Unfavorable Cytogenetics Research Articles

Long-Term Efficacy and Safety of Ibrutinib in the Treatment of CLL Patients: A Real Life Experience.

Ibrutinib has demonstrated a significant clinical impact in patients with de novo and relapsed/refractory chronic lymphocytic leukemia (CLL), even in cases with unfavorable cytogenetics and molecular markers. All CLL patients’ data treated at our Institute with ibrutinib have been retrospectively reviewed. Forty-six patients received ibrutinib either as frontline (10) or second or more advanced treatment (36). Five patients presented with TP53 mutations; 11 had the deletion of chromosome 17p; 17 displayed an unmutated immunoglobulin variable heavy chain status. The median number of cycles administered was 26. Among patients treated frontline, the best overall response rate (ORR) was 90.0%. In patients receiving ibrutinib as a second or later line ORR was 97.2%. Median progression-free survival was 28.8 and 21.1 months for patients treated frontline and as second/later line, respectively. Median overall survival was not reached for those treated frontline and resulted in 4.9 years for patients treated as second/later line. Grade 3–4 hematological toxicities were neutropenia, thrombocytopenia, and anemia. Grade 3–4 extrahematological toxicities included diarrhea, cutaneous rash, utero-vesical prolapse, vasculitis, and sepsis. Ibrutinib is effective and well tolerated in CLL. Responses obtained in a real-life setting are durable and the safety profile of the drug is favorable.

Protein Expression Signatures Predict Response, Relapse, and Survival after Venetoclax Containing Therapy in Adults with Acute Myeloid Leukemia

IntroductionWhen added to cytarabine (Ara-c) or hypomethylating agents (HMA), the BCL2 inhibitor, venetoclax (VTX), has been reported to improve response and overall survival (OS) rates. However, resistance and relapse still occur in the majority, and, although alterations in MCL1 and BCLXL are noted at relapse, identification of prognostic features remain unknown, notably not correlating with expression of the BCL2 target. Identification of prognostic markers could guide VTX use in patients and/or post-remission therapy. We searched for protein expression targets individually and collectively to predict VTX response and relapse in AML.MethodsReverse Phase Protein Array (RPPA) was performed on diagnostic leukemia samples of 818 adults with AML, of which 143 received VTX including 33 in combination with high dose Ara-C, 5 with standard dose Ara-C, 50 with HMA, and 13 with HMA and targeted therapy. Protein expression levels were evaluated using 390 validated antibodies were analyzed in the context of clinical data compiled by retrospective chart review. Pearson correlation was used to identify significant protein-protein correlations. Survival curves were generated by the Kaplan-Meier method and survival data was analyzed by multivariate cox regression model. Protein expression signatures were identified by hierarchical clustering and predictive models of classifiers were determined by classification and regression trees (CART) analysis.ResultsWe queried the 390 proteins assayed in the 143 VTX treated patients to identify proteins individually prognostic (p<0.01) for OS (n=27) or remission duration (RD, n=44). Notably, neither MCL1, BCLXL nor BCL2 expression at diagnosis were prognostic of OS or RD. From these, unbiased hierarchical clustering revealed two cohorts (N=102 & 41 patients) for OS and RD. The clusters were similar for clinical features with no significant differences noted for, age, gender, performance status, cytogenetics, or the presence of molecular mutation markers FLT3.ITD, IDH1/2, NPM1 or TP53. The groups did not differ by therapy combination. Remission rates were insignificantly less in cluster 1 (61% vs 77%). Clear differences were observed for OS with estimated 3-yr overall survival 27% vs 66% (p=0.009, Figure 1) and relapse risk (RR) at 1-yr 45% vs 18% (p=0.001, Figure 2) in cluster 1 vs 2, respectively. In multivariate analysis, protein cluster membership was in independent prognostic factor for OS (along with TP53 and NPM1 mutations) but unfavorable cytogenetics was not. Prognostication did not vary based on cytogenetics or therapy received. For RD, protein cluster membership and unfavorable cytogenetics were the only independent predictors. Of the 44 proteins in the protein signature, CART modeling identified 3 - SPI1, NOTCH1.cle, and PTPN12 - that could predict clustering with a computed accuracy of 94.3%. Similarly, when these three proteins were used as training variables for random forest classification, the error rate was 3.7%. Several previously unrecognized potential therapeutic targets for preventing VTX resistance were also identified.DiscussionProtein expression patterns, individually and in combination, were very highly predictive of outcome to VTX containing combination chemotherapy. A group with lower response rates, higher relapse rates, shorter RD and inferior OS was defined. A kit to prospectively determine cluster membership is in development. If validated this could be used to triage high-risk patients to alternate therapies, such as transplant, in CR1. Many new targets for combination therapy to prevent VTX resistance were identified and need to be tested in the laboratory for clinical relevance. [Display omitted] DisclosuresNo relevant conflicts of interest to declare.

The Tigit/CD226/CD155 Immunomodulatory Axis Is Deregulated in CLL and Contributes to B-Cell Anergy

The Tigit/CD226/CD155 Immunomodulatory Axis Is Deregulated in CLL and Contributes to B-Cell Anergy

Blinatumomab Associated Seizure Risk in Patients with Down Syndrome and B-Lymphoblastic Leukemia: An Interim Report from Children's Oncology Group (COG) Study AALL1731

INTRODUCTIONChildren with Down Syndrome (DS) and B-lymphoblastic leukemia (B-ALL) are at an increased risk of both relapse and treatment-related mortality, compared to those without DS. On COG study AALL1731 for de novo B-ALL, patients with DS and higher risk features (DS-High) are non-randomly treated with a regimen replacing intensive elements of conventional chemotherapy with three 28-day cycles of blinatumomab, with the combined goals of reducing toxicity and enhancing anti-leukemic efficacy. The DS-High group includes all NCI high risk (HR) patients; NCI standard risk (SR) patients with end-induction minimal residual disease positivity (>0.01%), unfavorable cytogenetics, CNS3 status, steroid pre-treatment, neutral cytogenetics with CNS2 status, or testicular disease. Neurotoxicity is a known risk of blinatumomab, with an incidence of 4% in block 1 and 1% in block 2 among pediatric patients with relapsed ALL (Brown et al, JAMA 2021). However, the specific risk in patients with DS has not been described to date. Here, we provide an early report of increased seizure incidence associated with blinatumomab in older DS-High patients enrolled on AALL1731 to date.METHODSWe reviewed seizure incidence among patients with DS enrolled on AALL1731 from June 2019 to June 2021 who had proceeded to receive blinatumomab. Blinatumomab was administered at a dose of 15 mcg/m 2/day, using dexamethasone pre-medication in cycle 1. Infusions were interrupted for seizures, with resumption at 5 mcg/m 2/d permitted following full resolution for grade 1-3 seizures.RESULTSAmong DS NCI HR patients, 8 of 47 (17%) had a seizure during blinatumomab infusion (Table 1). All 8 seizures occurred in patients over 10 years old. Six of the 8 seizures occurred in the first cycle of blinatumomab, most in the first 3 days of the infusion. Four had concomitant fever or cytokine release syndrome. Seizures were grade 2 (n=2) or grade 3 (n=6), and all resolved with full neurologic recovery. Of the 8 patients, 5 elected to resume blinatumomab; no further seizures occurred in these patients. There was no indication of increased seizure risk among NCI SR DS-High patients (1 seizure among 11 patients), or among DS or non-DS patients receiving blinatumomab on other study strata (0 of 7 DS SR-Avg; 1 of 146 non-DS SR-Avg; and 2 of 120 non-DS SR-High).CONCLUSIONSThe incidence of seizures associated with blinatumomab in DS-ALL patients older than 10 years appears higher than previously reported in children without DS. The majority of seizures occurred within the first 3 days, all fully resolved with no sequelae, and no patient who resumed blinatumomab infusion at a lower rate experienced further seizures. Seizure prophylaxis may be advisable in DS patients while receiving blinatumomab, particularly those >10 years of age. Further follow-up and a larger sample size are needed to confirm incidence and identify risk factors predisposing DS patients to neurologic toxicity. [Display omitted] DisclosuresLi: Novartis Canada: Membership on an entity's Board of Directors or advisory committees. Raetz: Pfizer: Research Funding; Celgene: Other: DSMB member. Loh: MediSix therapeutics: Membership on an entity's Board of Directors or advisory committees. Gupta: Jazz Pharmaceuticals: Consultancy, Membership on an entity's Board of Directors or advisory committees. Rau: Jazz Pharmaceuticals: Consultancy, Membership on an entity's Board of Directors or advisory committees, Other: Advisory Board; AbbVie Pharmaceuticals: Other: Spouse is employee and stock holder; Servier Pharmaceuticals: Consultancy. OffLabel Disclosure:This trial includes the use of blinatumomab in combination with chemotherapy for treatment of de novo B-lymphoblastic leukemia.

Efficacy and Safety of Chidamide Combined with Thalidomide, Cyclophosphamide, and Dexamethasone (TC2D) As a Novel Oral Quadruplet Regimen for the Treatment of Relapsed/Refractory Multiple Myeloma: Initial Results of a Phase IIa, Multicenter Clinical Trial

BackgroundResearch has demonstrated that histone deacetylase (HDAC) is overexpressed in plasma cells. Panobinostat was the first HDAC inhibitor (HDACi) approved by FDA for the treatment of patients with relapse and refractory multiple myeloma (RRMM) in 2015. Chidamide is an oral subtype-selective HDACi, which was independently developed in China and approved as peripheral T-cell lymphoma. Preclinical findings have demonstrated the anti-myeloma activities of chidamide in vitro and in vivo. Currently, patients are recommended to take bortezomib and/or lenalidomide in first line treatment and might become less sensitive or resistant when disease progressed. Choices are limited for these patients as not all the new agents (i.e., second generation of PIs/ IMiDs, monoclonal antibody, et al.) were covered by insurance in China, which calls for more efficient and economical options. Here we report the initial efficacy and safety of this prospective, phase IIa, multicenter clinical trial with the chidamide based oral quadruplet regimen in patients with RRMM (ChiCTR2000035100).MethodsThe TC2D regimen (thalidomide 100mg on days 1-28, chidamide 5mg on days 1-24, cyclophosphamide 50mg on days 1-24 and dexamethasone 20mg on days 1,8,15 and 22) was administered to patients with RRMM of a 28-day cycle. In this trial, evaluation of overall response rate (ORR) was based on patients whose response ≥MR and clinical beneficial rate (CBR) was calculated in patients completed at least 3 cycles of TC2D regimen and reached ≥SD in this trial.ResultsA total of 32 patients were enrolled as of June 30, 2021, with a median age of 63.5 years (range 49-74). iFISH detected high-risk cytogenetics (defined by the presence of del (17p) or p53 mutation, t (4:14), t (14:16), t (14:20), amp (1q)) in 23 patients, and 82% (19/23) of which had unfavorable cytogenetics. All patients were exposed to at least one kind of PIs and/or IMiDs and 75% were double refractory to bortezomib and lenalidomide. 18 patients received 1-3 prior lines and 43% (14/32) were heavily pre-treated (>3 lines). The median number of cycles completed was 3 (range 1-15) and 59% (19/32) patients completed ≥ 3cycles at the cut-off date (Table 1).With the median follow-up of 6 months (range 0.7-19.5), the median progression free survival (PFS) was 3.3 months and the 6-mon PFS rate was 27.5% (Fig1a). Median overall survival (OS) has not reached yet, 6-mon survival rate was 82%, and the estimated 12-month survival rate was 65% (Fig 1b). Study end points were death (8 cases, 25%) and disease progression (24 cases, 75%). Patients who received ≥3 cycles of treatment had a superior median PFS (3.8 vs 1.4 months, P=0.01) than < 3 cycles. Of the 28 patients whose follow-up time more than 3 months, ORR was 25% and CBR was 46.4%, respectively. Better CBR (56.3% vs. 33.3%) and ORR (31.3% vs. 16.7%) were observed in patients who received less than 3 prior lines of therapy, although with no significant statistical difference. Stratified analysis of PFS showed no significant differences in sex, age, clinical classification, cytogenetic risk, prognosis score (DS and ISS staging system), and the status of ASCT. Stratified analysis of OS showed similar results to those associated with PFS.Grade 3/4 adverse events were mainly hematological toxicity (neutropenia 28%, anemia 34%, thrombocytopenia 15.6%), which could be tolerated. Fatigue was reported in 68.8% (22/32) of the patients. The incidence of all-cause infection was 37.5% (12/32). There were no treatment related deaths observed.ConclusionsTo our knowledge, this is the first report of chidamide-based oral quadruplet regimen for patients with RRMM. The preliminary results suggested excellent efficacy and relatively high safety, and different groups of patients could benefit from treatment with this regimen. A longer treatment period may strengthen this effect. The most common adverse events were hematological toxicity which could be controlled. As we known, choices of treatment are also influenced by physical and emotional impact of hospitalization or frequent hospital visits, which reflects the patient's ability to continue their treatment and quality of life. Hospitalization and intravenous fluids are not involved in this oral quadruplet treatment, which bring far more convenience and could be a cost-effective alternative for patients with RRMM. Updated results will be presented at the following trial. [Display omitted] DisclosuresNo relevant conflicts of interest to declare.

Allogeneic Transplantation in Fit Older Adults Is Feasible and Encouragingly Efficacious. Post Remission Data from the Prospective ECOG-ACRIN (E2906) Clinical Study

Allogeneic Transplantation in Fit Older Adults Is Feasible and Encouragingly Efficacious. Post Remission Data from the Prospective ECOG-ACRIN (E2906) Clinical Study

Tolerability and Single Agent Anti-Neoplastic Activity of the CD3xCD123 Bispecific Antibody APVO436 in Patients with Relapsed/Refractory AML or MDS

Tolerability and Single Agent Anti-Neoplastic Activity of the CD3xCD123 Bispecific Antibody APVO436 in Patients with Relapsed/Refractory AML or MDS

Assessment of an Embedded Primary Care-Derived Electronic Health Record Frailty Index (eFI) in Older Adults with Acute Myeloid Leukemia

IntroductionAssessment of frailty is central to medical decision-making for older adults with newly diagnosed acute myeloid leukemia (AML), but validated frailty tools used at the point of care are lacking in this setting. An electronic frailty index (eFI), based on the theory of deficit accumulation, has been developed from routinely collected outpatient primary care data and embedded in the electronic health record (EHR) at Wake Forest Baptist Health (WFBH). The embedded eFI predicts hospitalization and mortality for older adults in a primary care cohort but has yet to be assessed for older adults with AML. The objectives of this analysis were to evaluate this tool among a cohort of newly diagnosed older adults with AML by determining the percent with available data to calculate a score, assessing the distribution of eFI categories (fit, pre-frail, and frail) at the time of treatment by therapy type, and exploring an association of eFI categories with survival.MethodsParticipants in this retrospective cohort study were adults aged ≥ 60 years with newly diagnosed AML from January 2018 - October 2020 who received treatment at WFBH. Patients with acute promyelocytic leukemia (APL) were excluded. Calculation of the EHR embedded eFI requires at least two ambulatory visits over a 2-year period. The eFI comprises demographic information, vital signs, smoking status, ICD-10 diagnosis codes, select outpatient laboratory measurements, and functional information (if available from past Medicare Annual Wellness Visits) during the 2 years prior to diagnosis. For this analysis, eFI was derived using date of treatment initiation as the reference date. Frailty status is categorized as fit (eFI ≤0.10), pre-frail (0.10<eFI≤0.21), and frail (eFI >0.21) based on the proportion of deficits present over the total number evaluated. Intensive therapy is defined as receipt of anthracycline-based chemotherapy. Less-intensive therapy includes hypomethylating agents, low dose cytarabine, and/or venetoclax. The association of eFI category to therapy type was evaluated using a chi square test. Median survival was estimated using the Kaplan-Meier method and compared using log-rank tests.ResultsAmong N=163 older adults treated for non-APL AML, 78 (43.3%) had a calculable eFI score. Among those with a calculable score, average age was 74.7 years (range 60 to 90), 68% were male, 90% were white, and average hematopoietic cell transplantation-comorbidity index (HCT-CI) score was 3.5 ± 2.7. Approximately 17% had favorable, 23% had intermediate, and 59% had unfavorable cytogenetics; 54% had secondary AML. Among those with a calculable eFI, 38.5% were classified as fit, 48.7% as pre-frail, and 12.8% as frail. For those who received intensive therapy (N=35), the majority were classified as fit (60%) and the remaining were pre-frail (40%); none were frail. The distribution of eFI categories differed for patients who received less-intensive therapies (N=43), with the majority classified as pre-frail (56%), a smaller proportion classified as fit (21%), and almost one-quarter as frail (23 %) (p<0.05). Median overall survival among those who received intensive therapy (12.1 months) was greater than those who received less intensive therapy (2.9 months) (p <0.01). In exploratory analyses, there was no significant difference in overall survival between eFI fit versus eFI pre-frail among those who received intensive chemotherapy (p=0.33). There was also no significant difference in overall survival among those who received less-intensive therapy by eFI category (p=0.38).ConclusionsThe embedded eFI derived from a longitudinal primary care population was not calculable using available data for most older adults with AML. This may reflect a skewed population referred to a Comprehensive Cancer Center that has higher-risk cytogenetics and/or does not receive primary care through the academic medical center. Among those with a calculable eFI, frailty categories significantly differed by treatment type. There was no association between survival and eFI category within treatment type in exploratory analyses. Our observations highlight the opportunity to adapt the EHR embedded eFI data capture process, including incorporation of inpatient labs, to the AML setting to effectively test the utility of a cancer-adapted passive digital marker for frailty. DisclosuresPardee: Rafael Pharmaceuticals: Consultancy, Research Funding; Karyopharm Pharmaceuticals: Research Funding; AbbVie: Membership on an entity's Board of Directors or advisory committees, Speakers Bureau; Genetech: Membership on an entity's Board of Directors or advisory committees; BMS: Speakers Bureau; Pharmacyclics: Speakers Bureau.

Evaluation of Early Treatment Response Utilizing the MAS-ALL18 Adapted Management Guideline in Four “Mexico in Alliance with St. Jude” (MAS) Member Hospitals

Introduction: Acute lymphoblastic leukemia (ALL) represents approximately 50% of all childhood cancers in Latin America. Mexico is not the exception. The impact of ALL survival on overall childhood cancer survival is significant. According to government data, five-year survival is about 52%. Mexico in Alliance with St. Jude (MAS) is a multi-site, intersectoral collaboration. The collaborative network has explored and reported on factors associated with this suboptimal outcome and have identified challenges with ALL risk group classification as a leading cause. For example, as many as 82% of children diagnosed with ALL in Mexico receive high-risk treatment and the tendency for higher-risk group assignment often occurs in response to limited access to cytogenetic testing and minimal residual disease (MRD) testing. This leads to higher intensity treatment and may explain the high rate of treatment-related death (TRD) (12%) documented during the induction but also subsequently. In our previous case series, only 75% of patients were alive at the end of the first year of treatment. These findings, led MAS to develop a consensus-derived standardized diagnosis and treatment schema (MAS-ALL18), which takes into account clinical, cytogenetic, and MRD results. Diagnostic testing is performed in a centralized laboratory. Although centred on delivery of standard of care, this experience represents is the first prospective multi-site cooperative group effort in Mexico. We report on early treatment (first 90 days) clinical and implementation outcomes utilizing the MAS-ALL18 adapted management guideline (AMG) in four member hospitals of the MAS collaboration network.Results: From June 2019 to June 2020, 137 patients received treatment utilizing the MAS-ALL18 AMG in four publicly funded hospitals in Mexico. B-cell ALL represented 91.9% of the cases, 20.4% of patients were older than 9 years of age, 25.5% had a white blood cell count greater than 50,000 at diagnosis and 58.3% were male. Complete remission at the end of the induction was achieved in 90.6% of patients. TRD during the induction phase was 8%. MRD at Day 15 in 123 patients with B-cell ALL, 84.5% of them had MRD <1% and 7.3% had MRD ≥5%. MRD at Day 29 was assessed for the 10 patients diagnosed with T-cell ALL, 4 patients had MRD <0.01%, 2 had 0.02%, and 4 died during the induction phase. MRD was also assessed during consolidation (at Day 84) in 99 patients, 94.9% had MRD <0.01% and 5 patients MRD ≥0.01%, from which 3 had MRD at day 15 >1% and none registered an MRD result <0.5%. Utilizing the MAS-ALL18 risk group stratification, 50% of patients were assigned to a favorable risk group at the end of the consolidation. In 34 patients, the risk group was reclassified following the standardized algorithm; 30 reclassification events happened at the end of the induction and four at the end of the consolidation. Only two events were reassigned to a lower risk group, while the rest of the reclassifications were conducted to assign patients to a higher risk group due to unfavorable cytogenetics or an inadequate early response to treatment. High-risk treatment was ultimately assigned to 30% of patients using the MAS-ALL18 risk classification schema.Conclusion: It is feasible to implement a standardized multi-site adapted management guideline for ALL risk group stratification and treatment allocation in Mexico in the context of a collaborative network. TRD remains high during the induction phase, nevertheless, this number shows an improvement (8%) compared to the 2015 data report (12%). The ALL risk group classification is transitioning from a rigid scheme that placed 80% of patients in a high-risk group to a dynamic classification system that considers cytogenetic testing and MRD conducted in a centralized and externally validated laboratory that serves as reference for all the participating hospitals. The standardized MAS-ALL18 approach allowed us to classify 50% of patients in a favorable risk group during and at the end of the induction phase, which implies receiving a lower intensity treatment with a high probability of cure and a lower risk of TRD. The implementation of MAS-ALL18 risk classification scheme reduced the number of children requiring high-risk treatment in the participating hospitals. [Display omitted] DisclosuresNo relevant conflicts of interest to declare.

Combination of treosulfan, fludarabine and cytarabine as conditioning in patients with acute myeloid leukemia, myelodysplastic syndrome and myeloproliferative neoplasms

PurposeTreosulfan and fludarabine (Treo/Flu) were successfully introduced into toxicity-reduced conditioning for SCT. However, the risk of post-SCT relapse remains a matter of concern. We report the results of a novel individual treatment approach with Treo/Flu and cytarabine (Treo/Flu/AraC) conditioning prior to allogeneic SCT in patients with acute myeloid leukemia (AML), myelodysplastic syndrome (MDS), or myeloproliferative neoplasms (MPN).Methods Seventy-seven patients (median age 54 years) at high risk of disease relapse due to unfavorable cytogenetics or failure to achieve complete remission prior to SCT were included. Median follow-up was 3.2 years.ResultsThe 1-, 2- and 3-year RFS rates were 49.4%, 41.7%, and 37.6% and OS rates were 59.3%, 49.3%, and 45.4%, respectively. Cumulative incidence of NRM was 10% at 100 days, 18.8% at 1 year and 20.1% at 2 years. The cumulative incidence of relapse increased from 31% at 1 year to 38.5% after 3 years. The cumulative incidences of engraftment, chimerism, graft-versus-host disease (GvHD) and toxicities were acceptable and comparable with similar patients conditioned with Treo/Flu or FLAMSA-RIC.Conclusion In conclusion, Treo/Flu/AraC provides tolerable, feasible, and effective conditioning for patients with AML, MDS or MPN, even in advanced disease states. The incidence of NRM and relapse is acceptable in this heavily pre-treated population with high-risk disease. Future research will aim to confirm these initial findings and include a larger number of participants in a prospective trial.

A novel 4-mRNA signature predicts the overall survival in acute myeloid leukemia.

Acute myeloid leukemia (AML) is an aggressive cancer of myeloid cells with high levels of heterogeneity and great variability in prognostic behaviors. Cytogenetic abnormalities and genetic mutations have been widely used in the prognostic stratification of AML to assign patients into different risk categories. Nevertheless, nearly half of AML patients assigned to intermediate risk need more precise prognostic schemes. Here, 336 differentially expressed genes (DEGs) between AML and control samples and 206 genes representing the intratumor heterogeneity of AML were identified. By applying a LASSO Cox regression model, we generated a 4-mRNA prognostic signature comprising KLF9, ENPP4, TUBA4A and CD247. Higher risk scores were significantly associated with shorter overall survival, complex karyotype, and adverse mutations. We then validated the prognostic value of this 4-mRNA signature in two independent cohorts. We also proved that incorporation of the 4-mRNA-based signature in the 2017 European LeukemiaNet (ELN) risk classification could enhance the predictive accuracy of survival in patients with AML. Univariate and multivariate analyses showed that this signature was independent of traditional prognostic factors such as age, WBC count, and unfavorable cytogenetics. Finally, the molecular mechanisms underlying disparate outcomes in high-risk and low-risk AML patients were explored. Therefore, our findings suggest that the 4-mRNA signature refines the risk stratification and prognostic prediction of AML patients.

Patterns of Genomic Associations Can Define Acute Myeloid Leukemia (AML) Phenotype

AML can develop after an anteccedent myeloid malignancy (secondary AML [sAML]) or arise de novo (pAML). Genome sequencing technologies have illuminated the complexity of genomic abnormalities that drive AML and contribute to its phenotype. Since identifying a single gene or co-mutated genes unlikely to yield an understanding on how these mutations define disease biology and phenotype, an unbiased approach is needed to study the relationship of those abnormalities to each other and to AML biology.Here, we study these associations using an unbiased approach analogous to Netflix or Amazon's recommender system in which customer who buys A, and B is likely to buy C (the occurrence of mutation A, B, and C is likely to be associated with pAML or sAML).We performed targeted mutational analysis of 468 patients with rigorously defined pAML and sAML. The association between mutations and disease phenotype was investigated by Apriori market basket analysis algorithm. Association rule is a machine learning method that can identify relationships between variables in a large dataset. Clonal architecture of driver vs. subclonal mutations was evaluated by using allele fractions of point mutations in samples with 2 or more mutations and statistically significant clonal heterogeneity.Of 468 patients (pts) were included in the final analysis, 247 had pAML and 221 sAML. The median age for the entire cohort was 64 years (range, 18-100) and 222 pts (47.4%) had normal karyotype (NK). Compared to pts with pAML, those with sAML were older (68 vs 60 years, P <.001), had a lower WBC at presentation (3.85 vs 13 ×109 g/l, P <.001), less likely to have NK cytogenetics (35.7 vs 57.9%, P <.001), and more likely to have unfavorable cytogenetics (36.7 vs 23.9%, P=.002). The most commonly mutated genes in pAML included: NPM1 (27%), DNMT3A (25%), TET2 (25%), FLT3 (ITD/TKD, 21%), and RUNX1 (10%) and in sAML: TET2 (17%), ASXL1 (16%), SRSF2 (11%), U2AF1 (11%), and DNMT3A (10%). Association rules identified mutations in NPM1, FLT3, and DNMT3A as commonly associated with each other predominantly in pAML. DNMT3A was associated with NPM1 in 30 pts (12%) with pAML (21% with NK), with FLT3 in 10% of pAML (17% of NK and 16% with unfavorable karyotype), and without NPM1 or FLT3 in 25 pts (10%). DNMT3A co-occurred with NPM1 and FLT3 in 16 pts (6%) of pAML (11% of NK). Among pts with DNMT3AWT/ NPM1WT/ FLT3WT (triple negative), RUNX1 was the most commonly mutated gene in 18 pts (7%) followed by TET2 13 pts (5%). Clonal architecture analysis showed that DNMT3A commonly occurred as a driver mutation while NPM1 +/- FLT3 were subclonal. In pts with triple negative disease, RUNX1 or TET2 were commonly found as driver mutations.Association rules identified the combination of ASXL1 and TET2 along with one of spliceosome mutations (SRSF2, U2AF1, or ZRSR2) as highly specific combination for the sAML phenotype (6% of pts with sAML). Among pts with sAML who does not have any of these mutations, TP53 occurred in 16 pts (7%), DNMT3A in 14 (6%) (Commonly with NPM1WT and FLT3WT), and NRAS in 11 pts (5%). In sAML, 22 pts had TP53, 18 of which (82%) were associated with unfavorable karyotype. Clonal architecture analysis showed that ASXL1 and TET2 were commonly co-mutated as driver clone along with the spliceosome mutations.Association rules can define combinations of genomic abnormalities that can define AML phenotype. This study also show that defining AML phenotype by one gene or two gene mutations undermine the complexity of genomic abnormalities in AML. Unbiased genomic combinations using the recommender system approach may help to understand the complexity of genomic information in AML. DisclosuresSekeres:Celgene: Membership on an entity's Board of Directors or advisory committees. Advani:Pfizer: Consultancy; Takeda/ Millenium: Research Funding. Gerds:CTI BioPharma: Consultancy; Incyte: Consultancy.

MET-PET and NGS Targeted Sequencing Guides Precision Medicine in a CNS Relapsed MM Patient

IntroductionCentral nervous system (CNS) involvement is an extremely rare manifestation of extramedullary multiple myeloma (MM), diagnosed in less than 1% of MM patients (pts). It is considered an ultimate high-risk feature, associated with unfavorable cytogenetics, and, even with intense treatment applied, survival is short, reaching less than 12 months in most cases.CaseAn 81y old male pt. with κ light chain MM on serum and urine, osteolytic lesions and bone marrow involvement in 2015, was referred to our institution. He presented with a CNS MM relapse in June 2017 after prior successful 1st line Bortezomib-based treatment. Cranial MRI confirmed multiple supra- und infratentoral lesions infiltrating the brain. His cerebrospinal fluid (CSF) demonstrated a high load of clonal plasma cells (PMCs) and κ free light chains (FLC), however, the disease was largely absent within the bone marrow of the patient.The use of positron emission tomography (PET) with 18F-2‘-deoxy-2‘-fluorodeoxyglucose (FDG) in MM has been strengthened by the recent publication of the updated imaging guidelines by the IMWG (Cavo et al., Lancet Oncol, 2017). Standard FDG based CNS imaging resolution, however, is impacted by the increased baseline glucose metabolism background of the brain. Therefore, we used radiolabeled 11C-methionine (MET) - that we recently identified as a sensitive imaging tracer in MM and in fact, high metabolic activity could be detected supra- and infratentorial as well as in the right femur and the clivus (Lapa et al., Theranostics, 2016).The pt. received 3 courses of an intrathecal triple therapy (Cytarabin, MTX, Dexamethasone) leading to a significant reduction of PMC-burden in the CSF. In addition, age adjusted systemic Thiotepa/Cytarabin-based therapy was applied, but had to be discontinued after one course of treatment as grade 4 neutropenia occurred with life-threatening septicemia.In parallel, we analyzed CD138+ cells obtained from BM and the CFS using customized next generation targeted sequencing (Ion torrent platform). The M3P (v 3.0) gene selection includes most commonly mutated MM genes, actionable drug targets and genes being associated with drug resistance. Average sequencing depth increased 700X and spatial MM heterogeneity was detected, as the CFS cells harbored a clonal BRAFV600E mutation, which was absent in the germline control and the bone marrow based CD138+ cells.We have initiated targeted therapy using the combination of Dabrafenib/Trametinib, known to be effective in BRAFV600E mutant melanoma brain metastases (Davies MA et al., Lancet Oncol, 2017); responses will be followed by combined cMRI and MET-PET imaging and results will be displayed at the meeting.Conclusion:This is an example of spatial genomic heterogeneity in MM and the first report of a patient with an isolated brain based BRAFV600E mutated MM tumor. This patient with otherwise very limited perspective leverages from innovative diagnostics including MET PET and targeted genome sequencing, demonstrating their clinical utility as they provide the basis for precision medicine concepts to be applied in this MM patient. [Display omitted] DisclosuresStewart:Amgen: Consultancy; Celgene: Consultancy; Janssen: Consultancy; Roche: Consultancy; Bristol-Myers Squibb: Consultancy.

Outcome of Acute Myeloid Leukemia Patients with Abnormal 12p after Allogeneic Hematopoietic Cell Transplantation at Fred Hutchinson Cancer Research Center

BackgroundClonal abnormalities of the short arm of chromosome 12 (Abn12p) are seen in 3~5% of patients with acute myeloid leukemia (AML). Anecdotal reports associate these aberrations with adverse disease prognosis; however, no large studies have been published to formally document its clinical impact on prognosis, especially in patients undergoing allogeneic hematopoietic cell transplantation (HCT). This study aimed to test the hypothesis that AML patients with Abn12p have an inferior survival outcome after HCT. Here we present data from 110 patients with Abn12p, to contrast with 442 comparable AML patients but without Abn12p, all who have received HCT at Fred Hutch.Patients and MethodsWe performed a retrospective comparative cohort analysis based on available data from the Gateway database at Fred Hutch. Inclusion criteria for the testing cohort was AML patients diagnosed according to the current WHO criteria with any chromosome 12p abnormality by karyotype analysis who underwent a HSCT at Fred Hutch. A comparison cohort of AML patients without 12p abnormality was identified based on the following matching criteria: patient age difference within 5 years, transplant time difference within 2 years, conditioning intensity, and donor type. Four matching patients were identified for each Abn12p patient. Overall survival (OS), cumulative incidence of relapse (CIR) and non-relapse-mortality (NRM) after HCT were analysed for the whole cohort and for patients receiving HCT in first complete remission (CR1).ResultsData from 552 patients with full karyotype information were analysed. The median age was 50 years with a range from 2 years to 80 years. Twenty-seven patients were younger than 18 years. Patients transplanted in CR1 accounted for 32% (=177/552), slightly lower among Abn12p patients than among the non-Abn12p patients (24% vs. 34%, P=0.045). 450 patients (82%) were treated with standard myeloablative conditioning (MAC) regimens while the remaining patients received reduced intensity conditioning (RIC). Donors were matched related in 38% (including 4% haploidentical), matched unrelated donors in 36%, and partially matched or mismatched unrelated donors in 14% of the patients. Thirty-nine patients received unrelated cord blood. With a median follow-up of 12 months (range from 0 to 370 months), the 5-year OS probabilities were 12% for the Abn12p patients and 41% for the non-Abn12p patients (Figure 1. Hazard ratio 2.33, P<0.0001, and 2.28 after adjustment for pre-transplant disease status). Patients transplanted in CR1 showed better outcome even among those with Abn12p. The 5-year survival probabilities were 25% for the Abn12p patients among those transplanted in CR1 and 6% for the other Abn12p patients (Figure 2, P=0.005). The primary cause of treatment failure was relapse. Cumulative incidence of relapse at three years was 29% and 56% for patients with and without Abn12p, respectively (P<0.0001). NRM was not significantly different between the two groups. Different types of 12p abnormalities - translocation, deletion, additional material of undefined origin, monosomy, and inversion - showed similar clinical associations with mortality and relapse. Co-variation analysis of cytogenetic abnormalities showed that complex and monosomal karyotypes were present in 82% and 60% of Abn12p patients, respectively, compared with 19% and 7% of non-Abn12p patients, respectively (both P-values < 0.0001). Abnormal chromosome 17p abnormalities were seen in 37% of Abn12p patients compared with 5% of non-Abn12p patients (P<0.0001). ELN classification of the Abn12p patients showed 85% unfavorable cytogenetics, 14% intermediate, and 2% favorable compared with 24%, 72%, and 4%, respectively, among non-Abn12p patients (P<0.0001).ConclusionIn conclusion, AML patients with Abn12p have a poor outcome after HCT. Abn12p tends to be present as part of a complex karyotype and hence considered unfavorable per ELN classification. Abn12p also overlaps with monosomal karyotype, but less so with 17p abnormalities. HCT in first complete remission still remains the treatment of choice for these patients. Clinical trial protocols should be considered for patients with Abn12p whenever possible. [Display omitted] DisclosuresNo relevant conflicts of interest to declare.

Outcome of NPM1 Mutated Acute Myeloid Leukemia (AML) Treated with Hypomethylating Agents (HMAs): A Report on 71 Cases

Background: NPM1 mutation is seen in 25 - 30 % of AML, and its incidence does not decrease with older age. While NPM1 mutation is associated with better prognosis in AML patients treated with intensive chemotherapy (IC), it is unknown if it also confers a good prognosis to patients unfit for IC who are treated with HMA.Methods: 71 AML patients with mutated NPM1 treated by HMA from 2007 to 2016 in 8 European and 1 US centers were retrospectively analyzed. 48 (68%) received azacitidine (AZA), 16 (22%) received decitabine (DAC), and 7 (10%) guadecitabine (SGI 110).All patients were tested for NPM1 and FLT3 mutations.Results: M/F was 25/46; median age was 75 years (36-85), 76% being 65 or older. 34 patients, considered unfit for IC, received HMA as first line treatment, and 37 after primary or secondary IC failure. Median WBC count at HMA onset was 5.3 x109/L (1.5 - 83). Sixty patients (84%) had normal cytogenetics, 6 had intermediate prognosis abnormalities, one had a complex karyotype, and two had missing data. In addition to NPM1 mutation, 26 patients (37%) had FLT3-ITD, one FLT3-TKD, and 10 (14%) had IDH1 or IDH2 mutation.The median number of HMA cycles received was 4. The overall response rate (ORR) was 35.1% (n=25), including 16 (22.5%) CR, 5 (7%) CRi, and 4 (5.6%) PR. The number of previous treatments before HMA, the type of HMA used, and baseline WBC had no impact on ORR. The ORR was 45.5% and 27% respectively in patients receiving HMA as first line or subsequent treatment (p=0.137); 45% and 27% respectively in mutated and non-mutated FLT3 (p= 0.302); 20% and 38.3% respectively in mutated and non-mutated IDH1/2 patients (p= 0.314). Among the 26 FLT3-ITD patients, 11 received concomitant therapy with sorafenib, without any impact on ORR or survival (OS), compared to FLT3-ITD patients who did not receive sorafenib (p= 0.73).Median OS was 280 days, 1 year OS was 17% and only one patient was alive after 2 years, but he died at 24.5 months. We failed to identify any prognostic markers for OS including whether HMA was administered as first line or subsequent treatment (median 289 vs 269 days, p= 0.90), and FLT3-ITD status (median 217 days vs 312 in FLT3-ITD negative, p=0.44). OS was significantly longer in responders (median 553 days vs 123 days, p<10-4). Four of the 6 patients in whom marrow NPM1 MRD was performed achieved a >3log reduction after six cycles of treatment, but 3 of them relapsed within less than six months, while one was alive in CR 12 months after the onset of HMA.We compared patients of the present series with 92 NPM1 unmutated AML patients previously treated upfront with AZA by our group (Desoutter, Leukemia, 2016). In this cohort, median age was 74 years, 69% had unfavorable cytogenetics, and 63% TP53 mutation. Despite a different molecular profile, there was no OS difference in patients with mutated or non-mutated NPM1 (median 280 vs 291 days, p= 0.53, respectively). This finding was also true when the analysis was restricted to NPM1 mutated patients treated with HMA as first line therapy (Figure 1, p=0.48)Conclusion: This is to our knowledge the first study reporting the efficacy of HMA in NPM1 mutated AML. Contrary to what is observed with conventional AML chemotherapy, HMA do not seem to improve the outcome of NPM1 mutated compared to unmutated AML cases, and are unable to provide long term remissions. Thus, in elderly AML patients, presence of a NPM1 mutation could contribute to decide the administration of intensive chemotherapy rather than a HMA, when possible. [Display omitted] DisclosuresRecher:Novartis, Celgene, Jazz, Sunesis, Amgen: Consultancy; Celgene, Sunesis, Amgen, Novartis: Research Funding. Fenaux:Astex: Honoraria, Research Funding; Celgene: Honoraria, Research Funding; Janssen: Honoraria, Research Funding; Novartis: Honoraria, Research Funding; Janssen: Honoraria, Research Funding; Amgen: Honoraria, Research Funding; Amgen: Honoraria, Research Funding; Astex: Honoraria, Research Funding; Celgene: Honoraria, Research Funding; Novartis: Honoraria, Research Funding.

Proteomic Profiling Identifies c-KIT and 53BP1 As Resistance Factors of AML Relapse Post Allogeneic Stem Cell Transplantation with G-CSF/Plerixafor/Busulfan-Fludarabine Conditioning

The CXCR4 inhibitor plerixafor in combination with G-CSF disrupts stroma-leukemia interactions, mobilizing leukemia cells from their niche microenvironment. This combination in conjunction with chemotherapy has been investigated in clinical trials in AML. We recently reported a phase 1/2 study of CXCR4 inhibition combined with chemotherapy prior to allogeneic stem cell transplantation (allo-SCT) (G-CSF-plerixafor (G+P) plus busulfan-fludarabine (Bu+Flu), Konopleva, et al. BMT 2015) and confirmed that patients who had not achieved remission at the time of transplant (“non-CR”) had poorer outcome than patients who were in remission at the time of allo-SCT (“CR”). Similar results have been reported in other clinical studies. Risk factors, such as the presence of circulating blasts and unfavorable cytogenetics are associated with poor outcome, but the molecular responses in patients treated with CXCR4 inhibitor and conditioning chemotherapy prior to allo-SCT are unknown. We investigated the hypothesis that the CXCR4 inhibition-driven preparative regimen modulates distinct signaling networks, which vary depending on disease status.Utilizing reverse phase protein array (RPPA), we profiled 157 proteins in 36 cellular signaling and functional groups in samples collected from ten AML patients who were studied in the phase 1/2 trial (Table1). Five CR patients had less than 1% blasts in bone marrow (BM) and no blasts in peripheral blood (PB) before conditioning regimen (baseline, day -9). Five non-CR patients had BM blasts ranging from 10-72% and PB blasts from 0-45%. Here we denote samples from “CR” patients as “normal” and from “non-CR” patient as “AML”. All “AML” patients with blasts had persistent blasts after G+P plus conditioning, ranging from 4-64%. However, four of five “AML” and five “normal” patients achieved complete response to allo-SCT. Engraftment was observed in all patients. Disease progression following allo-SCT was observed in four of five “AML” but not in “normal” patients. Overall survival in “AML” was significantly shorter than in “normal” patients (non-CR = 260 ± 55 days, CR = 2028 ± 103 days, P < 0.001).RPPA analysis of samples prior to conditioning (day -9) revealed that 9 proteins in 9 signaling pathways were expressed differently in “normal” and “AML” samples. Among them, c-KIT, 53BP1, a P53-binding DNA repair protein, and CIAP (a SMAC and IAP family member) had significantly higher expression in “AML”.G+P treatment significantly modulated 7 proteins in 4 pathways in “AML” samples, and 22 proteins in 13 signaling and functional groups in “normal” samples (Fig 1A). As a result, 22 proteins in 14 signaling and functional groups were differentially expressed in “AML” and “normal” samples post G+P treatment (day -7) (Fig 1B). Among the top 10 distinct proteins, PI3Kp110A, P53BP1, SMAD1 and p-C-JUN S73 had higher expression, and P38MAPK, p-HER2 Y1248, P-CADHERIN, SYK, P21 and TAU had lower expression in “AML” samples.Treatment with G+P plus Bu+Flu conditioning modulated 10 proteins in 7 signaling pathways in “AML” samples, and altered 40 proteins in 13 signaling pathways in “normal” samples (Fig 1C). As a result, G+P plus Bu+Flu conditioning caused significant differences in expression of 16 proteins in 14 signaling and functional groups in “AML” vs. “normal” samples (day -3) (Fig 1D). Among the top 10 distinct proteins, PI3Kp110A, XRCC1, p-ERA S118, 53BP1, and BCL2 had higher expression, and MIG6, SYK, TAU, p-AKT T308 and MEK1 had lower expression in “AML” samples. Notably, c-KIT and 53BP1 in “AML” baseline samples were persistently expressed at high levels in samples from G+P and G+P plus Bu+Flu treated patients, suggesting that c-KIT and 53BP1 mediated signaling might play a role in therapeutic resistance and disease relapse in patients with active disease at the time of transplant.In summary, CXCR4 inhibition combined with Bu+Flu conditioning triggered distinct molecular responses, resulting in differential signaling between “normal” and “AML” cells prior to allo-SCT. The persistence of c-KIT and 53BP1 might play a role in resistance and contribute to relapse in AML. [Display omitted] DisclosuresNo relevant conflicts of interest to declare.

The European Group for Blood and Marrow Transplantation Risk Score Predicts Outcome of Elderly Patients with Allogeneic Stem Cell Transplantation for Acute Leukemia and Myelodysplastic Syndrome

Introduction:Hematological malignancies are more and more common in elderly patients. Acute myeloid leukemia (AML) in elderly patients would have more unfavorable cytogenetics, frequently express drug resistance, respond less well to chemotherapy and more likely to be preceded by the myelodysplastic syndrome (MDS), while MDS is a predominantly malignant disease of elderly patients, with a median age of approximately 75 years old at diagnosis and more than 80% are noted to be older than 60 years. Although allogeneic hematopoietic stem cell transplantation (allo-HSCT) remains the curative therapy for refractory AML or high risk MDS, old age had been a limitation to access the eligibility for allo-HSCT and seldom prospective trial evaluates the outcomes for elderly patients with allo-HSCT. Here, we conducted a retrospective study to analyze the prognostic factors predicting outcome of elderly patients with allo-HSCT for acute leukemia and MDS at our institution during a 10-year period.MethodWe reviewed patients with diagnosis of acute leukemia or MDS, who underwent allo-HSCT at age older than 50 years old from January 2003 to December 2014. Clinical characteristics including age, sex, underlying disease, type of allogeneic transplant, conditioning regimens, European Group for Blood and Bone marrow Transplantation (EBMT) risk score, and presence of acute graft-versus-host disease (aGVHD) or chronic GVHD (cGVHD) were collected and analyzed. Cox proportional hazard model was adopted to explore the independent prognostic factors for overall survival (OS), disease-free survival (DFS) and non-relapse mortality (NRM).ResultsA total of 85 elderly patients were included during study period and the medial age at allo-HSCT was 55 years old. There were 63 (74%) patients receiving allo-HSCT for AML, which was the most common indication for transplantation in this cohort. 47 (55%) recipients' stem cell source were unrelated donors, while 46 (54%) patients underwent myeloablative conditioning regimens. 14 (17%) cases developed grade III-IV aGVHD, while 22 (26%) had moderate to severe cGVHD. The significant prognostic factors for worse OS after transplantation (Table 1) were EBMT risk score > 3 (hazard ratio [HR] 2.10, 95% confidence interval [CI] 1.14-13.88; P=0.01), and grade III-IV aGVHD (HR 4.36, 95% CI 2.13-9.93; P < 0.01), while patients with moderate to severe cGVHD would have better OS (HR 0.45, 95% CI 0.20-0.99; P=0.04). Similar finding was noted in DFS analysis: EBMT risk score > 3 (HR 2.27, 95% CI 1.31-3.94; P < 0.01), aGVHD (HR 4.70, 95% CI 2.41-9.17; P < 0.01), and moderate to severe cGVHD (HR 0.46, 95% CI 0.23-0.90; P = 0.02). In addition, EBMT risk score > 3 (HR 2.41, 95% CI 0.99-4.63; P = 0.05) and grade III-IV aGVHD (HR 5.87, 95% CI 2.43-14.13; P < 0.01) significantly correlated with non-relapse mortality (Table 2). The OS of patents with EBMT risk score < 3 was significant better than those with EBMT risk score >3 (log-rank p= 0.01), and Kaplan-Meier curve of OS divided by EBMT risk score were illustrated in figure 1.ConclusionWe identify EBMT risk score > 3 and grade III-IV aGVHD as adversely prognostic factors for OS, DFS and NRM in elderly patients underwent allo-HSCT. Development of moderate to severe cGVHD allows elderly patients to have better OS as well as DFS, and interestingly, it would not increase NRM significantly. It indicates graft-versus-leukemia may be essential important in survival and disease control for elderly patients experiencing allo-HSCT. This cohort study suggests that EBMT risk score > 3 predicts poor outcomes and careful management of GVHD may lead to better survival for elderly patients experiencing allo-HSCT.Key words: acute leukemia, myelodysplastic syndrome, elderly, allogeneic hematopoietic stem cell transplantation, European Group for Blood and Bone marrow Transplantation (EBMT) risk score, graft-versus-host disease [Display omitted] DisclosuresNo relevant conflicts of interest to declare.

Overexpression of BRD4 Is an Adverse Prognostic Factor in Acute Myeloid Leukemia

Background:Bromodomain containing protein 4 (BRD4), a member of the bromodomain and extra terminal domain (BET) protein family, has been implicated in the pathogenesis of a number of hematological and solid tumors. BRD4 is an epigenetic reader that plays a central role in transcriptional regulation, cellular growth control, and cell cycle progression. As a consequence, BET inhibitors elicit anticancer activity in numerous malignant contexts. While deregulation of BRD4 activity has been shown to be essential for the maintenance of AML, its expression profile and prognostic value in AML have not been investigated. Additionally, how BRD4 is regulated in cancer cells remains largely unknown.Methodology: We therefore evaluated the level of BRD4 expression using Reverse Phase Protein Array (RPPA) technology in marrow and blood samples from 511 newly diagnosed AML patients, and determined a correlation between BRD4 expression and clinical characteristics and overall survival in AML patients. We also correlated expression of BRD4 with 232 other proteins (encompassing signal transduction, metabolism, apoptosis and cellular proliferation pathways) that were included in RPPA. Potential role of molecular chaperone heat shock protein 90 (Hsp90) in regulating BRD4 protein stability was also investigated.Results: BRD4 expression was similar in peripheral blood and bone marrow and expression was found to be higher at diagnosis than at relapse (P = .035). Compared with normal bone marrow derived CD34+ cells, BRD4 expression in AML was higher in 28% of patients and that higher BRD4 levels significantly predicted shorter overall survival (P = .002). There was no significant difference in BRD4 expression on the basis of age, sex, or performance status, antecedent malignancies, and previous chemotherapy and/or radiotherapy. BRD4 expression levels were not strongly correlated with French-American-British classification (FAB), although levels were slightly higher in M5 subtype. BRD4 levels were found to be significantly higher in patients with NPM1 mutation (P = .003) or FLT3-ITD (P = .057) or between those with both FLT3-D835F and NPM1 mutation (P = .01). BRD4 levels were not associated with the attainment of complete remission (CR), although rates were somewhat lower for those with high. However, patients with high levels of BRD4 had significantly inferior remission duration (25.9 vs 50 weeks; P = 0.03) compared with those with normal levels of BRD4. The overall survival (OS) of patients with higher levels of BRD4 was significantly inferior compared with those with normal levels of BRD4 (28.3 vs 55.3 weeks; P = .002). Patients with unfavorable cytogenetics and above-normal levels of BRD4 had inferior survival compared with those with normal levels of BRD4 (22.4 vs 38.9 weeks; P = .0043; Figure 3C). BRD4 expression was found to be strongly correlated (R > 0.2 and P < 0.0001 or 0.00001) either positively (n = 48) or negatively (n = 14) with proteins known to be important in AML. BRD4 expression was positively correlated with various cell proliferation-related proteins (Hsp90, pSTAT5, nucleolin and mTOR), anti-apoptotic protein (Bcl-2), oncoproteins (FLI1, CREB and ELK1), proteins important for stem cell functions (Ash2L and LSD1), hematopoietic transcription factors (ERG and PU.1/Spi1), and Smad proteins, signal transducers for the members of the transforming growth factor-β (TGF-β) superfamily. The stability, activity and function of several mutated, chimeric, and overexpressed signaling proteins crucial for oncogenesis are often maintained by Hsp90. Our study also demonstrates that BRD4 stability is dependent upon Hsp90 activity and pharmacologic inhibition of Hsp90 promoted ubiquitination followed by proteasome-dependent degradation of BRD4 protein.Conclusions: These findings suggest BRD4 as a prognostic biomarker for unfavorable outcomes and supports the clinical rational for using BRD4 inhibitors in AML. Future studies could identify mechanistic insights into BRD4-associated proteins as biomarkers for response to BET inhibition. DisclosuresKarnad:ADC Therapeutics: Research Funding. Weitman:Tolero Pharmaceuticals, Inc.: Employment. Iyer:Takeda: Research Funding; Genentech: Research Funding.

Red Cell Distribution Width (RDW) As Prognostic Factor in Acute Leukemia Patients Undergoing Allogeneic Hematopoietic Transplantation

Background:Red cell distribution width (RDW) is an erythrocyte index influenced by anisocytosis and useful in approaching patient with various types of anemia or suspected myelodysplasia. RDW can predict mortality in sepsis, chronic kidney diseases and cardiovascular disease, RDW has a prognostic value also in patients with breast cancer, lung cancer, glioblastoma, myeloma and chronic lymphocytic leukemia. No data, however, are available on the prognostic value of RDW in patients affected by acute leukemia. We studied prognostic value of RDW-SD assessed at pre-transplant evaluation, in acute leukemia patients who underwent allogeneic transplantation.Methods:We retrospectively studied the prognostic value of RDW-SD in a group of 94 adult acute leukemia patients affected by AML (70) ALL (19) or advanced MDS (5). RDW-SD was measured after patients had received induction and consolidation chemotherapy to achieve maximal anti-leukemic response. A MINDRAY BC6800 automatic cell counter was used. Patients, subsequently, underwent allogeneic transplantation from a sibling or from an alternative donors (MUD or Haplo-identical donors). Median age was 46 years (18-70). Ninths-five percent of patients received a fully myeloablative conditioning. Cytogenetic classification of leukemic cells was available in 95% of AML/MDS patients (72/75). Fifty-four percent of all patients were in an early phase of disease (1st complete remission) while 46% in the advanced phase (2nd CR or active disease). RDW-SD upper normal limit was 55 fL and patients were grouped according to this threshold. Data were analyzed by R software.Results:At baseline, before the transplant, an RDW-SD higher than normal (=/> 56 fL) was observed in 44% of all acute leukemia patients. RDW-SD correlates with MCV (r=0.611, p=0.0001) but not with other hematological parameters present at the time of RDW assessment. A high co-morbidity score (HTC-CI score 2-5) at the pre-transplant screening was a factor significantly associated to high RDW-SD, in fact, 27% of patients having an “RDW-SD over normal” had a comorbidity score of 2-5, while in the group of patients having an “RDW-SD within normal” a comorbidity score 2-5 was observed only in 9% (Chi-square-test p:0.02). The group of patients having an “RDW-SD over normal” had in respect to group “RDW-SD within normal” a higher serum LHD (p: 0.02). An unfavourable cytogenetics was observed in 26% of patients in the group “RDW-SD over normal” versus 8% in the group “RDW within normal” (p=0.10). The two groups of patients were not significantly different in age, gender, diagnosis, phase of the disease, level of WT-1 before transplant, previous transplantation, C-reactive protein, ferritin, creatinine and arterial diastolic pressure. In the whole set of patients, the Overall Survival at 3 y was 45% with a median follow up, for uncensored patients, of 99 weeks. OS at 3 years in the group “RDW within normal” was 61% versus 25% in the group “RDW-SD over normal” (log-rank, p=0-01). Differences in OS between these two groups was present also when patients were stratified according to cytogenetics or phase of disease (Fig 1). In univariate analysis other factors important for OS were phase of disease (p=0.004), graft from an alternative donor (p=0.03) and age (p=0.005). The comorbidity score was not an important factor for OS. In multivariate analysis, using Cox proportional hazard, factors important for OS remained age (HR: 1.040; CI: 1010-1070; P=0.008) and a pre-transplant “RDW-SD over normal ” (HR, 3.274; CI: 1.694-6.328; p=0.0004). The group of patients having an “RDW over normal” had a Relapse Rate (RR) higher than the group having “RDW-SD within normal” (RR: 60% versus 30%, Gray test p= 0.05). Treatment related mortality (TRM) was 14% in the group “RDW within normal” versus 22% in the group “RDW over normal” (Gray test not significant).Conclusions:Abnormal RDW-SD is frequently found in acute leukemia patients treated by chemotherapy and in complete or partial response before allogeneic transplantation, “RDW-SD over normal” at time of pre-transplant screening is an independent negative prognostic factor for outcome after transplantation. The poor OS of the group of patients showing “RDW-SD over normal” is, at least in part, due to a higher relapse rate. The association of “RDW-SD over normal” and adverse cytogenetics deserves further studies. [Display omitted] DisclosuresNo relevant conflicts of interest to declare.

A Single Institution Comparison of Mitoxantrone, Etoposide and Cytarabine (MEC) Vs High-Dose Cytarabine and Mitoxantrone (Ara-C Couplets) for Treatment of Patients with Relapsed or Refractory Acute Myeloid Leukemia

Background:Relapsed or refractory acute myeloid leukemia (R/R AML) is a common occurrence and remains a therapeutic challenge due to its poor prognosis. Hematopoietic cell transplantation (HCT) is the only curative approach for R/R AML, and while chemotherapy regimens are generally used as a bridge to HCT, the ideal second-line therapy is unknown. For decades cytarabine (Ara-C) has been the backbone of a number of regimens that are frequently used in this R/R setting. At our academic institution patients who can tolerate aggressive therapy are treated with either MEC (mitoxantrone 8 mg/m2 IV, etoposide 80 mg/m2 IV and intermediate dose cytarabine 1 g/m2 daily for 5 days) or Ara-C couplets (mitoxantrone 30 mg/m2 x 1 and high dose cytarabine (2 g/m2) twice daily, on days 1 and 5). MEC is among the most studied regimens for R/R AML; up to 66% of patients achieve complete remission (CR), with a median survival of 36 weeks (Arcese et al., J Clin Oncol . 1991). The Ara-C couplets regimen has been shown to have a similar overall response rate of 55%, in a single study (Larson et al., Leukemia & Lymphoma . 2012). Currently, there are no studies that have directly compared these two treatments. The objective of this single institution retrospective analysis is to assess the efficacy and toxicity of MEC and Ara-C couplets therapy.Methods:R/R AML patients treated from January 1998 through May 2015 were identified using our hospital and pharmacy billing records. From a review of 118 patient charts a total of 51 R/R AML adult patients were identified who had received either MEC or Ara-C couplets, and all were included in this analysis. The efficacy and toxicity of the two regimens were compared by assessing the rates of CR, progression free survival (PFS), overall survival (OS), the duration of hospitalization, hematologic and non-hematologic toxicities and success in proceeding to HCT.Results:Fifteen patients, ages 20-64, were treated with MEC, and 36 patients, ages 22-75, were treated with Ara-C couplets. Baseline characteristics, including gender, race, and Charlson Comorbidity Index (CCI) were well balanced. Within the MEC group, there were an equal number of White, Black and Hispanic patients (n=4), and 3 patients who identified as other. Amongst the Ara-C couplets patients, 14 were White, 11 Black, 7 Hispanic, and 4 identified as other. Six of the MEC patients (9%) and 9 of the Ara-C couplets patients (25%) had unfavorable cytogenetics. The time from initial diagnosis to relapse or refractory disease was similar between the 2 groups, 253 days (MEC) and 244 days, respectively (p=0.38)CR was achieved in 64% of the MEC patients and 57% of the Ara-C couplets patients (p=0.75). OS was 6.5 months and 8 months respectively (p=0.35). PFS was 5.2 months in the MEC group and 4 months in the Ara-C couplets group (p=0.86). In both groups, 47% of patients (7 in MEC, 17 in Ara-C couplets) underwent HCT. Within the MEC group, the median number of days to ANC and platelet recovery was 45 days and 65 days respectively, and was similar within the Ara-C couplets group, 40 days and 55 days, respectively. The median duration of hospitalization for patients receiving MEC was 34 days while the median for those receiving Ara-C couplets was 31 days (p=0.2).The most common adverse event was febrile neutropenia, occurring in 100% of the MEC and 89% of the Ara-C couplets patients (p=0.3). Non-hematologic toxicities were minimal and there were no significant differences between groups in terms of pulmonary, liver or gastrointestinal toxicities. Within the Ara-C couplets group, one patient experienced grade 3, and another grade 4 cardiac toxicity (CHF).Conclusions:This is the first study that directly compares MEC and Ara-C couplets regimens in R/R AML patients; two salvage therapies commonly used at our institution. We show that both therapies are equally effective as second-line regimens with equivalent toxicities in a racially diverse population (n= 51). Our data suggests either regimen can be considered in those able to tolerate aggressive therapy and can serve as a bridge to HCT. A significant portion of patients with AML relapse, and, surprisingly, very few comparative studies have been performed in this population. In the future, large multi-center studies should be performed in order to establish the optimal chemotherapy regimen for these patients. DisclosuresPatel:Celgene: Consultancy, Honoraria. Khan:Takeda: Research Funding; Gilead: Consultancy; Teva: Speakers Bureau.