Prognostic Factor In Acute Myeloid Leukemia Patients Research Articles

Prognostic value of brain and acute leukemia cytoplasmic gene expression in egyptian children with acute myeloid leukemia.

BackgroundAcute myeloid leukemia (AML) accounts for 25%–35% of acute leukemia in children. BAALC gene (Brain and Acute Leukemia Cytoplasmic gene) is a recently identified gene on chromosome 8q22.3 that has prognostic significance in AML. The aim of this work was to study the impact of BAALC gene expression on prognosis of AML in Egyptian children.Patients and methodsThis study was conducted on 40 Egyptian children with newly diagnosed AML who were subjected to full history taking, clinical examination and laboratory investigations including: complete blood count, LDH, bone marrow aspiration, cytochemistry, immunophenotyping and assessment of BAALC Gene by real time PCR in bone marrow aspirate mononuclear cells before the start of chemotherapy.ResultsPositive BAALC gene expression was found in 24 cases (60%) and negative expression in 16 cases (40%). Positive BAALC gene expression group includes 14 males and 10 females with mean age at presentation of 8.35±2.63 while negative BAALC gene expression includes 10 males and 6 females with mean age at presentation of 7.74±3.23 with no statistically significant differences between patients with positive and negative BAALC gene expression regarding age, sex and clinical presentations at time of diagnosis including pallor, purpura, splenomegaly, hepatomegaly and lymphadenopathy and laboratory investigations including WBCs and platelets counts, hemoglobin and LDH levels, and peripheral blood and bone marrow blast cell counts. There was significant association between positive BAALC gene expression and M1 and M2 compared with negative BAALC gene expression which is significantly associated with M4. There were statistically significant differences in disease outcome between positive and negative BAALC gene expression groups with higher rate of relapse and death and lower rate of complete remission and disease free survival in positive BAALC gene expression group compared with negative BAALC gene expression group. (p = 0.017).Conclusion and RecommendationBAALC expression is an important bad prognostic factor in AML patients with normal karyotype and therefore we recommend its incorporation into novel risk-adapted therapeutic strategies to improve the currently disappointing cure rate of patients with AML.

Prognostic significance of monosomal karyotype in acute myeloid leukemia

目的探讨单体核型（MK）在急性髓系白血病（AML）中的预后意义。方法回顾性分析498例AML患者的临床资料并进行统计学分析。结果498例AML患者中233例（46.8%）为异常核型，MK 42例，占全部患者的8.4％及异常核型的18.0%，最常见的为−7、−17。复杂核型（CK)70例，占全部患者的14.1％及异常核型的30.0%。与不伴有MK的AML患者比较，伴有MK者发病年龄较高（中位年龄62.5岁对52岁，P=0.003），外周血血红蛋白浓度较低（62.5 g/L对77 g/L，P=0.009），白细胞计数较低（7.0×109/L对11.7×109/L，P=0.008）。MK中常见的不良预后核型是复杂核型、−7、−5、7q−、5q−。单因素分析发现伴有MK的患者预后明显差于不伴有者（中位生存期分别为7.3和26.3个月，P<0.001)。伴有CK的患者预后亦差于不伴有者（中位生存期分别为14.8和26.3个月，P<0.001）。在伴有CK患者中，伴有MK的患者预后差于不伴有者（中位生存期分别为7.4和19.2个月，P=0.007）。COX回归风险模型分析显示MK是AML患者独立于NCCN预后分组和CK的预后因素(HR=2.610, 95%CI 1.632~4.175,P<0.001)。结论MK是AML患者独立的不良预后因素。

TET2 Exon 2 Skipping Confers Sensitivity to AraC and Is an Independent Favorable Prognostic Factor in AML Patients Treated with Intensive Chemotherapy

The nucleoside analogue cytarabine (AraC) has served as the backbone of acute myeloid leukemia (AML) treatment for nearly forty years. About one-third of expressed genes are abnormally spliced in AML yet alternative exon usage (AEU) plays a role in the plasticity of tumor cells and may influence the response to treatment. Here the exon expression profiles of the erythroleukemia K562 cell line were compared to that of its AraC-resistant variant K562/AraC through Affymetrix HTA2 exon arrays. 5140 exon events harbored by 2583 genes distinguished the 2 cell lines. Among these, the skipping of TET2 exon 2 was identified in K562 cells sensitive to AraC whereas TET2 gene expression remained unchanged at the whole transcript level. The results were confirmed by exon-specific RTPCR (ESPCR). Microarray analysis did not evidenced any significant change in mRNA splicing for the 10 remaining exons of the TET2 gene.TET2 is a dioxygenase that catalyzes the conversion of 5-methylcytosine (5-mC) to 5-hydroxymethylcytosine (5-hmC) and promote DNA demethylation. TET2 somatic mutations occur in about 25% AML, distributing across the whole coding sequence without obvious hot spots. These mutations decrease TET2 enzymatic activity by truncating the protein or affecting its catalytic activity. TET2 exon 2 is spliced in a mutually exclusive manner with exon 1 yet it is used as an alternative promoter (https://fasterdb.lyon.unicancer.fr/). However, TET2 exon 2 is not translated into protein and its role in TET2 regulation is still unknown. Having found that AraC sensitive cells harbor the spliced TET2 isoform, we investigated whether or not skipping of TET2 exon 2 correlate with disease outcome in AML patients treated with AraC-based intensive chemotherapy (AraC-IC).The discovery cohort included 106 consecutive AML patients treated with AraC-IC (median age 57.91, 64 males). RNA was extracted from bone marrow MNCs and assayed for TET2 exon 2 skipping through real-time quantitative ESRTPCR (qESRTPCR) amplification of E1E3 (spliced) and E2E3 (unspliced) TET2 isoforms. TET2 exon 2 skipping was quantified by calculating the ratio E1E3/E2E3. For statistical analysis, the ratio E1E3/E2E3 was dichotomized using median value as the cutoff value. Skipping of TET2 exon 2 was associated with a significantly lower response rate: 65% vs 92%, p = 0.001 but with a significantly lower relapse rate: 39% vs 85%: p<10-4. Univariate analysis (27 months median follow-up) showed that in addition to age and cytogenetic risk, TET2 exon 2 skipping significantly influenced DFS; the higher the level of E1E3 isoform expression, the better the outcome [HR=0.27 (95% confidence interval (CI):0.13-0.53), p<10-4]. The favorable effect of TET2 exon 2 skipping on DFS remained in the 49 patients with normal karyotype: HR=0.31 (CI: 0.12-0.84), p=0.022. Multivariate analysis showed that age [HR=1.83 (CI:1.03-3.24), p=0.039], cytogenetics [HR=3.03 (CI:1.55-5.96), p=0.001], and TET2 exon 2 skipping [HR=0.38 (CI:0.19-0.77), p=0.007] were independent prognostic factors for DFS. The validation cohort included 103 patients with normal karyotype treated with AraC-IC (median age 61.12, 63 males). Skipping of TET2 exon 2 was associated with a lower response rate: 87.5% vs 91.1% (NS) and a significantly lower relapse rate: 3% vs 66%: p<10-4. Univariate analysis showed that in addition to age, FLT3 internal tandem duplication (FLT3-ITD), nucleophosmin (NPM1) exon-12 gene mutation, TET2 exon 2 skipping significantly influenced DFS, EFS, and OS. In multivariate analysis, TET2 exon 2 skipping was the sole prognostic factor for DFS [HR=0.07 (CI: 0.02-0.3), p<10-4], EFS [HR=0.32 (CI: 0.14-0.74), p=0.008], and OS [HR=0.42 (CI: 0.19-0.90), p=0.025]. As an additional control, the prognostic effect of TET2 exon 2 skipping was evaluated in a series of 36 AML unfit for IC and treated with hydroxyurea, azacitidine, decitabine, low dose AraC, or supportive care only. TET2 exon 2 skipping possessed no significant impact on the response rate, the relapse rate, OS, DFS, and EFS in this population.In conclusion TET2 exon 2 skipping is associated with a low relapse rate and possesses a strong favorable prognostic impact in AML treated with AraC-CTI. The mechanism linking this alternative exon usage with resistances to AraC are currently investigated while our results suggest that the determination of TET2 exon 2 splicing status might assist risk stratification. DisclosuresNicolini:Novartis: Consultancy.

Impact of FLT3-ITD Mutational Burden in 469 Acute Myeloid Leukemia (AML) Patients

Background:FLT3-ITD mutational status is a well known prognostic factor in AML patients. However, its prognostic value in case of low mutational burden is currently under debate, especially in patients with intermediate karyotype and NPM1 mutations. Indeed some studies suggested that patients with an allelic ratio (i.e FLT3-ITD/FLT3 WT) lower than 50 % might have the same prognosis as unmutated patients.Patients and methods:Four hundred and sixty nine (469) patients diagnosed with AML in a single center from 1995 to 2014 and who received intensive chemotherapy based on anthracycline and cytarabine were included. Patients with t(15;17)(q24;q21) or t(9;22)(q34;q11) translocations were excluded. 134 patients underwent allogeneic stem cell transplantation. FLT3-ITD allelic burden was determined using fresh or frozen cells drawn at time of diagnosis in all patients. The mutational status for FLT3-ITD was determined using high-resolution sizing of fluorescent dye-labeled PCR amplification of exons 14-15. Beyond its contribution to mutation detection, high-resolution sizing also allows to estimate the allelic burden by measuring peak height ratios (mutant/wild type) on a fluorescence scale. Low allelic burden was defined by an allelic ratio lower than 50%. NPM1 and CEBPA mutational status were determined in most patients (n=409 and n=349 respectively). Median follow-up time for patients who were still alive was 37 months.Results:Median age was 56 years (range 16-81). Karyotype was unfavorable in 110 (24%) patients, favorable in 45 (10%), intermediate in 298 (63%) patients and normal in 229 (48 %). Overall, FLT3-ITD was detected in 83 (17%) patients. Twenty three patients (5%) had a low allelic ratio and 60 (13%) had a high allelic ratio. NPM1 mutation was found in 100 (24%) patients and bi-allelic CEBPA mutations in 21 (6%).In the overall population, patients with FLT3-ITD had poorer outcome compared to other patients (OS at 3 years: 33+/-5% vs. 52 +/-3%, p =0.02). There was no difference between patients with low allelic burden or patients with high allelic burden for leukemia-free survival (7+/-7% vs. 38+/-8%, p=0.12), overall survival (25+/-5% vs. 37+/-6%, p=0.67) or CR reaching (70% in the two groups). In multivariate analysis, factors independently associated with OS were cytogenetic risk group, age, leukocyte count at diagnosis, NPM1 status, CEBPA status and FLT3-ITD status. There were no difference between patients with high vs. low allelic burden (HR=1.20 [0.59-2.42]).Results were the same when focusing on patients with intermediate karyotype. FLT3-ITD was associated with lower survival (p=0.003), but the mutational burden was not (OS at 3 years 30+/-12% vs. 36+/-7%, for low or high burden respectively, p=0.86). In multivariate analysis, factors independently associated with OS were age, leukocyte count, NPM1 status, CEBPA status and FLT3-ITD status. Again, there were no difference between patients with high versus low allelic burden (HR=0.98[0.45-2.08].Conclusions:In this series, low FLT3-ITD allelic burden had a similar prognostic significance compared to a higher allelic burden. Therefore, patients with low FLT3-ITD allelic burden should likely be considered as having the same prognosis as patients with high burden, and FLT3-ITD detection, but not FLT3-ITD allelic burden, should be the major factor to be considered for therapeutic decisions. DisclosuresNo relevant conflicts of interest to declare.

Telomerase reverse transcriptase (TERT) A1062T mutation as a prognostic factor in Egyptian patients with acute myeloid leukemia (AML).

This study aimed to evaluate the incidence and clinical and prognostic impact of TERT A1062T mutation in AML patients treated at Mansoura Oncology Center. Screening for TERT A1062T mutation in exon 15 of the TERT gene was performed on diagnostic DNA samples from 153 AML patients and 197 healthy subjects as a control group by using sequence-specific primers. TERT A1062T mutation was detected in 18 cases out of 153 patients (11.8 %) and in one out of 197 control group subjects (0.51 %). The achievement of complete remission was significantly higher in AML group with wild type as compared to that in the mutant one (53.3 vs 16.7 %, respectively). In addition, the relapse rate was significantly higher in the mutant patients as compared to those with wild type (62.5 vs 28.2 %, respectively). The AML patients with TERT (A1062T) mutation had shorter overall survival than patients with wild type (P = 0.001). In a multivariable analysis, TERT (A1062T) mutational status is independently worse predictor factor (P = 0.007) when controlling for cytogenetic status (P = <0.001), performance status (P = <0.001) and bone marrow blast cells (P = 0.001). In conclusion, TERT A1062T mutation is an independent negative prognostic factor in AML patients. Therefore, molecular testing for TERT A1062T mutation in patients with AML is recommended in order to delineate their prognostic status.

Frequency and Prognostic Relevance ofFLT3Mutations in Saudi Acute Myeloid Leukemia Patients

The Fms-like tyrosine kinase-3 (FLT3) is a receptor tyrosine kinase that plays a key role in cell survival, proliferation, and differentiation of hematopoietic stem cells. Mutations of FLT3 were first described in 1997 and account for the most frequent molecular mutations in acute myeloid leukemia (AML). AML patients with FLT3 internal tandem duplication (ITD) mutations have poor cure rates the prognostic significance of point mutations; tyrosine kinase domain (TKD) is still unclear. We analyzed the frequency of FLT3 mutations (ITD and D835) in patients with AML at diagnosis; no sufficient data currently exist regarding FLT3 mutations in Saudi AML patients. This study was aimed at evaluating the frequency of FLT3 mutations in patients with AML and its significance for prognosis. The frequency of FLT3 mutations in our study (18.56%) was lower than many of the reported studies, FLT3-ITD mutations were observed in 14.4%, and FLT3-TKD in 4.1%, of 97 newly diagnosed AML patients (82 adult and 15 pediatric). Our data show significant increase of FLT3 mutations in male more than female (13 male, 5 female). Our results support the view that FLT3-ITD mutation has strong prognostic factor in AML patients and is associated with high rate of relapse, and high leucocytes and blast count at diagnosis and relapse.

Lack of CD34 Expression in Acute Myeloid Leukemia (AML) Is a Favorable Prognostic Factor in Patients Treated with Stem Cell Transplant Irrespective of the Cytogenetic Risk

Abstract 1894 Background:Most of the studies of prognostic factors in acute myeloid leukemia (AML) are focused on predicting outcome after standard chemotherapy treatment. The studies that looked at the importance of these prognostic variables in predicting outcome after hematopoietic stem cell transplantation (HSCT) are very limited. Considering post-HSCT prognostic factors in stratifying AML patients may add a new level of confidence in any risk stratification of these patients. Toward this goal, we investigated the clinical relevance of CD34 expression in the primary leukemic cells on the outcome of allogeneic HSCT. Methods:Data collected from immunophenotyping of 110 patients with AML who were treated with HSCT was reviewed and the expression of CD34 on the blast population as determined by flow cytometry was correlated with clinical behavior and outcome. All the patients were treated with allogeneic HSCT. The median age of these patients was 24 (range: 14–57) and included 88 patients in the intermediate cytogenetic group and 22 in the adverse cytogenetic group. Of the 110 patients 71, (64.5%) were treated with HSCT in first remission (CR1). Results:Twenty-eight (25%) of all AML patients studied did not express CD34 on the surface of the blasts at diagnosis. Patients with CD34 negative blasts had significantly longer overall survival (OS) (P=0.003) as well as longer event free survival (EFS) (P=0.01) when all patients were considered. In the subgroup of patients who received HSCT in CR1, OS and EFS were significantly longer (P=0.017 and P=0.027, respectively) in the CD34-negative patients (N=20). Furthermore, if we consider only patients in the intermediate cytogenetic group at diagnosis, patients with CD34-negative blasts had significantly longer OS (P=0.007) and EFS (P=0.026). Even in patients with adverse cytogenetic abnormalities, OS and EFS were also significantly longer in the CD34-negative patients (P=0.01 for both). This was true when all patients were considered. The same was true when only patients transplanted in CR1 (P=0.05 for EFS in intermediate cytogenetics and P=0.05 for EFS in patients with adverse cytogenetic) were evaluated. Multivariate analysis including CD34 expression and FLT3 mutation status was carried out on a subset of patients (N=63) and showed CD34 expression was an independent prognostic factor for survival and EFS, while FLT3 mutation status became no longer a predictor. Conclusion:Our data suggests that CD34 expression on the blast cells at the time of AML diagnosis may have an adverse prognostic impact even after allogeneic HSCT. Lack of CD34 expression is a powerful independent favorable prognostic factor for AML patients if these patients are treated with HSCT after induction chemotherapy, irrespective if they were in CR1 or in CR2, and irrespective of their cytogenetic risk at diagnosis. [Display omitted] Disclosures:No relevant conflicts of interest to declare.

Low‐dose Gemtuzumab‐Ozogamicin as post‐consolidation therapy in elderly patients with acute myeloid leukaemia: a pilot study

Low‐dose Gemtuzumab‐Ozogamicin as post‐consolidation therapy in elderly patients with acute myeloid leukaemia: a pilot study

Intensified Induction Chemotherapy with Regimen Containing Intermediate Dose Cytarabine for De Novo Acute Myeloid Leukemia.

Objective To analyze the complete remission (CR) rate, disease free survival (DFS) and overall survival (OS) of de novo acute myeloid leukemia (AML) patients induced with HAD (Homoharringtonine-HHT, cytosine arabinoside-AraC, daunorubicin-DNR) regimen containing intermediate dose AraC (ID-AraC) and to explore the impact of cytogenetic abnormalities on the prognosis.Methods 87 AML patients were treated with HAD regimen containing ID-AraC as induction therapy. HAD regimen was as follow: HHT 2mg/m2.d, Day 1–7; Ara-C 100mg/m2, Day 1–4, 1–1.5g/m2/q12h, Day 5–7; DNR 40 mg/m2.d, Day 1–3. CR rate, DFS and OS were calculated.83 patients who had karyotype results were divided into 3 groups according to SWOG criteria respectively. Differences in CR rate, DFS and OS among different groups were evaluated.Results The CR rate of the 87 cases was 80/87 (92%). Median DFS of the 80 CR patients was NR (not reach). DFS rates at 1 and 3 years were 76.3% and 63.4% respectively. The median OS of the 87 patients was 16 (range from 2 to 67) months. OS rates at 1 and 3 years were 86.0% and 58.7% respectively. According to SWOG criteria, CR rate, median DFS and OS were 100%, NR for the favorable group„dG88.9%, NR and 16 months for the intermediate group„dG83.3%, 4.5 months and 7.5 months for the adverse group. The differences among the three groups were statistically significant excepting for CR rate between adverse and intermediate groups.Conclusions HAD regimen containing ID-AraC as induction chemotherapy regimen is very effective in de novo AML of adult patients, can achieve higher CR rate and longer survival time than standard dose HAD regimen. Most of the patients were able to endure therapy. Cytogenetics is the important prognostic factor for AML patients. The differences among the three groups were statistically significant.

Prevalence and Prognostic Significance of FLT3 Mutations in Acute Myeloid Leukemia: Association of ITDs with Poor Outcome in Patients with Normal Cytogenetics.

Acute Myeloid Leukemia (AML) is a difficult disease to treat, and better treatments are needed. Molecular targeted therapy represents a novel therapeutic approach.Activating mutations of FMS-like tyrosine kinase 3 (FLT3) are present in approximately one third of patients with de novo AML and have been implicated in its pathogenesis. The leukemic blasts of most AML patients have the internal tandem duplications (ITDs) in the juxtamembrane region or point mutations in Asp835 and Iso836 codons in the activation loop of the kinase domain (TKD) of the FLT3 receptor. Both mutations result in constitutive FLT3 receptor activity and may play a significant role in leukemogenesis.In this study we have analyzed the incidence and type of FLT3 mutations in a large series of newly diagnosed AML patients. Furthermore, we have evaluated the prognostic impact of FLT3 mutations.The FLT3/ITD was determined by polymerase chain reaction (PCR). The mutations of D835 and I836 codons were determined by PCR followed by restriction enzyme digestion (PCR-RFLP). For the estimation of the statistic significance of the differences in the clinical-biological characteristics, between the mutated patients and wild-type patients, it has been used the Student's test t for independent data. The probabilities of overall survival (OS) and disease free survival (DFS) were analysed by Kaplan-Meier method; the differences of OS and DFS, between the mutated patients and wild-type patients, were assessed using the log-rank test.Both FLT3/ITD and FLT3/TKD mutations were found in 15%. Dual mutations were found in 2% of 126 patients. Among the FAB subtypes of AML, the rate of FLT3 aberrations was higher in M4 (27%) and M5 (26%). FLT3/ITD was associated to leukocytosis (106.8x10(e)9/l vs 30x10(e)9/l in FLT3-wt, p=0.015) and high percentage of circulating blast cells (82% vs 42% in FLT3-wt, p<0.0001). Differently, FLT3/TKD mutations were not associated with high white blood cells count and blast cells percentage.FLT3 mutations were more prevalent in patients with normal karyotype (51%). In this group, DFS and OS were significantly inferior for patients with FLT3/ITD than patients withouth mutations (0 vs 5, p=0.0032; 5 vs 9, p=0.049, respectively). We have identified the FLT3/ITD as an independent poor prognostic factor in AML patients with normal cytogenetics. Therefore, targeting FLT3 mutations represents a potential therapeutic target for AML. These results suggest that new treatment modalities, such as therapy with a FLT3 tyrosine kinase inhibitor, are clearly needed for this group of patients with “standard risk” profile.

The percentage of myeloperoxidase-positive blast cells is a strong independent prognostic factor in acute myeloid leukemia, even in the patients with normal karyotype.

To examine whether the percentage of myeloperoxidase (MPO)-positive blast cells is useful as a prognostic factor for acute myeloid leukemia (AML), cytochemical analysis of MPO was performed in 491 patients who were registered to the Japan Adult Leukemia Study Group-AML92 study. Patients were divided into two using the percentage of MPO-positive blast (high [>or=50%] and low (<50%)). Complete remission rates were 85.4% in the former and 64.1% in the latter (P=0.001). The overall survival (OS) and the disease-free survival (DFS) were significantly better in the high MPO group (48.3 vs 18.7% for OS, and 36.3 vs 20.1% for DFS, P<0.001, respectively). Multivariate analysis showed that both karyotype and the percentage of MPO-positive blast cells were equally important prognostic factors. The high MPO group still showed a better survival even when restricted to the intermediate chromosomal risk group or the patients with normal karyotype (P<0.001). The OS of patients with normal karyotype in the high MPO group was almost equal with that of the favorable chromosomal risk group. The percentage of MPO-positive blast cells is a simple and highly significant prognostic factor for AML patients, and especially useful to stratify patients with normal karyotype.