ALBERT

Description: Recent data suggested that low levels of mutated myeloid genes could be detected in the peripheral blood of individuals with normal peripheral blood counts. While testing for MDS-related molecular abnormalities is not justified in individuals without a cytopenia, appreciating the linkage between abnormal peripheral blood counts and specific myeloid gene mutations would support the need for genetic testing. Furthermore, we found that approximately 50% of practicing hematologists and oncologists do not send MDS bone marrow specimens for conventional cytogenetic testing (Craig, et al. Leuk Res 2011), and even fewer order gene mutation profiling, despite the informative potential of results for diagnosis, prognosis and therapy. Hence, there is a gap in recognizing when to order genetic testing in MDS. To address this, bone marrow aspiration cells from patients with morphologically and clinically confirmed MDS were examined for genomic mutations by conventional cytogenetics and targeted next generation sequencing (NGS). Sequencing covered mutations in the following genes: TET2, SF3B1, ASXL1, DNMT3A, SRSF2, RUNX1, NRAS, ZRSR2, EZH2, ETV6, TP53, CBL, NPM1, JAK2, U2AF1, IDH1, KRAS, IDH2, FLT3, PTPN11, and SETBP1. The average depth of NGS was 10,000x and mutant allele frequency was 〉5%. Association between genomic mutations and peripheral blood counts were evaluated using the Kruskal-Wallis test. 147 patients with WHO-defined MDS were included in this study. 12/147 (8%) had very good cytogenetic risk disease, 104/147 (71%) were good risk, 22/147 (15%) were intermediate risk, 4/147 (3%) were poor risk, and 5/147 (3%) were very poor risk. Anemia was significantly associated with SF3B1 mutations (P=0.0017), while higher hemoglobin values were significantly associated with SRSF2 mutations (P=0.0051). Macrocytosis was associated with SF3B1 (P

Description: Background: Essential to cancer cell signaling, the growth receptor bound protein-2 (Grb-2) is evolutionarily conserved and utilized by oncogenic tyrosine kinases including Bcr-Abl to activate Ras, ERK, and AKT. BP-100-1.01is a neutrally-charged, liposome-incorporated antisense designed to inhibit Grb-2 expression. Aim: To define the safety, maximum tolerated dose (MTD), optimal biologically active dose, pharmacokinetics and anti-leukemia activity of BP-100-1.01 in patients (pts) with hematologic malignancies. Methods: This is a standard 3+3 phase I dose-finding study in pts with relapsed or refractory acute myeloid leukemia (AML), chronic myeloid leukemia in blast phase (CML-BP), acute lymphoblastic leukemia (ALL) and myelodysplastic syndrome (MDS). The starting dose was 5 mg/m2 twice weekly, IV over 2-3 hours for 28 days. Dose escalation proceeded through 5, 10, 20, 40, 60, and 90 mg/m2.Uponcompletion of single agent phase 1, combination of cytarabine 20 mg SubQ BID x 10 days + 60 mg/m2 of BP-100-1.01 was studied (Cohort 1B). Flow cytometric analysis was performed on peripheral blood samples from cohorts 3, 4, 5, 6 and 1B collected at baseline, on day 15 and at end-of-treatment (EOT). Fluorescent-labeled antibodies specific for Grb-2 or phosphorylated Erk (pErk) were utilized to determine Grb-2 protein levels and pErk levels in CD33-expressing cells. Results: A total of33 pts were included (13 in Cohort 1, 6 in Cohort 2, 3 each in Cohorts 3, 4, 5, and 4 in cohort 6). One patient has been treated in cohort 1B. The median age was 64 yrs (range, 32-89) and diagnoses were AML (n=24), CML-BP (n=5) and MDS (n=4). The median number of prior therapies was 4 (range, 1- 8). Of 33 pts, 21 were evaluable and 11 failed completion of a full 28-Day cycle due to disease progression (with no toxicity) and were replaced, per protocol. Only one pt (treated at 5 mg/m2) experienced dose limiting toxicity (DLT), grade 3 mucositis and hand-foot syndrome, while receiving concurrent hydroxyurea for proliferative CML-BP. The patient had a previous history of hydroxyurea-induced mucositis. Being the first patient to receive BP-100-1.01, these toxicities were considered possibly related to BP-100-1.01. The cohort was expanded to a total of 6 pts. No other DLTs have been noted in any pt. Among 21 evaluable pts, 11 experienced at least a 50% reduction in peripheral or bone marrow blasts from baseline. Additionally 2 pts with improvement in leukemia cutis lesions received 1 cycle each. Furthermore, 6 pts demonstrated transient improvement (n=3) and/or stable disease (n=3). Among the 21 evaluable pts, a median of 1 cycle was administered (1-5): Four pts received 2 cycles, 3 pts received 5 cycles, and all others received 1 cycle. Notably one pt (treated at 5 mg/m2)with CML-BP showed a significant reduction in blasts from 81% to 5%. Due to leptomeningeal disease progression therapy was discontinued before a full cycle. The 1st patient treated in cohort 1B achieved CR after 1 cycle. The patient did not experience any DLTs, but came off study due to failure to thrive in the context of dementia. The levels of Grb-2 and pErk proteins were indicated by their respective median fluorescent signals and are shown in the table. Median fluorescent signals of Grb-2 and pErk on days 15 and EOT were compared to baseline. On day 15 Grb-2 levels decreased by 〉25% in 7 out of 12 samples tested, and pErk levels by 〉25% in 6 out of 12 samples. The average decrease in Grb-2 levels was 61% (range: 47 to 85%) and in pErk levels 52% (range: 28 to 82%). On the last measured sample (EOT or day 22), BP-100-1.01 decreased 〉25% Grb-2 levels in 11 out of 13 samples, and 〉25% pErk levels in 7 out of 13 samples. The average decrease in Grb-2 levels was 49% (range: 28 to 91%) and in pErk levels was 52% (range: 27 to 91%). Table 1. Patient Number Grb-2 decrease (Day 15) pErk decrease (Day 15) Grb-2 decrease (Day 22 or EOT) pErk decrease (Day 22 or EOT) 022 0 0 57 0 023 0 3 28 45 024 56 28 47 35 025 63 82 54 91 026 47 0 0 0 027 NS NS 34 27 028 0 0 30 54 029 57 51 65a 0a 030 54 55 43 47 031 0 0 0 0 032 85 54 91 63 033 6 13 53 2 034 63 42 40 0 NS = no sample collected aFewer cells were used in the analysis of this sample than other samples, because this sample had less cells than other samples Conclusions: BP-100-1.01, at dose range 5 mg/m2 to 90 mg/m2 is well tolerated with no MTD yet identified. There is suggestion of Grb-2 target protein down-regulation, and possible anti-leukemia activity. Disclosures Konopleva: Novartis: Research Funding; AbbVie: Research Funding; Stemline: Research Funding; Calithera: Research Funding; Threshold: Research Funding. Tari:Bopath Holdings: Employment. Cortes:BerGenBio AS: Research Funding; Teva: Research Funding; Novartis: Consultancy, Research Funding; Pfizer: Consultancy, Research Funding; Ariad: Consultancy, Research Funding; BMS: Consultancy, Research Funding; Astellas: Consultancy, Research Funding; Ambit: Consultancy, Research Funding; Arog: Research Funding; Celator: Research Funding; Jenssen: Consultancy.

Description: Autoimmune lymphoproliferative syndrome (ALPS) is a genetic disorder characterized by early-onset, chronic, nonmalignant lymphoproliferation, autoimmune manifestations, and susceptibility to lymphoma. The majority of ALPS patients carry heterozygous germline (ALPS-FAS) or somatic mutations (ALPS-sFAS) of the TNFRSF6 gene coding for FAS. Although the clinical features of ALPS have been described previously, long-term follow-up data on morbidity and mortality are scarce. We performed a retrospective analysis of clinical and genetic features of 90 ALPS-FAS and ALPS-sFAS patients monitored over a median period of 20.5 years. Heterozygous germline mutations of TNFRSF6 were identified in 83% of probands. Somatic TNFRSF6 mutations were found in 17% of index cases (all located within the intracellular domain of FAS). Sixty percent of the ALPS-FAS patients with mutations in the extracellular domain had a somatic mutation affecting the second allele of TNFRSF6; age at onset was later in these patients. No other genotype-phenotype correlations could be found. Long-term analysis confirmed a trend toward spontaneous remission of lymphoproliferation in adulthood but mixed outcomes for autoimmune manifestations. We observed significant and potentially life-threatening disease and treatment-related morbidity, including a high risk of sepsis after splenectomy that calls for careful long-term monitoring of ALPS patients. We also noted a significantly greater occurrence of disease-related symptoms in male than in female patients.

Description: Aromatase inhibitors (AI) block the conversion of testosterone and androstenedione to the estrogen estrone by inhibiting the aromatase enzyme complex. AI are used to treat estrogen receptor positive (ER+) breast cancer in postmenopausal women. With AI therapy, estrogen levels decrease to 85–95% of baseline. In women with metastatic disease, androstenedione levels do not increase. We have evaluated 2 women for polycythemia during AI therapy. Case 1 is 52 years old with stage II breast cancer treated with lumpectomy, TAC × 6 and radiation. Tamoxifen was started 4 months later. The mean hemoglobin during 6 months of tamoxifen was 14.0±0.1 gm/dl. When switched to exemestane, the mean hemoglobin over the next 24 months was 16.1±0.5 gm/dl (Mann-Whitney, p

Description: Background: We have demonstrated that blood vessels can be a sanctuary site for acute myeloid leukemia (AML). Therefore, we evaluated a novel vascular disrupting agent, OXi4503, for the treatment of patients with AML and higher risk myelodysplastic syndromes (MDS). Methods: Patients with AML and MDS were treated with OXi4503 monotherapy in a phase IA 3x3 dose escalation/de-escalation study (ClinicalTrials.gov NCT01085656). Drug was administered via intravenous infusion on days 1, 8, 15, and 22 of a 28-day cycle. Dose escalation occurred as tolerated according to protocol. With the goal of defining maximum tolerated dose (MTD), patients were monitored for side effects and dose-limiting toxicities (DLTs). Therapy continued until drug intolerance or disease progression. Results: From May 2011 to May 2015, 18 patients diagnosed with refractory MDS (RAEB-1 or RAEB-2) or refractory AML were treated with OXi4503. Overall, 78% of patients were male, while 22% were female. The median patient age was 63 years (range, 24 to 80). Sixteen of 18 (89%) of patients had refractory AML and 2/18 (11%) had refractory MDS. For patients with AML, 11/16 (69%) were intermediate and 5/16 (31%) unfavorable cytogenetic risk. For patients with MDS, one had intermediate and one had very poor cytogenetic risk. The median number of prior therapies was 4 (range, 1-10). In two small run-up cohorts, two patients received 2.5 mg/m2 IV weekly and two received 3.75 mg/m2. In the main trial, nine patients received 5 mg/m2, three received 6.25 mg/m2, and two received 7.81 mg/m2. Expansion of the 5 mg/m2 cohort occurred after two patients withdrew due to disease progression and one patient withdrew due to grade 4 disseminated intravascular coagulopathy (DIC). The median number of cycles received was 1 (range, 1-10). Transient elevations in D-dimer were observed in 14/18 patients (78%). DIC was observed in 5/18 patients (28%). Four of five patients with DIC only had laboratory evidence and no clinical sequelae. One patient treated with 5 mg/m2 died of DIC; however, he also had evidence of infection. The coagulopathic laboratory changes typically resolved within 4-6 days. Fever occurred in 7/18 patients (39%) and typically resolved within 24 hours after drug administration. Fever was irrespective of coagulopathic laboratory changes. Other drug-related side effects (all grades) included bone pain in 5/18 (28%), flu-like symptoms in 5/18 (28%), hypertension in 5/18 (28%), thrombocytopenia in 5/18 (28%). Grade 3 or 4 hypertension and QT prolongation were not observed. One patient achieved a marrow complete remission after one cycle, but then died of fungal pneumonia. Another patient achieved partial remission and received 10 cycles of OXi4503 treatment. He eventually withdrew from the study due to disease progression. Conclusions: OXi4503 doses of up to 7.81 mg/m2 have been safely and feasibly administered to patients with AML and MDS. The MTD has not been reached and the trial is ongoing. Based on evidence that OXi4503 chemosensitizes AML cells to cell cycle agents, after reaching MTD, the next step is a phase IB/II clinical trial combining OXi4503 with cytarabine in relapsed/refractory AML and MDS. Disclosures Off Label Use: OXi4503. Chaplin:OXiGENE: Employment. Cogle:OXiGENE: Research Funding.

Description: Background Essential to cancer cell signaling, the adaptor protein growth receptor bound protein-2 (Grb-2) is evolutionarily conserved. With SH2/SH3 domains and lacking enzyme activity, Grb-2 is utilized by oncogenic tyrosine kinases such as Bcr-Abl to activate Ras, ERK, and AKT during cancer progression. Thus, Grb2 suppression has therapeutic potential. BP-100-1.01 is a neutrally-charged, liposome-incorporated antisense designed to inhibit Grb-2 expression. Aim To define the safety, maximum tolerated dose, optimal biologically active dose, pharmacokinetics and anti-leukemia activity of BP-100-1.01 in patients (pts) with hematologic malignancies. Methods This is a standard 3+3 phase I dose-finding study in pts with relapsed or refractory acute myeloid leukemia (AML), chronic myeloid leukemia in blast phase (CML-BP), acute lymphoblastic leukemia (ALL) and myelodysplastic syndrome (MDS). The starting dose was 5 mg/m2 twice weekly, intravenously (IV) over 2-3 hours for 28 days. Dose escalation has proceeded through 10, 20, 40, and 60 mg/m2 and will proceed to 90 and 135 mg/m2. Flow cytometric analysis was performed on peripheral blood samples from Cohorts 3, 4, & 5, collected prior to study initiation (baseline), on day 15 and on end-of-treatment day (EOT). Commercially available fluorescent-labeled antibodies specific for Grb-2 or phosphorylated Erk (pErk) were utilized to determine Grb-2 protein levels and pErk levels in CD33-expressing cells. Results A total of 28 pts were included (13 in Cohort 1, 6 in Cohort 2, and 3 each in Cohorts 3, 4, and 5). The median age was 62 yrs (range, 32 - 89) and diagnoses were AML (n=19), CML-BP (n=5) and MDS (n=4). The median number of prior therapies was 4 (range, 1 to 8). Of 28 pts, 18 were evaluable and 10 failed completion of a full 28-Day cycle due to disease progression (with no toxicity) and were replaced, per protocol. Only one pt experienced dose limiting toxicity (DLT), grade 3 mucositis and hand-foot syndrome, while receiving concurrent hydroxyurea for proliferative CML-BP. The patient had a previous history of hydroxyurea-induced mucositis. Being the first patient to receive BP-100-1.01, these toxicities were considered possibly related to BP-100-1.01. The cohort was expanded to a total of 6 pts. No other drug related toxicities have been noted in any of the pts treated. No other DLT have occurred. Among 18 evaluable pts, 9 experienced at least a 50 percent reduction in peripheral or bone marrow blasts from baseline. Furthermore, 5 pts demonstrated transient improvement and/or stable disease, 3 of whom received a total of 5 cycles each while 2 pts with improvement in leukemia cutis lesions received 1 cycle each. The remaining patients received 1 cycle each. Notably patient 002 with CML-BP showed a significant reduction in blasts from 81% to 5%. Due to leptomeningeal disease progression he discontinued therapy before a full cycle. The levels of Grb-2 and pErk proteins were indicated by their respective median fluorescent signals and are shown in the table. The median fluorescent signals of Grb-2 and pErk on days 15 and EOT were compared to baseline. On day 15, BP-100-1.01 decreased Grb-2 levels in 5 out of 8 samples tested, and pErk levels in 4 out of 8 samples. The average decrease in Grb-2 levels was 55% (range: 47 to 63%) and the average decrease in pErk levels was 54% (range: 28 to 82%). On EOT day, BP-100-1.01 decreased Grb-2 levels in 7 out of 8 samples, and pErk levels in 6 out of 8 samples. The average decrease in Grb-2 levels was 42% (range: 28 to 57%) and the average decrease in pErk levels was 50% (range: 27 to 91%). Conclusions Preliminary results suggest that BP-100-1.01, at dose range 5 mg/m2 to 60 mg/m2 is well tolerated with no MTD yet identified. There is suggestion of Grb-2 target protein down-regulation, and possible anti-leukemia activity. Accrual continues with cohort 6 open at 90 mg/m2. Disclosures: Tari: Bio-Path Holdings: Employment, Equity Ownership.

Description: Abstract 986 In 2011, we described the TEMPI syndrome in three patients, a rare condition characterized by the pentad of (1) Telangiectasias, (2) elevated Erythropoietin and resulting erythrocytosis, (3) Monoclonal gammopathy, (4) Perinephric fluid collections, and (5) Intrapulmonary shunting. Since this publication, two additional living patients have been identified. Of note, all patients carried a diagnosis of unexplained polycythemia for many years to decades prior to the realization that the erythrocytosis was only one part of a more complex syndrome. The underlying pathophysiology of the TEMPI syndrome is unknown. Given that the patients did not exhibit symptoms until their 3rd or 4th decade, we felt that the TEMPI syndrome was more likely to be acquired and less likely to be congenital. We hypothesized that the monoclonal paraprotein may play a role in triggering this very unusual pattern of symptoms. Based on this hypothesis, the patients began empiric treatment with the proteasome inhibitor bortezomib, either alone, or as part of an induction regimen prior to autologous stem cell transplantation. The first patient to receive bortezomib, a 48 year old woman, received 8 cycles of intravenous bortezomib, given in standard fashion. Her telangiectasias, which were concentrated over her lips and torso, disappeared rapidly. Her bilateral perinephric fluid collections disappeared and her serum erythropoietin normalized from a peak of 〉5000 mIU/ml. By the end of the 8 cycles, her IgG kappa paraprotein became undetectable. Before treatment, she was hypoxic to such a degree that she required a wheelchair and continuous supplemental oxygen. Following treatment, her intrapulmonary shunting resolved, her oxygen saturation normalized, and she has resumed jogging. She remains in a complete remission, now fifteen months after her last dose of bortezomib. The second patient, a 55 year old woman, had undergone surgical fenestration of the renal capsule to allow for drainage of the perinephric fluid into her abdomen. The fluid was produced at such a rate that she required regular paracentesis to remove the resulting ascites. She received 6 cycles of intravenous bortezomib. Her telangiectasias resolved, her serum erythropoietin normalized from a peak of 507 mIU/ml, her paO2 improved, and production of perinephric fluid decreased. However, after four months off treatment, the concentration of her IgG kappa paraprotein began to increase, as did her serum erythropoietin. Furthermore, she has developed pulmonary hypertension, which we suspect may represent a rare paraneoplastic condition seen in some patients with multiple myeloma. The third patient, a 52 year old man, has received ten cycles of intravenous bortezomib. He has tolerated therapy well without side-effects. His serum erythropoietin has decreased from 5500 to 2500 mIU/ml. However, he has not shown the same dramatic reduction in the level of his IgG kappa paraprotein, nor has he shown resolution of his telangiectasias, perinephric fluid, or intrapulmonary shunting. The response of the fourth patient to bortezomib was recently described as a letter to the editor in the New England Journal of Medicine. The fifth patient, a 49 year old woman, was referred for evaluation of unexplained and progressive hypoxia requiring the use of continuous supplemental oxygen. She had been diagnosed at age 34 with polycythemia vera and treated with periodic phlebotomy. Telangiectasias were present on the face, chest, abdomen, and back. Erythropoietin was elevated to 〉8000 mIU/ml and an IgG-kappa paraprotein was identified. Her cardiovascular shunt fraction was 27%. Given the variable response of the other patients to single-agent bortezomib, she began an induction regimen that included cyoclophosphamide, bortezomib, and dexamethasone (CyBorD) with plans for autologous SCT. The efficacy of treatment with bortezomib, as well as the reversible nature of the symptoms, lends support to the hypothesis that the abnormal plasma cell clone and monoclonal gammopathy are the cause of the TEMPI syndrome. Efforts to identify the antigenic target of the paraprotein are underway, using protein microarray and immunohistochemical techniques. We suspect that more patients with the TEMPI syndrome exist. The constellation of the described pentad should raise the potential of this syndrome. We welcome any reader insights into this unusual condition. Disclosures: Raje: Onyx: Consultancy; Celgene: Consultancy; Millennium: Consultancy; Acetylon: Research Funding; Amgen: Research Funding; Eli-Lilly: Research Funding. Somer:BioPat Holdings, Inc.: Consultancy. Off Label Use: We use bortezomib in the treatment of a newly described syndrome, the TEMPI syndrome.