ALBERT

Description: Background: Patients with AML who are not eligible for intensive therapy or stem cell transplantation have a dismal prognosis. Autocrine and paracrine secretion of angiogenic and hematopoietic growth factors such as vascular endothelial growth factor in the bone marrow (BM) microenvironment may promote proliferation and survival of leukemic blasts. The oral multikinase inhibitor pazopanib was reported to exert growth inhibitory and proapoptotic effects in myeloid cells. Methods: This phase II study evaluated pazopanib (800 mg orally once daily) in patients with relapsed or refractory AML or at initial diagnosis when no intensive treatment is possible. All patients who received pazopanib for 14 days or longer were included into the analysis of safety, tolerability and efficacy. Response criteria are defined according to the Revised Recommendations of the International Working Group for Diagnosis, Standardization of Response Criteria, Treatment Outcomes, and Reporting Standards for Therapeutic Trials in Acute Myeloid Leukemia. Co-primary endpoints were cumulative response rate (CR, CRp, CRi, PR) within up to one year and reduction of BM microvessel density (MVD) on day 28. Overall survival (OS) and progression free survival (PFS, time from first dose until progression or death from any cause) were measured from the first day of treatment until death of any cause or progression of disease. Results: Between February 2012 and September 2015, 20 AML patients with a median (range) age of 76 (52 - 86) years were treated with pazopanib. The majority of patients (n = 15, 75%) had relapsed (n = 7) or refractory (n = 8) AML, five patients (25%) were enrolled with newly diagnosed AML. Median (range) ECOG performance status was 1 (1 - 3). According to ELN 2010 criteria, four patients (20%) had adverse risk, 15 (75%) had intermediate risk, and one patient (5%) had favorable cytogenetic/molecular risk. Overall, the safety profile of pazopanib was similar to that reported in previous studies. The most common AEs of any grade, related to pazopanib as assessed by the investigator, were gastrointestinal AEs, including nausea (n = 8), diarrhea (n = 6), inappetence (n = 5) and vomiting (n = 3). Two out of 20 treated patients (10%) had a partial remission (reduction of blast count 〉 50%) and 14 (70%) a stable disease (SD) while on pazopanib. Four patients (20%) experienced initial PD. Median PFS was 65 days (95% CI 29 - 105). After the end of study period three remarkable responses occurred on subsequent therapies such as demethylating agents resulting in one CRi and one CRp and one CR after secondary BM transplantation. All these patients had SD while on pazopanib and improved general condition allowing escalation of therapy. However, at the time of OS evaluation all patients had died due to PD and/or infections. Median OS of the treated study cohort was 191 days (95% CI 87 - 435), and 1-year survival altogether was 35%. There was no significant change in BM MVD between day 1 and day 28. Conclusion: Pazopanib was found to be safe in patients with AML not eligible for intensive therapy. The survival data are encouraging but clearly necessitate a controlled randomized clinical trial for confirmation. Clinical trial information: NCT01361334. Disclosures Stelljes: Amgen: Honoraria; JAZZ: Honoraria; MSD: Consultancy; Pfizer: Consultancy, Honoraria, Research Funding; Novartis: Honoraria. Lenz:Roche: Consultancy, Honoraria, Other: Travel, Accomodations, Expenses, Research Funding; Bayer: Consultancy, Honoraria, Research Funding, Speakers Bureau; Novartis: Research Funding; Gilead: Consultancy, Honoraria; Janssen: Consultancy, Honoraria, Other: Travel, Accomodations, Expenses, Research Funding, Speakers Bureau; Celgene Corp.: Consultancy, Honoraria, Other: Travel, Accomodations, Expenses, Research Funding, Speakers Bureau. Brümmendorf:Takeda: Consultancy; Novartis: Consultancy, Research Funding; Pfizer: Consultancy, Research Funding; Janssen: Consultancy; Merck: Consultancy.

Description: Osteopontin (OPN) is a glycoprotein that is secreted by osteoblasts and hematopoietic cells. OPN suppresses the proliferation of hematopoietic stem cells in vitro and may regulate the hematopoietic stem cell pool. Increased serum OPN concentrations occur in chronic myeloid leukemia, multiple myeloma, and acute myeloid leukemia (AML). In the present study, we analyzed the prognostic impact of OPN in AML by investigating the expression and relevance of OPN in newly diagnosed AML patients from 2 large study groups (the German AML Cooperative Group and the Dutch-Belgian Hematology Oncology Cooperative group). IHC (n = 84), ELISAs of blood/BM sera (n = 41), and microarray data for mRNA levels (n = 261) were performed. Expression of OPN protein was increased in AML patients both in BM blasts (IHC) and in BM serum (ELISA) compared with healthy controls. Patients expressing high levels of OPN within the BM (IHC) experienced shortened overall survival (OS; P = .025). Multivariate analysis identified karyotype, blast clearance (day 16), and the level of OPN expression as independent prognostic factors for OS. This prompted us to analyze microarray data from 261 patients from a third cohort. The analysis confirmed OPN as a prognostic marker. In summary, high OPN mRNA expression indicated decreased event-free survival (P = .0002) and OS (P = .001). The prognostic role of OPN was most prominent in intermediate-risk AML. These data provide evidence that OPN expression is an independent prognostic factor in AML.

Description: The Armadillo repeat-containing X-linked protein 1 (ARMCX1)gene encodes a member of the ALEX family of proteins and is located on the X chromosome. We found this gene aberrantly expressed in acute myeloid leukemia (AML) cells. We analyzed ARMCX1 expression in a cohort of 508 AML patients who received intensive chemotherapy within AMLCG clinical trial. Expression levels of ARMCX1 were determined in pretreatment bone marrow or peripheral blood samples by using oligonucleotide microarrays (GSE37642). High transcript levels (dichotomized at the median expression) of ARMCX1 were predictors for inferior overall survival (OS) (p=0.0027, Log-Rank test) and a lower rate of complete remission (CR) (p=0.0017). Older patients (≥ 60 years) showed an elevated incidence of high ARMCX1 expression compared to younger patients (

Description: Angiopoietin-1 (Ang-1) and its natural antagonist Angiopoietin-2 (Ang-2), both ligands for the receptor tyrosine kinase Tie2, are known to play an essential role in normal and pathological angiogenesis. However, the importance of angiopoietin signaling in the pathophysiology of hematologic neoplasias such as acute myeloid leukemia (AML) remains to be elucidated. We investigated the expression of Ang-1, Ang-2 and Tie2 by immunohistochemical analyses in bone marrow biopsies of 64 adult patients with newly diagnosed AML and correlated angiogenic factor expression with clinicopathological variables and long-term survival. Expression of Ang-2 was significantly increased in the bone marrow of AML patients (median [interquartile ranges]: 4.7 [3.3 – 5.7] AU [arbitrary units]) as compared with 16 control patients (1.5 [1.5 – 1.8] AU; P 〈 0.0001). In contrast, Ang-1 expression levels in AML patients did not differ from those found in controls. Thus, we observed a reversal of the Ang-1 and Ang-2 expression balance in the neoplastic bone marrow (Ang-2:Ang-1 ratio: 1.73) as compared with normal bone marrow (0.51; P 〈 0.0001). Furthermore, the angiopoietin receptor Tie2 was significantly overexpressed in leukemic blasts (3.8 [2.8 – 4.9] AU vs. 1.8 [1.6 – 2.3] AU; P 〈 0.0001). Patients expressing high levels of Ang-2 showed significantly longer overall survival (OS) than those with low Ang-2 levels (52.7 vs. 14.7 months; P = 0.039). The impact of Ang-2 expression on OS was especially evident in AML patients simultaneously expressing low levels of Ang-1 (P = 0.0298). Multivariate Cox regression analysis revealed karyotype and Ang-2 expression as independent prognostic factors for OS (hazard ratio [CI]: 3.06 [1.39 – 6.70] and 0.31 [0.14 – 0.69], respectively; P 〈 0.01). In conclusion, these data provide evidence that the alteration of angiopoietin balance in favor of Ang-2 may play a critical role in the pathophysiology of AML. Furthermore, high pre-therapeutic bone marrow Ang-2 levels indicate a favorable prognosis in polychemotherapy treated AML by a yet unknown mechanism.

Description: Allogeneic SCT is the most potent post-remission therapy for AML patients, particularly in patients aged 〉40-45 years, and the only curative option for patients with refractory AML or with high-risk MDS. Although median age at diagnosis is above 65 years for both entities, for patients aged 60 years or older, studies evaluating allogeneic SCT as post-remission therapy or as salvage therapy are limited. Dose adapted / reduced conditioning for patients in remission and sequential conditioning (intensive chemotherapy followed by dose adapted conditioning), for patients with active leukemia / high-risk disease, together with improvement in supportive care, have shown improved outcome results for SCT in younger and older patients. Aiming to predict treatment outcomes of patients undergoing allogeneic SCT, various transplant specific risk models have been introduced in the past. Assuming that these risk models might be of value especially in older patients, we performed a retrospective single center analysis of transplanted patients, incorporating the Hematopoietic Cell Transplantation-Specific Comorbidity Index (HCT-CI), the European Group for Blood and Marrow Transplantation (EBMT) Score and the Disease Risk Index (DRI). Between 1999 and 2014, 187 patients (pts) with AML (87%) or MDS (13%) aged ≥60 years (median age of 64 years, range 60 - 77 years) received an allogeneic SCT at our institution, either from a HLA-identical related (50 pts.), HLA-matched unrelated (103 pts.), or an HLA-mismatched donor (34 pts). Median follow-up of surviving patients was 36 months (range 1 to 173 months). All patients with AML received a cytarabine-based standard induction therapy. Conditioning prior to transplant consisted of dose reduced / dose adapted therapy (TBI-, busulfan- or treosulfan-based) or sequential conditioning (for patients with high risk or refractory disease). Thirty-nine of the 47 AML patients transplanted in first complete remission (CR1) had a high-risk AML, defined by an adverse cytogenetic risk profile (16 pts), persisting AML after first induction therapy (12 pts), a secondary AML (6 pts.), or persisting / increasing minimal residual disease (5 pts). MDS patients had mainly an advanced disease with blast count 10-19% (19/24 pts). For all patients, an overall survival (OS) at 3 years of 35% (95% CI: 27-42%) was observed. Cumulative incidences of NRM and relapse at one year were 37% and 22%, respectively. Patients transplanted in CR1 showed a 3-year OS of 49%, whereas patients transplanted in subsequent remission, with active AML, or high-risk MDS had a 3-year OS of 26%, 28% and 31%, respectively. Univariate analysis of the whole group showed that advanced and/or active disease (advanced/active AML/MDS vs. AML CR1, p = .04), high DRI (high/very high vs. low/intermediate, p = .06), and poor Eastern Cooperative Oncology Group Score (ECOG; ≥2 vs. 0 or 1, p=.0001), were associated with an inferior OS. Patient age had no impact on outcome parameters. In a multivariate analysis of disease / transplant related risk factors (status pre transplant, EBMT-score, HCT-CI and DRI) only disease status pre transplant was an independent prognostic factor for OS (active / advanced disease vs. CR1, hazard ratio 1.55; 95% CI 1.01-2.38). These results indicate that patient's age ≥60 years in general is no limiting factor for an allogeneic transplant, even if refractory to conventional treatment. Pre-transplant selection of patients eligible for intensive treatment was most likely one relevant bias in our analysis, limiting the determination of the impact of preexisting comorbidities on treatment outcomes. Given the prognostic impact of the disease status at transplant, the improvement of transplant results in elderly patients, and the dismal prognosis of older patients with myeloid neoplasms receiving conventional treatment, the impact of allogeneic SCT, especially in early disease stages / CR1 of patients with MDS / AML eligible for intensive treatment has to be further studied in prospective trials. Disclosures No relevant conflicts of interest to declare.

Description: Purpose: The enhancer of zeste homolog 2 (EZH2) is a histone methyltransferase and key epigenetic regulator involved in transcriptional repression and embryonic development. Loss of EZH2 activity by inactivating mutations is associated with poor prognosis in myeloid malignancies such as MDS. More recently, EZH2 inactivation was shown to induce chemoresistance in acute myeloid leukemia (AML) (Göllner et al., 2017). Data on the frequency and prognostic role of EZH2-mutations in AML are rare and mostly confined to smaller cohorts. To investigate the prevalence and prognostic impact of this alteration in more detail, we analyzed a large cohort of AML patients (n = 1604) for EZH2 mutations. Patients and Methods: All patients analyzed had newly diagnosed AML, were registered in clinical protocols of the Study Alliance Leukemia (SAL) (AML96, AML2003 or AML60+, SORAML) and had available material at diagnosis. Screening for EZH2 mutations and associated alterations was done using Next-Generation Sequencing (NGS) (TruSight Myeloid Sequencing Panel, Illumina) on an Illumina MiSeq-system using bone marrow or peripheral blood. Detection was conducted with a defined cut-off of 5% variant allele frequency (VAF). All samples below the predefined threshold were classified as EZH2 wild type (wt). Patient clinical characteristics and co-mutations were analyzed according to the mutational status. Furthermore, multivariate analysis was used to identify the impact of EZH2 mutations on outcome. Results: EZH2-mutations were found in 63 of 1604 (4%) patients, with a median VAF of 44% (range 6-97%; median coverage 3077x). Mutations were detected within several exons (2-6; 8-12; 14-20) with highest frequencies in exons 17 and 18 (29%). The majority of detected mutations (71% missense and 29% nonsense/frameshift) were single nucleotide variants (SNVs) (87%), followed by small indel mutations. Descriptive statistics of clinical parameters and associated co-mutations revealed significant differences between EZH2-mut and -wt patients. At diagnosis, patients with EZH2 mutations were significantly older (median age 59 yrs) than EZH2-wt patients (median 56 yrs; p=0.044). In addition, significantly fewer EZH2-mut patients (71%) were diagnosed with de novo AML compared to EZH2-wt patients (84%; p=0.036). Accordingly, EZH2-mut patients had a higher rate of secondary acute myeloid leukemia (sAML) (21%), evolving from prior MDS or after prior chemotherapy (tAML) (8%; p=0.036). Also, bone marrow (and blood) blast counts differed between the two groups (EZH2-mut patients had significantly lower BM and PB blast counts; p=0.013). In contrast, no differences were observed for WBC counts, karyotype, ECOG performance status and ELN-2017 risk category compared to EZH2-wt patients. Based on cytogenetics according to the 2017 ELN criteria, 35% of EZH2-mut patients were categorized with favorable risk, 28% had intermediate and 37% adverse risk. No association was seen with -7/7q-. In the group of EZH2-mut AML patients, significantly higher rates of co-mutations were detected in RUNX1 (25%), ASXL1 (22%) and NRAS (25%) compared to EZH2-wt patients (with 10%; 8% and 15%, respectively). Vice versa, concomitant mutations in NPM1 were (non-significantly) more common in EZH2-wt patients (33%) vs EZH2-mut patients (21%). For other frequently mutated genes in AML there was no major difference between EZH2-mut and -wt patients, e.g. FLT3ITD (13%), FLT3TKD (10%) and CEBPA (24%), as well as genes encoding epigenetic modifiers, namely, DNMT3A (21%), IDH1/2 (11/14%), and TET2 (21%). The correlation of EZH2 mutational status with clinical outcomes showed no effect of EZH2 mutations on the rate of complete remission (CR), relapse free survival (RFS) and overall survival (OS) (with a median OS of 18.4 and 17.1 months for EZH2-mut and -wt patients, respectively) in the univariate analyses. Likewise, the multivariate analysis with clinical variable such as age, cytogenetics and WBC using Cox proportional hazard regression, revealed that EZH2 mutations were not an independent risk factor for OS or RFS. Conclusion EZH mutations are recurrent alterations in patients with AML. The association with certain clinical factors and typical mutations such as RUNX1 and ASXL1 points to the fact that these mutations are associated with secondary AML. Our data do not indicate that EZH2 mutations represent an independent prognostic factor. Disclosures Middeke: Janssen: Membership on an entity's Board of Directors or advisory committees, Research Funding; Abbvie: Membership on an entity's Board of Directors or advisory committees; Roche: Membership on an entity's Board of Directors or advisory committees. Rollig:Bayer: Research Funding; Janssen: Research Funding. Scholl:Jazz Pharma: Membership on an entity's Board of Directors or advisory committees; Abbivie: Other: Travel support; Alexion: Other: Travel support; MDS: Other: Travel support; Novartis: Other: Travel support; Deutsche Krebshilfe: Research Funding; Carreras Foundation: Research Funding; Pfizer: Membership on an entity's Board of Directors or advisory committees. Hochhaus:Pfizer: Research Funding; Incyte: Research Funding; Novartis: Research Funding; Bristol-Myers Squibb: Research Funding; Takeda: Research Funding. Brümmendorf:Janssen: Consultancy; Takeda: Consultancy; Novartis: Consultancy, Research Funding; Merck: Consultancy; Pfizer: Consultancy, Research Funding. Burchert:AOP Orphan: Honoraria, Research Funding; Bayer: Research Funding; Pfizer: Honoraria; Bristol Myers Squibb: Honoraria, Research Funding; Novartis: Research Funding. Krause:Novartis: Research Funding. Hänel:Amgen: Honoraria; Roche: Honoraria; Takeda: Honoraria; Novartis: Honoraria. Platzbecker:Celgene: Research Funding. Mayer:Eisai: Research Funding; Novartis: Research Funding; Roche: Research Funding; Johnson & Johnson: Research Funding; Affimed: Research Funding. Serve:Bayer: Research Funding. Ehninger:Cellex Gesellschaft fuer Zellgewinnung mbH: Employment, Equity Ownership; Bayer: Research Funding; GEMoaB Monoclonals GmbH: Employment, Equity Ownership. Thiede:AgenDix: Other: Ownership; Novartis: Honoraria, Research Funding.

Description: Introduction Despite substantial progress in the treatment of newly diagnosed AML, 20% to 40% of patients do not achieve remission with conventional induction chemotherapy. In addition, 50% to 70% of patients with CR1 are expected to relapse within 3 years. Currently, allogeneic HSCT is thought to be the most reliable curative option for patients with relapsed and/or refractory (r/r) disease. Compared to HSCT in CR1 allogeneic HSCT beyond CR1 is associated with lower survival rates. So far, different predictive factors influencing survival in r/r AML have been identified. However, pretransplantation variables delineating prognostic subgroups after allogeneic HSCT beyond CR1 are less well known and the total number of patients in trials addressing this issue has been limited. Methods We analyzed the outcome after allogeneic HSCT in non-APL-AML patients transplanted with either subsequent 2nd complete remission (CR2), r/r AML or with persisting cytopenia (PC, including patients with hematologic complete remission with incomplete hematologic recovery and patients with persisting bone marrow hypoplasia) after induction or salvage therapy. Of 3989 patients who enrolled into a multicenter clinical trial (AMLCG1999; NCT00266136) of the German Acute Myeloid leukemia Cooperative Group (AMLCG) we identified 498 subjects aged 17 to 74 years who underwent allogeneic HSCT beyond first CR. Before transplantation, all patients received first line treatment either with 6-Thioguanine, cyararabine, daunorubicin (TAD) and high-dose cytarabine, mitoxantrone (HAM) or HAM/HAM. After induction failure (n=97) or relapse (n=401) patients either received salvage chemotherapy (n=299) or directly underwent allogeneic HSCT (n=199). Overall survival (OS) and relapse free survival (RFS) after allogeneic HSCT were the main endpoints for this analysis. Kaplan-Meier analysis was performed to estimate survival probabilities in subgroups. Log-rank tests were used to compare survival groups. Relative hazard rates and differences in subgroups were calculated using cox regression analysis. Results At a median follow-up of 6.5 years for surviving patients, OS and RFS rates were 32% (95% CI 28-36%) and 30% (95% CI 26-34%), respectively. Subgroup analysis revealed an OS of 49% in 128 patients with allogeneic HSCT in CR2. In comparison, 73 patients who underwent allogeneic HSCT with PC after induction (n = 42) / salvage treatment (n = 31) and 297 patients with refractory disease (RD) exhibited an OS of 39% and 23%, respectively (Figure 1). The corresponding cumulative incidences (CI) at 1/6.5 years for death in remission after allogeneic HSCT were 25%/31% for patients transplanted in CR2, 29%/41% for patients transplanted with PC and 30%/46% for patients transplanted with RD, respectively. The cumulative incidence of relapse (CIR) after 6.5 years was 58% for patients transplanted with RD compared to 34% for patients transplanted in CR2 and 31% for patients with PC. Main prognostic factors for survival outcome were remission status prior to allogeneic HSCT and cytogenetic risk category at diagnosis. By contrast, patient age, donor, graft source, remission status after induction therapy and CMV status had no significant impact on survival outcome. Conclusions Long-term OS rates after allogeneic HSCT for patients with r/r AML are considered to range between 20 and 40%. Our analysis indicates that a substantial fraction of patients who received similar first line treatment within one prospective trial is able to achieve long term survival when transplanted beyond CR1. In addition, remission upon salvage therapy prior to allogeneic HSCT might be a relevant prognostic factor for patients with r/r AML. However, whether remission induction prior to HSCT can provide an overall survival benefit in patients with r/r disease is still elusive and is currently being evaluated in a prospective randomized clinical trial (ETAL3-ASAP; NCT02461537). Disclosures Beelen: Medac: Consultancy, Other: Travel Support. Scheid:Novartis: Honoraria, Research Funding; Janssen: Honoraria; Celgene: Honoraria; Takeda: Honoraria, Research Funding; BMS: Honoraria; Amgen: Honoraria. Lenz:Celgene Corp.: Consultancy, Honoraria, Other: Travel, Accomodations, Expenses, Research Funding, Speakers Bureau; Novartis: Research Funding; Roche: Consultancy, Honoraria, Other: Travel, Accomodations, Expenses, Research Funding; Bayer: Consultancy, Honoraria, Research Funding, Speakers Bureau; Janssen: Consultancy, Honoraria, Other: Travel, Accomodations, Expenses, Research Funding, Speakers Bureau; Gilead: Consultancy, Honoraria. Hiddemann:Bayer: Consultancy, Research Funding; Janssen: Consultancy, Honoraria, Membership on an entity's Board of Directors or advisory committees, Research Funding; F. Hoffman-La Roche: Consultancy, Honoraria, Membership on an entity's Board of Directors or advisory committees, Research Funding; Celgene: Consultancy, Honoraria, Membership on an entity's Board of Directors or advisory committees, Research Funding. Stelljes:MSD: Consultancy; JAZZ: Honoraria; Amgen: Honoraria; Novartis: Honoraria; Pfizer: Consultancy, Honoraria, Research Funding.

Description: In fit patients with newly diagnosed acute myeloid leukemia (AML), immediate treatment start is recommended due to the poor prognosis of untreated acute leukemia. We explored the relationship between time from diagnosis to treatment start (TDT) and prognosis in a large real-world data set from the German Study Alliance Leukemia–Acute Myeloid Leukemia (SAL-AML) registry. All registered non–acute promyelocytic leukemia patients with intensive induction treatment and a minimum 12 months of follow-up were selected (n = 2263). We analyzed influence of TDT on remission, early death, and overall survival (OS) in univariable analyses for each day of treatment delay, in groups of 0 to 5, 6 to 10, 11 to 15, and 〉15 days of TDT, adjusted for influence of established prognostic variables on outcomes. Median TDT was 3 days (interquartile range, 2-7). Unadjusted 2-year OS rates, stratified by TDT of 0 to 5, 6 to 10, 11 to 15, and 〉15 days, were 51%, 48%, 44%, and 50% (P = .211). In multivariable Cox regression analysis accounting for established prognostic variables, the TDT hazard ratio as a continuous variable was 1.00 (P = .617). In OS analyses, separately stratified for age ≤60 and 〉60 years and for high vs lower initial white blood cell count, no significant differences between TDT groups were observed. Our study suggests that TDT is not related to survival. As stratification in intensive first-line AML treatment evolves, TDT data suggest that it may be a feasible approach to wait for genetic and other laboratory test results so that clinically stable patients are assigned the best available treatment option. This trial was registered at www.clinicaltrials.gov as #NCT03188874.