Myelodysplastic Changes Research Articles

Outcomes and Hospital Resource Utilization Associated with Decreased Ven Exposure in Acute Myeloid Leukemia Patients: A Real-World Retrospective Review

Patients (pts) with acute myeloid leukemia who are ineligible for intensive chemotherapy are treated with hypomethylating agent (HMA) and Venetoclax (Ven). We previously reported outcomes on a cohort of our pts hospitalized for induction therapy demonstrating that the majority of pts required Ven exposure de-escalation. Despite its widely accepted clinical practice, no prospective study has evaluated the efficacy in retaining remission or the tolerability of less Ven exposure per cycle (cyc). Additionally, there is no study evaluating the effect of delaying treatment secondary to its myelosuppressive toxicities. We aim to present outcome data on a large cohort of all AML pts treated with HMA + Ven within our healthcare system. We queried Northwell Cancer Institute's electronic health records to identify all pts with AML who received at least one cyc of Ven and HMA between January 2019 and December 2022. Groups for analysis were created for pts who received at least 3 cyc of HMA and Ven based on the median Ven exposure days per cyc (≤ 14 days or ≥ 15 days) and the median days between cyc (≤ 34 or ≥ 35 days) excluding cyc 1 and 2. Median relapse-free survival (mRFS) and median event-free survival (mEFS) in months (m) were defined by ELN 2022 criteria. Pts who received allogeneic transplants (n=4) were excluded from survival evaluations. Kaplan-Meier (KM) method and log rank testing was used to compare time to event data. We identified 142 AML pts who received at least 1 cyc of Ven + HMA. Pts had an ORR of 42%, mEFS of 4m and mOS of 9.6m. The median age was 77. Only 76 pts received 3 or more cyc of HMA + Ven with mRFS 11.6m of and mOS of 20.6m. Of these pts, 39 had AML with myelodysplastic changes, 29 had De Novo AML and 8 had secondary AML. 75% of pts received HMA + Ven as first line treatment. Utilizing the 2022 ELN risk categories (Dohner et al, Blood 2022), 12 had favorable risk, 12 had intermediate risk and 52 had adverse risk. 93% had treatment regimen modifications by either reduced Ven/cyc or increased cyc intervals. All prognostic indicators appeared evenly dispersed among the groups. Pts with ≤14 days of Ven/cyc (n=35) had a median of 7 cyc (range 3-24) and remained on treatment for a median of 11.3 m. Meanwhile, pts with ≥15 days/cyc (n=41) had a median of 5 cyc (range 3-24) with a median of 10.1m on treatment. The ≤14 days of Ven/cyc group had significantly improved RFS (15.8m vs 8.7m) and OS (24.7m vs 11.3m) compared to the group of pts receiving ≥15 days/cyc (p <0.01). Additionally, there was a decrease in number of hospital days, RBC and platelet transfusions in this group compared to the ≥15 days/cyc group (figure 2). 66% of pts (n=50) required increased time interval between cycles. Both ≤ 34 and ≥ 35 days cyc interval groups completed median of 6 cyc. No significant difference was found in mRFS (11.6m vs 11.8m) or mOS (15.1m vs 21.8m). However, there was a reduction in hospital days, pRBC and platelet transfusions in the ≥ 35 day interval group (figure 2). The overall response rate, mRFS and mOS of all 144 patients seem to be decreased compared to reported prospective trials. This may be due to differences in frailty in our pt population. Although limited by the bias of retrospective analyses, our evaluation of pts outcomes demonstrates a statistically and clinically significant improvement in mRFS and mOS in pts with decreased Ven days/cycle. The majority of pts had Ven/cycle decreased by cycle 3 and most were intermediate or high risk. Our results also highlight the decrease in hospital resource utilization and transfusion needs in this group which may lead to improved quality of life and decreased costs. The ≤14days Ven/cycle group had improved survival compared to the VIALE-A and DEC10-VEN trial despite a larger proportion of our pts having adverse risk. We hypothesize that this improvement is likely multifactorial secondary to decreased mortality from higher Ven exposure, improved tolerance causing increased HMA exposure from timely dosage and from a theoretically possible decreased intracellular adaptive mechanisms generating resistance from continuous Bcl-2 inhibition. This emphasizes the need for continued reporting of outcomes of therapy with HMA/Ven. Additionally, due to the clinically significant improvement in mRFS and mOS, a prospective trial evaluating the efficacy, tolerability, and impact on quality of life of reduced Ven exposure/cyc should be considered.

Tandem Duplications of the UBTF gene in Adult AML: A Rare but Recurrent Alteration Associated with Myelodysplasia and Poor Outcome

The upstream binding transcription factor (UBTF) is a nucleolar protein that regulates the transcription of ribosomal genes as a component of the RNA Pol I pre-initiation complex. Recently, tandem duplication mutations of the UBTF gene (UBTF-TDs) were identified as recurrent alterations in pediatric AML (Umeda et al., 2022), potentially representing a new subtype-defining lesion. UBTF-TDs were found to be associated with normal karyotype (NK) or trisomy 8 (+8), FLT3-ITD and WT1 mutations as well as poor prognosis. Data on the role of UBTF-TD in adult AML are limited. In the present study, we therefore analyzed the prevalence and prognostic significance of UBTF-TDs in a large cohort of adult AML patients (pts). Methods: Pts included were registered and treated in clinical protocols of the Study Alliance Leukemia (SAL) (AML96, AML2003, AML60+, SORAML) or the SAL-registry. Screening for UBTF-TDs was done by PCR covering exon 13 of the UBTF gene with 6-FAM labelled primers followed by high-resolution fragment analysis using genomic DNA isolated at diagnosis. Mutations were confirmed by Sanger sequencing. All UBTF mutant samples were further analyzed by targeted next generation sequencing (Archer Myeloid Panel) for the presence of co-occurring alterations. Results: Somatic mutations in UBTF were identified in 52 (1.2%) of 4247 pts. Mutations varied in size (3 to 309 bps), all yielding in-frame insertions, duplications or deletions in exon 13 of the UBTF gene. UBTF-TD AMLs frequently presented with a normal karyotype (46%) or +8 (36.5%). Similar to findings in pediatric pts, the co-mutation profile showed significant differences between UBTF-mut and UBTF-wt pts, i.e. UBTF-TDs were significantly associated with FLT3-ITD (48%, p<.001) or WT1 mutations (52%, p<.001), while DTA co-mutations were exceedingly rare (DNMT3A 1.9%; TET2 3.8%; ASXL1 3.8%) (Fig. 1A). Furthermore, UBTF-TDs and several class-defining lesions, i.e. reciprocal translocations such as RUNX1::RUNX1T1,DEK::NUP214 or mutations in CEBPA or NPM1 were mutually exclusive. The prevalence of UBTF-TDs showed a strong negative correlation with increasing age, ranging from 10% in patients <20 years (yrs) to 0.05% in patients >70 yrs, respectively. Accordingly, pts with UBTF-TDs were significantly younger (median age 41 yrs; range 17-77 yrs) than wt pts (med. 57 yrs; range 15-90 yrs, p<.001). Association with clinical parameters revealed significantly lower hemoglobin levels and platelet counts at diagnosis for UBTF-mut pts compared to UBTF-wt pts (median Hb 8.7 vs. 9.2 g/dL; p=.02; median PLT 31.5 vs 53 x 109/L; p=.003). Although UBTF-TDs mainly affected younger pts, cytomorphologic assessment revealed a clear association with myelodysplastic changes in about 60% of patients. Univariate analysis showed a significantly higher rate of complete remissions (CR) in UBTF-mut pts (92.3%) compared to UBTF-wt pts (70.8%) (p<.001). However, UBTF-mut pts had shorter overall (OS) and event-free survival (EFS). This effect was particularly pronounced in the subgroup of pts under 60 years of age (median OS 20.4 months in UBTF-mut pts vs. 45.3 months in UBTF-wt pts, p=.079; median EFS 6.7 months in UBTF-mut pts vs. 11 months in UBTF-wt pts, p<.001) (Fig.1B), who represented the majority (45/52, 87%) of UBTF-TD patients, and in patients with co-mutations of the WT1 gene (data not shown). AlloSCT performed in CR1 in 11 pts (21%) did not improve outcome. In multivariable analyses, the presence of UBTF-TD was associated with a trend for shorter OS (HR: 1.39; 95% CI 0.98-2, p=.06) and significantly worse EFS (HR: 1.68; 95% CI 1.24-2.3; p<.001). Conclusions: This analysis of a large cohort of adult patients with newly diagnosed AML revealed that UBTFmutations can be found in about 1% of all patients with AML, but are considerably more common in young adults. As in pediatric patients, they are associated with a specific cytogenetic and molecular profile, i.e. high rate of +8, FLT3-ITD and WT1 mutations. As a novel finding, adult UBTF-TD patients frequently showed signs of myelodysplasia. The distinct molecular genotype and the fact that UBTF-TDs were associated with a dismal outcome, even in patients treated with alloSCT in CR1, support the classification of this group as a new disease entity and indicate that novel treatment strategies are needed in this subgroup of patients. Figure 1View largeDownload PPTFigure 1View largeDownload PPT Close modal

How Often Do Cytogenetics and NGS Information Impact Upfront Treatment in AML?

Introduction: Over the past ten years, the treatment of Acute Myeloid Leukemia (AML) has substantially changed. New therapies emerged, and with the advance in understanding the genetic and molecular basis of AML, we incorporated new biomarkers into the standard evaluation of patients. The 2022 ELN recommends immunophenotyping, cytogenetics, and molecular studies as the basic initial testing of any new patient. Those are necessary to establish risk stratification and diagnosis. In our retrospective study, we looked into whether we would have decided to change therapies or had more options presented to a patient in case we had molecular and cytogenetics studies upfront and before starting treatment. Methods: We collected data from patients with AML treated at our university hospital from June 2020 to June 2022. The specific information we captured was: blood counts on admission, ELN risk stratification, Charleston score, type of treatment, time to cytogenetics results, time to Next Generation Sequence results, the best response to therapy, MRD status, and consolidation with allogeneic stem cell transplant. After we collected all information, each patient had a reevaluation. If a patient had any of the following molecular/cytogenetics changes (FLT3, cytogenetics changes associated with myelodysplasia, p53 mutation, complex karyotype, BCR-ABL1, RUNX1-RUNX1T1, CBFB-MYH11, Variant-type PML/RARA), he was carefully reevaluated and included in the "other options of therapy" subgroup. We included 17 patients in the "other options of therapy" subgroup and twenty-two in the "standard" group.Results: We included 39 individuals. The mean age of diagnosis was 62.18 (27-83). Three patients were stratified as good ELN risk, 17 as adverse risk, and 19 as intermediate risk. The mean Charlson Comorbidity Index (CCI) was 5.51 (2-10); 17 patients received high intense chemotherapy and 22 low intense chemotherapy. The mean wait to start therapy was of 7 days. The mean waiting time for NGS results was 12.71 and 7.30 days for cytogenetics. Seventeen patients were classified in the "other options of therapy" group. And twenty-two on the "standard" group. In the standard group, the mean overall survival was 496.5 days, and on "other options of therapy" it was 447.7. There was no statistically significant difference in survival between the two groups (p=0.602). (figure 1)The main reason for other therapy options was the presence of myelodysplastic genes (3), tp53 (3), RUNX1-RUNX1T1(2), CBFB-MYH11(1), cytogenetics suggesting myelodysplastic changes (6), Variant-type PML/RARA (1) and FLT3 (3). Conclusions: In this study, we retroactively evaluated if having more initial therapy options would have impacted the overall survival of newly diagnosed AML patients. Our survival analysis showed no significant statistical difference between the two groups. The median time to results of NGS was 12.71, and for cytogenetics, 7.3 days. In our cohort, the median time for therapy from diagnosis was 7.00 days. The reasons to change therapies were: midostaurin on FLT3 patients, Gemtuzumab ozogamicin on good risk patients, CPX-351, or alternative induction strategies in patients with p53 or unfavorable cytogenetics, and alternative induction on patients with Variant-type PML/RARA. This study has limitations due to its retrospective nature, small population, and short follow-up period. Figure 1View largeDownload PPTFigure 1View largeDownload PPT Close modal

Role of Heparan Sulfate 6-O-Endosulfatases in Hematopoiesis

Heparan sulfate proteoglycans (HSPGs) are expressed at the cell surface and in the extracellular matrix, including within the bone marrow microenvironment. Heparan sulfate (HS) is the glycosaminoglycan side chain of HSPGs, and these side chains bind to a myriad of growth factors, cytokines, chemokines, and extracellular matrix molecules, mediating a diverse range of biological functions. It is well established that HS-protein interactions critically depend on the amount and position of 6-O-sulfate groups, which form binding sites for proteins. The HS 6-O-endosulfatases, the Sulfs (Sulf1 and Sulf2), remove 6-O-sulfates from specific HS intra-chain sites and are the only known enzymes that can modify HS sulfation status extracellularly. A gain or a loss of HS 6-O-sulfation can alter the outcome of HS-ligand interactions, such as with Wnt ligands, fibroblast growth factors (FGF), and transforming growth factor (TGF)-β1. Monocytes and macrophages express the Sulfs, predominantly Sulf2, and their secretion of the Sulfs can influence HS sulfation status in their surrounding microenvironments. The objective of this study was to examine the impact of myeloid lineage Sulf deletion on hematopoiesis. For this investigation, we generated a murine model of Sulf deletion in Lysozyme 2 (Lyz2) positive myeloid lineage cells by crossing Sulf1 and Sulf2 double floxed mice with the LysMcre mouse line (hereinafter LysM-Sulf-/-). At 8-12 weeks of age, the bone marrow of LysM-Sulf-/- male mice displayed myelodysplastic changes with reduced number of megakaryocytes (MK) compared to the control mice (Lyz2-cre+/-). Bone marrow-derived (BMD) macrophages from LysM-Sulf-/- mice exhibited enhanced proliferation but reduced phagocytosis of Escherichia Coli (E. Coli)in vitro. In addition, LysM-Sulf-/- BMD macrophages expressed reduced levels of key inflammatory mediators including inducible nitric oxide synthase (iNOS), tumor necrosis factor (TNF)-α and interferon gamma-induced protein 10 (IP-10) in response to lipopolysaccharide stimulation compared to control BMD macrophages. Complete blood cell counts revealed decreases in total white blood cells (4.6 ± 0.6 10E9 Cells/L vs. 8.1 ± 1.010E9Cells/L in control mice, P = 0.0193), red blood cells (RBC, 10.9 ± 0.1 10E12 Cells/L vs. 11.4 ± 0.2 10E12 Cells/L in control mice, P = 0.0385), and hematocrit (43.5 ± 0.3% vs. 46.3 ± 0.7% in control mice, P = 0.0054) in LysM-Sulf-/- males. In addition, LysM-Sulf-/- males (8-12 weeks of age) exhibit extramedullary hematopoiesis with splenomegaly (spleen size increased by 2.6-fold, 162.1 ± 11.5 mg vs. 79.1 ± 1.2 mg in control mice, P < 0.0001). Bone and spleen morphologies are shown in the accompanied Figure. In older LysM-Sulf-/- males (8-12 months of age), the reductions in RBC and hematocrits were further exacerbated with increased reticulocyte counts in the peripheral blood. In addition, thrombocytopenia was observed in 8-12 months old LysM-Sulf-/- males (platelet counts 125.8 ± 41.4 vs. 483.3 ± 7.1 in control mice, P = 0.0007). The above changes were accompanied by amplified splenomegaly (spleen size increased by 9.2-fold, 860.4 ± 157.6 mg vs. 93.2 ± 8.2 mg in control mice, P = 0.0152) and erythropoiesis in the liver. In terms of signaling, enhanced Smad2/3 phosphorylation (primary transducers of TGF-β1 signaling) was observed in both the spleens and the lungs of LysM-Sulf-/- male mice. Finally, in contrast to the male mice, complete blood cell counts were normal in both young and old LysM-Sulf-/- females without obvious extramedullary hematopoiesis. Our investigation revealed the importance of HS 6-O-sulfation in supporting normal hematopoiesis in the bone marrow, and alterations in HS 6-O-sulfation status in the bone marrow microenvironment due to LysM-Sulfdeletion leads to not only impairment in monocyte/macrophage development and function, but also age- and sex-dependent deficiencies in erythropoiesis and thrombopoiesis. Our study identifies TGF-β1 as one of the signaling pathways regulated by the Sulfs. The regulatory roles of the Sulfs in TGF-β1 as well as other signaling pathways in hematopoiesis warrant further investigation. Figure 1View largeDownload PPTFigure 1View largeDownload PPT Close modal

Abnormal Movement Following Transcobalamin II Deficiency Treatment Responding to Clonazepam: A Case Report

AbstractTranscobalamin II (TCII) is a transporter protein that facilitates cobalamin release from the bloodstream to the cell. Deficiency in TCII is an autosomal recessive disorder caused by a mutation in the TCN2 gene. Treatment with intramuscular injection of hydroxocobalamin is greatly effective in improving the symptoms of this disorder. However, abnormal involuntary movements can occur and have been reported in patients with cobalamin deficiency caused by nutritional deficiency. Though, it is rarely associated with the treatment of hereditary TCII deficiency. Here, we report such a case, aiming to alert practitioners treating hereditary TCII deficiency. A 2-year-old boy born to a consanguineous parents presented with failure to thrive, recurrent infection, and pancytopenia. His condition deteriorated rapidly, and his investigation was remarkable for pancytopenia, elevated methylmalonic acid, and myelodysplastic changes in the bone marrow. A flash whole-exome sequence confirmed the diagnosis of TCII deficiency. The patient began treatment with IM hydroxocobalamin, and on the second day, he developed an abnormal involuntary movement that was abated by clonazepam. Abnormal nonepileptic movements following IM hydroxocobalamin in a patient with TCII deficiency shows a remarkable response to clonazepam.

Avaliações histológica e imunoistoquímica da medula óssea do fêmur e do manúbrio esternal de cães reagentes para leishmaniose aos testes DPP® e ELISA

Abstract As the bone marrow is one of the most organs affected by canine visceral leishmaniasis (CVL), samples from this are frequently taken for parasitological tests, with occurrence of myelodysplastic changes, with consequent anemia, leukopenia, and thrombocytopenia. Thus, this study aimed to investigate the histological and immunohistochemical changes in the bone marrow of the femur and sternal manubrium of dogs reactive for leishmaniasis by DPP® and ELISA tests. For this, thirteen canines from the epidemiological routine for CVL carried out by the Directorate of Zoonosis Surveillance of Goiânia (DVZ), GO, Brazil, were subjected to anatomopathological examination. 46.2% of bone marrow samples from the femur showed a higher proportion of the red series, and 53.9% of bone marrow of the sternal manubrium evidenced a higher proportion of the red series. Also, there were varied macrophage hyperplasia, hemosiderosis, and megakaryocytic emperipolesis. Amastigote forms of Leishmania spp. in the bone marrow of the femur and sternal manubrium to histopathological and immunohistochemical evaluations were observed, with good agreement them, but without difference in the parasite intensity between the bone marrow of these anatomical sites. It was concluded that bone marrow of the femur and sternal manubrium of dogs reactive for leishmaniasis by DPP® and ELISA tests has histological changes resulting from the disease, regardless of the parasite presence or intensity, with macrophage hyperplasia, hemosiderosis, and emperipolesis being the main medullary changes in these animals. Also, the bone marrow of the femur and sternal manubrium are useful anatomical sites for the diagnosis of CVL by direct methods.

A Phase II Study of CPX-351 Plus Venetoclax in Patients with Relapsed/Refractory (R/R) or Newly Diagnosed Acute Myeloid Leukemia (AML)

A Phase II Study of CPX-351 Plus Venetoclax in Patients with Relapsed/Refractory (R/R) or Newly Diagnosed Acute Myeloid Leukemia (AML)

ALLOGENEIC HEMATOPOIETIC STEM CELL TRANSPLANTATION IN FANCONI ANEMIA; A SINGLE CENTRE EXPERIENCE

Objective: To determine the treatment outcome of Hematopoietic stem cell transplantation in Fanconi Anemia.&#x0D; Study Design: Case series.&#x0D; Place and Duration of Study: Armed Forces Bone Marrow Transplant Center, Rawalpindi, from Jan 2001 to Jun 2018.&#x0D; Methodology: Data of all Fanconi anemia patients who had fully HLA matched bone marrow transplant during this period was analysed for variables affecting the outcome in terms of overall survival. Those fanconi anemia patients who had myelodysplastic changes or acute myeloid leukemia were excluded.&#x0D; Results: Total 27 patients underwent fully HLA matched allogeneic bone marrow transplant for Fanconi Anemia. Mean age of patients at transplant was 12.12 ± 5.16 years. All patients at transplant were in aplastic phase. Conditioning was done with fludarabine 120mg/m2 , ATG 20 mg/kg and Cyclophosphamide at a dose of 20-40 mg/kg. Mean time to neutrophil engraftment was 12.3 ± 2.92days and for platelets 20 ± 10.3 days. Major posttransplant complications were neutropenic fever in 26 (96%), hypertension in 18 (66.6%), mucositis in 12 (44.4%), azotaemia in 8 (29.6%), gut toxicity in 7 (25.9%) and haemorrhagic cystitis in 5 (18.5%) patients. Four patients (14.8%) had acute graft versus host disease while 7 (26%) patients had chronic GVHD. Overall survival at 6 months, 1, 5 and 8 years was 67%, 63%, 59% and 55% respectively. While overall survival in patients transplanted at younger age (&lt;11 years) was 81.8% compared to 37.5% in older age group (&gt;11years) and was statistically significant (p-value = 0.03).&#x0D; Conclusion: Our study demonstrated...................

A Challenging Diagnosis of Acute Myeloid Leukemia with Myelodysplasia Related Changes in the Setting of Ayurvedic Supplements and B12 Deficiency

Abstract Introduction/Objective Bone marrow findings of myelodysplastic changes can be associated with vitamin or mineral deficiencies (B12, folic acid or copper), infections, inflammatory disorders, exposure to toxins, heavy metals, zinc excess, recent radio- or chemotherapy, or myeloid neoplasms including myelodysplasia (MDS) and acute myeloid leukemia (AML). We present a case of a 32 year old Indian woman who presented with fatigue and weakness. She has a history of vitamin B12 deficiency and has been taking Ayurvedic supplements. This clinical history is very important because studies have shown that vitamin B12 deficiency has led to incorrect diagnoses of AML and/or MDS. Additionally, Ayurvedic supplements can contain a variety of heavy metals which can contribute to myelodysplastic changes. Results A complete blood count and peripheral smear analysis showed pancytopenia with rare blasts. A bone marrow core biopsy with ancillary testing was performed to evaluate for a hematologic malignancy. Vitamin B12 testing and heavy metal analysis was necessary to reach a final diagnosis. Flow cytometric analysis of the marrow identified 19.5% CD34 positive myeloblasts. The aspirate and core are hypercellular with increased blasts (17% on aspirate and 20-25% on core biopsy) with trilineage dyspoiesis. AML panel by fluorescence in situ hybridization showed no abnormalities. Heavy metal analysis shows no increase in lead, cadmium, mercury and arsenic levels. Recent vitamin B12 tests show results within normal range secondary to successful replacement. Ultimately, chromosome analysis identifies t(3;12)(q26,p13) involving ETV6/MECOM characteristic of a very poor prognosis in MDS or AML. Molecular AML panel identified BCOR and PTPN11 gene mutations which are associated with more aggressive disease and a poor prognosis in myeloid neoplasms. Conclusion This case had multiple possible causes of myelodysplastic changes and it was necessary to exclude these factors before yielding the final diagnosis of Acute Myeloid Leukemia with myelodysplastic related changes which demonstrated a rare translocation t(3;12) ETV6/MECOM which has a poor prognosis.

IAMP21 in acute myeloid leukemia is associated with complex karyotype, TP53 mutation and dismal outcome.

Acute myeloid leukemia (AML) with intrachromosomal amplification of chromosome 21 (iAMP21) is rare and has not been well characterized. We report 13 patients, 7 men and 6 women, with a median age of 65 years. Eleven patients presented with AML with myelodysplasia-related changes, and two patients had therapy-related AML. Cytopenias were detected in all patients (11 pancytopenia and two bi-lineage cytopenia). Myelodysplastic changes were observed in all 11 patients with adequate cells to evaluate. Myelofibrosis was present in ten patients. All patients had a complex karyotype, including abnormalities of chromosomes 5, 7, 17, and hsr(21)(q22), and ten patients showed TP53 deletion and/or mutation. Eleven patients received AML-based chemotherapy, one of whom also received hematopoietic stem cell transplant. By the end of the last follow-up, eight patients died with median survival of 3.2 months, four patients were alive with persistent AML, and one was in complete remission. The median overall survival was 6 months for all patients. We conclude that AML with iAMP21 is often associated with cytopenias, myelodysplasia, a complex karyotype, TP53 mutation/deletion, and a poor prognosis despite current therapies.

Comparison of Fixed Dose, Reduced-Intensity Conditioning with Busulfan and Fludarabine to Reduced PK-Guided Busulfan AUC Conditioning in Patients Undergoing Hematopoietic Stem Cell Transplant for AML/MDS

<h3>Introduction</h3> The development of reduced-intensity conditioning (RIC) regimens has allowed more patients to receive allogeneic hematopoietic stem cell transplant (HSCT) by reducing toxicities associated with myeloablative conditioning (MAC). Key in reducing conditioning regimen intensity is modification of busulfan exposure, expressed as an area under the curve (AUC). Prior studies (including BMT CTN 0901) have demonstrated RIC regimens were associated with less toxicity at the cost of potentially decreased survival relative to weight-based MAC regimens. At OSU, we have utilized an AUC target of 4,000 μmol-min/L per day × 4 days in a subset of patients to balance toxicity with risk of relapse. Here we compare outcomes of AUC 4,000 to weight-based RIC Flu/Bu2. <h3>Objectives</h3> The objectives of this study were to assess differences in safety and efficacy in patients receiving different busulfan dosing strategies. <h3>Methods</h3> To compare regimens, a retrospective cohort study was conducted of patients undergoing HSCT for acute myeloid leukemia (AML) or myelodysplastic syndrome (MDS). In the AUC 4,000 group, the target busulfan exposure was 16,000 μmol-min/L divided over 4 daily doses. In the RIC group, patents received busulfan 0.8 mg/kg/dose for 8 doses (Flu/Bu2). The primary outcome was relapse free survival (RFS). Secondary outcomes included overall survival (OS); time to count recovery; incidence of acute and chronic graft vs host disease (GVHD); key adverse effects. <h3>Results</h3> Seventy-four patients were eligible. There were no differences in disease risk status, rate of AML with myelodysplastic changes, or therapy-related AML/MDS. The percent of patients with HCT-Comorbidity Index score of ≥ 3 was 52.9% for AUC 4,000 and 77.5% for RIC. At 18 months, RFS was not significantly different (p=0.37) (A). Eighteen-month overall survival was also not significantly different (p=0.63) (B). Cumulative incidence of acute and chronic GVHD were not also significantly different (p=0.82, p=0.18, respectively). There was a significant difference in the 18-month cumulative incidence of relapse in favor of AUC 4,000 (hazard ratio 4.08, 95% CI 1.15-14.5) (C). Grade 2-4 mucositis was more common in the AUC 4,000 group (p<0.01), but there were no significant differences in other adverse effects. <h3>Conclusion</h3> Though no difference existed in disease risk between groups, regimen choice was driven by physician judgement, perceived fitness, and ability to tolerate toxicity. Thus, the results of this study indicate that with patient selection, there is no significant RFS or OS difference, or risk of acute or chronic GVHD between targeted AUC 4,000 and RIC. However, AUC 4,000 was associated with a significantly lower incidence of relapse. Toxicities other than mucositis were not significantly different between groups. In order to definitively compare these two conditioning regimens, a prospective study is needed.

Features of an Unusual AML with t(4;12)/Pdgra-ETV6 As the Sole Cytogenetic Abnormality Associated with Myelodysplastic Changes: A Case Report and Literature Review

The t(4;12) cytogenetic abnormality is rare in AML, and is associated with a unique morphologic and immunophenotypic profile. Pseudo-lymphoid morphology of myeloid blasts (appearing as atypical lymphocytes), multilineage dysplasia, absence of eosinophilia, aberrant CD7 and lack of myeloperoxidase (MPO) expression, low frequency of FLT3 mutations, and treatment refractoriness are some of the characteristics of this AML subtype previously described in the literature. We report a case of AML with t(4;12) in a middle-age male who presented with pancytopenia: WBC 3.34 (65% lymphocytes), Hgb 6.9, Plt 13, and no known prior history of a myeloid neoplasm. Bone marrow aspirate revealed 78% blasts that appeared large with uneven chromatin distribution, prominent nucleoli, and inconspicuous granules; and significant dysplastic features in the erythroid and megakaryocyte elements. Immunostains performed on the trephine core biopsy showed blasts expressed CD34 (subset), CD71 (subset), and were CD117+ Bcl-2+ CD43+ CD7+ MPO-. Flow cytometry identified 74% myeloblasts, positive for CD34, CD38, CD123, CD117, CD33, HLA-DR, CD13 (subset), CD56, CD7, CD71; negative for monocyte-specific markers. The morphologic and immunophenotypic features were compatible with AML with MDS-related changes. Karyotype analysis identified t(4;12)(q12;p13) in 18/20 cells, and no additional chromosomal abnormalities. PDGFRA translocation to 12p was confirmed using PDGFRA and ETV6 FISH probes. Analysis of frequent genomic alterations in AML identified BCOR p.Leu1646Profs, TET2 p.Gln1627Ilefs, U2AF1 p.Ser34Phe mutations; and no FLT3 mutation. Conclusions: In AML with t(4;12)/PDGFRA-ETV6, though lack of a FLT3 mutation is relatively favorable, BCOR and U2AF1 mutations and multilineage dysplasia are unfavorable prognostic factors. Synergism of the additional oncogenic mutations with the PDGFRA activating mutation can be postulated. The t(4;12)/PDGFRA-ETV6 should be recognized in the WHO classification as a recurrent balanced translocation in AML with MDS-related changes. Disclosures No relevant conflicts of interest to declare.

Comparison of Fixed Dose, Reduced-Intensity Conditioning with Busulfan and Fludarabine to Reduced PK-Guided Busulfan AUC Conditioning in Patients Undergoing Hematopoietic Stem Cell Transplant for AML/MDS

Background: Consolidation therapy with allogeneic hematopoietic stem cell transplant (HSCT) is recommended to prevent relapse and improve survival in patients with intermediate and poor risk acute myeloid leukemia (AML) and myelodysplastic syndrome (MDS). Due to toxicity, older patients with comorbidities were historically not candidates for HSCT. The development of reduced-intensity conditioning (RIC) regimens has allowed more patients to proceed to HSCT by reducing toxicities associated with myeloablative conditioning (MAC).The cornerstone of reducing conditioning regimen intensity is modification of busulfan exposure, expressed as an area under the curve (AUC). This can be achieved by the use of patient-specific pharmacokinetic targets. Previous studies (including BMT CTN 0901) have demonstrated RIC regimens were associated with less toxicity at the cost of potentially decreased survival relative to weight-based MAC regimens. At OSU, we have utilized an AUC target of 4,000 μmol-min/L per day x 4 days in a subset of patients to balance reduced toxicity with risk of relapse. Here we compare outcomes of AUC 4,000 to weight-based RIC Flu/Bu2. Methods: To compare the two regimens, a retrospective, IRB-approved cohort study was conducted. The inclusion criteria were as follows: age 18-89 years, HSCT for a diagnosis of AML or MDS, and fludarabine + busulfan conditioning regimen ± antithymocyte globulin. In the AUC 4,000 group, the target busulfan exposure was 16,000 μmol-min/L divided over 4 daily doses. In the RIC group, patents received busulfan 0.8 mg/kg/dose for 8 doses (Flu/Bu2). The primary outcome was relapse free survival (RFS). Secondary outcomes included overall survival (OS); time to neutrophil recovery; time to platelet recovery; incidence of acute and chronic graft vs host disease (GVHD); sinusoidal obstructive syndrome; febrile neutropenia; graft failure; and grade 3-5 mucositis, acute kidney injury, or hepatic dysfunction. The log-rank test was used to compare RFS and OS, and Cox proportional hazard regression model was used to estimate the hazard ratio. Gray's test was used for competing risks analysis of relapse, acute GVHD, and chronic GVHD. Fine and Gray regression models were used to estimate the hazard ratio. Results: Seventy-four patients who received conditioning from 2015-2018 with either AUC 4,000 or RIC were identified. Disease type was similar between groups with 61.8% AML in the AUC 4,000 group and 52.5% in the RIC group. There were no significant differences in disease risk status. In the AUC 4,000 group, 17.6% had either AML with myelodysplastic changes or therapy-related AML/MDS, compared to 17.5% in the RIC group. The percent of patients with HCT-Comorbidity Index score of ≥ 3 was 52.9% for AUC 4,000 and 77.5% for RIC. At 18 months, RFS was not significantly different, at 66.9% with AUC 4,000 compared to 57.5% with RIC (p=0.37) (A). Eighteen-month overall survival was also not significantly different with 66.9% alive in the AUC 4,000 group and 60% in the RIC group (p=0.63) (B). Cumulative incidence of acute and chronic GVHD were not significantly different (p=0.82, p=0.18, respectively) (C,D). There was, however, a statistically significant difference in the cumulative incidence of relapse over 18 months in favor of the AUC 4,000 regimen (hazard ratio 4.08, 95% confidence interval 1.15-14.5) (E). Grade 2-4 mucositis was more common in the AUC 4,000 group (85.3% vs 30%, p&lt;0.01), but there were no significant differences in transaminitis, kidney injury, neutropenic fever, sinusoidal obstructive syndrome, or graft failure. Discussion: Though no significant difference existed in disease risk between the groups, choice of regimen was driven by physician judgement, perceived fitness, and ability to tolerate potential adverse effects. Thus, the results of this study indicate that with patient selection, there is no significant RFS or OS difference, or risk of acute or chronic GVHD between targeted AUC 4,000 and RIC. However, AUC 4,000 was associated with a significantly lower cumulative incidence of relapse. Adverse effects other than mucositis were not significantly different between groups. In order to definitively compare these two conditioning regimens, a prospective study is needed. Figure Disclosures Brammer: Verastem, Inc: Research Funding; Viracta Therapeutics, Inc.: Research Funding; Bioniz Therapeutics, Inc.: Research Funding. Jaglowski:Kite: Consultancy, Other: advisory board, Research Funding; Juno: Consultancy, Other: advisory board; Unum Therapeutics Inc.: Research Funding; Novartis: Consultancy, Other: advisory board, Research Funding. Mims:Jazz Pharmaceuticals: Membership on an entity's Board of Directors or advisory committees; Astellas Pharmaceuticals: Membership on an entity's Board of Directors or advisory committees; PTC Therapeutics: Membership on an entity's Board of Directors or advisory committees; Agios Pharmaceuticals: Membership on an entity's Board of Directors or advisory committees; Abbvie: Membership on an entity's Board of Directors or advisory committees. Vasu:Boehringer Ingelheim: Other: Travel support; Seattle Genetics: Other: Clinical trial support. William:Guidepoint Global: Consultancy; Techspert: Consultancy; Celgene Corporation: Consultancy; Kyowa Kirin, Inc.: Consultancy; Defined Health: Consultancy. Saad:Actinium Pharma Inc: Consultancy; Amgen: Other: Research Support; Kadmon: Other: Research Support; OrcaBio: Other: Research Support.

Outcomes of Patients with Acute Myeloid Leukemia with Myelodysplastic Are Dependent on Diagnostic Criteria and Therapy

Outcomes of Patients with Acute Myeloid Leukemia with Myelodysplastic Are Dependent on Diagnostic Criteria and Therapy

AML in Adults - An Update on Diagnosis, Risk Classification and Therapy

There are several changes in the revised WHO classification for acute leukemia. The latest version of the European Leukemia Network (ELN)-risk classification defines AML with mutations in RUNX1, ASXL1 or TP53 to fall in the unfavorable risk group. Consequently, the somatic molecular genetic testing at the time of initial diagnosis should encompass these before mentioned three genes next to the already routine testing of NPM1, CEBPA and FLT3-ITD. Several new innovative substances have been developed and approved for AML therapy. The multikinase inhibitor midostaurin is a new substance in the induction therapy for patients with FLT-3 mutated AML. CPX-351 (cytarabin and daunorubicin in liposomatic formulation in a defined molar relation) is a new option for therapy associated AML and AML with myelodysplastic changes. Enasidenib is a targeting drug for relapsed or refractory AML with IDH2 mutation. Gemtuzumab, a CD33 + antibody-drug-conjugate is approved for CD33 positive cases.

Characteristics of bone marrow cells in 107 patients with juvenile idiopathic arthritis: A retrospective study.

Few studies to date have reported on the myelodysplastic features of children with juvenile idiopathic arthritis (JIA). Bone marrow specimens were collected from 107 patients aged from 7-12 years who were initially diagnosed with JIA between May 2013 and October 2015. In 107 patients with JIA, bone marrow proliferation was higher than normal and hemophagocytes were more easily observed than usual. The characteristics of bone marrow cells in 107 patients with JIA were investigated and the associations of these characteristics with the disease was discussed in the present study. It was noticed that there were similar changes in the myeloid, erythropoietic and megakaryopoietic series in the majority of bone marrow specimens; the presence of hemophagocytes was also reported. The present findings suggest that JIA is associated with specific myelodysplastic changes, and that cellular immune system dysfunction and overreactive inflammatory cytokines may contribute to the development of these myelodysplastic changes in the bone marrow.

Abstract 5832: Sphingolipid metabolism determines the efficacy of nanoliposomal ceramide in acute myeloid leukemia

Abstract Therapeutic advances for the treatment of acute myeloid leukemia (AML) have been limited in part due to the heterogeneity and complexity of the disease and a poor understanding of its underlying biology. The leukemia stem cell (LSC) arguably resists current therapy resulting in relapses for most initially treatment sensitive patients. AML with myelodysplastic syndrome related changes (AML-MRC) highlights this challenge, representing a very poor outlook subset. The present study sought to understand the underlying sphingolipid biology in and AML, and to evaluate the efficacy of nanoliposomal ceramide (Lip-C6). Sphingolipids play essential roles in cell survival and proliferation, as well as stress and death. Lip-C6, which delivers a short-chain analog of the pro-apoptotic sphingolipid ceramide, has been in development as an anticancer therapeutic. The efficacy of Lip-C6 therapy was evaluated in both in vitro and in vivo models using primary AML cells and AML cell lines. Evaluation and characterization of the effect of treatment with Lip-C6 was done through lipidomic, short term assays such as apoptosis, autophagy and colony formation assays. Efficacy of Lip-C6 and vinblastine was tested in patient derived xenograft models and mouse - human cell line xenograft MV-411. NOD SCID gamma (NSG) mice were injected with luciferase/YFP labeled cells and monitored by bioluminescence imaging (BLI) for the leukemia progression and efficacy. Sphingolipid metabolism was observed to be elevated in patient samples with De Novo AML but not those with AML-MRC. Apoptosis induced by Lip-C6 in CD34+ve/CD38-ve “LSCs” was robust in AML-MRC, but limited in De Novo AMLs. Similarly, AML colonies forming cells were more sensitive to Lip-C6 in AML- MRC than in De Novo cases. It was hypothesized that elevated sphingolipid metabolism and the upregulation of pro-survival pathways such as autophagy contributed to Lip-C6 resistance in De Novo AML. Vinblastine, when combined with Lip-C6, focused sphingolipid metabolism towards pro-apoptotic metabolites and blocked autophagy. In-vivo combination of Lip-C6 and vinblastine uniquely yielded long term control of leukemia progression without systemic toxicity, translating in to prolonged overall leukemia free survival compared to single agents. Altogether, this study shows fundamental biological differences in sphingolipid metabolism between De Novo AML and AML-MRC. The combination of Vinblastine and Lip-C6 targets the LSC and yields apparent cure of lethal human xenograft AML. Citation Format: Charyguly Annageldiyev, Arati Sharma, Brian M. Barth, Todd E. Fox, Tye Deering, Viola Devine, Nicole R. Keasey, Stephan T. Stern, Megan M. Young, Hong-Gang Wan Wang, Jason Liao, Junjia Zhu, Aaron D. Viny, Ross L. Levine, Thomas P. Loughran, Mark Kester, David F. Claxton. Sphingolipid metabolism determines the efficacy of nanoliposomal ceramide in acute myeloid leukemia [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2018; 2018 Apr 14-18; Chicago, IL. Philadelphia (PA): AACR; Cancer Res 2018;78(13 Suppl):Abstract nr 5832.

Dynamics of DNMT3A mutation and prognostic relevance in patients with primary myelodysplastic syndrome

BackgroundDNMT3A gene mutation has been associated with poor prognosis in acute myeloid leukemia, but its clinical implications in myelodysplastic syndrome (MDS) and dynamic changes during disease progression remain controversial.ResultsIn this study, DNMT3A mutation was identified in 7.9% of 469 de novo MDS patients. DNMT3A-mutated patients had higher platelet counts at diagnosis, and patients with ring sideroblasts had the highest incidence of DNMT3A mutations, whereas those with multilineage dysplasia had the lowest incidence. Thirty-one (83.8%) of 37 DNMT3A-mutated patients had additional molecular abnormalities at diagnosis, and DNMT3A mutation was highly associated with mutations of IDH2 and SF3B1. Patients with DNMT3A mutations had a higher risk of leukemia transformation and shorter overall survival. Further, DNMT3A mutation was an independent poor prognostic factor irrespective of age, IPSS-R, and genetic alterations. The sequential study demonstrated that the original DNMT3A mutations were retained during follow-ups unless allogeneic hematopoietic stem cell transplantation was performed, while DNMT3A mutation was rarely acquired during disease progression.ConclusionsDNMT3A mutation predicts unfavorable outcomes in MDS and was stable during disease evolutions. It may thus be a potential biomarker to predict prognosis and monitor the treatment response.

Hematopoietic-Specific CSNK2B Loss in Mice Causes Impaired Erythropoiesis

CK2 (Csnk2, casein kinase 2) is a Ser-Thr kinase composed by two catalytic (α) and two regulatory (β) subunits and involved in the regulation of various signaling cascades, which are critical for stem cell biology and hematopoietic development. However, a direct role for CK2 during blood cell differentiation is still undefined. Here, we examined the function of CK2 in erythropoiesis by using a hematopoietic-specific conditional knockout mouse model of the β regulatory subunit (Vav1-CRE x Csnk2β f/f mice). Since CK2β knockout mice died in utero, the study was carried out during gestation collecting fetuses from 12.5 to 17.5 days post conception (dpc) and performing the analysis on fetal liver. CK2β knockout fetuses were pale and hydropic, displayed a smaller liver, disarrayed vascularization and haemorrhages. Lack of CK2β caused depletion of hematopoietic/precursor cells, in particular of common lymphoid progenitors and megakaryocyte-erythrocyte progenitors. CK2β loss resulted to affect both early and late erythroid maturation and red cell viability. CK2β knockout contained lower numbers of TER119 positive cells, which displayed a down modulation of the surface expression of transferrin receptor (CD71) and an increased spontaneous apoptosis. Erythroid cells showed alterations in morphology compatible with myelodysplastic changes. Loss of CK2β caused alterations of erythroid cell proliferation, which was different depending on the stage of erythroid maturation: indeed, BrdU and 7AAD staining showed that less mature erythroid cells (CD71+Ter119-) had a lower rate of proliferation but a normal viability; on the contrary, more mature (CD71-Ter119+) erythroid cells suffered in part of apoptosis and in part accumulated in the S phase. RNA seq analysis performed on purified Ter119+ cells revealed upregulation of TP53 -associated genes as well as of Cdkn1a (p21); on the contrary, there was a down-modulation of Stat5 (an erythropoietin receptor down-stream effector) and genes involved in red cell survival and differentiation in particular c-kit and genes associated to the PI3/Akt pathway. The expression of adhesion molecules and surface carriers for inorganic cations/anionsimportant for the osmotic equilibrium and cell membrane integrity was also found markedly dysregulated. Real time quantitative PCR and Western Blot (WB) analyses confirmed the expression data of Cdkn1a, c-Kit, Bcl-xL, Jak-Stat5 as well as of Akt-Gata-1 axis. Gata-1, the key transcription factor for definitive erythropoiesis, was reduced in CK2β knockout mice as were its downstream target genes such as Alas-2, Lrf, Eklf, Epo-R, β-globin. Immature fetal globins accumulated. In order to find a molecular mechanism, we used an in vitro model of erythroid differentiation based on G1ER cells, an estrogen inducible GATA-1 null murine erythroblast cell line; the combined treatment of β-estradiol and inhibition of CK2 through the chemical inhibitor CX-4945 or RNA interference against CK2β confirmed the negative effect on differentiation. Western blot analysis indicated a potential role of the kinase in the regulation of Akt, Gata-1 and Stat5 protein stability. Moreover, the blockade or down modulation of CK2 caused changes in Gata-1 nuclear distribution with loss of the speckled pattern induced by β-estradiol. Thus, CK2 is a likely essential controller of GATA-1 transcriptional function. Altogether, our work demonstrates that CK2 is a master regulator of erythroid development, by impinging on Stat5, Akt and Gata-1 signaling and influencing red cell viability, bioenergetics, proliferation and maturation. DisclosuresNo relevant conflicts of interest to declare.

Clonal chromosomal aberrations in Philadelphia negative cells such as monosomy 7 and trisomy 8 may persist for years with no impact on the long term outcome in patients with chronic myeloid leukemia

The appearance of clonal chromosomal aberrations in Philadelphia negative cells (CCA/Ph-) during the treatment of chronic myeloid leukemia (CML) was recently confirmed. Importance of these findings has not been clearly defined. We present data on the time of appearance, persistence, size of the CCA/Ph- clone in terms of drugs used and hematological, cytogenetic and molecular response rates. The focus was on the peripheral blood cytopenias and myelodysplastic changes in the bone marrow microscopic evaluation. In 5 out of 155 (3,2%) CML patients, the persistent presence (up to nine years) of CCA/Ph- was found (monosomy 7 and trisomy 8 in unrelated clones in two patients treated with tyrosine kinase inhibitors; trisomy 8 in two patients on imatinib; trisomy 21 in one patient on interferon alfa treatment). Aberrations were present in median 24% Ph- cells in 3-15 subsequent analyses at different cytogenetic and molecular response time points. No evident myelodysplastic changes nor transformation to MDS/AML occurred in patients with CCA/Ph-. All the patients achieved major molecular response (MMR). It seems that CCA/Ph- presence does not affect the long term outcome in patients with chronic myeloid leukemia. Further complex monitoring of the CML patients with CCA/Ph- is still needed.