ALBERT

Description: The essential pathogenic mechanism in acute myeloid leukemia (AML) is a heterogeneous group of malignant diseases arising as the result of progressive genetic damage occurring in hemopoietic progenitor cells. Mcl-1 (myeloid cell leukemia-1), an antiapoptotic protein of the Bcl-2 family, is located on chromosome 1 and has three exons and two introns. Overexpression of Mcl-1 delays apoptosis induced by cytotoxic agents, c-myc overexpression, and growth factor withdrawal in hematopoietuc cells. To evaluate the association between genetic variants of Mcl-1 gene and risk of AML, we genotyped two polymorphisms in promoter of Mcl-1[rs3738484; −324 C〉A and rs3831987; −284 insertion(6bp or18bp)/deletion]. A case-control study of 728 controls and 660 cases was conducted in Chonnam National University Hwasun Hospital, Korea. The Mcl −324 CA and combined CA/AA genotype was significantly associated with a decreased risk for AML [odds ratio (OR) CA = 0.75; 95% confidence interval (CI) = 0.60–0.95; ORCA/AA = 0.76; 95% CI = 0.61–0.96]. There was no association with the Mcl -284 insertion/deletion and AML. The haplotype A-ins18bp is significantly associated with the risk of AML. Using subjects with the haplotype A- del, the OR of haplotype A-ins18bp is 5.87 (95% CI 1.7–20.06 p= 0.006). Our results suggest that antiapoptotic protein, Mcl-1 polymorphism may influence susceptibility to AML.

Description: Xenobiotic-metabolizing enzymes influence the susceptibility to malignancies as well as prognosis by causing chemotherapy resistance. We analyzed genetic polymorphisms of glutathione S-transferases T1 and M1 (del GSTT1 and del GSTM1) and NAD(P)H quinone-oxoreductase (NQO1 C609T) to evaluate the association and risk of acute myeloid leukemia (AML). A large-scale population-based, case-control study of 1700 controls and 663 cases was conducted in Chonnam National University Hwasun Hospital, Korea. GST T1 null genotype was associated with increased risk for AML [odds ratio (OR) = 1.20; 95% confidence interval (CI) = 1.003–1.45, p=0.047]. GST M1 null genotype was highly associated with a decreased risk for AML (OR= 0.38; 95%CI = 0.31–0.46, p〈 0.0001). Analysis of the NQO1 C609T polymorphism failed to show an association with AML, although a near significant increase was also found in NQO1 609GG genotype (OR= 1.30; 95%CI = 0.54–4.77, p=0.06) Our results suggest an association of extensive GST with an increased or decreased risk for AML, possibly by an increase in the metabolic activation of chemical carcinogens or linkage to another cancer-causing gene. Inconsistent result in other studies may be due to geographical differences in the type of environmental carcinogens to which different populations are exposed.

Description: An internal tandem duplication of the FLT3 gene (FLT3/ITD) has been detected in approximately 20–30% of patients with acute myeloid leukemia (AML). These are frequently associated with poor outcome in AML patients, but it is still a matter of debate whether the FLT3/ITD mutations play a role in the prognosis of AML patients independently or not. We investigated the presence of FLT3/ITD mutation in 165 patients with de novo AML, except acute promyelocytic leukemia (APL), to evaluate its clinical and prognostic significance. The FLT3/ITD mutations were studied on bone marrow samples at diagnosis using PCR assay. Of the patients, 58 patients (35.2%) demonstrated the aberrant FLT3/ITD mutations. The patients with FLT3/ITD had significantly higher WBC counts at presentation compared with patients without FLT3/ITD (52.9 ± 66.9 ×109/L vs. 32.4 ± 41.8 ×109/L, p 〈 0.05). However, there was no statistically significant difference in age, gender, hemoglobin level, platelet count, percentage of peripheral or bone marrow blasts, or the presence of molecular abnormalities between the patients with FLT3/ITD and the patients without FLT3/ITD. To analyze the response to or outcome of therapy, we evaluated 118 patients who received intensive induction chemotherapy. In univariate analysis, there was no significant difference in complete response rate (p = 0.21), in median duration of overall survival (13.9±3.8 ms. vs. 16.5±0 ms., p = 0.07), or in median duration of leukemic-free survival (LFS) (9.8±3.5 ms. vs. 34.6±17.9 ms., p = 0.09) between the patients with FLT3/ITD and the patients without FLT3/ITD. However, the presence of FLT3/ITD was associated with lower LFS in the patients with a cytogenetically intermediate-risk group (p 〈 0.05). Furthermore, in multivariate analysis, FLT3/ITD mutations were an independent prognostic factor in LFS in AML patients with normal karyotype (p 〈 0.05). In conclusion, this study demonstrates that the presence of FLT3/ITD mutations is a significantly poor prognostic factor for leukemic free survival in non-APL patients with a cytogenetically intermediate-risk group, especially normal karyotype.

Description: Multiple loci with small genetic effects are thought to be linked to AML pathogenesis. To detect such loci requires systematic screening of large number of single nucleotide polymorphisms (SNPs) within large study population. In this study we tested whether 3104 SNPs in 200 candidate genes were associated with risk to AML. Genes were considered potential candidates for their known or suspected roles in DNA repair system, pharmacogenomics and transcriptional regulation in hematopoiesis or putative pathways related to leukemogenesis. Selection of SNPs was performed using dbSNP and HapMap project databases, with emphasis on non-synonymous SNPs or haplotype tagging SNPs. To discover potential SNPs responsible for AML susceptibility, we conducted a case-control study using Affymetrix targeted genotyping 3K array. We applied this platform to analyze the samples from 309 de novo AML patients and 382 healthy controls. Genotype scorings were processed using GeneChip scanner 3000 TG(Affymetrix) and analyzed with GCOS software(Affymetrix). In total more than 255,000 SNPs were genotyped for this study. Samples with suboptimal call rates were excluded. Statistical testing were carried out using χ2, Cochran-Armitage trend, Fisher’s exact, odds ratio, haplotype estimation, LD block definition. Here we report that 23 SNPs in 16 genes are associated with elevated or reduced risk to AML. Some of associated genes were transcription factors such as ZNF23 and ZNF233. While associated genes were distributed evenly among the whole genome, four associated genes were found on chromosome 1. Among those associated SNPs, two were located in coding region, one in exon-intron boundary, while the rest of SNPs were located in introns of associated genes. Among 23 SNPs identified, two intronic SNPs from 1st intron of BAALC(Brain and acute leukemia, cytoplasmic) gene were associated with the reduced risk to AML. Haplotype estimation and linkage disequilibrium pattern of 9 SNPs including two associated SNPs will be presented. In conclusion, we identified SNPs responsible for AML susceptibility by candidate gene-based SNP array approach. These promising data when supported by further molecular validation would greatly enhance the current understanding of AML predisposition and diseases progression. Implication of polymorphic variants in AML etiopathogenesis will be presented and discussed.

Description: Abstract 2272 To test the correlation of trough plasma Imatinib Mesylate (IM) levels and pharmacogenomic variation with cytogenetic or molecular responses, we measured trough plasma IM levels and analyzed various genetic polymorphisms in newly diagnosed CML patients at 6 months of IM treatment and compared them with the likelihood of achieving cytogenetic complete response (CyCR) or major molecular response to standard dose of IM. Newly diagnosed 94 CML patients were prospectively enrolled in the current study. CyCR was achieved in 71 patients (75.5%). Eighty-four patients (89.4%) showed optimal response (CyCR + cytogenetic partial response CyPR) at 6 months. Trough plasma IM levels were highly variable ranging from 203 to 4980 ng/ml: mean (±SD) was 1392±78.8 ng/ml. Among 47 patients with trough plasma IM level of A) was significantly associated with higher IM trough level than dominant genotype (p=0.021), whereas transporter genes did not show any significant results. The CC genotype of ABCG2 (421C〉A) gene was related with CCyR (OR 3.47, 95% CI 1.09–11.05; p=0.030). In conclusion, the incidence of optimal responses in newly diagnosed CML patients who had been treated with standard dose of IM for 6 months was significantly higher in the patient group with trough plasma IM level of ≥1320 ng/ml than the group with

Description: We have previously implicated ETS2 in the etiopathogenesis of acute myeloid leukemia through case-control study by revealing that polymorphisms of ETS2, a hematopoietic transcription factor gene is associated with increased risk to acute myelogenous leukemia (AML). Two SNPs out of 7 genotyped sites, rs711 and rs530 were shown to be associated with increased risk to AML with the odds ratio (OR) of 1.76 (95% C.I. 1.2–2.5, p=0.0019) for rs711 and 1.67 (95% C.I. 1.3–2.2, p=0.0003) for rs530 relative to wild type genotypes respectively. Haplotype and linkage disequilibrium (LD) map was estimated, but haplotype association was not found with statistical significance. Korean LD structure was similar to Japanese LD, but least similarity was shown with LDs from African (Yoruba in Ibadan, Nigeria). Since these two SNPs are located in the 3′ UTR region we simulated the change in secondary structure in silico of the 3′ UTR region with two variants introduced in the sequence. Most dramatic change in the secondary structure was observed in the rs530 containing domain suggesting this variant of being cis-acting genetic variant. Real time Q-PCR and western blot analysis showed that expression of ETS2 decreased in individuals with heterozygous or mutant homozygous genotypes, showing most abundant expression with two wild type copies of rs530, less expression with the rare homozygous or heterozygous genotype. Sequencing cDNA of 55 heterozygous AML patients revealed mRNA expression imbalance in 13 cases (24%) effectively reverting heterozygous genotype to homozygous wild type mRNA species. The detection of a discrepancy between the mRNA alleles of rs530 clearly proves cis-acting effect of rs530. However there was not a case in 51 healthy control samples suggesting differing transcript levels derived from the two alleles of an autosomal gene is disease-specific phenomena. Taken together, our results suggest that two polymorphic variants in the 3′ UTR region predispose individual to high-risk AML by inducing change in mRNA expression as a cis-acting variant.

Description: Thymidylate synthase (TS) catalyzes the conversion of dUMP by 5,10-methylenetetrahydrofolate to dTMP in DNA synthesis. Polymorphisms in the untranslated regions(UTRs) of TS, which may modulate TS transcription and expression, have been associated with susceptibility to several malignancies. In this study, to evaluate the association with TS the 28-bp tandem repeat(2R→3R) and the 6-bp deletion(6 bp-) and susceptibility to non-Hodgkin’s lymphoma(NHL), large-scale population-based case-control study was conducted in Chonnam National University Hospital between Mar 1997 and Feb 2006. 553 patients with histologically comfirmed lymphoma and 1,324 controls were evaluated. The cases consisted of 275 diffuse large B-cell lymphomas (DLBCL), 109 T-cell lymphomas and 169 unclassifiable lymphomas. TS 2R2R genotype was significantly associated with increased risk for NHL and T-cell lymphoma, but not for DLBCL. Using subjects with the TS 3R3R as a reference group, the OR of TS 2R2R was 2.00 (95% CI 1.21–3.31, p=0.007) for NHL and 3.30 (95% CI 1.52–7.17, p=0.003) for T-cell lymphoma. The association was 1.65 fold higher and more evident for T-cell lymphoma than NHL. However, there was no significant association of TS 6bp- with NHL. In conclusion, theses results suggest that TS (2R→3R) may play an important role in the pathogenesis of NHL, and that DNA synthesis may play a crucial roles in the pathogenesis of specific NHL subtypes.

Description: Abstract 3106 Background: Induction therapy followed by ASCT is the standard therapy for the newly diagnosed younger patients with MM. Recently, new drugs such as lenalidomide or bortezomib have shown the promising results as an induction treatment. However, these drugs are not available in many countries as a front line treatment and many different type of induction treatment regimens including old regimens are used. We evaluate the efficacy and safety of the brief course of high dose dexamethasone (HD) and the response adapted PAD (Bortezomib, Adriamycin, Dexamethasone) or VAD (Vincristine, Adriamycin, Dexamethasone) induction chemotherapy in the newly diagnosed younger patients with MM. Methods: One hundred fifty five newly diagnosed patients with MM from 23 institutions received 2 cycles of HD followed by PAD or VAD chemotherapy according to the response to the HD. PAD 4 cycles were given to nonresponsders and VAD 2 cycles were given to who achieved more than PR to HD. The primary endpoint was CR + nCR rate after ASCT. Among 155 patents enrolled this study from November 2009, 29 patients (19%) have been dropped out. This trial will be continued until total 210 patients will be enrolled. The trial is registered on National Cancer Institute website, number NCT01255514. Results: One hundred fifty five patients (88 male, 69 female) were enrolled (median age; 57). 34 (22%) patients had ISS stage I, 64 (41%) stage II and 55 (35%) stage III. Thirty six (26%) patients had abnormal cytogenetics. In FISH analysis, there were 25% del13, 9% del17, 21% t (4; 14), 13% t (14; 16) and 26% t (11; 14). Among the 115 evaluable patients, CR + PR rate was 53% (61/115) after 2 cycles of HD. 61 patients (53%) received subsequent VAD chemotherapy and 54 patients (47%) received PAD chemotherapy. Among the evaluable patients, CR + PR rate after induction therapy was 83% (79%, 48/61 in VAD group vs. 89%, 48/54 in PAD group). 95 patients finished ASCT. CR + nCR rate after ASCT were 74% (74% in VAD group vs 73% in PAD group). Mortality rate of this trial was 15% (17/115). The cause of death was disease progression (n=5), bleeding (n=1) and infections (n=11). Among 115 patients in whom VAD or PAD chemotherapy was actually performed, 1 year OS was 88.1%. (VAD arm 90.7% versus PAD arm 86.1% (P=0.105): median follow-up; 16.6 months). Conclusion: Risk adapted approach using initial HD response showed good response results after ASCT compared with previous trial (CR + nCR rate of IFM 2005-01 trial-Bortezomib+dexa induction & ASCT was 35%, J Clin Oncol. 2010;28:4621–9) The MM patients who showed poor response to HD also showed similar good response rate after ASCT compared with the patients who had good response to HD in this trial. PAD re-induction therapy after failure of initial steroid induction treatment might overcome the inferior results in the high risk MM patients. Our data shows that almost half of the patients who responded to HD can be saved of novel agents during induction treatment, and PAD can successfully rescue the other half who are not sensitive to HD. Therefore, initial steroid response adapted strategy might be the more cost-effective approach in the newly diagnosed ASCT eligible MM patients. Disclosures: No relevant conflicts of interest to declare.

Description: Purpose : This study evaluated the prognostic role of 18F-FDG PET/CT at baseline in patients with newly diagnosed multiple myeloa (MM) and evaluated the prognostic relevance of 18F-FDG PET/CT for each stage according to the Revised International Staging System (R-ISS). Method: We retrospectively analyzed the records of 167 patients with newly diagnosed MM. 18F-FDG PET/CT was performed prior to induction therapy in patients with newly diagnosed MM. A Focal lesions (FL) at diagnosis was defined as focally increased FDG uptake greater than the physiologic bone marrow or liver uptake, with or without any underlying lesion. Extramedullary disease (EMD) was defined as FDG-avid soft tissue that was not contiguous to bone. Results: A total of 102 patients (61.1%) had at least one FL at diagnosis, and 44.9% had more than three FLs. EMD was present in 13.2% of all patients. In the total cohort, the presence of more than three hypermetabolic FLs or EMD on baseline PET/CT was associated with significantly inferior progression free survival (PFS) and overall survival (OS) than other patients. Because most patients (91%) with EMD had more than three FLs, PET/CT positivity was defined as the presence of more than three FLs or the presence of EMD. The C-reactive protein level was higher (0.550 vs. 0.245 mg/L, P = 0.004) and the serum albumin level was lower in the PET/CT-positive group (3.5 vs. 3.6 g/dL, P = 0.040). Patients who were PET/CT-positive had a significantly lower complete response rate after first-line therapy compared with those who were PET/CT-negative (15.6% vs. 34.4%, P = 0.007). In multivariate analyses, PET/CT positivity was an independent predictor of PFS and OS in all patients. Fifty-five patients (46.1%) with R-ISS II were PET/CT-positive at baseline and had significantly shorter PFS and OS. PET/CT positivity was also correlated with poor PFS and OS in patients with R-ISS III. Conclusion : 18F-FDG PET/CT was an independent predictor of survival outcomes in patients with newly diagnosed MM. In addition, performing 18F- FDG PET/CT at diagnosis may be useful for determining the survival outcomes of MM patients with R-ISS II and III. Figure. Figure. Disclosures No relevant conflicts of interest to declare.

Description: Background High dose chemotherapy followed by autologous stem cell transplantation (ASCT) has become the standard approach for relapsed or high risk non-Hodgkin's lymphoma (NHL). Several different high dose therapy (HDT) conditioning regimens have been used for NHL, such as BEAM(carustine, etoposide, cytosine arabinoside, melphalan), BEAC( carmustine, etoposide, cytosine arabinoside, cyclophosphamide), and CBV(cyclophosphamide, carmustine etoposide). Carmustine is an active drug in the HDT of NHL but the supply of carmustine is limited in some countries. Intravenous busulfan containing regimens as conditioning regimen have been used for both allogeneic and autologous stem cell transplantation in patients with hematologic and non-hematologic malignancies. We and CISL have previously studied that conditioning regimen of i.v. busulfan/melphalan/etoposide was well tolerated and effective in patients with relapsed or high risk NHL. And busulfan/cyclophosphamide/etoposide conditioning regimen has been extensively utilized in ASCT for NHL. Therefore, based on the encouraging results, we conducted a randomized phase II multicenter trial of busulfan/etoposide/cyclophosphamide (BCT) versus busulfan/etoposide/ melphalan/ (BMT) as conditioning therapy for ASCT in patients with NHL. Methods Patients with chemosensitive high risk NHL or relapsed or primary refractory NHL underwent high dose chemotherapy at 16 centers in Korea. Patients were randomly assigned to receive BCT conditioning chemotherapy or BMT conditioning chemotherapy. BCT regimen consisted of iv busulfan 3.2 mg/kg/day i.v. on days -8,-7, and -6, etoposide 400mg/m2 day i.v. on days -5 and -4 and cyclophosphamide 50mg/kg/day i.v. on days -3 and -2 and BMT regimen were iv busulfan 3.2 mg/kg/day i.v. on days -8,-7, and -6, etoposide 400mg/m2 day i.v. on days -5 and -4 and melphalan 50mg/m2/day i.v. on days -3 and -2. The primary efficacy end points were 2 year progression free survival. Results Seventy five patients were enrolled onto the study. Patients randomly assigned to the BCT group (39 patients) or the BMT group (36 patients). Main subgroups were DLBCL (n=42, 56%) and T cell lymphoma (n=27, 36%). Thirteen patients (33.3%) in the BCT group and 11 patients (30.5%) in the BMT group had disease progression or died. 2 year progression free survival rate was 62.5% in the BCT group and 63.1% in the BMT group (p=0.924) (Fig 1). There was no treatment related mortality. Conclusions No significant differences were observed in progression free survival between BCT group and BMT group. Accordingly, busulfan based conditioning regimen may be regarded as an important treatment option to substitute for BEAM regimen. Further, considering R-CHOP or CHOP regimes are standard induction regimens, BMT conditioning will be good alternative to patients who can't be used cyclophosphamide. Figure PFS after autologous stem cell transplantation. Survival rates among all patient who underwent randomiazation Figure. PFS after autologous stem cell transplantation. Survival rates among all patient who underwent randomiazation Disclosures Kim: Celltrion, Inc.: Consultancy, Honoraria.