ALBERT

Description: Abstract 3432 Introduction. Dasatinib 100 mg QD is now validated as a first line option in patients with chronic myelogenous leukaemia in chronic phase (CML in CP). Our hypothesis was that significant adverse events observed with dasatinib including fluid retention, pleural effusions and grade 3–4 cytopenias, may be driven by the level of the residual dosage of dasatinib (Cmin). We initiated an optimization study based on the monitoring of dasatinib plasma levels (Cmin and Cmax) in patients with CML in chronic phase newly diagnosed and treated with dasatinib as front line therapy. Patients and methods. Patients aged 18 years old or more were eligible if they were diagnosed with CML in CP for less than 3 months without having being exposed to tyrosine kinase inhibitors. Dasatinib was initiated at the daily dose of 100 mg QD. Dasatinib daily dose adaptation was randomized in patients with a Cmin over 3nM. For all other patients, dasatinib was given at the dose of 100 mg QD. The pharmacokinetic (PK) evaluation (Cmin and Cmax measurements) was performed after 7 to 10 days of therapy and then every 15 days in the treatment adaptation arm (until a level of Cmin under 3nM) and every 3 months therafter as in the non-adapted arm. Cmax was assessed 2 hours after dasatinib intake. Results. The results of the first 78 patients included in the trial from May 2009 to May 2010 are reported. Median age was 47 years (19 – 77) with a sex ratio M/F of 1.85. The Sokal score distribution was 51.9%, 30.7% and 17.4% for Low, intermediate and high risk respectively. Median Cmin and Cmax values were 2.1 nM (range 0.2–18.7) and 107.6 nM (range 20.5–353) at first PK analysis. The median Cmin value was significantly lower in patients with age 47y (1.6 nM versus 2.8 nM, p=0.0028). By contrast, the median Cmax value was comparable in both age groups. Efficacy analysis was performed on the 53 patients with a 3 months follow-up and on the 36 patients with a 6 months follow-up. The complete cytogenetic response (CCR) rates at 3 and 6 months were 83.3% and 90.9% respectively. At 3 and 6 months, the major molecular response (MMR) rates were 15.1% and 69.4%. All patients in cytogenetic failure had high Sokal score values (p=0.023). Median PK values at months 3 and 6 were not statistically different compared to initial PK values, suggesting a stable exposure to the treatment with time. With a median follow-up of 7.2 months, the rate of significant adverse events was 11.5%. Fluid retention (n=2) and pleural effusion (n=1) were observed in patients with high Cmin values (mean 3.7 nM). A trend was observed between the Cmax and response at month 3 (CCR, p=0.05 and MMR, p=0.08). Patients with lymphocytosis may have a higher MMR rate (p=0.07). Conclusion. Dasatinib 100 mg QD as first line therapy in CP CML provided a high rate of MMR and CCR rates. Pharmacokinetic parameters of dasatinib were different in aged patients. A trend was observed first between Cmax and responses and second between Cmin and fluid retention or pleural effusion. A complete analysis with correlation to response and safety will be presented on more patients with 6 and 12 months follow-up. Disclosures: Rousselot: Bristol Myers Squibb: Research Funding. Off Label Use: Dasatinib as first line therapy for CML.

Description: Abstract 3377 It is generally accepted that the BCR-ABL oncoprotein transformes haematopoietic stem cell and initiates chronic myeloid leukemia (CML). However, leukemogenesis is a complex process, and genomic heterogeneity of the chronic phase (CP) of the disease has been reported. At the molecular level, this intrinsic heterogeneity could support a causative link with the varying response to treatment and disease progression. Genetic analysis of candidate genes in myeloid malignancies reported mutations of the ten-eleven translocation 2 (TET2), the isocitrate deshydrogenase (IDH) 1 and IDH2, and the additional sex combs like 1 (ASXL1) genes in myeloproliferative, acute myeloid and myelodysplasic neoplasms. Similarly, we can stipulate that these candidate genes may contribute to phenotypic heterogeneity of CML. To investigate whether TET2, IDH1, IDH2 and ASXL1 defect could represent a significant event in CML, we selected 91 CML patients (pts) treated with imatinib (IM) at first line and presenting five profiles of IM response at time of the analysis: 1) 25 pts in major molecular response (MMR) at 12 months of IM; 2) 11 pts in CCR but presenting additional Philadelphia (Ph) negative clonal evolution; 3) 20 pts in partial cytogenetic response at 18 months of IM, referred as primary resistant (R1); 4) 20 pts in acute transformation 4 to 72 months after onset IM; and 5) 15 pts relapsing in CP of the disease, referred as secondary resistant (R2). The search for mutation was performed by sequencing the entire TET2 coding region (11 exons), the IDH1 and IDH2 exon 4 and the ASXL1 exon 12. Analysis of paired samples from CML diagnosis, time of IM response and, when available, CCR revealed: 1) 2 pts (2.2%) in acute transformation presenting 3 TET2 stop mutations not located within conserved region (del at A2079, substitution T4893A - both also been detected at diagnosis -, and del at C4851 which has not been detected at diagnosis, even by mutation-specific ASO-PCR); 2) no IDH1 and IDH2 mutation; and 3) 8 pts (8.7%) presenting ASXl1 stop mutations at diagnosis. Among them, 3 pts (two ins at G646 and one ins at V751) have reached MMR without detected mutations at this time; one R1 pt presenting ins at G646 had major cytogenetic response with 5% Ph+ cells but the mutation was not found at this time and the pt have progressed to MMR 9 months later; one pt with 23 bp del at R634 has evolved in acute transformation with detected mutation at this time; and 3 R2 pts presenting either 4 bp del at S895, del at R860 or 2 pb ins at A752 have lost CCR associated with lost of hematologic response in one case. In this later group of 3 pts, except for del at R860, all ASXL1 mutations were found in samples at time of relapse. We therefore conclude that, contrary to what has been reported in other myeloid malignancies, TET2, IDH1 and IDH2 are not commonly acquired in CML and may not represent a major genetic event in CML transformation. However, ASXL1 alteration seems to be an early event in CML leukemogenesis but does not seem to participate in the disease transformation. Disclosures: No relevant conflicts of interest to declare.

Description: Introduction Clinical studies clearly show that treatment with tyrosine-kinase inhibitors (TKI) greatly improve the prognosis of patients with CML. Detailed treatment recommendations have since been deduced from clinical trial results by the European LeukemiaNet (Blood 122:872-884). However, little is known about whether these achievements can also be transferred to routine health care. This work investigates if all CML patients are treated in agreement with current standards and wether they achieve outcomes at least as good as those in clinical trials. Methods The web-based registry aimed to collect all newly diagnosed adult patients with chronic phase Ph+ and/or BCR-ABL1+ CML in 20 countries or pre-specified regions covering ~ 92.5 million inhabitants. Overall 2904 patients were registered between 2008 and 2012. Cytogenetic and molecular responses were analyzed using cumulative incidences considering death and progression as competing risks. Survival was analyzed using Kaplan-Meier curves and log rank tests. Results 2342 patients were diagnosed in chronic phase and had follow-up data available. The median age was 55 years (range: 18 to 99 years) and 53% were male; 11% of the patients were at high risk of not achieving complete cytogenetic remission (CCyR) at 18 months according to the EUTOS score. According to the Euro score 10% of the patients were in the high risk group, 51% in the intermediate and 39% in the low risk group. 18% were included in clinical trials. Treatment data of 1701 patients were contributed from 15 countries (85% of 2042 patients registered in those countries). As a first-line therapy 80% of patients received imatinib 15% nilotinib, 3% dasatinib and 3% hydroxyurea (HU). Of the patients receiving nilotinib or dasatinib 56% had been enrolled into clinical trials. There were no significant differences between female and male patients regarding the first-line therapy. More than half of the patients who were treated with HU alone were aged 70 or older. Time to first CCyR is known for 62% of patients. Median time to first CCyR was 10 months; after 12 months 57% (95% CI 54%-60%) and after 18 months 76% (95% CI 74%-79%) had achieved CCyR. Time to first CCyR differed significantly regarding the EUTOS score. Median time to first CCyR was 9 months for the low and 13 months for the EUTOS high risk group (p 〈 0.0001). After 18 months 78% (95% CI 75%-80%) of patients in the low and 69% (95% CI 60%-76%) of patients in the high risk group had achieved CCyR. The patients' age did not have major influence on the time to first CCyR (p=0.8974, median time to first CCyR: 18 to 39 years: 9 months, 40-65 years: 9 months, older than 65 years: 11 months). Time to first major molecular remission (MMR) could be calculated for 54% of patients. Median time to first MMR was 15 months. Cumulative incidence of MMR after 12 months was 41% (95% CI 38%- 44%). The median observation time of living patients was 29 months. 187 patients died (8%). Probability of OS for all patients at 12, 24 and 30 months was 97% (95% CI 96% - 97%), 94% (95% CI 93% - 95%) and 92% (95% CI 90% - 93%), respectively. 108 patients progressed of whom 62 subsequently died, while 125 patients died without prior progression. Probability of PFS for all patients at 12, 24 and 30 months was 95% (95% CI 94% - 96%), 92% (95% CI 91% - 93%) and 90% (95% CI 88% - 91%), respectively. Of the 187 patients who died, 33% died after progression. 67% died without prior progression. The probability of progression and subsequent death was 1% (95% CI 1% - 2%) after 12 months and 2% (95% CI 2% - 3%) after 24 months. The probability of dying without prior progression was 2% (95% CI 2% - 96%) after 12 months and 4% (95% CI 3% - 5%) after 24 months. Discussion The EUTOS population based registry provides the first unselected sample of adult Ph+ and/or BCR/ABL1+ adult CML patients in Europe. It shows that in Europe the success reported from commercial and academic studies is transferred to the general population. The majority of patients were treated first-line with imatinib, which was the only TKI approved for first-line use by the EMA during most of the registration period. Probabilities of PFS and OS in the registry are comparable to those in clinical trials. The importance of calculating both overall survival and leukemia-related survival is highlighted, since many patients die from different causes related or unrelated to leukemia and to treatment, but without progression. Disclosures Hoffmann: Novartis Oncology Europe: Research Funding. Baccarani:PFIZER: Honoraria, Membership on an entity's Board of Directors or advisory committees, Speakers Bureau; Bristol-Myers Squibb: Honoraria, Membership on an entity's Board of Directors or advisory committees, Speakers Bureau; ARIAD Pharmaceuticals, Inc.: Honoraria, Membership on an entity's Board of Directors or advisory committees, Speakers Bureau; NOVARTIS: Honoraria, Membership on an entity's Board of Directors or advisory committees, Speakers Bureau. Hasford:Novartis: Research Funding. Lindoerfer:Novartis Oncology Europe: Research Funding. Burgstaller:Novartis: Honoraria; Mundipharma: Honoraria; Celgene: Consultancy, Honoraria, Research Funding; AOP Orphan Pharmaceuticals: Honoraria, Research Funding. Mayer:Novartis: Consultancy, Other: funding of travel, accomodations or expenses, Research Funding; BMS: Consultancy, Other: funding of travel, accomodations or expenses, Research Funding. Koskenvesa:GSK: Consultancy; Pfizer: Consultancy; Ariad: Other: funding of travel, accomodations or expenses; BMS: Consultancy, Other: funding of travel, accomodations or expenses; Novartis: Consultancy, Research Funding. Castagnetti:Novartis: Consultancy, Honoraria; BMS: Consultancy, Honoraria; Pfizer: Consultancy, Honoraria; ARIAD: Consultancy, Honoraria. Griskevicius:Novartis: Consultancy, Research Funding; Baxalta: Research Funding. Sacha:Angelini: Consultancy; Adamed: Consultancy; Novartis: Consultancy; BMS: Consultancy. Hellmann:Novartis: Consultancy, Other: funding of travel, accomodations or expenses, Research Funding, Speakers Bureau; BMS: Consultancy, Other: funding of travel, accomodations or expenses, Speakers Bureau. Turkina:Pfizer: Consultancy; Bristol Myers Squibb: Consultancy; Novartis Pharma: Consultancy. Zaritskey:University of Heidelberg: Research Funding; Novartis: Consultancy. Sninska:Novartis: Consultancy. Simonsson:Novartis Pharma: Research Funding. Saussele:Novartis Pharma: Honoraria, Other: Travel grant, Research Funding; ARIAD: Honoraria; Pfizer: Honoraria, Other: Travel grant; BMS: Honoraria, Other: Travel grant, Research Funding. Hochhaus:ARIAD: Honoraria, Research Funding; Pfizer: Honoraria, Research Funding; Bristol-Myers Squibb: Honoraria, Research Funding; Novartis: Honoraria, Research Funding. Hehlmann:BMS: Consultancy; Novartis Pharma: Research Funding.

Description: Abstract 1974 Background: Conventional therapeutic guidelines in essential thrombocytemia (ET) are based on established criteria of higher incidence of vascular complications: age more than 60 years, history of thrombosis, platelets more than 1000–1500 ×109/L and cardio-vascular risk factors. Hydroxyurea or anagrelide are the most commonly used cytoreductive therapy for high risk ET. Despite a proven activity of Interferon-alpha (IFN-α) in Ph negative myeloproliferative disorders, generalized use and efficacy have been hampered by frequent side effects. Nonetheless it is still a nonleukemogenic therapeutic option for younger patients and during pregnancy. More recently, phase II trials using Pegylated (Peg-) forms of IFN-α in patients with polycythemia vera (PV) or high risk ET have provided interesting results: first the superior toxicity profile is generally associated with a rapid hematologic response Second the molecular response described for a subset of JAK2 V617F positive PV or ET patients treated with Peg-IFN α-2a have indicated a selective targeting of the malignant clone with that latter agent. Methods: We revised cases of high risk ET having being or currently treated with IFN-α and reported by centres of the French Intergroup of myeloproliferative disorders (FIM). The current retrospective analysis was performed on data collected for the first 67 patients (pts) that have been observed for a median of 72 months (range 11–273). Among them, 59 pts have received Peg-IFNα-2a therapy. Assessment of the hematologic responses was performed at months 1, 2, 3 and then every 6 months. Results: For the entire cohort, median age was 37 years (range 17–64) and sex ratio F/M of 2.33. Previous thrombosis was observed in 19 cases and micro vascular disturbance in 4 pts. At diagnosis, median platelets count was 926.0×109/L (range 428.0; 4000.0), haemoglobin 14g/dl (8.0-14.1), leucocytes count 9.7×109/L (2.7-28.0). Detection of the Jak2V617F mutation was positive in 33 cases and negative for 26 pts. Median time from diagnosis to IFN-α was 50 months (1-256 months). IFN-α was generally administered as second line after Hydroxyurea. No prior therapy has been used for 6 pts. Reasons for IFN-α initiation were absence of hematologic response (31%), toxicity to the prior treatment (14%), pregnancy (16%), or medical decision for younger pts (39%). Of 67 pts of the cohort, 59 pts have been treated with Peg-IFNα-2a with a median duration of Peg-IFNα-2a of 16 months (range 1 day to 45 months). Efficacy and safety of the Peg-IFNα-2a were assessed in that subgroup. Thus 58 pts were evaluable for the hematologic response with at least 1 month exposure to Peg-IFNα2a. Overall, absence of response was observed in 4/58 (7%) pts, partial hematologic responses in 9/58 (16%) and complete hematologic response (CHR) was achieved for 45/58 (76%) of patients according to the European LeukemiaNet criteria. Cumulative incidence of CHR at 1, 3, and 6 months was 29%, 52% and 65% respectively. At 18 months, estimated probability of CHR was 83% (95%CI 71–92). At the last follow up 47/58 (81%) of the pts were still treated with Peg-IFNα-2a and overall 36 pts are in CHR. Median time to achieve CHR was 3 months. Median dose of Peg-IFNα-2a was 88μg weekly (range 28–180μg weekly). Reasons for discontinuation of Peg-IFNα2a (11pts) were related non hematologic toxicity in 7/59 pts (12%), 1 failure, and 3 pregnancies. By analysing the response according to the Jak2 status (58 pts), the overall CHR rates were 31 and 14 for the 37 JAK2 V617F mutated and the 21 JAK2 negative pts respectively. The median time to achieve CHR was 6 and 3 months. At 18 months the estimated CHR rates were 87% (73-95) and 66% (45-86). The difference is not statistically significant. Median doses of Peg-IFNα2a were 90μg (12-180) and 75μg (45-144) weekly. Duration of exposure to Peg-IFNα2a was 16 months (1-36) and 15 months (1-45). Conclusion: This retrospective analysis is the first attempt to present results on efficacy and tolerance of Peg-IFN on a large cohort of high risk ET not included in clinical trials. These results support the use of Peg-IFN in HR ET pts. Increase patients number, molecular analysis and update of these preliminary data will be presented. Disclosures: Off Label Use: Interferon alpha and Pegylated-Interferon alpha for myeloproliferative disorders.

Description: Aims: To determine in children and adolescents with chronic myeloid leukemia (CML) in chronic phase (CP) treated with imatinib front line, (i) the probability of switch to a second line therapy, (ii) to characterize the reasons and the type of switch and (iii) to determine the impact of the switch on outcome. Methods: Children and adolescents (

Description: Abstract 2465 Background This study was designed to identify single nucleotide polymorphisms (SNPs) associated with probability of achieving a major molecular response (MMR) in chronic phase CML patients (pts) treated with imatinib. We used a non-commercial, pharmacogenetics-dedicated DNA chip containing 16561 SNPs covering 1916 candidate genes. We tested an exploratory cohort of pts treated with imatinib first line or after interferon therapy and then extended our finding in a validation set of pts included in the French SPIRIT trial (C Preudhomme, NEJM 2011) and randomized to the 400 mg or the 600 mg imatinib arm. Patients and methods Constitutive DNA samples from 312 pts were analyzed: samples from 91 pts in the exploratory set and 221 pts in the validation set (SPIRIT trial: 120 pts within the 400 mg imatinib arm and 101 pts within the 600 mg imatinib arm). We analyzed the expression of BCR-ABL/ABL standardized ratio as a function of the time elapsed since imatinib initiation for each patient using nonlinear (spline) interpolation and then derived the delay to achieve MMR or time of follow-up. With this method, we obtained a cumulative incidence curve of MMR in both groups. Relevant SNPs were identified using a COX model adjusted for covariates (sex, two first principal components and Sokal score when available). SNP with FDR (False Discovery Rate) below 30% in the exploratory cohort where subsequently investigate in the SPIRIT trial groups. Results Patient characteristics such as age, sex, Sokal score were homogeneous between exploratory and validations sets as well as within both arms of the SPIRIT trial. We confirmed the prognostic value of the Sokal score in term of cumulative incidence of MMR (CI-MMR) in both sets of pts (CI-MMR was 83%, 67% and 56% for low, intermediate and hight Sokal risk groups respectively, additive log rank, p 〈 0.001), as well as the significant improvement of CI-MMR within the SPIRIT trial for pts assigned to the 600 mg daily imatinib arm as compared to the 400 mg daily arm (CI-MMR was 80% in the 600 mg imatinib arm compared to 61% in 400 mg/day arm, log rank, p = 0.008). CI-MMR was similar between exploratory set and the 400 mg/day arm of the SPIRIT trial (63% vs 61%, log rank, p = 0.56) and higher in the 600 mg arm of the SPIRIT trial compared to the exploratory set: 80% vs 63% (log rank, p 〈 0.001), consistent with dose received in the exploratory set (imatinib 400 mg/d). Association study shows that 10 SNPs identified pts with significantly different probability to achieve MMR within the two first year of therapy (FDR less than 30% p 〈 0,01) in the exploratory cohort three of which belong to ABCG2 gene. In the SPIRIT trial (n=221), only two SNPs from ABCG2 locus were significantly associated with a higher probability of achieving MMR. We then analyzed separately both arms of the SPIRIT trial. All tree ABCG2-SNPs identified in the exploratory set of pts were significantly associated with CI-MMR in the 400 arm at the 5% level. In contrast, none of them were confirmed in the 600 mg arm. In order generalize our results and to get closer to the underling molecular structure of genotypes markers we performed haplotyping at locus of ABCG2 gene. Multivariate analysis distinguished two minor haplotypes (haplotype 1 and 3) linked to MMR achievement in pts receiving 400 mg/day of imatinib (from exploratory set and SPIRIT, n=211). Haplotypes 1 had G-C-G and haplotype 2 had G-T-G at rs12505410, rs13120400 and rs2725252 respectively and their frequencies were 26 and 6% respectively. Collapsing these haplotypes yielded a surrogate dominant marker highly associated to CI-MMR in this group (p 〈 0.001, figure 1A) whereas in the SPIRIT 600 mg arm, this phenomenon did not hold anymore (p=0.25, figure 1B). Interestingly, CI-MMR in the 400 mg/day harboring a copy of minor haplotypes (1 or 3) was comparable to the CI-MMR observed in pts receiving 600 mg/d imatinib lacking of at least one copy of the two minor haplotypes (75% vs 70% respectively, p=0.99) or whatever haplotype they had (75% vs 80%, p=0.37). Conclusion The ABCG2 gene product is a well-known protein involved in drug absorption in the bowel. Polymorphism of the ABCG2 gene has been implicated in drugs absorption including imatinib. We here confirm that ABCG2 haplotypes could distinguish patients at a lower probability to achieve MMR. We report for the first time that this unfavorable pharmacologic effect can be overcome in vivo by increasing imatinib daily dose from 400 mg to 600 mg. Disclosures: Rousselot: BMS, Novartis: Research Funding. Guilhot:ARIAD: Honoraria.

Description: Introduction: Philadelphia-positive chronic myelogenous leukemia (CML) is a rare disease in children and constitutes approximately 3-5% of all childhood leukemias. With tyrosine kinase inhibitors (TKI), the frequency of accelerated phase (AP) or blast crisis (BC) is remarkably reduced, estimated to 1% to 1.5% per year in adults compared with more than 20% per year in the pre-TKI era. But no data are available among children. Purpose: We described the characteristics, the treatment and the outcome of 21 children with CML, who evolved in accelerated phase and/or blast crisis under TKI. Results: From 2001 to april 2015, 415 European patients were enrolled in the CML pediatric database. Twenty-one patients (5.1%), in chronic phase (CP) treated by TKI, presented AP or BC. The median age of AP/BC cohort was 13.2 years (range: 4.5-16.9 years) with a sex ratio M/F at 2. At CML diagnosis, 15 patients (71%) had high risk Sokal Score with a median score of 1,4 (range: 0,16-2,4). All patients harbored t(9;22)(q34;q11) but one had a complex translocation t(1;9;22)(q12;q34;q11) and another one presented additional inv(3)(q21q26). Imatinib was the first line TKI for all patients. Before AP or BC, only five patients (24%) obtained a complete cytogenetic response (CCyR) and three achieved MMR. For incomplete molecular response or progression to accelerated phase, 8 patients (38%) were switched to dasatinib. Median duration of TKI before AP or BC was 11 months (range: 3 months-56.5 months). Six patients evolved to AP with a median interval of 8.7 months (range: 1 months-24 months), leading to blast crisis for 4 patients with a median time of 3.5 months (range: 0.3-5.4 months). Among the 2 patients remaining in AP, imatinib was increased for one and the other was switched for dasatinib, all before hematopoietic stem cells transplantation (HSCT). One patient died of post-transplant complication and the other one is still alive in complete molecular response without TKI. Nineteen patients presented BC, including 4 after AP. Thirteen patients (62%) presented ALL, five (24%) AML and one a bi phenotypic leukemia. Central nervous system (CNS) was involved for two patients with ALL, one isolated, one combined. At AP or BC, nine patients (43%) presented new additional cytogenetic abnormalities. Eighteen patients with BC were treated according to AML or ALL protocols, combined with second generation TKI for twelve patients. Only one patient underwent preparative regimen, without intensive chemotherapy before HSCT. Ten patients reached complete remission. Four patients died before HSCT, by progressive disease for 2 and by fatal infection for 2. Overall, 15 patients in BC were transplanted. Before HSCT, median molecular response was 0.2% (range: 0-29%) and only four patients had a complete molecular response. After transplant, seven patients received second generation TKI. Four patients died, including three related to transplant toxicity. Thirteen patients were alive, but one with ALL BC relapsed 26 months post-transplant and was waiting for second HSCT. With a median follow-up of 4.4 years, 4-year overall survival was 59% (66% for ALL BC versus 40% for AML BC). Conclusion: Incidence of AP/BC after imatinib for CP CML is at 5%, in the CML pediatric database. Despite second generation TKI, combined with HSCT, outcome remains poor. Post-transplant indication of TKI is heterogenic. Recommendations would be useful for practice. Figure 1. Figure 1. Disclosures Suttorp: Novartis, Bristol Meyer Squib: Honoraria, Membership on an entity's Board of Directors or advisory committees, Research Funding.

Description: Increased angiogenesis in bone marrow (BM) is one of the characteristics of chronic myeloid leukemia (CML), a clonal myeloproliferative disorder which expresses a chimeric Bcr/Abl protein. The therapeutic strategy in CML has been totally modified with the development of Imatinib Mesylate (STI571), a specific inhibitor of Bcr/Abl tyrosine kinase activity. Previously, we studied the effect of Imatinib on the Vascular Endothelial Growth Factor (VEGF), one of the most potent regulators of angiogenesis (1). Thus, we demonstrated, for the first time, the decrease in VEGF production in CML patients treated with Imatinib. It pointed out the potential prognostic value of determining the VEGF plasma level of patients in order to follow the evolution of this hematologic malignancy. Actually, we showed that low plasma VEGF levels could be one of the characteristics of complete cytogenetic remission. However, investigations with a larger number of patients were necessary to evaluate the potential of VEGF levels in the monitoring of CML patients treated with Imatinib. So, we analyzed VEGF plasma level in patients treated in the SPIRIT, the CML French Group phase III, multicenter, open-label, prospective trial. Patients are randomized between the 3 experimental arms [IM 400mg daily in combination with Peg-IFN-α2a (Peg-IFNα2a, 90 μg weekly) or with Ara-C (20 mg/m2/day, days 15–28 of 28-day cycles) or IM 600mg daily] and the reference arm, IM 400mg daily. The Endpoint are overall survival (primary), rate and duration of hematologic, cytogenetic and molecular responses and tolerability. This VEGF evaluation is based on a cohort of 110 pts [median age 51 yrs (19–81); Sokal distribution : 30% of pts low, 37% intermediate, and 33% high]. Males predominated (62%) and percentage of patients enrolled in IM 400mg, IM 600mg, IM 400 with Ara-C and IM 400mg with Peg-IFN arm is respectively 28%, 28%, 24% and 30%. At diagnosis, the median of VEGF plasma level is 945 pg/ml (range: 42.3–4001.5). After 3 months of treatment, the median of VEGF level decreases significantly (p

Description: In September 2003, the French CML study group (Fi-LMC) activated the four armed randomized SPIRIT trial comparing imatinib 400mg with imatinib 600mg, imatinib 400mg + ara-C and imatinib 400mg + pegylated interferon in newly diagnosed CML in chronic phase. The molecular monitoring was centralized and performed, according to the EAC protocol, in duplicate on the same BCR-ABL cDNA among two French laboratories (Bordeaux and Lille). Data were expressed as BCR-ABL/ABLx100 on the new internationally agreed scale (IS) using a conversion factor of 1.33 and 0.80 for Bordeaux and Lille respectively. A good correlation between the two laboratories was observed. During the first year of follow-up the quantification was performed each three months (M0 to M12). In May 2006, 297 of the 492 enrolled pts had a follow up of more than 12 months, and 263 pts were analysed at M12. Using the IS, the median values of the BCR-ABL/ABL normalized ratios were 90%, 6,4%, 0.68%, 0.32% and 0.16% at M0, M3, M6, M9, and M12 respectively. At M12, 15%, 29%, 27%, 17% and 12% of the pts presented a BCR-ABL/ABL ratio lower than 0.01%, 0.1% ,1%, 10%, and 100% respectively. Overall, 71% of the pts presented a ratio lower than 1%. Conventional cytogenetic data were available for 193 pts at M12: 156 pts (80%) were in complete cytogenetic response (CCR), 25 pts (13%) were in major cytogenetic response (MCR) and 12 pts (6.2%) were in minor or a lack of cytogenetic response. Among pts with a BCR-ABL transcript ratio lower than 1%, all except four were in CCR. The last 4 cases were in MCR associated with BCR-ABL ratios of: 0.96% for one pt, 0.08% and 0.12% for 2 pts (who further reached CCR at 6 and 18 months) and 0.128% for the last one. Percentages of Philadelphia positive metaphase (Ph+) were 4%, 6%, 5 % and 15% respectively. Among the 30 pts with a BCR-ABL ratio 〉 5%, none were in CCR and only 18 pts were in MCR. Among the 27 pts presenting a BCR-ABL ratio in the 1%–5% intervals, 20 pts were in CCR and 7 pts were in MCR (5 pts with Ph+ lower than 10% and two pts with 16% and 20% Ph+). In conclusion, our findings suggest that a ROC statistical test will be able to determine critical BCR-ABL/ABL ratios associated to CCR in our study. Nevertheless, at M12 the percentage of available data was superior using molecular than cytogenetic monitoring, suggesting that molecular monitoring expressed with the new international scale is probably sufficient fore more than 85 % of the pts treated by IM solely or in association.

Description: Background: Combination of Pegylated-Interferon alpha (Peg-IFNa) 2a and imatinib (IM) has been reported to significantly induce higher rates of molecular responses (including undetectable BCR-ABL transcript) over IM alone, as frontline therapy for CP-CML patients (pts) in a randomized phase 3 trial (SPIRIT, Preudhomme et al, NEJM 2010). Second generation TKIs such as dasatinib (DASISION, Kantarjian et al, NEJM 2010) enhance the speed and depth of molecular response (MR) in comparison to IM. Phase II trial using nilotinib and PegIFNa2a has recently reported high rates of deep molecular response (MR4.5) within 24 months (Nicolini FE et al, Lancet Haematology 2015). Aims: To determine the efficacy and safety of the combination of dasatinib and Peg-IFNa2b in CP-CML frontline. (EUDRACT Number: 2012-003389-42, Dasa-PegIFN trial). Methods: Newly diagnosed Ph+ CP-CML pts less than 65-year-old started dasatinib 100 mg/day. At 3 months, they were assigned to receive Peg-IFNa2b associated to dasatinib when platelets (plt) 〉 100 X 109/L, Neutrophils (ANC) 〉 1.5 X 109/L) and lymphocytes 〈 4.0 X 109/L counts were achieved. Otherwise, dasatinib was continued alone in the study according to the current international ELN guidelines. The maximum duration of the combination dasatinib and Peg-IFNa2b is 21 months. The primary endpoint is the cumulative rate of Molecular Response 4.5log (MR4.5 defined as BCR-ABL1/ABL1IS≤0.0032%) at 12 months. Molecular analyses were centralized and expressed according to the international scale (IS). Secondary endpoints included efficacy (cytogenetic and molecular responses at several time-points) and safety endpoints. Preliminary results are reported here. Results: 81 pts were enrolled between October 2013 and July 2014. All pts will have completed the 12 months follow-up time-point in August 2015. 79/81pts were included in the analysis (1 pt died of a CML-related haemorrhage before receiving dasatinib, 1 screening failure (masked Ph)). Median age was 48 (20-65) years. 54% of pts were male. Sokal scores were low, intermediate and high in 51%, 32% and 17% of pts respectively. After the first 3 months of therapy (M3), sixty-one patients (77%) started Peg-IFNa2b at the dose of 30 microg/week in association with dasatinib. For these pts after M3, reported hematologic adverse events (AE) were neutropenia (G3/4 n=11; G1/2 n=17), thrombocytopenia (G3/4 n=0; G1/2 n=7), anemia (G3/4 n=0; G1/2 n=7). Extra-hematologic AE were essentially of low grade (overall, G3/4 n=3; G1/2 n=113). According to NCI CTCAE V4.0, most frequent AE were infections (16%), general symptoms (15%), skin lesions (10%), hepato-biliary abnormalities (7.7%), nervous system/headache (7.7%) musculoskeletal pain (7%), psychiatric (7%), GI (6%) disorders. Eight serious AE (SAE) were reported after Peg-IFNa2b initiation: G4 neutropenia n=2, dysthyroitidis n=1, dyspnea n=1, pleural effusion n=1, lymphoid hyperplasia n=1, hemorrhoids n=1, rectal fistula (SUSAR) n=1. Efficacy was analysed according to the intention-to-treat principle (ITT), and considering missing data as no response to avoid inflated results. Overall at M3, 85% of pts had a BCR-ABL1/ABL1 ratio ≤10%. For eligible patients who received combined therapy (n=61), rates of MMR were 16%, 51%, 70%, and 70% (pending n=5) at M3, M6, M9 and M12, including MR4.5 rates 10%, 20%, 30% at M6, M9 and M12 respectively. Eighteen pts (22.7%) were not eligible to receive Peg-IFNa2b. Reasons, according to protocol criteria, were ANC