bluuebunny/crossref_metadata_2025 huggingface dataset:
Different Number of AML1/ETO Transcripts in Single Leukemic Cell, Estimated by Combined Measurement of MRD by FISH and Real-Time PCR, Is a Powerful Predictor of Relapse.
Authors: Maeba Hideaki , Nishimura Ryosei , Kuroda Rie , Horisawa Toru , Saikawa Yutaka , Koizumi Shoichi
Published: October 2019

The t(8;21)(q22;q22) translocation is observed in about 40% of pediatric cases of AML M2. Although patients with t(8;21) AML have a relatively good prognosis, relapses still occur in about 30% cases. To predict relapse, several studies examining sequential quantitation of minimal residual disease (MRD) by real-time PCR after chemotherapy or BMT have been attempted. However, these studies have shown that only a very small number of AML1/ETO transcripts are detectable in most t(8;21) AML patients who maintain complete long-term remission (CR). A recent study clearly demonstrated the existence of nonmalignant stem cells with leukemia specific genes. In another study, the suppression of AML1/ETO by siRNA in vitro resulted in the increased expression of genes associated with myeloid differentiation as well as antiproliferative genes in both leukemic blasts and cell lines. This suggests that cells expressing lower level of AML1/ETO might be well-differentiated malignant cells with slower proliferation rates compared to those expressing higher levels of AML1/ETO. Taken together, we hypothesized that the translocated gene detected by PCR, even in long-term remission patients, might be derived from nonleukemic stem cells or well-differentiated leukemic cells. If we can estimate AML1/ETO transcripts in single cells possessing leukemic translocation genes in BM in CR, we can predict, with high reliability, whether early relapse would occur or not. To test this hypothesis, we simultaneously assessed MRD by FISH with locus-specific probes with higher sensitivity and by quantitative real-time PCR in BM samples obtained from seven pediatric patients with AML1/ETO during and after chemotherapy/BMT. We then evaluated the value which was calculated by dividing normalized AML1/ETO copies/μgRNA by the percentage of t(8;21)-positive cells by FISH (RQ-PCR/FISH), which ideally reflected actual number of AML1/ETO transcripts in single cell with leukemic translocation in BM cells. RQ-PCR/FISH of non-relapse patients ranged from 5.5 × 102 to 5.5 × 103 (mean 2.5 × 103 ) in BM in CR. In marked contrast, 8.0 × 103 to 1.8 × 105 (mean 5.9 × 104 ) was observed from the patients who finally relapsed. Indeed, we demonstrated that in some cases showing low value of RQ-PCR/FISH, the AML1/ETO was detected only in terminally differentiated basophils (CD34− CD203c+ ), not in stem cell fractions (CD34+ CD203c± ). In conclusion, we propose that RQ-PCR/FISH can be a powerful predictor of relapse, especially in patients with lasting MRD positive after chemotherapy/BMT.
Short Telomeres Combined with Low Telomerase Activity Are Associated with a Longer Survival in Patients with Acute Myeloid Leukemia.
Authors: Saada Veronique , Ba Loc Pierre Tran , Legeai Camille , Castaing Marine , Bourhis Jean-Henri , Raphael Martine , Bennaceur-Griscelli Annelise
Published: October 2019

Telomeres - the terminal regions of human chromosomes, and enzyme telomerase - a ribonucloprotein that synthesizes telomeric DNA onto chromosomal ends, have been thoroughly investigated as potential markers for the prognosis of various cancers including leukemia. However, it is important to consider both parameters and only few studies have investigated the prognostic value of these two combined biomarkers in patients with acute myeloid leukemia (AML). Our work was designed to determine the impact of telomere length together with telomerase activity (TA) on survival in patients with AML. In this current retrospective study, TA (reflected by the quantitative expression of the catalytic subunit of telomerase i.e the hTERT mRNA/18s RNA ratio measured by Q-RT-PCR) and telomere length (determined by southern blot analysis of terminal restriction fragments) were assayed in the bone marrow of 40 patients diagnosed with AML between 1999 and 2003 at Institute Gustave Roussy’s division of Hematology. The patients’ characteristics are shown on table 1. All patients were treated according to standard AML-type chemotherapy protocols. The median of TA (hTERT mRNA/18s RNA ratio) was 0.0458. TA was not detectable in 4 patients. The median of telomere length was 7.6 Kb (range: 3.5–11.2 Kb). No correlation was found between TA and telomere length. A negative correlation existed between telomere length and age (r= −0.42; p=0.0097). The Kaplan-Meier statistical method and logrank test were used for univariate survival analysis and the Cox proportional hazard regression models for multivariate survival analysis. In multivariate analysis, when adjusted for age (>= 50 years versus younger), cytogenetics findings (poor prognosis versus others) and the nature of leukemia (secondary versus de novo), improved survival was found in patients with a combination of short telomere length (<7.6 Kb) and weak TA (<0.09, cut off point separating the upper tertile) and the worse survival was found in patients with long telomere length (>=7.6 Kb) and high TA (>=0.09) (hazard ratio=9.91; 95% CI: 1.75–56.03; p=0.01). Our results suggest that the combination of telomere length and telomerase activity can be considered as an independent prognostic factor for survival in patients with AML.

Table 1: Patients characteristics Sex (no. of patients) * AML post solid tumor (n=7), post myelodysplastic syndrome (n=1), post chronic myeloid leukemia (n=1) M 18 F 22 Age (years) Median 50 Range 22–74 Leukocyte count (Giga/L) Median 24.2 Range 1.3–360 Bone marrow blast percentage Median 76.5 Range 20–99 FAB Classification (no. of patients) M0 6 M1 9 M2 5 M4–M5 12 M4Eo 3 M6 1 Biphenotypic AL 3 NK AML 1 Type of leukemia (no. of patients) De novo 31 Secondary 9* Prognosis (based on karyotype) Good 5 Intermediate 21 Poor 10 Missing 4
Elevated Fas Ligand and BA21 Serorecognition as Disease Correlates in Bone Marrow Failure Disorders: Taking Advantage of the LGL Leukemia Model.
Authors: Nyland Susan B. , Cuthbertson David , Loughran Thomas P.
Published: October 2019

Persistently expanded large granular lymphocytes (LGL) are found in bone marrow failure disorders such as pure red cell aplasia, myelodysplastic syndromes, aplastic anemia, paroxysmal nocturnal hemoglobinuria (PNH), and in LGL leukemia. Many of the characteristics of BMF diseases overlap and it is postulated they share a fundamental pathogenetic link. LGL leukemia represents the best characterized disease of LGL, and was used as a model to study pathogenic LGL proliferation in bone marrow failure diseases. LGL leukemia cells are characteristically resistant to Fas-regulated death, despite expressing high levels of Fas receptor and Fas ligand (FasL). Elevated FasL may cause the neutropenia that is observed in many LGL leukemia patients. A poorly understood feature of LGL leukemia is serorecognition of a discreet epitope derived from the HTLV envelope BA21 region. To query the common pathogenesis in all of the BMF disorders, FasL expression and BA21 seroreactivity levels were obtained for patients with bone marrow failure disease (n=87). The serum FasL levels as determined by antigen capture were inversely correlated with neutrophil counts regardless of disease subtype. A positive correlation was noted between FasL expression and lymphocytosis, basophile counts, and serum chloride mEgL (Pearson correlation p values 0.0621, 0.0224, 0.0465). Negative correlations for FasL included neutrophil count and serum albumin levels (p= 0.0333 and 0.0657 respectively). Initial data from an assay we designed to obtain standardized anti-BA21 IgG data revealed a strong negative correlation for BA21 IgG and FasL (−0.3668) for the PNH cohort. An additional moderately positive Pearson correlation for FasL and BA21 IgG was found only for the LGL leukemia group (0.1813), although all BMF groups demonstrated elevated IgG recognition of BA21 (n=78). In addition, FasL and BA21 IgG levels were most elevated in female patients. Our results suggest that FasL and BA21 IgG levels correlate with certain laboratory features of hematopoeitic inhibition as well as with patient gender. A potential utility in discriminating between bone marrow failure disease subtypes and determining treatment response potentials could also be realized with further study.
Abnormal CD34 Positive Cells Are Present in NPM+ Acute Myeloid Leukemia (AML) Samples at Diagnosis.
Authors: Martinez Clara M. , Bussaglia Elena , Hernandez Carmen , Estivill Camino , Ubeda Josep , Brunet Salut , Aventin Anna M. , Sierra Jorge , Nomdedeu Josep F.
Published: October 2019

Nucleophosmin (NPM) gene mutations are the molecular hallmark of a large primary AML subgroup of patients. NPM mutated cases are commonly associated with FLT3-internal tandem duplications which seem to confer an adverse prognostic meaning. Blasts from NPM+ leukemias have been described as CD34 negative.

Objective: To assess the presence of CD34 positive populations and their phenotypic profile in NPM mutated samples at diagnosis. To investigate whether there are differences between NPM/FLT3- and those with an associated FLT3-ITD.

Patients and methods: Cells from forty-three bone marrow de novo NPM+ AML (26 females/ 17 males) patients enrolled in AML-CETLAM protocols were analyzed at diagnosis by means of multiparameter flow cytometry (MFC). In 18 cases an associated FLT3-ITD was detected (NPM+/FLT3+ group). Immature antigenic markers were investigated by triple combinations of direct conjugated MoAbs to CD15, CD34 and HLA-Dr ; CD34, CD123 and HLA-Dr; CD34, CD33 and CD19; CD15, CD117 and CD45. Minimal residual disease studies (7 cases) were performed in samples in complete remission using flow cytometry and real-time PCR (ABIPRISM 7700).

Results: In all the patients we were able to detect an abnormal CD34 population. CD15 coexpression, abnormal light scatter patterns, CD117 clusterization, antigenic overexpression and abnormal CD123 expression were all detected in these cases. NPM+/FLT3+ patients had 2,24% CD34+ cells(0,12%–42%) whereas for NPM+/FLT3- cases the mean CD34+ value was 1,05% (0,1–92%)(n.s.). Sequential samples to test in parallel the abnormal immunophenotype and NPM transcripts by real-time PCR were available in 7 cases (5 NPM+/FLT3+ and 2 NPM+/FLT3-). Relapses were observed in two NPM+/FLT3+ cases (4% and 42% CD34+ cells at diagnosis) and 1 NPM+/FLT3- patient (0.1% CD34+ cells at diagnosis). No definite pattern of relapse could be established given that in some cases NPM rises preceded the detection of phenotypically abnormal cells.

Conclusions: NPM mutated AML patients may be mostly categorized as CD34 negative following standard flow-cytometry positivity thresholds. Nevertheless, the constant detection of immature abnormal cells (CD34+CD123+CD117++) may help to identify the leukemic stem-cell pool in NPM+ and FLT3+ leukemias. It remains to be investigated whether the size of this compartment has prognostic relevance in some groups of normal karyotype AML.
Comprehensive Analysis of Genetic Alterations in Acute Myeloid Leukemia According to the WHO Classification.
Authors: Ishikawa Yuichi , Kiyoi Hitoshi , Tsujimura Akane , Miyazaki Yasusi , Tomonaga Masao , Kuriyama Kazutaka , Miyawaki Syuichi , Naoe Tomoki
Published: October 2019

Acute myeloid leukemia (AML) is a heterogeneous clonal disorder of hematopoietic progenitor cells, and is thought to be the consequence of two broad complementation classes of mutations: those that confer a proliferative and/or survival advantage to hematopoietic progenitors, and those that impair hematopoietic differentiation and confer properties of self-renewal. To date, several genetic alterations, which are involved in the pathophysiology of the AML development, have been apparent, and some of them have been disclosed to have an impact on the clinical management. Therefore, it is required to establish the detailed classification of AML according to the genetic status. In this study, we comprehensively analyzed the genetic alterations in AML patients in comparison with the WHO classification. The study population included 115 newly diagnosed AML patients consisting of 25 recurrent genetic abnormalities, 25 multilineage dysplasia, 7 therapy-related and 56 not otherwise categorized WHO subcategories. Bone marrow samples were obtained from the patients after obtaining informed consent for banking and molecular analyses. Mutations in FLT3, cKIT, NPM1, N-RAS, p53, C/EBPa, AML1 and AKT1 genes were analyzed as previously described. In consistent with previous reports, FLT3 (20.9%), NPM1 (14.8%) and C/EBPa (13.0%) mutations were frequently observed, while no AKT1 mutation was found. Furthermore, NPM1 mutation was not found in AML with recurrent genetic abnormalities and C/EBPa mutation was not found in AML with recurrent genetic abnormalities or therapy related. Nine cases have double mutations of FLT3 and NPM1 genes, and 3 have FLT3 and C/EBPa mutations. Of note is that 15 of 25 (60%) AML with multilineage dysplasia cases have at least one mutation in p53, NPM1, C/EBPa, FLT3, N-RAS and AML1 genes and that p53 mutation was selectively found in the cases with complex karyotype. However, 4 AML with multilineage dysplasia cases with normal karyotype did not have any mutations in the analyzed genes. Comprehensive genetic analysis clarifies the detailed molecular base of AML and could make the subdivision of the WHO classification by combining the analysis for clinical impacts. Especially, mutation status in p53, NPM1 and C/EBPa genes seems to be useful for the subdivision of the AML with multilineage dysplasia, which is the most heterogeneous subcategory in the WHO classification.
One-Mutation Model Can Explain Age Incidence in AML Carrying Nucleophosmin (NPM1) Mutations.
Authors: Liso Arcangelo , Castiglione Filippo , Cappuccio Antonio , Stracci Fabrizio , Thiede Christian , Ehninger Gerhard , Schnittger Susanne , Haferlach Torsten , Valk Peter , Lowenberg Bob , Martelli Massimo F. , Falini Brunangelo
Published: October 2019

Acute myeloid leukemia (AML) carrying nucleophosmin (NPM1) mutations and cytoplasmic NPM (NPMc+ AML) accounts for about one-third of all AML patients, and exhibits distinctive biological and clinical features. The role of NPM1 mutations in leukemogenesis remains elusive. Mathematical models have been developed that, starting from cancer incidence data, allow to infer the somatic mutation rate, or the number of genetic events required to cause cancer. We collected data on age at diagnosis of AML patients from four centers in three different countries, and calculated age-specific rates of NPMc+ AML. A total of 4,155 AML patients were investigated. NPM1 mutations these were detected in 1288. Patients carrying NPM1 mutations with age below 20 years and above 59 years were excluded from the study because of the low number of younger cases and because older patients are not always referred to major institutions for diagnosis and treatment. To investigate NPMc+ AML we adapted one-mutation model published by Michor et al (PNAS, 2006; 103: 14931). The mathematical model consider a population of N (hemopoietic stem) cells that at beginning are wild-type. These cells proliferate according to the Moran process. The growth follows a logistic law with a saturation term. Our process follows the “classical” Moran process up to the appearance of a successful mutant. After that, the clone expands to a limiting population size. This is done to account for the dramatic expansion of the initial compartment peculiar of AML. Finally the rate of AML detection is proportional to the number of mutated cells. Experimental incidence curves of AML in Germany (Ge), Netherlands (Nl), and Italy (It) plotted simultaneously with predicted one-mutation model estimates are shown in Fig. 1. Linear regression of curves representing age-specific rate of diagnoses per year showed similar slopes (about 4 on a double-log scale) in different countries. The one-event model reproduces well the “exponential phenotype” of NPMc+ AML. In conclusion the model is in accordance with the hypothesis that NPM1 mutations by themselves are sufficient to cause NPMc+ AML. Alternatively, it is still possible that NPM1 mutations might cooperate with other molecular alterations to cause AML. In particular, since NPM1 mutations cause haploinsufficiency of wild-type NPM in leukemic cells and in knock-out mice NPM haploinsufficiency results in a MDS-like syndrome and given that the NPM1 mutant has oncogenic properties, these alterations could act in concert to cause AML. Indeed, the effect of these two alterations occurring simultaneously could be seen as a single genetic event.

Figure Figure
CD52 Is Expressed in Childhood Acute Myeloid Leukemia and May Be a Target for Alemtuzumab.
Authors: Wegmann Matthew K. , Berger James , Bostrom Bruce , Messinger Yoav H.
Published: October 2019

Event free survival in children with Acute Myeloid Leukemia (AML) remains low at approximately 50%, and more effective therapy is urgently needed. Alemtuzumab is an anti-CD52 humanized antibody with activity in Chronic Lymphocytic Leukemia. In adults with AML, CD52 was expressed in 36% of patients. Alemtuzumab treatment in relapsed adult AML patients resulted in complete response without platelet recovery (CRp) in 2/9 (22%), reduction of marrow blasts in 1/9 (11%) and reduction of peripheral blasts in 5/9 (56%) (Cancer, 2006;106:2645–51). The expression of CD52 has not been reported in childhood AML. AML (excluding M3) was diagnosed in 48 children at our institution from February 2002 to February 2007. The flow cytometric expression of CD52 antigens was studied in 41 pediatric patients at diagnosis: 20 girls and 21 boys and median age 5.1 years (range 0–18). CD52 expression ≥ 20% of leukemic blasts was considered positive. Of the 41 AML patients, 19 (46%) were positive and 22 (54%) were negative for CD52. In the CD52 positive patients the median expression was 72% (range 22%–99%), and intensity was moderate to dim. Expression by cytogenetic risk groups is demonstrated in Table 1:

Cytogenetic Risk Group Low Risk: t(8;21) or Inv(16)/t(16;16) Intermediate Risk High Risk: −7 or -5/5q- Down Syndrome CD52 positive 7 9 2 1 CD52 negative 2 13 3 4

More low-risk patients were CD52 positive than negative, but the reverse was true for patients with Down syndrome. Age, gender, FAB subtype or presenting white blood cell count did not correlate with CD52 expression. Event free survival and overall survival were similar in CD52 positive and negative patients. In summary, CD52 is expressed in almost half of children with AML. The activity of single agent Alemtuzumab in adults with AML suggests that this agent should be evaluated to treat CD52-positive pediatric AML patients in combination with chemotherapy.
Clinicopathological Analysis of 32 Cases of Extra-Medullary Myeloid Tumour.
Authors: Todd Tony , Besser Martin W. , Craig Jenny I. , Marcus Robert E.
Published: October 2019

We performed a retrospective analysis of 32 cases of extramedullary myeloid tumour in patients aged 11 weeks – 85 years (median 26 years), identified from the records of the Addenbrooke’s Hospital Department of Pathology over a 10 year period from 1st January 1997 to 15th January 2007. Records were reviewed for diagnosis, immunohistochemical stains, demographics, clinical and radiological features, treatment and outcome. 9 patients (28%) had a pre-existing haematological disorder, 6 (19%) presented with simultaneous EMMT and leukaemia, and 17 cases (53%) with de novo isolated EMMT. The most commonly positive immunohistochemical stains were CD43 (100%), CD45 (95%), CD68-PGM1 (91%), MPO (83%), CD 15 (78%) and CAE (73%). None of the 26 cases tested was positive for CD3, cytokeratin was negative in all tested patients, two cases were positive for CD79a, 9 of 9 cases were strongly positive for MIB1, 6 of 6 were positive for bcl-2, and vimentin positive in 3 of 3 cases. Misdiagnosis occurred in 10 out of the 17(59%) isolated de novo presentations. These were thought to be lymphoma (6/10), sarcoma (1/10), plasmacytoma (1/10), rhabdomyosarcoma (1/10) and fibromyomatosis (1/10). All the bcl-2 positive cases were misdiagnosed as non-Hodgkin’s lymphoma, even in the absence of specific B- or T-cell markers, and 1 vimentin positive case as sarcoma. No misdiagnosed case was initially tested for chloroacetate esterase or myeloperoxidase, in 9 subsequent testing showed one or both to be positive. 9 of 32 cases were (28%) long term survivors with a median follow up 1610 days, 7 adults and 2 children. Two received local therapy only with excision and radiotherapy, all others received intensive AML chemotherapy. There was only 1 long term survivor of the 6 patients initially given non-AML chemotherapy as a result of misdiagnosis. In that patient the diagnosis was revised within 14 days. All other misdiagnosed patients treated with non AML chemotherapy progressed to AML and were unsalvageable. Isolated EMMT may give rise to significant diagnostic difficulty. These tumours are usually positive for CD45, MPO and CAE but unless these are tested for, isolated expression of vimentin and bcl-2 may be misleading. In our series outcome was adversely affected by diagnostic delay, initial non-AML therapy, lymphadenopathy and tumour bulk (>10cm) at diagnosis. In correctly diagnosed patients AML chemotherapy alone may be sufficient to achieve long-term disease free survival in contrast to other recently published studies.
Flt3 Mutations in Proximity to an Ubiquitin Dependent Endocytosis Motif Suspend Its Hdm2 Modulation.
Authors: Wergeland Line , Oveland Eystein , Sjoholt Gry , Bedringaas Siv Lise , Hovland Randi T. , Bruserud Oystein , Gjertsen Bjorn T.
Published: October 2019

Acute myeloid leukemia (AML) frequently features mutations in the receptor tyrosine kinase Flt3 and elevated expression of the oncogenic E3 ubiquitin ligase Hdm2. Additional to the p53 inhibitory effect of Hdm2, Hdm2 appears involved in endocytosis of cell surface receptors. In this study we explore the possibility of Flt3 modulation by Hdm2 in primary AML cells and cell lines (NB4 and MV4–11) with wild type Flt3 (Flt3-wt) or mutated Flt3 (Flt3-ITD). Flt3 ligand (FL), small molecular inhibitors and small interfering RNA (siRNA) were used to elucidate the relation between Flt3 and Hdm2 on protein level, mRNA expression and modulation of apoptosis. The basal level of Flt3 is higher in AML patients with Flt3-ITD than in patients with Flt3-wt. Flt3-ITD affects a ubiquitin endocytosis motif that in some patients are duplicated, possibly resulting in enhanced receptor cycling. Down-regulation of Flt3-wt by FL, small interfering RNA or PKC412 resulted in elevated level of Hdm2. Similarly, Hdm2 attenuation resulted in increased Flt3 protein expression. Flt3-ITD responded less to Flt3 down-regulation, and was only weakly responding to Hdm2 modulation. We demonstrate that modulation of Flt3 or Hdm2 results in reciprocal regulation, and that Flt3 with internal tandem duplications may suspend its Hdm2 modulation. Together, Flt3-ITD results in dysregulated receptor turnover and elevated Hdm2 thus interconnecting the two pathways of Flt3 and p53, both related to chemoresistance in AML.
Sucessful Management of Pregnancy and Remission-Induction of a Patient with Philadelphia Chromosome-Positive Acute Lymphoblastic Leukemia (Ph+ALL) by Means of Imatinib Mesilate and HyperCVAD.
Authors: Suzuki Toshiya , Abe Yu , Mori Yuki , Nakagawa Yasunori , Saito Keiko , Matsumoto Yoko , Miyauchi Akito , Sugimoto Mitsuhiro , Suzuki Kenshi
Published: October 2019

A 31-year-old female at 25 weeks and 5days of gestation was referred to the hematology department because of thrombocytopenia. Complete blood cell count was as follows; WBC 3,600/ml(blast 8%), RBC 393x104/ml, Hb11.7g/dl, Hct 34%, and Plt 4.4x104/ml. Bone marrow examination revealed peroxidase negative blasts increased 90% in the marrow. The result of karyotype analysis: 47, XX, t(2;7)(p11.2;p13), ider(9)(q10), t(9;22)(q34;q11), der(22)t(9;22), +der(22)t(9;22) [27/30] ;46, XX[3/30]. FISH analysis showed 88.5% of marrow cells were positive for bcr-abl chimeric DNA. To save mother and baby, we decided to operate cesarean section. A 716-gram healthy female was born at 26 weeks and 2days of gestation age. The day after operation, 600mg/day of imatinib mesilate started. One week after operation, the first course of hyperCVAD chemotherapy dose-reduced to 60% (CPA300mg, VCR 2mg, DOX 50mg, Dex 40g) started with 600mg of imatinib mesilate. Intra-thecal MTX 15mg, Ara-C 40mg, and PSL 20mg injection was given on day 8. Bone marrow was examined on day 21. Marrow blast cells were 0%. Karyotype analysis was normal. FISH analysis showed 2.5% cells had bcr/abl chimeric DNA. Major toxicities of the chemotherapy was not observed. She maintains complete remission until now. She has been treated with second course of modified hyperCVAD(MTX 1,000mg, Ara-C 2,000mg, mPSL 50mg) and is being prepared for unrelated umbilical cord blood stem cell transplantation. The baby grows heathy and no major hematological problems has been observed. Here we report the successful management of pregnancy and remission-induction of a mother with Ph+positive ALL at 25-weeks and 5days of gestation by means of imatinib mesilate and hyperCVAD.
Phase I/II Study of Clofarabine Plus Cyclophosphamide in Adults with Relapsed and Refractory Acute Lymphoblastic Leukemia (ALL).
Authors: Faderl Stefan , Thomas Deborah A. , Gandhi Varsha , Borthakur Gautam , Huang Xuelin , Plunkett William , Burger Jan , Cortes Jorge , O’Brien Susan , Ravandi Farhad , Bretz Jennie , Kwari Monica , Kantarjian Hagop M.
Published: October 2019

Clofarabine (CLO) is a nucleoside analog with activity in pediatric ALL salvage where it has received FDA approval. Less experience with CLO exists in adult ALL. As CLO inhibits DNA repair following exposure to DNA damaging agents, we designed a phase I/II study of the combination of CLO with cyclophosphamide (CY) for therapy of adult patients (pts) with primary refractory or relapsed ALL. Pts with NYHA class ≥ 3 and a cardiac ejection fraction < 45% were excluded. The continual reassessment method (CRM) was applied to determine MTD from 4 dose levels. The starting dose level was CLO 40 mg/m2 i.v. daily x 3d and CY 200 mg/m2 i.v. q12h x 3d. For cohort 2, the dose of CY was increased to 300 mg/m2. Cohorts 3 and 4 maintained these doses with the treatment duration extended to 4 and 5 days, respectively. Additional samples for clinical pharmacology were obtained from consenting pts prior to and following CY on d1 and d2 and prior to CLO on d2.Thirteen pts have been enrolled. Median age was 34 yrs (range 21–72 yrs). Eight pts had pre-B ALL, 2 pts T ALL/LL, 1 pt mature B ALL, and 2 pts biphenotypic acute leukemias. Karyotype was abnormal in 9 pts (no Ph). Median number of prior regimens was 2 (1–6). Two (15%) pts were primary refractory. Median remission duration to initial induction was 11 mos (0–29.8 mos). Three patients were treated in cohort 1 and 10 in cohort 2. Four pts in cohort 2 experienced DLTs (≥ grade 3): elevation of creatinine/renal failure (1), diarrhea (1), transaminase elevations (2), and hyperbilirubinemia (2). Twelve patients were evaluable for response. One pt (70 yrs, prim. refr. pre-B ALL, complex karyotype) of cohort 1 achieved CR after 2 courses, which lasted for 10.3 months. Four pts died on study from infectious complications (days 2, 15, 34, and 41, respectively). Although no MTD has been defined yet and accrual continues in cohort 2, it appears unlikely that the MTD will exceed the dose levels of cohort 2. More information on efficacy will be obtained in the phase II extension part of the study.
Venothromboembolism (VTE) in Patients (pts) with Acute Lymphocytic Leukemia (ALL), Burkitt’s Leukemia/Lymphoma (BL) or Lymphoblastic Lymphoma (LL).
Authors: Vu Khanh D. , Hubbard Julie C. , Lin E. , Faderl Stefan H. , Cortes Jorge E. , O’Brien Susan M. , Kantarjian Hagop M. , Thomas Deborah A.
Published: October 2019

It has been reported that cancer increases the risk of VTE 4-6-fold. The incidence of VTE in cancer pts has been estimated at 1 in 200 per year and has been well documented in solid tumors. Far less is known about the incidence of VTE in pts with hematological malignancies although a recent publication (Blom et al, JAMA293:715, 2005) suggested that pts with hematological malignancies such as lymphoma and multiple myeloma may be at a higher risk of developing VTE than pts with solid tumors. The incidence and risk of VTE has not been well studied in acute leukemias, a population in which prophylaxis is underutilized given the thrombocytopenia associated with intensive chemotherapy. To evaluate the incidence of VTE in pts with hematological malignancies further and to assess the need for VTE prophylaxis, we conducted a retrospective chart review of 299 pts with ALL, BL, or LL who were seen at M.D. Anderson Cancer Center Center from November 1999 to May 2005. Pts received a hyper-CVAD based regimen (fractionated cyclophosphamide, vincristine, doxorubicin, dexamethasone alternating with methotrexate and high-dose cytarabine). The median observation period was 188 weeks (range 1–328 wks) and included post-consolidation chemotherapy, allogeneic stem cell transplant, and/or salvage chemotherapy. Among 298 evaluable pts, 52 (17%) had confirmed VTE by imaging studies. In 7 pts, VTE was the presenting sign of the malignancy. The median age of pts who developed VTE was significantly higher than of those who did not develop VTE, 48.5 yrs (range 19–75) vs. 42 yrs (range 15–83), respectively (p=0.04). With each year increase in age, the risk of having VTE increased approximately by 1.7% (p=0.059). ALL pts with Philadelphia chromosome (Ph) had a higher incidence of VTE than all other pts (p=0.02), and were 1.8 times more likely to have VTE than non-Ph ALL pts (p=0.007). Caucasian pts or those with history of prior VTE had a significantly higher incidence of VTE (p=0.03 and p=0.002, respectively). The risk was 2 fold higher for Caucasians and 12 fold higher for those with a prior history of VTE. At the time of VTE, platelet counts were below 50 x 109/L in 33%, 50–100 x 109/L in 10%, and greater than 100 x 109/L in 57%. VTE occurs in a significant proportion of pts with ALL, BL, and LL. Thrombocytopenia does not preclude the development of VTE. Older age, Ph positivity, race, and history of prior VTE were significantly associated with the development of VTE. Further analysis of other known risk factors such as the use of erythropoiesis-stimulating agents, hormonal therapy, and other comorbidities is underway to better refine the subpopulation at risk.
Liver Engraftment by Transplanted Human Progenitor Cells with High Aldehyde Dehydrogenase Activity in a Novel Model, NOD/SCID/MPSVII Mice.
Authors: Zhou Ping , Hohm Sara , Hess David A. , Nolta Jan A.
Published: October 2019

Hematopoietic stem cells (HSC) have been reported to generate cells other than the blood lineage and thus hold enormous promise for repairing damaged tissues. Evidence from our lab and others suggests that hepatocytes can be derived from HSC. However, the frequency of HSC-derived hepatocytes varies tremendously among various studies which use different stem cell subsets and different mouse models. Therefore, the significance of hematopoietic stem cell contribution to the repair of liver damage is still controversial. To further explore this potential, we used the beta-glucuronidase (GUSB)-deficient NOD/SCID/MPSVII mouse model for better identification of engrafted human cells. We and others have previously shown that lineage depleted (lin−) human umbilical cord blood-derived cells with high aldehyde dehydrogenase activity (ALDHhi) are enriched for primitive HSC. In the current studies, ALDHhi lin− cells were transplanted into irradiated NOD/SCID/MPSVII mice. One month after transplantation, carbon tetrachloride (CCl4) was administrated into the mice twice a week for 4 weeks to induced liver damage. In this model, ALDHhi lin− cells gave rise to robust hematopoietic reconstitution (71%±13.1 in bone marrow, 12.8%±4% in peripheral blood and 10.7%±8.8% in spleen) while ALDHlolin− cells failed to engraft. In the liver, engraftment of human cells in mice tansplanted with ALDHhi lin− cells was demonstrated by the presence of human Alu DNA using PCR. CD45+ cells were detected by both FACS (2.11%±1.1) and by immunohistological staining in the liver sections. GUSB expression was frequently evident in kuffer cells adjacent to blood vessels and to a lesser extent in the liver parenchyma. GUSB+ cells were more abundant than CD45+ cells. Most interestingly, human liver-specific a-1-antitrypsin mRNA was detected in the recipient murine livers by RT-PCR analysis. Human albumin- expressing cells were also found in these livers, although such cells were rare as compared to human CD45+ or GUSB+ cells. In contrast, human cells were not detected in the livers of mice tansplanted with ALDHlolin− cells in any of our assays. Thus, ALDH-expressing progenitor cells demonstrated potent engraftment of variable cellular phenotypes, suggesting that these adult progenitor cells should be further explored in transplantation models of tissue damage. Our data also support the idea that hematopoietic stem cells may home to the injured liver and release trophic factors that hasten tissue repair, while direct differentiation of these stem cells to hepatocytes or fusion of these cells with hepatocytes is rare and contributes to a lesser extent to liver repair.
Minimal Residual Disease (MRD) after Frontline Therapy in Adolescent and Young Adult (AYA) Patients with Acute Lymphoblastic Leukemia (ALL) Treated on Two Separate Regimens.
Authors: Rytting Michael , Thomas Deborah , Jorgensen Jeffrey , Kantarjian Hagop , Garris Rebecca , Muriera Brenda , O’Brien Susan
Published: October 2019

Retrospective and prospective studies have demonstrated that AYA patients (pts) with ALL have superior outcomes when treated with pediatric rather than adult-type regimens. Pediatric ALL regimens are therefore being applied as frontline therapy for adults up to age 30. Given the relatively favorable outcome for this group and the length of therapy employed, it will be several years before the superiority of this approach can be confirmed. MRD by multiparameter flow cytometry (MFC) might be an early measurement of treatment efficacy, since detection of MRD after initial induction has been shown to predict for decreased disease-free survival (DFS). MRD monitoring may thus provide an early indication of later success for different ALL regimens in AYA patients. MRD was measured by four color MFC using lineage specific antibodies in conjunction with antibodies directed at aberrant antigens. The limit of detection was one cell in ten-thousand. MRD data for 43 pts </= 30 years of age treated with the adult regimen of hyper CVAD (fractionated cyclophosphamide, vincristine, doxorubicin, dexamethasone) with or without rituximab was compared with MRD data obtained from 13 pts treated with the pediatric ABFM regimen. The median age of the two groups was 22 years (range 15–30) and 20 years (range 14–28), respectively. MRD data on day 21 of therapy was available for 33 of 43 pts (77%) treated with hyer-CVAD; 22/33 (67%) were negative, 10/33 (30%) were positive, and one pt had insufficient cells for analysis. On day 90 of therapy, 21 of the 43 pts had data available, and all were MRD negative. All pts treated with the ABFM protocol had MRD assessments performed on day 29 of induction therapy; 8 (62%) were negative, 2 (15%) had suspicious cells in an insufficient sample, and 3 (23%) were positive. Of the 9 pts with MRD measurements on day 84 of therapy, all were negative except for 1 pt who relapsed before day 84. These preliminary data indicate that AYA pts with ALL receiving either hyper-CVAD or ABFM therapy have similar MRD status at the end of induction and after approximately 3 months of consolidation. Given the likely importance of MRD in predicting DFS, this comparison suggests that hyper-CVAD and ABFM may show similar outcomes in this population. Continued accrual and longer follow-up will be required to confirm this hypothesis.
A Case of Peripheral Neuropathy Combined with Leukoencephalopathy after Injection with Intrathecal Methotrexate and Vincristine.
Authors: Lee Hae-sang , Jung Hyun Joo , Park Jun Eun
Published: October 2019

Vincristine and methotrexate are the anchor drugs in the treatment of acute lymphocytic leukemia. The neurological complications caused by either vincristine or methotrexate have been well documented. A 10 year-old girl diagnosed acute lymphocytic leukemia without central nervous involvement and treated with CCG 1882 based therapy. She suffered from ascending paralysis from lower extremities without seizure or mental change three days after the fifth dose of vincristine and the fifth dose of intrathecal methotrexate during consolidation chemotherapy composed of 3-drug(vincristine, methotrexate, and L-asparaginase). Two days later, she developed dysarthria and respiratory discomfort. Her neurological examination showed a symmetric, flaccid, quadriparesis with loss of deep tendon reflex. But, she did not have sensory loss. We thought Guillain-Barre syndrome as first impression and carried out diagnostic evaluation. Viral study revealed no abnormality and cerebrospinal fluid study was not consistent with Guillain-Barre syndrome or infectious disease. Diffusion weighted magnetic resonance imaging showed a well-demarcated area of moderately high signal intensity in the white mater of the both parietal lobes. Neuromuscular conduction test revealed severe amplitude reduction in motor nerve action potential meaning on peripheral polyneuropathy. These findings were corresponded with drug-induced peripheral neuropathy and chemotherapy-related leukoencephalopathy that was detected incidentally. She did not receive further doses of vincristine and intrathecal methotrexate during the consolidation phase. There was gradual improvement of the weakness in the both lower and upper limbs for 3 months. She was recovery to walk with minimal support. We report peripheral neuropathy combined with subclinical leukoencephalopahty after injection with intrathecal methotrexate and vincristine.
Comparison of Different Chemotherapy Regimens in the Management of Acute Myeloid Leukaemia - 5 Years Experience from Pakistan.
Authors: Ullah Khalil , Ahmed Parvez , Raza Shahid , Mahmood Tariq , Khan Badshah
Published: October 2019

OBJECTIVES: This is a retrospective study in acute myeloid leukaemia (AML) patients carried out at Armed Forces Bone Marrow Transplant Centre Rawalpindi Pakistan between July 2001 and June 2006. Aim of the study was to evaluate outcome in AML patients treated with different remission induction and consolidation chemotherapy regimens in our population.

METHODS: During 5 years period between July 2001 to June 2006, 46 patients received treatment for AML at our centre. Twenty nine patients were males and 17 were females. Median age of patients was 21 years (range: 7–56 years). These 46 patients were categorized into two groups on the basis of type of leukaemia and chemotherapy given. In group-I 40 patients (group Ia: 23 patients of M1–M6, less M3 group Ib: 17 patients of AML M3) received anthracycline and cytarabin based chemotherapy. In group- II, six patients (AML- M3) received all trans retinoic acid (ATRA) based chemotherapy.

RESULTS: In group Ia, out of 23 patients, 14 patients (60.8%) achieved complete remission (CR) after remission induction chemotherapy,10 patients remained in CR after 3rd and 4th consolidation. Eleven patients died and five patients relapsed during treatment and follow up. In this group overall CR, relapse rate (RR) and mortality was 30.4% (7/23), 21.7% (5/23) & 48% (11/23) respectively. In group Ib out of 17 patients, 9 patients (53%) achieved CR after remission induction. Eleven patients died during treatment while one patient relapsed in this group. Overall CR, RR & mortality was 29.4% (5/17), 6% (1/17) & 55% (11/17) respectively. In group II all patients achieved CR (100%) after 1st course of chemotherapy. Two of these patients unfortunately died of uncontrolled sepsis during 1st consolidation, while remaining 4 patients 66.6% are on maintenance chemotherapy and are still in CR.

CONCLUSION: Overall CR, RR and mortality in all groups was 35% (16/46), 13% (6/46) and 52% (24/46) respectively at a median follow-up of 36 ± 8 months. Survival in AML-M3 patients treated with ATRA based chemotherapy is significantly superior than anthracycline based chemotherapy (66.6% vs 29.4%). Infection and chemotherapy toxicity being major causes of mortality.
Continuous Infusion of FLAG and Idarubicin for Patients Younger Than 60 Years with Resistant Acute Myeloid Leukemia; a Prospective, Multicenter Phase II Study.
Authors: Kim Hawk , Park Jae-Hoo , Lee Je-Hwan , Lee Jung-Hee , Joo Young-Don , Lee Won-Sik , Bae Sung-Hwa , Ryoo Hun Mo , Lee Kyoo-Hyung ,   Cooperative Study Group A for Hematology
Published: October 2019

Continuous infusion (CI) of cytarabine and fludarabine can accentuate drug activities. We studied the feasibility and the efficacy of fludarabine and cytarabin as a continuous infusion plus idarubicin for resistant AML under 60 years old. Inclusion criteria were AML except for acute promyelocytic leukemia, patients with resistant acute myeloid leukemia (failure to achieve CR after initial induction chemotherapy including standard dose cytarabine; early relapse, occurring after a first CR lasting less than 12 months; relapse after allogeneic HSCT; relapses more than 2 times). Induction chemotherapy consists of idarubicin 12 mg/m2 iv infusion over 30 min (day 1–3), fludarabine 30 mg/m2/d and cytarabine 1000 mg/m2/d (day 1–5) as a 24-hour CI. G-CSF was added on day 1–5. Three more cycles of induction chemotherapy except for idarubicin were followed for consolidation. All 29 patients were enrolled. Median age was 40 (18–57). Disease status were primary refractory in 8 (27.6%), early relapse in 19 (65.5%), multiple relapse in 1 (3.4%), and relapse after SCT in 1 (3.4%). Translocation (8;21) and variants (8, 27.6%), and 2 or 3 abnormalities (7, 24.1%) were most common chromosomal abnormalities. Two patients (6.9%) could not complete induction. Twenty three patients had the early evaluation on median day 15 (14–42); median PB blast 0 (0–9.7) % and median bone marrow blast 0 (0–64) %. Median days for hematological recoveries in CR patients were follows: ANC > 500/mm3 (29 days); ANC >1000/mm3 (32 days); platelet >20K/mm3 (31.5 days); platelet>100K/ mm3 (43 days). Response for induction were CR in 8 (27.6%), CRp in 2 (6.9%), and treatment failure in 19 (65.5%, aplasia in 14, indeterminate course in 3, resistant in 2). Median days required for CR was 45 (37–63) days. Consolidation stopped in 9/11: 7 patients underwent SCT; 1 patient died during consolidation; 1 patient stopped due to toxicity; 1 patient due to other cause. Seven patients are alive and two were lost to follow-up. Nineteen patients died of infection (14 patients), toxicity during consolidation (1 patient), relapse after SCT (3 patients) and persistent disease (2 patients). Autolous SCT performed in 2 and allogeneic SCT in 5. Median overall survival in all and CR patients were 2.47 (95% CI 0.83–4.10) and 11.38 (95% CI 1.32–21.44) months, respectively. Relapse occurred after autologous SCT in 2/2 and after allogeneic SCT in 2/5. CI infusion of FLAG plus idarubicin was effective for eradicating blasts with expense of high toxic death. Reduced doses are recommended for CI of FLAG plus idarubicin.
Impact of CRi on the Outcome of Elderly Patients with Acute Myeloid Leukemia.
Authors: Etienne Anne , Charbonnier Aude , Prebet Thomas , Coso Diane , Stoppa Anne-Marie , D’Incan Evelyne , Doglio Marie-Françoise , Sainty Danièle , Mozziconacci Marie-Joelle , Rey Jérome , Gastaut Jean-Albert , Vey Norbert
Published: October 2019

New international recommendations of response for treatment of acute myeloid leukemia (AML) include morphologic complete remission with incomplete blood count recovery (CRi). This response criteria was defined following evaluation of new drugs used for the treatment of AML in first relapse (Sievers et al., JCO2001;19:3244–3254). The objective of our study was to determine the outcome of elderly patients with newly diagnosed AML achieving CRi. Between 1995 and 2006, 240 patients aged 65 years or older with previously untreated acute non promyelocytic leukemia received a conventional anthracycline and cytarabine induction chemotherapy at a single institution. Median age was 71 years (range, 65–85). One hundred and nineteen patients achieved a complete response (CR) (50%), 15 patients achieved CRi (6%), 69 patients had persisting leukemia (29%), and 37 died during remission induction therapy (15%). Patients who reached a CR or CRi after 1 or 2 cycles of induction chemotherapy proceeded to consolidation. Only 9 patients in CRi received this consolidation chemotherapy course (60%) and none had intensification (intermediate-dose cytarabine and/or autologous stem cell transplantation) whereas for patients achieving CR, 88% (n=104) and 69% (n=82) had consolidation and intensification, respectively (p=0,01 and p=0,03). The median overall survival (OS) was respectively 9 and 18 months for patients in CRi and CR (p=0,08). OS was significantly lower for patients in CRi younger than 70 years (5 versus 17 months for CR, p=0,02). By landmark analysis, there was no difference in OS between patients in CRi and a group of 67 patients with induction failure surviving at less 40 days (p=0,14). Disease-free survival (DFS) and remission duration were not significantly different between patients in CRi and CR overall (5 and 8 months, and 5 and 7 months, respectively), but we found a difference for patients younger than 70 years (p=0,004 and p=0,009 for DFS and remission duration, respectively). There was significantly more multilineage dysplasia in patients achieving CRi (8 versus 33, p=0,009) and platelet count at diagnosis were lower (44 G/L versus 82 G/L). Cytogenetic did not differ between the two groups. Our results show that the outcome of elderly patients who achieved CRi is inferior to patients in CR, especially for patients younger than 70 years. Although this response criteria seems to indicate activity, we were not able to found a difference with patients who did not achieve CR. This result will be revaluated in a larger study. Our data also suggest that patients with CRi have different initial disease characteristics.

Figure Figure