorphism. These patients underwent WES with a trio approach and de novo heterozygous predicted pathogenic novel variants in the KAT6A gene were identified. The KAT6A gene encodes a histone acetyltransfrease protein and it has long been known for its structural involvement in acute myeloid leukemia; however, it has not previously been associated with any congenital disorder. In animal models the KAT6A ortholog is involved in transcriptional regulation during development. Given the similar findings in animal models and our patient's phenotypes, we hypothesize that KAT6A could play a role in development of the brain, face, and heart in humans. © 2016 Wiley Periodicals, Inc.