Mauro Turrini

Outcome of hyperleukocytic adult acute myeloid leukaemia: A single-center retrospective study and review of literature

Hyperleukocytic acute myeloid leukaemia is considered to have a poor prognosis due to high early death rate secondary to leukostasis. Supportive treatments do not seem to have reduced early exitus in this subset of patients. Prognostic impact of hyperleukocytosis on outcome has been the object of few studies. Clinical characteristics and outcome of 45 consecutive adult patients with newly diagnosed acute myeloid leukaemia presenting to our institution with a white cell count (WBC) above 100 x 10(9)L(-1) were reviewed. The outcome of this subset of patients was compared with 200 patients with a leukocyte count lower than 100 x 10(9)L(-1) similarly treated in the same period. Eight hyperleukocytic patients (17%) died of intracranial haemorrhage or pulmonary failure due to leukostasis within the first 7 days of treatment. A significant association was found between complete response (CR) and absence of hyperleukocytosis, but if early deaths were removed from analysis the difference was no longer significant. Hyperleukocytosis also significantly reduces the overall survival (OS) but does not significantly influence the disease-free survival (DFS). We reviewed in literature studies in which the outcome of series of at least 10 patients with hyperleukocytosis were compared with that of patients with a leukocyte count lower than 100 x 10(9)L(-1). Our data were consistent with those of the literature regarding the rate of early mortality and causes of death. In most of the reviewed series hyperleukocytosis does not seem to influence the outcome of patients. Avoiding early death seems to be an important step in this subset of patients. New data about pathophysiology of leukostasis are needed.

Assessing energy expenditure in cancer patients : A pilot validation of a new wearable device

BACKGROUND Nutrition problems are common in cancer patients and are frequently due to metabolic derangements. Thus, accurately assessing energy expenditure (EE) is important in planning adequate nutrition support. Indirect calorimetry (IC) represents the gold standard method but is not always available or applicable to all settings. The purpose of this study was to preliminary compare a new wearable device, the SenseWear armband (SWA), to IC in cancer patients. METHODS Ten (6 M, 4 F) subjects (mean +/- SD: 56.6 +/- 13.3 years) affected by newly diagnosed acute myelogenous leukemia, undergoing induction chemotherapy, were prospectively enrolled. Resting EE (REE) was measured simultaneously by SWA and IC on admission (day 0) and at discharge (end). Total daily EE (TDEE) was determined by SWA 4 times during the stay (days 0, 7, 14, and end) and predicted values were calculated according to IC REE estimates (TDEE = IC x correction factor 1.2). RESULTS Mean length of stay was 27.1 +/- 6.2 days. Bland-Altman plots revealed no significant differences between overall REE estimates (day 0 + end) performed by IC and SWA (mean +/- SD; 1645 +/- 282 vs 1705 +/- 278 kcal/d) and the correlation was high (r = 0.84; p < .0001). SWA TDEE showed a progressive reduction during the stay. No bias was detected between overall SWA TDEE (1799 +/- 153 kcal/d) and IC predicted TDEE (1974 +/- 176 kcal/d), but there was a wide 95% confidence interval (-672; +321 kcal/d). Moreover, the correlation between these values was significant (r = 0.68; p = .001). CONCLUSIONS SWA seems to provide accurate and reliable estimation of REE and useful information on TDEE also in cancer patients. Its use appears promising. Validation studies on larger samples and different cancer types should be considered.

Old and new prognostic factors in acute myeloid leukemia with deranged core-binding factor beta

Acute myeloid leukemia (AML) with deranged core‐binding factor beta (CBFβ) is usually associated with a favorable prognosis with 50–70% of patients cured using contemporary treatments. We analyzed the prognostic significance of clinical features on 58 patients with CBFβ‐AML aged ≤60 years. Increasing age was the only predictor for survival (P <0.001), with an optimal cut‐point at 43 years. White blood cells (WBCs) at diagnosis emerged as an independent risk factor for relapse incidence (P = 0.017), with 1.1% increase of hazard for each 1.0 × 109/L WBC increment. KIT mutations lacked prognostic value for survival and showed only a trend for relapse incidence (P = 0.069). Am. J. Hematol. 88:594–600, 2013.

Microarray Demonstrates Different Gene Expression Profiling Signatures Between Waldenström Macroglobulinemia and IgM Monoclonal Gammopathy of Undetermined Significance

Waldenström macroglobulinemia (WM) (symptomatic and indolent) and immunoglobulin M (IgM) monoclonal gammopathy of undetermined significance (IgMMGUS) can be identified based on the bone marrow (BM) infiltration and the existence of symptoms. The purpose of this study was to investigate the biological and genetic characteristics of both disorders comparing the molecular signature of WM versus IgMMGUS using microarray analysis. We investigated BM CD19(+) cells isolated from 21 WM patients and 10 IgMMGUS cases, and CD138(+) BM cells isolated from all of the WM patients and 4 of the IgMMGUS cases. Gene expression profiling of WM versus IgMMGUS CD19(+) cells highlighted 151 differently expressed genes and the comparison with CD138(+) cells demonstrated 43 differently expressed genes in WM versus IgMMGUS. Regulation of transcription, Janus kinase/signal transducer and activator of transcription, PI3K/Akt/mammalian target of rapamycin, mitogen-activated protein kinase signaling pathways are the relevant gene ontology biological processes occurring in CD19(+) cells, and immune response, cell activation, and signaling processes developing in CD138(+) cells mainly distinguish WM and IgMMGUS.

Intronless WNT10B-short variant underlies new recurrent allele-specific rearrangement in acute myeloid leukaemia.

Defects in the control of Wnt signaling have emerged as a recurrent mechanism involved in cancer pathogenesis and acute myeloid leukaemia (AML), including the hematopoietic regeneration-associated WNT10B in AC133bright leukaemia cells, although the existence of a specific mechanism remains unproven. We have obtained evidences for a recurrent rearrangement, which involved the WNT10B locus (WNT10BR) within intron 1 (IVS1) and flanked at the 5′ by non-human sequences whose origin remains to be elucidated; it also expressed a transcript variant (WNT10BIVS1) which was mainly detected in a cohort of patients with intermediate/unfavorable risk AML. We also identified in two separate cases, affected by AML and breast cancer respectively, a genomic transposable short form of human WNT10B (ht-WNT10B). The intronless ht-WNT10B resembles a long non-coding RNA (lncRNA), which suggests its involvement in a non-random microhomology-mediated recombination generating the rearranged WNT10BR. Furthermore, our studies supports an autocrine activation primed by the formation of WNT10B-FZD4/5 complexes in the breast cancer MCF7 cells that express the WNT10BIVS1. Chemical interference of WNT-ligands production by the porcupine inhibitor IWP-2 achieved a dose-dependent suppression of the WNT10B-FZD4/5 interactions. These results present the first evidence for a recurrent rearrangement promoted by a mobile ht-WNT10B oncogene, as a relevant mechanism for Wnt involvement in human cancer.

Wide-transcriptome analysis and cellularity of bone marrow CD34+/lin- cells of patients with chronic-phase chronic myeloid leukemia at diagnosis vs. 12 months of first-line nilotinib treatment

BACKGROUND Chronic myeloid leukemia (CML) is a clonal myeloproliferative disorder with heterogeneous biological and clinical features. The biomolecular mechanisms of CML response to tyrosine-kinase inhibitors are not fully defined. OBJECTIVE We undertook a gene expression profiling (GEP) study of selected bone marrow (BM) CD34+/lin- cells of chronic-phase CML patients at diagnosis and after 12 months of TKI nilotinib to investigate molecular signatures characterizing both conditions.

Nilotinib induced bone marrow CD34+/lin-Ph+ cells early clearance in newly diagnosed CP-chronic myeloid leukemia

To the Editor: Chronic myeloid leukemia (CML) is a clonal disorder characterized by Philadelphia (Ph) chromosome and/or BCR/ABL tyrosine-kinase (TK) presence. Target therapy with imatinib has greatly improved its outcome while deeper and faster responses are reported with the secondgeneration TKIs dasatinib and nilotinib. Sustained responses may enable TKI discontinuation. However, a fraction of treatment-free remission patients, including those in long-term complete molecular response (MR), may experience disease recurrence possibly due to persistence of quiescent leukemic precursor cells [ie, leukemic progenitor cells (LPCs) CD341/CD381/lin– and leukemic stem cells (LSCs) CD341/CD38–/lin–]. Time-course and mechanisms of LPCs/LSCs clearance during TKI treatment have not been clearly established yet, although in vitro data suggests that quiescent LSCs are indeed not sensitive to BCR/ABL inhibition. In vivo preliminary data suggest that residual CD341 Ph1 cells are very rarely detected in nilotinib-treated patients in complete cytogenetic response (CCyR), compared to imatinib-treated ones. Moreover, in five patients in CCyR at 3 months of nilotinib-treatment, undetectable CD341 Ph1 cells were reported. Despite the very limited number of patients reported, these in vivo data suggest that the rapid inhibitory activity of nilotinib on CML burden may affect stem cells as well. The PhilosoPhi34 (EudraCT: 2012–005062-34) is a multi-center, prospective single-arm study conducted on behalf of the Rete Ematologica Lombarda (REL). Its primary endpoint was to evaluate the rate of residual CD341/ lin–Ph1 cells in the bone marrow (BM) of CCyR patients after 6 months of nilotinib-treatment by cell selection system and fluorescence in situ hybridization (FISH) analysis. Secondary endpoints evaluated were: clearance of CD341/ lin–Ph1 cells in the BM of CCyR patients at 3 and 12 months of treatment; CCyR rate and the MRs in peripheral blood (PB) at 3, 6, and 12 months of treatment, respectively. The protocol design also included an exploratory study aimed at evaluating the Gene Expression Profiling (GEP) of selected CD341/ lin– cells at diagnosis and at 12 months of treatment using Affymetrix GeneChip Instruments and Software Systems, and Affymetrix GeneChip Human Genome HTA 2.0. This exploratory study was planned to initially include 30 consecutive patients. A total of 87 patients were enrolled and their median time onstudy was 26 months at data analysis. Of the enrolled patients, two discontinued nilotinib by 3 months of treatment while five additional patients discontinued treatment between 6 and 8 months (see Supporting Information Table 2). Of the 84 6-month evaluable samples, 79 showed CCyR and 78 were adequate for FISH analysis; 7 negative tests were excluded since less than 200 nuclei were analyzed. Only 5/71 (7%; CI 95%: 2.3%15.7%) evaluable FISH tested positive. Of the 84 3-month evaluable samples, 76 showed CCyR and 75 were adequate for FISH analysis (10 negative tests excluded); only 8/65 (12.3%; CI95%: 5.5%-22.8%) evaluable FISH tested positive. Of the 80 12-month evaluable samples, 79 showed CCyR and 78 were adequate for FISH analysis (9 negative tests excluded); none of the 69 evaluable FISH tested positive (0.0%; CI95%: 0.0%-5%) (Figure 1A). The 3-month MR of the FISH-positive patients (at 3 and 6 months) tested 0.175% international scale (IS). Evaluation of Response to Treatment. Five of 87 patients failed treatment; none of them progressed to an accelerated or blastic phase; 2 harbored a mutation. Intention to treat (ITT) cytogenetic analysis was as follows: CCyR 77/87 patients (88.5%) at 3 months; CCyR 79/87 patients (90.8%) at 6 months; CCyR 77/87 patients (88.5%) at 12 months. Figure 1B summarizes the ITT and per protocol (PP) rate of MRs at the different time points. Gene Expression Profiling of CD341/LIN– Cells. Gene expression profiling (GEP) experiments, for details see Ref. 5, were conducted on the first 30 evaluable patients enrolled. Since the number of selected CD341/lin– cells collected at diagnosis and at 3, 6, and 12 months showed two opposite trends, the first GEP experiments was performed on the CD341/lin– cells stored at diagnosis. Experiment 1. Patients were grouped according to CD341/lin– cell trends: class 1 (n524) showed highly reduced levels of CD341/ lin– cells while class 2 (n56) demonstrated increasing levels of CD341/lin– cells at both 3 and 6 months. Bioinformatics analysis was performed: 56 transcripts could be selected which differed between the two classes (Supporting Information Table 4). Of note, a large part of the transcripts identified have not been characterized yet; 31/56 transcripts were located on chromosome 15. Among the transcripts with known function, we focused on the NFKBIA gene for its biological relevance in the regulation of apoptotic pathways and cell proliferation. Sample analysis showed an over expression of NFKBIA in class 1 patients, ie those showing decreasing number of C341/lin– cells over time.

Secondary acute myeloid leukaemia in elderly patients: Patient's fitness criteria and ELN prognostic stratification can be applied to guide treatment decisions. An analysis of 280 patients by the network rete ematologica lombarda (REL)

KI (P< .005) (Figure 1B). The BCL-2 inhibitor venetoclax may represent another therapeutic option after KI withdrawal, especially in case of CLL progression. Preliminary data of a phase 2 study showed an estimated 12-month PFS of 80% for patients previously treated with either ibrutinib or idelalisib, with 45% of patients achieving MRD negativity in the peripheral blood, and one patient achieving bone marrow negative MRD. As a conclusion, our data suggest that the use of an alternative KI after first KI discontinuation because of adverse events may be a reasonable option for CLL patients. The outcome is significantly worse for patients progressing while treated by kinase inhibitor, and venetoclax represents a better alternative treatment in this particular setting.

Corrigendum: Intronless WNT10B-short variant underlies new recurrent allele-specific rearrangement in acute myeloid leukaemia (Scientific Reports (2017) 6 (37201) DOI: 10.1038/srep37201)

Scientific Reports 6: Article number: 37201; published online: 17 November 2016; updated: 26 April 2017 This Article contains typographical errors in the Methods section under subheading ‘WNT10B/WNT10B IVS1 Gene expression analysis’. “The WNT10B (P4-P2 primers) amplification was performed with following thermal conditions: 94 °C for 1 min, 33 cycles at 94° for 30 s, 58 °C for 30 s, 72 °C for 30 s and 72 °C for 5 min.