Preemptive treatment of relapse of acute myeloid leukemia (AML) holds the promise to improve the prognosis of this currently highly lethal condition. Proposed treatment modalities applicable in ...preemptive cytoreduction (e.g., demethylating agents or standard chemotherapy) differ substantially in interval from administration to antileukemic effect. The t(6;9) balanced translocation, producing the DEK‐NUP214 fusion protein, is seen in only 1% of patients with AML. We hypothesized that in these patients, who relapse with a very high frequency, a more detailed knowledge of leukemic relapse growth kinetics would improve the personalized decision‐making regarding re‐administration of chemotherapy. Based on standardized quantitative PCR data, we therefore delineated the relapse kinetics in a cohort of 27 relapsing DEK‐NUP214‐positive patients treated in four different European countries. The prerelapse leukemic burden increased with a median doubling time of 13 d (range: 5–51 d, median: 0.71 logs/month, range: 0.18–1.91 logs/month), with FLT3‐ITD‐positive patients relapsing significantly faster than FLT3‐ITD‐negative ones (median: 0.9 vs. 0.6 logs/month, Wilcoxon rank sum test, P = 0.041). Peripheral blood and bone marrow were equally useful for minimal residual disease (MRD) detection, and thus, we found that with sampling intervals of 2 months, 94% of relapses would be detected with a median time from MRD detection to hematological relapse of 64 d. In conclusion, this data provide algorithms for handling the rare patients with DEK‐NUP214‐positive AML allowing for planning of both MRD follow‐up and, upon molecular relapse, the timing of cytoreduction or possibly transplant procedures.
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Introduction: Gene expression studies have consistently identified a HOXA positive (HOXAPos) subgroup of T-cell acute lymphoblastic leukemia (T-ALL) (Ferrando et al, Cancer Cell 2002, Soulier et ...al, Blood 2005, Homminga et al, Cancer Cell 2011). It is however unclear if HOXAPos T-ALL constitutes a distinct and homogeneous clinical entity, and the biological consequences of HOXA over-expression have not been systematically examined.
Methods: We identified and characterized the biological characteristics and clinical outcome of 55 HOXAPos cases among a cohort of 209 adult T-ALL patients who were uniformly treated as part of the Group for Research on Adult Acute Lymphoblastic Leukemia (GRAALL)-2003 and -2005 studies.
Results: HOXAPos patients had higher rates of an early thymic precursor (ETP)-like immunophenotype (38% v 13.9%, p = 0.0008), early bone marrow chemoresistance (59.3% v 40.8%, p = 0.026) and positive minimal residual disease (MRD, 51.5% v 23.5%, p = 0.01) than the HOXANeg group. These differences were due to a particularly high frequency of chemoresistant ETP-ALL among HOXAPos cases harboring leukemic fusion proteins that trans-activate the HOXA locus (e.g. PICALM-MLLT10, SET-NUP214).
Strikingly, the presence of an ETP-like immunophenotype conferred marked differences in outcome within the HOXAPos group (5 year event-free survival (EFS) 25% for HOXAPos ETP v 52.2% for HOXAPos non-ETP, p = 0.02), which were mirrored by corresponding increases in cumulative incidence of relapse (CIR, 57.1% v 25%, p = 0.01, Figure 1). In contrast, these survival differences were not seen in the HOXANeg patients, where ETP and non-ETP cases had similar 5 year EFS (54.9% v 50%, p = 0.73) and CIR (34.5% v 41.2%, p = 0.57).
Multivariate analysis revealed that early bone marrow chemosensitivity was the clinico-biological covariate that had the strongest prognostic interaction with HOXA status. HOXA positivity conferred significant decreases in both the EFS and CIR of chemoresistant patients (p = 0.053 and 0.039 respectively), that was independent of white blood cell count (WCC), stem cell transplant (SCT), ETP phenotype, EGIL classification, and our recently reported risk classifier that integrates the prognostic effects of mutations of NOTCH1, FBXW7, RAS and PTEN (Trinquand et al, J Clin Oncol 2013). There were corresponding marked survival differences within the HOXAPos cohort between chemoresistant and chemosensitive cases. These disparities were not seen in the HOXANeg group, indicating that the prognostic value of chemosensitivity in adult T-ALL is specific to HOXAPos patients.
Discussion: Our data show that clinico-biological phenotype is intimately linked to the underlying mechanism of HOXA locus deregulation, and we identify HOXA overexpression as a novel prognostic variable in ETP-ALL. Multivariate analysis suggests that this poor outcome is strongly related to intrinsic treatment resistance, and that this effect is exclusive to the HOXAPos cohort. Patients in the GRAALL-2003 and -2005 studies received enhanced induction and/ or salvage therapy in the event of poor early treatment response. Our results suggest that pediatric regimen-based intensification provides significant survival benefits for HOXANeg chemoresistant cases. In contrast, these modifications are inadequate for therapeutic rescue of the majority of HOXAPos chemoresistant ETP-ALL. The dramatically inferior prognosis of this group mandates consideration for alternative treatments in future clinical trials.
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No relevant conflicts of interest to declare.
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Background: Risk stratification in childhood T-cell acute lymphoblastic leukemia (T-ALL) is crucial to drive treatment decisions. Since patients with induction failure or relapse are often ...refractory to further treatment, identifying high risk patients up-front will allow improved treatment. While minimal residual disease (MRD) is the strongest prognosis risk factor used after complete remission (CR), NOTCH1/FBXW7 (N/F) and RAS/PTEN (R/P) mutation profiles at diagnosis have recently been identified to predict outcome in adult T-ALL.
Objective: to test whether an oncogenetic classifier using N/F and R/P mutations could improve the detection of children with T-ALL at risk of relapse.
Methods: 405 patients with T-ALL aged from 1 to 14 years were treated according to FRALLE T guidelines (FRALLE Study group) between 2000 and 2010. Among them, 220 patients, for whom biological material at diagnosis was available, were tested retrospectively for N/F and R/P mutations. These study cohort patients were representative of overall FRALLE 2000 T-ALLs. CR was achieved in 213 patients. MRD (IgH-TCR markers) tested at CR (day 35) was available for 191 patients. MRD was <10-4 for 114 patients (60%) and ≥10-4 for 77 patients. Patients with N/F mutation and R/P germline (GL) were defined as oncogenetic low risk (LoR), while N/F GL and R/P GL or mutation and N/F mutation and R/P mutation were defined as high risk (HiR).
Results: 111 patients were classified as LoR and 109 as HiR. Five-year-CIR and DFS were respectively 35.5% (95% CI, 26.7-44.3) and 59% (95%CI, 50.2-69.6) for HiR versus 13% (95% CI, 6.8-19.2) and 86.8% (80.5-93.5) for the LoR group (Figures A and B). HiR patients were significantly associated with MRD ≥ 10-4 (p=0.0004) and higher risk of relapse (p=0.00002). Among patients with MRD ≥ 10-4, HiR feature worsened the risk of relapse: 5-year-CIR and DFS were respectively 42.8% (95% CI, 28.9-56.7) and 71.1% (95%CI, 56.0-90.2) in HiR versus 28.9% (95% CI, 11.7-46.1) and 50.9% (95%CI, 38.4-67.6) in the LoR group. Among patients with MRD <10-4, 5-year-CIR and DFS were respectively 28.9 % (95% CI, 15.0-42.8) and 71.0% (95%CI, 58.4-86.3) in HiR group versus 4.4% (95% CI, 0-9.2) and 95.5% (95%CI, 90.7-1.00) in LoR group (Figures C and D). As such, the classifier allowed identification of 63% of very low risk patients amongst the MRD<10-4 population. Prognostic values of new oncogenetic risk factors were then analyzed with conventional factors. By univariate analysis, factors identified to predict relapse were male gender (p=0.036), WBC count ≥ 200 G/L (p=0.023), chemoresistance at day 21 (p=0.007), MRD ≥10-4 (p=0.0006) and oncogenetic HiR (p<0.0001). A multivariable cox model including these variables selected the classifier together with WBC count, day 21 chemo-sensitivity and MRD. Based on a stepwise selection procedure, the three most discriminating variables were classifier, WBC count and MRD. The cause specific Hazard Ratio (HR) was 3.22 (95% CI, 1.64-6.28) for oncogenetic HiR versus LoR (p=0.0006), 2.30 (95% CI, 1.26-4.20) for MRD≥10-4 versus MRD<10-4(p=0.0070) and 1.85 (95% CI, 1.01-3.37) for WBC≥200G/L versus <200 G/L (p=0.0456). Based on these three parameters, 8 subsets of patients were defined according to the estimated 5-year CIR. The 58 patients (30%) associating WBC count < 200G/L, classifier LoR and MRD<10-4 were at very low risk of relapse, with a 5-y-CIR of 1.7%. Patients harboring at least one of: WBC count ≥200G/L, classifier HiR or MRD>10-4, demonstrated an increasing CIR, up to 45.8% if all three were associated.
Conclusion: in childhood T-ALL, oncogenetic classification using N/F and R/P mutation profiles is an independent predictor of relapse. When combined with MRD and WBC count ≥200 G/L, it significantly improved relapse prediction, particularly amongst the 60% of T-ALLs with MRD <10-4 at day 35. Appropriate integrating these 3 factors, will help optimize treatment.
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No relevant conflicts of interest to declare.
Abstract
Preemptive treatment of relapse of acute myeloid leukemia (
AML
) holds the promise to improve the prognosis of this currently highly lethal condition. Proposed treatment modalities ...applicable in preemptive cytoreduction (e.g., demethylating agents or standard chemotherapy) differ substantially in interval from administration to antileukemic effect. The t(6;9) balanced translocation, producing the
DEK
‐
NUP
214 fusion protein, is seen in only 1% of patients with
AML
. We hypothesized that in these patients, who relapse with a very high frequency, a more detailed knowledge of leukemic relapse growth kinetics would improve the personalized decision‐making regarding re‐administration of chemotherapy. Based on standardized quantitative
PCR
data, we therefore delineated the relapse kinetics in a cohort of 27 relapsing
DEK
‐
NUP
214‐
positive patients treated in four different European countries. The prerelapse leukemic burden increased with a median doubling time of 13 d (range: 5–51 d, median: 0.71 logs/month, range: 0.18–1.91 logs/month), with
FLT
3
‐
ITD
‐positive patients relapsing significantly faster than
FLT
3
‐
ITD
‐negative ones (median: 0.9 vs. 0.6 logs/month,
W
ilcoxon rank sum test,
P
=
0.041). Peripheral blood and bone marrow were equally useful for minimal residual disease (
MRD
) detection, and thus, we found that with sampling intervals of 2 months, 94% of relapses would be detected with a median time from
MRD
detection to hematological relapse of 64 d. In conclusion, this data provide algorithms for handling the rare patients with
DEK
‐
NUP
214‐
positive
AML
allowing for planning of both
MRD
follow‐up and, upon molecular relapse, the timing of cytoreduction or possibly transplant procedures.
Protein tyrosine phosphatase nonreceptor type 2 (PTPN2) is a phosphatase known to be a tumor suppressor gene in T-cell acute lymphoblastic leukemia (T-ALL). Because the full clinicobiologic ...characteristics of PTPN2 loss remain poorly reported, we aimed to provide a comprehensive analysis of PTPN2 deletions within a cohort of 430 patients, including 216 adults and 214 children treated according to the GRAALL03/05 (#NCT00222027 and #NCT00327678) and the FRALLE2000 protocols, respectively. We used multiplex ligation-dependent probe amplification to identify an 8% incidence of PTPN2 deletion, which was comparable in adult (9%) and pediatric (6%) populations. PTPN2 deletions were significantly associated with an αβ lineage and TLX1 deregulation. Analysis of the mutational genotype of adult T-ALL revealed a positive correlation between PTPN2 deletions and gain-of-function alterations in the IL7R/JAK-STAT signaling pathway as well as PHF6 and WT1 mutations. Of note, PTPN2 and PTEN (phosphatase and tensin homolog) deletions were mutually exclusive. Regarding treatment response, PTPN2-deleted T-ALLs were associated with a higher glucocorticoid response and a trend for improved survival in children, but not in adults, with a 5-year cumulative incidence of relapse of 8% for PTPN2-deleted pediatric cases vs 26% (P = .177).
•We provide a comprehensive analysis of PTPN2-associated genomic alterations and clinical implications in a large cohort of T-ALL.•PTPN2 loss associates with mutations in the IL7R/JAK-STAT signaling pathway, PHF6 and WT1, but is exclusive from PTEN deletions.
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Introduction: Mantle Cell Lymphoma (MCL) is characterized by frequent blood and bone marrow involvement. It has been demonstrated that use of Minimal Residual Disease (MRD) quantification in blood ...and/or bone marrow might be helpful in patient management. Gold standard MRD is based on Q-PCR clone specific amplification of IgH VDJ or IgH-BCL1 rearrangements, but these are relatively complex and time consuming and over half of the positive results are in a grey zone of borderline positivity. Flow cytometry (FCM) is more rapid and better adapted to individual patient management if quantitatively reproducible, but insufficiently sensitive when only 4 colors are used. We therefore developed a universal, 8-color, EuroFlow inspired, FCM strategy, which we compared with classical Q-PCR MRD in 61/97 patients included in (and 1 treated according to) the EU-MCL Younger and Elderly prospective trials who underwent Q-PCR MRD monitoring at Necker Hospital.
Method: Q-PCR MRD from IgH VDJ (n=92) or BCL1-IgH (n=5) was performed prospectively from ficolled blood (PB) or bone marrow, from which residual material was cryopreserved in DMSO for FCM quantitation, using 10 antibodies labelled with 8 fluorochromes for positive and negative (CD45, CD19, CD5, LAIR1, CD11a, IGK, IGL, CD3, CD14 and CD56) gating, after diagnostic phenotyping of fresh material, using the same panel and a EuroFlow B lymphoid screening tube. Sensitivity of both techniques was at least 0.01% (1E-04). FCM was only considered positive if above 0.01%, whereas Q-PCR results were considered positive below quantifiable range (BQR) if borderline, above sensitivity, within Euro-MRD criteria for MRD positivity. BQR samples were separated based on the number of positive, triplicate samples. The objectives were to compare the two techniques and to determine their suitability for regular screening, with a view to pre-emptive treatment on molecular or phenotypic (MRD) relapse. Two patients were treated with Rituximab at MRD relapse, prior to clinical relapse, as proof of principle.
Results: A total of 302 blood or bone marrow samples from 62 patients were quantified. Overall, 79% (42/53) of samples positive at or above 0.01% by PCR were also positive by FCM, compared to 29% (19/65) of those below 0.01%, but with at least 2 positive triplicates and virtually none of those with only 1 or no results above sensitivity (1%, 2/184). Quantification of the paired MRD results positive with PCR and/or FCM were significantly correlated (r2=0.74, P<0.0001).
Amongst the 62 patients, 30 have relapsed and 19 have died. Nine relapsing patients (including one off protocol patient treated and monitored at initial and second MRD relapses) had sufficient MRD points to assess the capacity of PB Q-PCR or FCM to predict future clinical relapse sufficiently to justify pre-emptive treatment at MRD relapse. Clinical relapse was preceded by MRD relapse in 9/10 relapses by Q-PCR and 7/9 by FCM. Six of the 9 relapsing patients had achieved Q-PCR negativity in at least one PB sample. The mean latency for prediction by Q-PCR, when considering any increase in positivity to at least 2 positive triplicates as positive, was 11.3 months (range 1-24mths) and 5.4 months (0.5-11) when only results above 0.01% were considered positive. The equivalent latency by FCM was slightly shorter, at 6.5 months (0.5-21) Pre-emptive treatment of 2 patients at MRD relapse, prior to clinical relapse allowed re-establishment of molecular complete remission and a durable second remission in at least one with sufficient follow-up (Cf Fig.).
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Conclusion: Eight color flow cytometry is a promising alternative to classical clone-specific Q-PCR strategies in monitoring therapy in MCL, with an excellent correlation (29/31, 94%) for MRD levels of at least 0.1% and acceptable correlation at 0.01-0.1% (13/22, 59%). While less sensitive at very low levels on cryopreserved material, FCM may clarify the clinical relevance of low-level borderline positivity; however it remains to be determined prospectively which technique will have greater prognostic value in patient management. FCM sensitivity will be improved by prognostic testing of fresh whole blood or bone marrow, and this pilot data clearly justifies such studies. Finally, MRD relapse precedes clinical relapse by several months, justifying pre-emptive treatment, monitored by prospective FCM and IgH Q-PCR within clinical trials.
Dreyling:Roche: Honoraria, Research Funding.
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Background: It has been suggested that using an acute lymphoblastic leukemia (ALL) rather than non-Hodgkin lymphoma protocol to treat patients with lymphoblastic lymphoma (LL) might be associated ...with better results (Hoelzer, Best Pract Res Clin Haematol 2002). To address this issue, the GRAALL and LYSA groups have conducted the Phase 2 LL03 trial in adult patients with LL, using the GRAALL-2003 protocol, which yielded good results in adult patients with ALL (Huguet, JCO 2009).
Patients and Methods: Between 2004 and 2012, 155 patients aged 18-59 years were enrolled, including 131 evaluable patients with T-cell LL (T-LL). The pediatric-inspired ALL treatment included a corticosteroid prephase, a 5-drug induction with sequential cyclophosphamide, high dose consolidation, late intensification, CNS prophylaxis with IT injections and cranial irradiation, and a 2-year maintenance. Response, including complete remission (CR) and unconfirmed CR (CRu), were assessed using Cheson criteria (Cheson, JCO 1999). Allogeneic stem cell transplantation (SCT) was offered to CR/CRu patients with high-risk disease (defined as need for a second-induction salvage course and/or CNS disease) and a donor.
Results: Of 131 T-LL patients (median age, 33 years; M/F ratio 4.0; mediastinal enlargement, 95%; CNS involvement, 5%), 119 patients (91%) reached CR/CRu (30 patients needing a salvage course) and 34 relapsed. Response evaluation was based on CT scan, as PET scan was performed in only 73/131 and 20/30 patients after first induction and salvage, respectively. At 5 years, estimated DFS, EFS and overall survival were 71%, 61% and 66%, respectively. The lymphoma IPI-score had no prognostic value, but increased serum LDH level (observed in 71% of the patients) was associated with a significant decrease in EFS (HR = 2.8 1.3 – 6.1) and OS (HR = 3.5 1.4 – 9.1) in multivariable analysis. Of note, need for a salvage course was not associated with shorter DFS in CR/CRu patients.
In a subset of 49 patients studied for oncogenetic markers, the 4-gene risk classifier (based on NOTCH1, FBXW7, N/K-RAS and PTEN status) we have recently reported to be a powerful predictor in T-ALL patients (Trinquand, JCO 2013) also demonstrated strong prognostic value in T-LL. Among these patients, 29 (60%) had a high-risk genetic profile (defined as no NOTCH1/FBXW7 mutation and/or N/K-RAS mutation and/or PTEN deletion). At 3 years, the high-risk genetic profile was predictive of shorter EFS (HR = 14.3 1.9 – 107.8), DFS (HR = 9.5 1.2 – 74.3) and OS (HR = 11.5 1.5 – 87.5) in univariable analysis, as well as in multivariable analysis after adjustment on age, ECOG-PS and LDH level (HR = 20.5 2.6 – 164.1, 12.6 1.5 – 104.8 and 17.0 2.1 – 136.8, respectively.
A total of 30 CR/CRu patients were eligible for allogeneic SCT (25 for late CR/CRu, 4 for CNS involvement, and 1 for both criteria) and 17 of them were actually transplanted in first CR/CRu. When analysed as a time-dependent event, allogeneic SCT was not associated with prolonged DFS in these high-risk patients.
Finally, Grade III/IV adverse events were those commonly observed with the GRAALL regimen. Overall, 46 patients died during the study (37 after relapse or progression; 5 during induction; 3 from allograft toxicity and 1 after a highway accident).
Conclusion: As compared to historical studies, we report here a relatively good outcome in T-LL patients treated with a pediatric-inspired ALL strategy. Very interestingly, the NOTCH1/FBXW7/RAS/PTEN T-ALL risk classification was also a strong prognostic factor in these T-LL patients. Allogeneic SCT did not appear to significantly influence the outcome of selected T-LL patients.
No relevant conflicts of interest to declare.
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