Ph-negative Acute Lymphoblastic Leukemia Research Articles

Loss of Heterozygosity in the Short Tandem Repeat (STR) Loci Found in Tumor DNA of De Novo Diagnosed ALL Patients As a Factor Predicting Poor Outcome

Introduction: Loss of heterozygosity (LOH) was described for many malignancies including leukemia. Using chromosomal microarray analysis (CMA) we have shown preliminary (Risinskaya et al. HemaSphere, 2019, V.3, No S1, P.782) that LOH in STR loci in tumor cells with the normal karyotype represents the loss of extended chromosomal areas and could be associated with uniparental disomy of the entire chromosomal arm or the entire chromosome. Uniparental disomy results not only in the elimination of the wild type allele, but also may lead to the duplication of the mutant allele of certain candidate tumor gene(s). Retrospective analysis of archival samples have shown that in most cases STR loci absent at the relapse of disease were already lost at the onset of disease. We noted LOH at STR loci is especially frequent for relapsed ALL patients and could be used as prognostic factor for possible poor clinical outcome. The aim: To identify LOH in the blast cells of the patients with ALL at the onset of disease and to analyze therapy outcome relative to the patients without LOH. We expect LOH in the de novo ALL to be an unfavorable factor, and those patients possibly should be treated like high-risk group. Patients and Methods: This study includes a comparative analysis of the STR profiles of the DNA of tumor and normal cells from bone marrow samples on a cohort of 32 patients with de novo diagnosed Ph-negative ALL undergoing treatment according to the "RALL-2016" regimen at the National Research Center for Hematology (Moscow, Russia). Inclusion criteria: de novo diagnosed Ph-negative acute lymphoblastic leukemia (ALL) patients, 18-55 years old, intermediate risk group without MLL translocation t(4;11)(q21;q23), treatment by RALL-2016 protocol. Exclusion criteria: other diagnosis, adult patients older than 55 years, MLL translocation t(4;11)(q21;q23), pretreatment or treatment by other protocol. The presence of blast cells in bone marrow samples was confirmed morphologically. DNA was isolated from patient bone marrow samples taken at different disease stages. Control DNA samples were taken from blood of patients in complete remission and/or from buccal epithelium (buccal swab). STR-profiles were assessed by PCR with COrDIS Plus multiplex kit for amplification of 19 polymorphic STR-markers and amelogenin loci (Gordiz Ltd, Russia). The fragment analysis was performed on ABI3130 Genetic Analyzer. The data processing was accomplished using GeneMapper v.4-0 software. A multivariate survival analysis was used to assess the independent impact of the LOH as risk factor against the background of the abnormal tumor karyotype as standard factor for this cohort of patients. We have chosen Failure Free Survival (FFS) as primary endpoint for short-time follow-up and small patient sample size. Death from any reasons, relapse and second leukemia were chosen as failure events, survival time interval starts from begin of treatment. SAS V9/4 was used for statistical analysis of the data. Results: Of the 32 patients six were found with LOH in the certain STR loci (19%). Of these six, two were resistant to therapy and died from disease progression. One patient with LOH is currently in relapse and one patient with multiple LOH has a second leukemia (Fig.1a). Only two from six patients are "Failure Free" now, whereas only three patients from 26 in group without LOH died (two from infectious complications and one from GvHD after BMT). P value < 0,05 (Fig.1b). Conclusions: We have found statistically significant association of clinical failures with the LOH in STR loci measured at the onset of ALL. We assume that LOH is an unfavorable prognostic factor for de novo ALL patients and could be used for risk stratification and choice of adequate therapy implying allogeneic hematopoietic stem cells transplantation or modern innovative therapy approaches. Disclosures No relevant conflicts of interest to declare.

Updated Results of a Phase II Study of Reduced-Intensity Chemotherapy with Mini-Hyper-CVD in Combination with Inotuzumab Ozogamicin, with or without Blinatumomab, in Older Adults with Newly Diagnosed Philadelphia Chromosome-Negative Acute Lymphoblastic Leukemia

Updated Results of a Phase II Study of Reduced-Intensity Chemotherapy with Mini-Hyper-CVD in Combination with Inotuzumab Ozogamicin, with or without Blinatumomab, in Older Adults with Newly Diagnosed Philadelphia Chromosome-Negative Acute Lymphoblastic Leukemia

Preliminary Minimal Residual Disease Analysis of the Australasian Leukaemia & Lymphoma Group (ALLG) ALL8 Study of Front-Line Blinatumomab with Chemotherapy in Adults with Ph Negative B-Cell Acute Lymphoblastic Leukaemia

Preliminary Minimal Residual Disease Analysis of the Australasian Leukaemia & Lymphoma Group (ALLG) ALL8 Study of Front-Line Blinatumomab with Chemotherapy in Adults with Ph Negative B-Cell Acute Lymphoblastic Leukaemia

Increased Relapse Risk of Acute Lymphoid Leukemia in Homozygous HLA-C1 Patients after HLA-Matched Allogeneic Transplantation: A Japanese National Registry Study.

Natural killer (NK) cells expressing killer cell immunoglobulin-like receptors (KIRs) can recognize specific HLA class I molecules as their ligands. By studying a large Japanese transplant registry, we compared transplant outcomes between patients heterozygous for HLA-CAsn80/CLys80 (HLA-C1/C2) and those homozygous for HLA-C1 (HLA-C1/C1) among patients who had undergone HLA-matched hematopoietic stem cell transplantation (HSCT). A high frequency of KIR2DL1 with strong HLA-C2 binding capacity and a low frequency of HLA-C2 and KIR haplotype B are characteristic of the Japanese population. In our previous report, HLA-C1/C1 patients with myeloid leukemia were less likely to relapse than HLA-C1/C2 patients. We newly assessed 2884 patients with acute lymphoblastic leukemia (ALL) who received HLA-matched allogeneic HSCT and analyzed their leukemia relapses by using adjusted competing-risk methods. HLA-C1/C1 patients with ALL experienced significantly higher relapse rates than HLA-C1/C2 patients (hazard ratio [HR]=1.55, P=.003), contrary to our results in patients with myeloid leukemia. We allocated patients with ALL to several subgroups and found a higher frequency of relapse (HR >1.8) in the HLA-C1/C1 group than in the HLA-C1/C2 group among patients with Ph-negative ALL, those who had no cytomegalovirus reactivation, those who received transplants from donors who were aged 41 years or older, and those who experienced acute graft-versus-host disease, especially if it required systemic treatment. One interpretation of our results is that KIR2DL1-positive NK cells disrupt T cells, antigen-presenting cells, or both from working efficiently in transplant immunity in HLA-C1/C1 patients with ALL. Another is that KIR2DS1-positive NK cells directly attack HLA-C2-positive ALL blasts in HLA-C1/C2 patients. Whether HLA-C2 can cause recurrence to decrease or increase in patients depending on the disease (ALL or myeloid leukemia) will be a very important finding. We hope that our results will provide clues to the real mechanisms behind relapse after transplantation in patients with different HLA profiles.

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.

Trends in the use of hematopoietic stem cell transplantation for adults with acute lymphoblastic leukemia in Europe: a report from the Acute Leukemia Working Party of the European Society for Blood and Marrow Transplantation (EBMT)

Hematopoietic stem cell transplantation (HSCT) is considered an effective way to prevent relapse in adults with acute lymphoblastic leukemia (ALL). This study aimed to assess general trends in the use of various types of HSCTs performed between 2001 and 2015 in Europe, based on data reported to the European Society for Blood and Marrow Transplantation registry. We also evaluated HSCT rates with respect to ALL incidence in selected countries. Altogether, 15,346 first allogeneic (n = 13,460) or autologous (n = 1886) HSCTs were performed in the study period. Comparing 2013–2015 and 2001–2003, the number of allogeneic HSCTs performed in first complete remission increased by 136%, most prominently for transplantations from unrelated (272%) and mismatched related donors (339%). The number of HSCTs from matched sibling donors increased by 42%, while the total number of autologous HSCTs decreased by 70%. Increased use of allogeneic HSCT was stronger for Philadelphia chromosome (Ph)-positive (166%) than for Ph-negative ALL (38%) and for patients aged > 55 years (599%) than for younger adults (59%). The proportion of allogeneic HSCT with reduced-intensity conditioning (RIC) increased from 6 to 27%. The age-standardized rates of allogeneic HSCT per ALL incidence varied strongly among countries. Our analysis showed a continued trend toward increased allogeneic HSCT use for adults with ALL, which may be attributed to increasing availability of unrelated donors, wider use of RIC regimens, and improving efficacy of pretransplant therapy, including tyrosine kinase inhibitors for Ph-positive ALL. Allogeneic HSCT remains a major tool in the fight against ALL in adults.

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.

ЛЕЧЕНИЕ ОСТРЫХ ЛИМФОБЛАСТНЫХ ЛЕЙКОЗОВ У БЕРЕМЕННЫХ ПО ПРОТОКОЛУ ОЛЛ-2009

Introduction . Acute leukemias are very rarely diagnosed during pregnancy, which makes large prospective or comparative studies of treatment of leukemias during pregnancy difficult. In 2009, the Russian Acute Lymphoblastic Leukemia Study Group decided to include women diagnosed with acute lymphoblastic leukemia (ALL) during various stages of pregnancy into the ALL-2009 prospective clinical study to determine the predictive role of pregnancy at diagnosis, and to estimate efficacy and tolerance of the ALL-2009 protocol in pregnant women. Materials and methods . During the period of 2009– 2017, 15 pregnant women with Ph-negative ALL aged 18–41 (median 28) years were enrolled in the multicenter clinical trial ALL-2009 (NCT number NCT01193933). Eleven women were treated at the National Research Center for Hematology in Moscow; the other four were treated in Russian regional hospitals. In cases when ALL was diagnosed during the first trimester of pregnancy (n = 3), the pregnancy was terminated. If ALL was diagnosed at week 34–40 (n = 3), the baby was delivered before the beginning of therapy. If ALL was diagnosed during the second or early third trimester, the treatment was performed during pregnancy. We compared toxicity and tolerance of chemotherapy according to the ALL-2009 protocol in pregnant patients and in young (30 years and younger) ALL patients. We also compared the results of treatment of pregnant patients with the control group (127 women of fertile age: 16–50 years old, with a median of 28 years old) enrolled in the study. For discussion of the results, we did a meta-analysis of available publications (retrieved via PubMed using the keywords “acute lymphoblastic leukemia” and “pregnancy”). Results . There was a significantly higher frequency of T-cell ALL than of B-cell ALL (53.3% vs 46,7% compared to 26% vs 69,3% in the control group, p = 0.025). Other than that, there were no significant differences in clinical or laboratory data between the groups. No significant differences were found in the duration of neutropenia, or in the duration and frequency of breaks in chemotherapy compared with other patients below 30 enrolled in the study. However, during the first remission induction phase, pregnant patients required blood transfusions, specifically platelets, at a higher rate (77.8% vs 46.6% of cases). Results of the treatment were similar regardless of pregnancy at the time of diagnosis (86.7% of complete remissions, vs 85.8% in the control group). Differences in the frequency of refractory leukemia (13.3% vs 4.7%) were not statistically significant. There were no cases of early mortality. Long-term results were also similar, both in terms of overall survival (58.6% vs 43.3% in the control group) and in terms of disease-free survival (46% vs 51%). Relapse probability was the same (49% vs 40.3%). Overall, the pregnant patients gave birth to 12 children (6 boys and 6 girls) at weeks 34–38 (median 35 weeks) of pregnancy. At the time of writing, all children are healthy and are developing in accordance with their age, which ranges from 2 years 1 month to 8 years 10 months (median 5 years and 2 months). Conclusion . The results of the study suggest that pregnancy at the time of diagnosis with ALL did not affect either the short-term or the long-term results of therapy according to the ALL-2009 protocol. The acceptable level of toxicity of the low-dose cytostatic therapy for both the mother and the child makes it possible to use the ALL-2009 protocol in treatment of pregnant patients.

Inotuzumab ozogamicin in combination with low-intensity chemotherapy (mini-HCVD) with or without blinatumomab versus standard intensive chemotherapy (HCVAD) as frontline therapy for older patients with Philadelphia chromosome-negative acute lymphoblastic leukemia: A propensity score analysis.

The outcome of older patients with newly diagnosed, Philadelphia chromosome (Ph)-negative acute lymphoblastic leukemia (ALL) is poor. The combination of targeted therapy with low-intensity chemotherapy is safe and effective. The objective of the current analysis was to compare the outcome of patients who received a combination of inotuzumab ozogamicin plus low-intensity chemotherapy (mini-hyperfractionated cyclophosphamide, vincristine, and dexamethasone [mini-HCVD]) with or without blinatumomab versus the outcome of those who received the standard, intensive, hyperfractionated cyclophosphamide, vincristine, doxorubicin, and dexamethasone (HCVAD) regimen. The authors analyzed 135 older patients with newly diagnosed, Ph-negative ALL who were treated prospectively with standard HCVAD (n=77) or with the combination of inotuzumab ozogamicin plus mini-HCVD with or without blinatumomab (n=58). A propensity score analysis was conducted using 1:1 matching using the nearest neighbor matching method. Propensity score matching identified 38 patients in each cohort. The antibody plus low-intensity chemotherapy combination induced higher response rates (98% vs 88%), with lower rates of early death (0% vs 8%) and lower rates of death in complete remission (5% vs 17%). With propensity score matching, the 3-year event-free survival rates for patients who received HCVAD and those who received the combination of inotuzumab ozogamicin plus mini-HCVD with or without blinatumomab were 34% and 64%, respectively (P=.003), and the 3-year overall survival rates were 34% and 63%, respectively (P=.004). By multivariate analysis, age (P=.019; hazard ratio, 1.045) and the combination of inotuzumab plus mini-HCVD with or without blinatumomab (P=.020; hazard ratio, 0.550) were identified as independent prognostic factors for survival. The combination of inotuzumab ozogamicin plus mini-HCVD with or without blinatumomab is safe and effective in older patients with newly diagnosed, Ph-negative ALL and confers a better outcome compared with standard HCVAD chemotherapy.

S100A16 suppresses the growth and survival of leukaemia cellsand correlates with relapse and relapse free survival in adults with Philadelphia chromosome-negative B-cell acute lymphoblastic leukaemia.

Refinement of risk stratification in Philadelphia chromosome (Ph)-negative B-cell acute lymphoblastic leukaemia (ALL) might aid the identification of patients who are likely to relapse. Abnormal S100 calcium binding protein A16 (S100A16) has been implicated in various cancers, but its function remains unclear. We found S100A16 transcript levels were higher in 130 adults with newly-diagnosed Ph-negative B-cell ALL compared with 33 healthy controls. In 115 of 130 patients who achieved first complete remission, those with high S100A16 transcript levels displayed a lower 3-year cumulative incidence of relapse (CIR; 34% [21, 47%] vs. 40% [48, 72%]; P=0·012) and higher 3-year relapse-free survival (RFS; 65% [53, 78%] vs. 35% [23, 46%]; P=0·012), especially when receiving chemotherapy only. In multivariate analysis a low S100A16 transcript level was independently-associated with a higher CIR (Hazard ratio [HR]=3·74 [1·01-13·82]; P=0·048) and inferior RFS (HR=5·78 [1·91, 17·84]; P<0·001). Function analysis indicated that knockdown of S100A16 promoted proliferation and anti-apoptosis and reduced chemosensitivity. S100A16 over-expression revealed an opposite trend, especially in a xeno-transplant mouse model. Western blotting analysis showed upregulation of PI3K/AKT and ERK1/2 in S100A16-knockdown and S100A16-overexpression B-cell ALL cell lines respectively. Inhibition assays suggested these two signalling pathways participated in the S100A16-mediated proliferation and survival effects in B-cell ALL cell lines. Trial Registration: Registered in the Chinese Clinical Trial Registry [ChiCTR-OCH-10000940]; http://www.chictr.org.cn.

Dose-Adjusted Intensive Chemotherapy Is Safe and Tolerable in Older Patients with Ph-Negative ACUTE Lymphoblastic Leukemia

Topic Significance & Study Purpose/Background/Rationale Outcomes of older adults with acute lymphoblastic leukemia (ALL) remain poor [PMID 19897583, 28419558, 22409379, 10653870]. PEG-Asparaginase (PEG-Asp) is a key component of the chemotherapeutic regimens for treatment of pediatric and younger adult ALL [PMID 29450465]. Older patients with Ph-negative ALL are often not offered PEG-Asp containing regimen due to concerns related to tolerability and safety [PMID 28355969]. Methods, Intervention, & Analysis The Adult Leukemia Program at Mount Sinai Hospital developed an age-based, dose-adjusted pediatric chemotherapy regimen for adults (≥40 years) with diagnosis of Ph-negative ALL. For patients up to 60 years, prednisone (PRD) dose was reduced to 40 mg/m2/day, and PEG-Asp to 1000 units/m2. For patients aged ≥61 years, PRD was further reduced to 25 mg/m2/day. A PEG-Asp oriented supportive care plan was developed to prevent and treat Asp-related adverse effects (AE) based on Antithrombin III (ATIII) and fibrinogen levels. Findings & Interpretation Fourteen patients with median age 60 years (45 – 76) were evaluable, and three patients were ≥ 70 years. Eleven patients had significant co-morbidities at diagnosis, including diabetes, hypertension, previous history of cancer, coronary artery disease, obesity, alcohol related chronic pancreatitis, and chronic diarrhea. Eleven patients (79%) attained a complete remission (CR) at the end of induction (EOI), four of them with detectable minimal residual disease (MRD). Five patients underwent allogeneic hematopoietic stem cell transplantation (HCT) while in CR (age range 46 – 60), four remain in CR at last follow up (median 563 days, range 259 – 883), and one died of relapsed disease 67 days post-HCT. The other eight patients who are receiving chemotherapy are in remission at last follow up (median 317 days, range 63 – 714). Observed PEG-Asp related AE were asymptomatic hypofibrinogenemia and low ATIII levels (n=10), severe hyperbilirubinemia (n=1), and non-life-threatening venous thrombosis (n=1). No patient experienced early death, severe allergic reaction or clinical pancreatitis. Discussion & Implications This dose-adjusted PEG-Asp containing regimen was associated with an encouraging CR rate and with tolerable and manageable AE in this patient population with significant co-morbidities. Treatment related mortality was 0%. Twelve of the 14 patients are currently in sustained remission (median follow-up 399 days, range 63-883). Further prospective evaluation is under way.

Higher Socioeconomic Status Is Associated with Improved Overall Survival in Adults with Philadelphia Chromosome Negative Acute Lymphoblastic Leukemia: A Population Study

▪Background:Socioeconomic status (SES) and other non-disease (social and demographic) characteristics are known to predict overall survival (OS) in children with acute lymphoblastic leukemia (ALL) (Petridou et al. Ann Oncol 2015). Less is known about the impact of these factors on survival of adults with ALL. We studied which non-biological risks impact OS in adults with Philadelphia chromosome negative (Ph negative) ALL, with emphasis on the impact of SES on survival.Methods:We assembled data from the National Cancer Institute's Surveillance, Epidemiology, and End Results (SEER-18) registry from 2000 to 2014. This registry covers 27.8% of the US population. We identified patients 18-69 years old diagnosed with Ph negative ALL between 2000-2012 using ICD-O-3 codes. We merged data with the Federal Information Processing Standards county codes and designated patients as metropolitan or non-metropolitan based on state and country 2013 rural-urban continuum codes. We assigned county-level median household income using the Census American Community Survey (www.census.gov).Descriptive statistics were calculated for age at diagnosis, sex, race/ethnicity, marital status, insurance status,median household income, and status with respect to the 200% of the federal poverty line (FPL). We stratified the population by age: 18-39 years (adolescent and young adult, or AYA, cohort) and 40-69 years (adult cohort). We also identified 3 eras of interest: 2000 to 2003, 2004 to 2007, and 2008 to 2012. Multivariable Cox proportional hazards (PH) regression assessed predictors of OS, with separate models for AYAs and adults. Analyses were performed using SAS.Results:In total, 5,858 patients met criteria for analysis. Median age was 41.4 years (25-75th%: 26.9-54.8), with 45.8%patients in the AYA cohort. 57.8% of patients were male, and half were non-Hispanic white (50.8%). Over 90% of all patients lived in metropolitan counties. One-third (35%) of patients lived below the 200% FPL. Median household income was $55,901 (25-75th%: $51,389-67,677). 49% of patients had missing data about insurance, so we omitted this variable from analysis. ALL lineage was B cell in 57%, T-cell in 10%, and unspecified in 33% of cases. 52% were married overall with more AYAs (61.3%) not married compared to older adults (34%).In Cox regression model for AYAs, higher median income was associated with better OS (HR=0.95 for every $10,000 above national household income, p=0.03). We also found that later era of diagnosis (2008-2012 vs. 2000-2003) was associated with better OS (HR=0.70, p<0.001), while older age (HR=1.04, p<0.0001), unspecified lineage (vs. B-cell, HR=1.20, p=0.04), and all races compared to non-Hispanic white were associated with poorer OS with the exception of Asian/Pacific Islander: American Indian (HR=2.82, p<0.001), Hispanic (HR=1.58, p<0.001), and non-Hispanic black (HR=1.50, p<0.001). Sex, marital status, and rural residence were not associated with OS in the AYA cohort.In the adult cohort, in a Cox regression model, patients with higher income had better OS (HR=0.95 for every $10,000 above median national household income, p=0.001). We also found that later era of diagnosis (2008-2012 and 2004-2007 vs. 2000-2003), and non-metropolitan geography (HR=0.81, p<0.001) predicted better OS, while older age (HR=1.03, p<0.0001), Hispanic race (HR=1.16, p=0.03), male sex (HR=1.09, p=0.03), and non-married status conferred poorer OS (HR=1.31, p<0.0001) (Table).Conclusion:We identify non-biological predictors of OS in adults with ALL in a large population-based registry. Notably, higher SES portends better OS in both AYAs and older adults with ALL, consistent with findings in the pediatric literature. Marital status affects OS only in older patients, while race/ethnicity in AYAs greatly impacts OS. All ages had improved OS in more recent years, suggesting that all age cohorts are benefitting from new ALL treatment approaches. Our findings of the impact of SES on OS call for more investigation and action to improve social support and possibly adherence in the adult population. DisclosuresKumar:Seattle Genetics: Research Funding. Rodday:Seattle Genetics: Research Funding. Stock:Jazz Pharmaceuticals: Consultancy. Parsons:Seattle Genetics: 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.

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.

Dose-Adjusted Intensive Chemotherapy Is Safe and Tolerable in Older Patients with Ph-Negative Acute Lymphoblastic Leukemia

BackgroundThe outcomes of older adults with acute lymphoblastic leukemia (ALL) remain poor when compared to younger ALL patients [PMID 19897583, 28419558, 22409379, 10653870]. Asparaginase (Asp) induces death of human lymphoblasts, and effective asparagine depletion is associated with improved outcomes in ALL. PEG-Asparaginase (PEG-Asp), which has a longer half-life than Asp, is a key component of the intensive chemotherapeutic regimens utilized for treatment of pediatric and younger adult ALL [PMID 29450465]. Frequently, older patients with Ph-negative ALL are not offered PEG-Asp containing pediatric chemotherapy regimen because of concerns related to tolerability and safety in this population [PMID 28355969].MethodsThe Adult Leukemia Program at Mount Sinai Hospital developed an age-based, dose-adjusted, CALGB 10403 based intensive chemotherapy regimen for adults (≥40 years) with a diagnosis of Ph-negative ALL. For patients up to 60 years, prednisone (PRD) dose was reduced from 60 to 40 mg/m2/day from D1 to D28, and PEG-Asp reduced from 2500 to 1000 units/m2 (D4). For patients aged 61 years and above, PRD was further reduced to 25 mg/m2/day, and PEG-Asp to 1000 units/m2 on D4. In CD20+ ALL, rituximab x 8 doses were added to the regimen. CNS-prophylaxis consisted of intrathecal methotrexate at D1, D8 and D29 during induction, and during subsequent courses of chemotherapy based on the CALGB 10403 protocol. A PEG-Asp oriented supportive care plan was developed to prevent and treat Asp-related adverse effects. After the administration of PEG-Asp, Antithrombin III (ATIII) and fibrinogen levels were monitored on the same day, twice a week, for at least two weeks. If ATIII levels were < 70% and/or fibrinogen levels < 120 mg/dL, levels were corrected with the administration of ATIII concentrate and/or cryoprecipitate, respectively.ResultsTwelve patients with a median age of 58 years (45 - 76) were evaluable, and three patients were ≥ 70 years. Nine patients had B-cell ALL and three T-cell ALL. Three patients had a white blood cell count > 30 x103/µL at diagnosis. An ECOG status ≤ 2 at diagnosis was described in all patients, and all of them had multiple complex cytogenetic and molecular abnormalities. Ten patients had significant co-morbidities at diagnosis, including diabetes, hypertension, previous history of cancer, coronary artery disease, obesity, alcohol related chronic pancreatitis, and chronic diarrhea. Nine out of the twelve patients (75%) attained a bone marrow morphological complete remission (CR) at the end of induction (EOI), three of them with detectable minimal residual disease (MRD) that became undetectable after completing course II. Of the three patients who had ≥5% bone marrow blasts at EOI, one attained a CR with undetectable MRD at the end of course IA and another when switched to blinatumomab, and the third one died of progressive disease. No patient experienced early death. Five patients underwent allogeneic hematopoietic stem cell transplantation (HCT) while in CR (age range 46 to 60 years) and four remain in CR at last follow up (median 489 days, range 181 - 841), and one died of relapsed disease 67 days post-HCT. The other six patients who are receiving chemotherapy are alive and in remission at last follow up (median 272 days, range 52 - 639).The common adverse effects associated with PEG-Asp administration in this older group of patients were asymptomatic hypofibrinogenemia and depleted ATIII levels requiring supplementation (n=8), severe hyperbilirubinemia (n=1), and non-life-threatening venous thrombosis (n=1). Severe allergic reaction, clinical pancreatitis and cognitive impairment were not observed.ConclusionThis age-based dose-adjusted PEG-Asp containing regimen was associated with an encouraging CR rate and a tolerable and manageable adverse event profile in this older patient population with significant co-morbidities. Treatment related mortality was 0%. Ten of 12 patients are currently in sustained remission, either with chemotherapy alone or following allogeneic HCT (median follow up 422 days, range 52 to 841 days). Treatment optimization for older patients with ALL utilizing an intensified, age-adjusted PEG-Asp containing induction and consolidation therapy regimen is associated with favorable outcomes and provides an effective bridge to potentially curative therapies such as HCT. Further prospective evaluation is under way. DisclosuresKremyanskaya:Incyte: Research Funding. Mascarenhas:Incyte: Membership on an entity's Board of Directors or advisory committees, Research Funding; Novartis: Research Funding; Promedior: Research Funding; Janssen: Research Funding; Celgene: Membership on an entity's Board of Directors or advisory committees; Merck: Research Funding; CTI Biopharma: Membership on an entity's Board of Directors or advisory committees, Research Funding; Roche: Research Funding.

Results of SWOG 1318: A Phase 2 Trial of Blinatumomab Followed By Pomp (Prednisone, Vincristine, Methotrexate, 6-Mercaptopurine) Maintenance in Elderly Patients with Newly Diagnosed Philadelphia Chromosome Negative B-Cell Acute Lymphoblastic Leukemia

Results of SWOG 1318: A Phase 2 Trial of Blinatumomab Followed By Pomp (Prednisone, Vincristine, Methotrexate, 6-Mercaptopurine) Maintenance in Elderly Patients with Newly Diagnosed Philadelphia Chromosome Negative B-Cell Acute Lymphoblastic Leukemia

Chemoimmunotherapy with Inotuzumab Ozogamicin Combined with Mini-Hyper-CVD, with or without Blinatumomab, for Newly Diagnosed Older Patients with Philadelphia Chromosome-Negative Acute Lymphoblastic Leukemia: Results from a Phase II Study

Chemoimmunotherapy with Inotuzumab Ozogamicin Combined with Mini-Hyper-CVD, with or without Blinatumomab, for Newly Diagnosed Older Patients with Philadelphia Chromosome-Negative Acute Lymphoblastic Leukemia: Results from a Phase II Study

Analysis of Factors Influencing Prognosis of 87 Adults with Ph Chromosome Negative ALL

To explore the factors influencing total complete remission (CR), recurrence, disease-free survival (DFS) rate and overall survival (OS) rate in adults with Philadelphia (Ph) chromosome negative acute lymphoblastic leukemia (ALL) and the effect of subsequent allogeneic hematopoietic stem cell transplantation (allo-HSCT) on prognosis. The clinical data of 87 adult patients with Ph negative ALL were retrospectively analyzed, the CHOP regimen plus L-asparaginase (L-Asp) was used for the induction therapy, and the CHOP+ modified Hyper-CVAD or methotrexate was set up as the consolidation chemotherapy regimen. After consolidation chemotherapy for 3-6 courses, 45 patients (51.72%) received allo-HSCT , and 42 patients (48.28%) continually received the maintained consolidation chemotherapy. The average follow up time of the surviving patients was 40.13 (3-60 months). Out of 87 patients with Ph-ALL one patient died (1.15%). In 86 patients who could be evaluated, 68 cases (79.67%) reached CR at the end of 1 course, 80 cases obtained CR (93.02%). Multivariate regression analysis showed that the enlargement of lever, spleen and lymphomode, WBC count≥ 100×109/L were affecting factors for total CR (P<0.05). Among 80 cases with CR, 27 cases (33.75%) relapsed, 5 years' overall survival (OS) rate and disease-free survival (DFS) rate were 47.50% and 45.00% respectively. Multivariate regression analysis yet showed that the induction chemotherapy without L-Asp, presence of CNS leukemia at diagnosis, absence of allo-HSCT and no CR after indution chemotherapy for 4 weeks were affecting factors for relapse and poor prognosis of patients (P<0.05). According to 4 prognostic factors such as presence of CNS leukemia or no, WBC count≥100×109/L or no, induction chemotherapy with L-Asp or no and CR after induction chemotherapy for 4 weeks or no, 86 patients were divided into low-risk group (without poor prognostic factor), middle-risk group (with 1 poor prognostic factor), high-risk group (with 2-4 poor prognostic factors). Statistical results showed that allo-HSCT treatment in low-risk group had no significant effect on OS and DFS (P>0.05). The rate of OS and DFS in middle and high-risk group were significantly higher than those of patients without allo-HSCT treatment (P<0.05). Patients with central nervous system leukemia, high white blood cell count (≥100×109/L), induction chemotherapy without L-Asp, no CR after 4 weeks of chemotherapy and absence of allo-HSCT treatment are the factors influencing the prognosis of adult patients with Ph negative ALL, so the patients with those poor prognostic factors should take active treatment of allo-HSCT.

Improved 4-week complete remission rate by additional use of daunorubicin in the medium term of induction chemotherapy in adult Ph-negative acute lymphoblastic leukemia with high proportion of blasts

Improved 4-week complete remission rate by additional use of daunorubicin in the medium term of induction chemotherapy in adult Ph-negative acute lymphoblastic leukemia with high proportion of blasts

Structure and significance of cytogenetic abnormalities in adult patients with Ph-negative acute lymphoblastic leukemia.

To evaluate occurrence, variety, structural peculiarities and prognostic meaning of cytogenetic abnormalities in adult patients with Ph-negative acute lymphoblastic leukemia (ALL) receiving therapy according to ALL-2009 protocol. The study included 115 adult patients with firstly diagnosed Ph-negative ALL: 58 male and 57 female aged from 15 to 61 years (mean age 26.5 years), who underwent treatment from September 2009 to September 2015 in National Medical Research Center for Hematology MH RF (n=101) and in hematology departments of regional hospitals (n=14). All patients received therapy of ALL-2009 protocol (ClinicalTrials.gov, NCT01193933). The median follow-up was 24.5 months (0.2-94.4 months). As a part of the study results of a standard cytogenetic assay (SCA) were analyzed and fluorescence hybridization in situ (FISH) with the use of DNA-probes was performed on archived biological material for structural changes in gene locuses MLL/t(11q23), с-MYC/t(8q24), TP53/ deletion 17p13, CDKN2A/ deletion 9p21, translocation t(1;19)/E2A-PBX1 и t(12;21)/ETV6-RUNX1; iAMP21 identification. Karyotype was defined using SCA in 86% of patients. Normal karyotype was found in 48.5% of them, chromosome aberrations in 51.5% (structural changes were found in 19.2%, hyperploidy in 27.2%, and hypoploidy in 5.1%). In 17.2% of patients complex karyotype abnormalities were found. With the use of FISH technique aberrations were found in 67% of patients: 9p21/CDKN2A deletion in 24.3%, MLL/t(11q23) gene abnormalities in 7.8%, 17p13/TP53 deletion in 5.2%, abnormalities of c-MYC/t(8q24) in 1.7%, t(1;19)/E2A-PBX1 in 0.8%, and iAMP21 in 0.8%, other abnormalities (additional signals/absence of signals from gene locuses) in 26.4%, t(12;21)/ETV6-RUNX1 was not found. FISH technique use in addition to SCA allows to increase aberrant karyotype location from 51.5 to 67%. A statistically significant correlation of 9p21/CDKN2A deletion with high serum lactate dehydrogenase activity (p=0.02); MLL/t(11q23) gene abnormalities - with leucocytosis and high blast cells level in blood (p=0.0016), hyperploidy - with normal leukocyte count (p=0.02) was shown. In groups with different cytogenetic abnormalities no statistically significant differences of treatment with ALL-2009 protocol were found (in terms of complete remission, early mortality and treatment resistance). When connection of cytogenetic abnormalities and their combinations with long-term results were analyzed according to ALL-2009 protocol, only two characteristics - MLL/t(11q23) and c MYC/t(8q24) gene abnormalities had a statistically significant influence on disease-free survival (HR - 176.9; p&lt;0.0001) and chance of recurrence (HR - 6.4; p=0.02). Adverse prognostic factors in terms of therapeutic management provided in ALL-2009 protocol were MLL/t(11q23) and с-MYC/t(8q24) genes abnormalities. CDKN2A/9p21 and TP53/17p13 genes deletions, quantative and complex karyotype abnormalities were not prognostic factors in adult patients with Ph-negative ALL in ALL-2009 protocol use.