Cytogenetically Normal Acute Myeloid Leukemia

J IEUN UHM

Hematology-Medical Oncology, Hanyang University College of Medicine

Case 평소 건강하였던 37세 남자 환자가 2주간 지속된 미열과 전신 무력감으로 내원하였다. 활력징후는

혈압 125/76 mmHg, 맥박수 86/분, 호흡수 18/분, 체온 37.2 ̊C였다. 결막은 약간 창백하였다. 흉부

진찰 및 복부 진찰에서는 특이 소견이 없었고, 만져지는 림프절도 없었다. 피부에도 특별한 병변은

관찰되지 않았다. 검사 소견은 다음과 같았다.

WBC 27,000 – Hb 7.8 – PLT 43K (ANC 450, Blast 61%)

Bone marrow exam: Hypercellular marrow (cellularity 90%), packed with immature cells

Immunophenotyping: CD13 (+), CD33 (+), CD 117 (+), MPO (+)

Acute Myeloid Leukemia

Case 평소 건강하였던 37세 남자 환자가 2주간 지속된 미열과 전신 무력감으

로 내원하였다. 활력징후는 혈압 125/76 mmHg, 맥박수 86/분, 호흡수

18/분, 체온 37.2 ̊C였다. 결막은 약간 창백하였다. 흉부 진찰 및 복부 진

찰에서는 특이 소견이 없었고, 만져지는 림프절도 없었다. 피부에도 특

별한 병변은 관찰되지 않았다. 검사 소견은 다음과 같았다.

WBC 27,000 – Hb 7.8 – PLT 43K (ANC 450, Blast 61%)

Bone marrow exam: Hypercellular marrow (cellularity 90%),

packed with immature cells

Immunophenotype: CD13 (+), CD33 (+), CD 117 (+), MPO (+)

Acute Myeloid Leukemia

Adult AML에서 가장 흔한 karyotype은?

1. t(8;21)(q22;q22)

2. inv(16)

3. Monosomy 7

4. Normal karyotype

5. Complexes (≥3)

Heterogeneity of AML

2008 WHO classification Acute myeloid leukemia with recurrent genetic abnormalities

◦ AML with t(8;21)(q22;q22); RUNX1-RUNX1T1

◦ AML with inv(16)(p13.1;q22) or t(16;16)(p13.1;q22); CBFB-MYH11

◦ APL with t(15;17)(q22;q12); PML-RARA

◦ AML with t(9;11)(p22;q23); MLLT3-MLL

◦ AML with t(6;9)(p23;q34); DEK-NUP214

◦ AML with inv(3)(q21;q26.2) or t(3;3)(q21;q26.2); RPN1-EVI1

◦ AML (megakaryoblastic) with t(1;22)(p13;q13); RBM15-MKL1

◦ Provisional entity: AML with mutated NPM1

◦ Provisional entity: AML with mutated CEBPA

Acute myeloid leukemia with myelodysplasia-related changes

Therapy-related myeloid neoplasm

Acute myeloid leukemia, not otherwise specified ◦ AML with minimal differentiation ◦ AML without maturation ◦ AML with maturation ◦ Acute myelomonocytic leukemia ◦ Acute monoblastic/monocytic leukemia ◦ Acute erythroid leukemia

◦ Pure erythroid leukemia ◦ Erythroleukemia, erythroid/myeloid

◦ Acute megakaryoblastic leukemia ◦ Acute basophilic leukemia ◦ Acute panmyelosis with myelofibrosis

Myeloid sarcoma

Myeloid proliferations related to Down syndrome

Blastic plasmacytoid dendritic cell neoplasm

Case 평소 건강하였던 37세 남자 환자가 2주간 지속된 미열과 전신 무력감으

로 내원하였다. 활력징후는 혈압 125/76 mmHg, 맥박수 86/분, 호흡수

18/분, 체온 37.2 ̊C였다. 결막은 약간 창백하였다. 흉부 진찰 및 복부 진

찰에서는 특이 소견이 없었고, 만져지는 림프절도 없었다. 피부에도 특

별한 병변은 관찰되지 않았다. 검사 소견은 다음과 같았다.

WBC 27,000 – Hb 7.8 – PLT 43K (ANC 450, Blast 61%)

Bone marrow exam: Hypercellular marrow (cellularity 90%),

packed with immature cells

Immunophenotype: CD13 (+), CD33 (+), CD 117 (+), MPO (+)

Acute Myeloid Leukemia

Adult AML에서 가장 흔한 염색체 검사 결과는?

1. t(8;21)(q22;q22)

2. inv(16)

3. Monosomy 7

4. Normal karyotype

5. Complexes karyotype (≥3)

Major cytogenetic subgroups of acute myeloid leukemia (AML) (excluding acute promyelocytic leukemia) and associated gene mutations.

Konstanze Döhner, and Hartmut Döhner Haematologica 2008;93:976-982

©2008 y Ferrata Storti Foundation

Case 평소 건강하였던 37세 남자 환자가 2주간 지속된 미열과 전신 무력감으

로 내원하였다. 활력징후는 혈압 125/76 mmHg, 맥박수 86/분, 호흡수

18/분, 체온 37.2 ̊C였다. 결막은 약간 창백하였다. 흉부 진찰 및 복부 진

찰에서는 특이 소견이 없었고, 만져지는 림프절도 없었다. 피부에도 특

별한 병변은 관찰되지 않았다. 검사 소견은 다음과 같았다.

WBC 27,000 – Hb 7.8 – PLT 43K (ANC 450, Blast 61%)

Bone marrow exam: Hypercellular marrow (cellularity 90%),

packed with immature cells

Immunophenotype: CD13 (+), CD33 (+), CD 117 (+), MPO (+)

Chromosome analysis: 46,XY [20]

Acute Myeloid Leukemia with normal karyotype

이 환자와 같이 CN-AML에서 좋은 예후를 시사하는 genetic

mutation 은?

1. Nucleophosmin 1 gene mutation

2. FMS-like tyrosine 3 gene internal tandem duplication

3. Single CCAAT enhancer-binding protein ɑ mutation

4. TET oncogene family member 2 mutation

5. Mixed-lineage leukemia gene partial tandem duplication

Mutations in the nucleophosmin 1 (NPM1) gene 1. Nucleophosmin 1

◦ An ubiquitously expressed, highly conserved phosphoprotein

◦ Physically resides in nucleoli and shuttles between nucleus and cytoplasm

◦ Proliferation and growth suppression pat-hways as well as cellular differentiation ◦ ribosome biogenesis, response to stress stimuli,

maintenance of genomic stability, regulation of activity and stability of tumor-suppressor genes such as p53, and transcriptional regulation

◦ Mutations of NPM1 gene are detectable in 45% to 62% of CN-AML cases

Pier Paolo Di Fiore J Cell Biol 2008;182:7-9 Grisendi et al. Nature Reviews Cancer 6, 493–505 (July 2006)

Minimal residual disease and 5-azacitidine

Katja Sockel et al. Haematologica 2011;96:1568-1570

MRD course of 7 patients with molecular response to single agent azacitidine.

Jan Krönke et al. JCO 2011;29:2709-2716

(A) (B) for patients in CR according to minimal residual disease (MRD) status after induction therapy in bone marrow

(C) (D) according to MRD status after completion of therapy in bone marrow

ATRA in combination with intensive chemotherapy In elderly patients (> 60 YO) with AML, all-trans retinoic acid as an adjunct to intensive chemotherapy improved RFS and OS in the patients with ‘mutant NPM1 without FLT3-ITD’ genotype (Haematologica 2009;94:54)

In younger patients (18-60 YO) with AML, ATRA in addition to conventional chemotherapy significantly improved response to induction therapy (OR 2.20, p=0.05) and EFS in NPM1-mutated AML (HR 0.65, p=0.02), independent of the FLT3-ITD status (OR, 0.66, p=0.33). OS of patients treated with ATRA was significantly better (p=0.02) compared with that of patients not treated with ATRA regardless of genotype (Richard F. Schlenk et al. 2011 ASH annual meeting).

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

Mutations of the FMS-like tyrosine 3 (FLT3) gene

Mark R. Litzow Blood 2005;106:3331-3332 Mohammad A. Rattu US Pharm. 2014;39(11)(Specialty&Oncology suppl):8-11

Mutations of the FMS-like tyrosine 3 (FLT3) gene FLT3 mutations

◦ Internal tandem duplication (ITD) mutations ◦ Detected in about 20% of unselected cases of AML and 30% of CN-AML

◦ Not mutually exclusive of AML with recurrent cytogenetic abnormalities detectable in cases carrying t(15;17) and t(6;9)

◦ TKD mutations ◦ Found in about 10% of all AML, mostly clustering with CN-AML and inv(16)

◦ Play a clinical role in leukemogenesis by cooperating with other mutations, especially those affecting NPM1 and DNMT3A genes

◦ FLT3-ITD mutations are generally associated with an inferior outcome in AML: shorter EFS, RFS, and OS

Rosemary E. Gale et al. Blood 2008;111:2776-2784

Clinical outcome stratified according to total FLT3/ITD level

Allogeneic hematopoietic cell transplant for FLT3-ITD mutation

EFS of FLT3-ITD positive patients transplanted in CR1

OS of FLT3-ITD mutated and wild-type patients transplanted versus no transplant

Amy E. DeZern et al. Biol Blood Marrow Transplant 2011 Sep; 17(9):1404-1409

Impact of FLT3-ITD on outcomes of allo-HCT

FLT3 inhibitors Sorafenib

◦ Sorafenib vs Placebo in addition to standard therapy in adult patients ≥60 years (SORAML Trial) ◦ Newly diagnosed 276 AML patients (2012 ASH annual meeting)

◦ 2 cycles of induction with Daunorubicin/Cytarabine followed by 3 cycles of high-dose cytarabine consolidation

◦ Allo-HCT for all intermediate-risk patients in CR with a family donor and for all high-risk patients with a matched donor

◦ Sorafenib 800mg/day or placebo as add-on to standard treatment

◦ 1-Yr EFS of 50% in placebo vs 64% in sorafenib (p=0.023)

◦ 2-Yr OS of 66% in placebo vs 72% in sorafenib (p=0.367)

◦ Sorafenib vs Placebo in addition to standard therapy in adult patients < 60 years (SAL-SORAML) ◦ Newly diagnosed 276 AML patients (2014 ASH annual meeting)

◦ 2 cycles of induction with Daunorubicin/Cytarabine followed by 3 cycles of high-dose cytarabine consolidation

◦ Allo-HCT for all intermediate-risk patients in CR with a family donor and for all high-risk patients with a matched donor

◦ Sorafenib 800mg/day or placebo as add-on to standard treatment

◦ 3-Yr EFS of 22% in placebo vs 40% in sorafenib (p=0.013)

◦ 3-Yr OS of 56% in placebo vs 63% in sorafenib (p=0.382)

FLT3 inhibitors Quizartinib ◦ As 1st salvage therapy for refractory or relapsed A

ML ◦ 2012 ASH annual meeting

◦ 92 FLT3-ITD mutated AML patients

◦ Age > 60

◦ Composite CR (CR, CRp, and CRi): 54%

◦ CRi: <5% marrow blasts, ANC < 1,000, PLT < 100K

◦ 0 CR, 3% CRp

◦ Median OS: about 6 months

◦ 23% of patients received HCT

◦ As 2nd salvage therapy for refractory or relapsed AML ◦ 2012 ASH annual meeting

◦ 99 FLT3-ITD mutated AML patients

◦ Age > 18

◦ Composite CR: 44%

◦ CRi: <5% marrow blasts, ANC < 1,000, PLT < 100K

◦ 4% CR, 0 CRp

◦ Median OS: about 6 months

◦ 34% of patients received HCT

◦ Median OS with HCT: 33.3 weeks

◦ Median OS without HCT: 17.7 weeks

Mutations of the CCAAT enhancer-binding protein ɑ (CEBPA) gene

Thomas Pabst, and Beatrice U. Mueller Clin Cancer Res 2009;15:5303-5307

Single or double mutated CEBPA gene

Single or double mutated CEBPA gene

FLT3-ITD and CEBPA

FLT3-ITD negative FLT3-ITD positive

Mutations in tet oncogene family member 2 gene TET2 gene

◦ Epigenetic regulation

◦ Myeloid neoplasm with mutant TET2: decreased hydroxylation of 5-methylcytosine

Myunggon Ko, and Anjana Rao Blood 2011;118:4501-4503

Prognostic impact of tet2 mutation

Wen-Chien Chou et al. Blood 2011;118:3803-3810

OS stratified by the status of TET2 mutations in different subgroups of patients.

OS in 172 patients with intermediate-risk cytogenetics stratified by status.

Meta-analysis of tet2 mutation

Liu WJ et al Leuk Lymphoma. 2014;55(12):2692-2698

Mixed-lineage leukemia gene Found in 5 to 11% of patients with CN-AML and frequently in those with AML with trisomy 11.

Leukemogenesis through DNA hypermethylation and epigenetic silencing of tumor suppressor genes

MLL-PTD: inferior CR duration and RFS

Nature Reviews Cancer 7,823-833

Case 평소 건강하였던 37세 남자 환자가 2주간 지속된 미열과 전신 무력감으

로 내원하였다. 활력징후는 혈압 125/76 mmHg, 맥박수 86/분, 호흡수

18/분, 체온 37.2 ̊C였다. 결막은 약간 창백하였다. 흉부 진찰 및 복부 진

찰에서는 특이 소견이 없었고, 만져지는 림프절도 없었다. 피부에도 특

별한 병변은 관찰되지 않았다. 검사 소견은 다음과 같았다.

WBC 27,000 – Hb 7.8 – PLT 43K (ANC 450, Blast 61%)

Bone marrow exam: Hypercellular marrow (cellularity 90%),

packed with immature cells

Immunophenotype: CD13 (+), CD33 (+), CD 117 (+), MPO (+)

Chromosome analysis: 46,XY [20]

Acute Myeloid Leukemia with normal karyotype

이 환자와 같이 CN-AML에서 좋은 예후를 시사하는 genetic

mutation 은?

1. Nucleophosmin 1 gene mutation

2. FMS-like tyrosine 3 gene internal tandem duplication

3. Single CCAAT enhancer-binding protein ɑ mutation

4. TET oncogene family member 2 mutation

5. Mixed-lineage leukemia gene partial tandem duplication

Case 평소 건강하였던 37세 남자 환자가 2주간 지속된 미열과 전신 무력감으로 내원하였다. 활력징후는 혈압 125/76 mmHg, 맥박수 86/분, 호흡수 18/분, 체온 37.2 ̊C였다. 결막은 약간 창백하였다. 흉부 진찰 및 복부 진찰에서는 특이 소견이 없었고, 만져지는 림프절도 없었다. 피부에도 특별한 병변은 관찰되지 않았다. 검사 소견은 다음과 같았다.

WBC 27,000 – Hb 7.8 – PLT 43K (ANC 450, Blast 61%)

Bone marrow exam: Hypercellular marrow (cellularity 90%),

packed with immature cells

Immunophenotype: CD13 (+), CD33 (+), CD 117 (+), MPO (+)

Chromosome analysis: 46,XY [20]

Acute Myeloid Leukemia with normal karyotype

CEBPA double-mutated, NPM1 wild-type, FLT3-ITD positive

Cytogenetics와 genotypes을 함께 고려하였을 때

동종조혈모세포이식을 시행하지 않을 때 예상되는

재발율은?

1. 30-40%

2. 50-60%

3. 70-80%

4. >90%

Mutational Complexity of AML

Patel JP et al. N Engl J Med 2012;366:1079-1089.

Risk Stratification of CN-AML Dohner H et al

Estey EH et al CR rate; Relapse w/3+7 w/o HCT

Favorable NPM1 mut/FLT3-ITD –

CEBPA mut

NPM1 mut/FLT3-ITD –

CEBPAdm > 80-90%; 35-40%

Intermediate I

NPM1 mut/FLT3-ITD +

NPM1 wt/FLT3-ITD +

NPM1 wt/FLT3-ITD –

NPM1 wt/FLT3-ITD –

CEBPAsm 50-80%; 50-60%

Intermediate II MLLT3-MLL FLT3-ITD + 50-80%; 70-80%

Unfavorable MLL rearranged <50%; >90%

Dohner H et al (ELN recommendation, Blood 2010;115:453-474) Estey EH et al (Am J Hema 2014;89:1064-1081)

Deciding on allogeneic transplantation in CR1

ELN group Postremission

Favorable Conventional consolidation with chemotherapy

Int-I Allo-HCT from MSD if risk NRM < 20-25%

Int-2 Allo-HCT from MSD or MUD if risk NRM < 30%; if FLT3-ITD +ve, consider use of FLT3 inhibitor post HCT

Adverse Allo-HCT from MSD or MUD if risk NRM < 40%

Cornelissen JJ H et al. Nat Rev Clin Oncol 2012;9:579-590

Modified based on Estey EH et al Am J Hema 2014;89:1064-1081

Case 평소 건강하였던 37세 남자 환자가 2주간 지속된 미열과 전신 무력감으로 내원하였다. 활력징후는 혈압 125/76 mmHg, 맥박수 86/분, 호흡수 18/분, 체온 37.2 ̊C였다. 결막은 약간 창백하였다. 흉부 진찰 및 복부 진찰에서는 특이 소견이 없었고, 만져지는 림프절도 없었다. 피부에도 특별한 병변은 관찰되지 않았다. 검사 소견은 다음과 같았다.

WBC 27,000 – Hb 7.8 – PLT 43K (ANC 450, Blast 61%)

Bone marrow exam: Hypercellular marrow (cellularity 90%),

packed with immature cells

Immunophenotype: CD13 (+), CD33 (+), CD 117 (+), MPO (+)

Chromosome analysis: 46,XY [20]

Acute Myeloid Leukemia with normal karyotype

CEBPA double-mutated, NPM1 wild-type, FLT3-ITD positive

Cytogenetics와 genotypes을 함께 고려하였을 때

동종조혈모세포이식을 시행하지 않을 때 예상되는

재발율은?

1. 30-40%

2. 50-60%

3. 70-80%

4. >90%

Future perspectives 1. Discovery of new mutations

2. Preferential association and mutual exclusions among mutations in the context of CN-AML

3. Hierarchy among gene mutations occurring in CN-AML

4. Improving the outcomes of CN-AML

5. Minimal residual disease

6. Molecular targeted therapy