ALBERT

Beschreibung: Abstract 1751 Because IDH mutations are frequent in blast-phase myeloproliferative neoplasms (MPN), they might contribute to leukemic transformation. We examined this possibility in 301 consecutive patients with chronic-phase primary myelofibrosis (PMF). All study patients were fully characterized for karyotype, JAK2 and MPL mutational status, and Dynamic International Prognostic Scoring System-plus (DIPSS-plus) risk status. DNA from bone marrow or peripheral blood was used to screen for IDH1 and IDH2 mutations, by direct sequencing and/or high resolution melting (HRM) assay. Mutant IDH was detected in 12 patients (4%): seven IDH2 (five R140Q, one R140W and one R172G) and five IDH1 (three R132S and two R132C). MPL exon 10 was mutated in 18 patients (6.3%) and constituted W515L in 14 patients, W515K in 3 and a frameshift mutation in 1 patient. JAK2V617F was detected in 169 (56%) patients. Six patients displayed both JAK2V617F and IDH mutations (IDH2R140Q in 2 patients, IDH2R140W in 1 and IDH1R132S in 3); JAK2V617F allele burden was 1%, 7%, 22%, 27%, 30% and 96%, respectively. One patient displayed both IDHR140Q and MPLW515R. One-hundred and seven (36%) patients were negative for all three mutations. The 12 IDH-mutated patients were clinically compared to patients belonging to the three other molecular subgroups: mutated for JAK2 only (n=164), mutated for MPL only (n=18) and unmutated for all three (n=107). The four molecular subgroups were remarkably similar in their phenotype with few exceptions; IDH-mutated patients were significantly older than those with no mutations (p=0.04) whereas age distribution was similar between patients with mutant IDH, MPL or JAK2. In univariate analysis, overall survival (OS) for IDH-mutated patients was significantly shorter than those for JAK2-mutated (p=0.03), MPL-mutated (p=0.047) or unmutated (p=0.0009) patients. IDH-mutated patients also showed significantly shorter leukemia-free survival (LFS), compared to those with mutant JAK2 (p=0.0008), mutant MPL (p=0.02) or no mutations (p=0.001). After accounting for age, the presence of mutant IDH remained a significant disadvantage for both OS (p=0.04) and LFS (p=0.005). Multivariable analysis of OS that included risk categorization per DIPSS-plus confirmed the independent prognostic relevance of mutant IDH (p=0.03): HR for patients with no mutations =0.39, 95% CI 0.2–0.75; HR for JAK2-mutated patients =0.50, 95% CI 0.27–0.95; HR for MPL-mutated patients =0.53, 95% CI 0.23–1.2. A similar analysis for LFS that included risk factors for LT (i.e. unfavorable karyotype and platelet count

Beschreibung: Background: In both polycythemia vera (PV) and essential thrombocythemia (ET), aspirin and/or hydroxyurea therapy provide adequate protection from thrombosis but not from disease transformation into acute myeloid leukemia/myelodysplastic syndrome (AML/MDS) or myelofibrosis (MF). In designing clinical trials with new drugs, including the use of small molecule JAK2 inhibitors, in either ET or PV, it is important to identify patients who are at a higher risk of early transformation into AML/MDS/MF as well as those in whom the long-term risk of these complications is too low to justify exposure to experimental drugs with unknown short-term and long-term toxicity profile. Methods: Information on an institutional database of 1061 patients with either PV (n=458) or ET (n=603) was updated in July of 2007. The World Health Organization criteria were used for diagnosis of PV, ET, AML, MDS, and MF. Two different approaches were used to assess both early and overall risk of AML/MDS/MF development in both ET and PV. In the first approach, three distinct groups were delineated and their presenting features compared; group A was comprised of patients who have remained AML/MDS/MF free after a minimum follow-up of 20 years whereas groups B and C included patients who developed either AML/MDS or MF, respectively, in the first decade of their disease. In the second approach, prognostic factors for AML/MDS/MF-free survival were examined among the entire cohort of 1061 patients. Results : In ET, the number of patients that fulfilled the above-mentioned criteria for inclusion in groups A, B, and C were 40, 12, and 8; the three groups displayed significant differences in the prevalence, at diagnosis, of lower than normal hemoglobin level (8% vs. 58% vs. 38%; p=0.0004), male sex (18% vs. 58% vs. 50%; p=0.01), and arterial thrombosis at diagnosis (p=0.03), respectively. However, only the former two remained significant during multivariable analysis that included age as a covariate. In PV, the number of patients in groups A, B, and C were 23, 18, and 12; the only difference between the three groups was the association between group B and leukocytosis (p=0.02). Cox regression analysis of the entire 1061 ET/PV patients cohort, including 65 AML/MDS/MF events in ET and 36 AML/MDS events in PV, confirmed the inferior AML/MDS/MF-free survival in ET associated with lower than normal hemoglobin and AML/MDS-free survival in PV associated with leukocytosis (Figure). Conclusion : The current study identifies PV patients with leukocytosis as being the most appropriate and ET patients without anemia as the least appropriate for consideration of participation in experimental drug treatment trials. Figure Figure Figure Figure

Beschreibung: The biological and clinical implications of p16 gene methylation in multiple myeloma (MM) are still unclear despite previous studies. In this comprehensive study, using methylation-specific PCR (MS-PCR), we show that p16 methylation is relatively common and occurs in monoclonal gammopathy of undetermined significance (MGUS; n = 17), smoldering multiple myeloma (SMM; n = 40), and MM (n = 522) at a prevalence of 24%, 28%, and 34%, respectively. However, p16 methylation does not appear to affect gene expression level. In a large cohort of patients with long-term follow-up information (n = 439), there was no difference in overall survival between patients with or without p16 methylation. We also found no association between p16 methylation and the main cytogenetic categories, although it was more common among patients with 17p13.1 deletions (p53 locus), a genetic progression event in MM. In addition, p16 methylation has no apparent effect on the cycle because there was also no difference in the plasma cell labeling index (a direct measurement of proliferation) between patients with and without p16 methylation. Our results question a major role for p16 methylation in the oncogenesis of the PC neoplasm, and we now believe p16 methylation may be a marker for overall epigenetic changes associated with disease progression, with no obvious direct biological or clinical consequences.

Beschreibung: Abstract 4109 Background: In a previous study, we reported safety and efficacy of low-dose (0.5 mg/d) pomalidomide and prednisone and pomalidomide alone (2 mg/d) for the treatment of anemia associated with myelofibrosis (J Clin Oncol 2009; 27: 4563). The current study examined the value of low dose pomalidomide alone (ClinicalTrials.gov No. NCT00669578). Methods: Persons with primary (PMF) or post-polycythemia vera/essential thrombocythemia (post-PV/ET MF) myelofibrosis were studied. The main eligibility criterion was RBC-transfusion-dependence or hemoglobin

Beschreibung: Background It is widely recognized that advanced age and prior thrombosis predict recurrent thrombosis in essential thrombocythemia (ET) and are used to risk-stratify patients. However, the paucity of large sample size and long-term follow-up has limited the development of similar prognostic models for survival and leukemic transformation (LT). Methods Data was abstracted from the medical records of a consecutive cohort of patients with WHO-defined ET seen at the Mayo Clinic. Cox proportional hazards was used to determine the impact of clinical and laboratory variables on survival and LT. Overall survival and leukemia-free survival was estimated by Kaplan-Meier plots. Results i. Patient characteristics and outcome The study cohort included 605 patients of which 399 (66%) were females (median age, 57 years; range 5–91). Median follow-up was 84 months (range; 0–424). During this period, 155 patients (26%) have died and LT was documented in 20 patients (3.3%) occurring at a median of 138 months (range; 23–422) from ET diagnosis. ii. Prognostic variables for overall survival Univariate analysis of parameters at diagnosis identified age ≥ 60 years, hemoglobin less than normal (defined as 〈 12 g/dL in females and 〈 13.5 g/dL in males), leukocyte count ≥ 15 x 109/L, tobacco use, diabetes mellitus, thrombosis, male sex, and the absence of microvascular symptoms as independent predictors of inferior survival. All of the above except the last two (i.e. male sex and the absence of microvascular symptoms) sustained their prognostic significance on multivariate analysis. Based on the first three prognostic variables: age, hemoglobin level, and leukocyte count, we constructed a prognostic model for survival: low-risk (none of the risk factors), intermediate-risk (1of 3 risk factors), and high-risk (≥ 2 risk factors). The respective median survivals were 278, 200, and 111 months (p

Beschreibung: Background : CC-5013 (Revlimid™) is an immunomodulatory analog of thalidomide that is substantially more potent than the parent drug in terms of both anti-angiogenic and anti-TNF-α activity. CC-5013 has shown therapeutic activity in thalidomide-responsive hematological malignancies including relapsed multiple myeloma (Blood2002;100:3063) and myelodysplastic syndrome (Blood2002;100:96a). Myelofibrosis with myeloid metaplasia (MMM) has also been shown to respond to thalidomide (BJH2002;117:288). Furthermore, both angiogenesis and altered TNF-α activity have been pathogenetically implicated in MMM. Methods : The current report considers the first 15 patients in an ongoing phase II treatment trial of single agent CC-5013 in MMM based on a minimum of 3 month follow-up from day 1 of protocol treatment. Study eligibility criteria included no concomitant MMM-directed therapy, a hemoglobin (Hgb) level of 〈 10 g/dL, an absolute neutrophil count (ANC) of ≥ 1 x 109/L, and a platelet count of ≥ 100 x 109/L. Previous thalidomide therapy in the absence of high-grade skin toxicity was allowed. All patients were started with daily oral CC-5013 (10 mg/day) to be taken for three 28-day treatment cycles. Three additional treament cycles were planned in case of anemia response. Results : Median age was 64 years (range, 40–75) and 10 pts were males. Twelve of the 15 study pts (80%) were red cell transfusion-dependent, 14 (93%) were previously treated including 12 with cytoreductive and 4 with thalidomide therapy. The spleen was palpably enlarged in 13 pts (median 18 cm, range 7–23). Eight of the 15 pts (53%) successfully completed 3 months of protocol treatment. Treatment was discontinued in the remaining 7 pts because of drug toxicity (2 pts), disease progression (1 pt), other co-morbid condition (3 pts), or patient discretion (1 pt). Treatment response data : Clinically relevant responses were documented in 4 patients (27%) and consisted of measurable improvements in anemia (2 pts), splenomegaly (2 pts), and/or constitutional symptoms (3 pts). One pt experienced an increase in Hgb level from 8.3 to 13.4 g/dL, a decrease in leukocyte count from 66.2 to 7.7 x 109/L, and complete resolution of myelophthisis including disapperance of circulating blasts that measured 9% before treatment. Another pt became transfusion-independent (Hgb level increased to 〉 10 g/dL) as well as enjoyed a profound improvement in constitutional symptoms. Interestingly, serum lactate dehydrogenase (LDH) level decreased in 11 pts (73%) to either within the normal ramge (5 pts) or by more than 30 % (6 pts). Treatment toxicity data : Grade 3 or 4 adverse events that were possibly, probably, or definitely attributed to CC-5013 included rash (2 pts), neutropenia (5 pts), thrombocytopenia (3 pts), and fatigue (2 pts). In addition, 3 patients experienced drug-associated extreme thrombocytosis while a histologically-proven disseminated extramedullary hematopoiesis was documented in one patient after one month of CC-5013 treatment. Conclusion : The current preliminary report suggests a substantial biological activity of CC-5013 in MMM with a therapeutic potential for a subset of patients. Additional studies with a longer duration of therapy, different dose schedules, and combinations of CC-5013 and corticosteroids are warranted.

Beschreibung: Clinical phenotype in systemic mastocytosis (SM) is markedly variable, which complicates prognostication and decision making regarding the choice and timing of therapy. In a retrospective study of 342 consecutive adult patients with SM seen at the Mayo Clinic between 1976 and 2007, disease subdesignation according to the World Health Organization (WHO) proposal was indolent (ISM) in 159 (46%), with associated clonal hematologic non–mast cell lineage disease (SM-AHNMD) in 138 (40%), aggressive (ASM) in 41 (12%), and mast cell leukemia in 4 (1%). KITD816V was detected in bone marrow–derived DNA by allele-specific polymerase chain reaction (PCR) in 68% of 165 patients evaluated (ISM, 78%; ASM, 82%; SM-AHNMD, 60%; P = .03); JAK2V617F was detected in 4%, all in SM-AHNMD. Compared with those with nonindolent SM, life expectancy in ISM was superior and not significantly different from that of the age- and sex-matched US population. In addition, multivariable analysis identified advanced age, weight loss, anemia, thrombocytopenia, hypoalbuminemia, and excess bone marrow blasts as independent adverse prognostic factors for survival. The current study validates the prognostic relevance of the WHO subclassification of SM and provides additional information of value in terms of both risk stratification and interpretation of clinical presentation and laboratory results.

Beschreibung: Recently, a gain-of-function MPL mutation, MPLW515L, was described in patients with JAK2V617F-negative myelofibrosis with myeloid metaplasia (MMM). To gain more information on mutational frequency, disease specificity, and clinical correlates, genomic DNA from 1182 patients with myeloproliferative and other myeloid disorders and 64 healthy controls was screened for MPL515 mutations, regardless of JAK2V617F mutational status: 290 with MMM, 242 with polycythemia vera, 318 with essential thrombocythemia (ET), 88 with myelodysplastic syndrome, 118 with chronic myelomonocytic leukemia, and 126 with acute myeloid leukemia (AML). MPL515 mutations, either MPLW515L (n = 17) or a previously undescribed MPLW515K (n = 5), were detected in 20 patients. The diagnosis of patients with mutant MPL alleles at the time of molecular testing was de novo MMM in 12 patients, ET in 4, post-ET MMM in 1, and MMM in blast crisis in 3. Six patients carried the MPLW515L and JAK2V617F alleles concurrently. We conclude that MPLW515L or MPLW515K mutations are present in patients with MMM or ET at a frequency of approximately 5% and 1%, respectively, but are not observed in patients with polycythemia vera (PV) or other myeloid disorders. Furthermore, MPL mutations may occur concurrently with the JAK2V617F mutation, suggesting that these alleles may have functional complementation in myeloproliferative disease.

Beschreibung: The diagnostic category of AML includes a very heterogeneous group of neoplasms but progress has been made in recent years to identify biologically and clinically relevant genomic biomarkers that aid in further sub classification, provide more accurate prognostic information and supply targets for tumor-specific therapy and monitoring of residual disease. At this time, clinically relevant biomarkers include single nucleotide variants (SNVs), small insertions and deletions (indels) and a variety of translocations. They involve many different genes, including CEBPA, which is a highly G/C nucleotide-rich gene that is extremely difficult to evaluate using standard NGS methods. Because of the number and complexity of biomarkers, it has been a challenge for clinical laboratories to provide testing that is of practical clinical use; most approaches require multiple testing modalities, including less than satisfactory commercial sequencing panels, resulting in poor clinical testing service with respect to biomarker coverage, turn-around time and cost. We have developed an integrated "laboratory-developed" NGS-based approach that evaluates all current, clinically relevant AML biomarkers simultaneously (including CEBPA and identity markers for post-transplant chimerism evaluation), in as little as 2.5 days (

Beschreibung: A somatic mutation in the JH2 autoinhibitory domain of the Janus kinase 2 (JAK2) tyrosine kinase was recently described in polycythemia vera, essential thrombocythemia, and myelofibrosis with myeloid metaplasia. The prevalence of this mutation in either “atypical” myeloproliferative disorders (MPDs) or the myelodysplastic syndromes (MDSs) is unknown. Bone marrow–derived genomic DNA from 245 patients—119 with chronic myelomonocytic leukemia (CMML), 101 with MDS, 11 with hypereosinophilic syndrome (HES), 8 with systemic mastocytosis (SM), and 6 with chronic neutrophilic leukemia (CNL)—was screened for the JAK2 V617F mutation. A mutant allele was detected in 11 patients: 3 with CMML (3%), 5 with MDS (5%), 2 with SM, and 1 with CNL. Interestingly, one of the patients with SM and the patient with CNL with JAK2 V617F had a history of lymphoma, and this patient with SM also had associated myelofibrosis and CMML. The current observation strengthens the specific association between JAK2 V617F and classic MPD, but also suggests an infrequent occurrence in other myeloid disorders.