Hematologic Malignancies CON 616, 2009 William H. Fleming, M.D., Ph.D. Division of Hematology & Medical Oncology Hematologic Malignancies Section Knight

Hematologic MalignanciesCON 616, 2009

William H. Fleming, M.D., Ph.D.Division of Hematology & Medical Oncology

Hematologic Malignancies Section

Knight Cancer Institute

OHSU

Blood Cell Formation

Acute vs. Chronic Leukemia

• Acute Leukemia (AML and ALL)– excess myeloblasts or lymphoblasts– short clinical course (weeks to months)

• Chronic Leukemia (CML and CLL)– accumulation of mature granulocytes or

lymphocytes– longer clinical course (several to many years)

Acute Leukemia

• A clonal, molecular abnormality of hematopoietic blast cells resulting in a failure of differentiation & uncontrolled cell proliferation

• Accumulation of leukemic blast cells results in marrow replacement, organ infiltration and metabolic effects

Acute Leukemia:AML versus ALL

• Adults - 85% of acute leukemia is AML

• Children-85% of acute leukemia is ALL

• Leukemic Blast morphology

– AML: cytoplasmic granules, Auer rods, more cytoplasm, 2-5 nucleoli

– ALL: no cytoplasmic granules, minimal cytoplasm, 1-2 nucleoli

Acute Leukemia:Clinical Manifestations

• Constitutional & Metabolic effects:

– Weight loss

– Fever

– Hyperkalemia

– Hyperuricemia

Acute Leukemia:Hematology Laboratory Findings

• Decreased, normal or elevated WBC

• Anemia

• Thrombocytopenia

• Blasts on peripheral blood smear (often)

• Hypercellular bone marrow with 20% or more blasts (normal is < 5%)


• Marrow replacement, organ infiltration & metabolic effects

• Marrow replacement

– Neutropenia: infection

– Anemia: pallor, fatigue, dyspnea

– Thrombocytopenia: abnormal bruising and bleeding


• Organ infiltration

– Bone pain

– Hepatosplenomegaly

– Lymphadenopathy

– Gingival hypertrophy

– Leukemic meningitis

AML With Minimal Differentiation(M0/M1)

Acute LeukemiaAML vs. ALL

• Cell Surface Markers by Flow cytometry

• AML• CD13, CD33, glycophorin (M6), platelet antigens (M7)

• ALL

B lineage: CD19, CD22, CD10 (+/-), surface Ig,

T lineage: CD2, CD3, CD5, CD7

AML:FAB classification

• French American British classification

• M0-M7 based on morphology, and special cytochemical studies

• Historically, distinguishing AML M0 from ALL was a major clinical problem

AMLFAB classification

• M0,M1, M2: Myeloblasts with no, little or some granulocytic maturation

• M3: Promyelocytic leukemia

• M4: Myelomonocytic or eosinophilic

• M5: Monocytic

• M6: Erythroleukemia

• M7: Megakaryoblastic

Not all that useful except for M3 or APL

Acute Leukemia:Blasts with Auer Rods

Auer rods = AML

Acute Leukemia:AML vs. ALL

• Cytochemistry AML ALL

• Myeloperoxidase + -

• Sudan black + -

• Non-specific esterase + (M4,5) -

• PAS + (M6) +

• Acid phosphatase + (M6) +

FAB is Supplemented by Cytogenetic and Molecular analysis

Flow Cytometry & FISH Analysis

Gingival Hyperplasia

Chloroma (Granulocytic Sarcoma)

Leukemia Cutis

AMLClinical Features & Prognosis

• Age– < 60 years: >80% remission, 20-30% DFS– > 60 years: ~60% remission, 5-15% DFS

• Prior marrow disorder: Myelodysplasia (MDS)

• Secondary AML (prior chemo or radiotherapy)

• Response to induction therapy

AMLCytogenetics & Prognosis

• Favorablet(8;21), t(15;17), inv(16)

• Intermediate (Most patients)normal, +8, +21, +22, del(7q), del(9q),

• Adverse-5, -7, del(5q), abnormal 3q, complex karyotype (> 3 -5 abnormalities)

AMLCytogenetics and Prognosis

• Group CR 5 year survival

• Favorable91% 65-75%

• Intermediate 86% 40-50%

• Adverse 63% <15%

AMLMutations & Prognosis

• Flt 3 (ITD) - Adverse

• NPM-1 mutation & no Flt3 - Favorable

• MLL (PTD) - Adverse

• CEBPA - Favorable

AML Treatment:Induction Chemotherapy

• Anthracycline (Idarubicin) for 3 days and Cytosine arabinoside (Ara-C) for 7 days (3+7, Younger/fit patients only)

• Three to 5 weeks of pancytopenia

• Supportive care red cell and platelet transfusions, prophylactic antibacterial, antifungals and antivirals

AML:Response to Induction

• Remission status determined by bone marrow at end of month following induction therapy (e.g. Day 14 & 28)

• Complete remission:– Normal peripheral blood counts– Normocellular marrow with < 5% blasts

and normal marrow cell maturation

AML Treatment:Consolidation

Following induction into Complete Remission

• 3-4 cycles of high dose cytosine arabinoside (HiDAC) administered approximately every 5-6 weeks

OR• Bone marrow (peripheral blood stem cell) transplant

(Depends on degree of risk)

AML Treatment:Alternative Consolidation

One or more cycles of consolidation chemotherapy then either:

Autologous stem cell transplant after high dose chemotherapy

or

Allogeneic bone marrow transplantation after high dose chemotherapy

AML TreatmentAutologous Transplant

AdvantageCollection and subsequent infusion of patient’s stem cells allows administration of otherwise lethal doses of chemotherapy

DisadvantagesDespite CR, leukemic cells may persist in marrow, blood and stem cell productHigh dose therapy more toxic than standard consolidation

AML Treatment:Allogeneic Transplant

Advantages

Stem cells from HLA-matched sibling or unrelated individual allow high dose therapy and are free of leukemia

Immunologic graft versus leukemia effect (GVL).Results in decreased rate of leukemic relapse


Disadvantages

– Immunologic graft versus host disease (GVHD) and immunosuppressive therapy result in significant morbidity and mortality

– GVHD incidence and severity increases with increasing age. (Best results in Pediatrics)

– Tolerability of high dose transplant limited by patient age. (Reduced dose being evaluated)

AML Treatment:A risk adapted approach

• FavorableConventional chemotherapy followed by transplant only if relapse occurs

• Intermediate Conventional chemotherapy alone or autologous or allogeneic transplant

• Adverse Conventional chemotherapy followed by

allogeneic transplant

Current Risk Stratification OHSU Acute Leukemia Program

(modified NCCN Guidelines v.1.2009)

Risk Status Cytogenetics Molecular Mutations

Better-risk Inv(16)1

t(8 ;21) 1

t(16 ;16) 1

Normal cytogenetics with isolated NPM1 mutation

Intermediate-risk Normal+8 onlyt(9 ;11)MK negative

c-KIT3 in patients with t(8;21) or Inv(16)

Poor-risk Complex (>3 abnormalities)-5, -7, 5q-, 7q-MK positive

Normal cytogenetics with isolated FLT3 mutations

AML:NCCN Guidelines

• National Comprehensive Cancer Network (NCCN) has issued guidelines for treatment of many cancers including AML (and other hematologic malignancies)

http://www.nccn.org/index.html

Acute Leukemia:AML versus ALL

• Adults: 85% of acute leukemia is AML

• Children: 85% of acute leukemia is ALL

• Blast morphology

– AML: cytoplasmic granules, Auer rods, more cytoplasm, 2-5 nucleoli

– ALL: no cytoplasmic granules, minimal cytoplasm, 1-2 nucleoli


• French American British classification based on the degree of blast differentiation along different cell lineages and extent of maturation

• M0-M7 based on morphology, lineage-specific cytochemical and immunologic findings


• M0,M1, M2: Myeloblasts with no, little or some granulocytic maturation

• M3: Promyelocytic leukemia (APL)

• M4: Myelomonocytic or eosinophilic

• M5: Monocytic

• M6: Erythroleukemia

• M7: Megakaryoblastic


• Cytochemistry AML ALL

• Myeloperoxidase + -

• Sudan black + -

• Non-specific esterase + (M4,5) -

• PAS + (M6) + (c)

• Acid phosphatase + (M6) + (T)


• Immunologic markers / Flow cytometry

• AML: CD13, CD33, glycophorin (M6), platelet antigens (M7)

• ALL:

– B lineage: CD19, CD22, CD10 (+/-), surface or cytoplasmic Ig, TdT (+/-)

– T lineage: CD7, CD3, TdT

AML-M3 (APL)

AML-M3 (APL)an important FAB subtype

• Acute Promyelocytic Leukemia (M3)

• Blasts and promyelocytes heavily granulated, Auer rods often abundant & disseminated intravascular coagulation (DIC) is common

• Treatment differs from all other AML subtypes. (Differentiating agent therapy)

• Favorable prognosis (>85% survival)

AML:Prognosis

• Age– < 60 years: 80% remission, 20-30% DFS– > 60 years: 50% remission, 5-15% DFS

• Prior marrow disorder: MDS or secondary AML (prior chemo- or radio-therapy)

• Cytogenetic analysis of blasts: specific chromosomal abnormalities dictate blast biology and have a major impact on outcome

• Response to first round of therapy

AML:Cytogenetics and Prognosis

• Favorable– t(8;21), t(15;17), inv(16)

• Intermediate– normal, +8, +21, +22, del(7q), del(9q),

abnormal 11q23, others• Adverse

Autosomal monosomy (-5, -7) abnormal 3q, complex cytogenetics

AML:Cytogenetics and Prognosis

• Group CR 5 year survival

• favorable 91% 65%

• intermediate 86% 41%

• adverse 63% 14%

AML Risk & Mutational Analysis

Frequency of mutations in 872 adults < 60 yrs with normal cytogenetics

• NPM1- 53%

• FLT3 ITD - 31% and FLT3 TK mutations-11%

• CEBPA -13%

• MLL PTD- 7% and NRAS-13%

Schlenk et al. N Eng J Med 358:2008

AML Risk & Mutational Analysis

Schlenk et al. N Eng J Med 358:2008

Significantly associated with complete remission• NPM1 mutation without FLT3 ITD• Mutant CEBPA• Younger age

Allogeneic transplant benefit in first CR was limited to patients with FLT3 ITD or wild type NPM1 and CEBPA

AML Treatment:Induction Chemotherapy

• Anthracycline (e.g. Idarubicin) for 3 days and Cytosine arabinoside (Ara-C) for 7 days

• Several weeks of pancytopenia

• Supportive care: anti-emetics, red cell and platelet transfusions, prophylactic and therapeutic antibacterial, antifungal and antiviral antibiotics

AML:Response to Induction

• Remission status determined by bone marrow at end of month following recovery from induction therapy ( Mean Day 28-35)

• Complete remission:– Normal peripheral blood counts– Normocellular marrow with < 5% blasts

and normal marrow cell maturation

AML Treatment:Subsequent Consolidation

• Following induction into Complete Remission: (favorable & ?intermediate)

• 3-4 Cycles of high dose cytarabine (HiDAC) administered approximately every 5-6 weeks

• No subsequent therapy

• Follow for evidence of relapse

AML Treatment:Alternative Consolidation

• One or more cycles of consolidation chemotherapy (Intermediate or high risk)

• Allogeneic bone marrow transplantation after high dose chemotherapy

• Autologous stem cell transplant after high dose chemotherapy


• Advantages

– Stem cells from HLA-matched sibling or unrelated individual allow high dose therapy and are free of leukemia

– Immunologic graft versus leukemia effect (GVL) translates into decreased rate of leukemic relapse. (How do we know?)


• Disadvantages– Toxicity of high dose chemotherapy– Immunologic graft versus host disease

(GVHD) and immunosuppressive therapy result in significant morbidity and mortality

– GVHD incidence and severity increases with increasing age

– Tolerability of standard transplant limited by patient age

AML Treatment:Autologous Transplant

• Advantage– Collection and subsequent infusion of

patient’s stem cells allows administration of otherwise lethal doses of chemotherapy

• Disadvantages– Despite CR, leukemic cells may persist in

marrow, blood and stem cell product– High dose therapy more toxic than

standard consolidation

AML:Disease Free Survival

Chemo Auto Sib Allo UD Allo

CR1 25-35% 50% 60% 40%

CR2 < 5% 38% 44% 37%

AML Treatment:Risk adapted approach

• Favorable– Conventional chemotherapy followed by

transplant only if relapse occurs• Intermediate

– Conventional chemotherapy alone or Autologous or Allogeneic transplant

• Adverse– Conventional chemotherapy followed by

Allogeneic transplant

(Patients < 60 yrs of age)

AML Treatment:Risk adapted approach

• Considerations include:

– Fitness for conventional chemotherapy

– Cytogenetics and molecular studies

– Co-morbid conditions (transplant vs. observation)

– Novel drugs eg, hypomethylating agents.

(Patients > 60 yrs of age)

AML:NCCN Treatment Guidelines

• National Comprehensive Cancer Network (NCCN) has issued guidelines for treatment of many cancers including AML (and other hematologic malignancies)

• Details can be found at http://www.nccn.org/index.html

AML-M3 or APL

AML-M3 (APL)Acute Promyelocytic leukemia

• HL-60, a human AML cell line (M3) And primary human APL differentiates in vitro following treatment retinoic acid.

• Initial clinical trials of retinoic acid failed. Why?

AML-M3 (APL)Acute Promyelocytic leukemia

• HL-60, a human AML cell line (M3) And primary human APL differentiates in vitro following treatment retinoic acid.

• Initial clinical trials of retinoic acid failed. Why?

• Lab studies & initial clinical trials done with cis-retinoic acid. (Chemical grade cis-retinoic acid is ~5% trans. The trans isomer is active.)

• Dr. Zhu Chen, Shanghi Institute of Hematology first published the all trans-retinoic acid results

AML-M3 (APL)Acute Promyelocytic leukemia• t(15;17) fuses PML gene with retinoic

acid receptor-(RAR-)• PML/RAR- protein represses RAR-

mediated gene activation and granulocyte differentiation

• ATRA (all trans retinoic acid) releases this repression and allows promyelocytes to differentiate

AML-M3 or APL

• Acute Promyelocytic Leukemia (APL M3)

• Blasts and promyelocytes heavily granulated, Auer rods often abundant

• Disseminated intravascular coagulation (DIC) common

• Treatment differs from all other AML subtypes once had the worst prognosis now the best prognosis

AML-M3 or APL

• Treated with a derivative of Vitamin A (all trans retinoic acid or ATRA)

• Favorable prognosis if diagnosed just prior to starting chemotherapy (>80% cured)

• Has chromosomal translocation, t(15;17) involving the retinoic acid receptor- gene that blocks normal granulocyte differentiation

Core Binding Factor in AML

• CBF is an alpha/beta heterodimeric transcription factor

• Disruption of alpha and beta subunits of CBF results in a favorable prognosis (>70% cured)

• t(8;21) fusion of the AML1 gene from chromosome 21q22 with the ETO gene on chromosome 8q22

• Inv(16) fusion of the CBFbeta gene from chromosome 16q22 with the MYH11 gene from chromosome 16p13

Ras Signaling in AML

• Ras proteins function as a hub of signal transduction pathways that promote cell cycling and proliferation and prevent apoptosis

• Receptor tyrosine kinases (RTK) (e.g. FLT3 PDGF, FMS, c-KIT,) bind ligand and transmit signal to activate Ras

• Ras and RTKs play a role in AML

Ras Pathway Mutations are Common in AML

• FLT3 internal tandem duplication 15-30%

• FLT3 point mutation 5-10%

• FMS point mutation 10-20%

• Kit point mutation, deletion, insertion <10%

• Ras point mutations 15-30%

• At diagnosis 30-50% of AML have mutations in Ras pathway and 50% have abnormal phosphorylation of ERK, indicating aberrant pathway activation

FLT3-ITD mutation

• Mutant FLT3 receptors spontaneously dimerize leading to autophosphorylation due to constitutive activation of the tyrosine kinase

• Allow autonomous, cytokine-independent growth in culture

FLT3-ITD mutation and AML

• Associated with leukocytosis and increased marrow blast percentage

• Associated with a poor prognosis due to increased relapse rate

• Can be detected by PCR assay

What to do about AML with FLT3 mutation ?

• More intensive therapy (e.g. Transplant)

• Targeted therapy (in clinical trials):- FLT3 kinase inhibitorsFarnesyl transferase inhibitors (block

transport of Flt3 to the membrane)-Novel agents

Leukemia & the Hematopoietic Microenvironment

• How do we know there’s a significant biologic effect?



• Post transplant, donor derived leukemia



• Post transplant, donor derived leukemia

• Resistance to imatinib (TK inhibitor for CML) occurs in some patients but the in vitro sensitivity to imatinib is unchanged.

AML Summary

• AML is a heterogeneous group of diseases

• Age is one of the most important prognostic factors

• State of the art cytogenetic and mutational analysis is critical to determine prognosis and to guide therapy

• Novel therapeutic agents may be effective in traditional unfavorable risk patients

Complex Cytogenetics Revisited

Breems et al. JCO:2008

• Complex cytogenetics considered unfavorable

• Criteria vary from > 3 to >5 cytogenetic abnormalities

• Favorable cytogenetics trump complex cytogentics?

• 1,975 AML patients aged 15-60 evaluated. Excluding normal cytogenetics and CBF, 733 patients evaluated



Of 733 patients with cytogenetic abnormalities:

Loss of a single chromosome was associated with poor OS (12% at 4 yr). Monosomy 7 most common but other monosomies with same OS.

Structural abnormalities influenced outcome only if associated with a single autosomal monosomy.

>2 monosomal abnormalities very poor prognosis

OS of 3%.




New definition of monosomal karyotype (MK) proposed

After excluding normal cytogentics and CBF subsets

MK negative (MK-) Poor Prognosis: Structural abnormality but

no autosomy. ( OS is 26% at 4 yr).

MK positive (MK+) Very poor prognosis: > 2 autosomal

monosomies or 1 autosomal monosomy and at least one

structural abnormality. ~25% of non-CN non-CBF AML

( OS 4% at 4 yr).

Complex Cytogenetic Revisited


Elderly AML: The importance of reaching CR

Rowe Blood 103:479, 2005 Rowe Leukemia 19:1324, 2003

Goffin & Eisenhauer. Annals of Oncology 2002; 13:1699

Azacitidine and Decitabine are Inhibitors of DNA Methyltransferase

Decitabine in Elderly Patients With AML

• Prospective, open-label, phase II study in elderly patients with untreated AML (N = 55)– Treatment: decitabine 20

mg/m2 on Days 1-5, every 4 weeks

• Patient population– Median age: 74 years

• Range: 61-87– ECOG PS 2: 18%– Poor cytogenetics: 44%– AML transformed from MDS:

35%

CR/Cri in 55 patients

AML De novo 7/31 23%

Transformed MDS 5/19 26%

Therapy related 2/4 50%

Poor risk cyto. 5/23 22%

Inter. risk cyto. 7/29 24%

*Ongoing Phase III trial

Cashen AF, et al. ASH 2008. Abstract 560.

Low-Dose Decitabine in Elderly Patients With AML

• Preliminary results from phase II study of decitabine in elderly untreated AML patients (15 with secondary AML): N = 33

– Median age: 74 years (range: 60-83)

– Risk factors

• > 70 years of age, AHD, poor cytogenetics, ECOG PS 2

• ≥ 3 (n = 16); 2 (n = 15); 1 (n = 2)

– Treatment: decitabine 20 mg/m2 IV daily x 10 days/month → consolidation for 3-5 days/month

• Median cycles: ≥ 3

• Median cycles to CR: 1

– CR: 11/22 (50%)

– Induction mortality: 4 (infections)

Blum W, et al. ASH 2008. Abstract 2957.

Documents

Hematologic Malignancies CON 616, 2009 William H. Fleming, M.D., Ph.D. Division of Hematology & Medical Oncology Hematologic Malignancies Section Knight