ALBERT

Description: Background. The recent ELN recommendations (2017) have introduced new criteria of response in AML - complete remission with MRD-negativity (CR/MRD-neg). It's a well-known fact that AML with different cytogenetics has different chemosensitivity, and so - CR rate in patients with favorable, intermediate or poor cytogenetic markers substantially differs. MRD negativity corresponds to more favorable long-term results in CR patients, but it's not clear whether the MRD-negativity rate is the same in favorable, intermediate or poor risk AML pts. As it is still poorly understood whether the high risk AML patients need classical «7+3» induction, we introduced a new approach for this cohort of patients - prolonged low-dose cytostatic exposure after hypomethylating priming. Aim. To evaluate the MRD-negativity in CR AML patients from different cytogenetic subgroups after the first classical non-intensive induction: «7+3», «Aza+7+3», «Aza-Ida-Ara-C», and the second induction differed by intensity. Materials and patients. 83 AML patients with a median age of 37 y.o. (17-59), m/f 31/52, after achieving CR (69 pts) were included in the MRD study in the National Research Center for Hematology. From March 2016 till Dec 2017, 49 pts disregarding cytogenetic risk were treated with «7+3» as the first induction course (Dauno 60 mg/m2 1-3 days, Ara-C 100 mg/m2 bid 1-7 days). The second induction course for these pts was «7+3» with continuous Ara-C infusion (200 mg/m2 1-7 days). Since Dec 2017 till July 2018 in all patients epigenetic priming with 3 days of Azacitidine (75 mg/m2) was applied additionally in order to obtain the cytogenetic results prior to cytostatic exposure. All patients were tested by molecular markers (FLT3, CEBPa, mNPM1) but this data did not influence the treatment choice. 8 pts from favorable/intermediate cytogenetic risk group after Aza-prephase have got «7+3» (Dauno 60 mg/m2 4-6 days, Ara-C 200 mg/m2 by continuous infusion, 4-10 days), and 13 pts from poor cytogenetic risk group (complex, -7,-5, inv3, monosomy) after Aza-priming received prolonged low-dose schedule (Ida 3 mg/m2 4-10 days, Ara-C 10 mg/m2 bid sc 4-17 days). The second induction course for favorable/intermediate risk group was FLAG-Ida, for poor risk group - the same as the 1st induction. MRD testing was performed by 6-color flow cуtometry with FACS Canto II (BD) machine after 1st and 2nd chemotherapy courses. The rate of MRD-negativity was calculated among CR patients. Results. Totally among 83 patients CR was achieved in 83%, early death was registered in 6% and refractory AML was diagnosed in 11%. The induction and MRD testing results after the 1st and the 2nd induction course according to prognostic group and treatment arm are demonstrated in the Table.1. Morphological CR rate differs substantially in patients from favorable/intermediate and poor risk by any treatment approach (p=0,04). The prolonged low-dose induction with Aza-prephase induced the same numbers of CRs as the classical «7+3»: 69% vs 46% (p=0,42). Epigenetic priming provided identical MRD-negative CRs in all treatment and cytogenetic groups: 75% vs 62% in favorable/intermediate risk group (p=0,29), 67% vs 50% in poor risk (p=0,62). The second intensive induction with Flag-Ida in favorable/intermediate risk group did not increase the portion of MRD-neg CR pts in comparison with «7+3»: 88% vs 71% (р=0,14). Early relapse rate through all groups showed comparable results. Conclusion. Though the morphological CR achievement is highly influenced by cytogenetic subgroup in AML, the MRD-negativity rate among CR pts by flow cytometry after the 1st and the 2nd induction course is similar. The de-intensification of induction for poor risk group did not lead to the deterioration of therapy efficacy and provided the same rate of MRD-negativity. The 2nd intensified induction after «7+3» did not increase the MRD-negativity in CR pts. Disclosures No relevant conflicts of interest to declare.

Description: Abstract 4899 Background: Abnormal karyotype in bone marrow (BM) cells is detected in 30–70% of patients with myelodysplastic syndromes (MDS) and acute myeloid leukemias with myelodysplasia-related changes (AML). The same cytogenetic abnormalities are found in isolated CD34+ hematopoetic progenitor cells (HPCs) of these patients. According to recent studies cytogenetic abnormalities are described in 10–70% MDS and AML patients in BM derived mesenchymal stromal cells (MSCs) [Flores-Figueroa et al. 2008, Blau et al. 2011]. These abnormalities can be clonal and nonclonal (spontaneous). The goal of the study was to characterize and compare the cytogenetic changes in BM derived MSCs and in CD34+ HPCs isolated from BM and peripheral blood (PB) in MDS and AML patients. Patients and methods: The data from 35 patients is presented: 6 pts with AML (1 pt with therapy-related AML), 29 pts with MDS (refractory anemia − 4 pts, refractory cytopenia with multilineage dysplasia − 13 pts, refractory anemia with ringed sideroblasts − 2 pts, refractory anemia with excess blasts − 7 pts, 5q-syndrome – 3 pts). Median age was 60 years (range 19 to 77). Patients' assignment to different groups was made according to the 2008 World Health Organization (WHO) classification. Cytogenetic analysis was performed using G-banding and FISH. MSCs were derived from bone marrow mononuclear cells then plated in 75 cm3flacks and harvested after 2–5 passages. CD34+ HPCs were collected from BM and PB by magnetic separation with anti-CD34 MicroBead Kit human (Miltenyi Biotec). Results: BM karyotype was normal in 17 pts, cytogenetic abnormalities were found in 18 pts − 4 AML and 14 MDS: in 9 pts (2 AML/7 MDS) – isolated del(5q), monosomy 7, i(14), inv(3) or trisomy 8; in 8 pts (2 AMl/6 MDS) – two or more abnormalities; and 1 pt displayed only constitutional abnormality (inv(9)(p13q21)). It is worth to note that routine cytogenetic analysis didn't present any mitosis in 3 MDS pts however FISH analysis revealed del(5) and del(7) simultaneously in one of these pts, trisomy 8 in one pt and normal karyotype in another one pt. Cytogenetic analysis of MSCs was carried out in 23 pts – 4 AML and 19 MDS pts. BM karyotype was normal in 10 pts and abnormal in 13 pts. Karyotype in MSCs was normal in all AML pts and in 16 MDS pts. There were cytogenetic changes in 3 MDS pts: in 1 pt - constitutional inversion (inv9(p13q21)), in 1 pt - nonclonal translocation and constitutional inversion (46XY,t(2;22)(p10;q11),inv(9)(p13q21)[1]/46XY,inv(9)(p13q21)[19]) and in 1 pt - clonal abnormalities (46XY,add(2q)[7]/46XY[13]). Patient with clonal cytogenetic abnormalities in MSCs had complex karyotype in BM (45–46XY,−5,−13,der(19),add(q13?or p13?),−20,+marx2,+mar del(13q21)?[15]/45–46XY idem, +dmin[2]/46XY[3]), but these changes were different. Constitutional inversion was confirmed in both cases by cytogenetic analysis in PB lymphocytes. FISH analysis was performed in CD 34+ HPCs magnetically isolated from BM and PB in 24 pts. Fourteen of these pts had normal BM karyotype and we confirmed that using FISH with LSI (5q33-q34), LSI (7q31)/CEP 7, CEP 8 (Vysis). We used the same DNA probes for evaluation of CD34+ HPCs from BM and PB in pts with normal BM karyotype. We used FISH in 10 pts with ascertained cytogenetic abnormalities in BM to confirm these findings with DNA probes LSI (5q33-q34), LSI (7q31)/CEP 7, CEP 8, LSI AML1/ETO, CEP X/CEP Y, LSI (20q12) (Vysis). FISH analysis didn't reveal any aberration in BM and PB CD34+ HPCs in patients with normal BM karyotype. In pts with distinguished abnormalities in BM the same pattern was demonstrated by FISH in CD34+ HPCs. We counted the percent of abnormal nuclei per 200. The means of percentages by FISH of BM, BM CD 34+ HPCs and PB CD34+ HPCs didn't differ and constituted 65.8%, 73.1% and 74.8% respectively. Conclusion: Cytogenetic analysis in MSCs revealed aberrations only in MDS patients (3 from 16). No cytogenetic abnormalities in MSCs in AML pts was found. Karyotype in MSCs didn't coincide with BM karyotype in the same patients. Hematopoetic progenitor cells from BM and PB of MDS and AML patients displayed the same cytogenetic abnormalities as the full population of bone marrow cells. The data shows that hematopoetic and mesenchymal precursors in MDS and AML are cytogenetically distinct. Disclosures: No relevant conflicts of interest to declare.

Description: Abstract 1879 Splenectomy in patients with MDS is a treatment option that is beeing applied very rare [Steensma D., et al, Leuk Res.,2003; Bourgeosis E., et al, Leukemia, 2001]. There are anecdotal reports with very few patients demonstrating its efficacy. In most cases splenectomy was indicated for MDS patients with immune related thrombocytopenia. Here we would like to report the results of 33 splenectomies in patients with MDS who have been treated in our Center during 1994–2010. Within this period of follow-up totally 155 patients were diagnosed with different forms of MDS, 35% of them presenting with hypoplasia. The MDS treatment algorithm in our Center incorporates splenectomy as one of the options for pts with hypoplastic forms of MDS with bone marrow blast count less than 10%, refractory to initial cyclosporin A treatment or refractory to transfusions. Among patients who were splenectomised there were 20 females, 13 males with a median age of 40 years (range 18–74). Median time from diagnosis to splenectomy was 12 months (range 4–107). By WHO-classification there were 2 patients with RA, 22 – with RCMD, 2 – with MDS and del (5q), 6 - with RAEB, 1 - with AML after MDS. Cytogenetic analysis was available in 32 cases, and karyotype was normal in 15 patients (47%).The most common abnormalities were: del (5q) - 3, del (20q) - 2, trisomy 8 - 2, tetrasomy 8 - 1, monosomy 7 - 2, complex karyotype - 4. Bone marrow biopsy revealed hypoplasia in 25 patients (75%), myelofibrosis – in 7 (21%). The median WBC count was 2,6*109/L (range 0,6-8,7), hemoglobin 6,9 g/dL (47-119) and platelets 26*109/L (6-170). 27 pts (82%) were RBC transfusion dependent, 22 (67%) - platelets transfusion dependent. 13 pts had received immunosuppression therapy (ATG, cyclosporine A) before splenectomy, 2 - cytotoxic chemotherapy, 3 - decitabine. The majority of splenectomies were done by laparoscopic method - 26 (79%), in one case the convertion was done. In all cases we performed liver biopsy. Postoperative complications (hemorrhage) occurred in 1 patient but there were no deaths due to operation. One death occurred in 7 days after splenectomy due to fulminant progression to AML. Median spleen weight was 180 gms (range 70–930). Median intraoperative blood loss was 250 ml (range 50–9350). Histology was available in 30 patients. Extramedullary hematopoesis was revealed in 3 cases (10%), blast infiltration - in 2 (7%), massive lymphoid infiltration was detected in 5 cases and in one patient in was proved to be clonal (marginal zone lymphoma, MZL). Hemosiderin depositions in the macrophages were seen in half of the cases -16 (53%). One case was characterized by granulomatosis in spleen and liver with negative immunohistohemical staining to Mycobacteria tuberculosis. Splenectomy lead to sustained improvement of cytopenias in 16 cases (48%): decreased transfusion dependence in 14 (42%) and transfusion independence in 2 (6%). After splenectomy 5 patients were followed by “wait and see” approach, 17 continued with immunosuppressive therapy (ATG,CyA), 3 patients were treated with cytotoxic chemotherapy, 1 – with decytabine, 2 received EPO, 1- danazol, 2 - iron chelation therapy, 2 – only transfusions therapy. We did not noticed the infections rate augmentation after splenectomy. Transformation to AML was registered 6 (18%) at median 6 months (0,3 -9). 13 splenectomized patients (39%) died at a median 12 months (range 0,3-84) and the main death reasons were: AML progression, aplasia deterioration followed by infections and hemorrhage. 20 patients are alive with a median follow-up after splenectomy 33 months (2-108). Analysis of our 15-years study data give us a confidence to conclude that splenectomy still may be an adequate option for distinct forms of MDS (hypoplastic forms with bone marrow blast count less than 10%, refractory to initial immunosupressive treatment or refractory to transfusions), producing cytopenia improvement in half of the patients with decreasing transfusion dependance also in half of the patients, sometimes bringing a clear diagnosis (MZL). The mechanism of action is not very clear but we can speculate that splenectomy removes the “cell-destroying” organ, deminishes immune pathways of cytopenias due to large lymphoid compartment deletion, provides the resustainment of sensitivity to immunosupressive agents. Disclosures: No relevant conflicts of interest to declare.

Description: Background Acute myeloid leukemia (AML) in older adults is a biologically and clinically distinct entity. These patients often have comorbidities, and their treatment must be chosen with caution. In AML patients over 60y old, cure rates are under 10% even after intensive chemotherapy (CT). Aim To compare the efficacy of different therapeutic approaches in elderly AML-pts treated in NRCH. Methods From 2002 till 2019, NRCH has conducted a prospective non-randomized study which included 80 AML-patients 60-81y (Me - 67y): 60-65 yy (n=53) and 〉65y (n=27); M/F - 35/45; de novo AML n=61 (76,25%), AML from MDS - n=13 (16,25%), «secondary» AML - n=6 (7,5%); cytogenetic risk: favorable n=1 (1,25%), intermediate n=49 (61,25%), poor n=30 (37,5%). The patients were stratified to different treatment approaches according to age. Patients 60-70y (n=40) mostly received 1-2 induction cycles 7+3 (ARA-C 100 mg/m2 bid; Dauno - 45-60 mg/m2 ), then 2 consolidation cycles 7+3 (Dauno - 45 mg/m2) and 2 years maintenance (5+5 with 6-MP). Patients 〉70y (n=22) were usually treated with 1-2 induction and 2 consolidation cycles of low dose Ara-C (LDAC) (10 mg/m2 sc bid, 28-days) and 3 years maintenance with 21-28-days LDAC. In some cases, fit patients over the age of 70y have got 7+3 (n=5) and some younger with comorbidities - LDAC (n=13). The analysis was done in May 2019. We evaluated treatment outcome according to age, cytogenetics and type of CT. Results The CR rate in the whole group of elderly AML-pts was 57,5% (46/80) with a median CR-duration - 10 mon (1-138 mon), early death - 16,25% (13/80) and resistance - 26,25% (21/80) with no major differences in the two age cohorts (70y). In order to assess of the efficacy of two chemotherapy options we have compared 7+3 and LDAC in patients aged 60-65 and older. In patients aged 60-65 CR-rate was higher -75% (21/28) after 7+3 vs 50% (2/4) after LDAC, with less resistant forms - 7% (2/28) vs 25% (1/4), respectively. In 〉 65y group CR-rate was identical in pts after 7+3 (47%, 8/17) and after LDAC (55%, 17/31) with similar numbers of resistant forms: 41% vs 29%. Early death rate did not differ among the groups. There was statistically higher CR-rate and lower resistant forms on 7+3 in pts aged 60-65 compared to older pts. - 75% vs 47% (p

Description: Abstract 4348 Acute leukemia during pregnancy is a rare but not an unique event: 1 case per 75–100.000 pregnant women and the majority of cases are registered in the 2nd/3rd trimester. The main law has to be carried out in this life threatening situation: to save two lives - mother's and child's. Though in the 1st trimester medical abortion is highly recommended, in the 2nd/3rd trimester chemotherapy should be applied without dose corrections. It is considered to be of no major danger to the fetus and gives good chances to the mother. Here we would like to report our 20 years experience with 32 pregnant women (median age 25y (19-35)) with acute leukemias: 13 AML, 5 APL and 14 ALL. 26 (81%) of them were diagnosed with AL in the 2nd/3rd trimester. We used the following approach: 1. up to 12 weeks of pregnancy medical abortions were performed (6 pts - 1 AML, 1- APL, 4-ALL); 2. at 35–40 weeks of pregnancy “cesar sections” were done and then chemotherapy was started (7 pts – 4 AML, 2 APL, 1 – ALL). All 7 children are alive and well; 3. at 13–34 weeks of pregnancy standard chemotherapy was applied according to AL subtype treatment protocol (19 pts – 8 AML; 2 APL, 9 ALL). In AML 7+3 protocol (ARA-C – 100 mg/m2 bid 1–7 days, Daunorubicin 45 mg/m2 (in 3 pts) or 60 mg/m2 1–3 days), in APL – 7+3+ATRA or AIDA (2 pts), in ALL - 8 weeks induction and prolonged post-CR therapy - were used. All together in 13 AML pts there were 9 CR (69%), 2 ED (15,5%), 2 DR (15,5%); in 5 APL pts – 4 CR (80%), 1 ED (20%); in 14 ALL pts – 9 CR (64,3%), 3 DR (21,4%), 2 ED (14,3%). 85% of pts had infectious complications during induction, 1 ATRA-syndrome, 1 emergency “cezar section” was performed at 30th week of pregnancy due to premature placenta unlayment (PPU) with hemorrhage due to L-asparaginase. There was one late spontaneous abortion (+21 weeks), no deaths and no defects were registed among newborns “treated” in uteri (n=18), all of them were followed in micropediatriac departments, neutropenias was registed in half of them and pneumonias in 3 (17%). All children (n=25) are alive and well. The oldest is 20 years old now, the youngest – 10 months. The probability of 5-years overall survival in AML pts was 34,6%, in ALL – 26,7%. In APL only 1 pt is alive in 1st CR due to 1 death in consolidation and two relapses. Within the period of the study we have developed some practical recommendations: 1. Daunorubicin in 7+3 courses should be used at 60 mg/m2 as there were no CR in pts receiving 45 mg/m2. It's a crucial point as CR must be achieved after the 1st course, especially in 30–32 weeks of pregnancy because delivery must be carried out in stable status. 2. Idarubicin can be used safely in resistant to daunorubicin AML pts and in AIDA protocol for APL. AIDA is less toxic than 7+3+ATRA for APL induction and well effective. 5-days mitoxantrone consolidation should be postponed to 3–4 months after delivery. 3. L-asparaginase should not be applied in ALL treatment during pregnancy (only after delivery) due to coagulation disturbances and possibility of premature placenta unlayment (PPU). 4. Delivery during AL treatment must be planned at 34–36 weeks of pregnancy. 60% of our patients had “cesar sections”. 5. Every day gynecologists care is absolutely needed (uteri hypertonus, fetus hypotrophy, PPU, etc). 6. Chemotherapy restart should be planned 3–4 weeks after delivery because immediate (within 5–7 days) continuation of cytostatic treatment caused severe combined infections complications due to postdelivery immunodeficiency and desadaptation. In case of resistant leukemia restart treatment in 2 weeks and not with high-dose protocols. 7. In newborn children all complications can be cured within 1–5 weeks in special micropediatic departments, children grew up healthy and intelligent. 8. The results in ALL pts with pregnancy seem to be worse than in general ALL population. 9. After CR in APL careful monitoring of MRD may provide better outcome and avoid aggressive consolidation courses. The main conclusion that comes up from this data is the obvious necessity to treat a pregnant woman with acute leukemia diagnosed in the 2nd/3rd trimester with adequate chemotherapy, that results in saving the child's life and - in many cases – the mother's. The overall survival in pregnant women with acute leukemia is quite similar to the outcome in all patients, though we wished it to be better. Disclosures: No relevant conflicts of interest to declare.