ALBERT

Description: Abstract 4334 BACKGROUD We designed a multicenter study (JALSG ALL 97) including an intensified consolidation program with dose-escalated doxorubicin (DOX) in order to improve outcome in adults with acute lymphoblastic leukemia (ALL) in pre-imatinib era. We reported here the efficacy and prognostic factors of mainly Philadelphia chromosome (Ph)-negative patients. METHODS From May 1997 to December 2001, patients (age ranges 15 - 64 years) with previously untreated ALL (excluding mature B-cell ALL) were consecutively registered in this study. We modified the standard induction program with five drugs; vincristine (VCR), daunorubicin, cyclophosphamide, prednisolone (PSL) and L-asparaginase and the maintenance program with daily 6-mercaptopurine, weekly methotrexate (MTX) and monthly pulses of VCR and PSL used in CALGB 8811 study. Consolidation therapy included eight courses featuring dose-intensified DOX and intermediate-dose MTX. The total dose of DOX in consolidation phase was 330 mg/m2. For patients with Ph or t(4;11), allogeneic stem cell transplantation (HSCT) was recommended during their first complete remission (CR), if donors were available; whereas for patients without Ph or t(4;11) there was no criteria for choosing HSCT. The 5-year overall survival (OS), the 5-year disease-free survival (DFS), and the prognostic factors were evaluated. RESULTS There were 404 eligible patients (median age, 38 years), of whom 256 were Ph-negative and 116 were Ph-positive. Of the eligible patients, 298 patients (74%) achieved CR. With a median follow-up time of 5.8 years, the estimated 5-year OS rate was 32% (95%CI: 27.1-36.9), and the 5-year DFS was 33% (95%CI: 26.8 - 38.2). The CR rates in Ph-negative and Ph-positive patients were 81% (n=208) and 56% (n=65), respectively. The 5-year OS in Ph-negative and Ph-positive patients were 39% and 15%, respectively. In Ph-negative patients, multivariate Cox analysis showed that older age, PS and WBC count were the independent prognostic factors for OS. The 5-year OS rates for patients younger than 35 years and a WBC count less than 30 × 109/L (risk group 1), for patients younger than 35 years and a WBC count above 30 × 109/L (risk group 2), for patients older than 35 years and a WBC count less than 30 × 109/L (risk group 3), and for patients older than 35 years and a WBC count above 30 × 109/L (risk group 4), were 51%, 29%, 33%, and 27%, respectively (P=0.0005). Of the 208 Ph-negative patients who achieved CR, 60 patients (29%) were underwent allogeneic-HSCT during their first CR (37 from a related donor and 23 from an unrelated donor), resulting that 8 (13%) died in remission, 16 (27%) relapsed, and 36 (60%) remained in continuous CR. The 5-year OS rate for the 60 patients was 63 %. Among them, the 5-year OS rates for the 31 patients of the risk group 1 (standard risk group) and for other 29 patients (high risk group) were 73% and 54%, respectively. Among 148 patients who did not receive allogeneic-HSCT during first CR, six (4 %) died in remission, 105 (71%) relapsed, and 37 (25%) remained in continuous CR. The 5-year OS rates for the 148 patients, for patients with standard risk, and for patients with high risk were 37%, 44% and 33%, respectively. CONCLUSION Result of this study was in the range of those reported by most large cooperative groups, but showed little improvement of adult Ph-negative ALL therapy. The prognostic factors for long term outcome of Ph-negative patients were similar to those in previous reported. This study also suggested that allogeneic-HSCT for Ph-negative patients in first CR might have contributed to the improvement of the outcome. Disclosures: No relevant conflicts of interest to declare.

Description: Abstract 3527 With modern intensive chemotherapy, about 90% of adult patients with Philadelphia chromosome (Ph)-negative acute lymphoblastic leukemia (ALL) achieve complete remission. However, the overall survival rate drops due to the high rate of relapse. Therefore, the establishment of optimal post-remission therapy is important, and the efficacy of allogeneic hematopoietic stem cell transplantation (HSCT) from a human leukocyte antigen (HLA)-matched sibling in first remission (CR1) has been demonstrated through clinical studies using genetic randomization. However, the efficacy of unrelated HSCT for adult patients with Ph-negative ALL in CR1 who lack an HLA-matched sibling remains unclear. Decision analysis is a statistical technique that aids the clinical decision-making process under uncertainty, especially in situations where a well-designed clinical trial is practically difficult to perform. We previously demonstrated through a decision analysis that HSCT is superior to chemotherapy (CTx) alone in CR1 for adult patients with Ph-negative ALL who have an HLA-matched sibling, even after an adjustment for quality of life (QOL) (Kako S et al, BMT 45 supp. p414, 2010). In a similar manner, we performed a decision analysis based on the decision tree (Figure 1) to evaluate the efficacy of unrelated HSCT for adult patients with Ph-negative ALL in CR1 who lack an HLA-matched sibling. The transition probabilities and utilities were estimated from studies of the Japan Adult Leukemia Study Group (JALSG) (ALL93; n=122, ALL97; n=119), the database of the Japan Marrow Donor Program (JMDP) (HSCT in CR1: n=231), and the literature. The primary outcome measure was the 10-year survival probability with or without a QOL adjustment, in which we especially consider the presence of chronic graft-versus-host disease (GVHD). Subgroup analyses were performed according to risk stratification based on the white blood cell count and cytogenetics, and according to age stratification with a cutoff of 35 years. In the whole population, the superiority of unrelated HSCT in CR1 was demonstrated in analyses both with and without a QOL adjustment (40.6% vs. 31.1% and 43.6% vs. 31.9%, respectively). A probabilistic sensitivity analysis using a Monte Carlo simulation supported these results. A similar tendency was observed in all subgroups (Table 1). The decision model was sensitive to the probability of disease-free survival following CTx and the probability of overall survival following HSCT in CR1 in standard-risk and higher-aged patients. In conclusion, to improve the probability of long-term survival, unrelated HSCT in CR1 is recommended for patients who lack an HLA-matched sibling donor. However, improvement of CTx in the future may change the result. Table 1. Expected 10-year survival probabilities with and without adjusting for quality of life (QOL) Expected survival probability without a QOL adjustment Expected survival probability With a QOL adjustment HSCT Chemotherapy HSCT Chemotherapy All patients 43.6% 31.8% 40.6% 31.0% Standard-risk patients 44.0% 36.7% 40.9% 36.0% High-risk patients 43.7% 23.8% 40.6% 23.1% Lower-aged patients 44.3% 30.0% 41.2% 29.2% Higher-aged patients 42.1% 33.1% 39.1% 32.6% Abbreviations: HSCT, hematopoietic stem cell transplantation. Disclosures: No relevant conflicts of interest to declare.

Description: Abstract 3090 Poster Board III-27 The outcome of Philadelphia chromosome-positive acute lymphoblastic leukemia (Ph+ALL) has dramatically improved since the start of treatment with imatinib. The Japan Adult Leukemia Study Group (JALSG) has reported a high complete remission (CR) rate for Ph+ALL treated with imatinib-combined chemotherapy (Yanada et al, J Clin Oncol 2006). Here we report a follow-up analysis of the results of the JALSG imatinib-combined chemotherapy. In the study, remission was induced by administering imatinib from day 8 to day 62 in combination with cyclophosphamide, daunorubicin, vincristine (VCR), and prednisolone (PSL). Consolidation regimen consisted of an odd course comprising high-dose methotrexate and high-dose cytarabine and an even course with 28 days administration of single-agent imatinib. The consolidation regimens were alternated for four courses each. Maintenance consisting of VCR, PSL, and imatinib was continued for two years after a CR. Allogeneic hematopoietic stem cell transplantation (allo-HSCT) was recommended if HLA identical sibling donor was available and was allowed from an alternative donor. A total of 103 newly diagnosed Ph+ALL patients were enrolled in the study between August 2002 and August 2004. Median age of the patients was 45 years (range, 15-64 years), and there were 57 males and 46 females. Median follow-up period was 2.6 years (range, 0.1-5.1 years). A CR was achieved in 100 (97.1%) of the 103 patients and not achieved in a patient in whom imatinib was discontinued because of ileus. There were two early deaths during induction. The probability of overall survival (OS) rate for the entire group at three years was 56.8%. No severe adverse effects were observed. Allo-HSCT was performed in the 1st CR (CR1) in 54 of the 74 CR patients under 55 years of age. Relapse occurred in 18 of 20 patients (90.0%) in whom allo-HSCT was not performed in CR1, but in only seven of the 54 patients (13.0%) who underwent allo-HSCT. At three years, the probability of OS rate for patients under 55 years of age was 75.0% in the transplanted group and 36.4% in the non-transplanted group. Allo-HSCT was performed in CR1 in eight of the 25 patients over 55 years of age. Two were myeloablative and six reduced intensity conditionings. Seven of eight patients who underwent HSCT are still alive in a CR. However, the probability of OS rate at three years in the non-transplanted group was 43.2%. In the group that did not receive allo-HSCT in CR1, age (55〈 years or 55〉 years), WBC count, bcr/abl transcript level, bcr/abl transcript type (major or minor), co-expression of myeloid antigens (CD13 and/or CD33), and additional chromosomal abnormalities at diagnosis were not associated with OS. The results demonstrated that the imatinib-combined chemotherapy regimen was effective and feasible. The regimen provided a better chance to receive allo-HSCT which resulted in an excellent outcome. However, relapse still remains a problem, especially in patients who are not candidates for allo-HSCT. Disclosures No relevant conflicts of interest to declare.

Description: Several reports indicate that there might be differences in clinical features between Asian and Western myelodysplastic syndrome (MDS) cases. We analyzed refractory anemia (RA) in French-American-British (FAB) classification cases diagnosed in Japan and Germany to perform a more exact comparison between Asian and Western MDS types. In the first step, we analyzed agreement of morphologic diagnosis between Japanese and German hematologists. Blood and bone marrow slides of 129 patients diagnosed with FAB-RA, FAB-RA with ringed sideroblasts (RARS), or aplastic anemia were selected randomly and evaluated separately by each group. The agreements of diagnoses according to FAB and World Health Organization (WHO) classifications were 98.4% and 83.8%, respectively. Second, we compared clinical features between 131 Japanese and 597 German patients with FAB-RA. Japanese patients were significantly younger than German patients. Japanese patients had more severe cytopenias. However, prognosis of Japanese patients was significantly more favorable than that of German patients. Japanese patients had a significantly lower cumulative risk of acute leukemia evolution than did German patients. Frequency of WHO-RA in Japanese patients with FAB-RA was significantly higher than that in German patients. In conclusion, our results indicate that the clinical features of Japanese patients with FAB-RA differ from those of German patients.

Description: The treatment of Philadelphia chromosome-positive acute lymphoblastic leukemia (Ph+ ALL) has been changed dramatically since the introduction of imatinib. We previously reported a 96% complete remission (CR) rate in newly diagnosed patients treated with imatinib-combined chemotherapy (Yanada et al. J Clin Oncol2006;24:460–466), and showed that the combination therapy is useful in terms of providing patients with a better chance for receiving allogeneic hematopoietic stem cell transplantation (HSCT) in first CR. However, little is known about the outcome after allogeneic HSCT in such patients. To address this issue, we analyzed detailed data from 60 patients who underwent allogeneic HSCT in first CR following a uniform treatment protocol consisting of imatinib and chemotherapy. The median age of the studied patients was 37 years (range, 15–64 years), with 32 males and 28 females. Donors were HLA-matched related (n=24), matched unrelated (n=21), mismatched cord blood (n=9), and mismatched related (n=6). All 52 patients aged less than 55 years received a myeloablative conditioning regimen, whereas 6 of 8 patients aged 55 years or older received a reduced intensity conditioning (RIC) regimen. Grade 2–4 acute graft-versus-host disease (GVHD) was recorded in 20 patients, and chronic GVHD was recorded in 32 patients, 17 of whom had the extensive form. During a median follow-up of 2.6 years (maximum, 4.6 years) after transplantation, relapse and death in first CR occurred in 9 and 15 patients. The probabilities for overall survival (OS) and relapse-free survival (RFS) were 64% and 53%, respectively, at 3 years. Patients younger than 40 years had a trend toward better RFS than those at 40 to 54 years (60% vs. 38% at 3 years, p=0.16). Unexpectedly, all of the 8 patients aged 55 years or older remained alive in first CR. In relation to the donor type, RFS did not differ among patients allografted from a matched related donor, a matched unrelated donor, and mismatched cord blood (52% vs. 59% vs. 56% at 3 years, p=0.92). For risk factor analysis, the following variables were examined: donor type (sibling vs. unrelated vs. cord blood), age group (

Description: Constitutive activation of Fibroblast Growth Factor 3 (FGFR3) tyrosine kinase have been identified in various human cancers and have been reported to play an important role in some hematopoietic neoplasms. We have previously reported that TEL-FGFR3 in a patient with peripheral T-cell Lymphoma and AML conferred IL-3 independency to Ba/F3 cells and activates PLCγ, PK3K, STAT3, STAT5, MAPK through its constitutive tyrosine kinase activity in TEL-FGFR3 transfected Ba/F3 cells (TF-V5). In KMS-11, human multiple myeloma cell line which expresses constitutively active mutant FGFR3, activations of PI3K and STAT3 pathways have been reported. However, little is known about how FGFR3 tyrosine kinase (TK) activates these downstream molecules. Here, we show that PYK2, a member of focal adhesion kinases, plays a pivotal role for the activation of PI3K, STAT3 and STAT5 in FGFR3 oncogenic pathways, and is a candidate for therapeutic target. PP1/PP2, a kinase inhibitor of SRC and PYK2, inhibited the cell growth of TF-V5 and KMS-11 cells in a dose-dependent manner (IC50=15μM, 25μM respectively), not affecting the cell growth of IL-3 dependent Ba/F3 cells. Another specific SRC inhibitor did not affect the cell growth of TF-V5 and KMS-11 cells. TEL-FGFR3 transfection to Ba/F3 cells led to the overexpression of PYK2 but not FAK. Expression and phosphorylation of PYK2 were identified in KMS-11 cells. Immunoprecipitation analysis using FGFR3 TK inhibitor SU5402 showed that the activation of PYK2 which was recruited to FGFR3 was dependent on the kinase activity of FGFR3. The cell growth of TF-V5 was completely inhibited at the concentration of PP1/PP2(30μM), which inhibited auto-phosphorylation of PYK2. PP1/PP2 suppressed the activation of PI3K-ATK pathway and decreased expression of C-MYC, inducing G1-arrest of TF-V5. PP1/PP2 induced intrinsic apoptosis of TF-V5 and did not affect activation of BAX but decrease expression of BCL-2 and BCL-XL through inactivation of STAT3 and STAT5. PP1/PP2 also inhibited the activation of PI3K and STAT3 in KMS-11 cells, inducing G1-arrest and apoptosis. PP1/PP2 inhibited tyrosine kinase of PYK2 mesured by in vitro kinase assay (IC50=23μM, 13μM, respectively). Further PYK2 C-terminus Associated Protein (PAP) siRNA expression plasmid significantly decreased the proliferation of TF-V5 but not mock transfected Ba/F3 cells. Our data demonstrates that PYK2 is an attractive molecular target for FGFR3 associated hematopoietic neoplasm.

Description: Imatinib-combined chemotherapy is highly effective for newly diagnosed Philadelphia chromosome-positive acute lymphoblastic leukemia (Ph+ ALL); however, a substantial proportion of patients experience relapse. Here, we evaluated 80 patients enrolled in the phase II study by the Japan Adult Leukemia Study Group (JALSG) with extended follow-up with the aim of identifying factors associated with relapse-free survival (RFS). For remission induction therapy, imatinib was administered from day 8 to day 63 in combination with daunorubicin, cyclophosphamide, vincristine (VCR) and prednisolone (PSL). Consolidation therapy consisted of an odd course (C1) comprising high-dose methotrexate (MTX), high-dose cytarabine (Ara-C) and methylprednisolone, and an even course (C2) with single-agent imatinib for 28 days. C1 and C2 were alternated for 4 cycles each. After completion of the consolidation therapy, patients received maintenance therapy consisting of VCR, PSL and imatinib up to 2 years from the date they had attained complete remission (CR). The daily dose of imatinib used in this study was 600 mg. The protocol was reviewed and approved by the institutional review board of each of the participating centers and was conducted in accordance with the Declaration of Helsinki. A total of 80 patients aged between 15 and 63 years were recruited between September 2002 and January 2005. For a median follow-up of 26.7 months (maximum, 52.5 months), 28 of the 77 CR patients showed relapse. Of the 17 relapses observed during the consolidation therapy, 13 occurred during the imatinib course. The probability of RFS was 50.5% at 2 years. Allogeneic transplantation was performed for 60 patients, including 44 in first CR, 12 in second CR, and 12 in non-CR. Neither transcript types nor copy numbers at diagnosis were associated with RFS (p=0.763 and 0.912). Furthermore, RFS for those with an undetectable BCR-ABL level at the end of induction therapy was similar to that for the other CR patients (p=0.707). In contrast, the presence of secondary chromosome aberrations in addition to t(9;22) or variant translocations detected at diagnosis, particularly +der(22)t(9;22) and abn(9p), was significantly associated with inferior RFS (p=0.003). Multivariate analysis revealed that the presence of additional chromosome aberrations was the only significant prognostic factor for RFS (HR, 2.84; 95% CI, 1.12–7.19; p=0.027). Even after allogeneic HSCT, patients with additional aberrations appeared to have a trend for shorter RFS than those without (p=0.080), but this might reflect a larger proportion of transplantation beyond first CR in the former (31% vs 17%). Although these results need to be validated in the context of the ABL kinase domain mutations, our findings may be of clinical importance for the future treatment of Ph+ ALL.

Description: Rituximab-based chemotherapy for B-cell lymphoma is available in Japan since ‘01. We have treated twenty-eight B-cell lymphoma patients with rituximab and found four patients relapsed with posterior radiculopathy of the spinal cord due to lymphoma involvement. Because frequency of CNS lymphoma is reported to be 1~2%, we are surprised at the high incidence (14.2%) and thereafter we routinely repeat intrathecal cytarabine (Ara-C), methotrexate (MTX), and prednisolone (PDN) administrations during rituximab-based chemotherapy. Up to now, there is no new spinal cord relapse. The followings are the four spinal cord relapse cases we have experienced, which are characterized by severe back pain. (Case 1) A 46-years-old male with follicular lymphoma. Clinical stage (CS) was IIIB. He had cervical lymphadenopathy and breast involvement. He was treated with three courses of CHOP chemotherapy and achieved CR. Then he was treated with 1 course of rituximab alone and relapsed with severe neck and back pain five-days later. MRI imaging revealed posterior radiculopathy of the spinal cord between C2 and C4. (Case 2) A 48-years-old female with diffuse large B-cell lymphoma, CS IIIA. She had uterine cervix lymphoma and cervical lymphadenopathy four-years after acute lymphocytic leukemia (ALL) therapy. She was treated with 8 courses of biweekly R-CHOP and achieved CR. She relapsed with severe back and left arm pain with double vision six-months later. MRI imaging revealed posterior radiculopathy of the spinal cord between C5 and C6, and Th2 and Th3. She also had trigeminal radiculopathy and facial nerve oppression. The involved nerves were swollen like dumbbell. (Case 3) An 83-years-old female with MALToma, CSIIA. She had cervical lymphadenopathy. She was treated with 5 courses of rituximab alone and relapsed with severe back and lumbar pain one-month later. MRI imaging revealed posterior radiculopathy of the spinal cord between Th6 and Th7, and, Th12 and L1. (Case 4) A 63-years-old male with mantle cell lymphoma, CSIIIB. He had general lymphadenopathy. He was treated with 8 courses of CHOP, achieved CR, and relapsed with general lymphadenopathy and breast involvement thirteen-months later. He was treated with additional 7 courses of R-CHOP and relapsed again with severe oral, bilateral leg, and back pain seven-days later. MRI imaging revealed posterior radiculopathy of C2 and sacrum. All the patients except case 3 died due to lymphomas. When we treated the four patients with rituximab-based therapy, we did not repeat intrathecal Ara-C/MTX/PDN injections. Our data suggest that rituximab possibly induce posterior radiculopathy of spinal cord lymphoma involvement via some unknown pathway. In conclusion, we recommend repeated intra-thecal injections during rituximab administration.

Description: ERK1/ERK2 MAP kinase (MAPK), protein kinase C (PKC) and Akt kinase have been shown to inhibit cellular apoptosis. We measured the expression levels of these protein kinases in a total of 102 samples from patients with lymphoid malignancies: 26 with acute lymphoblastic leukemia (ALL), 15 with multiple myeloma (MM), 49 with non-Hodgkin’s lymphoma (NHL), 3 with Hodgkin’s lymphoma (HL) and 6 with chronic lymphocytic leukemia (CLL). Plasma cells were separated by using magnetically labeled CD138, and the purity of the cells were more than 95%. The MAPK and PKC assay systems are based upon the enzyme catalyzed transfer of the [γ-32P] ATP to a specific peptide. Activity of Akt kinase was measured by Western blotting using phospho-specific Akt (Ser 473) antibody. MAPK activity was 0.4±0.0, 4.7±0.7 and 19.0±21.6 p mol/min/106 cells in normal blood mononuclear cells (n=3), normal bone marrow plasma cells (n=10), and patient samples (n=85), respectively. MAPK and PKC activities were 17.1±10.5 and 50.7±58.3 p mol/min/106 cells in ALL, 29.3±39.3 and 29.1±18.9 in MM, 17.3±16.4 and 46.5±46.7 in NHL, 13.6±3.2 and 4.0±3.2 in HL, and 7.3±4.8 and 2.2±0.2 in CLL, respectively. MAPK activity of CLL was significantly low (P

Description: In hematologic malignancies, deletion of 3p25-26 is a rare but recurrent cytogenetic aberration, indicating the presence of tumor suppressor gene (TSG) on this choromosome arm. We revealed a t(3;5)(p25;q35) that was identified by conventional cytogenetics results in a novel fusion of KIAA0379 on 3p25 to NUP98 on 11p15 in a patient with refractory MDS/AML by the molecular analysis. Fluorescence in situ hybridization (FISH) analysis using whole chromosomal painting and telomeric probes unclosed a criptic three-way translocation t(3;5;11)(p25;q35;p15). FISH restriction using BAC contig revealed that the 3p25 breakpoint is involved in KIAA0379 which locates between BAC 792N12 and 259O19. Split signals of BAC 265K23 for 5q35 and 348A20 for 11p15 showed that NSD1 on 5q35 and NUP98 on 11p15 are the responsible genes of this translocation. As the results of this translocation, expression of three chimeric transcripts were identified by RT-PCR. In KIAA0379-NUP98, exon 18 of KIAA0379 was fused in-flame with exon 13 of NUP98. In NUP98-NSD1, exon 12 of NUP98 was fused in-flame with exon 7 of NSD1. NSD1-KIAA0379 resulted in out-flame fusion. To investigate the expression of KIAA0379 in leukemic cells, RT-PCR for full-length KIAA0379 transcript was performed on bone marrow cells from the patient and a healthy volunteer, and leukemic cell line K562, HL-60 and KG-1a cells. Full-lengh PCR product with expected size was found in all samples, however, short variant transcript was amplified significantly from KG-1a and HL-60 cells. Subsequent sequence analysis of the short PCR product from KG-1a cells revealed a direct fusion of a part of exon 10 to a part of exon 28 without any hidden splicing sites. Southern blot analysis using a cloned KIAA0379 cDNA fragment suggested an internal deletion of KIAA0379 in KG-1a cells. KIAA0379 locates at 3p25.1 about 5.5Mb centromeric to VHL and is predicted to have 28 ankyrin repeat motifs by computational analysis. It is thought to be involved in protein to protein interaction whereas its precise funtion remains unclear. Immunostaining for KIAA0379 protein in NIH3T3 cells transfected with the wild KIAA0379 and the short variant KIAA0379 revealed that the wild KIAA0379 protein localized in cytoplasm and nuclear membrane, on the other hand, the truncated KIAA0379 protein localized exclusively on nuclear membrane. KIAA0379-NUP98 fusion protein is expected to localize on nuclear membrane by sub-localization signal of C-terminal of NUP98. Therefore, dysfunction of KIAA0379 protein might lead to leukemogenesis and KIAA0379 may be potential candidate for a novel TSG. In addition, it has been reported that t(5;11)(q35;p15.5) results in NUP98-NSD1 fusion in childhood AML. To our knowledge, this is the first report in adult case.