Elisabetta Calistri

Incidence, risk factors and management of pleural effusions during dasatinib treatment in unselected elderly patients with chronic myelogenous leukaemia

To assess the most important features and clinical impact of pleural effusions, which are a common toxicity during dasatinib treatment and often impair its high efficacy, 172 unselected consecutive patients with chronic myelogenous leukaemia in chronic phase treated in 27 Italian centres, with dasatinib when aged >60 years for resistance/intolerance to imatinib, were examined. During treatment, 52/172 patients (30.2%) presented pleural effusion, which was grades 1–2 in 38 patients and grades 3–4 in 14 patients (8.1% of the entire cohort of patients), according to the WHO scale; in 14/52 patients (26.9%), there was a concomitant pericardial effusion. Pleural effusion was recurrent in 25/52 patients (48.0%). Median time from dasatinib to first pleural effusion was 11.0 months (interquartile range 3.6–18.6). Eleven patients (6.4%) required permanent dasatinib discontinuation. Only presence of concomitant pulmonary disease ( p = 0.035) and initial daily dose of dasatinib (140 mg vs 100 mg, p = 0.014) were significantly associated with pleural effusions. There were no differences among patients with or without pleural effusions as concerns response rates and overall survival. Pleural effusions were common in our unselected ‘real‐life’ population of elderly patients but were clinically manageable and did not seem to affect treatment results. Copyright

Biological and clinical features of T-biphenotypic acute leukaemia: report from a single centre.

We read with interest the work from Rubio et al (2003) on adult T-biphenotypic leukaemia, reporting the clinical and biological characteristics of this rare clinical entity. We have reviewed our file of acute leukaemias, both lymphoblastic and myeloid, to identify the biphenotypic acute leukaemias (BAL) and, among them, the cases co-expressing T-lymphoid and myeloid markers. In the last 10 years (1993–2003), we have diagnosed 280 acute leukaemias, 202 myeloid (AML) and 78 lymphoblastic (ALL). Using the diagnostic criteria recently proposed (Bene et al, 1995), 26 (9%) patients had a BAL. In accordance with other reports (Legrand et al, 1998; Killick et al, 1999), the most common BAL phenotype consisted of the co-expression of myeloid and B-lymphoid markers, but three of these patients (11Æ5%) had a T-BAL. Clinical and biological characteristics of the patients are listed in Table I. Two of the patients were female and one was male. The median age at diagnosis was 58 years (range 26–60 years). According to the French–American–British (FAB) classification, all the patients had a type 2 ALL, with co-expression of myeloid markers, with a score of at least two for both T-lymphoid and myeloid markers. Cytogenetic analysis was available for two patients. Both showed a deletion of chromosomes 7 and 12, plus other abnormalities; no Philadelphia chromosome (Ph+) metaphases were documented. When karyotype was missing, BCR-ABL transcripts were not detected by molecular biology. We analysed the multidrugresistance (MDR) proteins and found an overexpression of P-glycoprotein with a mean of 7Æ2 (range 6Æ6–8Æ1), while lung resistance-related protein and multidrug resistance-related protein 1 were normally expressed. Two patients (patients 2 and 3) received an ALL-designed induction therapy (vincristine, idarubicin, prednisone and asparaginase). Patient 2 died during induction due to a haemolytic-uraemic syndrome and pneumonia. Patient 3 achieved a complete remission (CR) that was consolidated with two courses of therapy (high-dose cytarabine, then vincristine, methotrexate, cyclophosphamide and adriamicin). She relapsed after 5 months but attained a second CR with salvage therapy (liposomal daunorubicin and high-dose cytarabine). The remission lasted for another 4 months, then the patient relapsed again and died of cerebral haemorrhage. Patient 1 displayed a more undifferentiated morphology, with two blast populations. He initially received an AML-like course with idarubicin and low-dose cytosine arabinoside. Day +14 bone marrow was still completely blastic, but with more distinctive lymphoid features. He therefore was switched to our ALL protocol, attaining a CR and subsequently underwent an autologous bone marrow transplant. He is alive in CR, 9 years after transplant. Our small experience partially confirms the findings of Rubio et al (2003). In addition, our patients were morphologically classified as L2 and presented superficial adenopathies at diagnosis, but none of them had mediastinal involvement. Leucocytosis and peripheral blast count were generally low or moderate. None of our patients had the Philadelphia chromosome or BCR-ABL rearrangement, but two cases displayed unfavourable cytogenetics, with deletions of chromosome 7. In a previous report, four of six patients with T-BAL had a complex karyotype and none was Ph+ (Carbonell et al, 1996). Treatment of BAL remains controversial and these patients have generally a bad prognosis. Except in patient 2, who died during induction, we observed a good response when a mixed or ‘sequential’ AML/ALL induction therapy was used, possibly followed by intensification with transplantation. When an ALL-type course was used alone (patient 3), a CR was obtained but it was short-lived, and also a salvage therapy with high-dose cytarabine and liposomal daunorubicin was only

Complete remission induced by thalidomide in a case of angioimmunoblastic T-cell lymphoma refractory to autologous stem cell transplantation

Angioimmunoblastic T-cell lymphoma (AITL) is a peripheral T-cell lymphoma characterised by a very aggressive clinical course. Despite conventional treatment, usually intensive adriamycin-containing chemotherapy, patients affected by AITL have a poor prognosis with a median survival of less than 3 years [1]. High-dose chemotherapy with stem cell transplantation (HDCT/ASCT) may rescue patients who fail to achieve the complete remission (CR) after induction chemotherapy, finally leading to an improved long-term event-free survival [2], but chemosensitivity is the widely accepted requirement at the time of transplantation [3]. In this scenario, efforts to identify novel approaches aimed at overcoming resistance to conventional cytotoxic agents are warranted. Here we present a case of AITL refractory both to first line chemotherapy and HDCT/ASCT that achieved a 6-month lasting CR with thalidomide alone. The patient was a 52-year-old male who presented in November 2005 complaining of a 2-month history of systemic symptoms. Physical examination and positron emission tomography/computed tomography scan (PET/CT) showed generalised lymphadenopathies, marked splenomegaly, mild hepatomegaly and bilateral pleural effusions. Laboratory evaluation documented pancytopenia with evidence of concomitant autoimmune hemolytic anemia (increased unconjugated bilirubin, reduction of plasma haptoglobin levels and positive direct antiglobulin test) and hypergammaglobulinemia. Biopsy of a left axillary lymph node confirmed AITL. Trephine bone marrow biopsy showed a diffuse infiltrate of lymphoma cells. Because of the hemolytic process, first line therapy was based on prednisone 1 mg/kg/day with a rapid improvement of the hemoglobin level. Starting in December 2005 the patient received MACOP-B regimen (methotrexate 400 mg/m weeks 2, 6 and 10 with leucovorin rescue, doxorubicin 50 mg/m weeks 1, 3, 5, 7, 9 and 11, cyclophosphamide 350 mg/m weeks 1, 3, 5, 7, 9 and 11, vincristine 1.4 mg/m weeks 2, 4, 6, 8, 10 and 12, prednisone 40 mg/m weeks 1–12, and bleomycin 10 mg/m weeks 4, 8 and 12) that induced only a partial reduction of B-symptoms. BFM protocol (cycle A: methotrexate 3000 mg/m day 1 with leucovorin rescue, vincristine 2 mg/m day 1, cyclophosphamide 200 mg/m days 1–4, doxorubicin 25 mg/m day 4, dexamethasone 10 mg/m days 1–4; cycle B: methotrexate 3000 mg/ m day 1 with leucovorin rescue, vincristine 2 mg/m day 1, ifosfamide 800 mg/m days 1–4, cytosine arabinoside 150 mg/m day 4, VM-26 100 mg/m day 4, dexamethasone 10 mg/m days 1–4) was delivered as salvage therapy starting in April 2006. After two cycles of the latter therapy, although the complete resolution of systemic symptoms was observed, only a partial reduction (550%) of lymphadenopathies and of splenomegaly was documented. Bone marrow lymphoma infiltration reduced to less than 10%. We then addressed the

EUTOS score predicts long-term outcome but not optimal response to imatinib in patients with chronic myeloid leukaemia

To test the recently developed EUTOS score in predicting optimal response to imatinib and the long-term outcome, 265 patients with early chronic phase chronic myeloid leukaemia treated with standard dose imatinib were analysed. Achievement of optimal response endpoints were higher in low-risk patients, though the difference was not statistically significant: PCyR at 6th month 86% vs 67% (p=0.06), CCyR at 12th month 80% vs 63% (p=0.09), MMR at 18th month 61% vs 36% (p=0.11). However, EUTOS score was predictive for the long-term response. With a median follow-up of 61 months, 53% high-risk patients experienced imatinib failure, compared to 23% in the low-risk group (p=0.013). Among high-risk patients, 4/17 (23%) progressed to accelerated/blastic phase or died, compared to 11/248 (5%) low-risk patients, with 5-year progression-free survival rates of 84±10% and 96±1%, respectively (p=0.04). Our data confirm that EUTOS score envisions the long-term outcome of imatinib therapy.

Imatinib and polypharmacy in very old patients with chronic myeloid leukemia: effects on response rate, toxicity and outcome

Background About 40% of all patients with chronic myeloid leukemia are currently old or very old. They are effectively treated with imatinib, even though underrepresented in clinical studies. Furthermore, as it happens in the general population, they often receive multiple drugs for associated chronic illnesses. Aim of this study was to assess whether or not in imatinib-treated patients aged >75 years the exposure to polypharmacy (5 drugs or more) had an impact on cytogenetic and molecular response rates, event-free and overall survival, as well as on hematological or extra-hematological toxicity. Methods 296 patients at 35 Italian hematological institutions were evaluated. Results Polypharmacy was reported in 107 patients (36.1%), and drugs more frequently used were antiplatelets, diuretics, proton pump inhibitors, ACE-inhibitors, beta-blockers, calcium channel blockers, angiotensin II receptors blockers, statins, oral hypoglycemic drugs and alpha blockers. Complete cytogenetic response was obtained in 174 patients (58.8%), 78 (26.4%) within 6 month, 63 (21.3%) between 7 and 12 months. Major molecular response was obtained in 153 patients (51.7%), 64 (21.6%) within the 12 month. One hundred and twenty-eight cases (43.2%) of hematological toxicity were recorded, together with 167 cases (56.4%) of extra-hematological toxicity. Comparing patients exposed to polypharmacy to those without, no difference was observed pertaining to the dosage of imatinib, cytogenetic and molecular responses and hematological and extra-hematological toxicity. Conclusion Notwithstanding the several interactions reported in the literature between imatinib and some of the medications considered herewith, this fact does not seem to have a clinical impact on response rate and outcome.

Imatinib-treated chronic myeloid leukemia patients with discordant response between cytogenetic and molecular tests at 3 and 6 month time-points have a reduced probability of subsequent optimal response

The 2013 version of the European LeukemiaNet (ELN) recommendations for the management of chronic myeloid leukemia (CML) patients defines as optimal response the achievement of a partial cytogenetic response (PCyR) and/or BCR-ABL1 transcript ≤10%IS at 3 months, and of a complete cytogenetic

EUTOS score predicts early optimal response to imatinib according to the revised 2013 ELN recommendations

Dear Editor, One of the most significant novelty of the revised version of the European LeukemiaNet (ELN) recommendations for the management of chronic myeloid leukemia (CML) patients is that an earlier achievement of complete cytogenetic response (CCyR), at 6 months, and major molecular response (MMR), at 12months, is regarded as optimal [1]. Moreover, prognostic value of the depth of molecular response at 3 (BCR-ABL ≤10 %) and 6 (BCR-ABL ≤1 %) months is recognized. Our group reported that EUTOS score predicts long-term outcome of imatinib therapy, and that high-risk patients had a trend for lower probability to achieve all the cytogenetic and molecular endpoints defined as optimal by 2009 ELN recommendations [2]. We retrospectively evaluated our cohort of CML patients treated with frontline standard dose imatinib to test the ability of EUTOS [3] and Sokal [4] scores to predict 2013 ELNdefined optimal response to therapy. A total of 314 consecutive patients treated with imatinib 400 mg/day for early chronic phase CML were analyzed. Median age at diagnosis was 57 years (range 19–85 years). According to the Sokal score, there were 133 (42 %) low risk, 127 (40 %) intermediate risk, 52 (17 %) high risk, and 2 (1 %) unknown risk cases, respectively. For the purposes of this analysis, and as suggested by ELN experts, we considered lowand intermediate-risk patients as a single group (n =260). The distribution according to the EUTOS score assigned 289 patients (92 %) to the low-risk and 25 (8 %) to the high-risk group. Definitions of partial cytogenetic response (PCyR), CCyR, and MMR were in accordance with ELN recommendations [1]. Results are reported in Table 1. Considering EUTOS score, at 3 months, we observed a significant higher rate of optimal molecular response (BCR-ABL ≤10 %) in low-risk (76 %) compared to high-risk (52 %, p =0.03) patients, while there was only a trend for cytogenetic response (PCyR) (86 vs 75 %, p =0.20). At 6 months, both cytogenetic (CCyR) and molecular (BCR-ABL ≤1 %) optimal responses were higher in the low-risk group: 76 versus 46 % (p =0.003) and 67 versus 33 % (p =0.004), respectively. At 12 months, 58 % of low-risk patients were in MMR, compared to 41 % in the high-risk group (p =0.20). According to Sokal score, we found a significant difference in favor of intermediate–lowrisk patients in terms of cytogenetic response both at 3 (PCyR 88 vs. 72%, p =0.03) and at 6 (CCyR 79 vs. 48%, p =0.0001) months, while no significant differences were seen in molecular response at 3 (BCR-ABL ≤10%: 76 vs. 62 %, p =0.13), 6 (BCR-ABL ≤1 %: 67 vs. 50 %, p =0.08), or 12 (MMR: 56 vs. 55 %, p =1.00) months. Our results suggest that EUTOS score is able to predict optimal response to imatinib, in particular, achievement of molecular response at 3 months, a marker of emerging importance in predicting long-term outcome [5], and of CCyR at 6 months, that has been associated with superior progressionMassimiliano Bonifacio and Mario Tiribelli equally contributed to this work.

Effect of amifostine on the cytotoxicity of daunorubicin and daunoxome in tumor and normal cells

Anthracyclines are powerful cytotoxic agents, used as first-line treatment of leukemias and many other tumors, but host-tissue toxicity is their main dose-limiting factor. However, their therapeutic effects depend not only on the toxicity, hence on the dose, but also on drug resistance. Among the mechanisms that can account for cell sensitivity to anthracyclines, there is an overexpression of drug transport proteins, like the transmembrane P-glycoprotein (PGP), the multidrug- resistance-related protein (MRP) and the lung-resistance-related protein (LRP). Attempts to reduce the toxicity of chemotherapeutic agents without affecting their efficacy have been made using liposomal anthracyclines or cytoprotective agents, as Amifostine. The aim of this study was to evaluate and compare the toxic effects of Daunorubicin, in normal or liposomal formulation, used in combination with WR1065, the active metabolite of Amifostine, against normal and tumor cells. In conclusion these data show that the preincubation with WR-1065 does not inhibit the drug toxic effect on blast cells and on tumor cell lines, independently by their multidrug resistance phenotype, but has a cytoprotective effect on stem cells causing a drug cytotoxicity reduction of 10–20%. This advantage is even higher using the liposomal formulation of DNR. Therefore, Amifostine can offer a chance of protecting normal cells from the toxicity of anthracyclines, in normal or liposomal formulation. The combination of liposomal anthracyclines with Amifostine can confer further advantages in management of leukemic patients, especially the elderly where treatment toxicity is a main problem. These patients may be candidates for alternative therapeutic strategies and the combination of DNX and Amifostine is an attractive treatment for these cases where a low nonhematological toxicity is required.

Combination of EUTOS score and 3-month BCR-ABL transcript level identifies a group of good-risk chronic myeloid leukemia patients with favorable response to frontline imatinib therapy.

as one of the potential putative driver mutations. ZEB2 has been implicated to have crucial role in hematopoietic stem cell differentiation, mobilization, and homing [3]. Conditional overexpression of ZEB2 in mice has been reported to induce T-cell leukemia and deleterious mutations of ZEB2 have been identified in other leukemias [4,5], further suggesting the possible association between altered ZEB2 function and leukemogenesis. These are consistent with ZEB2 being a likely driver mutation in this case. The PCR capillary electrophoresis (PCR-CE) assay detected an NPM1 p.W288fs and several different sizes of FLT3-ITD in both samples (Supporting Information table). We next inferred a model of clonal evolution by tracing cancer cell fraction (CCF) of the detected variants (Fig. 1). Both primary and relapse AML shared the same founder clone with IDH1, ZEB2, and most likely the NPM1 mutation. Although the method of variant allelic fraction (VAF) calculation is different between WES and PCR-CE, VAF of NPM1 mutation on PCR-CE was stable around 0.5. Further, a previous study has shown that NPM1 mutation is almost always an early founding event in AML, consistent with the NPM1 mutation as early clonal event in this case. We did not incorporate FLT3-ITD into our model because association between respective ITD sizes and clonality has not been well understood. However, as a whole, FLT3-ITD was clearly detected at two time points, suggesting that this mutation persisted in the dominant clone. Our model suggests that the founder clone persisted after initial therapy and relapsed 19 years later with additional mutations acquired. Overall, it is consistent with one of the models that were proposed by Ding et al., who performed whole genome sequencing on eight relapsed AML cases, all of which relapsed within 3 years of remission [6]. Our report differs in that our case had a larger fraction of relapse-specific mutations and fewer shared mutations between primary and relapse AML. This would be consistent with the much longer period before relapse and accumulation of additional mutations over this time period. We also observed the emergence of a minor population with an SF3B1 mutation at relapse. CCF of the SF3B1 mutation did not follow that of the founder clone after salvage therapy (Fig. 1). SF3B1 mutation is frequently associated with MDS but rare in AML. The studied patient was suspected to have MDS 3 years before she experienced relapse (Supporting Information Appendix). Taken together, it is likely that the clone with SF3B1 mutation represents the co-occurrence of MDS in the context of a relapsing AML. In summary, longitudinal genomic characterization of an individual with a late relapse of AML revealed that the founder clone of the primary AML persisted after treatment and constituted the basis of relapsed disease 19 years later, hence confirming “true” relapse. More cases of late relapse in AML need to be examined to better characterize the mechanisms of relapse and disease latency.

Excellent outcomes of 2G-TKI therapy after imatinib failure in chronic phase CML patients

Second-generation tyrosine kinase inhibitors (2G-TKIs) dasatinib and nilotinib produced historical rates of about 50% complete cytogenetic response (CCyR) and about 40% major molecular response (MMR) in chronic myeloid leukaemia (CML) patients failing imatinib. Direct comparisons between dasatinib and nilotinib are lacking, and few studies addressed the dynamics of deep molecular response (DMR) in a “real-life” setting. We retrospectively analyzed 163 patients receiving dasatinib (n = 95) or nilotinib (n = 68) as second-line therapy after imatinib. The two cohorts were comparable for diseases characteristics, although there was a higher rate of dasatinib use in imatinib-resistant and of nilotinib in intolerant patients. Overall, 75% patients not in CCyR and 60% patients not in MMR at 2G-TKI start attained this response. DMR was achieved by 61 patients (37.4%), with estimated rate of stable DMR at 5 years of 24%. After a median follow-up of 48 months, 60% of patients persisted on their second-line treatment. Rates and kinetics of cytogenetic and molecular responses, progression-free and overall survival were similar for dasatinib and nilotinib. In a “real-life” setting, dasatinib and nilotinib resulted equally effective and safe after imatinib failure, determining high rates of CCyR and MMR, and a significant chance of stable DMR, a prerequisite for treatment discontinuation.