Good Prednisone Response Research Articles

MiRNAs as predictive biomarkers of response to treatment in pediatric patients with acute lymphoblastic leukemia.

MicroRNAs (miRNAs/miRs) are promising prognostic biomarkers in pediatric acute lymphoblastic leukemia (ALL). The present study aimed to identify miRNAs that could serve as prognostic biomarkers or as novel therapeutic targets in ALL. The expression levels of 84 miRNAs were assessed in the bone marrow aspirates of 10 pediatric patients with newly diagnosed ALL at diagnosis and on day 33 of induction of the ALL Intercontinental Berlin-Frankfurt-Münster 2009 protocol, and associations with established prognostic factors were evaluated. The levels at diagnosis of 25 miRNAs were associated with ≥2 prognostic factors. Higher expression levels of let-7c-5p, miR-106b-5p, miR-26a-5p, miR-155-5p, miR-191-5p, miR-30b-5p and miR-31-5p were significantly associated with a good prednisone response. The expression levels of miR-125b-5p, miR-150-5p and miR-99a-5p were significantly higher in standard- or intermediate-risk patients compared with those in high-risk patients (P=0.017, P=0.033 and P=0.017, respectively), as well as in those with a complete response at the end of induction (P=0.044 for all three miRNAs). The change in expression levels between diagnosis and the end of induction differed significantly between risk groups for three miRNAs: miR-206, miR-210 and miR-99a (P=0.033, P=0.047 and P=0.008, respectively), with the post induction levels of miR-206 increased in high-risk patients, whilst miR-210 and miR-99a levels were increased in intermediate/standard risk patients. Therefore, miRNAs that could be integrated into the risk stratification of pediatric ALL after further evaluation in larger patient cohorts were identified.

Outcome of ALL With ALL-BFM-95 Protocol in Nepal.

Data on survival outcomes in patients with acute lymphoblastic leukemia (ALL) originating from Nepal are limited. We aim to present the real-world data on treatment outcomes of patients with de novo ALL treated with pediatric ALL-Berlin-Frankfurt-Muenster (BFM)-95 protocol in Nepal. We used the medical records of 103 consecutive patients with ALL treated in our center from 2013 to 2016 to evaluate the overall survival (OS) and relapse-free survival (RFS) and analyzed the effects of clinicopathologic factors on survival outcomes in patients with ALL. The 3-year OS and RFS in the entire cohort was 89.4% (95% CI, 82.1 to 96.7) and 87.3% (95% CI, 79.8 to 94.7), with a mean OS and RFS of 79.4 months (95% CI, 74.2 to 84.5) and 76.6 months (95% CI, 70.8 to 82.4), respectively. Patients with prednisone good response (PGR) showed better mean OS and RFS, whereas complete marrow response on day 33 was associated with better mean OS alone. Patients with Philadelphia (Ph)-positive ALL showed worse mean RFS compared to those with Ph-negative status. On multivariate analysis, PGR (hazard ratio [HR], 0.11; 95% CI, 0.03 to 0.49; P = .004) and sagittal vein thrombosis (SVT; HR, 5.95; 95% CI, 1.30 to 27.18; P = .02) were the only independent predictors of OS and RFS, respectively. Adverse events on BFM-95 protocol included SVT (4.9%), peripheral neuropathy (7.8%), myopathy (20.4%), hyperglycemia (24.3%), intestinal obstruction (7.8%), avascular necrosis of femur (6.8%), and mucositis (46%). BFM-95 protocol appears to be a safe and effective strategy in adolescent and young adults and adult Nepalese population with ALL with a low toxicity profile.

Impact of T-cell Receptor Status on Mutational Landscape and Outcome in T-ALL.

Impact of T-cell Receptor Status on Mutational Landscape and Outcome in T-ALL.

Polo-like kinase 1 Decrease During Induction Therapy Could Indicate Good Treatment Response, Favorable Risk Stratification, and Prolonged Survival in Pediatric Acute Lymphoblastic Leukemia.

Polo-like kinase 1 (PLK1) modulates leukemia cell apoptosis, proliferation, and cell cycle arrest in the progression of acute lymphoblastic leukemia (ALL). This study intended to investigate the dysregulation of PLK1 and its association with induction therapy response and prognosis in pediatric ALL patients. Bone marrow mononuclear cell samples were collected from 90 pediatric ALL patients at baseline and on the 15th day of induction therapy (D15), as well as from 20 controls after enrollment, for the detection of PLK1 by reverse transcription-quantitative polymerase chain reaction. PLK1 was increased in pediatric ALL patients compared with controls ( P <0.001). In pediatric ALL patients, PLK1 decreased from baseline to D15 ( P <0.001). Lower PLK1 at baseline was associated with a good prednisone response ( P =0.002), while decreased PLK1 at D15 was related to good prednisone response ( P =0.001), better bone marrow response ( P =0.025), and favorable risk stratification ( P =0.014). In addition, reduced PLK1 at baseline was linked with better event-free survival (EFS) ( P =0.046), and decreased PLK1 at D15 was related to prolonged EFS ( P =0.027) and overall survival (OS) ( P =0.047). Moreover, PLK1 decline ≥25% was linked to favorable EFS ( P =0.015) and OS ( P =0.008). Further multivariate Cox proportional regression analysis revealed that PLK1 decline ≥25% was independently linked with prolonged EFS (hazard ratio (HR)=0.324, P =0.024) and OS (HR=0.211, P =0.019). The reduction of PLK1 after induction therapy reflects a good treatment response and correlates with a favorable survival profile in pediatric ALL patients.

Treatment Outcome of Dasatinib in Combination with Less-Intensive Induction, Homobarringtonie, Cytarabine, G-SCF in Newly Diagnosed Patients with Ph+ALL

Unprecedented achievement has been made in the treatment of childhood ALL within the past decades. However, how to improve the outcome of Ph+ALL remains a conundrum for the care providers towards the cure of the disease. Using Auto-hematopoietic stem cell transplant (HSCT), after a negative BCR-ABL, or allo-HSCT has become the curative options for Ph+ALL cases although either relapse or life threatening transplant related complications could lead to treatment failure.To determine the safety and efficiency of a dasatinib based mild induction with homobarringtonie, cytarabine, G-SCF (HAG) contained regimen, we enrolled 67 patients with de novo Ph+ALL from 2012-2017 for the trial. The medium follow-up time was 39 months (17 months to 65 months). In brief, the induction consisted of vincristine and prednisone, in addition to daily dasatinib (70mg; bid), followed by six cycles of HAG regimen (homobarringtonie 1mg/m2/days 1-14; G-CSF 5ug/kg on day one; Ara-C 10mg/q12h/days 1-14; every three month/cycle) plus daily dasatinib (70mg; bid). The maintenance included two cycles of HAG (every six months) in addition to daily dasatinib. The intrathecal injection was given 11 times along with the treatment to prevent CNS leukemia. A serial MRD detection of BCR-ABL by qPCR was performed every three months.There were four patients eligible for the study. Among the 63 evaluated patients, 55 (88%) achieved CR in induction. There was no treatment related mortality during the induction. Good prednisone response was indicated among 51 patients (81%) on day eight. The day 30 MRD detection for those in CR indicated 43 (68%) reached ≤5 *10-2 and four (7%) achieved 10-3. The MRD detection at month three and six suggested that 38 (60%) vs 33 (52%) patients were within the level of ≤5 *10-2 and six (10%) vs 10 (16%) achieved 10-3, respectively. Relapse-related death occurred in 11 of 63 patients (16%), and four patients (6%) experienced treatment-related mortality. Grade 3-4 adverse events were observed among 10 cases (30%). The main toxicities were liver dysfunction and coagulation abnormality which can be solved by close monitoring and multi-disciplinary care. Four-year probability of event-free survival (pEFS) was found to be 58%. Those who went with hematopoietic stem cell transplantation (HSCT) after chemotherapy achieved significantly better pEFS than only chemotherapy (65.7% vs 50.5%,p=0.03). Our protocol can be used as an effective and less toxic treatment option to improve the outcome of Ph+ALL with promising survival and acceptable adverse effects shedding new light on treating Ph+ALL. DisclosuresNo relevant conflicts of interest to declare.

Long non-coding RNA MEG3 as a candidate prognostic factor for induction therapy response and survival profile in childhood acute lymphoblastic leukemia patients

Childhood acute lymphoblastic leukemia (cALL) is a common hematological malignancy in children with unfavorable prognosis. Identifying novel prognostic factors is critical to optimize personalized treatment and improve their long-term outcomes. Thus, this study aimed to explore the correlation of longitudinal change of long non-coding RNA maternally expressed gene 3 (lnc-MEG3) with induction therapy response and survival profile in cALL patients. Totally 117 cALL patients and 50 pediatric patients (as controls) were recruited. Their lnc-MEG3 expressions from bone marrow mononuclear cells were detected by reverse transcription-quantitative polymerase chain reaction (before induction treatment and at day 15 after induction treatment). For their survival profile, the event-free survival (EFS) and overall survival (OS) were analyzed using follow-up data. Lnc-MEG3 expression was decreased in cALL patients (vs. controls) (p < .001). Meanwhile, higher baseline lnc-MEG3 expression was correlated with good prednisone response at day 8 (p = .001) and good bone marrow response at day 15 (p = .046) in cALL patients. However, no correlation of baseline lnc-MEG3 expression with immunophenotype (p = .088), or risk stratification (p = .155) in cALL patients was found. Notably, lnc-MEG3 expression was elevated during induction therapy (p < .001). Furthermore, lnc-MEG3 expression at day 15 was associated with good bone marrow response (p = .001) and its increment was also correlated with good bone marrow response (p = .022). More importantly, high lnc-MEG3 expression at baseline and day 15 were associated with prolonged EFS (both p < .05) and OS (both p < .05) in cALL patients. Lnc-MEG3 may serve as a prognostic factor for induction therapy response and survival profile in cALL patients.

Philadelphia Chromosome-Positive (Ph+) Childhood Acute Lymphoblastic Leukemia: Good Initial Steroid Response Allows Early Prediction of a Favorable Treatment Outcome

Among 4,760 acute lymphoblastic leukemia (ALL) patients enrolled from 1986 to 1995 in two subsequent trials of the BFM and AIEOP study group, 61 patients were found to have Philadelphia chromosome-positive (Ph+) ALL. These patients were analyzed for presenting features and treatment outcome to identify specific prognostic factors. Treatment stratification was based on initial cell mass and early response as determined by blast count in peripheral blood after a 7-day induction prephase with prednisone and one dose of intrathecal methotrexate on day 1. All patients were treated by similar intensive Berlin-Frankfurt-Münster (BFM) protocols. The median age of Ph+ patients was 7.5 years, the median white blood cell count (WBC) was 75 × 109/L, 77% of patients had common ALL, and 29% coexpressed myeloid markers. After a median observation time of 4.2 years, 29 of 61 patients are alive (survival probability [pSUR] at 4 years, 0.49; standard error [SE], 0.06), and 24 of 61 are in first complete remission (CR1; probability of event-free survival [pEFS] at 4 years, 0.38; SE, 0.06). Twenty (35%) of 57 evaluable patients had ≥1,000 leukemic blasts per microliter of blood on day 8 of induction (defined as prednisone-poor-response [PPR]). These patients were older (10.0v 6.88 years; P = .02) and had a higher WBC (144v 29 × 109/L; P = .0016) as compared with patients with prednisone good response (PGR; <1,000 blasts/μL at day 8). Only 2 of 20 patients (10%) with PPR remained in CR1 and alive: 6 patients with PPR did not survive after allogeneic bone marrow transplantation (BMT) due to recurring disease (n = 3) and toxicity (n = 3), and 12 nontransplanted patients died due to progression (n = 5) or relapse (n = 7). In contrast, 26 (70%) of the 37 patients with PGR are alive. Of 18 patients transplanted by allo-BMT, 1 relapsed (now in CR2) and 4 died after BMT. Among the 19 patients with PGR treated by chemotherapy alone, 8 remained in CR1 and 11 relapsed, of which 4 are in CR2 or CR3. The prednisone response emerged as the only independent prognostic factor for survival in Cox regression analysis. Thus, two thirds of Ph+ childhood ALL cases can be identified early by PGR, which, when treated with intensive BFM chemotherapy, with or without BMT, have a significantly lower risk of treatment failure. With a median continuous complete remission (CCR) time of 4.1 years, pEFS for PGR is 0.55 (SE, 0.08) compared with 0.10 (SE, 0.07) in patients with PPR (P = .0001). PGR is also an indicator for treatment responsiveness and durable second remission after relapse, which in turn may provide a second chance for BMT.© 1998 by The American Society of Hematology.

Bmi-1 as A Molecular Marker for Prognosis of Pediatric ALL

To study whether the Bmi-1 gene can be a biomarker for analysis of clinical risk stratification and prognosis of ALL patients. The expression level of Bmi-1 gene in bone marrow samples from 127 cases of newly diagnosed ALL was detected by qRT-PCR, at the same time the expression level of Bmi-1 protein in bone marrow samples from above-mentioned cases was detected by Western blot. The collected samples were divided into 3 groups: high, intermediate and low risk according to clinical risk stratfication, the relationship between Bmi-1 expression and risk grade of ALL patients was analyzed; at the same time the collected samples were divided into 2 groups: prednisone good response (PGR) and prednisone poor respouse (PPR) according to the sensitivity of prednison test, and the sensitivily to prednisone in 2 groups was compared; moreover, the collected samples were divided into 2 groups: high level and low level according to median of Bmi-1 level, and the relation of Bmi-1 level with prognosis of patients was analyzed by using the Kaplan-Meier method. The expression level of Bmi-1 in low risk group was lowest, while that in high risk group was highest, however that in intermediat risk group was between the low and high risk groups, statistical analysis showed significant difference (P＜0.05). The expression level of Bmi-1 in PPR group was significantly higher than that in PGR group (P＜0.001). The Kaplan-Meier analysis showed that the RFS rate in Bmi-1 high expression group was significantly lower than that in Bmi-1 low expression group (73.0% vs 90.6%) (P＜0.001). The Bmi-1 can be used as a molecular marker for the analysis of chinical risk and prognosis of pediatric ALL.

PB1686 USE OF FLOW CYTOMETRY AND IMMUNOHISTOCHEMISTRY TO RULE OUT CNS RELAPSE OF ACUTE LYMPHOBLASTIC LEUKEMIA

Background: Increased cerebrospinal fluid (CSF) cellularity in an otherwise asymptomatic patient with acute lymphoblastic leukemia (ALL) may indicate CNS disease. Aims: To describe how flow cytometry and immunohistochemistry helped in ruling out suspicion of CNS relapse because of unexpected CSF findings in a child with acute lymphoblastic leukemia in CR during maintenance phase of chemotherapy. Methods: Examination of cytospin CSF samples with flow cytometry, fluorescent in vitro hybridization (FISH) for centromeres of chromosomes 7 and 8 on 200 cells and immunohistochemistry for CD10 and terminal deoxynucleotidyl transferase (TdT). Results: A 15-year old girl was diagnosed in 2005 with B common ALL with hyperdiploidy including trisomy 8, and no CNS involvement. She was treated according to a modified New York II protocol with good prednisone response and negative flow cytomerty minimal residual disease (MRD) on day 33, and prophylactic cranial radiation of 1200 cGy. She went on with maintenance treatment consisting of 6-mercaptopurine 300 mg/m2/d d0-3, cyclophosphamide 1200 mg/m2 d4, vincristine 1.5 mg/m2 d11, 18, 25, prednisonse 180 mg/m2/d d18-25, methotrexate 200 mg/m2 over 4 h d25, daunorubicin 20 mg/m2 d40, 41, cytosine arabinoside 100 mg/m2, thioguanine 40 mg/m2/dose 6 doses d42-44, methotrexate IT d60/0. Days 0 and 60 CSF findings were normal. However, on day 0 of the subsequent cycle, increased ceullarity was found incidentally. CSF cell number was 45/μL and increased up to 130/μL despite additional methotrexate IT injections. Examination of cytospin preparations showed 75% lymphocytes and 25% monocytes/macrophages. Morphological discrimination between lymphoblasts and mature lymphocytes was difficult. Protein level in CSF was mildly increased up to 71 mg/dL and glucose level in CSF was normal. The patient was free of symptoms and the neuroimaging was normal. Immunohistochemistry on cytospin preparation showed no TdT expression on lymphocytes. Flow cytometry of CSF using the initial immunophenotype showed normal lymphocytes and monocytes and no leukemic blasts. FISH on a cytospin preparation to detect trisomy 8, which was present at diagnosis, and using as an internal negative control chromosome 7 ploidy, was normal with two signals for chromosomes 8 and 7, respectively. Those results in addition to increasing cellularity despite intrathecal chemotherapy and progressive enrichment of CSF in monocytes and uneventful clinical course and undetactable MRD in bone marrow, led to the conclusion that high CSF high cellularity was of reactive nature. CSF cellularity returned to normal within 2 weeks. The patient completed maintenance treatment and remains in persistent complete first remission for 10 years. Summary/Conclusion: Incidental high CSF cellularity arousing suspicion of CNS relapse may be misleading. Sensitive methods of immunophenotyping and genotyping at the cellular level provide confidence in diagnosing reactive CSF pleocytosis secondary to previous intrathecal chemotherapy and avoid unnecessary treatment plan modifications.

NK Cells as Possible Prognostic Factor in Childhood Acute Lymphoblastic Leukemia

Deficiency or impaired function natural killer (NK) cells might result in the development of serious infections and promote the development of malignancies. The aim of our study was to assess the prognostic role of NK cell percentage in bone marrow on the day of acute lymphoblastic leukemia (ALL) diagnosis. 84 children (49 males = 58%; median age 5 yrs) with ALL were enrolled. The NK cell percentage was assessed using flow cytometry with antibodies against the cluster of differentiation (CD): CD3, CD56, and CD16. We evaluated two groups: group I (NK+), patients with NK cells in the bone marrow (n = 74), and group II (NK-), patients without NK cells in the bone marrow (n = 10) (cut-off value of negative <1%). In the patients from group I, the prednisone good response on day 8 and the remission on day 15 of treatment were observed significantly more often (p = .01, p = .03). The children from group I had significantly better survival as compared to those from group II (p = .02) (HR 2.59; 95% CI: 1.38-4.85). The presence of NK cells in the bone marrow at diagnosis can be a prognostic factor in children with ALL. The presented results should be the basis for further research.

Prognostic value of the response to prednisone for children with acute lymphoblastic leukemia: a meta-analysis.

To systematically review prednisone induced test results in the prognosis assessment of acute lymphoblastic leukemia in children. Based on the established inclusion and exclusion criteria, studies of prednisone induced test in evaluating the prognosis of childhood acute lymphoblastic leukemia were electronically searched from January 1990 to November 2016 using Pubmed, Embase, The Cochrane Library, Web of Science, WanFang, VIP, and CNKI database. Two independent researchers browsed literature, extracted data and assessed the risk of bias of studies. Meta-analysis was performed using RevMen 5.3 software. A total of 17 articles were included. Meta-analysis showed that after complete prednisone induced test in children, 5y-EFS, 8y-EFS adverse reactions, persistent remission and relapse were statistically significant differences between the prednisone good response (PGR) and prednisone poor response (PPR). There were statistical significance in T cell immune typing and the initial WBC of the two groups. Prognosis of prednisone good response group is better than prednisone poor response group. The prednisone induction test is an important factor in predicting the prognosis of children with ALL.

Prognostic Value of Prednisone Response in CCLG-ALL 2008

To ovaluate the prognostic value of prednisone response in treatment regimes of children with acute lymphoblastic leukemia. A total of 598 newly diagnosed ALL patients were enrolled and received prednisone pre-treatment. Based on the peripheral lymphoblast count on day 8, these patients were divided into 2 groups: prednisone good response (PGR) and prednisone poor response (PPR). PPR patients were classified into high risk group immediately and then received intensed chemotherapy. The all enrolled patients were followed up and the clinical features and treatment outcomes of the two groups were analyzed. Compared with PGR group, PPR group had different characteristics. They were older in age and had higher initial white blood cell count (P<0.05). T-cell ALL (T-ALL) and Philadelphia chromosome positive ALL (Ph+ ALL) were frequent in PPR group (P<0.05). Event-free survival (EFS) rate of PPR group was significantly lower than that of PGR group (P<0.05). 2 year event-free survival(EFS) rate of PGR group was (88.3±1.5)%, while the 2-year EFS rate of PPR group was (58.4±5.3)%. 5 year EFS rates of PGR and PPR were (80.8±2.1)% and (53.4±6.0)%, respectively. The EFS rate of PPR group was falling rapidly within 2 years. PPR group had higher relapse rate, and most relapses occurred within 18 months (P<0.05). PPR group had more high incidence of minimal residual disease (MRD) both on day 33 and on week 12 (P<0.05). No significant difference of EFS and relapse time was found between PPR and high risk PGR patients (P>0.05). In multi-variate regression analysis, the PPR, the presence of BCR-ABL1 and MLL were significantly unfavorable factors (P<0.05). Prednisone response has been confirmed to be still great prognostic value and PPR children patients have poor outcomes generally. It is likely that the response to prednisone does not make much sense to high risk ALL patients.

NOTCH1 and FBXW7 mutations favor better outcome in pediatric South Indian T-cell acute lymphoblastic leukemia.

The NOTCH1 signaling pathway is essential for hematopoiesis and a critical regulatory step for T-cell proliferation and maturation. The E3 ubiquitin ligase FBXW7 controls NOTCH1 protein stability. Mutations in NOTCH1/FBXW7 activate NOTCH signaling and are of prognostic significance in patients with T-cell acute lymphoblastic leukemia (T-ALL). In this study we analyzed NOTCH1 and FBXW7 mutations in 50 South Indian T-ALL patients treated by a modified ALL BFM 95 regimen. The hot spot exons (HD-N, HD-C, TAD, and PEST) of NOTCH1 and exons 9 of the 10 of FBXW7 were polymerase chain reaction amplified and sequenced. In total, 20 of the 50 (40%) T-ALL patients revealed heterozygous mutations in the NOTCH1 domains, and a predominance of missense mutations in HD-N (70%) and PEST (15%) domains. FBXW7 mutations were detected in 5 of the 50 (10%) T-ALL patients. T-ALL patients with NOTCH1/FBXW7 mutations expressed higher protein level of NOTCH1 compared with patients without NOTCH1/FBXW7 mutations. Six of the mutations detected in NOTCH1 were not reported previously. When tested in a Dual Luciferase Renilla reporter assay some of these conferred increased NOTCH activity, suggesting that these are activating mutations. Importantly, 13 of the 20 (65%) NOTCH1/FBXW7-mutated T-ALL patients showed a good prednisone response (P=0.01) and a better clinical outcome compared with NOTCH1/FBXW7 nonmutated patients (P=0.03). These data suggest that NOTCH1/FBXW7 mutations are present in T-ALL patients from Southern India and may be useful biomarkers to predict prognosis in T-ALL.

Evaluation of early response to treatment and its prognostic value in childhood acute lymphoblastic leukemia

This study was purposed to investigate the prognostic value of early response to treatment in childhood acute lymphoblastic leukemia (ALL). Four indexes were used to assess early response to treatment including response to prednisone on day 8 (D8-PR), percentage of lymphoblast in bone marrow on day 22 (D22-BM) and day 33 (D33-BM), the level of minimal residual disease (MRD) on day 33 (D33-MRD) by morphological and molecular biological method in 426 children with ALL. Prognostic impact of early response to treatment was analyzed, and multivariate analysis of the predictive value was performed by Cox-regression analysis. All patients were followed up until October 31, 2013, with a median follow-up time of 80 months (0.5 to 106 months). The results showed that there were significant differences between event free survivals (EFS) of the sub-groups divided according to the four indexes. The 8 years-EFS in patients with prednisone good response (PGR) was significantly higher than that in patients with prednisone poor response (PPR);patients with M1 in bone marrow on day 22 or day 33 had the better outcomes than that of patients with M2/M3;patients with high level of MRD ( ≥ 10(-4)) had the worse outcomes as compared with patients with low level of MRD (<10(-4)) (P < 0.001). Cox proportional hazard model analysis showed that BCR/ABL fusion gene positive, D8-PR, D33-BM and D33-MRD were the independent prognostic factors for childhood ALL, and the hazard ratio of D33-MRD ≥ 10(-2) was highest (HR:11.886, P < 0.001). It is concluded that early response to treatment is an independent prognostic factor with important prognostic values, and it has important clinical guiding instructive significance for risk stratification in the treatment of children ALL.

Impactof NOTCH1, FBXW7and SETD2 Mutations On Early Treatment Response In Childhood T-Cell Acute Lymphoblastic Leukemia：A China Children's Leukemia Group Study

T-cell lymphoblastic leukemia (T-ALL) is an aggressive malignancy accounting for about 15% of newly diagnosed acute lymphoblastic leukemia (ALL) in children. Although the prognosis has been improved by intensified therapies, the outcome of high risk patients is still not optimistic. Activating NOTCH1 and/or FBXW7 mutations have been reported to be the leading genetic abnormality in T-ALL with good prognosis but few studies about the role of NOTCH1 and FBXW7 in T-ALL were conducted in China and their mutation distributions and clinical prognosis are still unclear. On the other hand, loss of function mutations of SETD2, a histone methyltransferase specific for trimethylation of histone H3 on Lys36 (H3K36me3), has been found in renal cell carcinoma, gliomas and early T cell precursor ALL (ETP-ALL). SETD2is a potential tumor suppressor gene and may play a deleterious role in human cancer. We attempted to investigate the role of these mutations in Chinese T-ALL children. Thirty-seven bone marrow samples from childhood patients with newly diagnosed T-ALL (26 boys and 11 girls; age＜14 years) enrolled into the China Children's Leukemia Group (CCLG) ALL-2008 trail from September 2010 to December 2012 were analyzed for SETD2, NOTCH1, FBXW7 mutations. All exons of SETD2, exons 25-28, 34 of NOTCH1 and exons 5, 7-12 of FBXW7, including intron-exon boundaries, were sequenced by Sanger method.NOTCH1 mutations were observed in 43.2% (n=16) of the T-ALL patients. Thirteen missense mutations were found in HD-N domain, HD-C domain and TAD domain of NOTCH1 while only frameshift insertions and deletions were identified in PEST domain. Besides missense mutations, five inframe insertions were also observed in HD-N domain of NOTCH1. We only found one FBXW7 synonymous mutation in our patients, which was extremely low compared with that in other studies. SETD2 somatic mutations were found in 8.1% (n=3, one female and two males) of 37 T-ALL patients. Of the three patients, two patients had truncated SETD2 protein because of nonsense mutation (c.6229 C＞T) and frameshift insertion (c.7516_7517insTTATA) respectively. Both SETD2 and NOTCH1 mutations were found in one patient. In our study, no significant relationships between NOTCH1 status and age, sex, mediastinal or Central Nervous System (CNS) involvement, immunophenotype and cytogenetics were observed. However, White Blood Cell (WBC) count at diagnosis in patients without NOTCH1 mutation were much higher (221×109/L vs 76.95×109/L, P=0.015). Patients with NOTCH1 mutations had a better early treatment response: higher prednisone good response rate (81.2% vs 47.6%, p=0.048), higher incidence of bone marrow M1 status (blast cell＜5%) on day 15 (73.3% vs 33.3%, p=0.04), and higher rate of favorable minimal residual disease (MRD) level on day 88 (100% vs 59.9%, p=0.012). In contrast, patients without NOTCH1 mutations were more likely to fall into the high risk group (71.4% vs 21.4%, p= 0.006) according to our treatment protocol. After a median follow-up of 11 months, 1 patient did not reach complete remission (CR), 2 patients died during induction and 2 patients relapsed in 6 months. Patients who suffered relapse and induction failure are all in the NOTCH1 wild type group. SETD2 mutations seemed to have no relationship to sex, age, WBC, cytogenetics, CNS and mediastinal involvement. In contrast to previous study that found SETD2 mutations only in EPT ALL patients, none of our SETD2 mutated patients were ETP ALL, two were cortical-T ALL and one was pre-T ALL. All of the patients with SETD2 mutations were alive without the disease at the last follow-up. However, all of the patients were in the high risk group. The patient who had both NOTCH1 and SETD2 mutations responded poorly to prednisone. Although the other two patients without NOTCH1mutations had good response to prednisone, favorable BM status on day 15 and low MRD on day 33, they had very high MRD levels (0.21% and 0.44% respectively) on day 88.NOTCH1 activating mutations were found in 43.2% of pediatric T-ALL patients enrolled in the CCLG ALL-2008 study with good treatment response while FBXW7 mutation rate was much lower. SETD2 mutation was a recurrent event in pediatric T ALL not only in ETP ALL. It seems that patients with SETD2 mutations have high risk of poor response to chemotherapy regardless of NOTCH1 status. Further studies are needed to find out the prognostic significance of SETD2 mutation in pediatric T ALL. Disclosures:No relevant conflicts of interest to declare.

Clinical significance of glucocorticoid induction test in Chinese childhood acute lymphoblastic leukemia

Acute lymphoblastic leukemia (ALL) is the most common childhood cancer, while glucocorticoid (GC) is a critical component in multi-agent chemotherapy protocols currently used for the treatment of ALL. The purpose of this study was to investigate the relationship between the glucocorticoid induction test and the clinical features and the prognosis of Chinese childhood ALL. The study recruited 309 hospitalized patients (187 male and 122 female) with childhood ALL, the sex, age, initial WBC count, immunophenotype, chromosome and gene expression were recorded. After diagnosis, all patients received GC induction test for 7 days. Then they were divided into prednisone good response (PGR) group and prednisone poor response (PPR) group according to the peripheral lymphoblast count on D8. Early responses to chemotherapy and treatment outcomes of the patients in the two groups were also analyzed. Of the 309 patients, 263 belonged to PGR group and 46 belonged to PPR group. Initial WBC count was higher in PPR group than in PGR group (86.30×10(9)/L vs. 30.97×10(9)/L, P < 0.01) . B lineage ALL showed more sensitive to GC than T-ALL (86.6% vs. 60%, P < 0.05). Different initial-risk-group's sensitivity to GC differed from one another (high-risk:51.4%, medium-risk: 82.7%, standard risk: 93.7%, P < 0.0125). There was no significant difference between two groups in chromosomal karyotypes (P > 0.05). BCR-ABL positive ALL showed lower sensitivity to GC (P < 0.05) , while MLL, TEL-AML1, E2A-PBX1 positive rates in two groups were of no statistical significance (P > 0.05). Bone marrow was reviewed on D15 and D33, and the CR rates in PGR group were significantly higher than that in PPR group (D15: 60.5% vs. 32.6%, D33: 94.6% vs. 73.3%, P < 0.01) ; Minimal residual disease (MRD) levels were examined on D33, W12, and both were much lower in PGR group (D33: P < 0.01, W12: P < 0.05). Of the PGR group 215 patients (81.7%) remained continuously in complete remission (CCR) while only 28 cases (60.9%) in PPR group did so. The CCR rate was much higher in PGR group than that in PPR group (P < 0.01). Closely related to clinical features and the outcomes of treatment, GC induction test is also an important prognostic factor in Chinese childhood ALL.

NOTCH1 and/or FBXW7 mutations predict for initial good prednisone response but not for improved outcome in pediatric T-cell acute lymphoblastic leukemia patients treated on DCOG or COALL protocols

Aberrant activation of the NOTCH1 pathway by inactivating and activating mutations in NOTCH1 or FBXW7 is a frequent phenomenon in T-cell acute lymphoblastic leukemia (T-ALL). We retrospectively investigated the relevance of NOTCH1/FBXW7 mutations for pediatric T-ALL patients enrolled on Dutch Childhood Oncology Group (DCOG) ALL7/8 or ALL9 or the German Co-Operative Study Group for Childhood Acute Lymphoblastic Leukemia study (COALL-97) protocols. NOTCH1-activating mutations were identified in 63% of patients. NOTCH1 mutations affected the heterodimerization, the juxtamembrane and/or the PEST domains, but not the RBP-J-κ-associated module, the ankyrin repeats or the transactivation domain. Reverse-phase protein microarray data confirmed that NOTCH1 and FBXW7 mutations resulted in increased intracellular NOTCH1 levels in primary T-ALL biopsies. Based on microarray expression analysis, NOTCH1/FBXW7 mutations were associated with activation of NOTCH1 direct target genes including HES1, DTX1, NOTCH3, PTCRA but not cMYC. NOTCH1/FBXW7 mutations were associated with TLX3 rearrangements, but were less frequently identified in TAL1- or LMO2-rearranged cases. NOTCH1-activating mutations were less frequently associated with mature T-cell developmental stage. Mutations were associated with a good initial in vivo prednisone response, but were not associated with a superior outcome in the DCOG and COALL cohorts. Comparing our data with other studies, we conclude that the prognostic significance for NOTCH1/FBXW7 mutations is not consistent and may depend on the treatment protocol given.

The Favorable Effect of Activating NOTCH1 Receptor Mutations On Long Term Outcome in T-ALL Is Treatment Related and Can Be Separated From NOTCH Pathway Activation by FBXW7 Loss of Function.

Abstract 908▪▪This icon denotes an abstract that is clinically relevant.Precursor T-cell acute lymphoblastic leukemia (T-ALL) remains one of the challenges in pediatric oncology. While overall treatment results have considerably improved over recent years, T-ALL relapses are still frequently fatal. Therefore, it is vital to identify molecular risk factors that allow early and effective treatment stratification. We have recently shown that activating NOTCH 1 receptor mutations signify a favorable prognosis in patients treated on protocols of the ALL-BFM study group, although this effect has not been found with other treatment protocols (see abstract submitted by Zuurbier et al on behalf of the DOC and COALL study groups). We have now tested the hypothesis that activation of the Notch pathway at different steps may have similar clinical effects and may act in a synergistic fashion. An analysis of an extended data set of 301 children with T-ALL, who were enrolled in the ALL-BFM 2000 protocol confirms the overall favorable effect of activating NOTCH 1 mutations (pEFS 0.87 SE 0.03 vs. 0.74 SE 0.04 p=0.0091; relapse incidence at 5 years 0.07 SE 0.02 vs. 0.17 SE 0.03, p= 0.006). Interestingly, subgroup analysis now reveals that the NOTCH 1 effect can only be observed in the cohort of 168 patients with a rapid early treatment response (pEFS 0.95 SE 0.03 in the Notch 1 mutated vs. pEFS 0.80 SE 0.05 in the non-mutated group, p=0.01, incidence of CNS relapse 0.01 vs. 0.03), who were stratified into the ALL-BFM 2000 standard and medium risk groups. By contrast, there is no significant effect of NOTCH 1 mutations on long term outcome in the cohort of 133 patients, who had initially responded more slowly and were stratified into the BFM high-risk group (pEFS 0.70 both, with and without NOTCH 1 mutations). In striking contrast to the BFM patients, EORTC high-risk patients (who do not receive prophylactic cranial radiotherapy) with NOTCH 1 mutations have a dismal prognosis and tend to develop CNS relapses (see abstract submitted by Clappier et al for the EORTC study group), whereas CNS relapses are rare in BFM-treated patients in general but also in the high-risk group, who received prophylactic cranial radiotherapy. A possible mechanistic link between NOTCH 1 activation and T-ALL CNS tropism has recently been suggested by the finding that the chemokine receptor CCR7 is controlled by NOTCH 1 and required for targeting leukemic cells to the CNS (Buonamici et al., Nature, 2009). We thus suggest that the influence of NOTCH 1 receptor mutations on long term outcome is likely treatment dependent.We next analyzed the effect of inactivating mutations of the E3 ubiquitin ligase FBXW7 in 294 patients of whom sufficient DNA was available. Mutations were found in 42 (14%) patients. Interestingly, 88% (37/42) of the patients with FBXW7 mutations showed a prednisone good response (PGR), whereas only 12% (5/42) showed a prednisone poor response (PPR). By contrast, in the group without FBXW7 mutations 55% (138/252) showed a PGR and 45% (114/252) a PPR (p = 0.00003). With regard to prednisone response FBXW7 and NOTCH 1 mutations (both present in 30 patients) clearly synergize (PGR in 93%, 28/30; PPR in 7%, 2/30). The MRD kinetics were available in 39/42 patients with FBXW7 mutations. A favorable minimal residual disease (MRD) response on days 33 and 78 was observed in 16/39 and in 28/39 patients, respectively, and an unfavorable MRD response in 23/39 and 11/39 patients, respectively. On day 33, the difference between the FBXW7-mutated and non-mutated groups was significant (p=0.03), whereas FBXW7 mutations lost their significant predictive value for a favorable early treatment response on day 78, although there was still a trend (p=0.07). Inactivation of FBXW7 is thus associated with a rapid early treatment response in a univariate analysis and also significantly synergizes with activation of the NOTCH 1 receptor in this regard. Surprisingly, however, FBXW7 inactivation does not synergize with NOTCH 1 mutations to predict a significantly more favorable long term outcome (pEFS 0.86 in both, NOTCH 1 only and in NOTCH 1/FBXW7 double mutations). In conclusion, the favorable long term effect of NOTCH 1 receptor gain of function is specified to operate only in those patients with rapid early treatment response. This effect is separable from that of FBXW7 inactivation, which predicts excellent early treatment response but does not add to the favorable long term treatment outcome that is specified by NOTCH 1 receptor mutations alone. Disclosures:No relevant conflicts of interest to declare.

Dexamethasone in Induction Can Eliminate One Third of All Relapses in Childhood Acute Lymphoblastic Leukemia (ALL): Results of An International Randomized Trial in 3655 Patients (Trial AIEOP-BFM ALL 2000)

From 07/2000 to 06/2006, 4741 eligible pts with ALL (age range 1–17 years) were enrolled in the trial AIEOP-BFM ALL 2000 (registered at http://clinicaltrials.gov with identifiers NCT 00430118 (BFM) and NCT 00613457 (AIEOP)). 3655 patients from Germany, Italy, Austria, and Switzerland entered the randomized comparison of dexamethasone (DEX) at 10 mg/m2/d vs prednisone (PDN) at 60 mg/m2/d (both given daily from d8 to d29 of induction plus 9 days tapering after a 7d prednisone prophase). Induction therapy also comprised vincristine (1.5 mg/m2) and daunorubicine (30 mg/m2) both given on d8, 15, 22, 29, as well as L-asparaginase given at 5,000 IU/m2 x8 q3d from d12. I.T. methotrexate was given thrice (in CNS-2 and CNS-3 patients for 5 times) in induction. Post-induction therapy was derived from trial ALL-BFM 95 (A. Möricke et al, BLOOD 2008) but stratification and subsequent treatment intensity was based on early response as measured by prednisone response (on d8) and MRD quantification on d33 and d78. With a median follow-up of 4.4 years, 6-year event-free survival (6y-EFS) was 84.1% (SE 1%) and 79.1% (1%) for patients randomized to receive DEX or PDN, respectively (log-rank p=0.0083). The 6-year cumulative incidence (CI) of relapse was 11% (1%) and 18% (1%) for patients randomized to receive DEX or PDN, respectively (Gray p<0.001). The difference between the two groups was observed for isolated BM relapses (8% vs 12%), CNS-relapses (2% vs 4%) and other relapses (2% vs 3%). Higher toxicity was observed in patients treated with DEX: CI for death in induction was 2.0% for DEX and 0.9% for PDN (p=0.003). The latter value was similar to that of study ALL-BFM 95 (0.7%). CI for death in remission was similar being 2.0% and 1.6% for DEX and PDN groups. In each arm, only 0.2% did not achieve CR after intensive consolidation. Severe toxicities, mainly infections, were recorded for DEX treated patients more frequently. Three years into the trial, the DSMC and the TSC decided to halt the randomization for patients aged 10 years or older. CI for relapse/death in induction in this age group is now at 15%/4.5% for DEX, and 20%/2.4% for PDN (p=0.09/0.13). In patients less than 10 years of age, the CI for relapse/death in induction was 11%/1.4% if treated with DEX, and 18%/0.5% if treated with PDN (p<0.001/0.01). If specific biological subgroups were analyzed, a significantly lower CI of relapse for patients randomized to receive DEX was observed in T-ALL as well as TEL/AML1 positive and negative pcB-ALL patients. The reduction was most pronounced in T-ALL patients with good prednisone response after the prophase: CI for relapse in DEX treated patients (n=135) was only 6% (SE 2%) as compared to 20% (SE 4%) in PDN treated patients (n=138; p=0.003). Four patients died in the DEX arm, 3 in the PDN arm for toxicity. In TEL/AML1-positive patients with good prednisone response, the CI for relapse was 4% (SE 1%) in the DEX group and 13% (SE 2%) for PDN treated patients (p<0.001). This large difference became most evident only more than 2 years from diagnosis. The percentage of patients found negative for MRD at d33 was very similar between the randomized groups: It was 47.9% for patients treated with DEX, and 45% for patients treated with PDN. Interestingly, patients with pcB-ALL found MRD negative at d33 had significantly less subsequent relapses if treated with DEX in induction (p(Gray)=0.012). In conclusion, the use of DEX at the same dosage as applied in delayed intensification (10 mg/m2/d for 3 weeks) although associated with a greater risk of severe toxicity leads to a marked reduction of the risk of relapse, translating this into a significant benefit in terms of EFS. This was most evident in patients with in vivo sensitivity to the prednisone prephase, while the efficacy of DEX in poor responding patients was not convincing. In the future, more intensive clinical monitoring and early anti-infective interventions could render the advantage of using DEX even more evident. Moreover, other potentially toxic agents such as anthracyclines may be limited in induction for carefully selected subgroups of patients with the aim of limiting early or late toxicities.

Notch Pathway Activation by a Combination of Activating NOTCH1-Receptor and Inactivating FBXW7 Mutations Robustly Predicts Excellent Early Treatment Response in Pediatric T-ALL.

In contrast to pre B-ALL, robust DNA-based biomarkers with prognostic and predictive value are not available in T-ALL. We have previously shown that common activating mutations of the NOTCH1 receptor predict good early treatment response and excellent long term outcome in T-ALL (Breit et al., Blood 2006). We now aimed at analyzing if recently described inactivating mutations of FBXW7, the E3 ubiquitin ligase of NOTCH, contribute to the predictive power of the Notch1 pathway activation in pediatric T-ALL. [Display omitted] We genotyped FBXW7 in 137 T-ALL and found inactivating mutations in 22 patients. We next analyzed the influence of this mutation on treatment response and found that most patients with FBXW7 mutations showed a prednisone good response (PGR; 19/22), whereas PGR was observed in only 58/115 with no FBWX7 mutation (p=0.0006). This beneficial effect of FBXW7 inactivating mutations is enhanced when the NOTCH1 mutational status was considered. Among 17 patients with NOTCH1 and FBXW7 mutations, only 1 showed a prednisone poor response (PPR; p=0.0003). These results suggest a synergistic effect of NOTCH1 and FBXW7 mutations in early treatment response in pediatric T-ALL.Notably, FBXW7 mutations occur in the group of leukemias with NOTCH1 heterodimerisation (HD) domain mutations only and do not occur in those with truncations of the PEST domain, where FBXW7 physiologically targets NOTCH for degradation. One might thus predict that patients with NOTCH1-HD/PEST double mutations would be biologically similar to those with NOTCH1-HD/FBXW7 double mutations. A comparison of early treatment response between these groups indeed showed PGR in 10/13 patients with NOTCH1-HD/PEST and 16/17 with NOTCH1-HD/FBXW7 status. Furthermore, these groups taken together exhibit a significantly better prednisone response than both, the patients with single mutations in either NOTCH1 or in FBXW7 or those with detectable mutations in neither NOTCH1 nor FBWX7 (see bar diagram).These data indicate that activation of the Notch1 pathway by a combination of receptor gain of function mutations and inactivating mutations of its E3 ubiquitin ligase has a strong favorable effect on in-vivo prednisone sensitivity. Notch pathway activation may thus define a novel group of biomarkers that predict early treatment response and thus help to stratify risk of children and adolescents with T-ALL.