Risk Karyotype Research Articles

Differences In Clinical Characteristics and Prognostic Features Between Patients with Myelodysplastic Syndromes (MDS) From Korea, Japan, and Germany

AbstractAbstract 1882Evidence exists for differences between eastern and western type MDS. However, for the development of the IPSS Score, 6 of the participating study groups were European or US, while only one group originated from Japan.In order to find out more about the differences in MDS patients (pts) from separate ethnic groups we performed an analysis of 1048 pts from Dusseldorf, Germany (G), 242 pts from Seoul, Korea (K), and 143 pts from Saitama, Japan (J). Initially, we compared clinical characteristics. Then we evaluated the influence of important prognostic factors. For all pts included at least the parameters needed to determine the IPSS had to be available. For survival analyses pts who received induction chemotherapy or allogeneic transplantation were excluded.Median age was 66 yrs in Germany, 54 in Korea, and 68 in Japan. The distribution of gender, with a male preponderance, was comparable in all cohorts. Median blast count was <5% in all groups. Median cell counts were significantly lower in the Japanese and Korean, when compared to the German pts. However, although Asian pts tended to have more severe cytopenias regarding all 3 lineages, they also had a significantly higher percentage of refractory cytopenias with unilineage dysplasia (21% (K) and 36% (J) compared to 7% (G)). MDS with del5q was significantly more frequent in German pts (9 vs 0 vs 1%) as well as RCMD (40 vs 22 vs 18%), while the frequency of RAEB I/II was comparable. Due to the high incidence of pancytopenia Asian pts rarely had a low risk IPSS (2% (K), 12% (J) vs 27% (G)), while the int I risk group was larger and int II and high risk groups were of almost the same size. Regarding karyotype (KT) risk according to IPSS, the intermediate risk group was smaller, and the low risk group was larger in Asian pts.To evaluate the relevance of different prognostic factors we first compared the whole cohorts of not intensively treated pts. Since the result was all factors analyzed were important in German while many were not in Asian pts we decided to look at a smaller subgroup of German pts to compare similar sizes. Pts were chosen by chance to avoid any kind of bias by matching. The results are presented in table 1. Already survival was very different in the 3 groups: 31 months (ms) (G) vs 43 ms (K) vs 157 ms (J). In univariate analysis in German pts variables with significant influence on survival were Hb, sex, age, LDH, platelets, blast count, KT, and IPSS, while in the Korean and Japanese pts the 3 different cytopenias and LDH had no influence on survival (except a borderline influence of Hb in Japanese pts). Very striking was the importance of gender in the 2 Asian countries. In both men lived for a median of only about 2 years, comparable to German pts, while women had a very long survival with median not reached. Regarding KT risk, the intermediate risk group had in the Asian countries a significantly longer survival than in Germany (nr vs 24 ms), possibly due to a high frequency of +8. The IPSS divided, again in both Asian countries, 2 different risk groups, but not 4. Multivariate analysis identified Hb, platelets, blasts, LDH, age, and KT as independent risk factors for German pts, compared to ANC, blast count, and age in Korean, and blast count plus KT in Japanese pts.It is established that survival of Asian MDS pts is longer than that of European, but it remains unclear why there is such a strong difference between Korean and Japanese pts although the former are younger and most other features are very comparable between the two. The most striking features of Asian MDS are the strong influence of gender, as well as the lesser importance of cytopenias compared to European pts. This, together with a slight difference in the survival according to KT, leads to an inferior separation of risk groups by the IPSS. The most important factor with equal relevance in all MDS pts remains blast count.Table 1:Germany n = 250Korea n = 224Japan n = 139survival/ms psurvival psurvival pall pts3143157Hemoglobin </≥10 g/dl24 vs 520,0236 vs 73ns145 vs nr0,01Sex m/w24 vs 390,00517 vs nr<0.0000530 vs nr<0.00005Age </≥ 60 years61 vs 240,0004100 vs 16<0.00005207 vs 1010,01LDH </≥ 240 U/l21 vs 520,000116 vs 40ns145 vs 174nsPlatelets </≥ 50000/μl17 vs 47<0.0000533 vs 53ns98 vs 207nsANC </≥1000/μl31 vs 33ns40 vs. 52ns101 vs 174nsKT -risk42 vs 24 vs 10<0.0000553 vs nr vs 120,001207 vs nr vs 22<0.00005Blast count </≥ 5%61 vs 22<0.00005100 vs 16<0.00005207 vs 20<0.00005IPSS82 vs 31 vs 23 vs 8<0.00005nr vs 73 vs 16 vs 12<0.0000598 vs nr vs 21 vs 22<0.00005 Disclosures:No relevant conflicts of interest to declare.

Allogeneic Stem Cell Transplantation for Secondary or Therapy-Related Acute Myeloid Leukemia or Myelodysplastic Syndrome with Poor-Risk Cytogenetics.

AbstractAbstract 3470 Introduction:Allogeneic stem cell transplantation (alloSCT) represents a curative treatment option for the post-remission therapy of patients with acute myeloid leukemia (AML) or myelodysplastic syndrome (MDS). The presence or absence of distinct karyotypic abnormalities has a substantial impact on the risk of relapse and overall outcome. In particular, complex, i.e. ≥3, chromosomal aberrations are associated with a poor outcome. Patients and Methods:We retrospectively analyzed 91 patients (47 female, 44 male) with secondary AML or therapy-related AML (n=50; CR1: n=22, CR>1: n=2, no CR: n=24) or MDS (n=41; RA/RCMD: n=14, RAEB-1: n=11, RAEB-2: n=16) who underwent alloSCT at our center between 1995 and 2008. An intermediate-risk karyotype was present in 47 patients, whereas 38 patients had a poor-risk karyotype. Among those, 22 patients had aberrations of chromosome 5 and/or 7. 45 patients were treated with standard myeloablative conditioning (MAC) (12 Gy total body irradiation, 2×60 mg/kg cyclophosphamide) prior to alloSCT, whereas 46 patients received reduced intensity conditioning (RIC) (fludarabine 6×30 mg/m2, busulfan 2×4 mg/kg, anti-thymocyte globulin 4×10 mg/kg). 35 patients had a matched-related donor (MRD) and 37 or 13 patients had a matched-unrelated (MUD) or a mismatched-unrelated (MMUD) donor. Results:After a median follow-up of 58 (12-170) months, 42/91 patients (46%) are alive and in CR. 20/91 patients (22%) succumbed to relapse and 27/91 patients (30%) died from treatment-related mortality (TRM). Projected OS (DFS) at 1, 3, or 5 years was 60% (55%), 52% (53%), or 50% (48%) and TRM was 27%, 27%, or 31%. Patients with a poor-risk cytogenetic profile had a significantly lower DFS as compared to patients with an intermediate-risk cytogenetics, i.e. 57% versus 36% at 5 years (p=0.04). However, within the group of patients with a poor-risk karyotype, those with aberrations of chromosome 5 and/or 7 had significantly lower OS (30% versus 50% at 5 years; p=0.03), or DFS (26% versus 50%; p=0.01) as compared to patients with complex aberrations. In contrast, the OS of patients with complex chromosomal aberrations excluding those who have chromosome 5 and/or 7 aberrations had a similar OS, DFS, or probability of relapse as compared to patients with an intermediate risk karyotype. Of note, in this subgroup there was no statistically significant difference in OS or DFS between patients conditioned with either standard MAC or RIC. Likewise, there was no statistically significant difference between patients transplanted from a MRD or a MUD. Conclusions:Taken together, these results indicate that the presence of a poor-risk karyotype has a substantial prognostic impact in patients with secondary AML, therapy-related AML or MDS undergoing alloSCT. In particular, patients with aberrations of chromosome 5 and/or 7 are highest risk of relapse. Nonetheless, a substantial proportion of these patients may achieve durable remissions following either standard or RIC-alloSCT. Disclosures:No relevant conflicts of interest to declare.

OUTCOME of Allogeneic Hematopoietic CELL TRANSPLANTATION for AML: A Single CENTER Retrospective ANALYSIS.

AbstractAbstract 4567 Background:Allogeneic hematopoietic cell transplantation (alloHCT) is a potentially curative treatment for patients (pts) suffering of AML with high risk features at diagnosis and beyond 1st complete remission (CR1) it remains the sole rescue treatment. In this retrospective study we analysed the data of all pts (149) allografted concecutively in our BMT unit for AML from 1991 to 2009. The aim of the study was to estimate the outcome in terms of overall survival (OS), disease free survival (DFS), relapse rate (RR) and non relapse mortality (NRM). Sixty-three pts of a median age 35 (8-63) years suffered from de novo (58), secondary (4) and biphenotypic AML (1) were transplanted in CR1. Cytogenetic analysis was available in 40/63 pts (intermediate 32, poor risk 8). Donors were siblings in 55, relative (1 antigen mismatch) in 3, unrelated (4 mismatched with 1–2 alleles) in 8 pts. Graft source was bone marrow (BM) in 12 and peripheral blood (PB) in 51 pts. Fifty-six received a myeloablative (MA) and 7 non- myeloablative (NMA) conditioning regimen. Eighty-six pts were allografted beyond CR1. Disease status was primary refractory (Prim. Ref) in 42/86, CR2 in 15, 1st refractory after re-induction relapse (Rel1) in 23 and advanced (CR3; Rel2+) in 6 pts. Three pts were retransplanted from the original donor for relapsed disease after alloHCT. In the cohort of pts with disease beyond CR1, cytogenetic analysis was available in 71 (favourable 4, intermediate 53, poor risk 14). Donors were siblings in 58, syngeneic (1 antigen mismatch) in 8, unrelated (3 with mismatch) in 17, unrelated double cord blood (CB) in 1, haploidentical in 5 pts. The majority of the pts received mobilized PB (72) as graft source and myeloablative conditioning regimen (82). Results:For pts transplanted in CR1 OS was 63%, NRM 23%, DFS 60% and RR 21% at 13 years. Seventeen pts transplanted before 2000 had an estimated OS and DFS 59%, RR 9% and NRM 35% whereas for forty-six pts transplanted after 1999 the OS was 64%, DFS 61%, NRM 17% and RR 25% at 9 years. DFS for pts in CR1 with an unrelated donor was 47% and 62% for siblings. Myeloablative regimen resulted in 65% DFS while NMA in lower DFS (21%) due to higher RR. According to cytogenetics OS and DFS were 62% and 64% for the intermediate risk group (n=32), 44% and 45% for the poor risk (n=8) respectively. For the cohort of pts transplanted for Prim. Ref. disease (n=42) OS was 20% (plateau at 3 years), DFS 17% (plateau at 2 years), RR 78% and NRM 34% at 12 years. Despite the small number of pts with poor risk karyotype (n=7) the prognosis seemed to be dismal (DFS and OS 0%) versus 25% and 31% respectively for the intermediate risk group (n=28). For pts transplanted in CR2 (n=15) OS was 51% and DFS 46% (plateau at 1year), RR 43% and NRM 16%. For pts in REL1 (n=23) OS was 15%, NRM 56%, DFS 4% and RR 86%. For the 6 pts transplanted for advanced disease (CR3; REL2+) OS was 17%, DFS 17%, RR 67% and NRM 50%. The 5 pts undergone haploidentical alloHCT (2 Prim. Ref., 2 CR2, 1 CR3) after TBI 8/thiotepa/fludara/ATG had OS and DFS 40% at 8 years. One of 3 pts retransplanted is alive in CR and the rest succumbed to their disease. Discussion:In 2010 when the use of alternative transplantation has been expanted the selection of pts upon the best stratification and the timing of the transplantation still remain open questions. The majority of patients are classified in the intermediate risk group with normal karyotype. According to our experience during the last two decades alloHCT for AML in early disease phase (CR1) can offer the best results and possibly cure in a significant number of patients (60%). Transplantation procedures have been continuously improved over time leading to improvement of the outcome mostly in the era of alternative donor alloHCT. For poor risk pts in CR1 and for all pts with AML beyond CR1 (apart from acute promyelocytic leukemia in molecular remission) alloHCT remains the only treatment option. In this cohort of pts results from our data indicate that pts in CR2 may attain long term survival after alloHCT (OS 51%, NRM 16%). Among pts refractory to induction and salvage treatment therapies (> CR2, Prim Ref., REL) a small proportion of pts (15-20%) may be rescued by alloHCT. Disclosures:No relevant conflicts of interest to declare.

Comparative Analysis of An Azacytidine Versus Azacytidine-HSCT Approach for the Treatment of Older Patients with AML/MDS

AbstractAbstract 2375While allogeneic HSCT remains the only curative option for patients with MDS, it is associated with considerable morbidity and mortality. 5-azacytidine (5-aza) has been shown to improve the overall survival (OS) of patients with int-2/high risk MDS when compared with best supportive care and conventional chemotherapy. The feasibility of 5-aza in the pre-transplant setting has been demonstrated allowing disease remission induction whilst minimising the toxicity of “induction” chemotherapy. However the additional benefit gained by patients receiving HSCT post 5-aza as compared to patients who receive continuous 5-aza therapy remains to be determined.We report on our single centre experience on the use of 5-aza in a cohort of 71 patients receiving 5-aza as de-novo therapy for high risk MDS/AML. The patients were classified into 2 cohorts. 41 patients received 5-aza in a non-intensive group (defined as patients with advanced age or significant co-morbidities precluding them from HSCT) and 30 patients received 5-aza induction therapy with the intention of proceeding to an allogeneic HSCT (intensive group). Patients in the non-intensive group were significantly older at start of 5-aza therapy than the intensive group (median age: 72 yrs vs 62 yrs, p=<0.01). There was no difference in the proportion of patients with advanced disease (int-2/high IPSS or AML) between groups (non-intensive: 80% vs intensive: 76%, p=0.76). Similarly, there was no significant difference in blast percentage at diagnosis or karyotype risk group between the non-intensive and intensive groups.In the intensive group, the median no. of cycles of 5-aza administered was 7(range 1–30). Out of 30 patients, 15(50%) patients did not proceed to transplant. 14 of these patients had disease progression while on 5-aza, out of which 11 patients received conventional chemotherapy. None of these 11 patients proceeded to HSCT primarily as a result of refractory MDS/AML or chemotherapy toxicity. 15(50%) patients attained a morphological remission (<5% bone marrow blasts) post-5-aza and eventually received a RIC HSCT (including two patients who received umbilical cord blood transplants). All transplanted patients had durable engraftment and the incidence of GVHD at 1 year post-transplant was 50%. At last follow-up, 6 patients who received HSCT were still alive. The actuarial OS at 1 yr post transplant was 35%+/−7%. Among the 41 patients in the non-intensive group, the median number of cycles of 5-aza received was 7 (range:1-46). At last follow-up, 8 patients (19%) were alive with 7 patients receiving ongoing 5 aza. The main reason for cessation of therapy was disease progression.In summary, only 50% of patients commencing 5-aza in the intensive group were subsequently able to receive an allogeneic HSCT. While the non-intensive group consisted of older patients, the median OS from start of 5-azacytidine was 22 months for both intensive and non-intensive groups. The 1 yr and 2 yr actuarial OS was 57%+/−8% and 24%+/−8% for the non-intensive group and 76%+/−8% and 17%+/−8% for the intensive group (p=0.76). While the development of RIC regimens has facilitated the expansion of allogeneic HSCT to older patients with AML/MDS, these findings suggest that in certain patients with co-morbidities, non-intensive novel therapies may be a preferable therapeutic option. Further studies in older AML/MDS patients to evaluate the benefit of novel agents such as 5-azacytidine when compared with HSCT are warranted. Disclosures:Mufti: Celgene: Consultancy, Honoraria, Research Funding, Speakers Bureau.

Second‐line mitoxantrone, etoposide, and cytarabine for acute myeloid leukemia: A single‐center experience

The majority of patients with acute myeloid leukemia (AML) will require second-line chemotherapy for either relapsed or refractory disease. Currently, only allogeneic hematopoietic cell transplantation (HCT) offers a curative option in this setting and no preferred regimen has been established. The reported efficacy of second-line regimens is widely disparate, thus limiting informed clinical decision making. A retrospective review of 77 patients receiving therapy between 2001 and 2008 with relapsed, 42, and refractory, 35, AML was performed to determine overall response rate and survival following mitoxantrone (8 mg/m(2)/day), etoposide (100 mg/m(2)/day), and cytarabine (1,000 mg/m(2)/day) chemotherapy administered over 5 days. Among 77 patients (median age of 54 years and 64% intermediate risk karyotype) with median follow-up of 153 days, 18% achieved a complete response and 8% a morphologic leukemia-free state. Fifty-seven (74%) experienced treatment failure, 10 of whom achieved a remission after additional therapy. Median overall survival (OS) was 6.8 months. Among patients achieving a response, 50% received consolidation with allogeneic HCT, autologous HCT (5%), or consolidation chemotherapy alone (45%). A nonsignificant trend in overall response (50%, 27%, and 23.8%) and median OS (8.3, 6.8, and 4.7 months) was observed by cytogenetic stratification into favorable, intermediate, and unfavorable risk. Patients with refractory versus relapsed disease had similar overall responses (20% and 31%, P = 0.41) and median OS (5.3 and 7.6 months, P = 0.36). Despite risk stratification by the European Prognostic Index, our series demonstrates inferior rates of response and survival, illustrating the limited activity of this regimen in our cohort.

A Randomized Phase 2 Study of Sapacitabine, An Oral Nucleoside Analogue, in Elderly Patients with AML Previously Untreated or in First Relapse.

Abstract 1061Poster Board I-83 Introduction:Sapacitabine is a novel nucleoside analogue with a unique ability to cause irreparable single-strand DNA breaks and induce G2 cell cycle arrest. It is orally administered and has demonstrated promising anti-leukemic activity against relapsed or refractory AML and MDS in a phase 1 trial. We are conducting a multi-center, open-label, randomized phase 2 study to evaluate 3 dose regimens of this drug in elderly AML. The primary objective is to evaluate 1-year survival rate. The study uses a selection design to identify a dose regimen which produces a better 1-year survival rate in the event that all three dose regimens are active. The planned sample size consists of 60 patients or 20 patients in each arm. The study also uses a Bayesian continuous monitoring rule to stop accrual in one or more arms of the study in the event that a dose regimen does not have a sufficient number of responses. Patients and Methods:Eligible patients must be ≥70 years with AML previously untreated or in first relapse, ECOG 0-2, creatinine ≤ 1.5 x ULN, total bilirubin or direct bilirubin ≤ 1.5 x ULN and ALT ≤ 2.5 x ULN or ≤ 5 x ULN if the liver is involved by leukemic blasts. Patients were randomized 1:1:1 to receive one of the 3 dose regimens: 200 mg b.i.d. x 7 days every 3-4 weeks (Arm A), 300 mg b.i.d. x 7 days every 3-4 weeks (Arm B), or 400 mg b.i.d. x 3 days per week x 2 weeks every 3-4 weeks (Arm C). There is no limit on the maximum number of cycles. The primary efficacy endpoint is 1-year survival. Secondary efficacy endpoints include the rate of CR, CRp, PR, CRi or hematological improvement (HI) and their corresponding response durations. Results:Between December 2007 and October 2008, 60 elderly patients with AML were enrolled and treated. Median age was 77 and 35% of patients were 80 years or older. Fifty-one patients had previously untreated AML and 9 patients had AML in 1st relapse. The majority of the patients (87%) had intermediate/unfavorable risk karyotypes and 45% of AML were preceded by an antecedent hematological disease (AHD). As of August 2009, 9 patients are still on study. The median number of cycles was 3 and 18 patients (30%) received ≥ 6 cycles. Four patients (7%) discontinued treatment for unacceptable toxicity. The overall response rate is 45% on Arm A (10% CR, 35% PR/major HI), 25% on Arm B (10% CR/CRp, 15% PR/major HI), 35% on Arm C (25% CR, 10% major HI). Median time to response is 3 cycles (range 1-9). Eight deaths of all causes occurred within 30 days of randomization and one death was considered to be possibly related to sapacitabine. According to interim safety data, common adverse events (all grades, regardless of causality) included fatigue, nausea, diarrhea, anemia, febrile neutropenia, thrombocytopenia and peripheral edema, most of which were mild to moderate in intensity. Conclusion:Sapacitabine is safe and active across all 3 dose regiments with the highest CR rate observed on the 3-day dose regimen (Arm C). Mature 1-year survival data will be presented at the meeting. Disclosures:Kantarjian:Cyclacel, Inc.: Research Funding. Garcia-Manero:Cyclacel, Inc.: Research Funding. Chiao:Cyclacel, Inc.: Employment, Equity Ownership.

Outpatient Treatment with Clofarabine in a Phase II Study of Older Adult Patients with Previously Untreated Acute Myelogenous Leukemia (AML).

Abstract 4162 IntroductionThe CLASSIC II trial previously reported an overall remission rate of 46% (38% complete remission [CR] and 8% CR with incomplete platelet recovery [CRp]), median duration of remission 56 weeks, median disease-free survival 37 weeks, median overall survival 41 weeks, and 30- and 60-day mortality rates 10% and 16%, respectively (JCO 2009; 27:371s, A.7062). Among the patients achieving remission, 75% achieved a CR or CRp after the first induction cycle and 25% after the re-induction cycle. This trial allowed physicians the discretion to treat patients with inpatient (IP) or outpatient (OP) clofarabine (CLO). This report describes the experience with OP CLO treatment. MethodsCLASSIC II was a single arm, Phase II study of patients ≥ 60 years of age with untreated AML with at least one unfavorable baseline prognostic factor (PF): age ≥70 years, ECOG performance status 2, antecedent hematological disorder (AHD), and/or intermediate/unfavorable risk karyotype. CLO was administered days 1-5 at 30 mg/m2 IV over 1hour during induction and at 20 mg/m2 during re-induction/consolidation for a maximum of 6 cycles. Patients with confirmed AML who received one dose of CLO were eligible for analysis. Results112 patients (median age 71 years) received a median of 2 cycles of CLO. Thirty-five (31%) patients received OP CLO for a total of 72 outpatient cycles (Table). This report will focus only on OP CLO in cycles 2-6, since only 2 patients received OP CLO in cycle 1. 66 patients initiated a second cycle of clofarabine (38 as re-induction; 28 as consolidation). 33/66 (50%) patients received at least 1 OP cycle of CLO for a total of 70 OP cycles (57% of all cycles 2-6). 12/33 received at least 2 OP cycles of CLO. Patients received a median of 1 OP cycle (range 1-5). All 70 OP cycles were administered for 5 OP days except for 2 cycles given for 2 OP days followed by 3 IP days (associated with OP toxicities: Grade 3 rash in 1 patient and increasing transaminase levels in 1 patient). For the 70 OP cycles, 42 (60%) cycles did not require any subsequent hospitalization, while 28 (40%) cycles required hospitalization. Baseline patient and disease characteristics and treatment toxicities for patients receiving OP versus IP CLO and the reasons for hospitalization after OP CLO will be presented at the meeting. ConclusionsOutpatient clofarabine can be safely administered to older patients with previously untreated AML and at least one unfavorable prognostic factor. OP CLO was primarily used for cycles 2-6, including both cycle 2 re-induction and consolidation. 60% of OP CLO cycles never required hospitalization. Proper patient selection, education, and monitoring for adverse events after OP CLO are necessary. OP CLO offers patients a more convenient option for treatment of their AML.TABLEInductionRe-InductionConsolidationCycle 1Cycle 2Cycle 2Cycle 3Cycle 4Cycle 5Cycle 6Number of patients and CLO cycles11238282316108OP study drug administration* (n=70 for cycles 2-6)2 (2%)12 (32%)18 (64%)14 (61%)11 (69%)8 (80%)7 (88%)OP cycles not requiring subsequent hospitalization (% OP cycles) (n=42 for cycles 2-6)0 (0%)4 (33%)8 (44%)10 (71%)8 (73%)6 (75%)6 (86%)OP cycles requiring subsequent hospitalization (% OP cycles) (n=28 for cycles 2-6)2 (100%)8 (67%)10 (56%)4 (29%)3 (27%)2 (25%)1 (14%)Days in hospital for OP cycles requiring hospitalization, median (range)22 (19-25)6 (2-17)11 (6-52)9 (1-11)8 (2-39)5 (5-5)7 (NA)*All OP cycles = 5 days except 2 patients with 2 days OP followed by 3 days IP Disclosures:Claxton:Genzyme: Research Funding. Myers:Genzyme: Employment. Erba:Lilly: Research Funding; Antisoma: Research Funding; Wyeth: Research Funding; Cephalon: Honoraria, Research Funding; MGI Pharma: Honoraria; Pharmion: Honoraria; Celgene: Honoraria; BMS: Honoraria; Novartis: Honoraria, Research Funding; Genzyme: Consultancy, Honoraria, Research Funding; Gemin-X: Research Funding; Kanisa: Research Funding. Faderl:Genzyme: Research Funding. Arellano:Genzyme: Research Funding. Lyons:Celgene: Consultancy; Johnson&Johnson: Consultancy, Honoraria, Speakers Bureau; GlaxoSmithKline: Consultancy, Speakers Bureau; Amgen Inc.: Consultancy, Honoraria, Research Funding, Speakers Bureau; Genzyme: Research Funding. Kovacsovics:Genzyme: Research Funding. Gabrilove:Genzyme: Research Funding. Warnock:Genzyme: Employment. Kantarjian:Genzyme: Research Funding.

Clinical Characterization and Proteomic Consequences of Mutated Ras in Acute Myeloid Leukemia.

Abstract 330▪▪This icon denotes an abstract that is clinically relevant. Background:Activating mutations in the Ras protooncogene occur in 12-27% of patients (pts) with acute myeloid leukemia (AML) & play an important role in leukemogenesis by conferring a proliferative advantage & an antiapoptotic phenotype. Recent data suggests that AML pts with mutated Ras (mutRas) may derive greater benefit from post-remission therapy with high dose cytarabine (AraC) than those with wild-type Ras (wtRAS). Additionally, newer molecularly targeted agents under development such as Mek inhibitors are directed at the activated Ras pathway. Aim:To establish the clinical characteristics of pts with AML & mutRas & explore proteomic differences in their leukemia cells. Methods:We reviewed the records of pts with newly diagnosed AML treated at our institution from 2003 – 2007 & analyzed their clinical characteristics & disease course based on Ras mutational status. Mutation analysis was performed on bone marrow (BM) samples for exon 1 (codons 12 & 13) & exon 2 (codon 61) of NRAS & KRAS using PCR-based DNA sequencing. Proteomic analysis of matched, banked, pretreatment pt BM samples was performed using a reverse phase protein array (Kornblau, Blood 1/2009). Results:A total of 620 pts with AML, in whom Ras mutational analysis was performed, were identified. These pts had been treated with several different regimens that could be broadly categorized as high dose AraC based (hAraC), conventional dose AraC based (cAraC), or non AraC based (nAraC). The median age of this cohort was 64 yrs (range 17–88). Sixty-six pts (10.6%) had mutRas, with a median age of 54 yrs (25–88). Compared to pts with wtRAS (median age 65 yrs), those with mutRas tended to be younger (59% ≤59 yrs (p=0.004)). Karyotypes represented in the mutRas cohort were: Diploid or –Y in 27 (49%); t(8;21) in 3 (4.5%); t(15;17) in none; inv(16) in 10 (15.2%); +8 in 8 (12%); -5/-7 in 8 (12%); 11q abnormality in 3 (4.5%) & other in 7 (10.6%). Compared to the wtRas cohort, inv(16) karyotype was significantly overrepresented (p<0.001) & the -5/-7 abnormalities were significantly underrepresented (p=0.026) in pts with mutRas. Among pts with inv(16) AML (n=26), 38% had mutRas. Among pts with -5/-7 abnormalities (n=143) 6% had mutRas. Pts with mutRas were less likely than those with wtRas to have an antecedent hematologic disorder (AHD) (48% vs. 64%, p=0.021) & more likely to have WBC >9.9 (p<0.001) & pretreatment BM blast count > 49% (p=0.01). Overall, across all therapies & karyotypes, there was no difference in CR rate, CR duration, or overall survival (OS) between mutRas & wtRas pts. In mutRas pts, there was no difference in CR rate between those treated with hAraC vs. cAraC, but a significantly higher rate of induction failure or primary resistance in those treated with nAraC (p<0.001). In pts with a poor risk karyotype, there was a trend towards a worse median OS in pts with mutRas compared with wtRas (12 weeks (wks) vs 29 wks; p=0.069). Among the pts with poor risk karyotype & mutRas, those who received hAraC induction had a median OS of 19 wks vs. 12 wks in those that received nAraC (p=0.078). In pts with intermediate risk karyotype & mutRas, there was a significant OS benefit for cAraC (median 119 wks) vs. hAraC (67 wks) vs. nAraC (17 wks) (p=0.018). Proteomic profiling was performed on 228 samples (198 wtRas & 30 mutRas) using reverse phase protein arrays probed with a validated panel of 176 proteins. Protein expression levels were significantly different between wt & mutRas for 37 proteins (false discovery rate = 8.8 proteins). The mutRas samples had significantly lower levels of activated apoptosis markers (cleaved caspase 3,7 & PARP) & had significantly higher levels of activated proteins along pathways downstream from Ras (pAKT, pMEK, pP38, pGSK3 & pEBP1). Samples from wtRas pts showed significantly higher levels of integrin-B3 & fibronectin. Conclusion:The inv(16) karyotype occurs frequently in adult pts with mutRas. Overall, pts with mutRas are younger, have a higher presenting WBC & BM blast counts, are less likely to have AHD, & benefit from induction with ara-C containing regimens. Pts with poor risk karyotype & mutRas may have a particularly adverse prognosis & should be considered for clinical trials evaluating new, risk-adapted strategies. Proteomic analysis of mutRas leukemia confirms constitutive downstream pathway activation, suggesting potential therapeutic targets, but also highlighting the need to inhibit multiple targets to overcome redundancy. Disclosures:No relevant conflicts of interest to declare.

Complete Response to Clofarabine Is Durable and Correlates with Survival in Previously Untreated Older Adult Patients with Acute Myeloid Leukemia (AML) and Unfavorable Prognostic Factors.

Abstract 2061Poster Board II-38 Background:We have previously reported efficacy and safety of clofarabine in patients = 60 with at least one unfavorable prognostic factor. Retrospective analyses have suggested that survival in AML is related to quality of response. [Estey, Clinical Advances in Hematology Oncology, 2008]. In this report, we present durability and survival data for complete responders in each of the prognostic subgroups in the CLASSIC II trial, and a landmark analysis to evaluate the relationship between complete response and survival. Methods:This single arm, Phase II, open-label study enrolled adults with untreated AML =60 years old with at least one adverse prognostic factor: age =70 years, ECOG performance status (PS)=2; antecedent hematological disorder (AHD); and/or intermediate/unfavorable risk karyotype. Clofarabine was given on days 1-5 at 30 mg/m2 during induction and 20 mg/m2 during re-induction/consolidation. Primary endpoint was ORR (CR + CRp). Secondary efficacy endpoints included duration of remission (DoR), disease-free survival (DFS) and overall survival (OS). Due to interest about outcome of CR alone with respect to remission durability, such secondary endpoints were analysed and are reported below for the overall population and for each prospectively defined prognostic subgroup. Analyses of overall survival (OS) using both best response and landmark timepoints were performed. Landmark analyses eliminate survivorship bias by evaluating the robustness of the relationship between response and survival in patients who survived until a landmark timepoint and using the response at this timepoint for assessment rather than best response. Since this analysis was defined post hoc, 3 analyses of median overall survival in patients who survived at least 30, 45, and 60 days were performed to eliminate time-to-response bias. Results:112 patients were evaluable. For patients with complete response (CR, n=42), median duration of remission (DoR) was 65 weeks (95% CI 41, not estimable [NE]), median disease free survival (DFS) 48 weeks (28, 65), and median overall survival (OS) 72 weeks (53, NE). Patients = 70 years (n=69) had 33% CR, median DoR and DFS 65 weeks (17, NE), and median OS = 48 weeks (48, NE). Patients with ECOG PS2 (n=25) had CR 24%, median DoR 7 weeks (6,NE), median DFS 9 weeks (6, 12), and median OS 16 weeks (12, 33). Patients with AHD (n= 41) had 39% CR; median DoR, DFS, and OS are NE. Patients with intermediate/unfavorable karyotype (n= 108) had 39% CR, median DoR 65 weeks (41, NE), median DFS 48 weeks (28, 65) and median OS 72 weeks (53, NE). Patients with unfavorable karyotype (n=62) had 32% CR, median DoR 56 weeks (28, NE), median DFS 33 weeks (23, 56), and median OS 59 weeks (48, NE). Median OS was 59.1 weeks (95% CI=49.9 weeks, NE) for CR + CRp; 33.4 weeks (95% CI=19.3, 55.0 weeks) for CRp; and15.4 weeks (95% CI=12.0, 29.9 weeks) for non-responders.In the landmark analysis, patients who had a complete response to clofarabine survived longer than non responders (Table 1), regardless of starting point (30, 45, or 60 days). The survival benefit of responders was statistically significant for all time points (p<0.05).Table 1:Sensitivity Analysis of Overall Survival by Complete Response using Landmark AnalysisLandmark Timepoint In DaysNumber of Responders (CR)Median OS for Responders1Number of Non-RespondersMedian OS Non-responders1Hazard Ratio (95% CI; p-value)0 days24272.47019.33.78 (2.15, 6.65; p<0.0001)30 days13NE8836.43.25 (1.17, 9.02; p=0.0234)45 days28NE6835.32.12 (1.09, 4.12; p=0.0266)60 days33NE6132.12.35 (1.25, 4.43; p=0.0082)NE=non-evaluable1Median number of weeks past the landmark time point2Note this analysis uses best response rather than response at landmark Summary/conclusions:CRs were consistent, durable, and associated with survival of > 13 months in all prognostic subgroups except PS2, and complete responders lived longer than non-responders. Achievement of a CR correlates with clinical benefit and survival in older AML patients. Single agent clofarabine is an effective treatment option for older adult patients with untreated AML and unfavorable prognostic factors. Disclosures:Gabrilove:Genzyme: Research Funding. Faderl:Genzyme: Research Funding. Erba:Lilly: Research Funding; Antisoma: Research Funding; Wyeth: Research Funding; Cephalon: Honoraria, Research Funding; MGI Pharma: Honoraria; Pharmion: Honoraria; Celgene: Honoraria; BMS: Honoraria; Novartis: Honoraria, Research Funding; Genzyme: Consultancy, Honoraria, Research Funding; Gemin-X: Research Funding; Kanisa: Research Funding. Claxton:Genzyme: Research Funding. Arellano:Genzyme: Research Funding. Lyons:Celgene: Consultancy; Johnson&Johnson: Consultancy, Honoraria, Speakers Bureau; GlaxoSmithKline: Consultancy, Speakers Bureau; Amgen Inc.: Consultancy, Honoraria, Research Funding, Speakers Bureau; Genzyme: Research Funding. Kovacsovics:Genzyme: Research Funding. Eckert:Genzyme: Employment. Huebner:Genzyme: Employment. Kantarjian:Genzyme: Research Funding.

Low-Level FLT3-ITD Mutations Do Not Predict for Higher Relapse Rate in AML with Standard Risk Karyotpye.

Abstract 1591▪▪This icon denotes an abstract that is clinically relevant.Poster Board I-617High-level FLT3-ITD mutations predict for a higher relapse rate and inferior survival among patients with standard risk karyotype AML. The influence of low-level FLT3-ITD mutations is less clear, although the MRC group (Gale et al, 2008) reported that low-level mutations are associated with an inferior prognosis as compared to an unmutated group. In the absence of FLT3-ITD, NPM1 mutations predict for a lower relapse rate. We analyzed outcomes of intensive chemotherapy in patients with standard risk karyotype AML (n=131) between 2004-2008. Patients received uniform induction chemotherapy consisting of cytarabine plus daunorubicin (7+3), followed by 2 consolidations consisting of high-dose cytarabine plus daunorubicin for pts under age 60 (n=96) or 7+3 followed by NOVE for pts age 60+ (n=35). Patients were divided into 3 groups based on the ratio of FLT3-ITD:FLT3-wt: There were 73 patients with negative FLT3-ITD (defined as FLT3-ITD:wt ratio < 0.01), 30 patients with low-level ITD (ratio > 0.01 – 0.37), and 28 patients with high-level ITD (ratio > 0.37). The mean presenting WBC was 32.2 ×109/L in the group with negative ITD, 49.4 ×109/L in the group with low-level ITD and 97.2 ×109/L in the group with high-level ITD (p < 0.0001). At a median follow-up of 19 months (range 2-95 months), the median OS of the entire group was 21.3 months. Patients with high-level ITD had a significantly inferior RFS (p = 0.0009) and OS (p = 0.003) as compared to the low-level and negative groups. Comparing the negative ITD and low-level ITD groups, there was no significant difference in RFS (p = 0.65) or OS (p = 0.18). The frequency of NPM1 mutations was not significantly different between these two groups (42% vs. 35%). These data were re-analyzed using a different cutoff according to % FLT-ITD positivity: negative < 1% (n=73), low-level 1 – 50% (n=42), high level > 50% (n=16). Using these ranges, the low-level FLT3-ITD group had a significantly lower CR rate (74% vs. 93%, p = 0.004) and OS (36% vs. 61%, p = 0.01) as compared to the group with negative FLT3-ITD, but there was no significant difference between these two groups with respect to RFS (2 year RFS 48% in low-level ITD group vs. 40% in negative ITD group). The high-level ITD group demonstrated significantly inferior RFS (p = 0.02) and OS (p = 0.01) as compared to the other two groups. These findings confirm the poor prognosis associated with high-level FLT3-ITD mutations due to high relapse rates. However, in contrast to previously reported data, we did not find that low level FLT3 –ITD mutations were associated with inferior RFS, although we did find, unexpectedly, that this low-level group had a lower CR rate. DisclosuresNo relevant conflicts of interest to declare.

Comparable Disease-Free and Overall Survival After “Well-Matched” Unrelated Donor and Matched Sibling Donor Transplantation in Acute Myeloid Leukemia with Adverse Risk Karyotype in First Complete Remission: A Report From the Acute Leukemia Working Committee of the Centre for International Blood and Marrow Transplant Research.

Abstract 526In patients with acute myeloid leukemia (AML) in first complete remission (CR1), the indications for matched sibling donor (MSD) transplants and unrelated donor (URD) haemopoietic stem cell transplantation (HSCT) are different. We sought to determine the prognostic impact of donor type on the outcomes of AML with adverse risk karyotype in CR1, a high-risk AML population considered as a standard indication for MSD and URD HSCT. We evaluated the outcomes of 584 patients undergoing allogeneic HSCT for AML with adverse risk karyotype in CR1 between 1995 and 2006, reported to the CIBMTR. Adverse risk karyotype was defined according to SWOG/ECOG classification. Cytogenetics abnormalities were further classified as: complex karyotype (3 or more abnormalities), 32%; and Non-complex divided as abnormal chromosome 7, 25%; chromosome 5, 9%; MLL gene rearrangements, 18%; t (6;9), 5%; and others, 10%. 226 patients underwent MSD and 358 URD. URD were classified based on high resolution typing as:” well matched” [n=254 (71%)] with no known disparity at HLA A, B, C, DRB1; and, “partially matched” [n=104 (29%)] with one locus known or likely mismatched. Previous MDS was present in 19% and 14% had therapy-induced (t-AML). Conditioning regimens were myeloablative and reduced intensity in 74% and 26%, respectively. At 3 years treatment-related mortality (TRM) incidence was 28% (95% CI 24-31); relapse 36%(32-40); disease-free survival (DFS) 36%(32-41) and overall survival (OS) 39%(35-44). Multivariate analyses are summarized in the table. “Well matched” URD and MSD yielded similar DFS and OS, while outcomes were significantly inferior for “partially matched” URD. Cytogenetically defined subsets had similar outcomes. Evaluated as a time-dependent covariate, chronic GVHD had a significantly lower risk of relapse (RR 0.68, p=0.046), while acute GVHD had no effect (RR 0.99, p=0.96). “Well matched” URD and MSD lead to similar DFS and OS in AML CR1patients with adverse risk karyotype. The pool of patients who may benefit from graft-vs-leukemia effect generated with allogeneic HSCT may be considerably expanded with “well-matched” URD HSCT. If a suitable MSD is not availabel, “well-matched” URD should be strongly considered where a MSD HSCT would otherwise be undertaken.TableDonor typeTRMRelapseDFSOSRR (95% CI)P-valueRR (95% CI)P-valueRR (95% CI)P-valueRR (95% CI)P-valueMatched sibling donor (n=212)1.001.001.001.00“Well-matched” URD (n=249)1.55 (1.02-2.37)0.041.04 (0.76-1.42)0.821.10 (0.86-1.40)0.441.06 (0.83-1.37)0.63“Partially matched” URD (n=99)3.04 (1.94-4.77)<0.0010.78 (0.48-1.24)0.291.38 (1.02-1.87)0.041.42 (1.04-1.94)0.03 Disclosures:No relevant conflicts of interest to declare.

Pre-Transplant Risk-Assessment for Patients with Acute Myeloid Leukemia (AML) Receiving Allogeneic Hematopoietic Stem Cell Transplants.

Abstract 2302Poster Board II-279 Purpose:The presence of comorbidities was shown to have a substantial impact of the outcome of patients undergoing cancer treatment. In chronic myeloid leukemia (CML) the EBMT risk score proofed to be highly valuable in predicting the outcome of patients following allogeneic stem cell transplantation (alloSCT). We therefore investigated, whether a slightly modified EBMT risk score may be used to predict the outcome of patients with AML following alloSCT. Patients and Methods:We retrospectively analyzed 233 patients with AML (median age: 47 years, range: 17 – 68 years) who underwent alloSCT at our institution between 1994 and 2007. 180 patients (77%) had de novo AML and 53 patients (23%) had secondary or therapy-related AML. A favorable karyotype was present in 11 patients (5%) whereas 101 (43%) or 82 patients (35%) had an intermediate risk or a poor risk karyotype. 131 patients (56%) received myeloablative conditioning (MAC) whereas 102 patients (44%) were conditioned using reduced intensity conditioning (RIC). The EBMT risk score was calculated analogous to the original score established by Gratwohl et al. (Lancet 352, 1998) and included the following variables: age (<20, 20-40 or >40 years), interval from diagnosis to alloSCT (<1 year or ≥1 year), disease stage (CR1, >CR1 or no CR), donor/recipient gender match (female donor/male recipient or other), and donor type (HLA-identical sibling or other). Altogether, 6 patients (3%) were younger than 20 years, 82 patients (35%) were between 20-40 years, and 145 patients (62%) were older than 40 years. The interval from diagnosis to alloSCT was <1 year in 180 patients (77%) and ≥1 year in 53 patients (23%). 121 patients (52%) were transplanted in CR1, 41 patients (18%) underwent alloSCT >CR1, and 71 patients (30%) had active (relapsed/refractory) disease at the time of alloSCT. A female donor/male recipient transplantation was performed in 59 patients (25%). Transplants were from a matched-related donor (MRD) in 103 patients (44%). A matched-unrelated or a mismatched-unrelated donor was chosen in 101 (44%) or in 28 patients (12%). Only 1 patient was transplanted from a haplo-identical donor. Results:After a median follow-up of 48 months (range: 6 – 170 months) for the surviving patients, 108 patients (46%) are alive, 101 (43%) of which are in continuous CR. Causes of death (total 125 patients (54%)) were relapse in 70 patients (30%), infections/graft versus host-disease in 54 patients (23%), or other (1 patient (0.5%)). At 10 years after alloSCT, projected overall survival (OS) or disease-free survival (DFS) were 41% or 39%. Non-relapse mortality (NRM) or incidence of relapse were 32% or 43%. Of the 233 patients, 30 (13%) had an EBMT risk score of 0-1, 48 (21%) had a score of 2, 50 (21%) had a score of 3, 40 (17%) had a score of 4, 51 (22%) had a score of 5, and 14 (6%) had a score of 6-7. OS in the different score groups were 67% (score 0-1), 50% (score 2), 48% (score 3), 33% (score 4), 23% (score 5), or 21% (score 6-7) and differed significantly between the groups (p=0.0005). NRM in patients with an EBMT risk score >4 as an abritary cut-off was significantly higher as compared to patients with a score ≤4 (53% versus 25%; p=0.009). Likewise, the incidence of relapse was significantly lower in patients with an EBMT risk score ≤3 as an abritary cut-off when compared those with a score >3 (31% versus 57%; p<0.0001). In univariate analysis, disease stage had a negative prognostic impact on OS (CR1: 54%, >CR1: 32%, no CR: 25%; p<0.0001). Likewise, OS in patients with a MRD was significantly higher as compared to patients with other donor types (MRD: 50%, other: 34%; p= 0.003). In contrast, age, interval from transplantation to alloSCT, and donor/recipient gender match did not influence OS in our analysis. Conclusions:These data indicate that a modified EBMT risk score may be used to predict the outcome of patients with AML following alloSCT. Disclosures:No relevant conflicts of interest to declare.

Lack of Inhibition of AKT Predicts Clinical Resistance to Therapy with Imatinib + Reinduction Chemotherapy in Relapsed/Refractory c-Kit+ Acute Myeloid Leukemia.

Abstract 2073Poster Board II-50Patients age 18-65 with acute myeloid leukemia (AML) who had persistent leukemia after 3+7 induction with cytarabine and daunorubicin, or relapsed within 24 months of achieving CR, and whose blasts were c-kit (CD117) positive, were enrolled in a phase I/II clinical trial with imatinib on Days 1-10 combined with mitoxantrone 10 mg/m2/day IV Days 4-8, etoposide 100 mg/m2/day IV Days 4-8 and cytarabine 1.5 g/m2 IV q12h × 4 doses on Days 9-10. Imatinib was escalated through 3 dose levels (200, 300, 400 mg daily) in successive 6 patient cohorts. The combination was well-tolerated up to 400 mg/day imatinib, and an additional 15 patients were enrolled at this dose level. Of the 21 patients treated at the 400 mg imatinib dose, 13 (62 %) achieved CR, 7 (33 %) were non-responders, and one died during reinduction. The CR rate was 82% (9/11) among patients with standard risk AML karyotpye, compared to 33% (3/9) for patients with adverse risk karyotype. The CR rate for primary 3+7 non-responders was 6/14 (43%) vs. 7/7 (100%) for relapsed patients. For 14 patients on the Phase II portion of the study, AML blasts from peripheral blood were assayed for pAKT and pERK by flow cytometry, after stimulation with stem cell factor, on Days 1 and 4, pre- and 1 and 2 hours post-imatinib dosing on each day. A heterogeneous response pattern was seen, with some samples exhibiting marked inhibition of pAKT and/or pERK after imatinib therapy, while others demonstrated little change in levels. Of 8 patients achieving CR with re-induction, 6 demonstrated marked (>50%) pAKT inhibition with imatinib therapy, 1 showed no inhibition, while 1 showed intermediate levels of inhibition. In contrast, all 6 non-responders to re-induction demonstrated a lack of pAKT inhibition with imatinib therapy (p<0.01). Of 5 patients with adverse risk karyotype, 4 demonstrated lack of pAKT inhibition with imatinib therapy and none of these responded to re-induction; the remaining patient whose blasts demonstrated pAKT sensitivity to imatinib did achieve CR with re-induction. In contrast pERK inhibition did not correlate with response to therapy. These results indicate that lack of pAKT inhibition in vivo correlates with resistance to re-induction therapy using this regimen. Further studies using agents that are able to inhibit AKT more effectively are warranted to try to overcome drug resistance in this setting. The treatment regimen appears active in relapsed patients, but this requires confirmation in a larger series. Disclosures:Off Label Use: Imatinib for c-kit positive AML.

Varying Importance of Prognostic Factors in Subgroups of Myelodysplastic Syndromes Defined by Blast Count, Cytogenetic Risk Group, or WHO Classification.

Abstract 2776Poster Board II-752 Introduction:We wondered whether prognostic factors have similar relevance in different subpopulations of MDS patients. Methods:Our analysis was based on patients with primary, untreated MDS, including 181 RA, 169 RARS, 649 RCMD, 322 RSCMD, 79 5q-syndromes, 290 RAEB I, 324 RAEB II, 266 CMML I, 64 CMML II, and 209 RAEB-T. The impact of prognostic variables in univariate analysis was compared in subpopulations of patients defined by medullary blast count, namely <5%, ≥5% (table), ≥10%, and ≥20% (not shown), as well as 3 subpopulations defined by the cytogenetic risk groups according to IPSS (table). Multivariate analysis of prognostic factors was performed for cytogenetically defined subgroups and WHO-subtypes./<5% blasts≥5% blastsCytogenetic risk groupgoodintermediatepoorLog-RankpLog-Rankp/Log-RankpLog-RankpLog-RankpHemoglobin </≥10g/dl76<0,000190<0,0001/24,1<0,00010,740,382,60,1Sex m/w140,00020,40,52/31<0,000130,0800,9Age </≥60years64<0,000110,50,001/42<0,00014,10,0410,3LDH </≥200U/l55<0,000133<0,0001/30<0,000110,20,00140,04Platelets </≥50000/μl29<0,000135<0,0001/4,80,0276,80,0091130,0003ANC </≥1000/μl40,0430,08/0,80,80,80,372,90,08WBC </≥20000/μl21<0,00013,80,051/17,9<0,000115,20,00014,40,03Transfusion y/n72<0,000168<0,0001/11,70,00060,30,530,08Fibrosis y/n100,00110,20,001/4,90,021,50,20,40,5Karyotype-risk51<0,000145<0,0001///////Blast count </≥ 5%/////36,6<0,00019,80,0018,90,02Blast count </≥ 10%/////54,7<0,00016,20,0112,40,0004Blast count </≥ 20%/////58,4<0,00013,10,0890,0026 Results:Strong prognostic factors in all blast-defined subgroups were hemoglobin, transfusion dependency, increased WBC, age, and LDH. However, all variables became less important in patients with ≥20% blasts (RAEB-T) and increased WBC was rare. Platelet count and cytogenetic risk groups were relevant in patients with <5%, ≥5%, and ≥10% marrow blasts, but not in RAEB-T. Marrow fibrosis was important in patients with <5% or ≥5% blasts, but not ≥10%. Gender and ANC <1000/μl were significant only in patients with a normal blast count. Furthermore, we looked for the effect of the karyotypes, relevant for IPSS scoring (-Y, del5q, del20q, others, del7q/-7, complex), and found a comparable influence on survival, irrespective whether patients had < or ≥5% marrow blasts.In subpopulations defined by cytogenetic risk groups, several prognostic factors were highly significant in univariate analysis, if patients had a good risk karyotype. These included hemoglobin, sex, age, LDH, increased WBC, transfusion need, and blast count (cut-offs 5%, 10%, and 20%). In the intermediate risk group only LDH, platelets, WBC, and blasts were significant prognostic factors, while in the high risk group only platelets and blast count remained significant.Multivariate analysis was performed for the cytogenetic risk groups and for subgroups defined by WHO subtypes. The analysis considered blast count (</≥5%), hemoglobin, platelets, ANC, cytogenetic risk group, transfusion need, sex, and age. In the subgroup including RA, RARS, and 5q-syndrome, LDH, transfusion, and age in descending order were independent prognostic parameters. In the RCMD+RSCMD group, karyotype, age, transfusion, and platelets were relevant factors. In the RAEB I+II subgroup, the order was hemoglobin, karyotype, age, and platelets, while in CMML I+II only hemoglobin had independent influence. In RAEB-T none of the factors examined was of independent significance. Looking at cytogenetic risk groups, in the favorable group, several variables independently influenced survival, namely transfusion, blasts, age, sex, and LDH (in this order). Interestingly, in the intermediate and high risk group, only blast count and platelets retained a significant impact. Conclusion:Univariate analysis showed prognostic factors (except ANC) included in IPSS and WPSS are relevant in most subgroups defined by marrow blast percentage. However, they all lose their impact if the blast count exceeds 20%. Regarding cytogenetic risk groups, several prognostic factors lose their influence already in the intermediate risk group. This underscores the prognostic importance of MDS cytogenetics. Multivariate analysis showed MDS subpopulations defined by WHO types also differ with regard to prognostic factors. In particular, CMML and RAEB-T stand out against the other MDS types. Disclosures:Kuendgen:Celgene: Honoraria. Hildebrandt:Celgene: Research Funding. Gattermann:Novartis: Honoraria, Participation in Advisory Boards on deferasirox clinical trials. Germing:Novartis, Celgene: Honoraria, Research Funding.

Comorbidity Indices Predict Survival Among Elderly Patients with Acute Myelogenous Leukemia but Do Not Aid in Selecting Between Traditional Induction Chemotherapy and 5-Azacytidine Treatment.

Abstract 1040Poster Board I-62Treatment of the elderly patient with acute myelogenous leukemia remains problematic as many have poor performance status precluding aggressive therapy and others have high risk features including abnormal cytogenetics. The success of 5-azacitidine among patients with advanced myelodysplastic syndromes in controlling blast cells and prolonging survival has led to its use in AML. However choosing between potentially curative hospital-based induction chemotherapy and palliative outpatient hypomethylating treatments is difficult. The availability of predictive comorbidity scores may aid in guiding patients in this decision. Methods:Patients with a new diagnosis of AML, ages 60 and older, were offered traditional in-patient induction therapy (7 days cytarabine 100 mg/m2 CI with 3 days idarubicin 12mg/m2) or out-patient therapy (5-azacitidine 75 mg/m2 IV 5 days per month). We report a retrospective review of clinical outcomes among patients treated between June 2003 and August 1, 2009. A review of presenting clinical features, placing patients into prognostic groupings by the Charlson Comorbidity Index (J Chronic Dis 1987; 40:373), Hematopoietic Cell Transplantation – Specific Comorbidity Index (Blood 2007; 110:4606), and the Myelodysplastic Syndrome – Specific Comorbidity Index (Blood 2008; 112: abstr 2677) was performed. Points for a diagnosis of leukemia were excluded from the indices. Results:99 patients with AML were treated at our center, all with leukemic blasts >20% (median 48%). 75 chose traditional 7+3 and 24 chose 5-aza. The median age was younger for those choosing 7+3 (67 vs 77 years, p<0.001). The median survival for all patients was 340 days (95% CI 258, 422). The median survival was longer with 7+3 at 367 days (95% CI 306,428) compared to a median survival with 5-aza of 186 days (95% CI 122, 250) (p=0.07). Only one patient age <65 chose 5-aza. The median survival for pts with 7+3 was similar by age groups: <65 yrs (n=34) 367 days, 65-69 yrs (n=19) 340 days, and ≥70 yrs (n=22) 467 days (log-rank p=0.31). Cytogenetic features (SWOG criteria) at baseline correlated with survival: good risk (n=3) 186 days, intermediate risk (n=54) 604 days, and poor risk (n=28) 241 days. (p=0.03). Similarly, cytogenetic risk continued to remain significant regardless of treatment choice: 7+3: intermediate/poor risk karyotype 664 days vs 340 days, and 5-aza: intermediate/poor risk 604 days vs 67 days (p=0.03). All 3 examined comorbidity indices were able to predict overall survival for the entire cohort (n=99). Using the CCI, better scores led to improved outcome (log-rank p=0.007): Score 0 (n=41): 475 days; score 1 (n=23): 213 days; score 2 (n=25): 196 days; score 3 (n=8): 186 days; score 4 (n=2) 1404 days. Similar results were obtained using the HCTS-CI (log-rank p=0.01): Score 0 (n=33): 475 days; score 1 (n=24): 353 days; score 2 (n=13): 146 days; score 3 (n=17): 196 days; score 4 (n=5) 1113 days; score 5 (n=5) 337 days; score 8 (n=1) 1404 days. And using the MDS-CI (log-rank p=0.02) better scores predicted improved survival: Score 0 (n=64): 375 days; score 1 (n=18): 241 days; score 2 (n=13): 186 days; score 3 (n=3): 69 days; score 4 (n=1) 1404 days. In addition, patients who scored well on the CCI did better (p=0.005) than patients with poor scores by type of treatment (ie, a low score patient treated with 7+3 did better than a high score patient treated with 7+3, and a low score patient treated with 5-aza did better than a high score patient treated with 5-aza). Similar relationships were noted between scores on the HCTS-CI and MDS-CI and treatment choice. However, in all CCI score categories, 7+3 treatment was superior to 5-aza (score 0: 839 vs 298 days; score 1: 276 vs 69 days; score 2: 279 vs 106 days; score 3: 435 vs 90 days) (p=0.08). Similarly 7+3 treatment appeared superior to 5-aza by HCTS-CI score (p=0.02) and MDS-CI (p=0.05). Conclusions:Elderly patients with AML can achieve survivals approaching one year with current treatment options. 5-azacytidine is a reasonable option for patients declining aggressive hospital based treatments especially if cytogenetic features are favorable, however overall survival may be inferior to standard induction chemotherapy. Although comorbidity indices are able to stratify potential outcomes among elderly patients with AML choosing a particular treatment, in our series we could not identify a comorbidity score that would dissuade aggressive treatment in favor of less intensive therapy. Disclosures:Goldberg:Celgene: Speakers Bureau. Off Label Use: 5-azacytidine use in AML. Masood:Celegene: Speakers Bureau.

Barriers to Reduced-Intensity Conditioning (RIC) Transplant in Patients with Chronic Lymphocytic Leukemia.

Abstract 1374Poster Board I-396 Introduction:Allogeneic stem cell transplantation is the only potentially curative therapeutic option for patients with CLL. However, in spite of recent improvements in transplant-related mortality due to the introduction of reduced-intensity conditioning (RIC), only a proportion of patients go on to receive a stem cell transplant. The aim of this study was to quantify how many patients are evaluated for transplant versus how many go on to transplant, and to examine the reasons why transplantation was not performed. Patients and methods:A list of all patients with CLL who have been referred to the Ohio State University for a transplant evaluation from January 2003 to the present was obtained. Two electronic databases, E-Results and TransChart, were reviewed to determine if a consultation was performed, if patients were subsequently transplanted, and if not, why. Results:The outcomes of the referrals are summarized in Table 1. From January 2003 to the present, 205 patients with CLL were referred to our center for a transplant evaluation. Of those, 34 (16.6%) underwent transplantation. For patients who did not receive a transplant, it was not indicated at the time of consult according to current standard of care in 37 patients (18%), and in 29 (14.1%), transplant was indicated but patients were unable to obtain a remission in order to proceed. The differences between patients who went on to transplant and those who could not obtain remission were analyzed more closely. The median age in the transplant group was 55, and the median age in the group that could not obtain remission was 58. Both groups received a median 2 lines of treatment prior to transplant evaluation. The cytogenetic abnormalities of the groups are summarized in Table 2. Conclusions:The majority of patients who did not undergo transplantation did not have an indication for transplant, reflecting previous standards of care prior to the understanding of the poor prognosis of patients with high risk karyotype and fludarabine-refractory CLL. In contradistinction, an inability to obtain a remission in order to proceed to transplantation was the second most common reason transplantation was deferred. These data reflect the difficulty in some cases of determining the appropriate timing for allogeneic transplantation in CLL and the risk of delaying a transplant referral in patients with fludarabine refractory disease. Appropriate timing of transplant referral and choice of effective salvage therapy are critical to the successful long-term management of patients with fludarabine-refractory CLL. [Display omitted] Table 2Cytogenetic abnormalityTransplantedNo remissionp valuedel17p11150.0968del11q320.577del13q240.263trisomy 12200.287del11q and 13q430.591del17p and 11q200.287del17p and 13q300.151del6q100.54t(14;19)310.369normal320.577unknown020.208Total3429 Disclosures:No relevant conflicts of interest to declare.

Comorbidity Is An Independent Prognostic Factor in AML: Comparison of Two Comorbidity Scores.

Abstract 3106Poster Board III-43 ObjectiveMany factors have been studied to predict outcome and allocate treatment in AML. The best established prognostic factors are karyotype and age. However, comorbidity may play an important role in the outcome of AML. We applied two comorbidity scores at the time of first admission in order to test this hypothesis. MethodsWe retrospectively analysed 198 consecutive patients with AML. All patients were included irrespective of the applied therapy. Karyotype risk group was 11.6 % good, 68.0 intermediate and 20.4 % poor risk, respectively. The median survival was 382 days. The median age was 62 years (range 20 – 81), 95 were male, 103 were female. The criteria of the Charlson Comorbidity Index (CCI) and the recently developed Hematopoietic Cell Transplantation-Specific Comorbidity Index (HCT-CI) were applied. However, the cut-offs were set lower than in the original publication in order to detect the possible impact of minor comorbidity. ResultsIn our study, the HCT-CI (left figure) separated clearly between patients with a score of more than one (dotted line), one (dashed line) and zero (continous line) (median survival: 100 vs 328 vs 718 days; log rank test p<0.0001). Similarly, the CCI separated the patients with more than one (dotted line), one (dashed line) and none (continous line) (median survival: 94 vs 293 vs 515 days; log rank test p<0.0001). Karyotype (p < 0.001), HCT-CI (p = 0.003) and age (cut-off 60 years; p = 0.006) we shown as independent risk factors by multivariate analysis. The CCI (right figure) separated only between patients with a score of zero (continous line) and those with at least one score point. Patients with one (dashed line) and patients more than one (dotted line) were not separated. [Display omitted] [Display omitted] ConclusionsOur findings show that HCT-CI is an additional prognostic factor in AML, at least in our cohort. We extend previous findings severalfold. Firstly, our analysis includes 90 patients younger than 60 years and was not restricted to patients older than 60 years.Secondly, we directly compared two comorbidity indices, showing that the HCT-CI discriminaates between three risk groups. Thirdly, we showed that comorbidity is an independent predictor for survival.In conclusion comorbidity seems to be an independent prognostic factor and should be studied prospectively to clarify its use for stratification in therapeutic studies. DisclosuresNo relevant conflicts of interest to declare.

IDH1 Mutations Are Detected in 9.3% of All AML and Are Strongly Associated with Intermediate Risk Karyotype and Unfavourable Prognosis: a Study of 999 Patients

Abstract LBA-3▪▪This icon denotes an abstract that is clinically relevant. Introduction:IDH1 is the gene coding for the soluble isocitrate dehydrogenease 1 (NADP+), which catalyzes the oxidative decaroxylation of isocitrate to 2-oxoglutarate. The gene has been shown to be frequently mutated in high-grade gliomas at residue p.R132, which is located in the substrate binding site of IDH1. So far, several other tumors have been analyzed without detection of the respective mutation (Bleeker et al., Human Mutation 2009). However, recently a next generation sequencing project found IDH1 mutated in 8.5% of AML with normal karyotype (Mardis et al., NEJM, 2009). Aim:To further evaluate the importance of IDH1R132 (IDH1mut) in AML we have analyzed a cohort of 999 comprehensively characterized AML cases. Methods:The respective base exchange was analysed by a LightCycler based melting curve assay with subsequent sequencing of the positive samples. Results:The cohort was comprised of 536 male and 463 female patients (median age: 65.9 years; range: 17.1- 93.3 years). 833 had de novo AML (83.4%), 122 AML following MDS (s-AML,12.1%) and 44 AML after previous treatment of different malignancies (t-AML, 4.4%). Karyotype was available in all cases: 681 had a normal karyotype (NK) AML, and 319 had chromosomal aberrations (t(15;17): n=29; inv(16): n=12, t(8;21): n=23, t(11q23): n=10, t(6;9): n=4, inv(3): n=3; -7: n=27, +8: n=29, +13: n=11, -Y: n=4; complex aberrant: n=60, others: n=106). Overall, in 93 pts IDH1 p.R132 mutations were detected (9.3%). Five different amino acid exchanges were observed: R132C (n=49), R132L (n=22), R132 H and G (n=7, each), and R132S (n=5). With respect to history of the patient IDH1mut were found in 80/833 of de novo AML (9.6%), 11/122 (9.0%) of s-AML, and 2/44 (4.5%) of t-AML, respectively (n.s.). More females (57/463, 12.3%) than males (36/536; 6.7%) had IDH1mut (p=0.003). Age was slightly higher in the mutated cases (63.9 vs. 61.9 years, n.s.). No differences were found for WBC count. IDH1mut were distributed differently between karyotypes: in NK 69/681 (10.1%) and in aberrant karyotypes 24/318 (7.5%). However, IDH1 was never mutated in inv(16), t(8;21), t(6;9), t(11q23), inv(3), or in complex aberrant karyotypes (n=112). In 2 of 27 cases (7.4%) with t(15;17) an IDH1 mutation was detected. Thus, the IDH1 mututations clustered in the intermediate risk karyotype group in comparison to the good or poor risk groups (91/771; 11.8% vs 2/134 (1.5%), p<0.001). The cohort was also characterized for several other molecular mutations. FLT3-ITD was present in 22% (212/954), FLT3-TKD in 6.7% (33/496), NPM1 in 35.4% (329/929), NRAS in 14.6% (48/328), MLL-PTD in 6.9% (64/932), CEBPA mutations in 7.4% (48/645) and RUNX1 mutations in 33.0% (99/299) of analysed cases, respectively. IHD1 mutations were found to be more frequent in NPM1 mutated than in NPM1wt cases (41/329; 12.4% vs 48/598; 8.0%, p= 0.019) and in those with MLL-PTD (11/64; 17.2% vs 77/867; 8.9%, p= 0.031). With lower frequencies IDH1mut were also detected together with RUNX1 mutations (n=8/99), CEBPA mutations (n=2/48), NRAS mutations (n=7/48), and FLT3-TKD (n=1/33). IDH1 was similarly distributed between FLT3-ITD mutated and unmutated cases (18/212; 8.5% vs. 72/744; 9.7%). In 22 (23.7%) of all IDH1mut AML no additional mutation was detected, whereas in 48 (51.6%) one additional, in 22 (23.7%) two additional and in one case three additional mutations were found. An unfavourable effect of IDH1mut on event free survival (EFS) was observed in the total group (median: 272 vs. 456 days; p=0.007) as well as in those with intermediate risk karyotype (median: 272 vs. 449 days; p=0.008). A shorter EFS of the IDH1mut was particularly seen in the NPM1wt cohort (median: 244 vs. 375 days; p=0.038) with a strong trend for an independent effect in a multivariate analysis (p=0.089). Conclusions:IDH1 mutations are frequent in AML and are prognostically unfavourable especially in the NPM1wt cohort. IDH1 mutations seem to be a new class of mutation probably complementing with the classical type 1 and type 2 mutations. Disclosures:Schnittger:MLL Munich Leukemia Laboratory: Equity Ownership. Haferlach:MLL Munich Leukemia Laboratory: Equity Ownership. Ulke:MLL Munich Leukemia Lab: Employment. Kaya:MLL Munich Leukemia Lab: Employment. Weiss:MLL Munich Leukemia Laboratory: Employment. Kern:MLL Munich Leukemia Laboratory: Equity Ownership. Haferlach:MLL Munich Leukemia Laboratory: Equity Ownership.

Expression analysis of proteins involved in the non homologous end joining DNA repair mechanism, in the bone marrow of adult de novo myelodysplastic syndromes

Myelodysplastic syndromes (MDS) are characterized by genetic instability which is associated with abnormal DNA repair mechanisms. The most lethal type of DNA damage are double strand DNA breaks (DSBs), which are mainly repaired by Non Homologous End Joining Mechanism (NHEJ), whose core enzyme components include the Ku70/Ku80 heterodimer, DNA-PKcs, XRCC4 and DNA Ligase IV. The aim of the present study was the analysis of expression of proteins required for NHEJ in bone marrow cells of adult de novo MDS and their association with clinical characteristics and prognosis. Our analysis included 48 cases of MDS; 19 RA, 5 RARS, 19 RAEB, 3 RAEB-T, 1 CMML, 1 transformation to AML according to FAB classification. The expression of the enzymes Ku70, Ku80, XRCC4, DNA-PKcs and Ligase IV was determined by Western Blotting. The mean Ligase IV expression value was significantly lower in MDS patients compared to normal controls (0.53 vs. 0.78, p = 0.03). A negative correlation was found between karyotype risk group and Ligase IV values. (p = 0.05). Moreover, Ku70 expression levels were significantly lower in patients with a good prognosis karyotype (p = 0.04). Furthermore, a negative correlation between Ku70 expression values and Hb levels was observed (p = 0.04). Finally, a positive correlation was observed between enzyme Ku70 expression values and level of blasts (p = 0.04). Our findings suppor-t a potential role of NHEJ enzyme Ligase IV in the pathogenesis of MDS. Larger numbers of cases need to be screened in order to draw definite conclusion.

Successful routine cytogenetic analysis from trephine biopsy specimens following failure to aspirate bone marrow

The clinical importance of determining marrow cytogenetics in haematological malignancy is well recognised (Greenberg et al, 1997; Grimwade et al, 1998) particularly with regard to the determination of prognosis and on occasion, diagnosis. Not infrequently, however, a ‘dry’ bone marrow aspirate (BMA) precludes successful cytogenetic analysis. In these circumstances, peripheral blood may be an option if circulating blast cells are of sufficient frequency to allow metaphase preparations, although this is often not the case. Over the last 5 years we have submitted a trephine sample (either an additional core or a piece of the initial core in standard tissue culture medium) to our local genetics laboratory in 20 cases where cytogenetic analysis was deemed necessary and marrow aspiration had failed. On receipt, these specimens were agitated gently by hand to free cellular material from the biopsy and subsequently processed using standard methodology. Adequate metaphases for analysis were obtained in five cases, a yield of 25%. The three cases featured illustrate the usefulness of this approach. Case 1. A 64-year-old female had a history of breast carcinoma, treated with surgery, adjuvant chemotherapy [Epirubicin/CMF (cyclophosphamide, methotrexate, 5-fluorouracil)], local radiotherapy and Tamoxifen, 3 years prior to presentation. In March 2005 she presented with shingles and was found to be pancytopenic. A blood film showed neither blasts nor obvious promyelocytes. The initial aspirate was a dry tap. Due to the possibility of a secondary haematological malignancy, a trephine core piece was sent for urgent cytogenetic analysis. This revealed translocation t(15;17). Induction chemotherapy was instituted immediately. The patient remains in remission following treatment on the Spanish arm of the acute myeloid leukaemia (AML) 15 protocol. Case 2. A 58-year-old female presented with anaemia and thrombocytopenia with dysplastic features on blood film. BMA was a dry tap. Trephine cytogenetics revealed monosomy 5 and 7 plus multiple complex abnormalities in keeping with the morphological diagnosis of acute panmyelosis. Unfortunately the patient died of sepsis and respiratory failure prior to treatment. Case 3. A 40-year-old male presented with a leucoerythroblastic film, thrombocytopenia and splenomegaly. Again an aspirate was not obtainable. Chronic myeloid leukaemia was suspected and the absence of the Philadelphia chromosome abnormality in all of 20 cells obtained helped exclude this diagnosis. Two further cytogenetic results were obtained from this method and revealed a normal karotype in both cases. In one young female patient with a diagnosis of acute lymphoblastic leukaemia, normal cytogenetics were obtained from 20 cells, excluding a high risk karyotype requiring allogeneic bone marrow transplantation in first remission. If it is not possible to achieve dividing cells through culture by this method, fluorescence in situ hybridization can, of course, be performed on non-dividing cells obtained by this sampling technique. This has resulted in a further seven successful analyses of the cellular material obtained from trephine cores. We recommend, in patients where cytogenetic analysis is of paramount importance to diagnosis and/or prognosis and marrow aspiration has failed, that a second trephine core be sent in standard transport medium. If a sufficiently long trephine is obtained, a section of this may be dissected and used rather than obtaining a second trephine. We believe the yield is sufficiently high enough to warrant this practice and can be performed at no additional cost to that of standard cytogenetic analysis from aspirates. As seen in the above cases, important information can be obtained to guide subsequent patient management using this very simple approach.