The Changing Paradigm of Acute Myeloid Leukemia with Normal Cytogenetics

TzuTzu-Fei Wang Hematology/Oncology Fellow October 22, 2010

Disclosure


Financial Relationships: I have nothing to disclose

Acute Myeloid Leukemia



AML is a disorder that results from a block in the differentiation of hematopoietic progenitor cells along with uncontrolled proliferation. Cytogenetics is the most important prognostic factor in AML In about 50-60% of cases, recurrent 50chromosome aberrations can be identified by cytogenetic techniques.

AML Cytogenetics


Good prognosis
  

t(15;17) PML-RARA PMLt(8; 21) AML1-ETO AML1inv (16) CBF -MYH11 normal cytogenetics t(9;11) -5, 5q-, -7, 7q5q7q11q23 but not t(9;11) inv (3) EVI1, t(6;9), t(9;22) Complex cytogenetics (3 abnormalities)

Intermediate prognosis
 

Poor Prognosis
   

Overall survival based on cytogenetic risk groups

Byrd, J. C. et al. Blood 2002;100:4325-4336
Copyright 2002 American Society of Hematology. Copyright restrictions may apply.

AML With Normal Cytogenetics

 

The largest subgroup of AML patients, which encompasses 40-50% of patients. 40Although this group has been categorized together as intermediate risk, the 5 year overall survival rates vary wildly (24%-42%). (24%Treatment options after induction chemotherapy include consolidation with high dose AraC or allogeneic stem cell transplant.

Gregory TK et al. Journal of Hematology & Oncology. 2009, 2:23 Schlenk RF, Dhner K. et al. N Engl J Med. 2008;358:1909-18

AML With Normal Cytogenetics



In recent years, multiple acquired genetic alterations were identified in this group, proving the heterogeneity in this group. These genetic mutations not only have prognostic indications but can also have important roles in the decision of treatment options.

Genetic Mutations in AML-NC AML         

FLT3-ITD FLT3FLT3-TKD FLT3NPM1 CEBP mutation MLLMLL-PTD IDH1 and IDH2 mutations BAALC over-expression overERG over-expression overWT1 mutation (Wilms Tumor 1) MN1 over-expression (Meningioma 1) over-

FLT3FLT3-ITD (fms-like tyrosine (fmskinase/internal tandem duplication)

30-40% of NC-AML FLT3 is a membrane bound tyrosine kinase receptor expressed on hematopoietic stem cells regulates cell proliferation and differentiation mutation results in constitutively active FLT3 protein that promotes Stat 5 phosphorylation, leading to uncontrolled hematopoietic cell proliferation. patient characteristics -high wbc and blast counts correlates with adverse prognosis in DFS and OS longer duplication correlates with worse outcome
Gregory TK et al. Journal of Hematology & Oncology. 2009, 2:23

FLT3FLT3-TKD (FLT3/tyrosine kinase domain)



 

A missense mutation in the activation loop of the second tyrosine kinase domain of FLT3 --> constitutive phosphorylation of the protein --> Incidence: 5-10% 5Clinically, no clear effect on prognosis

Baldus, C.D. et al. British Journal of Haematology 2007;137:387-400.

NPM1(nucleophosmin) Mutation


Most frequent genetic mutations (45-63%) in (45NCNC-AML. NPMNPM-1 gene encodes a nucleo-cytoplasmic nucleoshuttling protein that mostly resides in the nucleolus and regulates ARF-p53 tumor ARFsuppressor pathways Mutation of NPM-1 leads to abnormal NPMaccumulation of the protein in the cytoplasm

Falini B. et al. Blood 2007;109(3):874-885.

Patient characteristics associated with NPMm

female  increased blast count and platelet count  extramedullary involvement  monocytic differentiation (particularly FAB M4, M5)  CD34 negative (>95%)  normal cytogenetics  high frequency with FLT3-ITD mt(40%), low FLT3frequency with CEBP  improved CR, OS, EFS/DFS in NPM1m/FLT3-ITDwt /FLT3

NPM1(nucleophosmin) Mutation

Falini B. et al. Blood 2007;109(3):874-885. Gregory, TK. et al. Journal of Hematology & Oncology. 2009, 2:23

NPM1 mutations closely associate with AML-NK and FLT3-ITD

Falini, B. et al. Blood 2007;109:874-885

Copyright 2007 American Society of Hematology. Copyright restrictions may apply.

CEBP (CCAAT/enhancer binding protein- ) Mutation protein 

Mutations are found in 15-20% of NC-AML. 15NCIt is an essential transcription factor for granulocytic differentiation, and mutation leads to failure of granulocytic differentiation. Patient characteristicscharacteristics  

higher Hgb, lower platelet, higher blast counts less likely to have extramedullary presentations Higher incidence in M1 and M2

improved CR duration, EFS/DFS, and OS, but not CR rate (only in double mutation?)

Preudhomme, C. et al. Blood 2002;100:2717-2723. Wouters et al. blood. 2009; 113(13):3088-91. Pabst T. et al. British Journal of Cancer. 2009;100:1343-46.

Overall survival (OS) for AML patients with normal cytogenetics according to CEBPA mutation status -- similar results in two studies

Preudhomme, C. et al. Blood 2002;100:2717-2723

Copyright 2002 American Society of Hematology. Copyright restrictions may apply.

Copyri t ric oci ty of Cli i c l O cology

Frohling, S. et al. J Clin Oncol; 22:624-633 2004

Prognostic Impact of Genotypes

Schlenk RF, Dhner K. et al. N Engl J Med. 2008;358:1909-18.

MLLMLL-PTD (mixed lineage leukemia/partial tandem duplication)

 

In NC-AML patients, MLL-PTD occurs in about NCMLL8% (5-11%) (5MLL encodes a histone methyltransferase that plays a role in hematopoiesis. The MLL gene can undergo partial tandem duplication (exons 5-11 or 5-12) and produce an 55elongated protein, which silences the wild-type wildallele in AML blasts. associated with decreased remission duration, EFS, but NOT CR or OS.

Dhner K. J Clin Oncol 2002, 20(15):3254-3261.

Remission Duration (p=0.02)

Overall Survival (p=0.427)

Dhner K et al. JCO 2002;20:3254-3261

2002 by American Society of Clinical ncology

IDH (isocitrate dehydrogenase) Mutation

 

 

Initially found in glioblastoma, astrocytoma, oligodendroglioma Recently, IDH1 mutation was first identified in AML by the sequencing of an entire NC-AML genome by Dr. Timothy Leys NCteam (present in 16% NC-AML samples) NCIDH1IDH1-cytoplasmic, IDH2- mitochondrial IDH2Function - oxidative decarboxylation
NAD/NADP IDH NADH/NADPH

Isoitrate -ketoglutarate Patient characteristics

   

older age higher platelet counts and lower wbc counts associated with normal cytogenetics associated with NPM1 mutations (esp. NPM1m/FLT3-ITDwt) NPM1m/FLT3-

Mardis, E.R. et al. NEJM. 2009; 361:1058-66. Paschka P et al. JCO 2010;28:3636-3643

IDH mutation predicts poor outcome only in patients with NPM1m/FLT3-ITDwt

NPM1m/FLT3-ITDwt P=0.02 other genotype

NPM1m/FLT3-ITDwt P=0.03

other genotype

Paschka P et al. JCO 2010;28:3636-3643


2010 by American Society of Clinical ncology

Outcome of cytogenetically normal acute myeloid leukemia (CN-AML) according to IDH mutational status.

Impact of isocitrate dehydrogenase enzyme isoform (IDH) 1 mutation on normal cytogenetics acute myeloid leukemia (CN-AML) patient outcome.

NPM1m/FLT3-ITDwt

NPM1m/FLT3-ITDwt

four-gene genotype

four-gene genotype

Boissel N et al. JCO 2010;28:3717-3723


2010 by American Society of Clinical ncology

BAALC (The Brain and Acute Leukemia Cytoplasmic) Gene

 

little is known about its function primarily expressed in neuroectoderm-derived neuroectodermtissues, hematopoietic precursors, and blasts. high blood BAALC mRNA level at diagnosis is associated with worse EFS and OS, irrespective of FLT3 and CEBPA mutation status Patients with high BAALC expression have lower relapse rate when undergoing allo SCT compared to auto.

Baldue, C.D., et al. Blood. 2003; 102:1613-1618.

ERG (ETS-Related Gene) (ETSOverOver-expression



ERG is a member of the ETS family, most of which are downstream targets of signal transduction pathways regulating cell proliferation, differentiation, and apoptosis. Patients with highest level of ERG (top 25%) have worse relapse rate, CR, EFS, and OS*. can further risk stratify FLT3-ITD negative/ FLT3NPM1-positive patients based on their NPM1expression levels

Marcucci G, et al. J Clin Oncol 2007;25(22): 3337-3343

CALGB 19808

CALGB 9621

Event-free survival (EFS) according to ERG expression levels (all patients)

FLT3-ITD-

FLT3-ITD+

NPM1+

NPM1-

 



Copyright

Marcucci, G. et al. J Clin Oncol; 25:3337-3343 2007

ric oci ty of Cli i c l O cology

  

Summary of Recurrent Genetic Alterations in AMLAMLNC

Name FLT3-ITD MLL-PTD IDH-1 IDH-2 BAALC ERG NPM-1 CEBP FLT3-TKD MN1 WT1 Prevalence 30-40% 5-11% ~10-15% ~5-10% 65.7% 25% 50-60% 15-20% 5-10% NA 10.5% Chromosome 13q12 11q23 2q33.3 15q26.1 8q22.3 21q22 5q35 19q13.1 13q12 22q11 11p13 Expression Mutation Mutation/overexpression Mutation Mutation Over-expression Over-expression Mutation Mutation Mutation Over-expression Mutation Prognosis Unfavorable Unfavorable Unfavorable Unfavorable Unfavorable Unfavorable Favorable Favorable No clear effect Unfavorable Unfavorable

The Impact of Genotype on Therapeutic Options

   

FLT3 inhibitors ATRA with chemotherapy AlloSCT DNA methyltransferase inhibitor (decitabine) and/or histone deacethylase inhibitor (depsipeptide) in MLL-PTD mutations MLL-

FLT3 Targeted Therapy

CALGB 10603 study

27

Leukemia & Lymphoma, May 2008; 49(5): 852863

Use of ATRA in NPM1m/FLT3-ITDwt Patients

All AML (intention-to-treat) AML-NC (intention-to-treat )

NPM1m/FLT3-ITDwt, +ATRA

NPM1m/FLT3-ITDwt, No ATRA

Schlenk, R. F. et al. Haematologica 2009;94:54-60

Copyright 2009 Ferrata Storti Foundation

Genotype can Influence Therapy options

NPM1mt/FLT3ITDwt patients do not benefit from alloSCT

Relapse-free Survival among Patients in Whom a Complete Remission Was Achieved, According to the Availability of an HLA-Matched Related Donor. Dhner K, Blood 2005;106:3740-3746. Schlenk RF et al. N Engl J Med 2008;358:1909-1918.

AML Treatment - Past

Induction Good risk New AML Intermediate risk Poor risk HiDAC x 3-4 HiDAC or alloSCT alloSCT or clinical trial

Proposed AML-NC Treatment AMLCurrent/Future

IDH1/2 mt

IDH1/2 wt

Baldus C.D. British Journal of Haematology 137, 387-400.

Conclusion


AML is a heterogeneous disorder characterized by cytogenetics and acquired genetic mutations. More and more important genetic mutations are identified and can play crucial roles in both prognostic and therapeutic aspects

References
 

Baldus C.D., et al. Clinical outcome of de novo acute myeloid leukaemia patients with normal cytogenetics is affected by molecular genetic alterations: a concise review. British Journal of Haematology 137, 387-400. 387Boissel N et al. Prognostic impact of isocitrate dehydrogenase enzyme isoforms 1 adn 2 mutations in acute myeloid leukemia: A study by the acute leukemia French association group. JCO 2010;28(23):3717-3723. 2010;28(23):3717Byrd, J. C. et al. pre-treatment cytogenetic abnormalities are predictive of induction success, cumulative preincidence of relapse, and overall survival in adult patients with de novo acute myeloid leukemia: results from Cancer and Leukemia Group B (CALGB 5461). Blood 2002;100:4325-4336 2002;100:4325Dhner K. prognostic significance of partial tandem duplications of the MLL gene in adult patients 16 to 60 years old with acute myeloid leukemia and normal cytogenetics: a study of the acute myeloid leukemia study group Ulm. J Clin Oncol 2002, 20(15):3254-3261. 20(15):3254Dhner K, et al. Mutant nucleophosmin (NPM1) predicts favorable prognosis in younger adult with acute myeloid leukemia and normal cytogenetics: interaction with other gene mutations. Blood 2005;106:37402005;106:37403746. Falini B. et al. acute myeloid leukemia carrying cytoplasmic/mutated mucleophosmin (NPMc+AML): biologic and clinical features. Blood 2007;109(3):874-885. 2007;109(3):874Frohling, S. et al. CEBPA Mutations in Younger Adults With Acute Myeloid Leukemia and Normal CEBPA Cytogenetics: Prognostic Relevance and Analysis of Cooperating Mutations. J Clin Oncol 2004;22:624-633. 2004;22:624Gregory TK et al. Molecular prognostic markers for adult acute myeloid leukemia with normal cytogenetics. Journal of Hematology & Oncology. 2009, 2:23, 1-10. 1Ley, T. J. et al. DNA sequencing of a cytogenetically normal acute myeloid leukaemia genome. Nature. 2008; 456:66-72. 456:66-

References
 

Marcucci, G. et al. High expression levels of the ETS-related gene, ERG, predict adverse outcome and ETSimprove molecular risk-based classification of cytogenetically normal acute myeloid leukemia: a cancer riskand leukemia group B study. J Clin Oncol 2007; 25(22): 3337-3343. 3337Mardis, E.R., et al. Recurring mutations found by sequencing an acute myeloid leukemia genome. N Engl J Med. 2009;361:1058-1066. 2009;361:1058Pabst, T. et al. Heterogeneity within AML with CEBPA mutations; only CEBPA double mutations, but not single CEBPA mutations are associated with favourable prognosis. British Journal of Cancer. 2009;100:13432009;100:1343-1346. Paschka P et al. IDH1 and IDH2 mutations are frequent genetic alterations in acute myeloid leukemia and confer adverse prognosis in cytogenetically normal acute myeloid leukemia with NPM1 mutation without FLT3 internal tandem duplication. JCO 2010;28(22):3636-3643. 2010;28(22):3636Pratz, K and Levis, M. Incorporating FLT3 inhibitors into acute myeloid leukemia treatment regimens. Leukemia & Lymphoma, May 2008; 49(5): 852863. 852 Preudhomme, C. et al. Favorable prognostic significance of CEBPA mutations in patients with de novo acute myeloid leukemia: a study from the acute leukemia French association. Blood 2002;100:2717-2723. 2002;100:2717Schlenk RF, Dhner K. et al. N Engl J Med. Mutations and treatment outcome in cytogenetically normal acute myeloid leukemia. 2008;358:1909-18 . 2008;358:1909Schlenk, R. F. et al. Gene mutations and response to treatment with all-trans retinoic acid in elderly allpatients with acute myeloid leukemia. Results from the AMLSG trial AML HD98B. Haematologica 2009;94(1):542009;94(1):54-60. Wouters, B.J. et al. Double CEBPA mutations, but not single CEBPA mutations, define a subgroup of acute myeloid leukemia with a distinctive gene expression profile that is uniquely associated with a a favorable outcome. Blood. 2009;113:3088-3091. 2009;113:3088-