Prognosis Of Acute Myeloid Leukemia Patients Research Articles

Patients with FLT3 Negative Acute Myeloid Leukemia and Normal Cytogenetic who Have the Combination Mutations (NPM1-/CEBPA-) Have Better Survival Than Patients Who Have the Combination Mutations (NPM1+/CEBPA+)

Abstract 4874 Introduction:Acute Myeloid Leukemia (AML) is the most common type of acute leukemia in adults. About 50% of patients with AML have normal karyotype, and are categorized as intermediate risk group. However, the clinical behavior and response to treatment in this group is heterogeneous. As a result, there is strong interest in characterizing molecular genetic features in the intermediate-risk AML patients that might rectify their stratification risk. In this group, FLT3-ITD (Internal Tandem Duplication) and FLT3-TKD (Tyrosine Kinase Domain) mutations are known to confer unfavorable risk whereas NPM1 and CEBPA mutations are known to be favorable risk markers. The purpose of this study is to analyze the combination of NPM1 and CEBPA mutations in presence or absence of FLT3 mutations on prognosis of AML patients referred to the State's largest tertiary care center over a period of 10 years for the treatment of leukemia. Patients and Method:We performed a retrospective chart review of all patients with AML evaluated at University of Oklahoma Health Sciences Center between January 2000 and December 2010. Patient's age, gender, race, laboratory and clinical data as well as bone marrow biopsy and aspirate findings were reported. PCR and Fragment Analysis were conducted on all available DNA preserved bone marrow materials to test the FLT3, NPM1 and CEBPA mutations. For statistical analysis, Kaplan-Meyer curve was used. Results:A total of 239 patients were evaluated. Male to female ratio was 2/1. Median age at diagnosis was 46y. 21 out of the 239 patients were less than 18 year old. DNA samples were present on 132 patients and mutation analysis for FLT3, CEBPA and NPM1 was performed. Correlation between mutations and AML prognosis was determined. 67/132 (50.8 %) patients were categorized into intermediate risk group (majority of patients had normal cytogenetics). 14/67 (20.9%) pts were FLT3+ (FLT3-ITD or FLT3-TKD mutation). 17/67 (23.9%) were NPM1+. 7/67 (10.4%) were CEBPA +. Kaplan-Meier curve was used to identify cumulative proportion surviving over time. FLT3 presence or absence itself was not identified to be statistically significant (p 0.416) in terms of overall survival. Interestingly, presence or absence of combined NPM1/CEBPA mutation in FLT3 negative patients, among intermediate risk group, was found to be statistically significant (p<0.05) in determining overall survival. In this subgroup, presence of NPM1/CEBPA combination (NPM1+/CEBPA+) was associated with poor prognosis (figure 2, lower curve), while absence of NPM1/CEBPA combination (NPM1-/CEBPA-) carries a better prognosis (figure 2, upper curve). [Display omitted] [Display omitted] Conclusion:Results of our study highlight the importance of performing combinations of mutation analysis in evaluation of overall prognosis in AML patients. FLT3-/NPM1+ profile in patients with normal cytogenetics is thought to confer a favorable prognosis. We demonstrated in this study that using combination mutation analysis in patients with FLT3- can change the risk stratification in patients with intermediate risk group and might affect therapeutic interventions in this patient population.Larger prospective studies are needed in the future for further validation of our findings. Disclosures:No relevant conflicts of interest to declare.

FLT3 Inhibitors Are Promising Salvage Therapy for Relapsed or Refractory Acute Myeloid Leukemia (AML) in Patients with FLT3-ITD Mutations,

Abstract 3623 Background:The FMS-like tyrosine kinase (FLT3) is a transmembrane tyrosine kinase that belongs to the class III family of receptor tyrosine kinases. Internal tandem duplication (ITD) in the juxtamembrane domain of the FLT3 is found in approximately 15–30% of AML cases and its constitutive activation of kinase cascade is considered to contribute to leukemogenesis. The prognosis for AML patients (pts) with FLT3-ITD mutation is significantly worse than that with wild-type FLT3 pts and largely a result of a high relapse rate with poor response to salvage therapy. Recently, several FLT3 inhibitors (FLT3i) have been introduced to clinical trials and some of them are exhibiting clinical efficacy. Data are lacking on whether the use of FLT3i as salvage therapy for relapsed or refractory AML pts with FLT3-ITD mutations will improve long-term outcomes and how they compare to salvage therapy with standard chemotherapy. Aim:To determine the long-term efficacy of FLT3 inhibitors when used as first salvage therapy for refractory and relapsed AML in pts with FLT3-ITD mutations and compare it with that of conventional chemotherapy. Methods:We conducted a retrospective study of 120 pts with AML having FLT3-ITD mutation who had relapsed after or exhibited disease refractory to front-line therapy, thus received salvage therapy in various clinical trials. The cohort was divided into two groups that received a salvage regimen consisting of 1) conventional cytotoxic chemotherapy or 2) one of several FLT3i (e.g., sorafenib, PKC-412, CEP-701, AC-220, KW-2449, AP24534) either alone or in combination with chemotherapy. Pts who had received FLT3i as part of their front-line therapy were excluded from the study. Response to salvage therapy was classified according to the International Working Group (including CR, CRp, or CRi). Results:Between August 1995 and June 2011, 120 pts were treated, of which 75 received conventional chemotherapy (Conventional group; 71/75 were Ara-C based) and 45 received a FLT3i (FLT3i group). Among them, 43 pts were refractory to induction (Conventional = 26 [35%] vs FLT3i = 17 [38%]) and 77 had relapsed disease (Conventional = 49 [65%] vs FLT3i = 28 [62%]). The median duration of 1st remission for the latter group was 8.9 months. The median follow-up durations in the Conventional and the FLT3i groups were 71.5 weeks and 62.3 weeks, respectively (p=0.73). Baseline characteristics, such as age, sex, ECOG performance status and other laboratory parameters were similar in both groups. The number of pts who received stem cell transplant (SCT) as part of the salvage therapy was not statistically different (Conventional = 21/75 [28%] vs FLT3i = 11/45 [24%]; p = 0.67). Of those pts, SCT was performed while they were in CR in 9/21 pts in the Conventional and 2/11 in the FLT3i group (p=0.18). SCT was performed in 1st CR only in one patient in the Conventional and none in the FLT3i group.Response to the salvage therapy (CR, CRp and CRi) in the two groups was not statistically different (16/75 [21%] in conventional group vs 9/45 [20%] in the FLT3i group; p=0.41). The median overall survival (OS) was 41 weeks in the Conventional and 58 weeks in the FLT3i group (p=0.312). There was no significant difference in OS by treatment arm when analyzed separately for older (age above 60) and younger pts. Of the FLT3i group, 31/45 [69%] received FLT3i alone and it was combined with chemotherapy in 14/45 [31%]. The median OS was significantly better when FLT3i was combined as opposed to FLT3i monotherapy (median OS 102 weeks vs 49 weeks; p<0.05); the duration was also superior to that in Conventional group (41 weeks; p<0.05). In the pts whose initial CR duration was shorter than 12 months or who never had a CR with front-line therapy (N=88), the median OS was significantly better in FLT3i group (N=25) than that in the Conventional group (N=63) (58 weeks vs 33 weeks; p<0.01). Conclusions:Salvage therapy including a FLT3 inhibitor appears to be beneficial for relapsed or refractory AML pts with FLT3-ITD mutation, especially when combined with cytotoxic chemotherapy. Pts who never experienced a CR to front-line therapy or whose CR duration was less than 12 months benefited the most from FLT3 inhibitor therapy. Although further prospective studies are necessary to confirm these results, they suggest that a FLT3 inhibitor should be included in salvage regimens for relapsed or refractory AML pts with FLT3-ITD mutation. Disclosures:Ravandi:Bater/Onyx: Honoraria, Membership on an entity's Board of Directors or advisory committees, Research Funding.

Is Type of Monosomy (Total or Partial) Crucial for Prognostic Value of Monosomal Karyotype in AML Patients? – Preliminary Results of Retrospective Polish Adult Leukemia Group (PALG) Study,

Abstract 3537 Objectives:Cytogenetics is one of the most important prognostic factors in acute myeloid leukemia (AML). Breems et al., based on banding techniques (BT), have identified a monosomal karyotype (MK) to be associated with particularly poor survival. MK is defined by the presence of an autosomal monosomy in conjunction with at least one other autosomal monosomy or structural abnormality. However, classical BT may be not sufficient to confirm the “real” loss of a particular chromosome, especially in patients with complex karyotype (≥ 3 or ≥ 5 separate abnormalities) where parts of „missing” chromosomes could be involved in structural aberrations such as: additions, derivative chromosomes, rings, marker chromosomes and dicentrics. Molecular cytogenetic techniques, such as FISH, could be useful to verify if observed monosomy was “total” (loss of a complete chromosome) or “partial” (loss of only a part of chromosome including centromere).The aim of our study was to assess if the type of monosomy (total or partial), defined using FISH influences the prognosis of AML patients with MK.Materials and methods: Fifty newly diagnosed AML patients with MK, treated between January 2005 and January 2011 with PALG AML1/2004 and AML2/2004 protocols were included into the study. Cytogenetic analysis was performed on metaphases from bone marrow aspirates taken at diagnosis using standard BT. Karyotypes were centrally reviewed by two independent cytogeneticists and reported in accordance with the ISCN. In 41 cases FISH was performed with painting probes and in justified cases additionally with satellite probes and locus-specific probes to assess the type of monosomy. In 9 patients no confirmation by FISH was needed. Results:In 8/50 (16%) patients FISH verification proved the complex, but not monosomal (total or partial) karyotype. These patients were excluded from further study. The median age of 42 evaluable patients was 58 years (range 20–71 years). There were 26 males and 16 females. Twenty three (55%) patients received intensive induction chemotherapy according to PALG protocols (Holowiecki et al. Leukemia 2004), 8 patients - low dose cytarabine and 11 patients with high frailty index received treatment with hydroxyurea (n=9), and best supportive care (n=2).In 38/42 (90.5%) analyzed cases with MK abnormalities were complex. In all but one ≥5 separate aberrations were present. In 27/42 (64.3%) cases a total monosomy was confirmed by FISH (group A) and in 15/42 (35.7%) cases FISH revealed a monosomy to be the partial one (group B). Both groups A and B were comparable in terms of age, sex, immunophenotype and factors associated with tumor mass (leukemic bone marrow infiltration, WBC and peripheral blood blast count, as well as LDH activity). There was also no difference in the proportion of intensive and non-intensive treatment strategies between both groups. Six (26,1%) of intensively treated patients achieved complete remission (CR). The CR rate in patients with partial monosomy (40%) was higher than in total monosomy group (15,4%), however the difference was not significant (p=0.19; Fisher’s exact test). The median overall survival (OS) for all evaluable patients was 66 days (range 1–659 days) and the probability of OS at 1 yr was 14% (95% CI 4–23%). Total monosomy was the only factor associated with decreased probability of OS both in univariate (p=0.036) (Fig. 1) and multivariate (p=0.037) analyses in AML patients with MK. [Display omitted] Additionally, in patients with total monosomy the frequency of distinct monosomies was analyzed. The most frequent monosomies were monosomy 7 (n=13; 48%) and monosomy 18 (n=10; 37%). Other total monosomies included: monosomy 17 (n=3; 11%), monosomy 16 (n=2; 7%) and others (n=4). We did not observe any total monosomy 5. Conclusions:Our results indicate for the first time that partial monosomy is associated with significantly better OS than total monosomy in high risk AML with MK and provide further evidence for the heterogeneity of this defined cytogenetic group. These data also clearly demonstrate an important role of FISH method for precise evaluation of complex karyotype, which results in correct classification within MK group, as well as in adequate description of monosomy type. Disclosures:Wierzbowska:Genzyme: Membership on an entity's Board of Directors or advisory committees. Dmoszynska:Roche: Honoraria; Mundipharma:.

TET2 mutation is an unfavorable prognostic factor in acute myeloid leukemia patients with intermediate-risk cytogenetics

AbstractThe studies concerning clinical implications of TET2 mutation in patients with primary acute myeloid leukemia (AML) are scarce. We analyzed TET2 mutation in 486 adult patients with primary AML. TET2 mutation occurred in 13.2% of our patients and was closely associated with older age, higher white blood cell and blast counts, lower platelet numbers, normal karyotype, intermediate-risk cytogenetics, isolated trisomy 8, NPM1 mutation, and ASXL1 mutation but mutually exclusive with IDH mutation. TET2 mutation is an unfavorable prognostic factor in patients with intermediate-risk cytogenetics, and its negative impact was further enhanced when the mutation was combined with FLT3-ITD, NPM1-wild, or unfavorable genotypes (other than NPM1+/FLT3-ITD− or CEBPA+). A scoring system integrating TET2 mutation with FLT3-ITD, NPM1, and CEBPA mutations could well separate AML patients with intermediate-risk cytogenetics into 4 groups with different prognoses (P < .0001). Sequential analysis revealed that TET2 mutation detected at diagnosis was frequently lost at relapse; rarely, the mutation was acquired at relapse in those without TET2 mutation at diagnosis. In conclusion, TET2 mutation is associated with poor prognosis in AML patients with intermediate-risk cytogenetics, especially when it is combined with other adverse molecular markers. TET2 mutation appeared to be unstable during disease evolution.

Acute myeloid leukemia: leukemia stem cells write a prognostic signature

In a recent interesting article, analysis of gene expression between phenotypically defined acute myeloid leukemia (AML) leukemia stem cells (LSCs) and more mature leukemia progenitor cells is used to generate a differentially expressed gene signature for LSCs. Through clever bioinformatic weighting analysis, the authors describe a method to convert this signature into a single score for any given sample and then test the prognostic utility of this 'LSC score' in publicly available gene expression profiles from bulk AML samples. They demonstrate that a high LSC score is associated with poor prognosis in AML patients and further demonstrate that the score is independent of known prognostic factors, including age, karyotype and mutation of the FLT3 or NPM1 genes. These findings are important and directly relate transcriptional dysregulation in AML LSCs with the outcome in patient samples, thus reinforcing the belief that these cellular populations are crucial for the initial propagation and subsequent relapse and resistance of leukemia.

A Pathway-focused GSEA Platform In AML That Interrogates Interaction of Flt3ITD and tMLL with Their Epigenetic Targets (p16INK4a, DAPK1, and RUNX3), While Accurately Reporting Broad-based AML Prognosis and Targeting-agent Sensitivity.

AbstractAbstract 1660GSEA (gene-set enrichment array) analysis for expression levels in acute myeloid leukemia (AML) blasts of hoxA9/meis1, has afforded additional prognostic capacity to cytogenetically-defined subtypes. Signaling pathway (KEGG, GO, Ingenuity) analysis of Affymetrix gene expression data has also been used to predict prognosis of AML patients, identifying an adverse high MAPK gene signature. Genome-wide epigenetic (DNA methylation) profiling has added to AML prognostication. We analyzed patient prognosis and in vitro sensitivity for blasts by pathway-targeting agents, in relation to expression clusters defined by the results of GSEA profiling. Blast cell sensitivity was assayed using the agents: (Tyrosine kinase inhibitors for: Flt3: Sorafenib (Onyx/Bayer) and Syk/Flt3: R406 (AstraZeneca); Bortezomib (Millenium), a proteasome- and NFkB- inhibitor, inducer of endoplasmic reticulum (ER) stress; or the pan-histone deacetylase (HDAC) inhibitor, SBHA, Vorinostat analogue). A group of 70 AML cases was studied. GSEA's (Taqman/RQ-PCR, ABI) were performed on two different 31-gene platforms interrogating the interaction of tyrosine kinase survival pathways (eg. Flt3) with downstream epigenetic targets: tumor suppressor genes DAPK1, p16INK4a/CDKN2A, and RUNX3. Expression levels of these are responsive to input from c-jun/AP-1, non-canonical NFkB isoforms/HDAC's, polycomb genes, and ets/ERG, which were monitored. Analysis of overall patient survival (OS) by Kaplan-Meier plots revealed conformity with established outcomes for conventional cytogenetic categories. Also, poor-risk categories defined by normal karyotype Flt3ITD mutation, as well as high hoxA9 and meis1 expressions were recognized. Classification categories involving NKFlt3ITD/high hoxA9/meis1 or complex cytogenetics/high MAPK were most strictly separated by Kaplan-Meier curves, and by representation on the GSEA heatmaps, vs. CBF/PML-RAR translocations. Specific association, between repression of the tumor suppressor DAPK1 (normalized to c-jun, a transcriptional activator) with high expressions of hoxA9 and DAPK1-repressive, non-canonical NFkB/relB, was apparent in most NKFlt3ITD and tMLL cases. Also, a known functional interaction implicating high Id1 expression with its repression of p16INK4a(CDKN2A) was linked by their expression levels on GSEA. The DAPK1/CDKN2A clusters demonstrated significant overlap, often with additional RUNX3 repression. The DAPK1-repressed(R) clusters demonstrated independent prognostic importance. There was median OS for DAPK1-R cluster #1(lower MAPK signature) of 17 months vs. for DAPK1-R cluster #2 of 6 months. This latter cluster was described by higher MAPK signature evidenced by heightened transcript levels of BRCA1 [Bullinger et al. Blood, 2007], FoxM1, bcl-2, IL-1b. The dominant cytogenetic/molecularly-defined phenotypes represented in these DAPK1-R clusters were NKFlt3ITD+ve and tMLL. A very-high MAPK/complex cluster, evidenced median OS 4.5 months vs. good prognosis (low MAPK/DAPK1, and low hoxA9/meis1) group: median OS> 3 years. Interestingly, in vitro activity for the dual inhibitor R406 on blasts was greatest in the category with strongest repression of both p16INK4a/CDKN2A and DAPK1, and with lowest expression of syk transcripts (10-fold compared with high patient values), with a median IC50 of between 10 nM (tMLL)-100nM (Flt3ITD). By contrast, Sorafenib demonstrated its greatest activity in a high MAPK phenotype, including but not restricted to Flt3ITD+ve status. Bortezomib demonstrated median IC50 40 nM. However, high expression levels of FoxM1, putative Bortezomib target, were negatively-associated with its activity. SBHA, the HDAC inhibitor, demonstrated lower activity on a molar basis, but had important synergy with tyrosine kinase inhibitors, a property that was optimal in the context of Id1 hyperexpression. Bortezomib was strongly synergistic with Flt3/syk inhibitors, particularly on FltITD+ve blasts. Indeed, both Bortezomib and the HDAC inhibitor demonstrated by correlation analysis (coefficients=63.3 and 13.4, respectively) optimal activities with Id1 hyperexpression. In conclusion, a pathway-focused genetic and epigenetic prognostic classification that also reports targeting agent sensitivity was established and further validated in a phase I (Sorafenib/Vorinostat) trial in AML (H Sayar, these abstracts). Disclosures:Sayar:Onyx/Bayer: Research Funding.

PET-CT Scan for Detection of Extramedullary Acute Myeloid Leukemia

AbstractAbstract 2156 Background:Acute myeloid leukemia (AML) at initial diagnosis or relapse may present with extramedullary (EM) AML. Data on the prevalence of EM AML at diagnosis are scarce and rely mostly on retrospective, clinical analyses. However, previous studies attributed EM AML as an impacting prognostic factor in AML. Furthermore, studies have not been carried out so far in order to define the prevalence and the prognostic impact of EM AML at diagnosis prior to initiation of therapy. 18Fluorodesoxy-Glucose Positron Emission Tomography (18FDG-PET) is able to detect highly metabolic tissue and has proven efficacy in imaging studies in various types of malignant diseases. The aim of this pilot study was to perform 18FDG-PET-CT scans on patients with newly diagnosed AML as well as relapsed AML in order to study its feasibility on detection of EM AML. Patients and Methods:A total of 15 patients with AML (newly diagnosed AML, n = 10 and relapsed AML, n = 5) had total body 18FDG-PET-CT scans at diagnosis after giving informed consent to the study. Patients were included only if a delay of ≤ 5 days of initiation of induction- or re-induction chemotherapy was necessary to perform the study. 18FDG-PET-CT scans were performed using a Siemens Sensation 16 as part of a biograph with i.v. application of 18FDG (range of activity of 225 to 391 MBq). Results:A total of 15 patients with newly diagnosed or relapsed AML (age 26 to 80) underwent total body 18FDG-PET-CT imaging prior to initiation of induction- or re-induction therapy. Adverse reactions due to the application of i.v. 18FDG were not observed. A positive 18FDG-PET imaging result detecting an EM manifestation of AML was observed in 8 patients (53%). Sites of EM AML were soft tissue (n=7), mammary gland (n=1), liver (n=1), ovary (n=1), and lymph nodes (n=2). In 6 patients with clinically overt EM AML additional EM manifestations were detected. In 5 patients in whom there was no EM manifestation suspected, 2 had 18FDG-PET positive findings. Finally, most patients with positive 18FDG-PET uptake with either isolated EM or in combination with systemic AML relapsed within a short period of time after initiation of therapy or had a progressive disease despite therapy. Conclusions:18FDG-PET-CT imaging is a useful tool in order to study EM AML either in combination or as a solitary event without fulfilling the criteria of systemic AML. 18FDG-PET is a feasible and safe imaging procedure and can therefore be performed prior to initiation of chemotherapy without a delay of time. 18FDG-PET might be a diagnostic tool in order to delineate the prevalence of EM AML and to define its impact to the prognosis of AML patients. Future studies to identify the prevalence and define the relevance of imaging studies in order to detect extramedullary AML are necessary. Disclosures:Platzbecker: Celgene: Honoraria, Membership on an entity's Board of Directors or advisory committees, Research Funding.

WT1 mutation in 470 adult patients with acute myeloid leukemia: stability during disease evolution and implication of its incorporation into a survival scoring system

AbstractThe impact of WT1 mutations in acute myeloid leukemia (AML) is not completely settled. We aimed to determine the clinical implication of WT1 mutation in 470 de novo non-M3 AML patients and its stability during the clinical course. WT1 mutations were identified in 6.8% of total patients and 8.3% of younger patients with normal karyotype (CN-AML). The WT1 mutation was closely associated with younger age (P < .001), French-American-British M6 subtype (P = .006), and t(7;11)(p15;p15) (P = .003). Multivariate analysis demonstrated that the WT1 mutation was an independent poor prognostic factor for overall survival and relapse-free survival among total patients and the CN-AML group. A scoring system incorporating WT1 mutation, NPM1/FLT3-ITD, CEBPA mutations, and age into survival analysis proved to be very useful to stratify CN-AML patients into different prognostic groups (P < .001). Sequential analyses were performed on 133 patients. WT1 mutations disappeared at complete remission in all WT1-mutated patients studied. At relapse, 3 of the 16 WT1-mutated patients who had paired samples lost the mutation and 2 acquired additional mutations, whereas 3 of 110 WT1-wild patients acquired novel mutations. In conclusion, WT1 mutations are correlated with poor prognosis in AML patients. The mutation status may be changed in some patients during AML progression.

Leukemic Stem Cell Assessment in Remission Bone Marrow of Acute Myeloid Leukemia Patients Is a New Prognostic Parameter.

Abstract 399In acute myeloid leukemia (AML), relapses originate from the outgrowth of therapy surviving leukemic blasts know as minimal residual disease (MRD). Accumulating evidence shows that leukemia initiating cells or leukemic stem cells (LSCs) are responsible for persistence and outgrowth of AML. Monitoring LSCs during and after therapy might thus offer accurate prognostic information. However, as LSCs and hematopoietic stem cells (HSCs) both reside within the immunophenotypically defined CD34+CD38- compartment, accurate discrimination between LSCs and HSCs is required. We previously showed that within the CD34+CD38- stem cell compartment, LSCs can be discriminated from HSC by aberrant expression of markers (leukemia associated phenotype, LAP), including lineage markers like CD7, CD19 and CD56 and the novel LSC marker CLL-1 (van Rhenen, Leukemia 2007, Blood 2007). In addition, we reported that flowcytometer light scatter properties add to even better detection of LSCs, allowing LSCs detection in AML cases lacking LAP (ASH abstract 1353, 2008). Using this gating strategy, we determined LSC frequency in 64 remission bone marrow samples of CD34+ AML patients. A stem cell compartment was defined as a minimum of 5 clustered CD34+CD38- events with a minimal analyzed number of 500,000 white blood cells. After first cycle of chemotherapy, high LSC frequency (>1 × 10-3) clearly predicted adverse relapse free survival (RFS, figure 1a). LSC frequency above cut-off led to a median RFS of 5 months (n=9), while patients with LSC frequency below cut-off (n=22) showed a significantly longer median RFS of >56 months (p=0.00003). In spite of the relatively low number of patients, again a high LSC frequency (>2 × 10-4) after the second cycle and after consolidation therapy predicted worse RFS: after second cycle, median RFS was 6 months (n=9) vs. >43 months for patients with LSC frequency below cut-off (p=0.004). After consolidation, these figures were 6 months (n=7) vs. >32 months (n=6, p=0.03). Although total blast MRD (leukemic blasts as % of WBC) is known to predict survival (N.Feller et al. Leukemia 2004), monitoring LSCs as compared to total blast MRD has two major advantages: the specificity is higher (van Rhenen et al. Leukemia 2007) and well-known LSC makers like CLL-1, CD96 and CD123 can in principle be used for LSC monitoring, but not for total blast MRD detection since these markers are also expressed on normal progenitor cells. On the other hand, LSCs constitute only a small fraction of all leukemic blasts and therefore monitoring total blast MRD may have the advantage of a higher sensitivity. We thus tested the hypothesis that even more accurate prognostic information could be obtained by combining LSC frequency with total blast MRD. Total blast MRD after first cycle was predictive for survival with borderline significance (p=0.08): a cut-off of 0.3% resulted in two patient groups with median RFS of 9 months vs. >56 months. Figure 1b shows the result of the combined data of LSC and MRD frequency after first cycle therapy. We used the terms LSC+ and MRD+ for cell frequencies above cut-off and LSC- and MRD- for those below cut-off. We could clearly identify that apart from LSC+/MRD+ patients, LSC+/MRD- patients too have very poor prognosis, while MRD+/LSC- patients show an adverse prognosis as compared to LSC-/MRD- patients. These results from the first study on the in vivo fate of LSCs during and after therapy, strongly support the hypothesis that in CD34+ AML the leukemia initiating capacity originates from the CD34+CD38- population and is important for tumor survival and outgrowth. These results show that LSC frequency might be superior in predicting prognosis of AML patients in CR as compared to MRD total blast frequency, while the combination of both may offer the most optimal parameter to guide future intervention therapies.This work was supported by Netherlands Cancer Foundation KWF. [Display omitted] Disclosures:No relevant conflicts of interest to declare.

B-Lymphocyte Development Is Impaired by FLT3/ITD Signaling in Knock-in Mice Because of Defective Non-Homologous End-Joining.

Abstract 184Constitutive activation of FLT3 by internal tandem duplication (ITD) mutations is one of the most common molecular alterations found in up to 35% of acute myeloid leukemia (AML) and 3% of acute lymphoid leukemia (ALL). Its roles in leukemic transformation of normal hematopoietic stem/ progenitor cells (HSPCs) are not yet fully understood. We have generated a FLT3/ITD knock-in mouse model in which mice heterozygous for a FLT3/ITD mutation develop myeloid proliferation and a block in B-lymphocyte development at the Pro-B stage. To investigate the mechanisms for this block in lymphoid development, we studied V(D)J recombination in the B-lineage cells from the bone marrow (BM) of FLT3/ITD mice. The ligation-mediated PCR assay showed that Pro-B cells from FLT3/ITD mice accumulated high levels of signal-end recombination intermediates, generated by DNA cleavage at the DJH recombination signal sequences (RSSs), with a concomitant decrease in the frequency of completed DJH rearrangements when compared to wild-type littermate controls. These observations are consistent with decreased repair of double strand breaks (DSBs) introduced by the V(D)J recombinase in B cell progenitors from FLT3/ITD mice, resulting in impaired development beyond the Pro-B stage.The classical Ku and DNA-PK-dependent non-homologous end-joining (NHEJ) pathway is required for rejoining DSBs during V(D)J recombination. In vivo NHEJ assays demonstrate that BM cells, including Pro-B cells, with FLT3/ITD mutations have a lower efficiency and decreased accuracy of repair of DSBs, suggesting a defect in the classical NHEJ pathway. Quantitative RT-PCR and Western blotting analysis of Pro-B cells from FLT3/ITD mice demonstrate greatly reduced expression of Ku70/Ku86 and Ligase IV, key components of the the classical NHEJ pathway, confirming the idea that Classical NHEJ is defective. We and others have recently demonstrated that alternative (ALT) NHEJ pathway(s) compensate for deficiencies in classical NHEJ. Components of this pathway include DNA ligase III/XRCC1 and poly (ADP) ribose polymerase 1 (PARP1). Indeed, we show by Western blotting analysis that steady state levels of ALT NHEJ components DNA ligase III and PARP1 are increased in FLT3/ITD cells, compared with wild-type controls.These data suggest that during the process of DJH recombination in Pro-B cells from FLT3/ITD mice, impairment of the classical NHEJ pathway decreases the ability of cells to complete post-cleavage DSB ligation, resulting in failure to complete DJH recombination with a subsequent block of Pro-B cell maturation. With the classical NHEJ pathway impaired, BM cells from mice with FLT3/ITD mutations appear to repair DSBs through the highly error-prone ALT NHEJ pathway. The resultant increased genomic instability might underlie an important mechanism for the leukemic transformation of normal HSPCs by FLT3/ITD mutations and explain the poor prognosis of AML patients with this mutation. Disclosures:No relevant conflicts of interest to declare.

High Serum Level of Placental Growth Factor (PlGF) Predicts Adverse Overall Survival in Patients with Acute Myeloid Leukemia Treated with Standard Chemotherapy

Background: Angiogenesis plays an important role in the pathogenesis of acute myeloid leukemia (AML) and vascular endothelial growth factor (VEGF) is an essential positive regulator of this process. Placental growth factor (PlGF) is a member of VEGF family that exerts its angiogenic action by synergizing with VEGF. There is also evidence that PlGF may be survival factor for angiogenic endothelial cells. The role of PlGF in patients with acute leukemia have not been investigated at all.Material and methods: We measured the plasma concentrations of VEGF and PlGF in 61 patients with newly diagnosed AML and 22 healthy controls using the ELISA assay. Additionally, in AML patients we correlated the plasma levels of angiogenic cytokines with the number of viable (CEC) and apoptotic (CECAnnV+) circulating endothelial cells, known prognostic factors, response to induction therapy as well as overall survival (OS). The AML group consisted of 34 women and 27 men with a median age of 49 years (range 25–76 years). All patient received standard induction chemotherapy (according to 3+7 protocol). Statistical analysis included the following variables: VEGF and PlGF levels, age, sex, performance status, cytogenetic risk group according SWOG, presence of multilineage dysplasia, WBC and PLT count, hemoglobin level, LDH activity, % of bone marrow blasts and CEC as well as CECAnnV+ number.Results: The PlGF and VEGF median levels (23,6 pg/ml and 45,1 pg/ml respectively) were significantly higher in the AML at diagnosis than in the healthy subjects (9,5 pg/ml; p<0,0001 and 25,2 pg/ml; p<0,03 respectively). Moreover, the VEGF level at diagnosis in patients who did not respond to induction chemotherapy was significantly higher than in patients who achieved complete remission (CR) (84,7 vs 31,2 pg/ml; p<0,01). The significant negative correlation between the VEGF and percentage of apopototic CECAnnV+ was also observed.Median follow-up was 12,1 months (range: 1– 43 months). 50 patients (82%) achieved CR. The CR rate in low and high VEGF expressors was respectively 86% and 70% (p=0.07). The CR rate in high- and low PlGF expressors did not differ significantly (74% and 80% respectively). In univariate analysis poor cytogenetics was the only factor associated with increased risk of treatment failure. The median time of OS in analysed group was 15 months. In the univariate analysis high (over median) PlGF levels was associated with shorter OS (p=0.005) (Figure1).Shorter OS was also associated with age>40 years (p=0.009), failure to achieve CR (p=0.009) and higher (>50%) bone marrow infiltration with leukemic blasts (p=0.005). In the multivariate Cox proportional hazard model the elevated PlGF plasma level was strongly associated with shorter OS (p<0.007). The other factors found to influence shorter OS were: high bone marrow infiltration with leukemic blasts (p=0.02), age>40 years (p=0.04), failure to achieve CR (p=0.04).Conclusions: In conclusion we can state that the high plasma concentration of PlGF is associated with poor prognosis in AML patients. Observed in our study significantly higher PlGF level in AML patients compared to healthy controls may indicate that this angiogenic cytokine plays an important, independent of VEGF role in pathogenesis of AML [Display omitted]

Hierarchical Cluster Analysis of Immunophenotype in AML Patients with NPM1 Gene Mutation Reveals Two Distinct Groups with Different Prognosis.

Acute myeloid leukemia (AML) is a group of heterogeneous diseases characterized by increasing immature progenitors in the bone marrow and peripheral blood. Prior reports suggested a relationship between surface antigens expression and prognosis of AML. However, there were some debates in subsequent studies. In this study, we performed cluster analysis of the immunophenotype expression profile in AML patients with NPM1 gene mutation, and correlated the result with clinical characteristics, other gene mutations and prognosis.Patients and Methods A total of 534 patients diagnosed as having AML at the National Taiwan University Hospital from 1987 to 2007 were recruited in this study. A panel of monoclonal antibodies was used to characterize the phenotypes of the leukemic cells. Expression of surface antigens on the leukemic cells was shown by an indirect immunoalkaline phosphatase method before 1998 and by flow cytometry thereafter. Cytogenetic study was done on bone marrow cells after 1–3 days of unstimulated culture. Analysis of gene mutation of NPM1, FLT3, CEBPA, MLL/ITD, AML1, JAK2, PTPN11, WT1, NRAS and KRAS were performed by polymerase chain reaction and direct sequencing. Abnormal sequencing results were confirmed by at least two repeated analyses. Comparisons were made with the ANOVA and the Chi-square test. Hierarchical cluster analysis was performed with agglomeration schedule, and cluster distance measured with Binary Square Euclidean distance. Dendrogram was plotted with average linkage method. Survival curves were plotted by the Kaplan-Meier method; differences between curves were analyzed by the log-rank test. All statistical analyses were performed by use of SPSS 13.0 for Windows (SPSS, Chicago, IL). Values of P< 0.05 were considered significant.Result: Clinical characteristics of patients withNPM1gene mutation. There were 309 men and 225 women. 51 were children less than 18 years and 483 were adults. NPM1 gene mutations were detected in 106 (19.8%) of the total AML patients and 37% of those with a normal karyotype, similar to our previous report (Cancer Res. 2006). Most patients with NPM1 mutation were HLADR(−)CD33(+) CD34(−) (p<0.001). The patients with NPM1 mutations were older than the others (56 vs 47 years, p<0.001).Hierarchical cluster analysis of immunophenotypes in patients withNPM1gene mutations. The cluster analysis was performed based on the expression profile of eight surface markers (HLADR, CD34, CD13, CD33, CD7, CD14, CD15, CD56). The clustering result was displayed by the Treeview dendrogram. The rows represented individual cases and the columns were the results of expression of individual surface markers. The blue color indicates positive expression and yellow color, negative. A total of 89 patients with NPM1 mutation and complete immunophenotype data were enrolled to the hierarchical cluster analysis. The clustering analysis divided the patients with NPM1 mutations into two groups, designated as cluster groups I (n=73, green) and II (n=16, red), based on the expression profiles of immunophenotype (Figure 1). Most patients in group I showed CD34(−)/CD7(−) but with variable expression of other antigens, while most group II patients showed HLA DR(+)/CD34(+)/CD7(+). With a median follow-up time of 56 months, groups II patients showed significantly shorter relapse free survival (RFS, median: 4 vs 22 months, p=0.005) and overall survival (OS, median: 8 vs 94 months, p=0.05) than group I patients. There was no association of immunophenotypic cluster with any other gene mutation, such as FLT3, CEBPA, MLL, AML1, JAK2, PTPN11, WT1, NRAS or KRAS. Multivariate analysis of variables including clinico-laboratory data (age, sex, WBC, Hb, PLT, LDH) and gene mutations revealed that immunophenotype cluster was an independent prognostic factor (RFS, p=0.002; OS, p=0.024) in AML patients with NPM1 mutation. For more practical use, we compared the outcome of patients with positivity for all HLADR, CD34 and CD7, with that of other patients; it was also shown that the former groups had significantly poor prognosis than the latter one (RFS, p=0.0005, OS, p=0.01).Conclusion: Hierarchical cluster analysis of the immunophenotype profile of patients with NPM1 gene mutation could reveal two distinct groups with different prognosis. The immunophenotypic cluster with HLADR(+) CD34(+) CD7(+) predicts poor prognosis in AML patients with NPM1 mutation, independently from other gene mutations and clinico-laboratory variables. [Display omitted]

High Leukemic Stem Cell Frequency in Remission Bone Marrow Predicts Poor Outcome in Acute Myeloid Leukemia

Relapses of acute myeloid leukemia (AML) originate from the outgrowth of therapy surviving leukemic blasts known as minimal residual disease (MRD). We and others have shown that immunophenotypical detection of MRD in remission bone marrow (BM) is a strong prognostic factor for survival. However, some patients relapse despite low MRD levels, indicating the presence of remaining, but undetectable leukemic stem cells (LSCs). These LSCs are proposed to give rise to AML and because we previously found a correlation between stem cells at diagnosis and MRD (van Rhenen et al., CCR 2005), they might be responsible for relapse. Therefore, we investigated whether LSCs could be detected in remission BM and whether monitoring remaining LSCs might predict clinical outcome more accurately as compared to the immunophenotypically defined “total blast” MRD. We defined LSCs by FACS analysis by the use of aberrant lineage markers, as well as the novel LSC marker CLL-1 (van Rhenen et al., Leukemia 2007 and Blood 2007) in 22 patients with CD34+ leukemia. In patients with more than 20% leukemia associated phenotype (LAP) positive CD34+ CD38− stem cells, 37 follow-up remission BM samples were collected (17 after first cycle, 13 after second cycle and 7 after third cycle of chemotherapy) and analysed for LAP expression. A stem cell compartment was defined as a minimum of 5 clustered CD34+ CD38− events when a minimum of 500,000 white blood cells (WBCs) were measured. In cases of less than 5 events, LSC frequency was set at <1/500,000 (< 2 × 10−4) LSCs/total WBC. In 10 follow-up samples, no CD34+CD38− compartment could be detected. In the other samples, the markers CD7 (n=9), CD11b (n=2), CD19 (n=3), CD56 (n=1) and CLL-1 (n=12) were used to detect LSCs. In addition, in 4 of these cases, CD45 expression, cell size (forward light scatter, FSC) and cell granularity (sideward light scatter, SSC) characteristics were used as a secondary gating strategy to exclude malignant cells in the aberrant marker negative fraction (M.Terwijn, accompanying abstract for this meeting). After the first cycle of chemotherapy (n=17), high LSC frequency (> 1 × 10−3) clearly predicted overall survival (OS), relapse free survival (RFS) and disease free survival (DFS). Regarding OS, LSC frequency above this cut-off lead to a median survival of 8 months (n=7) vs. >29 months in the group above cut-off (n=10, p=0.028). Median RFS in the high LSC frequency group was 8 months vs. >27 months (p=0.019) and for DFS, these numbers were 6 months vs. >27 months, respectively (p=0.025). After the second and third cycle of chemotherapy a cut-off of 2 × 10−4 was used. Again, a high LSC number predicted OS, RFS and DFS (p=0.035, 0.029 and 0.029, respectively) with a median RFS of 6 months (n=6) versus >30 months (n=7) in patients with a low LSC frequency. Although only limited number of patients was followed after the third cycle, trends were similar: 3/3 patients with a high LSC frequency relapsed within 6 months after CR, while only 1/4 patients with a low LSC frequency relapsed within 6 months. The remaining 3 patients had a RFS of 11, 21 and 31 months. In contrast to LSC frequency, “total blast” MRD frequency did not predict prognosis after the first, second or third cycle of chemotherapy, which likely is due to the small sample size. LSC frequency is superior in predicting prognosis of AML patients in CR as compared to MRD total blast frequency. The prognostic value of remaining LSCs supports the hypothesis that the leukaemia initiating capacity in patients with AML originates from this population. The identification of LSCs in remission BM and the possibility to distinguish these from HSCs will allow monitoring differential effects of present and future therapies.This work was supported by Netherlands Cancer Foundation KWF.

Internal tandem duplication of FLT3 (FLT3/ITD) induces increased ROS production, DNA damage, and misrepair: implications for poor prognosis in AML

AbstractActivating mutations of the FMS-like tyrosine kinase-3 (FLT3) receptor occur in approximately 30% of acute myeloid leukemia (AML) patients and, at least for internal tandem duplication (ITD) mutations, are associated with poor prognosis. FLT3 mutations trigger downstream signaling pathways including RAS-MAP/AKT kinases and signal transducer and activator of transcription-5 (STAT5). We find that FLT3/ITD mutations start a cycle of genomic instability whereby increased reactive oxygen species (ROS) production leads to increased DNA double-strand breaks (DSBs) and repair errors that may explain aggressive AML in FLT3/ITD patients. Cell lines transfected with FLT3/ITD and FLT3/ITD-positive AML cell lines and primary cells demonstrate increased ROS. Increased ROS levels appear to be produced via STAT5 signaling and activation of RAC1, an essential component of ROS-producing NADPH oxidases. A direct association of RAC1-GTP binding to phosphorylated STAT5 (pSTAT5) provides a possible mechanism for ROS generation. A FLT3 inhibitor blocked increased ROS in FLT3/ITD cells resulting in decreased DSB and increased repair efficiency and fidelity. Our study suggests that the aggressiveness of the disease and poor prognosis of AML patients with FLT3/ITD mutations could be the result of increased genomic instability that is driven by higher endogenous ROS, increased DNA damage, and decreased end-joining fidelity.

Gene expression profile related to prognosis of acute myeloid leukemia

Acute myeloid leukemia (AML) is a heterogeneous group of diseases with respect to biology and clinical course. Through genome-wide scanning, we can have an improvement of the diagnosis and assay system of AML. Microarray was performed for the identification of acute myeloid leukemia prognosis. We divided patients into two groups (good prognosis group, GPG and poor prognosis group, PPG) based on differences in the individual reactions to treatment. Gene expression profiles were analyzed using microarray. Among genes up-regulated at least two-fold and down-regulated at least 0.5-fold in HL-60, we chose three up-regulated genes (PPP2CA, ME3, and CCDN2) and three down-regulated genes (GLO1, ANXA2, and BMI1) and confirmed the expression of these six genes by RT-PCR. We created a leukemia-specific subclass microarray, based on the gene expression profiles. Clinical samples from the bone marrow of four patients were hybridized on this microarray. Among the genes selected by the microarray technology, NB4, silenced TRIB3 and overexpressed XRN2 were not differentiated in spite of treatment with ATRA. This indicates that XRN2 and TRIB3 play an important role in cell differentiation. These data provided an expression profile for the diagnosis and prognosis of AML patients and identified candidate genes that might allow the prognosis of AML through the relative comparison of the expression level of genes between GPG and PPG.

Prognostic Significance of FLT3/ITD Mutation in AML1/ETO-Associated Acute Myeloid Leukemia.

Background: AML1-ETO fusion gene in acute myeloid leukemia (AML) usually predicts a good response to chemotherapy with a high remission rate and a relatively long median survival. An internal tandem duplication of the FLT3 gene (FLT3/ITDs) is known to be associated with poor outcome after standard induction chemotherapy in AML patients with normal cytogenetics. However, this mutation is reported to be rarely found in cases with AML1/ETO positive and it remains a matter of debate as to whether these mutations play an independent role in the prognosis of AML patients with AML1/ETO fusion gene.Aims: To determine the prevalence and the prognostic role of FLT3/ITD in patients with AML1/ETO positive AML.Methods: FLT3/ITD and NPM1 mutation status was evaluated by performing DNA polymerase chain reaction assays on 39 bone marrow samples obtained at initial diagnosis from the patients with AML1/ETO fusion gene positive AML. GeneScan analysis was performed to confirm the FLT3/ITD mutation and to measure mutant levels.Results: Of total 39 patients, 11 patients (28.2%) demonstrated the aberrant FLT3/ITD mutations. The median age of patients was 40 years (range, 17–75 years). There were 24 males (61.5%) and 15 females (38.5%). There was no statistically significant difference in age, gender, leukocyte count, hemoglobin level, platelet count and percentage of peripheral or bone marrow blasts between the patients with or without FLT3/ITD. No NPM1 mutation was found in these AML Patients. To analyze the response to or outcome of therapy, we evaluated 34 patients who received intensive induction chemotherapy containing cytarabine. In univariate analysis, there was no significant difference in complete response rate (FLT3/ITD+: 100% vs. FLT3/ITD−: 95.6%, p = 0.48). However, the presence of FLT3/ITD was associated with higher relapse rate in these patients (FLT3/ITD+: 72.7% vs. FLT3/ITD−: 27.3%, p = 0.01).Significant shorter leukemic-free survival (LFS) was observed in patients with FLT3/ITD compared with those without FLT3/ITD (6.9±1.0 ms vs. 18.9±10.9 ms, p = 0.01), but there was no statistical significance in overall survival (OS) (10.6±0.6 ms vs. 16.5± NA ms, p = 0.56).Conclusions: This study demonstrates that the presence of FLT3/ITD mutations is a significantly higher relapse rate and shorter LFS in AML1/ETO positive patients. Therefore, a stratified treatment plan such as stem cell transplantation may be warranted for the AML1/ETO positive AML harvoring FLT3/ITD mutation.

Vascular endothelial growth factor (VEGF) gene (VEGFA) polymorphism can predict the prognosis in acute myeloid leukaemia patients

Increased angiogenesis, mediated by vascular endothelial growth factor (VEGF), was associated with poor prognosis in acute myeloid leukaemia (AML) patients. The current study investigated the impact of VEGF gene (VEGFA) single nucleotide polymorphisms (SNPs) on treatment outcomes for AML. Four VEGFA SNPs were analysed for -2578C>A (rs699947), -460T>C (rs833061), +405G>C (rs2010963) and +936 C>T (rs3025039) loci in 138 AML patients. The +936 CC/CT genotype showed strong correlation with favourable leukaemia-free survival (LFS) at 2 years (51.3%) versus with +936 CC genotype (33.6%, P = 0.03). Strong linkage disequilibrium was noted among loci -2578, -460 and +405, but not with +936. Accordingly, four haplotypes were generated based on the genotypes of -2578, -460 and +405 as follows: CTC (40.2%), CTG (35.0%), ACG (22.0%) and ATC (1.2%). The LFS and event-free survival (EFS) inversely correlated with CTG haplotype (P = 0.03 for LFS; P = 0.05 for EFS). We scored the VEGFA polymorphism marker based on +936 C>T genotype and CTG haplotype for -2578, -460 and +405, which demonstrated a good correlation with the treatment outcomes: LFS (P = 0.01), EFS (P = 0.03) and overall survival (P = 0.01). The VEGFA +936 C>T genotype and CTG haplotype seemed to have an additive effect to predict the prognosis in AML patients.

Overexpression of CXCR4 predicts adverse overall and event‐free survival in patients with unmutated FLT3 acute myeloid leukemia with normal karyotype

CXC chemokine receptor 4 (CXCR4) expression in acute myeloid leukemia (AML) is reported to correlate with FLT3 gene mutation and poorer prognosis. The prognostic significance of CXCR4 expression in patients with AML that have a normal karyotype and no evidence of FLT3 gene mutations was examined. The prognostic significance of CXCR4 expression in 122 AML patients with normal karyotype and no evidence of FLT3 gene mutation treated at our institution between 1997 and 2003 was analyzed. All patients received intensive chemotherapy according to institutional protocols; 84% received cytarabine-containing regimens. Bone marrow biopsy or clot specimens obtained before treatment were immunostained for CXCR4. There were 70 men and 52 women with a median age of 62 years (range, 22-82 years). Median follow-up was 18 months (range, <1-97 months). Seventy-six patients achieved complete remission (CR); 39 had recurrence. Sixty-six patients died, including 9 with no evidence of disease. CXCR4 was positive in 70 and negative in 52 patients, with CR rates of 58% and 71%, respectively (P = .09). Multivariate analysis demonstrated that CXCR4 expression, presence of multilineage dysplasia, and high creatinine level predicted poorer overall (OS) and event-free (EFS) survival. CONCLUSIONS.: The results suggest that CXCR4 expression is associated with poor prognosis in AML patients with an unmutated FLT3 gene.

Overexpression of CXCR4 in Acute Myeloid Leukemia Predicts Adverse Overall and Progression-Free Survival Independently of FLT3 Gene Mutation.

CXC chemokine receptor 4 (CXCR4) expression in acute myeloid leukemia (AML) is reported to correlate with FLT3 gene mutation and poorer prognosis. We analyzed the prognostic significance of CXCR4 expression in 122 AML patients with diploid karyotype and no evidence of FLT3 gene mutation treated at our institution between 1997 and 2003. All patients received intensive chemotherapy according to institutional protocols; 84% received cytarabine-containing regimens. Bone marrow biopsy specimens obtained at diagnosis from untreated patients were immunostained with an antibody specific for CXCR4 (Abcam, clone 2074; Cambridge, MA). Statistical analysis included the following variables: CXCR4 expression, age, sex, race, incorporation of cytarabine in the therapeutic regimen, presence of multilineage dysplasia, history of antecedent hematologic disorder, history of prior chemotherapy (for either hematological or non-hematological disorder), performance status, leukocytosis, hemoglobin, platelet count, bilirubin, and creatinine. There were 70 men and 52 women with a median age of 62 years (range, 22–82 years). Median follow-up was 18 months (range, <1–97 months). Seventy-six patients achieved complete remission (CR); 39 relapsed. Sixty-six patients died, including 9 with no evidence of disease. CXCR4 was positive in 70 and negative in 52 patients, with CR rates of 58% and 71%, respectively (p=0.09). In the univariate Cox model, CXCR4 expression was associated with shorter overall survival (OS), p=0.008, and disease-free survival (DFS), p=0.012, figure1. [Display omitted] Shorter OS was also associated with failure to achieve CR (p=<0.0001), age (p=0.01), presence of multilineage dysplasia (p=0.006), poorer performance status (p=0.049), higher creatinine level (p=0.00002), and lower hemoglobin level (p=0.042). Shorter DFS was associated with failure to achieve CR (p=0.0002), presence of multilineage dysplasia (p=0.02), history of prior chemotherapy (p=0.04), and higher creatinine level (p=0.0009).In multivariate analysis, shorter OS was associated with CXCR4 expression (p=0.047), age (p=0.029), presence of multilineage dysplasia (p=0.042), and high creatinine level (p=0.016). Shorter DFS was associated with CXCR4 expression (p=0.036), history of prior chemotherapy (p=0.044), presence of multilineage dysplasia (p=0.007), and high creatinine level (p=0.034). These results suggest that CXCR4 expression is associated with poor prognosis in AML patients and is independent of FLT3 gene mutation.

Quality of Life in Elderly Patients with Acute Myeloid Leukemia.

Treatment of acute myeloid leukemia (AML) in elderly patients is generally tailored on the basis of age, performance status, concomitant diseases and patient consent. Toxicity and low-response rates are major constraints and therapeutic options are most likely conditioned by clinicians' opinions rather than patient preferences. Health-related quality of life (HRQoL) may be useful in this setting. We designed a prospective multicenter study to evaluate the predictive potentials of HRQoL measures on prognosis in AML patients aged over 60 years. We present results in 95 patients of median age 72 (range 61–90) years. HRQoL was measured by the QOL-E and the EORTC QLQ-C30 questionnaires. Demographic and disease-related factors were also evaluated. The questionnaires showed good internal consistencies. Scores were low at baseline (reflecting poor HRQoL), particularly in the QOL-E fatigue (41.8), disease-specific (33.2) and treatment-related index (S_TOI=53.1) scales. Increasing age was correlated with concomitant diseases (r=0.256, p=0.012) and with EORTC global health (r=−0.217, p=0.041), QOL-E general/total (r=−0.239, p=0.022 / r=−0.247, p=0.019), physical function (QLQ-C30 r=−0.304, p=0.003; QOL-E r=−0.249, p=0.016), role function (QLQ-C30 r=−0.347, p=0.001), functional and fatigue (QLQ-C30 r=0.329, p=0.001; QOL-E r=−0.301, p=0.003) and QOL-E S_TOI (r=−0.281, p=0.007) scores. The presence of concomitant diseases was associated with poorer general health (p=0.019), physical well-being (p=0.011), role (p=0.026) and emotional function (=0.036). Baseline Hb levels correlated with fatigue, pain, dyspnea, insomnia, appetite loss and role function (QLQ-C30 p<0.001, p=0.013, p=0.013, p=0.021, p=0.010 and p=0.032, respectively) as well as functional, fatigue and total health (QOL-E p=0.024, p=0.002 and p=0.030, respectively). ECOG PS grades were associated with peripheral and bone marrow blasts (p=0.034 and p=0.042, respectively), with loss of appetite (EORTC p=0.024), and inversely with Hb levels (p=0.001) and QOL-E functional scores (p=0.014). After 1 month, 67 patients were alive for re-evaluation: decrease in QLQ-C30 physical functioning (delta=−9.096, p=0.019), role functional (delta=−17.836, p=0.002, but with increase at 6 months (delta=+15.385, p=0.032), cognitive function (p=0.035, with further decrease up to 12 months, p=0.014), and social function (delta=−11.111, p=0.019, but with an increase at 6 months (delta=+14.74, p=0.008) were observed. The fatigue score increased at one month (delta=+9.319, p=0.030) but decreased up to 12 months (delta=−6.837). Appetite loss improved at 6 months (delta=−15.55, p=0.024). Though QOL-E physical score decreased (p=0.002). there were significant relative increases in specific (p=0.006) and treatment outcome index (p=0.021) scores by month 12. In conclusion, HRQoL is poor at diagnosis, especially with increasing age and in patients with concomitant diseases, and it deteriorates during initial treatment. However, survivors at 6 and 12 months experience improvements in HRQoL, representing patients worth treating. HRQoL may indicate patient-tailored therapy in elderly AML patients.