Ph-negative Acute Lymphoblastic Leukemia Patients Research Articles

Philadelphia-like B-Cell Acute Lymphoblastic Leukemia in a Largely Hispanic Population: Disease Features and Outcomes in the Era of Immunotherapy a Single Institutional Study

Introduction: Philadelphia (Ph)-like B-cell acute lymphoblastic leukemia (ALL) is a high-risk subgroup of B- cell ALL with distinct genotypes, unified by a gene expression profile similar to Ph-positive ALL but lacking the BCR: ABL1 fusion. Previous studies have noted the increased prevalence of Ph-like B-cell ALL in Hispanic patients. Our study evaluates Ph-like B- cell ALL clinical/genomic features and outcomes in a predominantly Hispanic population. Methods: This is a retrospective chart review of ALL patients that underwent treatment for B-cell ALL at Norris Comprehensive Cancer Center (NCCC) between 2011 and 2023. Identification of fusions associated with Ph-like B-cell ALL was performed using cumulative results from RNA-seq, conventional cytogenetics, and fluorescence in situ hybridization (FISH) with reflex gene fusion transcript analysis. Additionally, we used the Anchored Multiplex PCR™-based multi-gene NGS assay designed to detect known and novel fusions and elevated gene expression levels using a proprietary algorithm in ALL. Cumulative incidence of relapse (CIR) was evaluated using competing risk regression (Fine-Gray method), with death as a competing outcome. Overall survival (OS) and event-free survival (EFS) were analyzed using Cox proportional hazards model. Events of interest for EFS were relapse, treatment failure, and death. Ph-negative B-cell ALL patients were set as the reference for survival analysis. Results: 253 patients were included with a median age at diagnosis of 42 years (range: 18-80). ALL subtypes included 64(25.3%) Ph-like, 77(30.4%) Ph-positive, and 112(44.3%) Ph-negative. Most were Hispanic (N = 186, 73.5%), and the median follow-up time was 27 months. The 3-year OS, EFS, and CIR were 81.3% (95% CI 75.7-87.4%), 49.1% (95% CI 42.7-56.5%), and 39.9% (95% CI 33.0-46.7%). CRLF2 related mutations constituted 44(68.8%) of Ph-like patients, with 9(14.0%) CRLF2-P2RY8, 24(37.5%) CRLF2-IGH, and 11(17.2%) CRLF2-other gene rearrangements. 19 Ph-like patients had non-CRLF2 mutations consisting of 13(20.3%) IGH, 3(4.7%) ABL1/2, 3(4.7%) JAK2, and 1(1.6%) EPOR rearrangements. Compared to Ph-negative, Ph-like patients were more likely to have a refractory disease (20.6% vs. 6.2% P=0.006) and require Blinatumomab (67.2% vs. 39.3% P<0.001), with a non-significant trend towards lower rates of CR (84.1% vs 90.9% P=0.21). Ph-like patients had significantly worse EFS (HR = 1.63; 95% CI 1.09-2.45; P=0.018), but similar OS (HR = 0.88; 95% CI 0.39-1.99; P=0.75) and CIR (HR = 1.06; 95% CI 0.65-1.70; P = 0.83). Ph-positive patients displayed improved EFS relative to Ph-negative (HR = 0.56; 95% CI 0.35-0.91; P = 0.018), similar OS (HR = 0.73; 95% CI 0.35-1.50; P = 0.39), and a trend towards improved CIR (HR = 0.67; 95% CI 0.40-1.10; P=0.11). When controlling for age, sex, and treatment type, EFS was worse in Ph-like (HR = 1.57; 95% CI 1.03-2.41; P = 0.037) and improved in Ph-positive (HR = 0.56; 95% CI 0.33-0.93; P = 0.026). Our incidences of CRLF2 mutations in Ph-like patients aged>40 compared to age ≤40 was (73.3% vs 64.7%, P=0.591). On subgroup analysis of Ph-like patients, univariate regression revealed CRLF2-related Ph-like patients had a worse CIR (HR = 5.68; 95% CI 1.91-16.9; P = 0.002) but similar OS(P=0.99) and EFS(P=0.18). PAX5 expression was also a predictor of poor OS (HR = 8.89; 95% CI 1.06-74.7; P = 0.044) and EFS (HR = 2.51; 95% CI 1.09-5.77; P = 0.031), with a trend towards increased CIR (HR = 2.30; 95% CI 0.92 -5.78; P = 0.075). Compared to non-CRLF2 mutations, CRLF2-Ph-like had worse CIR (HR = 5.68; 95% CI 1.91 -16.9; P = 0.002). Relative to Ph-like patients who achieved MRD negativity during induction, patients who remained MRD positive had worse CIR(HR = 2.92; 95% CI 1.23 -6.94; P = 0.015) and EFS (HR = 4.32; 95% CI 1.890-9.84; P < 0.001). However, after controlling for Blinatumomab administration, the effect diminished (CIR: P=0.73, EFS P=0.28). There were no differences in EFS(P=0.34), CIR(P=0.69), and OS(P=0.36) between Ph-like patients who were transplanted vs not. Conclusions: Ph-like B- Cell ALL represents a high-risk disease subtype of adult B-ALL, with poor EFS and frequent treatment failure. CRLF2 translocation confers worse CIR and EFS within Ph-like patients and requires novel treatment approaches.

SIOG2023-4-P-260 - Impact of treatment intensity on outcome in older Ph-negative acute lymphoblastic leukemia patients

SIOG2023-4-P-260 - Impact of treatment intensity on outcome in older Ph-negative acute lymphoblastic leukemia patients

Higher incidence of delayed methotrexate clearance in pediatric acute lymphoblastic leukemia patients treated with imatinib

BackgroundPediatric patients with Philadelphia chromosome positive (Ph+) or ABL-class fusion positive acute lymphoblastic leukemia (ALL) are currently treated with the tyrosine kinase inhibitor (TKI) imatinib added to a chemotherapy backbone that also contains several courses of high-dose methotrexate (HDMTX). A limited number of case studies suggested delayed MTX clearance in patients concomitantly using HDMTX and imatinib. MethodsMTX clearance and serum creatinine in 24 newly diagnosed Ph+/ABL-class fusion positive pediatric ALL patients treated with imatinib (imatinib group) were compared with 281 randomly selected age-matched Ph-negative pediatric ALL patients treated without TKI (control group), receiving in total 61 and 897 HDMTX courses, respectively. ResultsMild to severe delayed MTX clearance (MTX level at T48 hours>0.4 µM) was more frequently found in the imatinib group than in the control group in all courses (55.7% vs 41.1% p = 0.036). After the first HDMTX course, 12.5% (n = 3) of the imatinib group presented with a severe delayed MTX clearance (T48 > 5 µM) versus 2.3% in the control group (p = 0.039). In two (8.3%) of these patients in the imatinib group, this was accompanied by increased creatinine, therefore meeting the criteria for Delayed MTX Elimination (DME). In the control group 12/281 (4.3%) patients presented with DME. Glucarpidase was administered in 2 (8.3%) vs 4 (1.4%) patients in the imatinib group and control group, respectively. ConclusionImatinib increased the risk of delayed MTX clearance in newly diagnosed pediatric Ph+ chromosome or ABL-class fusion positive ALL patients. We therefore recommend stringent supportive care measures and for patients with severe delayed MTX clearance resulting in severe toxicities temporary discontinuation of imatinib or a lower dose of MTX during the next HDMTX courses.

The use of pegaspargase in adult Ph-negative acute lymphoblastic leukemia patients in the treatment according to the all-2016 protocol

The use of pegaspargase in adult Ph-negative acute lymphoblastic leukemia patients in the treatment according to the all-2016 protocol

Updated Comparison of Outcomes in Hispanic and Non-Hispanic Patients with Ph-Negative Acute Lymphoblastic Leukemia Using the Modified Pediatric-Based University of Southern California Acute Lymphoblastic Leukemia (USC ALL) Regimen in the Era of Novel Agents

INTRODUCTION: Hispanic patients with acute lymphoblastic leukemia (ALL) are historically known to have poor outcomes compared to non-Hispanic patients which may be associated with healthcare disparities, although further elucidation is needed. Since we take care of a large population of Hispanic patients, we now report further updated outcomes in Hispanic compared to Non-Hispanic ALL patients using the modified USC ALL regimen in the era of novel agents like blinatumomab and inotuzumab. METHODS: This retrospective chart review included adults 18 years old with newly diagnosed Ph-negative ALL (2016-2020). Primary objectives were 3-year over-all survival (OS), event-free survival (EFS) and disease-free survival (DFS) stratified by MRD flow status and blinatumomab use. Secondary objectives were complete remission/complete remission with incomplete recovery (CR/CRi), MRD by flow, descriptive statistics of patients stratified into Hispanic and non-Hispanic cohorts evaluated using Fisher's exact test. OS, DFS, EFS reported through Kaplan Meier curves and Log-rank tests. Two-sided p-value ≤0.05 was significant. RESULTS: 121 Ph-negative ALL patients were reviewed. 87 Hispanic patients (HP) and 34 non-Hispanic patients (NHP). Median ages in HP and NHP were 39 and 35 years; median BMI 29 and 26.9 kg/ m2 (p=0.42-0.51), respectively. About equal males and females in HP while NHP had 70.6% males compared to 29.4% females (p=0.08). Both HP and NHP were mainly Ph-negative ALL, 50.6% vs 47.1%, 25.4% vs 20.6% were Ph-like, respectively (p=0.884). Most of our population had unfavorable risk by NCCN, 86.8% in HP and 90.5% in NHP (p=0.99). 71.1% HP and 62.5% NHP received PEG during induction 1 (p=0.37), and 69.6% of HP and 63% of NHP received PEG during induction 2 (p=0.52). After induction 1: 91.1% of HP and 80% in NHP achieved CR/Cri (p=0.18). 55.7% of HP and 40.9% of NHP achieved MRD negativity by flow (p=0.23). After induction 2: 92.7% of HP and 79% of NHP achieved CR/CRi, with 7.3% in HP being refractory compared to 21.1% of NHP (p=0.19). 73.3% of HP and 64.7% of NHP achieved MRD negativity by flow (p=0.54). 26.4% of HP and 35.3% of NHP had relapse (p=0.33), 4.6% of HP and 20.6% of NHP had refractory disease (p=0.01), while 4.6% of HP compared to 20.6% of NHP died (p=0.27). Blinatumomab was given in 35.6% of HP and 32.3% of NHP (p=0.73). Meanwhile only 6.9% of HP and 2.9% of NHP received inotuzumab (p=0.67). 39.1% of HP underwent allogenic hematopoietic stem cell transplant (allo-HSCT) versus 26.5% in NHP (p=0.19). 26.4% HP and NHP who received blinatumomab did not undergo allo-HSCT. 3.4% of HP and 11.8% of NHP underwent CAR-T (p=0.096). 3y OS was 82.4% in HP vs 75.8% in NHP (p=0.18). 3y EFS was 58.6% in HP vs 43.7% in NHP (p=0.008). 3y DFS was 62.4% in HP vs 57.1% in NHP (p=0.08). In HP when stratified by MRD flow negativity post induction, there was no statistically significant difference in 3y OS (79.1% vs 90%) (p=0.4), 3y DFS 65.9% vs 60.4% (p=0.8) and 3y EFS 65.9% vs 52.9% (p=0.66). In NHP when stratified by MRD flow negativity post induction, there was also no statistically significant difference in 3y OS (100% vs 88.9%) (p=0.56), 3y DFS (75% vs 67.5%) (p=0.84) and 3y EFS (75% vs 67.5%) (p=0.8). Of note, when survival is stratified by blinatumomab use, in HP: 3y OS 71.6% vs 88.3% (p=0.14), 3y EFS was 27.8% vs 76.6% (p=0.001), 3y DFS was 37.2% vs 76.6% (p=0.001) (Fig 1-2). In NHP: 3y OS 72.7% vs 77.7% (p=0.56), 3y EFS was 36.4% vs 44.4% (p=0.2), 3y DFS was 42.4% vs 64% (p=0.02). No clear difference in grade 3/4 PEG toxicities were found in HP compared to NHP except grade 4 hypertriglyceridemia which was noted more in HP 31.3% compared to 9.7% in NHP (p=0.019). CONCLUSIONS: Our updated data shows a trend to better outcomes in HP compared to NHP in terms of OS and DFS, and a statistically significantly better EFS in the Hispanic population. Having MRD negativity by flow showed no statistically significant difference in both groups. Of note, 3y EFS and 3y DFS were significantly lower in HP who received blinatumomab since these patients were MRD flow positive and lacked deeper remissions, but 3y OS (71.6%) remained high regardless, even though 26.4% who received blinatumomab were not able to go for allo-HSCT. In NHP, the trend is like that of HP but less pronounced. This suggests the beneficial effect of blinatumomab especially in Hispanic patients. Further follow-up is necessary to provide a more robust and mature survival data. Figure 1View largeDownload PPTFigure 1View largeDownload PPT Close modal

Updated Outcomes in Adult Philadelphia-Positive Acute Lymphoblastic Leukemia Patients Using Tyrosine Kinase Inhibitors Combined with the Modified University of Southern California (USC ALL) Regimen without Peg-Asparaginase in the Era of Novel Agents

Introduction: Prior to the introduction of tyrosine kinase inhibitors (TKIs), the presence of BCR-ABL1 conferred a poor prognosis in patients with acute lymphoblastic leukemia (ALL). We published our analysis in 2017 comparing the survival of Ph-Positive (Ph+) and Ph-negative ALL patients during the period when TKIs were universally available in the United States for Ph+ ALL using a Surveillance, Epidemiology, and End Results (SEER) Database analysis, but despite using TKIs, we have continued to remain reliant on cytotoxic chemotherapy and allogenic hematopoietic stem cell transplant (allo-HSCT) to achieve the best long-term outcomes. However, with the introduction of more potent TKIs and other novel agents, and better methods for monitoring minimal residual disease (MRD), the best approach is yet to be determined. In this study we present updated data from our institution with incorporation of TKIs in our modified USC ALL pediatric-based regimen without PEG. Methods This retrospective, single institution chart review included adults aged 18 with newly diagnosed Ph+ ALL between 2016 and 2020. Primary objectives were Overall survival (OS) and event-free survival (EFS) at 3 years and secondary objectives were rates of complete remission/complete remission with incomplete recovery (CR/CRi), minimal residual disease (MRD) by flow cytometry and presence of BCR-ABL1 fusion transcript by real time polymerase chain reaction. Descriptive statistics of patients were reported and evaluated using Fisher's exact test. OS and EFS were reported through Kaplan Meier curves and Log-rank tests. Two-sided p value ≤0.05 considered significant. RESULTS: 25 Ph+ ALL patients were reviewed. Median age at diagnosis was 43.5 years with 44% males and 56% females in this study. Median BMI was 31.9 kg/ m2. Most patients were Hispanic at 84%, 12% White and 4% Asian.43.5% had hepatic steatosis and 4% had CNS disease pre-induction. After induction 1, 80% of patients achieved CR/CRi, 4% were refractory, and 50% were MRD negative by flow, with 24% of patients with undetectable BCR-ABL1 by PCR. After induction 2, 90.5% had achieved CR/CRi, none were refractory and 56.3% were MRD negative by flow with 32% of patients with undetectable BCR-ABL1 PCR. 48% of patients received blinatumomab for MRD flow positivity with a median of 3 cycles, none received inotuzumab. 44.4% underwent allo-HSCT, none were sent for CAR-T. Of note, 64% of patients received Dasatinib only, 0.04% received imatinib and 32% received at least 2 TKIs. Overall, 12% had known relapse, none were refractory, and 12.5% died. The 3y OS was 89.4%, 3y EFS and DFS was at 77%. When stratified by blinatumomab use, 3y OS was 87.5% vs 91.7% (p=0.49), 3y DFS was 80.2% vs 76.4% and 3y EFS was 80.2% vs 76.4% (p=0.8). When survival was stratified by transplant status, 3y OS with allo-HSCT was 100% vs 76.9% (p=0.048), 3y EFS/DFS with allo-HSCT was 100% vs 50.1% (p=0.033) (Fig 1-2). CONCLUSIONS: The use of the modified USC ALL regimen without PEG for the treatment of newly diagnosed Ph+ ALL combined with TKI continued to lead to a high 3-year OS at 89.4% and 3-year EFS and DFS at 77%. All patients received TKI, half of the patients received blinatumomab and received allo-HSCT which led to high OS, EFS and DFS even without PEG. This was statistically significant in those who were able to undergo allo-HSCT (3y OS/EFS/DFS 100% vs 76.9% OS/50.1% EFS/DFS) (p=0.033-0.048). This study further highlights the importance of allo-HSCT in Ph+ ALL patients who received TKI without PEG. Figure 1View largeDownload PPTFigure 1View largeDownload PPT Close modal

Updated Outcomes of the University of Southern California (USC) ALL Frontline Regimen (based on CCG-1882) after Protocol Modification in the Era of Novel Agents in Ph-Negative ALL Patients

INTRODUCTION: Pediatric inspired regimens in adolescent young adults and adults have improved outcomes in acute lymphoblastic leukemia (ALL). CALGB 10403 was prospectively tested in patients 17-39 years and achieved a 3-year event free survival of 59%. In 2007, we reported outcomes after incorporating peg-asparaginase (PEG) dosed at 2000mg/m in induction for patients aged 17- 55 years. This was well tolerated and achieved a complete remission (CR) rate of 96%. In 2014, we reported experience with the use of multiple doses of PEG (CCG-1882) for newly diagnosed ALL adult patients achieving a 7-year overall survival (OS) of 51%. Since then, the USC ALL regimen consisting of 2 induction phases, was further modified with a goal of maintaining good outcomes and improving compliance and toxicities. Fractionated doses of cytarabine were changed to a single dose, the methotrexate dose of 1g/ m2 (2.5 g/m2 if T cell) given D1,15 in intensification phases was changed to 3g/ m2 (B and T cell) given in single doses, and consolidation was increased to six cycles allowing for PEG holidays. Moreover, the approval and incorporation of novel agents such as blinatumomab and inotuzumab also changed outcomes in ALL. Therefore, this study reports an update of outcomes since further modification of the USC ALL pediatric-based regimen in the era of novel agents. METHODS: This is a retrospective review which included adults aged 18 years with newly diagnosed Philadelphia negative ALL (2016-2020) treated at the USC/Norris Comprehensive Cancer Center and the Los Angeles County Hospital (LAC). Primary objectives were over-all survival (OS), event-free survival (EFS), disease-free survival (DFS) at 3 years. Secondary outcomes were complete remission/complete remission with incomplete recovery (CR/CRi) and minimal residual disease (MRD) by flow cytometry rates. OS, DFS, EFS were reported through Kaplan Meier curves and Log-rank tests. Two-sided p value ≤0.05 was significant. RESULTS: 121 patients with Ph-negative ALL were reviewed (49.6% Ph-negative B-ALL, 23.9% Ph-like B-ALL, 0.8% B cell lymphoblastic leukemia (LBL), 9.1% T cell ALL, 4.1% T cell LBL, 4.1% early T-cell, 5.8% mixed phenotype acute leukemia (MPAL). Median age at diagnosis was 39.3 years. There were 71.9% Hispanic, 15.7% White, 9.9% Asian, 2.5% African Americans. 57.9% males, 42.1% females. In terms of risk stratification, the majority were unfavorable at 54.6% and 37.8% unknown. Median BMI was 29.6 kg/ m2. 52.5% had hepatic steatosis and 5% had CNS disease pre-induction. 68.7% received PEG during induction 1, and 67.9% during induction 2. Post-induction 1, 83.5% patients achieved CR/Cri with 49% MRD negativity by flow. Post-induction 2, 75% achieved CR/Cri with 57.1% MRD negativity by flow. 26.4% received blinatumomab but not allo-HSCT. 20% received blinatumomab and underwent allo-HSCT. 34.7% received blinatumomab for MRD flow positivity, median 2 cycles, only 5.8% received inotuzumab, 35.5% underwent allogenic stem cell transplant. 28.9% and 9.1% had any relapse and refractory disease, respectively. Mortality rate was at 14.9%. 3y OS was at 80.7%, 3y EFS at 54.3% and 3y DFS 61.3%. When stratified by MRD flow negativity after induction 1 and 2, 3y OS was 83.7% vs 91.1% (p=0.55), 3y DFS was 68% vs 64.1%(p=0.98) and 3y EFS was 68% vs 59.5% (p=0.84). When stratified by blinatumomab use, 3y OS 72.5% vs 85.1% (p=0.15), 3y EFS was 31.6% vs 67.5% (p=0.001), 3y DFS was 40.1% vs 73.1% (p=0.001) (Fig 1-2). Use of PEG resulted in grade 3/4 toxicities including hypersensitivity (4.1%), transaminitis (21.5%), pancreatitis (5.4%), hypertriglyceridemia (49.5%), hypofibrinogenemia (45.5%), hyperbilirubinemia (21.5%) and thrombosis (16.5%). CONCLUSIONS: The modified pediatric-based USC ALL induction regimen using PEG maintained a high 3y OS at 85.3% and appreciable 3y EFS at 54.3% and 3y DFS at 61.3%, with tolerable toxicities in an era of novel agents like blinatumomab. This compares favorably with the original USC ALL regimen, CALGB 10407 and GRAALL 2005. Of note, 3y EFS and 3y DFS were significantly lower in those who underwent blinatumomab since these patients were MRD flow positive and lacked deeper remissions, but 3y OS (72.5%) remained high regardless, even though 26.4% who received blinatumomab were not able to go for allo-HSCT. This suggests the beneficial effect of blinatumomab. Further follow-up is necessary to provide a more robust and mature survival data. Figure 1View largeDownload PPTFigure 1View largeDownload PPT Close modal

An Update on Outcomes Using the USC ALL Frontline Regimen (based on CCG-1882) after Further Modification of Protocol in the Era of Novel Agents in Ph-Negative ALL Patients; A Retrospective Study

▪INTRODUCTION: The use of pediatric inspired regimens in adolescent young adults and adults has improved outcomes in acute lymphoblastic leukemia (ALL). CALGB 10403 was prospectively tested in patients 17-39 years, showing a 3-year event free survival of 59%.In 2007, our institution reported outcomes after incorporating peg-asparaginase (PEG) dosed at 2000mg/m 2 in induction for patients aged 17- 55 years. This regimen was well tolerated and resulted in a complete remission (CR) rate of 96%. In 2014, we reported experience with the use of multiple doses of PEG (CCG-1882) for newly diagnosed ALL adult patients, with a 7-year overall survival (OS) of 51%. Since our last report, the USC ALL regimen consisting of 2 induction phases, has been further modified with a goal of maintaining good outcomes, and improving compliance and toxicities. Fractionated doses of cytarabine were changed to a single dose, the methotrexate dose of 1g/m 2 (2.5 g/m 2 if T-cell) given D1,15 of intensification phases was changed to 3g/m 2 (B and T cell) given in single doses, and consolidation was increased to six cycles allowing for PEG holidays (Table 1).Moreover, the approval and incorporation of novel agents such as blinatumomab and inotuzumab also changed outcomes in ALL. Therefore, this study reports an update of outcomes since further modification of the USC ALL pediatric-based regimen in the era of novel agents. METHODSThis is a retrospective review which included adults aged >18 with newly diagnosed Philadelphia negative ALL between 2016 and 2020 treated at USC/Norris Cancer Center and Los Angeles County Hospital (LAC). Primary objectives were over-all survival (OS), event-free survival (EFS), disease-free survival (DFS) at 3 years, and secondary outcomes were complete remission/complete remission with incomplete recovery (CR/CRi) rates and minimal residual disease (MRD) by flow cytometry. OS, DFS, EFS were reported through Kaplan Meier curves and Log-rank tests. Two-sided p value ≤0.05 was significant.RESULTS: 121 patients with Ph-negative ALL were identified (49.6% Ph-negative B-ALL, 24% Ph-like B-ALL, 0.8% B cell lymphoblastic leukemia (LBL), 9.1% T cell ALL, 4.1% T cell LBL, 4.1% early T-cell, 5.8% mixed phenotype acute leukemia (MPAL). Median age at diagnosis was 38.5 years and maximum age of patient to receive pegasparagase during induction 1 was 63 years. 71.9% Hispanic, 15.7% white, 9.9% Asian, 2.5% African American. 57.9% males, 42.1% females. 3.4% were favorable, 4.2% intermediate, 54.6% unfavorable and 37.8% unknown by karyotypic risk stratification. Median BMI was 28.9 kg/m 2.54.6% had hepatic steatosis either on history or imaging and 5.1% had CNS disease pre-induction.Post-induction 1, 81.4% of patients achieved CR/CRi and 50% MRD negative. Post induction 2, 82.2% achieved CR/CRi, 67.7% MRD flow negative. Post-consolidation 1, 90.9% were MRD flow negative. 33.1% subsequently received blinatumomab for MRD positive disease, 5% given inotuzumab for relapsed disease, 32.2% underwent allogenic hematopoietic stem cell transplant (allo-HSCT). Median number of pegasparagase doses received during treatment was 2, rate of relapse and mortality was 27.3% and 13% respectively.Median OS and DFS were not reached but median EFS was 35 months. 3-year OS was 85.3%, when stratified according to MRD post induction 2; 3-year OS was 91.7% for MRD positive patients and 91.2% for MRD negative patients (p=0.55). 3-year DFS was 83.2%; 88.2% for MRD positive patients and 97.4% for MRD negative patients (p=0.22). 3-year EFS was 47.3%; 51.3% for MRD positive patients and 50.6% for MRD negative patients (p=0.49) (Tables 2-3).Use of pegasparagase resulted in grade 3/4 toxicities including hypersensitivity (4.1%), transaminitis (21.5%), pancreatitis (5.4%), hypertriglyceridemia (49.5%), hypofibrinogenemia (45.5%), hyperbilirubinemia (21.5%) and thrombosis (16.5%). CONCLUSIONSPediatric-based modified USC ALL induction regimen led to a high 3-year OS (85.3%), DFS (83.2%) and EFS (47.3%) with predictable toxicity and compares favorably with original USC ALL regimen, CALGB 10407, GRAALL 2005 and USC/MSKCC regimen.Interestingly, MRD positivity after induction 2 did not adversely affect OS, DFS or EFS, which is likely due to incorporation of blinatumomab and inotuzumab. These agents could have allowed for deeper remissions allowing Ph-negative patients with residual disease to receive allo-HSCT. [Display omitted] DisclosuresChaudhary: Oncotartis: Consultancy; Pancella: Consultancy; Moderna: Current equity holder in publicly-traded company; Celldex: Current equity holder in publicly-traded company; TCR2: Current equity holder in publicly-traded company; Allogene: Current equity holder in publicly-traded company; Athelas: Consultancy, Current holder of stock options in a privately-held company; Angeles Therapeutics: Current holder of individual stocks in a privately-held company, Current holder of stock options in a privately-held company, Membership on an entity's Board of Directors or advisory committees, Other: Founder, Patents & Royalties: Cell therapy . Douer: Servier: Consultancy, Speakers Bureau; Amgen: Consultancy, Speakers Bureau; Adaptive: Current holder of individual stocks in a privately-held company, Current holder of stock options in a privately-held company, Speakers Bureau; Jazz: Consultancy. Yaghmour: Novartis: Consultancy, Speakers Bureau; BMS: Speakers Bureau; Alexion: Speakers Bureau; Astellas: Speakers Bureau; Takeda: Consultancy, Speakers Bureau; Jazz: Speakers Bureau; Agios: Consultancy, Speakers Bureau.

Clinical Significance of Additional Cytogenetic Abnormalities (ACA) Acquired at the First Relapse in Adult Patients with Philadelphia Chromosome (Ph)-Negative Acute Lymphoblastic Leukemia (ALL)

Background: Although cytogenetic abnormalities at diagnosis are recognized as one of the most potent prognostic factors in acute leukemia patients, they are not stable through their clinical courses. ACA, the most frequent form of cytogenetic changes, are considered as a result of genetic instability and clonal evolution of leukemia cells. Recently, we described that ACA at the first relapse was associated with the significantly low second complete remission (CR) rate and poor survival in adult AML patients. However, the clinical significance of ACA has not been elucidated in adult Ph-negative ALL patients. So, we conducted this retrospective study to address this unsolved issue. Patients and methods: Of the 144 adult patients diagnosed with Ph-negative ALL between 1990 and 2015, 48 relapsed patients whose cytogenetic abnormality data both at diagnosis and at the first relapse were available were included in this study. All these patients underwent intensive chemotherapy. Cytogenetic changes between the time of diagnosis and the first relapse were classified into four groups: (1) no change, (2) ACA was acquired at time of the first relapse, (3) cytogenetic abnormalities observed at diagnosis were reduced or had disappeared at the time of the first relapse, and (4) cytogenetic abnormalities observed at diagnosis were reduced or had disappeared, and completely different ACA was acquired at the time of the first relapse. In this study, groups 2 and 4 were defined as those with ACA acquisition. Overall survival (OS) was defined as the interval from the date of the first relapse to the date of death. Fisher's exact test was used to compare binary variables. OS was estimated with the Kaplan-Meier method and compared using the log-rank test. The Cox proportional hazard model were used for multivariate analysis of prognostic factors. Values of p < 0.05 were considered to indicate statistical significance. Results: Of the 48 patients included in this study, 33 patients were male, and 15 were female. The median age was 41 years (range, 16-75 years). According to the definition described above regarding cytogenetic changes between the time of diagnosis and the first relapse, 20 (42%), 25 (52%), 1 (2%), and 2 (4%) patients were categorized into group 1, 2, 3, and 4, respectively; thus, 27 patients (54%) acquired ACA at the first relapse. To identify the predisposing factors for ACA acquisition, age, cytogenetic abnormalities and WBC count at diagnosis, duration of the first CR, and undergoing after allogeneic stem cell transplantation (allo-SCT) in the first CR were assessed. However, none was extracted as a significant predisposing factor. The 27 patients with ACA acquisition showed a significantly lower second CR rate compared with those without ACA acquisition (14.8% vs. 76.2%, respectively; p < 0.001). Furthermore, the 1-year OS rate after the first relapse in patients with ACA acquisition was significantly poorer than that in those without ACA acquisition (55.3% vs. 25.9%, respectively; p = 0.004), and no one with ACA acquisition was alive at the time of analysis. Multivariate analysis extracted ACA acquisition as an only negative prognostic factor (hazard ratio: 2.55, p = 0.006), whereas age, cytogenetic abnormalities at diagnosis, duration of the first CR, and relapse after allo-SCT did not reach significant level. Of the 27 patients with ACA acquisition (median age: 34, range; 16-72 years), seven underwent allo-SCT after the first relapse, and all seven patients were not in remission at the time of transplant. The 1-year OS rates after the first relapse were not significantly different between patients undergoing allo-SCT after the first relapse and those treated only with chemotherapy (28.6% vs. 25.0%; p = 0.249). Conclusion: These findings suggested that ACA acquisition at the time of the first relapse was associated with chemo-refractive disease and poor prognosis in adult patients with Ph-negative ALL, just like those with AML. As no patients with ACA acquisition achieved long-term survival, even undergoing allo-SCT, innovative therapeutic strategy is warranted. Clarification of the biological background of ACA acquisition may contribute to the development of novel therapeutic strategies and improved treatment outcomes in adult Ph-negative ALL patients. DisclosuresNo relevant conflicts of interest to declare.

The Role of Genetic Polymorphisms ofTPMTandNUDT15Genes in Adult Patients with Ph-Negative Acute Lymphoblastic Leukemia in Russia

Context: TPMTandNUDT15polymorphisms are involved in the toxicity and therapeutic efficacy of thiopurine drugs (6-mercaptopurine (6-MP)). The frequencies of polymorphisms of these genes are different across diverse populations. The role ofTPMTandNUDT15genes in adult patients (pts) with Ph-negative acute lymphoblastic leukemia (ALL) in Russia is still unclear. Objective:Evaluation of frequency and significance ofTPMTandNUDT15polymorphisms in the cohort of adult Ph-negative ALL pts treated by the RALL-2016 protocol. Design and Patients:Since April 2017 till July 2020 56 adult Ph-negative ALL patients treated by RALL-2016 protocol were included in the research ofTPMTandNUDT15polymorphisms. Median age was 32 у (range, 18-54), m/f: 39 (70%) / 17 (30%). B-ALL/LBL were diagnosed in 26 (46,4%) pts, T-ALL- in 26 (46,4%) and MPAL- in 4 (7,2%). Genomic DNA was extracted from peripheral blood samples of given pts. Genetic polymorphisms inNUDT15(*2, *3)and TPMT(*2, *3A, *3B, *3C)genes were detected using the allele-specific RT-PCR. The dose of 6-MP was calculated only for 54 pts from 56 (one of these pts stopped the therapy and another received the 1 st phase of induction by RALL-2016 without 6-MP). According to the RALL-2016 protocol 6-MP dose correction imply: if the level leukocytes&amp;lt;2,0*109/l, thrombocytes &amp;lt;100*109/l pts got 50% from the required dose. The therapy of 6-MP was stopped, if the level leukocytes &amp;lt;1,0*109/l, thrombocytes &amp;lt;50*109/l. On the 2 induction therapy by the protocol, the doses of 6-MP were calculated only for 47 pts with CR. The group of pts who didn't have remission on the 36 day by the protocol took the drug without corrections. Results:From 54 pts CR rate was 87 % (n=47) and resistance - 13% (n=7). One patient died in CR. The frequency ofTPMTandNUDT15polymorphisms in study group was 17,8 % (n=10): 6 (23%) of 26 pts with B-ALL, 3 (11,5 %) of 26 pts -T-ALL and 1 (25%) of 4 pts - MPAL. In our cohort these polymorphisms were found significantly more frequently in pts with B-ALL (p&amp;lt;0.001). These polymorphisms were detected in 8 (80%) men and 2 (20%) women (p=0.432). All detected polymorphisms were presented as heterozygous variants:NUDT15*3was in 2 (20%) pts,TPMT*2-1(10%),TPMT*3A-6 (60%),TPMT*3C-1 (10%). The doses of 6-MP in 5 pts withTPMTandNUDT15and 42 pts withWTwere 54% (27-89%) vs 71% (25-100%), respectively. Statistics analysis didn't show correlation between the 6-MP toxicity (difference of the fact dose of 6-MP therapy) and the polymorphisms in our cohort (fig.1). The frequency of resistance cases didn't different in cohort with/withoutTPMTandNUDT15polymorphisms in 3 (37, 5%) from 8 pts and 4 (10, 5%) from 42 pts, respectively. Only 1 patient with heterozygousTPMT*2died in CR due to toxicity and infection. Two-years overall survival (OS) in pts with the genetic polymorphisms was worse 75 % than in pts without them - 83,6% (p=0,67) (fig.2). Conclusions:In our study the frequency ofTPMTandNUDT15polymorphisms in adult pts with Ph-negative ALL was 17,8%. The statistical analysis showed that polymorphisms of these genes were detected more frequently in pts with В-ALL. Only one patient withTPMT*2had significant toxicity on the therapy of 6-MP and died in CR. However, we don't know whether this is due to deficient 6-MP metabolism. We didn't find a correlation between the 6-MP toxicity and the polymorphisms in our pts. There is a tendency that OS within 2-years in pts withoutTPMTandNUDT15polymorphisms is better than in the group of pts with them. But our cohorts are small and require further study. Keywords:acute lymphoblastic leukemia, toxicity, 6-mercaptopurine,TPMT,NUDT15 Disclosures No relevant conflicts of interest to declare.

Unmanipulated haploidentical peripheral blood stem cell transplantation for patients with Philadelphia-negative acute lymphoblastic leukaemia in first complete remission

Haploidentical peripheral blood stem cell transplantation (Haplo-PBSCT) is a promising treatment option for patients with Ph-negative acute lymphoblastic leukemia (ALL). In this study, we retrospectively analyzed data from Ph-negative ALL patients who underwent haplo-PBSCT during their first complete remission (CR1), and compared the long-term outcomes between the standard-risk and high-risk patients. The 3-year probability of relapse was 7.6% and 16.7% for the standard- and high-risk group (p = .274). The 3-year probability of disease-free survival (DFS) and overall survival (OS) for the standard-risk versus high-risk groups were 84.6% versus 50% (p = .0063) and 92.3% versus 61.1% (p = .046), respectively. Univariate analysis showed that a diagnosis of high risk with fusion/mutation genes were associated with worse outcomes, which was confirmed by multivariate analysis (p = .016). In summary, haplo-PBSCT may be a promising alternative for patients with Ph-negative ALL in CR1, although the fusion/mutation genes in high-risk patients may relatively impair the long-term efficacy compared with standard-risk patients.

Prognostic impact of cytogenetic abnormalities in adult patients with Philadelphia chromosome-negative ALL who underwent an allogeneic transplant.

Although cytogenetic abnormalities at diagnosis are recognized as an important prognostic factor in patients with Philadelphia chromosome (Ph)-negative acute lymphoblastic leukemia (ALL), the prognostic impact has not been evaluated in allogeneic stem cell transplant (allo-SCT) recipients. Thus, we assessed 373 Ph-negative ALL patients who underwent allo-SCT. The high-risk (HR) group included those with t(4;11), t(8;14), low hypodiploidy, and complex karyotype, and the standard risk (SR) group included all other karyotypes. Among the 204 patients who underwent a transplant during the first remission (167 in the SR group and 37 in the HR group), the overall survival (OS) rates were similar between these groups (64.1% vs. 80.0% at 5 years, respectively; p = 0.12). Conversely, among the 106 patients who underwent a transplant while not in remission (84 in the SR group and 22 in the HR group), patients in the SR group showed a significantly superior OS rate compared to the HR group (15.4% vs. 4.5% at 5 years, respectively; p = 0.022). These results suggested that treatment outcomes of Ph-negative ALL patients with HR cytogenetic abnormalities may improve following allo-SCT, especially in the first remission. Innovative transplant approaches are warranted in patients who are not in remission.

Minimal Residual Disease (MRD) Status after Induction Therapy Is a Strong Prognostic Factor in the Treatment of Adult Ph (-) Acute Lymphoblastic Leukemia (ALL): Results of a Prospective Study (ALL MRD2008 Study)

IntroductionA clinical indication for allogeneic hematopoietic stem cell transplantation (HSCT) in adult Philadelphia-chromosome negative [Ph (-)] acute lymphoblastic leukemia (ALL) patients in complete remission 1 (CR1) remains to be clarified. Minimal residual disease (MRD) status has been reported to be a strong prognostic factor in adult ALL patients (Blood. 2006 107:1116, 2009 113:4153)( J Hematol Oncol. 2013 6:14). We prospectively monitored MRD status during induction and consolidation therapy in adult Ph (-) ALL patients to determine a clinical indication for HSCT.Materials & MethodsFrom December 2008 to November 2013, 103 adult ALL patients were enrolled in this study. Eligibility criteria included non-L3 ALL, 16-65 years of age, and adequate organ function. Of these patients, 95 were eligible for this study and 59 were Ph (-). The treatment protocol used in this study was modified CALGB 19802. Treatment consisted of 6 courses given in the order of A-B-C-A-B-C, followed by a maintenance phase. Induction chemotherapy (course A) consisted of cyclophosphamide (1,200 mg/m2), daunorubicin (60 mg/m2 x 3), vincristine (VCR) (1.3 mg/m2 (max 2mg) x 4), L-asparaginase (3,000 U/m2 x 6) and prednisolone. Granulocyte colony-stimulating factor was started on day 4 and continued until neutrophil recovery. Consolidation B consisted of mitoxantrone (10 mg/m2 x 2), cytarabine (2,000 mg/m2/day x 4) and intrathecal (IT) administration of methotrexate (MTX). Consolidation C consisted of VCR (1.3 mg/m2 (max 2mg) x 3) and MTX (1,500 mg/m2 x 3) with leucovorin rescue and IT MTX. Patients received maintenance chemotherapy on a monthly basis: prednisolone 60 mg/m2 on days 1-5, VCR (1.3mg/m2 (max 2mg) x 3) on day 1, oral MTX 20 mg/m2 weekly, and oral 6-mercaptopurine 60 mg/m2 daily. MRD status was evaluated after induction therapy (first course A) and after second consolidation therapy (first course C). When MRD statuses after the consolidation were positive, patients were supposed to proceed to HSCT whenever possible.ResultsAmong the 59 Ph-negative ALL patients, 51 patients (86%) could be monitored for MRD status, and the remaining 8 patients were not because of no clonal TCR/Ig targets or chimeric mRNA. The MRD status was determined by PCR analysis of major gene rearrangements and/or chimeric mRNAs (18 were positive for TCRγ, 16 for TCRδ, 13 for IgH, 1 for TCRγ and MLL-AF4, 1 for TCRγ and ETV6-RUNX1, 1 for IgH and MLL-AF4, and 1 for IgH and MLL-ENL). MRD quantifications were performed using ASO-primers with a sensitivity of ≤1 × 10−4, and MRD positivity was defined as a lower limit of detection of ≥1 × 10−3. The median follow-up time was 1597 days (range, 16-2870 days). A total of 51 patients included 29 males and 22 females, and their median age was 29 years ranging from 16 to 65. The median white blood cell count at presentation was 8.5 × 103/L (range 1.2-650.4). CR was achieved in 45 patients (88%). One patient died during induction due to intestinal bleeding. There were 29 survivors after the median follow-up period. The probability of 3-year OS and DFS in these patients with Ph-negative ALL was 69% (95%CI 54-80) and 50% (95%CI 36-63, respectively. In terms of CR1 status, MRD-negative patients after induction chemotherapy A in the first course (n = 17) showed a better 3-year DFS (65%) compared with MRD-positive patients (n = 31; 43%), as shown in Figure 1. The difference was not statistically significant (p = 0.07). There was no patient who proceeded to allogeneic HSCT among 17 MRD-negative patients after induction therapy in CR. In contrast, patients who were MRD-positive after induction but became MRD-negative after consolidation chemotherapy C in the first course (n = 11) showed a worse 3-year DFS compared with patients who were MRD-negative after induction chemotherapy A in the first course (45% vs. 65%, p = 0.08). Fourteen patients were MRD-positive after consolidation chemotherapy C in the first course. Among them, 5 patients proceeded to allogeneic HSCT in 1CR, and 9 did not. Three-year DFS with or without allogeneic HSCT were 60% (95%CI 13-88) vs 44% (95%CI 14-72, p=0.52), respectively.DiscussionThe present study indicates that MRD status after induction and consolidation therapies is a strong prognostic factor. Post-induction MRD-negative patients have been identified to have good-prognosis with chemotherapies, not suitable for up-front allogeneic HSCT. [Display omitted] DisclosuresTakamatsu:Taisho Toyama Pharmaceutical: Research Funding; TAIHO Pharmaceutical: Research Funding; Pfizer: Research Funding; Bristol-Myers Squibb: Research Funding; Ono Pharmaceutical: Research Funding; Astellas Pharma: Research Funding; Kyowa Hakko Kirin: Research Funding; Chugai Pharma: Research Funding; Takeda Pharmaceutical: Research Funding; Celgene: Honoraria. Akashi:Celgene: Research Funding, Speakers Bureau; Novartis pharma: Research Funding; Ono Pharmaceutical: Research Funding; Eisai: Research Funding; sanofi: Research Funding; Pfizer: Research Funding; Chugai Pharma: Research Funding; Kyowa Hakko Kirin: Research Funding, Speakers Bureau; Asahi-kasei: Research Funding; MSD: Research Funding; Otsuka Pharmaceutical: Research Funding; Taiho Pharmaceutical: Research Funding; Bristol-Myers Squibb: Research Funding, Speakers Bureau; Astellas Pharma: Research Funding; Eli Lilly Japan: Research Funding.

Clinical Significance of Clonal Cytogenetic Heterogeneity (CCH) at Diagnosis in Adult Patients with Acute Lymphoblastic Leukemia (ALL)

Background:Although cytogenetic abnormalities at diagnosis are recognized as one of the most potent prognostic factors in acute leukemia patients, CCH acquisition at diagnosis, which are considered as a result of clonal evolution of leukemia cells, is not taken into account in prognostic classifications. Recent studies reported that CCH acquisition was observed in 24 - 32% of adult AML patients with abnormal karyotype, was more likely to occur in patients with older age and complex karyotype, and showed adverse prognostic impact. However, the clinical significance of CCH acquisition has not been investigated in adult ALL patients to date. Patients and methods: Of the 238 adult ALL patients diagnosed between 1990 and 2016, 120 patients with abnormal karyotype at diagnosis, who underwent intensive chemotherapy, were included in this study. CCH was defined as presence of two or more cytogenetically abnormal clones. A defined ancestral clonal evolution included either mother-daughter and/or branched patterns. In the mother-daughter pattern, a daughter clone showed all cytogenetic abnormalities of a mother clone plus additional abnormality(s), which define a distinct subclone. In a branch pattern, all subclones possessed common cytogenetic abnormalities suggesting presence of a common ancestry, but each subclone acquires unique additional abnormality(s), which define them as distinctive subclones. Both patterns of cytogenetic clonal evolution were sometimes seen in a patient. Composite karyotypes were applied to patients where a common ancestry could not be clearly determined because of too complicated cytogenetic findings. Fisher's exact test was used to compare binary variables. The logistic regression model was used for multivariate analysis of predisposing factors. Overall survival (OS) was estimated with the Kaplan-Meier method and compared using the log-rank test. The Cox proportional hazard model was used for multivariate analysis of prognostic factors. Values of p < 0.05 were considered to indicate statistical significance. Results:Of the 120 patients included in this study, 64 patients were male, and 56 were female. The median age was 50 years (range, 16-79 years). Karyotypes at diagnosis were Philadelphia chromosome (Ph) in 56 patients, complex in 15, and t(8;14) in seven. According to the definition described above, 47 patients (39%) showed CCH at diagnosis, and two (4%) among them were categorized as composite karyotype. Of the 45 patients harboring a defined ancestral clonal evolution, numbers of subclones were two, three, and four in 32 patients (68%), 11 (24%), and 2 (4%), respectively. Mother-daughter pattern, branched pattern, and both were seen in 34 patients (76%), 5 (11%), and 6 (13%). In univariate analysis for predisposing factors of CCH acquisition, only younger age was significantly associated with CCH acquisition (48% in age <= 50 vs. 29% in age > 50; p = 0.04), but not karyotype. This statistical significance was confirmed with multivariate analysis (odds ratio = 0.44; p = 0.03). When investigating the prognostic impact of CCH acquisition, patients were divided into Ph-negative or Ph-positive ALL groups. In the 64 Ph-negative ALL patients, the CR rates were not significantly different between patients with or without CCH (78% vs. 78%, respectively; p = 1.00). The OS rates were similar between two groups (26% vs. 39% at five years, respectively; p = 0.56). Multivariate analysis for OS revealed that complex karyotype and t(8;14) were independent prognostic factors, but not CCH acquisition. Likewise, in the 56 Ph-positive ALL patients, CCH acquisition was not significantly associated with the CR rates (92% vs. 78%, respectively; p = 0.27), and the OS rates did not significantly differ between the two groups (34% vs. 40% at five years, respectively; p = 0.90). In multivariate analysis for OS, no independent prognostic factor was identified. Conclusion: Adult ALL patients with abnormal karyotype acquired CCH at diagnosis with a frequency comparable to that of AML patients. However, unlike AML patients, CCH acquisition was more frequently observed in younger population and did not show any prognostic impact in ALL patients. These findings suggested that biological backgrounds of CCH acquisition at diagnosis were possibly different between in patients with ALL and AML. So, to confirm these important findings, clinical studies with larger study subjects are warranted. DisclosuresHanda:Celgene: Honoraria, Research Funding, Speakers Bureau; Takeda: Consultancy, Honoraria, Research Funding, Speakers Bureau.

Prognostic Impact of Cytogenetic Abnormalities in Adult Patients with Philadelphia-Chromosome (Ph)-Negative Acute Lymphoblastic Leukemia (ALL) Who Underwent Allogeneic Stem Cell Transplant (allo-SCT)

Background: Cytogenetic abnormalities at diagnosis are recognized as a potent prognostic factor for acute leukemia patients. Among acute myeloid leukemia patients, the prognostic implications of cytogenetic abnormalities have been established for those treated with chemotherapy as well as those undergoing allo-SCT. In the context of Ph-negative ALLpatients, cytogenetic abnormalities at diagnosis clearly stratify the prognosis, whereas it has not been elucidated whether similar prognostic stratification is applicable to allo-SCT recipients.Objective: The aim of this retrospective study was to assess the prognostic impact of cytogenetic abnormalities in adult Ph-negative ALL patients who underwent allo-SCT.Patients and Methods: The study cohort included 373 adult Ph-negative ALL patients aged over 15 years who underwent allo-SCT for the first time between January 2001 and December 2012 at the 23 institutions participating in the Kanto Study Group for Cell Therapy (KSGCT). Patients' clinical data were collected from the KSGCT database. The Institutional Review Board of Gunma University approved the protocol of this study. Karyotypes considered high risk (HR) included t(4;11), t(8;14), low hypodiploidy, and complex (equal or more than five abnormalities), and all other karyotypes were designated standard risk (SR). On this basis, 308 patients (82.6%) were categorized as SR and 65 patients (17.4%) were categorized as HR at diagnosis. Of the 373 patients, 267 underwent allo-SCT in complete remission (CR) (224 in the SR group and 43 in HR group), and 106 in non-CR (84 in the SR group and 22 in HR group). For analysis, the study population was stratified based on disease status at the time of transplant. Almost all patients were conditioned with total body irradiation (TBI)-containing myeloablative conditioning (MAC) regimens prior to transplantation. Overall survival (OS) was defined as the interval from the date of transplantation to the date of death. Non-relapse mortality (NRM) was defined as any death in continuous complete remission (CR). The Fisher's exact test was used for comparison of binary variables. OS and RFS were estimated by the Kaplan-Meier method, and compared using the log-rank test. Cumulative incidences (CI) of relapse and NRM were compared using the stratified Gray test. P < 0.05 was considered as statistically significant.Results:[Patients in CR] No significant difference in patient characteristics and transplant procedures was observed between the SR and HR groups. The 5-year OS rates were similar between the SR and HR groups (60.5% vs. 74.1%, respectively; p = 0.225) (Figure 1). Similarly, there were no significant differences in the 5-year CI of relapse and NRM rates between the two groups (relapse: 26.3% vs. 24.8%, respectively; p = 0.498, NRM: 19.6% vs. 10.0%, respectively; p = 0.232). Multivariate analysis for OS identified MAC and TBI-containing regimens, not cytogenetic risk, as significant positive prognostic factors.[Patients in non-CR] No significant difference was observed between the SR and HR groups in terms of patient characteristics or transplant procedures, although there was a female predominance in the HR group. Patients in the SR group had a significantly superior 5-year OS rate compared to the HR group (15.4% vs. 4.5%, respectively; p = 0.022). There was no significant difference in the 5-year CI of relapse between the SR and HR groups (60.3% vs. 50.0%, respectively; p = 0.411), whereas the 5-year CI of NRM in the SR group was significantly lower than that in the HR group (24.8% vs. 45.5%, respectively; p = 0.024). Multivariate analysis revealed cytogenetic risk group as an independent prognostic factor.Conclusion: These findings suggest that adult Ph-negative ALL patients in remission with HR cytogenetic abnormalities have similar transplant outcomes to those in the SR group. Considering the reported equality of the CR rates between the two groups, allo-SCT at an early clinical phase is recommended for HR group patients, reminiscent of Ph-positive ALL patients in the pre-imatinib era. Current transplant procedures do not improve outcomes for patients who are not in remission, especially those with HR cytogenetic abnormalities. DisclosuresUsuki:MSD: Other: personal fees, Research Funding; SymBio Pharmaceutical: Other: personal fees, Research Funding; GlaxoSmithKline: Other: personal fees, Research Funding; Shionogi: Other: personal fees; Fujimoto Pharmaceutical: Research Funding; Bristol-Myers Squibb: Other; Takeda Pharmaceutical: Research Funding; Nippon Shinyaku: Other: personal fees, Research Funding; Sanofi: Other: personal fees, Research Funding; Shire: Research Funding; Kyowa Hakko Kirin: Other: personal fees, Research Funding; Otsuka Pharmaceutical: Research Funding; Eisai: Research Funding; Novartis: Other: personal fees, Research Funding; Boehringer Ingelheim: Other: personal fees, Research Funding; Celgene: Other: personal fees, Research Funding; Sumitomo Dainippon Pharma: Other: personal fees, Research Funding; Chugai Pharmaceutical: Other: personal fees; Fuji Film RI Pharma: Other: personal fees; Taiho Pharmaceutical: Other: personal fees, Research Funding; Astellas: Research Funding. Nakaseko:Novartis: Honoraria, Research Funding, Speakers Bureau; BMS: Honoraria, Research Funding, Speakers Bureau; Pfizer: Honoraria, Research Funding, Speakers Bureau; Otsuka: Honoraria, Research Funding.

A High Incidence of Disseminated Intravascular Coagulation in Philadelphia Chromosome-Positive Acute Lymphoblastic Leukemia and Its Management

IntroductionDisseminated intravascular coagulation (DIC) occurs about 10% of adult patients with acute lymphoblastic leukemia (ALL) at presentation, and develops in approximately 30-40% of adult patients after starting induction therapy. Although reports of DIC developing with a high frequency in Philadelphia chromosome-positive (Ph+) ALL are scarce, we have experienced many cases of DIC in Ph+ ALL patients.We start chemotherapy and prednisolone (PSL) at the same time after diagnosis of ALL, and give imatinib (IM) at the time it is found to be Ph+. However, we have experienced cases of early death due to severe DIC and tumor lysis syndrome (TLS) when utilizing this approach. Therefore, we have tried mild tumor reduction via initiation of PSL, IM and chemotherapy at different times.We investigated the difference in the incidence of DIC between Ph+ ALL patients and Ph negative (Ph-) ALL patients and discuss the management of DIC and its effect.Patients and methodsWe examined ALL patients who received their first treatment at our institution between January 2012 and December 2014.We monitored for DIC by twice daily blood testing, and diagnosed DIC according to the diagnostic criteria for DIC of the Japanese Ministry of Health, Labour and Welfare. When DIC developed, the patients were encouraged to rest, and we treated DIC with recombinant human soluble thrombomodulin (rTM) and/or gabexate mesylsate (FOY). To prevent bleeding episodes, platelet (Plt) and fresh frozen plasma transfusion were given to maintain Plt count >50,000/ul and fibrinogen (Fib) level >100 mg/dl.For induction therapy, to avoid rapid development of DIC and TLS, we first administered PSL 60 mg/m2. While confirming a decrease in leukocyte counts and fibrin degradation products (FDP), we started IM followed by chemotherapy (daunorubicin + vincristine + cyclophosphamide + L-asparaginase) in Ph+ ALL patients. We began PSL followed by the same chemotherapy in Ph- ALL patients as well. We used rasburicase to prevent TLS.ResultsA total of 35 patients with newly diagnosed ALL were examined: 18 patients were Ph+ and 17 were Ph-. The incidence of DIC was 82.3% (14/17) in Ph+ patients and 38.9% (7/18) in Ph- patients. The group with Ph+ showed a significantly higher rate of DIC (p value = 0.015). Duration of the treatment of DIC was 4-14 days (median, 10 days) in Ph+ patients, and 3-10 days (median, 5 days) in Ph- patients. The group with Ph+ also showed significantly longer duration of treatment (p value = 0.02).Twelve Ph+ patients developed DIC (two patients were excluded because of treatment that was different from that described above); five were men and seven were women. Median age was 61 years (range, 34-78 years). Leukocyte counts at the time of diagnosis were 4400-542100 /ul (median 34400 /ul), hemoglobin value was 6.4-15.6 g/dl (median 11.6, g/dl), Plt counts were 6000-262000 /ul (median, 56000 /ul), Fib value was 199-707 mg/dl (median, 299 mg/dl), and FDP value was 3.4-45.7 ug/ml (median, 9.7 ug/ml). DIC occurred at 1-8 days (median, 3 days) from diagnosis. One patient (8%) had DIC at presentation, and the remaining 11 patients (92%) had DIC after the initiation of induction therapy. We started IM at day 3-6 (median, day 5), DIC developed in two patients starting IM, and chemotherapy was started at day 5-10 (median, day 7). Only one patient had slight elevation of FDP, and this value decreased in a progressive fashion in the remaining 11 patients. The maximum FDP value during the treatment of DIC was 32-1162.8 ug/ml (median, 140 ug/ml). We treated DIC with FOY single agent (one patient) or a combination of rTM and FOY (10 patients); all patients showed improvement. The period for improvement of DIC was 4-14 days (median, 8 days), and none of the patients had bleeding or organ damage. Only one patient had TLS, but it immediately improved. In these Ph+ patients, 11/12 patients (92%) achieved complete remission (CR), and one patient had partial remission. Further, 5/5 patients (100%) achieved CR, and none had TLS in the group with Ph-.ConclusionDIC occurred at a high incidence in Ph+ ALL patients. By starting PSL, IM, and chemotherapy at the right time, we can perform induction therapy without generating serious complication due to DIC. DisclosuresNo relevant conflicts of interest to declare.

Value of Cytogenetic Abnormalities in Adult Patients with Philadelphia Chromosome (Ph)-Negative Acute Lymphoblastic Leukemia (ALL) Treated in the Pediatric-Inspired Trials from the Group for Research on Adult ALL (GRAALL)

Background: Numerous recurrent chromosomal abnormalities have been described in adult Ph-negative ALL, often observed in small patient cohorts. In the largest MRC/ECOG study (Moorman, Blood 2007), t(4;11)(q21;q23), 14q32 involvement, complex karyotype (≥5 abnormalities), and low hypodiploidy/near triploidy (Ho-Tr) were associated with shorter event-free survival (EFS), while patients with high hyperdiploidy or del(9p) had a better outcome. We aimed to confirm these observations in 955 adult patients (15-60y; median, 35y) with Ph-negative ALL treated in the pediatric-inspired GRAALL-2003/2005 trials.Patients and Methods: Overall, a karyotype was performed for 946 (611 BCP-ALL, and 335 T-ALL), successful for 811 (523 BCP-ALL and 288 T-ALL) and abnormal in 590 patients (387 BCP-ALL and 203 T-ALL). FISH and/or PCR screening for relevant abnormalities and DNA index were also performed, finally allowing for the identification of cytogenetic abnormalities in 677/955 patients (71%). All were centrally reviewed. Ultimately, 857/955 patients (90%; 542 BCP-ALL and 315 T-ALL) could be classified in 18 exclusive primary cytogenetic subsets as detailed below. Endpoints were cumulative incidence of failure (CIF, including primary refractoriness and relapse) and EFS. With a median follow-up of 4 years, 5-year CIF and EFS were estimated in these patients at 31% and 51%, respectively. As some abnormalities, including MLL rearrangements, Ho/Tr, t(1;19)(q23;p13)/TCF3 and complex karyotypes were used to stratify allogeneic stem cell transplantation (SCT) in GRAALL trials, some comparisons were repeated after censoring patients transplanted in first CR at SCT time.Results: The 542 informative BCP-ALL patients were classified as: t(4;11)(q21;q23)/MLL-AFF1 (n=72; 13%); other MLL+ 11q23 abnormalities (n=11; 2%); t(1;19)(q23;p13)/TCF3-PBX1 (#28; 5%); Ho/Tr (n=33; 6%); high hyperdiploidy (n=36; 7%); abnormal 14q32/IGH translocation (n=27; 5%); t(12;21)(p13;q22)/ETV6-RUNX1 (n=2; 0.4%); iAMP21 (n=3; 0.6%); other abnormalities (n=210; 39%); and no abnormality (n=120; 22%). The 315 informative T-ALL patients were classified as: t(10;14)(q24;q11)/TLX1 (n=64; 20%); other 14q11 or 7q34/TCR (n=31; 10%); t(5;14)(q35;q32)/TLX3 (n=29; 9%); t(10;11)(p12;q14)/PICALM-MLLT10 (n=14; 4%); deletion 1p32/SIL-TAL (n=18; 6%); MLL+ 11q23 abnormalities (n=6; 2%); other abnormalities (n=93; 30%); and no abnormalities (n=60; 19%). A complex karyotype was observed in 27/527 (5%) BCP-ALL and 21/298 (7%) T-ALL patients and a monosomal karyotype (as per Breems, JCO 2008) in 82/518 (16%) BCP-ALL and 26/286 (9%) T-ALL patients. In BCP-ALL, trends towards higher CIF and shorter EFS were observed in t(4;11) patients, with or without SCT censoring (HRs, 1.34 to 1.64; p values <0.10). Shorter EFS was observed in 3 subsets: 14q32 (HR, 2.10; p=0.002), Ho/Tr (HR, 1.45; p=0.10), and monosomal karyotype (HR, 1.42; p=0.029), but CIF were not different. This might be related to the older age of patients in these subsets (medians, 43y, 53y and 44y; p=0.029, <0.001 and <0.001, respectively) and worse treatment tolerance. For instance, higher incidences of non ALL-related deaths were observed in patients with 14q32 abnormalities or monosomal karyotype (p=0.031 and 0.067, respectively). Patients with high hyperdiploidy only tended to have lower CIF and longer EFS. Complex karyotype did not impact CIF and EFS, even after SCT censoring. Conversely, in T-ALL, complex karyotypes were associated with shorter EFS (HR, 2.20; p=0.004), even if the difference in CIF did not reach significance. A worse outcome was also observed in patients with t(10;11)(p12;q14)/PICALM-MLLT10 (HR, 2.45 and 2.14; p=0.016 and 0.021, for CIF and EFS respectively). A longer EFS was observed in patients with t(10;14)(q24;q11)/TLX1 (HR, 0.55; p=0.014), with a trend for lower CIF (HR, 0.59; p=0.070), while no inferior outcome was observed in t(5;14)(q35;q32)/TLX3 patients.Conclusion: These results show that, in the context of an intensified pediatric-inspired protocol designed for adult Ph-negative ALL patients, few cytogenetic subsets remained reliably predictive of response to therapy. Differences observed in EFS might partly be due to treatment-related mortality. Combining cytogenetics, molecular genetics and minimal residual disease monitoring could allow for better individual risk assessment (Beldjord, Blood 2014). DisclosuresNo relevant conflicts of interest to declare.

Optimal treatment of adult Ph negative acute lymphoblastic leukemia

To analyze the difference of safety and efficacy between the traditional and the pediatric inspired acute lymphoblastic leukemia (ALL) chemotherapy regimen, and to further observe whether patients in different age group will benefit from the two regimens. Adult de novo Ph negative ALL patients in our hospital from Jan 4, 2009 to Sep 4, 2013 were involved in this study and divided into 2 groups according to treatment regimens, the traditional regimen (regimen 1) and modified pediatric regimen (regimen 2) groups, respectively. The safety and the efficacy of all patients and different regimen groups were evaluated statistically. All 144 patients received the induction therapy. The total complete remission (CR) rate was 95.8%, one course CR rate was 92.4%, and 5 year overall survival (OS) and progression free survival (RFS) were 59.0% and 48.6% respectively. The CR rate, 3 year OS and 3 year RFS between the two different regimens were 95.6% vs 96.1% (P = 0.783), 65.3% vs 63.4% (P = 0.885) and 56.0% vs 50.0% (P = 0.931), respectively. Further analysis stratified with age was also performed. For the patients treated with regimen 1, the 3 year OS and RFS between the two different age groups (14-30 years and 31-60 years) was 69.6% vs 54.7% (P = 0.042) and 56.5% vs 57.0% (P = 0.472). For the patients treated with regimen 2, the 3 year OS and RFS between the two different age groups (14-30 years and 31-60 years) was 65.7% vs 60.3% (P = 0.423) and 51.5% vs 46.6% (P = 0.655). No differences were found on the respiratory failure, cardiac dysfunction, fungal infection and intestinal obstruction between the two treatment regimen groups. The incidence of renal dysfunction for regimen 1 was lower than that of regimen 2 (P = 0.011). The incidence of bacteremia for regimen 1 was higher than that of regimen 2 (P = 0.000). The two treatment regimens for adult Ph negative ALL patients were well tolerated and showed relative favorable CR rate and long term survival rate. The older patients (31-60 years) tended to benefit from the regiment 2 which was less intensive and consisted of more agents with low suppression to bone marrow.

Minimal Residual Disease Levels At Time Of CR1 and Transplant Predict Outcome In Philadelphia Chromosome-Negative Adult ALL

IntroductionHigh relapse rate has always been the primary element threatening the long-term survival of acute lymphoblastic leukemia (ALL). The risk stratification depending on conventional prognostic factors indeed assists to detect patients with high risk of relapse, but not efficiently. The detection of minimal residual disease (MRD) has been widely used to further identify patients with poor prognosis. Lots of studies focused at pediatric ALL had demonstrated the prognostic effect of MRD levels for predicting relapse risk and survival in children, but the data and evidences seemed not that sufficient in adult ALL. And it was still unknown to what extent of the MRD levels at remission that the allogenic hematopoietic stem cell transplantation (allo-HSCT) should be implemented. This study was designed to evaluate the prognostic effect of MRD levels at time of CR1 and transplant for adult Philadelphia chromosome-negative ALL (Ph-negative ALL), and to discover the subgroup that benefits from HSCT based on the stratification by the MRD levels at CR1. MethodsDuring January 2006 to December 2011, 107 adult Ph-negative ALL patients in our center were admitted in this study, of whom 45 were assigned chemotherapy and 62 allo-HSCT. All the patients received induction mainly composed of vincristine and corticosteroids (VDP, VDCP, VDLP, VDCLP), and consolidation of VDCP, VMCP, hyper-CVAD etc. For patients allocated allo-HSCT, conditioning regimen mainly involved BuCy without total body irradiation, and the grafts were from alternative donors—15 HLA-matched sibling donors (24.2%), 27 unrelated donors (43.5%), 20 haploidentical donors (32.3%). The bone marrow samples were collected for MRD detection by 4 color flow cytometry. The time point for MRD detection in chemotherapy arm was the first morphologic remission, defined as MRD at CR1; and the HSCT arm added MRD at transplant (the MRD levels just before HSCT) in addition. As some samples lost in the final statistical analysis, there were totally 36 MRD at CR1 samples in chemotherapy arm, 47 MRD at CR1 and 61 MRD at transplant samples in HSCT arm. Comparing and analyzing the differences of survival among risk groups stratified by MRD levels with the cut-off of 0.02% and 0.2%. Further, within the same MRD at CR1 levels, the differences of survival between chemotherapy and HSCT arms were examined to discover the subgroups benefited from allo-HSCT. ResultsThe HSCT arm had a 3-year improved OS and DFS than chemotherapy arm (55.7% vs. 27.9%, P=0.002; 54.4% vs. 18.2%, P<0.001). The relapse rate was significantly lower in the HSCT arm (29.9% vs. 76.5%, P<0.001). In the chemotherapy arm, the 3-year OS for MRD at CR1≤0.02%, 0.02%<MRD at CR1≤0.2%, MRD at CR1>0.2% were 70.0%, 24.8%, 0% (P=0.005, Figure 1a); In the HSCT arm, the 3-year OS for MRD at CR1≤0.02%, 0.02%<MRD at CR1≤0.2%, MRD at CR1>0.2% were 81.8%, 58.4%, 23.4% (P=0.004, Figure 1b); and the 3-year OS for MRD at transplant≤0.02%, 0.02%<MRD at transplant≤0.2%, MRD at transplant>0.2% were 84.6%, 59.3%, 30.0% (P=0.020, Figure 1c). Then, the 3-year improved OS with HSCT was observed in the MRD at CR1>0.02% subgroup (0.02%<MRD at CR1≤0.2%, HSCT 58.4% vs. chemotherapy 24.8%, P=0.017, Figure 1e; MRD at CR1>0.2%, HSCT 23.4% vs. chemotherapy 0%, P=0.016, Figure 1f), but not in the MRD at CR1≤0.02% subgroup (HSCT 81.8% vs. chemotherapy 70.0%, P=0.666, Figure 1d). Multivariate Cox analysis confirmed that higher levels of MRD at CR1 and MRD at transplant were the most statistically significant adverse factors for OS. [Display omitted] ConclusionsMRD levels at time of CR1 and transplant can strongly predict the outcome of adult Ph-negative ALL; the subgroup whose MRD at CR1>0.02% benefits from allo-HSCT. Disclosures:No relevant conflicts of interest to declare.

Whole-Exome Sequencing Of Adult Philadephia-Negative Acute Lymphoblastic Leukemia From Diagnosis To Relapse After Allogeneic Hematopoietic Stem Cell Transplantation Reveals Clonal Evolution and Relapse-Associated Mutated Genes

▪ IntroductionAlthough steady progress of effective chemotherapy in childhood acute lymphoblastic leukemia (ALL) carried with exceeding 80% of individuals now cured, the majority of adult patients with ALL are not cured by chemotherapy, and allogeneic hematopoietic stem cell transplantation (allo-HSCT) is the only curative option. However, relapse remains the most leading cause of death after allo-HSCT. Adverse genetic alterations are generally accepted to be responsible for treatment failure and relapse. Several structural chromosomal alterations including rearrangement of the myeloid-lymphoid or mixed-lineage leukemia gene (MLL) and Philadelphia chromosome (Ph), have been mostly found in relapsed ALL. However, many Ph-negative (Ph-) ALL patients with normal karyotype , lacking known risk factors, also experienced relapse. The underlying pathologic determinants leading to relapse and prognostic markers in these cases remain poorly understood. More importantly, allo-HSCT is a distinct treatment option from tradtional chemotherapy and has 2 important forms to eliminate and select on malignant cells. The malignant cells that go on to causing relapse must initially survive ablation of chemotherapy before allo-HSCT and conditioning regimen in allo-HSCT. Then, after allo-HSCT, they must survive the effect of graft-versus- leukemia (GVL) reaction. Following this rationale, we hypothesized that there may be pivotal genetic causes confer leukemic cells a fitness advantage to undergo huge selective pressures and expand after allo-HSCT. To elucidate the genomic basis underlying relapse after allo-HSCT to aid to discover novel predictive biomarkers and identify therapeutic targets, we carried out the first whole-exome sequencing analysis in longitudinal matched samples from diagnosis to relapse after allo-HSCT in adult patients with the most common subtype of ALL, Ph- B-cell ALL (B-ALL). MethodsWhole-exome sequencing was conducted for 9 genomic DNA samples from 3 relapsed cases with Ph- B-ALL (discovery cohort) at 3 specific time points including: diagnosis, complete remission (CR) after induction chemotherapy before allo-HSCT, relapse after allo-HSCT to discover candidate relapse-associated mutated genes. We identified putative somatic mutations by comparing each tumor ( diagnostic samples or relapsed samples) to normal (CR samples) from the same patient. To confirm candidate somatic gene mutations, screen relapse-associated gene mutations and define the frequency of somatic mutations identified by whole-exome sequencing analysis, we further carried out target genes whole coding regions sequencing in an ALL extended validation cohort including 58 adult Ph- B-ALL cases, where 27 patients experienced relapse at a median time of 6.5 (range 2-33) months after allo-HSCT and 31 patients did not relapse after allo-HSCT at a median follow-up for 34 (range 12–56) months. Results(1) We discovered novel associations of recurrently mutated genes (CREBBP, KRAS, PTPN21) with the pathogenesis of adult Ph- B-ALL relapse after allo-HSCT, which were mutated in at least two relapsed cases, but were not mutated in non- relapsed patients. (2) The generation of high-depth whole-exome sequencing data in longitudinal matched samples from diagnosis to relapse after allo-HSCT in initial 3 patients allowed us to directly assessed the evolution of somatic mutations. Our data suggested that in the progression of leukemia relapse after allo-HSCT, the relapse clone had a clear relationship to the diagnosis clone, either arising from a subclone already exsiting in the diagnostic tumor, or originating from a common preleukemic progenitor with the diagnosis clone. In the latter pattern, the relapse clone acquires new genetic alterations while retaining some but not all of the alterations found in the diagnostic tumor. In contrast, in some cases, leukemia recurrences afer allo-HSCT may be composed of second malignancies with completely distinct sets of mutations from the primary tumor. ConclusionsOur study is the first to explore genetic basis of adult Ph- B-ALL from diagnosis to relapse after allo-HSCT over time, which will provide novel genetic biomarkers on risk “index” to improve individualized treatment intensification and intervention strategies, and potential therapeutic targets for Ph--ALL relapse after allo-HSCT. Disclosures:No relevant conflicts of interest to declare.