Biologia Molecolare: Leucemie Mieloidi Acute

Maria Teresa VosoDipartimento di Biomedicina e Prevenzione

Università Tor Vergata, Roma 20’

Name of Company

Research support

Employee Consultant Stockholder Speaker’s Bureau

Advisory Board

Other

Celgene/BMS x x x

Astellas x

Jazz x x x

Abbvie x

Disclosures

WHO classification of acute myeloid leukemia and related neoplasms

Arber et al., Blood 2016

*

* Defined by MDS-cytogenetics in about 30% of cases

~60-65%

~30%

~10%

AML-MRC

Cytogenetic abnormalities

Previous history of MDS or MDS/MPNDysplasia in >50% of cells in 2 or more BM lineages, in the absence of NPM1 or CEBPA mutations

Genetic heterogeneity of Acute Myeloid Leukemia

Dohner et al., Blood 2017

Adapted from Dohner H et al., Blood 2017

European LeukemiaNet (ELN) 2017: prognostic stratification

with FLT3-ITDlow

Impact of cytogenetics on survival

Analysis of 5,876 cases entered in MRC AML10, 12, and 15 trials

Grimwade D. et al., Blood. 2010*Excluding patients with t(15;17), t(8;21), inv(16), t(9;11), t(6;9), inv(3)/t(3;3). **Excluding patients with any other abnormalities listed previously.

• Targeted resequencing of 111 myeloid cancer genes (combined with cytogenetic profiles) in 1540 AML patients

• 5,236 driver mutations (i.e. fusion genes, copy number alterations, gene mutations) involving 77 loci

• 6 genes mutated in >10% patients; 13 genes 5-10% patients; 24 genes 2-5% patients; 37 genes <2% patients

Additional mutations by NGS

Adapted from Papaemmanuil E. et al., N Engl J Med. 2016

Genomic classification

Risk-adapted strategies

Therapeutic targets

NPM1/FLT3-ITD mutations

50-60% of NK-AML cases

One of the most frequently mutated gene in AML

Associated with good prognosis without concomitant mutation of FLT3-ITD or with FLT3-ITDlow

NPM1 represents an important prognostic indicator in AML

Pratcorona et al, Blood 2013

Overall Survival CIR

161 NPM1-mut pts, FLTD-ITDallelic ratio: high: >0.5

low: <0.5

Other mutations

Schnittger S. et al., Blood 2011

Mutations of RUNX1 present in 10–16% of AML RUNX1mut AML is a new provisional entity in the

revised WHO classification RUNX1 mutations are associated with adverse

overall survival and with disease progression

TP53 mutations present in 5–10% of AML Prognosically unfavourable, especially in

multi-hit state

Prochazka KT. et al., Haematologica 2019

“very favorable”

“favorable”

“intermediate”

“adverse”

“very adverse”

Patients with inv(16)/t(16;16) or biallelic

CEBPA mutations

Patients with TP53 mutations and a complex karyotype

Refinement of the 2017 ELN genetic risk stratification of AML

“favorable”

“intermediate”

“adverse”

ELN-2017

Adapted from Herold T. et al., Leukemia 2020

Refined ELN-2017Relapse-free survival

Overall survival

- PML-RARA: 24 hours - RUNX1-RUNX1T1, CBFB-MYH11, KMT2A, (Chr 5/7 FISH panel): 2–3 days- G-banding: 1 week

- FLT3 ITD, TKD, NPM1: 72 hrs - CEBPA: 1 week

What do we need from the labs

Immunophenotype (LAIP)

1. Arber DA, Erber HP. Am J Clin Pathol 2020;154:731–41;2. Döhner H, et al. Blood 2017;129:424–47

Prior to starting treatment

To plan post-remission therapy

CEBPA, RUNX1, ASXL1, TP53or extended gene panel

or whole genome sequence

AML-MRC

Impact of MRD in patients with AML in remission post-IC3

Identification of ≥ 0.1% MRD by multiparameter flow cytometry, or molecular methods is an important

prognostic marker that can help guide treatment (Tx) decisions

Short et al. JAMA Oncol 2020

Overall Survival Disease-free Survival

Dynamic Survival Prediction: Minimal/measurable Residual Disease (MRD)

Preleukemic Leukemic

FLT3-ITDFLT3-TKDRASPTPN11KIT

DNMT3ATET2ASXL1IDH1/2SF3B1

PML/RARANPM1RUNX1-RUNX1T1CBFB-MYH11Other transloc.

SensitivePotentially unspecific

SpecificLost in 10-50%

SensitiveSpecific

Post-Onset Drivers

Suitability of MRD Detection Markers

QRT-PCR for PML/RARA

Cicconi et al., Leukemia 2016, Diverio et al, Blood 2008

>60% of patients tested +ve for PML/ RARA after induction therapy

Reduction of PML/RARA after induction was greater in patients receiving ATRA–CHT

PML/RARA levels at the time point of post-induction were not predictive of subsequent relapse

Kinetics of PML/RARA clearance in pts treated with ATRA-chemo vs ATRA-ATO

Diagnosis

Post-induction

Post III consolidation

PML/RARA +ve patients by QRT-PCR Cumulative Incidence of Relapse

MRD by RQ-PCR in PB after 2 Cycles of CHT

Ivey A et al., NEJM 2016

NPM1-mut in 2° post cons: higher risk of relapse at 3 years and lower rate of survival

BM MRD testing for NPM1-mutated AML does appear to be more sensitive than testing via PB

The presence of MRD in PB was highly informative among patients in morphologic CR

QRT-PCR for NPM1mut: PB better than BM

Log-reduction of transcripts predicts relapse in CBF-AML

• Upfront genetics and MRD determination in CBF-AML

• 198 patients

• QRT-PCR transcripts determination after first consolidation

• A less than 3-log MRD reduction or a level >0.1% was associated with a higher specific hazard of relapse

Jourdan et al., Blood 2013

Targeted NGS at diagnosis and after induction therapy (during CR)

Jongen-Lavrencic et al. NEJM 2018

Persistent mutations were detected in 51.4% of the patients

“DTA” mutations were most common

MRD monitoring by NGS

Kronke et al J Clin Oncol 2011Jongen-Lavrencic M, et al. N Engl J Med

MRD: NGS vs MFC or both?

MRD, assessed by cytofluorimetry (MFC) or molecular methods, including NGS, significantly predicts relapse

NGS has significant additive value to MFC

Normal-K AML at relapse

Greif et al, Clin Cancer Res 2018

Karyotype evolution:6/28 (21%)

Disease evolution at Relapse

Schmalbrok et al, Blood 2021

FLT3-ITD mutations

Markers Diagnosis Prognosis MRD Targeted Th.

PML-RARA x x x x

RUNX1/RUNXT1 x x x

CBF/MYH11 x x x

NPM1mut x x x

FLT3-ITD x x

FLT3-TKD x

CEBPAmut BA x

RUNX1 x x

BCR-ABL x x x x

TP53 x

ASXL1 x

t(9;11), inv(3), t(6;9), t(1;22)

x x

MDS-RC K x x

Clinical Role of Molecular Markers

WGS for AML diagnosis

Duncavage et al., NEJM 2021

Personalized Medicine in AML

Acknowledgements

M. Domenica DivonaEmiliano Fabiani

Giulia FalconiTiziana Ottone

Serena Travaglini

Giorgio ArceseFrancesco Buccisano

Maria Ilaria Del PrincipeLuca Maurillo

Raffaele PalmieriAdriano Venditti