ALBERT

Description: The advent of more intensive chemotherapy and the improvement of supportive cares have dramatically changed the natural history of childhood acute lymphoblastic leukemia (ALL), with current estimated 5-year overall survival of about 80%. The increased survival rate and the establishment of follow-up survey for long term survivors (LTS) have allowed the identification of late chemo-radiotherapy adverse effects on psychological and general health. We retrospectively evaluate the incidence and type of sequelae and / or late effects in a cohort of 301 childhood ALL LTS, followed in a single pediatric AIEOP center. From June 1986 to June 2013, 301 LTS (154 male and 147 female), aged

Description: Recently, a novel subgroup of B Cell Precursor (BCP) Acute Lymphoblastic Leukemia (ALL), called Philadelphia-like (Ph-like) ALL, has been described. This high-risk group, despite the absence of BCR-ABL1 rearrangement, shows genomic abnormalities that result in aberrant expression of cytokine receptors genes or tyrosine-kinase-activating signaling. These patients are poor responder to conventional chemotherapy but potentially sensitive to Tyrosine-Kinase Inhibitors (TKIs). Herein we report the case of a 10 year-old girl who received diagnosis of precursor B-ALL on February 2018. She started therapy according to observational protocol ALL 2017 of the Italian Association of Pediatric Hemato-Oncology (AIEOP). After pre-phase, the patient resulted prednisone poor responder and continued induction therapy, including daunorubicin, vincristine, PEG-L-Asparaginase, prednisone and intrathecal methotrexate. Bone marrow evaluation showed persistence of disease on day 15 (88% of lymphoblasts) and 33 (60% of blasts) in flow cytometry. At the end of IA induction phase, Minimal Residual Disease (MRD) in RT-PCR showed high positivity (marker 1 = 7.2x10-1, marker 2= 8.11x10-1). At this time, further molecular studies, using RNA targeted next generation sequencing (PanCancer, Illumina), revealed the presence of EBF1-PDGFRβ gene fusion. Since the patient was resistant to conventional therapy and literature's evidences demonstrated potential sensitivity of EBF1-PDGFRβ to TKIs therapy, we decided to add dasatinib, a second generation TKI, to IB induction, with cyclophosphamide, cytarabine and 6-mercapthopurine. After one week of therapy, clinical course was complicated by Klebsiella Pneumoniae sepsis, followed by digestive hemorrhage. Since we retained that the hemorrhagic event could be related to dasatinib, the drug was temporarily discontinued. However, bone marrow evaluation, after only 10 days of dasatinib administration, showed hematologic remission (3% of lymphoblast) and MRD reduction 〉1 logarithm (markers 1=1-10-2 e markers 2= 9.9 x 10-3). Given the resistance to chemotherapy alone and the excellent response to dasatinib but its related toxicity in combination, we decided to start immunotherapy with blinatumomab, a bi-specific CD3-CD19 monoclonal antibody, alternated to dasatinib, in order to achieve MRD negativity before to proceed with allogeneic hematopoietic stem cell transplantation (HSCT) from HLA-identical sibling. The patient received 2 courses of blinatumomab for 28 days continuous infusion (15 mcg/mq days 1-28), interspersed by 15 days of dasatinib (60 mg/mq/day). After the first cycle the patient achieved complete hematological remission and MRD negativity. MRD negativity was confirmed after first course of dasatinib, second course of blinatumomab and second course of dasatinib. Dasatinib, given alone, was well tolerated and no serious adverse event were reported. Actually, the patient is undergoing HSCT by HLA-identical sister. To our knowledge, only few cases of EBF1-PDGFRβ ALL, treated with TKIs, are described in literature and this is the first in which MRD negativity was obtained with a sequential combination of dasatinib and blinatumumomab, a chemo-free approach, showing efficacy and good tolerability. This case highlights also that screening for targetable lesions at diagnosis or in case of resistance to induction phase is mandatory to identify patients who might benefit from alternative therapies as TKIs, immunotherapy or their combination. A longer follow-up is required to definitively establish the long-term efficacy of this biological approach in our patient. Nevertheless, it is interesting to speculate that alternative treatment with TKIs or immunotherapy could avoid, in the future, an intensive chemotherapy, or probably a transplant approach in selected patients, in order to achieve a durable cure in these Ph-like patients. Disclosures Locatelli: Bellicum: Consultancy, Membership on an entity's Board of Directors or advisory committees; bluebird bio: Consultancy; Novartis: Consultancy, Membership on an entity's Board of Directors or advisory committees; Miltenyi: Honoraria; Amgen: Honoraria, Membership on an entity's Board of Directors or advisory committees. Parasole:Baxalta: Membership on an entity's Board of Directors or advisory committees; behring: Consultancy; jazz: Honoraria, Speakers Bureau.

Description: Clofarabine is a new promising chemotherapic agent active in the treatment of pediatric acute leukemia. We planned to utilize the same drugs’ combination currently evaluated in USA as phase II study salvage therapy: clofarabine (40mg/m2/day) in combination with etoposide (100mg/m2/day) and Cyclophosphamide (440mg/m2/day) (CLOVE). We planned to treat the patients (pts) (aged 1–18) with relapsed or refractory acute lymphoblastic leukemia (ALL) or acute myeloblastic leukemia (AML) with 1 or 2 induction cycles (5 days chemotherapy) to reach complete remission (CR) or complete remission without platelet recovery (CRp) and with 1 or 2 consolidation cycles (4 days chemotherapy). ALL patients (pts) received intrathecal methotrexate at day 6 and AML patients intrathecal cytarabine at Day 0. Prednisone was added (0,5 mg/Kg/day) to prevent systemic inflammatory response syndrome (SIRS). Fourteen children (5 AML, 9 ALL) were treated, median age 5,7 years (range 1,75–16,5), 7 pts in first, 3 pts in second and 4 pts in third relapse. Four AML pts had one prior bone marrow transplantation (BMT): 1 autologous, 1 matched familiar donor and 2 matched unrelated donor (MUD) transplants. Five ALL pts had one prior BMT : 2 autologous, 1 syngenic and 2 MUD. The AML pts were in first relapse, and three of them were refractory to FLAG-X protocol: 3/5 (60%) achieved remission (1CRp, 2 CR), response data are currently pending for1 patient (day + 20 first induction), and 1 patient died for disease progression. The remission rate of nine ALL pts was 66% (4 CR, 2CRp). Infection grade 3 was observed in one patient, diarrhea and abdominal pain occurred in 4 pts. Febrile neutropenia was e common toxicity. Severe muscles pain with functional impairment was observed in two pts (1 AML, 1 ALL) 7 days post induction cycle: the gabapentin therapy in association with prednisone was efficient and the symptom quickly disappeared. One ALL patient refractory to first induction cycle, died after second cycle (day + 6) for cardiac failure. One ALL patient relapsed after CLOVE induction, after two more cycles he obtained partial response (BM Blast cells 10% ), and he underwent MUD transplantation and died for infection. The overall survival is 58 %, 7/9 (77 %) responders are alive. The median survival is 3 months (range 20 days –10 months). Four out 9 responding patients proceeded to BMT from unrelated donor, and three of them are alive and in CR. No unexpected transplant related toxicity was encountered. We confirm that the association of Clofarabine with Etoposide and Cyclophosfamide is active in heavily pretreated relapsed or refractory pediatric acute leukemia. patients.

Description: Intensive chemotherapy significantly improves the outcome of pediatric acute lymphoblastic leukemia (ALL) but unfortunately increases the incidence and severity of acute adverse events. The current study analyses the incidence of central nervous system (CNS) complications during ALL treatment in a single pediatric institution. CNS leukemic infiltration at diagnosis, therapy-related peripheral neuropathy and leukoencephalopathy and neurocognitive defects after treatment were excluded by the study. From September 2000 to July 2008, two hundred and forty ALL patients (pts) were treated in our Institution according to BFM-AIEOP ALL 2000 protocol. Twenty-four out of 240 patients (10 %) (15 females and 9 males, median age at the event 7.7 years, range 2–16 years) developed CNS complications during treatment. Thirteen presented tonic-clonic seizures, four showed dyskinesia and dyslalia, one presented visual impairment and enuresis, and six had loss of consciousness. In 18 pts a rapid resolution of the event was obtained by administration of benzodiazepines or barbiturates; 6 pts required admission in intensive care unit, instead. Only two out of twenty-four patients presented neurological sequelae (one pts with recurrent seizures and one pts with right limb disability). Co-morbidity at the time of neurological accident included: blood pressure increase (6 pts), electrolytes imbalance (4 pts), LDH increase (4 pts), coagulation disorders (6 pts), hepatic enzyme increase (2 pts), severe anemia (1 pts), severe thrombocytopenia (4 pts), renal failure (1 pts), and Syndrome of Inappropriate Antidiuretic Hormone Secretion (SIADH) (1 pts). Radiological scanning (either CT or MRI) and electroencephalography (EEG) performed within 48 hr from the onset of the clinical symptoms revealed different etiologies: 8 posterior reversible leukoencephalopathies (PRES), 3 cerebral bleedings, 2 ischemic cerebral diseases, 2 methotrexate toxicity, 1 SIADH, 2 temporal lobe epilepsy and 6 unidentified problems. In conclusion this retrospective study on CNS complications during ALL treatment shows that the most frequent neurological accident (33%) is the PRES.

Description: Abstract 4121 Background Mixed acute leukemias are an heterogeneous category of poorly differentiated leukemias, affecting people of all ages. These forms of leukemias are very rare, 3-5% of all acute leukemias, and are characterized by co-expression of myeloid and lymphoid associated-antigens on the same leukemic cells. The therapeutic approach is not defined because, often, mixed leukemias switch their lineage of origin during treatment and the prognosis is very poor. We describe a novel, never reported before, cytogenetic abnormality in a child with a mixed acute leukemia. Methods On January 2009, a nonsyndromic 5 year-old boy was admitted at our Institution for an acute hyperleukocytosic leukemia (WBC 〉 100.000/L). The patient showed spleen enlargement and massive mediastinal lymphadenopathy. Morphological diagnosis of acute leukemia was based on the French-American-British criteria and the immunophenotypic diagnosis was performed by flow cytometry using a large panel of leukemia-associated antibodies (myeloid and B/T lymphoid markers). Cytogenetic analysis was performed on unstimulated overnight culture of bone marrow, followed by RHG-banding. The expression of T-cell receptor and rearrangement of heavy chain immunoglobulin was assessed by molecular methodology. Results Morphologic evaluation showed lymphoid blasts according to the FAB-L2 classification with same aberrations such as myeloid blebs and prominent nucleoli. The immunophenotype showed mixed expression of myeloid markers (MPO 〉 3%, CD33, CD11a, CD11b, CD117) and T lymphoid antigens (surface CD7, CD99 and cytoplasmic CD3) and an aberrant lineage-B expression (CD19). On the basis of these data the diagnosis of acute mixed leukemia was carried out. Cytogenetic analysis showed trisomy of chromosome 7, a chromosomal aberration never reported before in acute myeloid or lymphoid leukemia (figure 1). Ig or T-cell receptor gene rearrangements were not identified as well as translocations commonly found in either lymphoid and myeloid leukemias. The treatment was initially performed according to the acute lymphoblastic leukemia protocol (AIEOP ALL2000) but unresponsiveness as seen up to day +12 required a shift to a mixed personalized protocol with cyclophosphamide, dexamethasone and L-asparaginase associated with more specific drugs for myeloid lineage such as high dose cytarabine and etoposide. After a febrile aplasia, bone marrow reconstitution showed about 75% of mixed blasts. So the child shifted to a rescue protocol with fludarabine, cytarabine, idarubicine (FLA-Ida) repeated 2 times with a good haematological and cytometric response (0,9% of blasts). For consolidation of remission, was performed 1 cycle with clofarabine, cyclophosphamide and etoposide followed by 1 cycle with clofarabine and cytarabine with a minor response (1,9% of blasts by immunophenotype). Actually, the child is undergoing an unrelated mismatched transplant. Conclusion At the best of our knowledge, this case is the first report of trisomy 7 in a mixed acute leukemia in childhood. The only cytogenetic aberration known so far in pediatric mixed leukemias are: isochromosome 7, monosomy 7, or inversion 7 as well as translocations such as t(1;7), t(4;7) or t(7;15). Trisomy 7 is also described in some mesenchymal and neurogenic neoplasms such as brain, colon, ovary, prostate, bladder and kidney tumors and also in some non-neoplastic inflammatory disease such as rheumatoid arthritis and osteoarthritis. In haematological field, trisomy 7 is reported only in few cases of myeloma, non-Hodgkin lymphoma and amyloidosis. The prognostic significance of this cytogenetic aberration in mixed acute leukemias is still unknown. Disclosures: No relevant conflicts of interest to declare.

Description: The importance of genetic alterations and their prognostic impact is of growing interest in multiple myeloma (MM). Chromosome 13 abnormalities (del 13q and monosomy) have been associated with lower response rate and shorter survival in patients affected by MM, indipendently from the type of detection (karyotype versus FISH) and the type of treatment (standard versus high-dose chemotherapy). The presence of these abnormalities also in monoclonal gammopathy of uncertain significance (MGUS), suggests that they are an early genetic event, even thought it is not clear if they have a role in disease progression or represent only an initiation event. Alterations involving the immunoglobuline heavy chain locus on 14q32 are also frequent events in plasma cell dyscrasias. The variety of partner genes suggests that it may contribute to tumor progression. The most frequent translocation is t(11;14) (30%) and t(4;14) (25%), both of high prognostic impact. In our Institution, 40 MM patients (29 at diagnosis, 8 at relapse and 3 during post CHT follow-up) were studied by conventional cytogenetics and FISH analysis. The mean age was 63.4 (range 32–80), with male prevalence. The serum monoclonal component was IgG and IgA in 26 and 8 patients respectively; 4 patients had light chain only, 1 patient had IgD and one IgG+IgM. At the time of analysis, the stages were: I/II (n=14), IIIA (n=15) and IIIB (n=11). At the time of cytogenetic analysis, the mean bone marrow plasma cell percentage was 47.5% (range 6–100 %). Cytogenetics and FISH analysis were performed simultaneously. An abnormal karyotype was detected in 11/19 successful cultures: 2 patients showed del (13q), one patient monosomy 13, 4 patients had hypodiploid karyotype, 2 patients showed chromosome 1 abnormalities in a hyperdiploid karyotype, 1 patient revealed del 1q in a normal karyotype, 1 patient had hyperdiploid karyotype with +iso11q. FISH analysis, performed with LSI D13S19 (13q14.3) and LSI IgH/CCND1-XT (VYSIS) probes, was informative in all 40 patients: all 3 patients with chromosome 13 abnormalities had del(13q); in addition, 11/40 patients with normal or non informative karyotype showed del(13q) by FISH analysis. The mean of cells carrying del(13q) was 34% (range 15–80%); the highest values were found in patients who showed hypodiploid karyotype or del(13q) or chromosome 13 monosomy by conventional cytogenetic analysis. FISH analysis with a t(11;14) translocation probe showed 1/40 positive patient; in addition, 5 patient showed an extra signal of 11q13, and 5 others showed an extra signal of the IgH gene, suggesting the first over expression of the CCND1 gene and the second a translocation with a different partner chromosome. The impact of chromosome 13 deletion on time to progression and overall survival was analyzed only considering the most sensitive technique used (FISH). The time to progression analysis showed a significantly worse prognosis in del(13q) patients (p=0.0260); overall survival tended to be shorter in patients carrying del (13q), without reaching statistical significance. Our data, even thought in a small series, confirm the negative impact of chromosome 13 deletion on prognosis and survival of MM patients. We would like to emphasize the usefulness of a very sensitive technique such as the FISH analysis, for the assessment of genetic alterations in the context of clinical trials specifically designed for MM patients with adverse prognostic features.