scholarly journals Childhood Hyperdiploid Acute Lymphoblastic Leukemia

Blood ◽  
2015 ◽  
Vol 126 (23) ◽  
pp. 4990-4990
Author(s):  
Marketa Zaliova ◽  
Martina Vaskova ◽  
Lenka Hovorkova ◽  
Ondrej Hrusak ◽  
Jan Stary ◽  
...  
Keyword(s):  
Flow Cytometry ◽  
High Risk ◽  
Risk Stratification ◽  
Snp Array ◽  
Good Prognosis ◽  
Leukemic Cells ◽  
Dna Index ◽  
Childhood All ◽  
Favorable Prognosis ◽  
Risk Treatment

Abstract Background: Acute lymphoblastic leukemias (ALL) with 51-67 chromosomes in leukemic cells are defined as high-hyperdiploid (HHD). In childhood, these leukemias comprise 25-30% of all cases, typically arise from B lymphocyte precursors and are generally associated with good prognosis. Besides the number of chromosomes, the hyperdiploid ALLs can be determined also by DNA index (established by flow cytometry), representing ratio of DNA content in leukemic vs. normal diploid cell. Cases with DNA index >=1.16 and <1.6 are often considered as "typical" high hyperdiploid ALLs. Leukemias with >50 chromosomes and DNA index <1.16 are only rarely studied separately and here we assign these cases as "low DNA index HHD" (LDI-HHD). Favorable prognosis is associated mainly with the "high DNA index HHD" (HDI-HHD) cases (DNA index >= 1.16) and, according to some studies, particularly with cases characterized by "triple-trisomy", i.e. concurrent gain of chromosomes 4, 10 and 17. However, as the triple-trisomy significantly overlaps with HDI-HHD, it is not clear whether the favorable prognosis is driven rather by the triple-trisomy itself or by the higher ploidy of these patients (with most cases having DNA index >= 1.16). In this study we aimed to analyze biological and clinical features of HHD leukemias, compare LDI-HHD and HDI-HHD cases and verify prognostic role of triple-trisomy of chromosomes 4, 10 and 17. Patients and methods: We tested 75 patients with hyperdiploid childhood ALL defined by the presence of 51-67 chromosomes (46 HDI-HHD, 29 LDI-HHD). To determine the type of hyperdiploidy we used flow cytometry (DNA index) and whole genome single nucleotide polymorphism (SNP) array. SNP array also enabled precise determination of amplified chromosomes as well as partial gains and losses and calculation of a SNP array-based "theoretical" DNA index. From clinical features we analyzed final risk stratification of patients (based in this subgroup on early treatment response measured at day +8 by morphology ("prednisone response"), at day +15 by flow cytometry and at day +33 and week +12 by PCR quantification of immunoglobulin a T-cell receptor rearrangements) and their outcome. Results: Our data show that correlation of DNA content in leukemic cells determined by flow cytometry and by SNP-array is very high (Spearman correlation: rho = 0.96; p-value < 2,2e-16). Besides the HHD patients we analyzed DNA index and SNP array in 53 non-high hyperdiploid patients (<=50 chromosomes); all the non-HHD cases had DNA index <1.1. In HHD patients we found negative correlation between DNA index and final risk stratification (decrease of DNA index with increasing risk (standard - medium - high), p=0.004). As expected, patients with triple-trisomy have higher DNA index and number of chromosomes (p<0.0001); however, 4/38 were found among the LDI-HHD patients. None of the triple-trisomy patients was stratified into the high-risk treatment, while in patients without the triple-trisomy the distribution of high risk vs. non-high risk therapy was 13 vs. 24 (p<0.0001) with 10/25 (40%) HR cases among LDI-HHD and 3/12 (25%) HR cases among HDI-HHD patients. Patients with triple-trisomy have better very early response to treatment measured at day +15 (p=0.009) and this difference remains significant also when only patients with HDI-HHD are analyzed separately (p=0.014). There is no significant difference in event free survival analysis as overall outcome of this group is very good - only 4 events emerged within the whole cohort so far (1 secondary AML in patient with triple-trisomy and one relapse and two deaths in 3 patients without triple-trisomy, one of those from the LDI-HHD group). Conclusion: High hyperdiploidy can be determined by karyotype, SNP array and also by flow cytometry, where cases with DNA index > 1.1 are highly likely to carry > 50 chromosomes. Patients with high hyperdiploidy over 50 chromosomes form a subgroup of childhood ALL with a generally very good prognosis. However, some heterogeneity within this group is present. Our data suggest that patients with LDI-HHD are more often stratified into high risk treatment. On the other hand, patients with triple-trisomy of chromosomes 4, 10 and 17 are characterized by a rapid response to initial therapy, which is not just a result of coexisting HDI-HHD status. Supported by grant IGA MZ NT14350/3. Disclosures No relevant conflicts of interest to declare.

Childhood ALL Treatment and Protocol Compliance Failure at a Single Institute from Most Developed Area of China.

Blood ◽  
2004 ◽  
Vol 104 (11) ◽  
pp. 4487-4487
Author(s):  
JingYan Tang ◽  
HuiLiang Xue ◽  
Long-Jun Gu ◽  
Jing Chen ◽  
Ci Pan ◽  
...  
Keyword(s):  
Risk Factor ◽  
High Risk ◽  
Treatment Failure ◽  
Developing Country ◽  
Early Response ◽  
Low Risk ◽  
Dna Index ◽  
Childhood All ◽  
Total Treatment ◽  
Protocol Compliance

Abstract Purpose To analyze the main reason of failure in children with ALL at a single institute which is at most developed city of developing country China. Method All the ALL patients who was diagnosed at our hospital from 1998.10 to 2003.12 were analyzed. The date was created from our department tumor registry database. Patient was divided into 3 groups, high, middle and low risk, depends on 1.Age >=10 year, 2. 50×109/L>WBC<100×109/L, 3. chromosome<45,or DNA index <1.16, 4. t(4;11), 5. T-ALL, 6.CNSL and/or TL, 7. WBC>=100×109/L, 8.t(9;22), 9.<1 year or >12 year, 10. Early response (1) Pred.test day 8,pripherial blast >=1,000/μl, (2) Induction day19–21 or day 35 bone marrow blast >=5%. Anyone from item 1 to 5 was middle risk factor, item 6 to 9 was high risk factor. The patients not receiving any therapy after ALL diagnosis were accounted as early protocol compliance failure, receiving therapy less than 15 days were middle protocol compliance failure, giving up therapy or losing follow-up after 15 day with stable disease or CR were accounted as late compliance failure. Results Total 224 ALL were diagnosed, of them 38 patients went home with no any therapy. That means early protocol compliance failure was 17%. Of the remained 186 patients, 26 patients(12%) belonged to middle protocol compliance failure and 6 (3%) was late compliance failure. So total protocol compliance failure was 31%. The main reason of compliance failure was lacking financial support. Within the 160 patients who received more than 15 days therapy, 50(31%) was high risk, 51(32%) middle risk, and 52(33%) low risk, another 7 at un-know risk group. Of them, 48 patients relapsed(40) or not reached CR(8), 10 died of complication(mainly infection), total treatment failure was 48(30%). Conclusion Besides the treatment failure, protocol compliance failure is a important reason for childhood ALL survival failure in developing country.

EBF1-PDGFRΒ Fusion in Paediatric Acute Lymphoblastic Leukaemia (ALL): Genetic Profile and Clinical Implications

Blood ◽  
2014 ◽  
Vol 124 (21) ◽  
pp. 1068-1068
Author(s):  
Claire Schwab ◽  
Rebecca Andrews ◽  
Lucy Chilton ◽  
Alannah Elliott ◽  
Gerald Keil ◽  
...  
Keyword(s):  
High Risk ◽  
Tyrosine Kinase ◽  
Chemotherapy Regimen ◽  
Snp Array ◽  
Intensive Chemotherapy ◽  
Chromosome 5 ◽  
Standard Chemotherapy ◽  
Childhood All ◽  
The Third ◽  
Failed Induction

Abstract Incorporating cytogenetics into risk stratification for the treatment of childhood ALL has contributed to increased survival rates. However 25% patients, the B-other subgroup, do not have any of the known major chromosomal abnormalities. Within this group, BCR-ABL1-like cases show a similar gene expression profile to those with BCR-ABL1 fusion and share the same high risk of relapse. BCR-ABL1-like cases are genetically heterogeneous and some harbour tyrosine kinase activating gene fusions e.g. EBF1-PDGFRB. Recent reports suggest patients with EBF1-PDGFRB ALL who are refractory to conventional therapy respond to the tyrosine kinase inhibitor (TKI), imatinib. Here we present 14 patients treated on ALL97 (n=3), UKALL2003 (n=10) or UKALL2011 (n=1) who were EBF1-PDGFRB positive including 1 patient treated with imatinib. Involvement of PDGFRB and EBF1 was confirmed using dual colour break-apart probes (normal signal pattern=0R0G2F). Eleven patients showed signal patterns (1R0G1F) consistent with a deletion of 5q33 having breakpoints within EBF1 and PDGFRB, as seen in previously reported cases of the fusion. The presence of the deletion was confirmed by single nucleotide polymorphism (SNP) array in 6 cases. Three cases showed signal patterns (1R1G1F) consistent with a balanced rearrangement resulting in the EBF1-PDGFRB fusion and a balanced t(5;5)(q33.1;q33.3) was seen in one of these cases. SNP array analysis for 2 of these cases showed no copy number abnormalities of chromosome 5. However, in the third case a series of deletions were seen along the long arm of chromosome 5, indicating that the EBF1-PDGFRB fusion was generated by a complex rearrangement such as chromothripsis. Multiplex Ligation-dependent Probe Amplification (MLPA) using the P335 IKZF1 kit (MRC Holland) was carried out in 11 cases. Deletions of the probe for exon 16 of EBF1 were seen in all cases with the 5q33 deletion. Loss of PAX5 was detected in 4 patients, while IKZF1 and CDKN2A/B were deleted in 3 cases each. Among the 14 patients there was a predominance of females (n=10). The median age was 12 years with 9 patients >10 years at diagnosis. The median white cell count (WCC) was 34.4 x109/L with 5 patients presenting with a WCC of >50×109/L. Two of 3 patients treated on ALL97 remain alive (one after relapse); both patients received regimen C and a transplant. The third patient, who was not treated as high risk, relapsed and died within 5 years. An unselected cohort of 276 B-other UKALL2003 patients revealed 8 (3%) cases of EBF1-PDGFRB (~0.6% of BCP-ALL). All 8 patients achieved CR but were MRD positive at day 29. Overall 4 patients relapsed, including 2/3 patients who received standard chemotherapy (regimen A/B) and 2/5 patients who received high risk chemotherapy (regimen C). Three relapsed patients were salvaged and remain in second CR 1-7 years post relapse. Targeted screening of 13 UKALL2003 patients who failed induction revealed 2 more patients with EBF1-PDGFRB; one subsequently died while the second remains in 1st CR 7 years later. None of the UKALL2003 or ALL97 EBF1-PDGFRB patients received TKI therapy. As a result of these findings, patients entered on UKALL2011 are screened for EBF1-PDGFRB fusion if they fail to achieve CR by day 29 or remain MRD positive (>0.5%) at week 14. A 5 year old girl who failed induction (50% blasts at day 35) tested positive for EBF1-PDGFRB. This prompted her withdrawal from UKALL2011 and she was treated according to EsPhALL with standard BFM consolidation plus imatinib (300mg/m2) followed by 3 intensive BFM HR blocks. After 4 weeks consolidation therapy her MRD levels had fallen to 6% and she was MRD negative by flow cytometry after 8 weeks. She continues in molecular remission 2 months after a transplant. In this largest cohort of EBF1-PDGFRB patients reported to date, we demonstrate the genetic mechanisms by which the fusion occurs and the spectrum of cooperating mutations. EBF1-PDGFRB fusion is associated with female sex, older age and a mixed outcome. Although these patients had high levels of MRD and a high relapse rate there was also evidence of durable remissions; especially with intensive chemotherapy. Evidence from this study and others suggest patients with this abnormality who fail standard chemotherapy may respond to imatinib. It is possible that treatment with imatinib might avoid the need for intensive chemotherapy to achieve a cure in these patients but that would need to be tested within a prospective trial. Disclosures No relevant conflicts of interest to declare.

scholarly journals Towards CD177 As a Predictive Biomarker for Hypomethylating Agent Response in Myelodysplastic Syndrome

Blood ◽  
2021 ◽  
Vol 138 (Supplement 1) ◽  
pp. 4665-4665
Author(s):  
James Ignatz-Hoover ◽  
Pingfu Fu ◽  
Shufen Cao ◽  
Benjamin Tomlinson ◽  
Howard Meyerson
Keyword(s):  
Bone Marrow ◽  
Flow Cytometry ◽  
High Risk ◽  
Risk Stratification ◽  
Myelodysplastic Syndrome ◽  
Treatment Response ◽  
Myelodysplastic Syndromes ◽  
Bone Marrow Biopsies ◽  
Wide Range ◽  
Very High

Abstract Background Myelodysplastic syndrome (MDS) represents a heterogenous spectrum of pre-leukemic conditions with a wide range of outcomes. Higher risk MDS as classified by the revised international prognostic scoring system (IPSS-R) score is associated with poor overall survival and up to 30% of patients progressing to acute myeloid leukemia. Hypomethylating agents (HMA) such as azacitadine can improve cytopenias and delay progression to leukemia in about 30% of patients, but these agents may take months to promote response and initially exacerbate cytopenias. Thus treatment related biomarkers that help predict eventual hematologic response are of interest. CD177 is expressed in neutrophils and plays a role in cellular adhesion. In healthy cells, it exhibits bimodal expression by flow cytometry that is stable over time within an individual. The percentage of CD177 positive neutrophils is often decreased in hematopoietic malignancies and myelodysplastic syndromes. Our group has demonstrated that CD177 has diagnostic utility in the identification of myelodysplastic syndromes. As transcription of CD177 is regulated by CpG methylation of its promotor, we hypothesized that treatment with HMAs may improve CD177 expression in clinical responders and potentially guide continuation of HMA therapy. Methods To interrogate the above, we performed a retrospective review of patients with a diagnosed with MDS or MDS/MPN overlap syndromes who received disease modifying therapy with HMA at our institution from 2015 to 2018. Inclusion criteria required documentation of serial bone marrow biopsies with aspirate flow cytometry analysis. CD177 positivity was determined by increase in mean florescence intensity compared to isotype controls. Data was analyzed with using cox multivariate and univariate analysis correlating to treatment response. Results Of the 237 patients, 27 patients met the above criteria. Their average age was 62 (21 to 77) at time of diagnosis with 20 men and 7 women. They exhibited a range of R-IPSS risk stratification with four very high risk, eight high risk, six intermediate risk, and four low risk. Five cases were MDS/MPN overlap. Patients received on average 10 months of HMA treatment with a wide range from 1 month to 42 months of treatment. Median baseline CD177 positivity was 16, 31, 28.5, and 72 percent respectively amongst R-IPSS groups. Of the 27 patients analyzed with repeat bone marrow biopsies, eight patients exhibited 20% or greater increase in CD177(+) neutrophils, ten exhibited a decrease in CD177(+) neutrophils of 20% or greater, and nine exhibited less than a 20% change in CD177(+) neutrophils. with similar distribution of R-IPSS risk stratification amongst groups. (CD177-decreased: 1 very high, 3 high, 1 intermediate, 2 low risk, CD177-stable 1 very high, 2 high, 2 intermediate, and 1 low, Improved-CD177 1 very high, 4 high, 2 intermediate and 1 low). Cox proportional hazard analysis suggests that patients exhibiting a decrease or stable CD177 were less likely to exhibit a treatment response with results trending to significance (OR= 0.13 p=0.099). Conclusion Our initial data suggests that change in CD177 may help predict HMA treatment response. More uniform prospective analysis is indicated to compared CD177 changes over initial treatment. Furthermore, CD177 in peripheral blood and bone marrow samples correlate excellently (R 2=0.95). Prospective studies are underway to correlate CD177 change and initial treatment response utilizing flow analysis of pre-treatment CBCs. Disclosures No relevant conflicts of interest to declare.

Identification of Post-Induction Minimal Residual Disease by Multidimensional Flow Cytometry Identifies Patients with AML at High Risk of Relapse and Poor Outcome- a Report From the Children's Oncology Group

Blood ◽  
2010 ◽  
Vol 116 (21) ◽  
pp. 1702-1702
Author(s):  
Soheil Meshinchi ◽  
Todd A. Alonzo ◽  
Robert B. Gerbing ◽  
Phoenix A. Ho ◽  
Alan S. Gamis ◽  
...  
Keyword(s):  
Flow Cytometry ◽  
High Risk ◽  
Minimal Residual Disease ◽  
Residual Disease ◽  
Patient Specific ◽  
Intermediate Risk ◽  
Oncology Group ◽  
Childhood All ◽  
Post Induction ◽  
Minimal Residual

Abstract Abstract 1702 Multidimensional flow cytometry (MDF) is used to identify risk in childhood ALL; however, its utility in AML has been limited. We used 4-color MDF with standard (rather than patient-specific) panels to evaluate diagnostic and postinduction bone marrow specimens from patients treated on Children's Oncology Group (COG) study AAML03P1 for evidence of minimal residual disease (MRD). A total of 254 patients submitted marrow specimens for MRD assessment at the end of induction I, the end of induction II, and the end of therapy. Of the 222 patients with evaluable specimens at the end of induction I, 191 (86%) were in morphologic remission, and 27 (12.2%) had persistence of morphologic disease, 3 had persistent CNS disease and 1 was not evaluable for response. Of those with morphologic disease, 15 were in partial remission (PR, 5%-20% blasts), and 12 had refractory disease (RD, >20% blasts). MDF of specimens showing morphologic disease revealed that 7 (26%) did not have evidence of disease; thus, MDF identified patients with reported morphologic disease who did not have immunophenotypic evidence of disease. Overall, in 222 patients with evaluable marrow at the end of induction I, 69 (31%) had evidence of various levels of MRD by MDF (% blast range, 0.02%-43%, median, 1.5%). For the 208 patients with known cytogenetic data, the presence of MRD was evaluated in the following cytogenetic subgroups: favorable risk, defined as t(8;21) or inv(16) (the Core Binding Factor leukemias); unfavorable risk, defined as –5/del(5q) or –7; and intermediate risk, defined as all other cytogenetic subtypes. MRD prevalence at the end of Induction I in patients with favorable, intermediate-risk, or high-risk cytogenetics was 13%, 36%, and 67%, respectively. Prevalence of MRD at the end of induction I was 50% (10/20) in patients with FLT3/ITD, 40% (4/10) in patients with CEBPA mutations, and 0% (0/5) in patients with NPM1 mutations. Of the 222 patients with evaluable specimens at the end of induction I, 191 had morphologic response to the initial chemotherapy. Of those, 57 (28%) had evidence of disease by MDF. Cumulative relapse risk (RR) and disease-free survival (DFS) was assessed in those with or without MRD. Those with MRD at the end of induction I had a RR at 3 years from the end of induction of 60% vs. 29% for those without MRD (p <0.001). DFS was 32% for those with MRD and 65% for those without MRD (p<0.001). In a multivariate analysis, which included cytogenetic and molecular risk factors, the presence of MRD was highly associated with outcome and was an independent predictor of relapse (p<0.001) and worse survival (p<0.001). We further evaluated the significance of clearance of residual disease. Of the 91 patients evaluated for MRD at the end of therapy, 7 (8%) were MRD-positive (6 of whom relapsed). Of the 84 patients who were MRD-negative, 22 (26%) had previously documented MRD. For those with a history of MRD, RR from the end of therapy was 64%, and for those without previous MRD, it was 25% (p<0.001). Therefore, despite clearance of MRD, patients with previous MRD had a high RR. Given the high correlation of MRD with RR, MDF assessment of post-induction response should be incorporated into AML clinical trials for risk identification and assignment to the appropriate risk-based therapy. Disclosures: No relevant conflicts of interest to declare.

Detection of Minimal Residual Disease by Flow-Cytometry Otimizes Risk Stratification When Combined with Cytogenetics in AML.

Blood ◽  
2007 ◽  
Vol 110 (11) ◽  
pp. 4242-4242
Author(s):  
Francesco Buccisano ◽  
Luca Maurillo ◽  
Giovanni Del Poeta ◽  
Maria Ilaria Del Principe ◽  
Paola Panetta ◽  
...  
Keyword(s):  
Risk Assessment ◽  
Flow Cytometry ◽  
Risk Stratification ◽  
Minimal Residual Disease ◽  
Relapse Rate ◽  
Residual Disease ◽  
Adult Patients ◽  
Leukemic Cells ◽  
Intermediate Risk ◽  
Minimal Residual

Abstract Cytogenetic risk assessment at diagnosis is a major determinant of outcome in adult patients with AML. Nevertheless, the impact of this up-front prognosticator may be altered by additional factors intervening during and after treatment such as toxicity, speed of blast clearance and minimal residual disease (MRD), both the latters reflecting the quality of response. We have demonstrated that the persistence of given amounts of leukemic cells after consolidation, affects the prognosis of AML, independently from cytogenetics, leading to a faster leukemic relapse. In the present study, we aimed at proving that the integrated analysis of karyotype and MRD determination by multiparametric flow-cytometry (MPFC) may improve the risk stratification process of patients belonging to established cytogenetic groups. We analyzed 127 non-M3 AML cases entered into the EORTC/GIMEMA protocols AML10/AML12 (age <61yrs) or AML13/AML15/AML17 (age >61 yrs). By applying the maximally selected log-rank statistics, the threshold discriminating MRD negative from positive cases was set at 3.5 x10−4 residual leukemic cells, a level that distinguished, at the post-consolidation time-point, discrete subsets of patients with different prognosis. According to the MRC classification, 18/127 (14%) and 7/127 (6%) were classified into the favorable and unfavorable risk categories, respectively; 102/127 (80%) patients had an intermediate risk karyotype. As expected, having a favourable, intermediate or unfavourable karyotype was associated with a significant difference in terms of relapse rate (28%, 63%, 100%; p=0.005), 5-years overall survival (OS) (67%, 27%, 14%; p<0.001) and 5-years relapse free survival (RFS) (68%, 28%, 0%; p<0.001). These three groups, also differed for the rate of MRD negativity: 78% in the favourable group, 28% in the intermediate group, whereas none among unfavourable risk patients reached a MRD− status (p<0.001). Therefore, we examined each cytogenetic group according to the MRD status and we observed that: patients bearing favourable karyotypes and achieving MRD negativity (good-MRD−) had a better outcome in terms of 5-years OS (81%) and RFS (76%) as compared to those remaining MRD positive (good-MRD+) (5-years OS % and RFS 25% and 43%, respectively) (p=0.06). also the patients with intermediate risk karyotype were dissected in two distinct categories by MRD status, MRD+ patients (Int-MRD+) with a very poor prognosis (5-yrs RFS and OS less than 20% for both) and MRD− ones (Int-MRD−) (5-yrs RFS and OS 69% and 50%, respectively) (p<0.001). Therefore, favorable karyotype does not guarantee by definition a good prognosis; in fact, good-MRD+ patients have a high relapse rate (50%) and a disappointing long term outcome; similarly, the outcome of Int-MRD+ patients was comparable to that of poor risk cytogenetics whereas Int-MRD− patients fared as favorably as those in the good karyotype category. In conclusion, an appropriate risk assessment should result from the combination of pre-treatment and delayed parameters (cytogenetics plus post-consolidation MRD determination) rather than relies on the evaluation of sole up-front prognosticators; this approach would enable to outline in a more reliable manner the outcome of adult patients with AML and the relative post-remissional therapy.

Relapse of Leukemia with Loss of Mismatched HLA Due to Uniparentaldisomy Follwing Haploidentical Hematopoietic Transplantation.

Blood ◽  
2009 ◽  
Vol 114 (22) ◽  
pp. 2457-2457
Author(s):  
Yoshiyuki Takahashi ◽  
Itzel Bustos ◽  
Yoshiki Akatsuka ◽  
Hideki Muramatsu ◽  
Nobuhiro Nishio ◽  
...  
Keyword(s):  
Bone Marrow ◽  
Flow Cytometry ◽  
T Cell ◽  
T Lymphocyte ◽  
Copy Number ◽  
Cytotoxic T Lymphocyte ◽  
Snp Array ◽  
Leukemic Cells ◽  
Hla Alleles ◽  
Limiting Dilution

Abstract Abstract 2457 Poster Board II-434 Introduction: Down-regulation or loss of human leukocyte antigen (HLA) expression can lead to impaired T-cell recognition and a blunted immune response to malignant tumors. We investigated HLA expression on leukemic cells derived from patients at the time of diagnosis and relapse after HLA haploidentical hematopoietic stem cell transplantation (HSCT) using flow cytometry with locus-specific antibodies. We hypothesized that the loss of HLA haplotype caused leukemic cells to escape immunosurveillance and consequently led to relapse of the disease. Materials and methods: The CD13+/34+ leukemic blasts were sorted by flow cytometry from bone marrow cells at the time of diagnosis and at the time of relapse. Genomic DNA was extracted from leukemic cells by fluorescence-activated cell-sorter as well as phytohemagglutinin-stimulated patient-derived T cells and subjected to single-nucleotide polymorphism (SNP) array analysis using GeneChip NspI arrays (Affymetrix, Tokyo, Japan). Allele-specific copy number was detected using Copy Number Analyser for GeneChip® software. The frequencies of cytotoxic T lymphocyte precursor (CTLp) specific for the recipient mismatched HLA molecules were analyzed using a standard limiting dilution assay. Allo-HLA-restricted CTL clones were isolated by standard limiting dilution and expanded for cytotoxicity assay against mismatched HLA transduced HLA class I-deficient 721.221 B-LCLs. Results: Two of three relapsed patients after HLA haploidentical HSCT demonstrated loss of HLA alleles on leukemic cells at the time of relapse and this loss was limited to the mismatched alleles in both patients. However, none of seven relapsed patients experienced haplotype loss following HLA matched HSCT. SNP array analyses of sorted leukemic cells at the time of diagnosis and at the time of relapse further revealed the copy number-neutral loss of heterozygosity, namely acquired uniparental disomy (UPD) on the short arm of chromosome 6, resulting in the total loss of the mismatched HLA haplotype. Recipient alloantigen-specific cytotoxic T-cell clones were generated from the donor that did not recognize the leukemic cells at the time of relapse, whereas those cells taken at diagnosis were recognized and efficiently killed. In one of the patients, we sought to determine if the number of CTLp had changed during the post-transplant course. A limiting dilution analysis with a split-well 51Cr-release assay was carried out to compare the CTLp frequencies specific for the mismatched antigens between the recipient and donor. Surprisingly, the CTLp frequencies reactive with recipient T cell blasts in CD8+ T cells obtained around Days 100, 180, and 300 (4 months before relapse) were undetectable, while the CTLp frequency obtained at Day 520 (1 month after the third DLI or 2 weeks after remission confirmed by bone marrow aspirate) was 8.6 × 10-5 [95% confidence interval (CI), 1.49 × 10-6 – 5.0 × 10-5]. The CTLp frequency in the donor CD8+ cells was 4.3 × 10-5 (95%CI, 7.2 × 10-5 – 2.5 × 10-5), which was close to that obtained after DLI in the recipient. Conclusions: These results suggest that the cytotoxic T lymphocyte response to mismatched HLA alleles can eradicate leukemic cells; however, escape from immunosurveillance by the loss of mismatched HLA alleles using UPD may be involved in relapse after haploidentical HSCT. Disclosures: No relevant conflicts of interest to declare.

Impact of chromosomal translocations on prognosis in childhood acute lymphoblastic leukemia.

1991 ◽  
Vol 9 (12) ◽  
pp. 2183-2192 ◽  
Author(s):  
C M Rubin ◽  
M M Le Beau ◽  
R Mick ◽  
M A Bitter ◽  
J Nachman ◽  
...  
Keyword(s):  
Acute Lymphoblastic Leukemia ◽  
High Risk ◽  
Lymphoblastic Leukemia ◽  
Intensive Therapy ◽  
Univariate Analysis ◽  
Prognostic Significance ◽  
Chromosomal Translocations ◽  
Leukemic Cells ◽  
Childhood All ◽  
Wbc Count

The presence of a chromosomal translocation in the leukemic cells at diagnosis of acute lymphoblastic leukemia (ALL) in children is associated with a high risk for treatment failure. We have reexamined the relationship between translocations and prognosis in 146 children with ALL who received risk-based therapy such that high-risk patients were treated with intensive drug schedules. In univariate analysis, multiple factors were associated with a relatively poor event-free survival (EFS) including age less than 2 years or greater than 10 years (combined group), WBC count greater than 10 x 10(9)/L, French-American-British (FAB) morphologic classification L2, absence of common ALL antigen (CALLA, CD10) expression, absence of hyperdiploidy with a chromosome number of 50 to 60, and presence of the specific translocations t(4; 11)(q21;q23) or t(9;22)(q34;q11) (combined group). However, there was no disadvantage with respect to EFS in patients with translocations compared with those who lacked translocations (73% at 4 years in both groups). Furthermore, when patients with specific cytogenetic abnormalities for which the prognostic significance has been well established (hyperdiploid 50 to 60, t(4;11), and t(9;22] were removed from the analysis, the remaining group with other translocations had a better EFS than the remaining group lacking translocations, although this was not statistically significant (81% v 65% at 4 years, P = .24). In a multivariate analysis, a model including WBC count and FAB classification was the strongest predictor of EFS. The presence or absence of translocations was not an independent predictor of EFS and did not contribute to the ability of any model to predict EFS. In conclusion, when effective intensive therapy is used to treat childhood ALL with high-risk clinical features, categorization of patients on the basis of chromosomal translocations without attention to the specific abnormality is not useful as a prognostic factor.

scholarly journals T-Lymphoblastic Leukemia (T-ALL) Shows Excellent Outcome, Lack of Significance of the Early Thymic Precursor (ETP) Immunophenotype, and Validation of the Prognostic Value of End-Induction Minimal Residual Disease (MRD) in Children’s Oncology Group (COG) Study AALL0434

Blood ◽  
2014 ◽  
Vol 124 (21) ◽  
pp. 1-1 ◽  
Author(s):  
Brent L. Wood ◽  
Stuart S. Winter ◽  
Kimberly P. Dunsmore ◽  
Meenakshi Devidas ◽  
Si Chen ◽  
...  
Keyword(s):  
Flow Cytometry ◽  
High Risk ◽  
Risk Stratification ◽  
Low Risk ◽  
Phase Iii ◽  
High Dose ◽  
Prognostic Information ◽  
Color Flow ◽  
Excellent Outcome ◽  
To Receive

Abstract Background: Although outcomes for children and young adults with T-ALL continue to improve, relapse on therapy continues to be a major cause of treatment failure. COG AALL0434 is a phase III study for patients with T-ALL that used a standard 4-drug induction followed by response-based risk stratification at Day 29 with Intermediate and High-risk patients randomized to receive or not receive six 5-day courses of nelarabine during consolidation, delayed intensification and maintenance. All patients are also randomized to receive either Capizzi or high-dose methotrexate during interim maintenance and all patients except those who were Low-risk received cranial irradiation (1200 cGY for CNS1 or 2 and 1800 cGy for CNS3). Risk stratification incorporates MRD detection by flow cytometry at Day 29 using the following cutoffs: Low-risk < 0.1%, Intermediate-risk < 1%, and High-risk > 1%. Recently, the immunophenotype has been associated with a particularly poor outcome in T-ALL, a finding that requires confirmation in a large prospective trial using contemporary therapy. Methods: 1144 children with T-ALL enrolled on COG AALL0434 between January 22, 2007 and June 30, 2014 were categorized at the time of study enrollment as ETP (n=130; 11.3%), Near-ETP (ETP but with elevated CD5; n=195; 17%) or Not-ETP (n=819; 71.6%) by flow cytometry. MRD was assessed by 8-9 color flow cytometry at Day 8 in peripheral blood (PB) and Day 29 in bone marrow (BM). Flow cytometry to characterize ETP status and MRD was performed in a single central laboratory. Event-free survival (EFS) and Overall survival (OS) were estimated by Kaplan-Maier curve analysis. Results: Despite significantly higher (P<0.0001) rates of induction failure (>25% blasts by morphology at end induction) for ETP (7.8%) and Near-ETP (6.7%) than Not-ETP (1.1%), all 3 immunophenotypic groups showed excellent 5-year EFS and OS that were not statistically different: ETP (87.0%; 93.0%), Near-ETP (84.4%; 91.6%), and Not-ETP (86.9%; 92.0%). In all 3 groups, most events occurred within 12 months from diagnosis and plateaued after 2 years, although events generally occurred earlier for ETP and Near-ETP than Not-ETP. There were no relapses in ETP patients later than 12 months post diagnosis. Initial white blood cell count (WBC) greater than 200,000/microliter was seen in 9.6% of ETP and 30% of Not-ETP/Near-ETP (P<0.0001) and was associated with inferior EFS and OS for Near-ETP (EFS p=0.0003) and Not-ETP (EFS p=0.012), but not ETP. Day 29 MRD > 0.01% was associated with inferior EFS (76.3% vs. 89.0%; p=0.0001) and OS (86.6% vs. 93.8%; p=0.0008) for the total cohort and was detected in 81.4%, 64.8%, and 30.5% of ETP, Near-ETP and Not-ETP patients, respectively. Interestingly, there was no difference in EFS or OS for Day 29 MRD <0.01% vs. 0.01%-1.0%, suggesting significance largely for MRD > 1.0%. Day 29 MRD >0.01% was also associated with inferior EFS (76.6% vs. 90.8%; p=0.0001) and OS (84.3% vs. 94.0%; p=0.0064) in Not-ETP and inferior EFS (80.2% vs. 94.0%; p=0.0073) in Near-ETP, but no difference was seen for EFS or OS in ETP. Day 8 PB MRD > 0.01% was associated with inferior EFS (80.3% vs. 92.0%; p=0.017) but not OS and lost significance in the subset having Day 29 MRD < 0.01%, suggesting Day 8 does not add prognostic information to Day 29 MRD. Conclusions: AALL0434 is the largest study of T-ALL ever conducted and shows excellent outcomes for T-ALL. In particular, ETP is found to have an outcome identical to non-ETP patients. WBC count > 200,000/microliter is associated with inferior outcome in non-ETP T-ALL. BM MRD > 1% at Day 29 is able to identify a subset of non-ETP T-ALL patients having inferior outcomes. PB Day 8 MRD does not provide unique prognostic information. Disclosures No relevant conflicts of interest to declare.

Single IGH/TCR MRD Marker Is More Informative and Cost-Effective in Risk-Stratified Therapy for Childhood ALL: Prospective Treatment Trial Results from the Malaysia-Singapore (Ma-Spore) ALL 2003 Study

Blood ◽  
2008 ◽  
Vol 112 (11) ◽  
pp. 2551-2551
Author(s):  
Allen Eng Juh Yeoh ◽  
Hany Ariffin ◽  
Ah Moy Tan ◽  
Thi Thu Ha Truong ◽  
Hai Peng Lin ◽  
...  
Keyword(s):  
High Risk ◽  
Risk Stratification ◽  
Risk Group ◽  
Clonal Evolution ◽  
Cost Effective ◽  
Intermediate Risk ◽  
Childhood All ◽  
Free Survival ◽  
Time Points ◽  
Time Point

Abstract Background: Several large cohort studies–like from BFM and St Jude groups-have shown that minimal residual disease (MRD) is the single most important predictor of treatment outcome in childhood acute lymphoblastic leukemia. However, lingering concerns about clonal evolution of IgH/TCR rearrangements may result in false-negative MRD. Hence, the AIEOP-BFM ALL 2000 study utilized at least 2 sensitive MRD markers with at least 10−4 sensitivity for risk-stratification. This stringent minimum of 2 sensitive MRD markers criteria limits the applicability of MRD stratification to &lt;80% of patients and it is more costly and time consuming. The Malaysia-Singapore ALL 2003 study trial adopted a similar strategy of primarily early response assessment like Day-8 prednisolone response (PR) and a simplified methodology of at least one MRD marker (IgH/TCR) for risk stratification. We hypothesize that clonal evolution does not occur early during therapy and that a single marker PCR-based methodology is more informative and cost-effective, without hampering the accuracy of MRD risk stratification. Methods: A total of 362 patients (B-lineage=333, T-lineage=29) were enrolled in Ma-Spore ALL 2003 from July 2002 to August 2008, with a median age of 5.61 years (range 0.14 to 15.29). The treatment protocol is based on the modified BFM ALL 2000 backbone without randomization. Risk-stratification is based primarily on MRD levels at end of induction (Day-33) and week 12, Day-8 PR, and presence of BCR-ABL or MLL. In patients whom we are unable to quantify MRD, are assigned IR risk group. Screening for IgH/TCR rearrangements is carried out using multiplex BIOMED-2 primers (JJM van Dongen et al 2003) with standardization with the European MRD Study Group, which we are an active member. Selection of MRD markers is based on frequency and stability of IgH/TCR rearrangements. MRD quantifications were carried out using Real-time PCR (LightCycler 1.0, Roche Diagnostics). We define three distinct treatment subgroups: Standard-Risk (SR) who had MRD &lt;10−4 at both time-points; High-Risk (HR) who had poor PR or no clinical remission or BCR-ABL or infant MLL or MRD at week 12 &gt;1×10−3; remaining patients formed Intermediate-Risk (IR). The SR patients received decelerated therapy while HR group was treated under intensified therapy or bone marrow transplant. Results: Of 362 patients enrolled, Ma-Spore risk stratification is possible in 360 patients (n=2 delayed treatment), out of which 239 have completed 2 years therapy, 15 had induction failures, and 22 had relapses (isolated BM=17, isolated CNS=4, isolated testis=1.) Patients stratified into SR=29% (n=106/360); IR=50% (n=180/360), and HR=21% (n=74/360). At the end of the study, 4-years overall survival (0S) was SR=94.2±2.5%; IR=95.3±1.6%; HR=66.2±6.5%; event-free survival (EFS) was SR=91.8±3%; IR=86.2±3.4%; HR=52.9±6.4%, and leukemia-free survival (LFS) was SR=94.8±2.6%; IR=90.5±3.2%; HR=62.7±6.6%. Within the HR subgroup, using multivariate analysis, high MRD levels at week 12 (&gt;10−3) is significantly associated with adverse treatment outcome (OS=27.5±15.8%, EFS=17.9±14.4%; LFS=23.1±17.8%), whilst poor prednisolone responders alone in the absence of high risk MRD or high risk BCR-AL or MLL-AF4 did well (OS=84.1±7.4%, EFS=84.1±7.4%, LFS= no event). Of the 362 patients, at least 91% (n=309/339) of patients had at least 1 sensitive MRD marker; the remaining patients have no diagnostic samples (n=9), died before time-point 1(n=10), and default before time-point 1(n=4). For risk-stratification using only MRD levels, 45.7% of the patients (n=128/280) were low-risk with MRD&lt;10−4 at both time-points; 3.2% of the patients (n=9) were high-risk with MRD&gt;10−3 at week 12; and the remaining 51.1% (n=143) were stratified as intermediate-risk MRD. Overall survival in MRD low-risk group was 93.2±2.5%, MRD intermediate-risk was 93.6±2.4% and MRD high-risk MRD was 45±18.8%. Conclusion: We have demonstrated that a simplified MRD methodology using a single PCR-based marker (IgH/TCR) can be successfully implemented to tailor therapy for childhood ALL without adversely affecting outcome. It is cost-effective and can be applied to a larger group of patients (91%). This is particularly useful for countries with limited resources to pursue risk stratification incorporating MRD. Deceleration of therapy in the SR group would also help to reduce long-term side effects and better quality life in these children.

Masked Hypodiploidy: Hypodiploid Acute Lymphoblastic Leukemia (ALL) in Children Mimicking Hyperdiploid ALL: A Report From the Children's Oncology Group (COG) AALL03B1 Study.

Blood ◽  
2009 ◽  
Vol 114 (22) ◽  
pp. 1580-1580 ◽  
Author(s):  
Andrew J. Carroll ◽  
Nyla A. Heerema ◽  
Julie M. Gastier-Foster ◽  
Caroline Astbury ◽  
Robert Pyatt ◽  
...  
Keyword(s):  
Acute Lymphoblastic Leukemia ◽  
Conflicts Of Interest ◽  
Residual Disease ◽  
Lymphoblastic Leukemia ◽  
Significant Proportion ◽  
Treatment Strategies ◽  
Good Prognosis ◽  
Leukemic Cells ◽  
Outcome Analysis ◽  
Dna Index

Abstract Abstract 1580 Poster Board I-606 Hyperdiploidy with greater than 50 chromosomes is usually associated with a good prognosis in childhood acute lymphoblastic leukemia (ALL). By contrast, hypodiploidy with 44 or fewer chromosomes is a recurring abnormality detected in approximately 1% of children with ALL and is associated with an extremely poor prognosis with a projected event-free survival of less than 35% (Nachman et al Blood 110:1112, 2007; Harrison et al Br J Haematol 125:552, 2004; Raimondi et al Cancer 98:2715, 2003). Three distinct subgroups of hypodiploidy are recognized; near-haploidy (24-31 chromosomes), low hypodiploidy (32-39 chromosomes), and high hypodiploidy (40-44 chromosomes). It is common for leukemic cells with near-haploid or low hypodiploid chromosome numbers to undergo an exact or nearly exact doubling of the hypodiploid clone that results in a modal chromosome number in the hyperdiploid range, which might be misconstrued as indicating a good prognosis. In these cases of hypodiploid doubling, most chromosomes will be disomic or tetrasomic, but not trisomic. These cases are usually found to be mosaic with both hypodiploid and hyperdiploid (doubled) clones visible by standard cytogenetics, DNA Index (DI) by flow cytometry, and/or fluorescence in situ hybridization (FISH). We reviewed the cytogenetics and presenting clinical features of children with ALL enrolled on the COG AALL03B1 study between 12/29/03 and 6/30/09. Among 8091 eligible patients, 92 (1.1%) had abnormal cytogenetics that were suggestive of hypodiploidy with fewer than 44 chromosomes. Of the 92 hypodiploid patients with visible chromosome abnormalities 54 were near-haploid, 32 low hypodiploid, and 6 high hypodiploid. Thirty-three patients (36%) had only the hypodiploid clone, 36 (39%) were mosaics with both a hypodiploid and a doubled hypodiploid clone identified, and most importantly, 23 (25%) patients displayed only the doubled hypodiploid clone. While the few previously described cases with only the doubled clone have always been shown to have evidence of hypodiploidy by DI, we found that only 10 of these 23 cases had a DNA index that suggested the presence of a hypodiploid clone. The remaining 13 cases had ploidy and FISH results consistent with the presence of a single, hyperdiploid (doubled) clone, thus effectively masking the underlying hypodiploidy. However, these cases all demonstrated a unique chromosome pattern characterized primarily by tetrasomy rather than trisomy, which distinguished them from a “typical” hyperdiploid case with an equivalent number of chromosomes. Tumor and germline DNA from all 13 masked hypodiploid patients were evaluated for loss of heterozygosity (LOH) using a microsatellite panel that tested 15 distinct loci on 13 different chromosomes. In all 13 patients LOH at multiple loci confirmed that the hyperdiploid cells had arisen by way of a doubling of a hypodiploid clone. Although numbers are too small for outcome analysis, there were no statistically significant differences in NCI Risk group or response to induction therapy (marrow morphology at day 15 or 29, and day 29 minimal residual disease levels) among masked hypodiploid cases and others in which the hypodiploid clone was visible. We conclude that a significant proportion (15-25%) of blast cell hypodiploidy may have been overlooked in children with ALL in previous studies due to the presence of a doubled hypodiploid clone and the absence of hypodiploid interphase/metaphase cells. Heightened awareness among cytogeneticists and clinicians about the unique karyotypic “signature” of a doubled hypodiploid clone coupled with the coordinated use of DI, FISH and LOH studies when indicated are important for the identification of patients with masked hypodiploidy so that they can be assigned to appropriate very high-risk treatment strategies. Disclosures No relevant conflicts of interest to declare.

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