Standard Induction Chemotherapy Research Articles

Eradication of Measurable Residual Disease in AML: A Challenging Clinical Goal.

Simple SummaryRelapse is still a major problem in AML because it occurs in about 60–80% of patients, even those who have previously achieved complete remission (CR), defined by the presence of ≤5% bone marrow (BM) leukemic cells. Thus, since CR is unable to predict the relapse risk, significantly more sensitive techniques aimed at identifying AML cells in BM or peripheral blood, a parameter termed measurable residual disease (MRD), have been developed. Among them, RT-qPCR, which analyses appropriate molecular markers, and multiparameter flow cytometry (MFC), which analyses aberrantly expressed antigens, have been identified as the methods of choice for MRD detection. Nowadays, various studies that assessed MRD by these techniques have provided compelling evidence that MRD positivity (MRD+) after standard induction/consolidation chemotherapy and before allo-HSCT is predictive of a very poor clinical outcome. In addition, other studies, which showed that MRD+ clearance even at late time points of the course of the disease may improve the disease clinical outcome, have further strengthened the relevance of MRD+. Thus, a complete MRD eradication, potentially attainable through novel innovative treatments, has emerged as an un-met clinical need in AML and is expected to improve our patients’ prognosis.In non-promyelocytic (non-M3) AML measurable residual disease (MRD) detected by multi-parameter flow cytometry and molecular technologies, which are guided by Consensus-based guidelines and discover very low leukemic cell numbers far below the 5% threshold of morphological assessment, has emerged as the most relevant predictor of clinical outcome. Currently, it is well-established that MRD positivity after standard induction and consolidation chemotherapy, as well as during the period preceding an allogeneic hematopoietic stem cell transplant (allo-HSCT), portends to a significantly inferior relapse-free survival (RFS) and overall survival (OS). In addition, it has become absolutely clear that conversion from an MRD-positive to an MRD-negative state provides a favorable clinical outcome similar to that associated with early MRD negativity. Thus, the complete eradication of MRD, i.e., the clearance of the few leukemic stem cells—which, due to their chemo-radiotherapy resistance, might eventually be responsible of disease recurrence—has become an un-met clinical need in AML. Nowadays, this goal might potentially be achieved thanks to the development of novel innovative treatment strategies, including those targeting driver mutations, apoptosis, methylation patterns and leukemic proteins. The aim of this review is to analyze these strategies and to suggest any potential combination able to induce MRD negativity in the pre- and post-HSCT period.

Marrow Hypocellularity, but Not Residual Blast Count, Is Prognostic on Day-14 Assessment in Acute Myeloid Leukemia

Background: Standard induction chemotherapy for acute myeloid leukemia (AML) with “7+3” regimen consisting of cytarabine and daunorubicin (DNR) yields a complete remission (CR) rate of 40-80%. Current practice, endorsed by the National Comprehensive Cancer Network, is to perform a repeat bone marrow assessment on day 14 (D14) of initial induction. A blast count greater than 5-10% with a marrow cellularity of 10-20% at that time suggests residual leukemia and recommendation is for a second round of induction chemotherapy. Most studies only note blast count as the key value in decision making. Large studies have confirmed a prognostic value of D14 bone marrow biopsy based on blast percentage, yet controversy lies in its use as treatment decision point. In this single center retrospective study, we evaluated the role of cellularity on clinical outcomes in patients with residual morphologic blasts on day-14 bone marrow biopsy. Methods: All consecutive patients 18 years or older who received induction chemotherapy for newly diagnosed AML from 1/1/06 to 5/1/13 at the Lifespan Cancer Institute were identified. Outcomes were followed until 5/1/17. On D14 marrow assessment, patients were determined to have residual leukemia if the morphologic blast count was ≥5%, deemed to have an intermediate response (IR) if blasts counts were 5-19%, and considered hypocellular if the cellularity was Results: Of 113 patients identified, 68 underwent D14 bone marrow biopsy and 35 had residual disease on D14 determined by blast count. Sixteen of these patients received reinduction. Nineteen had hypocellular bone marrows and 16 were non hypocellular. Between the hypocellular and non hypocellular groups no demographic or leukemia specific variables were significantly different (Table 1). In terms of outcome data, more patients with hypocellular D14 bone marrows attained an IR (12 of 19, 63%) compared to a non hypocellular marrow (3 of 16, 19%, p=.008). Furthermore, hypocellular D14 marrows showed improved post induction complete response (74% v. 31%, p=0.12) and improved median overall survival (17 v. 8.5 months, p=0.03, Figure 1) compared to non hypocellular D14 marrows. Based on logistic regression, there was no benefit for reinduction based on cellularity for either CR (OR 0.056, 95% CI 0.002-1.47) or OS (HR 1.96, 95% CI 0.4-9.6). Using a blast count of ≥5% on the day-14 marrow assessment as a positive screening test for residual leukemia demonstrated PPV of 42%, NPV of 79%, sensitivity of 53% and specificity of 70% for achieving CR. Using the alternative cutoff of Conclusions: In our single center retrospective review, we found that D14 bone marrow hypocellularity significantly predicted CR and OS in patients with residual morphologic blasts. We found no benefit to additional chemotherapy based on D14 marrow assessment in terms of attaining CR or improvement in OS. Furthermore, there was no benefit for reinduction based on D14 marrow cellularity using logistic regression. There is improved specificity for D14 bone marrow biopsy to detect residual disease when a morphologic blast cutoff of 20% or greater and bone marrow cellularity of 20% or greater is utilized. For those patients with residual blast counts over 20% and non hypocellular marrow, strong consideration should be made for clinical trial or novel therapeutic agent. Although these are relatively small numbers, this data underscores the continued value of D14 bone marrow morphologic assessment for prognostication. Download : Download high-res image (142KB) Download : Download full-size image Figure 1 . Disclosures Reagan: Teva: Membership on an entity's Board of Directors or advisory committees.

The Clinical and Biological Implications of Aberrant Alternative Splicing in Patients with De Novo, Non-M3 Acute Myeloid Leukemia

BackgroundAberrant alternative splicing (AS) were reported important in the pathogenesis and prognosis of acute myeloid leukemia (AML). Previous studies reported inferior outcomes in AML patients carrying mutations in genes encoding RNA-splicing proteins, which accounted for 18% of AML patients. However, whether aberrant AS is correlated with these mutations or carried clinical and biological significances in AML patients remain unknown. In this study, we aimed to answer these questions by a set of array data from a large cohort.Materials and MethodsA total of 171 newly diagnosed non-M3 AML patients, who received standard induction chemotherapy and had complete clinical and genetic information were enrolled. There were 20 healthy marrow donors for comparison. We extracted RNA from mononuclear cells (MNC) in the bone marrow (BM), followed by hybridization on the microarrays of Affymetrix Human Transcriptome Array 2.0, which contained >6 million distinct probes covering 44710 coding, 22829 non-coding transcripts, and exon-exon junctions. This comprehensive coverage facilitated investigation of the global splicing patterns. The splicing index (SI) of a probe in a gene was derived from the ratio between AML patients and normal controls in terms of the probe intensity divided by the gene expression level, i.e., SI = [(intensity of probe A in gene A) / (gene A expression level)] of AML patient / [(intensity of probe A in gene A) / (gene A expression level)] of normal control. When the value is less than 1, SI is defined as the negative reciprocal. SI had to be less than -2 or more than 2 to be denoted as an aberrant AS event. A gene with at least one aberrant AS event would be called an aberrant AS gene. SI values were log2 transformed and analyzed for the association with overall survival (OS) by the univariable Cox proportional hazards model. Functional annotation for significant aberrant AS events was performed by the Database for Annotation, Visualization and Integrated Discovery (DAVID) web tool with default settings. The aberrant AS events were then merged into a Least Absolute Shrinkage and Selection Operator (LASSO) regression, which identified the best subset of aberrant AS events for the prediction of OS. We adopted a leave-one-out cross validation scheme to identify the subset with the best performance. A beta value was assigned to each of the selected aberrant AS events by LASSO. Based on the results, we constructed a scoring system by a weighted sum of the selected features, where the weights were LASSO beta values. The scoring system was applied to predict OS and relapse-free survival (RFS).ResultsAt first, univariable Cox analysis identified 95 OS-associated aberrant AS events (P<0.01; n=171) in 69 coding and 6 non-coding genes. A DAVID analysis was performed to explore the functional relevance of these events. Of note, 41 of the involved coding genes were known involved in RNA splicing pathways (P=0.049). Furthermore, the aberrant AS genes were associated with AMPK signaling pathway (P=0.007), PI3K-Akt signaling pathway (P=0.025), and HIF-1 signaling pathway (P=0.042). We used a LASSO regression model to identify the subset of aberrant AS events that best predicted OS by a leave-one-out cross validation test. As a result, a simple scoring system of 9 aberrant AS events was developed. The system was composed of a weighted sum of aberrant AS events on APP, CD93, CT45A3, CUX2, PIK3R3, RORA, SCRN1, and ZSCAN31, and a non-coding transcript. A high score was predictive of inferior OS (Figure 1A; P<0.001; median survival, 18.0 and 108.1 months) and RFS (Figure 1B; P=0.005; median survival, 10.2 vs. 88.8 months; n=137). Patients with detectable mutations in spliceosome (n=16) did not have a higher aberrant AS score (P=0.589). Age, hemogram, cytogenetics, and FAB classification were not correlated with aberrant AS score, either. However, a higher score was predictive of lower complete remission rate (P=0.01), a higher relapse rate (P=0.006), and higher incidence of FLT-3 -ITD. In addition, multivariate analyses revealed a higher aberrant AS score as an unfavorable prognostic factor for OS and RFS (both P< 0.001) independent of age, WBC counts, cytogenetics, genetic mutations of NPM1 and CEBPA and FLT-3 -ITD (Table 1).We present the clinical significance and prognostic impact of an aberrant AS scoring system in de novo, non-M3 AML patients. Large prospective cohorts are needed to confirm our observations. [Display omitted] DisclosuresTang:Celgene International Sàrl: Research Funding. Yao:Celgene International Sàrl: Research Funding. Li:Celgene International Sàrl: Research Funding. Huang:Celgene International Sàrl: Research Funding. Ko:Celgene International Sàrl: Research Funding. Hsu:Celgene International Sàrl: Research Funding. Lin:Celgene International Sàrl: Research Funding. Wu:Celgene International Sàrl: Research Funding. Tsai:Celgene International Sàrl: Research Funding. Tien:Celgene International Sàrl: Research Funding.

Low Relapse Rate in Younger Patients ≤ 60 Years Old with Newly Diagnosed FLT3-Mutated Acute Myeloid Leukemia (AML) Treated with Crenolanib and Cytarabine/Anthracycline Chemotherapy

Background:While midostaurin, a pan-kinase inhibitor, represents an advance in the treatment of newly diagnosed patients <age 60 with FLT3-mutated AML, numerous challenges remain. In the RATIFY trial, approximately 40% patients relapsed after achieving a complete remission (CR) with chemotherapy plus midostaurin (Stone et al., NEJM 2017). Crenolanib is a potent type I FLT3 specific inhibitor, which can be safely administered at maximal doses in combination with 7+3 induction and high dose cytarabine (HiDAC) consolidation. We report the CR and relapse rates of patients <60 years old with FLT3-mutated AML who were treated with crenolanib combined with standard induction chemotherapy.Methods: Results from 29 patients in the trial (n=44) who were ≤60 years old with newly diagnosed FLT3-mutated AML are included. Patients received standard 7+3 induction with cytarabine 100 mg/m2 for 7d and either daunorubicin 90 mg/m2 (n=16) or idarubicin 12 mg/m2 (n=13) for 3d. Crenolanib 100 mg TID was administered continuously starting 24h after chemotherapy until 72h prior to the next chemo cycle. Re-induction was allowed in case of morphological evidence of residual leukemia. Consolidation cycles (up to 4) consisted of six doses of HiDAC q12h on days 1,3,5, (dosed at 3g/m2 for <60 yrs and 1g/m2 for 60 yrs) with crenolanib starting 24h after the final HiDAC dose in each cycle. Eligible patients proceeded to allogeneic hematopoietic stem cell transplant (HSCT). Maintenance crenolanib at 100mg TID was started after HiDAC or 30-90 days after HSCT for a maximum of 12 months.Results: 21 of 29 (72%) patients achieved a CR after one cycle of induction with cytarabine/anthracycline/crenolanib. An additional 3 patients achieved a CR either after re-induction (1 patient) or after treatment with HiDAC or HSCT (1 patient each).Of these 24 patients with complete remission, 18 received HiDAC consolidation (range 1-4 cycles). Sixteen underwent HSCT, including: matched unrelated (n=9), matched related (n=2) or haploidentical donor (n=2). One patient underwent a cord blood transplant. 8 patients did not receive a transplant (7 due to lack of donor, social issues or other comorbidities and 1 too early). The demographics of these 24 patients are presented in Table 1.23/24 patients in complete remission are currently in follow up (median follow-up of 14 months, range 5-26 months). One patient died in CR due to post-transplant complications. Two patients have relapsed. Of these two, one had a bone-marrow relapse 71 days after undergoing a haplo HSCT as his only consolidation therapy. The second patient's blasts harbored four mutations (FLT3-ITD, IDH1, TET2, MLL) with a WBC count of 181,000/µL at presentation. He had a CNS relapse 7 months after a haplo HSCT following one cycle of HiDAC. The overall survival (OS), disease-free survival (DFS) and cumulative incidence of relapse (CIR) curves are shown below.Conclusion: In patients aged ≤ 60 yrs with FLT3 mutated AML, induction treatment with cytarabine/anthracycline/crenolanib resulted in a CR in 24/29 (83%) patients. With a median follow up of 14 months, only one systemic and one isolated CNS relapse have occurred in these 24 patients who achieved a CR. These data suggest that adding crenolanib, a potent FLT3 inhibitor, to standard induction chemotherapy in younger patients with FLT3-mutated AML may be associated with a low relapse rate, especially if HSCT is routinely used. A phase 3 trial of crenolanib in combination with 7+3 vs midostaurin in combination with 7+3 is being initiated. [Display omitted] DisclosuresStone:Sumitomo Dainippon: Consultancy; Roche: Consultancy; Pfizer: Consultancy; Ono: Consultancy; Novartis: Consultancy; Juno Therapeutics: Consultancy; Jazz,: Consultancy; Janssen: Consultancy; Cornerstone: Consultancy; Astellas: Consultancy; Amgen: Consultancy; Agios: Consultancy; Celgene: Consultancy, Membership on an entity's Board of Directors or advisory committees; AbbVie: Consultancy, Membership on an entity's Board of Directors or advisory committees; DSMN: Consultancy. Walter:ADC Therapeutics: Research Funding; Aptevo Therapeutics: Research Funding. Jain:Arog: Equity Ownership. Collins:Arog: Research Funding; Agios: Research Funding; Celgene Corporation: Research Funding; BMS: Research Funding.

Frontline Azacitidine As a Bridge to Allogeneic Transplantation in Acute Myeloid Leukemia

Introduction: Treatment with the hypomethylating agent (HMA) azacitidine (AZA) has become a standard treatment option for older acute myeloid leukemia (AML) patients thought unfit for standard induction chemotherapy with infusional cytarabine and an anthracycline. AZA is generally well-tolerated, and carefully selected AML patients who achieve complete remission (CR) with frontline HMA therapy may subsequently improve to become suitable candidates for reduced intensity conditioning (RIC) allogeneic hematopoietic cell transplantation (HCT) (Lübbert 2009). However, there are very limited data available regarding the use of AZA as a bridge to HCT in AML. The purpose of this study was to evaluate remission status and survival outcomes in patients treated with upfront AZA who undergo HCT.Methods: All AML patients at our institution diagnosed between December 2015 and October 2016 who were initially deemed unfit for intensive chemotherapy and received frontline AZA as a direct bridge to HCT were included in this analysis. Remission statuses after AZA therapy, immediately before transplant, and following transplant were evaluated and categorized as CR, CR with incomplete platelet recovery (CRp), CR with incomplete hematologic recovery (CRi), refractory, or relapsed. Descriptive statistics were used for categorical and continuous variables. The Kaplan-Meier method estimated overall survival (OS) and leukemia-free survival (LFS).Results: Ten patients treated with frontline AZA proceeded directly to HCT; by comparison, during the same period, 17 patients in this age range who received upfront AZA at our institution did not undergo HCT. Of those patients proceeding directly to HCT, there was a male predominance (80%), and median age at diagnosis was 70.5 years (range 60-77; Table 1). Of the 10 patients bridged to HCT, 3 were favorable risk by NCCN guidelines, 3 were intermediate risk, 3 were poor risk, and 1 had an unknown risk status. All patients received 75 mg/m2 of AZA administered daily intravenously on days 1-7 of a 28-day cycle, for a median of 6 cycles (range 4-11), without delays or dose reductions. Four patients received other chemotherapeutic agents concomitantly with azacitidine.During AZA therapy, 5 patients achieved CR, 4 obtained CRi, and 1 was refractory (despite exhibiting a reduction in bone marrow blasts). All patients maintained their respective remission statuses following AZA therapy until immediately prior to HCT. Nine patients underwent haploidentical peripheral blood HCT, and 1 underwent matched related peripheral blood HCT. All patients received a RIC regimen consisting of fludarabine, cyclophosphamide, and total body irradiation as well as post-transplant cyclophosphamide. One patient died from septic shock early during his transplant admission and was included in survival analyses but did not undergo post-HCT disease assessment. At their first disease assessment following HCT, 3 patients achieved CR, 3 obtained CRp, 2 exhibited CRi, and 1 had relapsed. For the aggregate patient cohort, Kaplan-Meier analyses revealed a 1-year OS rate of 86% and a 1-year LFS rate of 75% (Figure 1). Median OS was 19.2 months (95% CI [12.0, N/A]), and median LFS was not reached during the study. Median follow-up time from diagnosis was 14.5 months (range 9.6-19.7).Conclusions: Treatment with AZA was well-tolerated and adequately effective to yield remissions in an older patient population that typically experiences poor outcomes with intensive chemotherapy. Such patients may sufficiently improve while in remission to then proceed with HCT. Frontline AZA can thus be used as a successful bridge to HCT in selected elderly AML patients who were originally considered unfit for standard induction. These results require validation in a larger cohort. [Display omitted] DisclosuresGrunwald:Incyte: Consultancy, Research Funding; Genentech: Research Funding; Alexion: Consultancy; Pfizer: Consultancy; Amgen: Consultancy, Research Funding; Forma Therapeutics: Research Funding; Celgene: Consultancy; ARIAD: Consultancy; Cardinal Health: Consultancy; Janssen: Research Funding. Trivedi:Pharmacyclics: Consultancy, Honoraria.

Simultaneous Identification and Stratification of Low Molecular Risk AML Patients Using a Single LSC17-Based Nanostring Assay at Diagnosis

Refractoriness to induction chemotherapy and relapse after achievement of remission are the main barriers to cure in acute myeloid leukemia (AML). Currently, most AML patients receive standard induction chemotherapy because risk stratification depends on cytogenetic and molecular tests that typically take weeks to return results. We recently reported a rapid 17-gene leukemia stem cell score (LSC17, Ng et al., Nature 2016) that can accurately determine risk within 24 to 48 hours of diagnosis. Patients with high LSC17 scores have poor outcomes with current treatments and could be enrolled in clinical trials evaluating novel upfront treatment strategies.A small subset of AML patients with normal cytogenetics, NPM1 mutation and no FLT3-ITD are classified as low molecular risk (LMR) and are considered to have better outcomes, but ~35% relapse within 2 years following conventional therapy. In our prior study, we derived an optimized, re-weighted sub-score for LMR patients in which only 3 of the 17 genes contribute to the calculated score (LSC3). A high LSC3 score identifies LMR patients who have worse outcomes following standard induction therapy, and who might benefit from novel frontline therapy. Currently however, the LSC3 score can only be employed for risk-adapted therapy decisions in the post-remission setting, as LMR patients are only identified following cytogenetic and molecular testing. Earlier identification of high-risk LMR patients will facilitate clinical trials of novel frontline therapy in this patient subset.To determine whether a subset of the LSC17 signature genes could be used to identify LMR cases at diagnosis, we applied sparse binomial regression to relate the expression of the 17 signature genes to LMR vs. non-LMR cases in a large training cohort comprising AML patients of all subtypes (GSE6891, n=495 patients including 48 [9%] LMR cases). The resulting 13-gene sub-score (LMR13) can accurately identify LMR patients in 6 large independent validation cohorts spanning n=1559 cytogenetically and molecularly diverse AML patients using gene expression data from several different platforms (Figure 1; microarray datasets: GSE37642, n=542, area under the receiver operating characteristic curve (AUROC)=0.88; GSE15434, n=251, AUROC=0.92; TCGA AML, n=183, AUROC=0.92; ALFA-0701, n=192, AUROC=0.89; RNA-Seq dataset: TCGA AML, n=169, AUROC=0.92; NanoString datasets: GSE76004, n=237, AUROC=0.96; PM AML, n=154, AUROC=0.86). Importantly, the LMR13 score for each patient can be calculated from the same NanoString assay used to determine the patient's LSC17 and LSC3 risk scores. The ability to identify LMR cases rapidly at diagnosis enhances the clinical utility of the LSC17 assay, as it will allow clinicians to use the most appropriate risk score (LSC3 vs LSC17) for all newly-diagnosed AML patients, and enable evaluation of novel upfront treatment strategies for higher-risk LMR cases. Furthermore, integration of our functionally defined stem cell gene list with patient survival data using statistical learning approaches provides a basis for ongoing characterization of the molecular pathways associated with clinical outcomes, irrespective of mutational profile. [Display omitted] DisclosuresNo relevant conflicts of interest to declare.

Somatic Mutations Associated with Myeloid Transformation of RUNX1 -Mutated Familial Platelet Disorders with Propensity to Myeloid Malignancies Using Targeted Next-Generation Sequencing

INTRODUCTIONRUNX1 is a master transcription factor associated with hematopoiesis. Germ-line RUNX1 mutations are associated with familial thrombocytopenia and platelet disorders with bleeding phenotype and propensity to myeloid malignancies (FPDMM), such as myelodysplastic syndromes (MDS) and acute myeloid leukemia (AML). Although only 40 families with germ-line RUNX1 mutations have been described, its autosomal dominant inheritance pattern and the finding that 50% of the families with more than one first degree relative with MDS and/or AML had RUNX1 mutations underscore the importance of this entity.Despite the elevated frequency of transformation to AML/MDS the array of somatic mutations involved in this process is not fully characterized. Here we describe three patients from two families who had a diagnosis of FPDMM, progressed to MDS and/or AML and had DNA samples available for Next-Generation Sequencing (NGS). METHODSWe identified five patients from two different family pedigrees with AML/MDS between 2014 and 2016. We've had access to DNA samples from three of these patients extracted from one of three sources (buccal swab, peripheral blood leukocytes, and bone marrow) throughout their follow-up. Patients agreed with sample collection after informed consent, according to the Declaration of Helsinki.NGS was performed using a custom-designed 48 gene panel related to myeloid malignancies, using the IonTorrent® sequencing platform as previously described (PMID: 28486043). RESULTSThe pedigrees of both families are described in Figure 1. Patient I-2 from pedigree 1 was diagnosed with acute lymphoblastic leukemia at age 57 and died shortly after. Her son, patient II-3 came to us initially with thrombocytopenia (80,000-100,000/ μl) and mild bleeding symptoms (bleeding assessment tool score: 3) 12 years prior to his AML diagnosis. He also had a colorectal cancer (treated surgically) diagnosed 6 months prior. At AML diagnosis, he had a normal karyotype and underwent standard induction chemotherapy and achieved a complete response. He received one cycle of consolidation with high-dose cytarabine and died shortly after due to metastatic colorectal cancer. His oral epithelial cell DNA sample from the beginning of follow-up was positive for a RUNX1 p.Arg166Ter mutation. Bone marrow (BM) DNA sample from the AML diagnosis showed an additional p.Arg204Ter RUNX1 mutation and an additional p.Gln139fs NFE2 mutation.Patients III-4 and III-5 from pedigree 2 belonged to a family with an extensive previous history of thrombocytopenia and AML. Patient III-5 came to us with thrombocytopenia (50,000-70,000/μl) 2 years prior his AML diagnosis. BM DNA obtained at this time was positive for a p.Arg201Ter RUNX1 mutation and for a p.Pro95Arg SRSF2 mutation. At AML diagnosis, his karyotype was normal and BM DNA was positive for a p.Gly12Asp NRAS mutation in addition to the aforementioned mutations. He underwent three cycles of induction and received a matched unrelated donor bone marrow transplant (BMT) while in refractory disease. He achieved a complete remission that lasted a year and is currently under treatment with hypomethylating agents. His oral epithelial cell DNA sample obtained prior his BMT was only positive for the RUNX1 p.Arg201Ter mutation.Patient III-4 had been followed up for thrombocytopenia for three years and presented to us with pancytopenia and multilineage dysplasia. BM DNA at the onset of pancytopenia showed a p.Arg201Ter RUNX 1 mutation, and emerging TET2 Ser471fs and NRAS Gly12Asp mutations. These findings are summarized in Table 1. CONCLUSIONSWe report a longitudinal DNA sequencing follow-up of three patients with FPDMM. Our findings highlight the heterogeneity of genetic pathways to myeloid transformation in FPDMM. Some of these, as loss of the functioning RUNX1, have already been described. However, here we report for the first time the association of NFE2 and NRAS mutations with myeloid transformation in FPDMM. [Display omitted] DisclosuresOzelo:Pfizer: Consultancy, Research Funding, Speakers Bureau; Roche: Consultancy, Speakers Bureau; CSL Behing: Consultancy; Shire: Consultancy, Research Funding, Speakers Bureau; Biogen: Consultancy, Research Funding, Speakers Bureau; Grifols: Speakers Bureau; Novo Nordisk: Consultancy, Research Funding, Speakers Bureau.

Over-Expression of ERG Predicts Poor Outcome in Acute Myeloid Leukemia

Introduction: Acute myeloid leukemia (AML) treatment aims at the eradication of all leukemic cells to achieve cure. Available treatments produce complete remission (CR) in up-to 80% of patients. However, ~60% of them will relapse. Various prognostic factors such as baseline white blood cell count (WBC), cytogenetics and mutations of FLT3 , NPM1 , CEBPA have been shown to affect the survival. The high expression of brain and acute leukemia cytoplasmic (BAALC) and ETS- related gene (ERG) has been associated with poor prognosis but due to limited prospective studies, their role as prognostic factors is still unclear. We aim to substantiate the prognostic value of BAALC and ERG expression in adult AML patients.Materials and methods: All patients included in this prospective study (N=149) between March 2012 and February 2015 underwent marrow for following investigations: (i) Cytogenetic analyses- by standard techniques of chromosome banding and FISH (ii) Mutation profiling of NPM1 , FLT3 -ITD and CEBPA by capillary electrophoresis and direct DNA sequencing. Long range PCR was done to detect KMT2A-PTD (MLL -PTD) (iii) BAALC and ERG expressions by quantitative real time PCR assays. Abelson (ABL ) gene was used as an internal control. According to the baseline median values of BAALC and ERG expression, patients were divided into high and low expressers.Patients received standard induction chemotherapy with daunorubicin 60 mg/m2 for 3 days and cytosine arabinoside 100 mg/m2 for 7 days. Marrow was done 21-28 days after start of chemotherapy. If marrow was in remission, then patients received 3 courses of consolidation therapy with 12-18 gm/m2 of cytosine arabinoside (HiDAC). Patients underwent allogeneic transplant if feasible according to molecular and cytogenetic risk.Statistical analysis was done using SPSS-21. Overall survival (OS) was defined as time from start of induction therapy to time to last follow up or death. Relapse free survival (RFS) was defined as time from achieving CR to time to relapse, death or last follow up if in CR. Results of the expression studies, cytogenetic and molecular groups were analyzed for their impact on OS and RFS. Variables known to have prognostic implications such as baseline WBC, cytogenetics risk groups and molecular markers were grouped according to high/low BAALC and ERG expressers. Comparison of these prognostic factors within high/low expressers was carried out by Chi-square method. Survival was calculated by Kaplan-Meier method and prognostic factors were compared by log-rank test. Multivariate analysis was carried out using the Cox proportional hazards model. All covariates whose univariate models reflected a P value less than 0.2 were considered for inclusion in the model.Results: A total of 149 patients were accrued. The median age of the cohort was 27 years (range 15-58 ) with male predominance (M:F =98:51). Of 149 patients, 105 achieved CR after 1 or 2 cycles of chemotherapy. Twenty-seven patients were refractory of which 18 were lost to follow up and hence excluded from OS analysis. Seventeen patients died during induction. The OS of 131 patients was 36.5% at 2 years. The OS and RFS of 105 patients who achieved CR was 54% and 43.8% respectively. The median value (60 BAALC copies /ABL and 58 ERG copies /ABL ) was used to distinguish high expressers from low expressers. At baseline, copy numbers of 149 patients ranged from 11.58 to 242.23 for BAALC and 16.2 to 328.2 for ERG. For BAALC , 69/149(46.3%) were high expressers as compared to 80/149 (53.7%) as low expressers. Concerning ERG , 76/149(51%) were high and 73/149(49%) were low expressers. The OS and RFS of high BAALC versus low BAALC expressers at 2 years was 13.8% vs 59.8% (p<0001) and 17.6% vs 72.1% (p<0001) respectively. Similarly OS and RFS of high ERG vs low ERG expressers at 2 years was 5.3% vs 66.4% (p<0001) and 5% vs 71.2% (p<0001) respectively (Figure).The median baseline WBC count was significantly higher in high BAALC/ERG expressers. There was no difference in distribution of FLT3 -ITD, NPM1, CEBPA, MLL -PTD and cytogenetic risk groups in high versus low BAALC and ERG expressers. Multivariate analysis showed that ERG overexpression was only prognostic factor affecting OS and RFS compared to high BAALC expressers, MLL -PTD mutation, cytogenetic risk groups and baseline WBC.Conclusion: This study shows that high ERG expression adversely affects prognosis of AML patients independent of other well known prognostic factors [Display omitted] DisclosuresNo relevant conflicts of interest to declare.

Preclinical and Early Phase 1 Clinical Data of AZD2811 Nanoparticle in AML, an Aurora B Kinase Inhibitor

Background: Aurora kinases are critically involved in several stages of mitosis and are a potential target for anticancer therapy in solid tumours and haematological malignancies. The aurora kinase B inhibitor AZD1152 (barasertib) has shown promising efficacy in elderly patients with untreated acute myeloid leukaemia (AML) with a 35.4% objective complete remission rate (CR+CRi) compared to low-dose AraC (11.5%) when given as a seven day continuous infusion. Responses were seen in all cytogenetic risk groups and tended to occur in the 1st or 2nd cycle of treatment. (Kantarjian HG et al., Cancer 2013). Methods and Results: AZD2811 nanoparticle is a novel, encapsulated slow release inhibitor of aurora kinase B which offers several advantages compared to AZD1152 (Ashton S et al., Sci Transl Med 2016). It can be administered as a short intravenous infusion and is currently in an ongoing clinical phase 1 study in solid tumours (NCT02579226). We have investigated the preclinical activity of AZD2811 nanoparticle in several subcutaneous xenografts and a disseminated AML disease model, both as a single agent and in combination with Ara-C (Floc'h N et al., Mol Cancer Ther 2017). The xenograft data indicate that AZD2811 nanoparticle reduces AML tumour growth in a dose-dependant manner. The AZD2811 nanoparticle, dosed at 98.7mg/kg administered on day 1, causes a durable >90% tumour regression for approximately 40 days in the HL-60 subcutaneous xenograft model and in the MOLM-13 disseminated tumour model increases median overall survival of the mice from 10 to 23.5 days (placebo vs treated mice) and reduces the human tumour burden within the mouse peripheral blood and bone marrow. In order to measure target engagement of AZD2811 nanoparticle, pharmacodynamic (PD) assays to quantify phospho-histone H3 levels and endoreduplication in tumour samples and peripheral tissues have been developed. Conclusion: Based on the promising clinical proof of principle data with AZD1152 and the preclinical evidence for AZD2811 nanoparticle, a clinical phase 1/2 study in elderly patients with newly diagnosed AML who are unfit for standard induction chemotherapy or in previously treated AML patients with relapsed disease has been initiated (NCT03217838). The study is currently enrolling patients in the dose escalation phase. DisclosuresBrugger:AstraZeneca: Employment, Equity Ownership. Ashton:AstraZeneca: Employment, Equity Ownership. Taylor:AstraZeneca: Employment, Equity Ownership. Hattersley:AstraZeneca: Employment, Equity Ownership. Wen:AstraZeneca: Employment, Equity Ownership. Maratea:Astrazeneca: Employment, Equity Ownership. Overend:AstraZeneca: Employment, Equity Ownership; GSK: Equity Ownership. Barry:AstraZeneca: Employment, Equity Ownership. MacDonald:AstraZeneca: Employment, Equity Ownership; GSK: Equity Ownership; Hoffman La Roche: Equity Ownership; Novartis: Equity Ownership. Pease:Astrazeneca: Employment, Equity Ownership.

Evaluation of the Correlation between Response and Duration of Treatment in a Phase 2 Study of Pracinostat Plus Azacitidine in Elderly Patients with Acute Myeloid Leukemia (AML)

Introduction: Inhibition of histone deacetylation and DNA hypermethylation induces re-expression of silenced genes in myeloid malignancies in a synergistic fashion. Pracinostat, a potent oral Class I, II, IV histone deacetylase (HDAC) inhibitor, in combination with azacitadine (AZA) showed promising efficacy in a Phase 2 study in patients ≥65 years with AML not eligible for induction chemotherapy (Garcia Manero, Blood 2016). The overall response rate (all complete/partial remissions) was 64% and the median overall survival was 19.1 months. An evaluation of somatic mutations in this study suggested that continued treatment after achieving a response either lowered the variant allele frequency or cleared residual mutations (Takahashi, JCO 2017). To further explore the benefit of continued treatment we conducted post-hoc analyses to determine the time to first response and assess whether there was a correlation between the duration of treatment and occurrence of a response.Methods: This was a multicenter, phase 2 study in 50 patients ≥65 years with untreated de novo or secondary AML (ie, > 20% bone marrow blasts) and intermediate/high-risk cytogenetics who were not candidates for intensive therapy due to co-morbidities and/or AML features. Treatment consisted of pracinostat 60 mg orally 3 days/week on alternate days for 3 weeks and AZA 75 mg/m2 either subcutaneously or intravenously daily for 7 days or a 5-2-2 schedule. Cycles were repeated every 28 days until disease progression, lack of response or poor tolerability. Time to marrow complete response (CR) was calculated and logistic regression modeling was used to assess the probability of a CR utilizing ECOG performance status (PS), cytogenetic risk, and duration of treatment as covariates.Results: The median age was 75 years (range 66-84 years). Most patients were male (28; 65%) with de novo AML (33, 66%), ECOG PS 0-1 (38; 88%) and with intermediate-risk (27; 54%) or high-risk (21; 42%) cytogenetics. Median bone marrow (BM) blasts at entry were 40% (range 20%-89%). The median number of treatment cycles was 6.5 (range 1-27+). While 27 patients (54%) received ≥5 cycles, 13 (26%) received only 1-2 cycles. Median time to BM blasts <5% was 2 cycles (57 days; range 25-243); however, 3 patients (12%) required >6 cycles to respond. Of the 21 patients (42%) achieving a morphologic CR, 15 (71%) achieved this after at least 100 days of therapy. The logistic regression analysis indicated a statistically significant correlation between treatment duration and occurrence of CR.With a median follow-up of 24.2 months (range 14.7-32.9), 19 patients (38%) discontinued due to progressive disease, 11 (22%) due to patient or investigator decision and 14 (28%) due to adverse events, the majority of which were fatigue, failure to thrive, neutropenia, or thrombocytopenia. Of these, 6 patients discontinued during the first 3 cycles, 2 between cycles 4-6, and the remaining 6 after cycle 6. No unexpected toxicities were observed with the combination of pracinostat and AZA.Conclusions: A high response rate with pracinostat + AZA has been previously reported in this study of elderly patients with AML. These post-hoc analyses suggest that while marrow remission may be achieved early, prolonged exposure is likely to be beneficial in maximizing clinical response. A phase 3 study of pracinostat in combination with AZA in untreated patients with AML unfit for standard induction chemotherapy is ongoing. In that study it is recommended that patients who have no evidence of disease progression should receive a minimum of 6 cycles of study treatment, if and when possible, to maximize the likelihood of a response to treatment. DisclosuresAtallah:ADC Therapeutics: Research Funding. Khaled:Daiichi Sankyo, Inc: Other: Travel Support; City of Hope: Research Funding. Spezia:Helsinn: Employment, Patents & Royalties: co-inventor. Palmesino:Helsinn: Employment.

A Genomic Signature Predicting Venetoclax Treatment Response in Acute Myeloid Leukemia (AML) Identified By Protein Network Mapping and Validated By Ex Vivo Ddrug Sensitivity Testing

A Genomic Signature Predicting Venetoclax Treatment Response in Acute Myeloid Leukemia (AML) Identified By Protein Network Mapping and Validated By Ex Vivo Ddrug Sensitivity Testing

Genetic Ontogeny Defines Distinct Prognostic Subgroups in AML Patients Age 60 and Older Following Hematopoietic Stem Cell Transplantation

▪BackgroundThe prognosis for older adults diagnosed with acute myeloid leukemia (AML) is poor. The response to conventional chemotherapy in these patients is frequently brief, and long-term survival is largely limited to those who undergo allogeneic hematopoietic stem cell transplantation (HSCT). However, mortality after transplantation HSCT is also high, with deaths attributable both to relapsed AML and to transplant-related complications. There is thus a critical need for strategies that can reliably discern older AML patients who are most likely to benefit from current transplantation approaches and those for whom novel approaches should be developed.We have previously shown that genetic characteristics can divide AML patients into three clinically distinct categories: (1) TP53 -mutated AML; (2) “secondary-type” AML, defined by mutations in any of eight genes with high specificity for the presence of antecedent myelodysplastic syndrome; and (3) “de novo” type AML, defined by absence of TP53 and secondary-type mutations. We showed that older patients with de novo-type AML have improved response to standard induction chemotherapy and significantly superior event-free survival than those with either secondary-type or TP53- mutated AML. Since disease burden prior to HSCT has been linked to post-HSCT outcomes, we hypothesized that diagnostic ontogeny classification would be associated with relapse and survival among older AML patients receiving HSCT in first complete remission.MethodsWe identified AML patients age 60 or older who underwent HSCT at Dana-Farber Cancer Institute (DFCI; Boston, MA) in first complete remission between 2012-2016, for whom next-generation sequencing of the diagnostic AML sample was available. Based on targeted gene panel sequencing of recurrent myeloid driver alterations, we classified AML as TP53 -mutated, secondary-type (SRSF2, SF3B1, U2AF1, ZRSR2, BCOR, ASXL1, EZH2, or STAG2 mutations), or de novo type (neither TP53 mutation nor secondary-type mutations). We extracted data on clinical outcomes from the medical record and assessed the impact of diagnostic AML genetics on overall survival and cumulative incidence of relapse following HSCT.ResultsFifty-five patients met inclusion criteria, with a median age of 67 (range 60-76). All had received intensive induction chemotherapy; nine (16.4%) received myeloablative conditioning regimens, while the remainder received reduced intensity regimens. Of the 55 patients, 13% (n=7) had TP53 mutations, 40% (n=22) had secondary-type mutations, and 47% (n=26) had de-novo type mutations. Patients with de-novo type mutations had significantly superior 2-year overall survival than those with secondary-type mutations, who in turn had significantly superior survival than those with TP53 mutations (82.2% versus 48.1% versus 14%, p<0.001 for all comparisons, Figure 1A). These differences reflected a significant difference in the 2-year cumulative incidence of relapse following HSCT (100% for TP53 versus 56.7% for secondary-type versus 33.4% for de-novo type mutations, p<0.001 for all comparisons, Figure 1B).ConclusionIn our cohort of older AML patients who underwent HSCT in first complete remission after intensive induction chemotherapy, genetic ontogeny classification at the time of diagnosis was significantly associated with overall survival and rate of relapse after HSCT. Our findings, which merit further evaluation in a larger cohort, suggest that genetic classification of ontogeny can form the basis of a robust prognostic model that accurately predicts post-HSCT outcomes in older AML patients. [Display omitted] DisclosuresKoreth:Amgen Inc.: Consultancy; Millennium Pharmaceuticals: Research Funding; Prometheus Labs: Research Funding; Kadmon Corp: Membership on an entity's Board of Directors or advisory committees; Takeda Pharmaceuticals: Membership on an entity's Board of Directors or advisory committees. Nikiforow:Kite Therapeutics: Membership on an entity's Board of Directors or advisory committees. Armand:Sigma Tau: Research Funding; Sequenta/Adaptive: Research Funding; Affimed: Research Funding; Infinity: Consultancy; Bristol-Myers Squibb: Consultancy, Research Funding; Genmab: Consultancy; Roche: Research Funding; Pfizer: Consultancy, Research Funding; Merck & Co., Inc.: Consultancy, Research Funding; Tensha: Research Funding; Otsuka: Research Funding. Antin:Gentium SpA/Jazz Pharmaceuticals: Membership on an entity's Board of Directors or advisory committees. Lindsley:MedImmune: Research Funding; Jazz Pharmaceuticals: Consultancy; Takeda Pharmaceuticals: Consultancy.

CPX-351 versus 7+3 cytarabine and daunorubicin chemotherapy in older adults with newly diagnosed high-risk or secondary acute myeloid leukaemia: 5-year results of a randomised, open-label, multicentre, phase 3 trial

Daunorubicin and cytarabine are used as standard induction chemotherapy for patients with acute myeloid leukaemia. CPX-351 is a dual-drug liposomal encapsulation of daunorubicin and cytarabine in a synergistic 1:5 molar ratio. Primary analysis of the phase 3 trial in adults aged 60-75 years with newly diagnosed high-risk or secondary acute myeloid leukaemia provided support for approval of CPX-351 by the US Food and Drug Administration and European Medicines Agency. We describe the prospectively planned final 5-year follow-up results. This randomised, open-label, multicentre, phase 3 trial was done across 39 academic and regional cancer centres in the USA and Canada. Eligible patients were aged 60-75 years and had a pathological diagnosis of acute myeloid leukaemia according to WHO 2008 criteria, no previous induction therapy for acute myeloid leukaemia, and an Eastern Cooperative Oncology Group performance status of 0-2. Patients were randomly assigned 1:1 (stratified by age and acute myeloid leukaemia subtype) to receive up to two induction cycles of CPX-351 (100 units/m2 administered as a 90-min intravenous infusion on days 1, 3, and 5; on days 1 and 3 for the second induction) or standard chemotherapy (cytarabine 100 mg/m2 per day continuous intravenous infusion for 7 days plus intravenous daunorubicin 60 mg/m2 on days 1, 2, and 3 [7+3]; cytarabine for 5 days and daunorubicin on days 1 and 2 for the second induction [5+2]). Patients with complete remission or complete remission with incomplete neutrophil or platelet recovery could receive up to tw cycles of consolidation therapy with CPX-351 (65 units/m2 90-min infusion on days 1 and 3) or chemotherapy (5+2, same dosage as in the second induction cycle). The primary outcome was overall survival analysed in all randomly assigned patients. No additional adverse events were collected with long-term follow-up, except data for deaths. This trial is registered with ClinicalTrials.gov, NCT01696084, and is complete. Between Dec 20, 2012, and Nov 11, 2014, 309 patients with newly diagnosed high-risk or secondary acute myeloid leukaemia were enrolled and randomly assigned to receive CPX-351 (153 patients) or 7+3 (156 patients). At a median follow-up of 60·91 months (IQR 60·06-62·98) in the CPX-351 group and 59·93 months (59·73-60·50) in the 7+3 group, median overall survival was 9·33 months (95% CI 6·37-11·86) with CPX-351 and 5·95 months (4·99-7·75) with 7+3 (HR 0·70, 95% CI 0·55-0·91). 5-year overall survival was 18% (95% CI 12-25%) in the CPX-351 group and 8% (4-13%) in the 7+3 group. The most common cause of death in both groups was progressive leukaemia (70 [56%] of 124 deaths in the CPX-351 group and 74 [53%] of 140 deaths in the 7+3 group). Six (5%) of 124 deaths in the CPX-351 group and seven (5%) of 140 deaths in the 7+3 group were considered related to study treatment. After 5 years of follow-up, the improved overall survival with CPX-351 versus 7+3 was maintained, which supports the previous evidence that CPX-351 can contribute to long-term remission and improved overall survival in patients aged 60-75 years with newly diagnosed high-risk or secondary acute myeloid leukaemia. Jazz Pharmaceuticals.

Effect of DNMT3A variant allele frequency and double mutation on clinicopathologic features of patients with de novo AML

The clinicopathologic features of DNA methyltransferase 3A (DNMT3A)-mutated de novo acute myeloid leukemia (AML), and the significance of variant type, variant allele frequency (VAF), and multiple concomitant DNMT3A mutations, remain poorly defined. We examined 104 DNMT3A-mutated de novo AML patients from 2 major centers. Most (82%) had normal karyotype (NK); R882H variants were frequent(38%). The most commonly comutated genes included nucleophosmin (NPM1; 53%), Fms-related tyrosine kinase 3 (FLT3)–internal tandem duplication (25%), IDH1 (23%), IDH2 (23%), and TET2 (21%). Patients with high DNMT3A VAF at diagnosis (≥44%; DNMT3AHIGH) had more significant leukocytosis and higher blast counts in peripheral blood and bone marrow. DNMT3AHIGH cases were associated with much shorter event-free survival (EFS; 14.1 vs 56.8 months) and overall survival (OS; 18.3 months vs not reached) compared with cases of patients with low DNMT3A (DNMT3ALOW). Thirteen patients had 2 DNMT3A variants and similar VAFs at diagnosis that tracked together at multiple time points after chemotherapy and/or stem cell transplantation (SCT). In multivariable analyses performed in NK patients who received standard induction chemotherapy, presence of 2 DNMT3A mutations (hazard ratio [HR] = 3.192; P = .038) and SCT in first complete remission (HR = 0.295; P = .001) independently affected EFS; increasing marrow blast percentage (HR = 1.026; P = .025), high DNMT3A VAF (HR = 3.003; P = .010), and 2 DNMT3A mutations (HR = 4.816; P = .020) had independent effects on OS. These data support the adverse prognostic significance of DNMT3AHIGH reveal a novel association between 2 concomitant DNMT3A mutations and inferior outcome in DNMT3A-mutated de novo AML with a NK.

Association of post-transplant outcomes with induction intensity in patients with acute myeloid leukemia.

e19026 Background: The USFDA has recently approved several oral targeted therapies for the treatment of acute myeloid leukemia (AML). The relative survival impact of these agents vs standard induction chemotherapy in the frontline setting is unknown, especially in patients who undergo allogeneic hematopoietic cell transplant (HCT). Methods: This is a retrospective, single-institution study of 125 patients with AML diagnosed 2015-2020 who received HCT. Patients were included if induced with high intensity chemotherapy (HiC) or lower intensity targeted therapy (LITT). HiC was defined as cytarabine + anthracycline given on a “7+3” based schedule. LITT was defined as venetoclax, gilteritinib, enasidenib, or ivosidenib alone or combined with hypomethylating agent. Patients receiving liposomal cytarabine-daunorubicin were excluded. Outcomes of interest were overall survival (OS), non-relapse mortality (NRM), and cumulative incidence of relapse (CIR). Between-groups analysis was conducted comparing receipt of any HiC to LITT only. OS was analyzed by Kaplan-Meier method and compared using log-rank test; NRM and CIR was estimated through cumulative incidence function and compared by Fine-Gray test. Results: Of 125 HCT recipients, 108 received any HiC and 17 LITT only. Two patients received HiC after suboptimal response to LITT. Median age at HCT was 61 years, 48% were female, and 90% were in complete remission at HCT. Population characteristics and outcomes as well as between-groups comparison are presented in the table. LITT only group was older with longer time to HCT and exclusively received RIC. With median follow-up of 23 months, median OS had not been reached. There were no statistically significant differences in median OS or one-year NRM or CIR between groups. Conclusions: Despite differences in age, conditioning regimen, and time to HCT in patients receiving any HiC vs LITT only, we have shown similar OS, CIR, and NRM. Difference in age is in contrast to lack of difference in HCT-CI and KPS, but is partially explained by limited access to LITT for younger patients. Longer time to HCT among LITT only recipients represents a major opportunity for pre-HCT optimization of recipient health. Prospective study from time of diagnosis will be important to understanding the appropriate use of LITT in HCT-eligible patients.[Table: see text]

Safety of same day HD-MTX with induction therapy for DLBCL with concurrent CNS disease or as prophylaxis for high risk of CNS relapse.

e19545 Background: High-dose methotrexate (HD-MTX) at a dose between 2.5 to 5 gm/m2 is commonly administered in conjunction with standard induction chemotherapy to patients with Diffuse Large B Cell Lymphoma (DLBCL) at high risk of central nervous system (CNS) relapse, as defined by the Lymphoma International Prognostic Index (CNS-IPI). Optimal timing of HD-MTX in relation to induction chemotherapy is unknown. A recent study suggested that HD-MTX intercalated with R-CHOP cycles was associated with increased toxicity and treatment delays without improvement in survival or CNS relapse compared with end of treatment MTX (Wilson et al 2020). This retrospective study evaluates the toxicities and treatment delays associated with HD-MTX administered on day 1 of cycles of chemo-immunotherapy. Methods: This single center retrospective cohort study included 45 patients (pts) with DLBCL with concurrent CNS disease or at high risk of CNS relapse who received HD MTX on day 1 of chemo-immunotherapy at our center. Data was abstracted from chart review and included variables describing clinical and treatment characteristics, time to MTX clearance, toxicities experienced and treatment delays. Results: 31 pts received HD-MTX on the day of R-CHOP chemotherapy, 6 pts received HD-MTX on the day of R-EPOCH (Rituximab, Etoposide, Doxorubicin, Vincristine, Cyclophosphamide, and Prednisone), and 8 pts received HD-MTX with R-MiniCHOP (dose reduced R-CHOP). Same day HD MTX with chemo-immunotherapy was associated with acute kidney injury (AKI; 17-25%), treatment delays &gt;7 days (13-17%), and grade 2 mucositis (11-50%). The burden of toxicities was numerically higher in patients treated with R-EPOCH vs. R-CHOP (Table). Clinical outcomes are summarized in table below. Conclusions: In our heterogeneous population of pts, we describe that the incidence of toxicities and treatment delays experienced with same day HD-MTX are higher with R-EPOCH than with R-CHOP. Comparative studies with intercalated or end of treatment MTX will determine if the incidence of treatment delays, toxicities and de-escalations are higher with same day HD-MTX administration. [Table: see text]

Escape From Treatment; the Different Faces of Leukemic Stem Cells and Therapy Resistance in Acute Myeloid Leukemia.

Standard induction chemotherapy, consisting of an anthracycline and cytarabine, has been the first-line therapy for many years to treat acute myeloid leukemia (AML). Although this treatment induces complete remissions in the majority of patients, many face a relapse (adaptive resistance) or have refractory disease (primary resistance). Moreover, older patients are often unfit for cytotoxic-based treatment. AML relapse is due to the survival of therapy-resistant leukemia cells (minimal residual disease, MRD). Leukemia cells with stem cell features, named leukemic stem cells (LSCs), residing within MRD are thought to be at the origin of relapse initiation. It is increasingly recognized that leukemia “persisters” are caused by intra-leukemic heterogeneity and non-genetic factors leading to plasticity in therapy response. The BCL2 inhibitor venetoclax, combined with hypomethylating agents or low dose cytarabine, represents an important new therapy especially for older AML patients. However, often there is also a small population of AML cells refractory to venetoclax treatment. As AML MRD reflects the sum of therapy resistance mechanisms, the different faces of treatment “persisters” and LSCs might be exploited to reach an optimal therapy response and prevent the initiation of relapse. Here, we describe the different epigenetic, transcriptional, and metabolic states of therapy sensitive and resistant AML (stem) cell populations and LSCs, how these cell states are influenced by the microenvironment and affect treatment outcome of AML. Moreover, we discuss potential strategies to target dynamic treatment resistance and LSCs.

Addition of Nimotuzumab to Standard TPF Regimen in Locally Advanced Head and Neck Cancer: A Single Institutional Study

Background Induction docetaxel, cisplatin, and 5-fluorouracil (TPF) chemotherapy followed by definitive concurrent chemoradiation remains the standard of care in locally advanced squamous cell carcinoma of head and neck cancers despite which the survival remains low. So, we analyzed the efficacy and adverse effect profile of the addition of nimotuzumab to standard TPF induction chemotherapy. Methods. We included 20 patients with locally advanced squamous cell carcinoma of the head and neck. Patients were administered with induction chemotherapy with nimotuzumab plus docetaxel, cisplatin, and 5-fluorouracil (TPF + N) followed by definitive concurrent chemoradiation with carboplatin. Treatment responses were assessed by PET-CT following induction chemotherapy and concurrent chemoradiation. Response rates, survival, and adverse effects data were tabulated and analyzed using the Kaplan Meier method. Results At a minimum follow-up of two years, the median progression-free survival (PFS) and median overall survival (OS) were 16 months and 38 months, respectively. PFS and OS were not reached (NR) in patients who showed a complete radiological response (CR). Median PFS and OS in patients who had partial response were 17.6 and 34.5 months, respectively. All subsites of primary including oral cavity, hypopharynx, and oropharynx showed similar response rates and survival. Overall the treatment was well tolerated with predominantly grade 1/2 toxicities. Conclusions Patients with locally advanced head and neck cancer could possibly have a better response and survival with nimotuzumab added to the standard TPF regimen. A complete response may serve as a good surrogate for survival irrespective of the primary site of head and neck cancer.

IDH Inhibitors in AML-Promise and Pitfalls.

Mutations in isocitrate dehydrogenase genes (IDH1 and IDH2) are common in acute myeloid leukemia (AML), occurring in up to 30% of AML cases. Mutations in IDH leads to abnormal epigenetic regulation in AML cells and blocks differentiation. Inhibitors of mutated IDH1 and IDH2, ivosidenib and enasidenib, respectively, were recently approved by the FDA for relapsed/refractory AML; ivosidenib is also approved for newly diagnosed AML patients not fit for standard chemotherapy. Here, we discuss the clinical development of IDH inhibitors, their unique side effects, and outline future combination approaches in AML. IDH inhibitors are well-tolerated but can induce differentiation of AML cells, which leads to the on-target side effect of differentiation syndrome in up to 20% of patients. Although IDH inhibitors demonstrate efficacy as monotherapy, recent trials have shown that they have higher response rates in combination with hypomethylating agents (HMAs). Current trials of IDH inhibitors include combination with standard induction chemotherapy, as maintenance therapy, and in combination with venetoclax-based regimens. IDH inhibitors are active and have a favorable toxicity profile in AML therapy. Current clinical trials are evaluating how to best incorporate IDH inhibitors into combination therapy to optimize outcomes and duration of response for AML patients with IDH mutations.

Experience with FLT3 Inhibitor Midostaurin in Newly Diagnosed Acute Myeloid Leukemia Patients

Introduction With the introduction of FLT3 inhibitors in recent years, the presence of FLT3 mutation in newly diagnosed acute myeloid leukemia (AML) patients has become more important. it was observed that the addition of Midostaurin to remission induction and consolidation chemotherapy, brought a 22% reduction in mortality risk in patients with FLT3 mutation. In the light of the above information, we aimed to share our experience regarding the use of Midostaurin in our newly diagnosed AML patients.&#x0D; Methods The data of 20 patients who were diagnosed with AML between April 2020 and November 2020 in the Hematology Department of Bursa City Hospital and who were eligible for standard remission induction therapy were evaluated retrospectively. Standard remission induction chemotherapy consisting of a combination of cytosine arabinoside (ARA-C) and an anthracycline was applied to patients. Consolidation treatment with high dose ARA-C was given to patients in remission; Midosaturin 100 mg was added to High-dose ARA-C between days 8 and 21 in patients with FLT3 mutation.&#x0D; Results: Twenty patients included in the study, 14 were men and 6 were women. There were six patients with the FLT3 mutation. Five patients with FLT3 mutation were male and one was female. The mean age of the patients is 53.8; the mean age of the patients with FLT 3 mutation was 49.8 years. Two patients with FLT 3 mutation died due to sepsis during remission induction treatment; In Four patients, complete response was obtained with remission induction therapy. Four patients had been given midostaurin with high dose ARA-C and referred for bone marrow transplantation. &#x0D; Conclusion The use of FLT3 inhibitors in combination with chemotherapeutic agents in the treatment of AML patients with FLT3 mutation is considered as a standard. However, it takes a certain amount of time for the FLT3 mutation to result. For this reason, Midostaurin treatment could be added not during remission induction but consolidation. Although our study included a limited number of patients it shows the importance of Midostaurin treatment in newly diagnosed AML patients with FLT3 mutation as real-world data.