Acute myeloid leukemia (AML)

1. Acute myeloid leukemia (AML) Justyna Rybka Department of Haematology, Blood Neoplasms and Bone Marrow Transplantation Wroclaw Medical University Klinika Hematologii, Nowotworów Krwi i Transplantacji Szpiku

2. AML is a heterogeneous haematological malignancy of the myeloid blood cells1 Lineage affected in AML AML causes clonal expansion of blast cells • Any myeloid neoplasm with ≥20% blasts in the PB or BM may be considered an AML2 1. NCCN clinical practice guidelines in oncology. Acute myeloid leukaemia. Version 1.2014. Available at NCCN.org 2. Vardiman JW, et al. Blood 2009;114:937–51 AML = acute myeloid leukaemia BM = bone marrow; PB = peripheral blood

3. Several risk factors are associated with mutations in AML1 De novo* (large proportion) Genetic disorders e.g. Down’s syndrome Somatic mutations Physical and chemical exposures e.g. Benzene, cigarettes Leukemogenicrisk factors (small proportion) Radiation exposure Chemotherapy *No clinical history of prior MDS, MPD, or exposure to leukaemogenic therapies or agents2 MDS = myelodysplastic syndrome; MPD = myeloproliferative disorder 1. Deschler B & Lübbert M. Cancer 2006;107:2099–107 2. Cheson BD, et al. J Clin Oncol 2003;21:4642–9

4. Incidence of AML increases with age Males Females Incidence rate per 100,000 inhabitants AML is predominantly a disease of older patients with a slight prevalence in males; the majority of cases occur in patients ≥65 years of age 1. Cancer Research UK. Leukaemia incidence statistics. Available at: http://www.cancerresearchuk.org/cancer-info/cancerstats/types/leukaemia/incidence/uk-leukaemia-incidence-statistics

5. Common symptoms of AML Haematological symptoms Non-haematological symptoms Headache Anaemia → fatigue Loss of appetite Fever Neutropenia → infections Dyspnoea Thrombocytopenia → bleeding Hepatomegaly or splenomegaly Leukostasis (rare) Skin rash American Cancer Society. Available at: http://www.cancer.org/cancer/leukemia-acutemyeloidaml/detailedguide/leukemia--acute-myeloid--myelogenous--signs-symptoms

6. Diagnostic work-up for suspected AML Purpose Techniques Histological staining Assessment of blasts BM and PB morphology Morphological assessment Flow cytometric and/or IHC assessment of blasts Assessment of lineage Immunophenotyping Assessment of cytogenetics and mutational analysis Conventional karyotyping, FISH, RT-PCR, SNP-A Genetic risk assessment Diagnosis FISH = fluorescence in-situ hybridisation; IHC = immunohistochemistryRT-PCR = reverse transcriptase polymerase chain reactionSNP-A = single-nucleotide polymorphism array Vardiman JW, et al. Blood 2009;114:937–51

7. Morphological assessment is essential in the diagnostic work-up of AML1,2 myeloblasts monoblasts Sample collection (PB and BM aspirate;* both required) Included in blast count BM smear (1:1000)(Wright–Giemsa stain) + promonoblasts (≥200 leukocytes on any blood sample; ≥500 nucleated cells on any BM sample) megakaryoblasts Not included in blast count PB smear (1:1000)(Wright–Giemsa stain) proerythroblasts *Trephine biopsy may be considered for IHC in some patients if the aspirate is poor quality or in the presence of marrow fibrosis, especially when blasts are CD34+ 1. Dohner H, et al. Blood 2010;115:453–74; 2. Vardiman JW, et al. Blood 2009;114:937–51

8. Confirms cells as blasts using specific antigenic markers e.g. CD34, CD117 Cell sorting allows lineage assessment Method of choice for immunophenotyping of haematological neoplasms1 Immunophenotyping is used to determine lineage involvement in suspected AML Flow cytometry IHC • Confirms cells as blasts via staining of antigenic markers • Staining patterns can allow differentiation of lineage • Less effective than flow cytometry; however, may be useful when flow cytometry is unavailable2 Normal AML Negative IHC staining of bone marrow (MPO stain) Positive IHC staining of bone marrow (MPO stain) Myeloid blast population 1. Craig & Koon. Blood 2008;111:3941–672. Manaloor EJ, et al. Am J ClinPathol 2000;113:814–22

9. Other techniques for the genetic assessment of patients with suspected AML1 RT-PCR2 FISH3 SNP-A karyotyping4 • Can play a supplementary role to conventional karyotyping when chromosome morphology is poor quality • SNP-A can detect microdeletions and regions of uniparentaldisomy that are undetectable by conventional karyotyping • May play a supplementary role in detecting gene rearrangements when conventional karyotyping fails 1. Dohner H, et al. Blood 2010;115:453–74 2. Mrózek K, et al. J ClinOncol 2001;19:2482–923. Frohling S, et al. J ClinOncol 2002;20:2480–54. Raghavan M, et al. Cancer Res 2005;65:375–8

10. Conventional karyotyping is integral to the evaluation of patients with suspected AML1 • Conventional karyotyping allows analysis of cytogenetics via assessment of specific banding patterns on patient chromosomes • A minimum of 20 metaphase cells is considered obligatory to establish a diagnosis1 Normal healthy karyotype AML t(16;21)(p11;q22) karyotype Owing to the high prevalence of chromosomal abnormalities in patients with AML,2,3cytogenetic evaluation should be considered mandatory at diagnosis 1. Dohner H, et al. Blood 2010;115:453–74 2. Mrózek K, et al. Blood Rev 2004;18:115–363. Grimwade D. Best PractClinHaematol Res 2001;14:497–529

11. The French–American–British classification was originally used to classify AML FAB = French–American–British; MPO = myeloperoxidase; SBB = Sudan black B; NSE = nonspecific esterase Bennett JM, et al. Br J Haematol 1982;51:189–99

12. In 2008, WHO revised their classification in line with up-to-date scientific and clinical information AML with recurrent genetic abnormalities AML with t(8;21)(q22;q22); RUNX1-RUNX1T1 AML with inv(16)(p13.1q22) or t(16;16)(p13.1;q22), CBFβ/MYH11 Acute promyelocyticleukemia with t(15;17)(q22;q12), PML/RARA AML with t(9;11)(p22;q23); MLLT3-MLLAML with t(6;9)(p23;q34); DEK-NUP214AML with inv(3)(q21q26.2) or t(3;3)(q21;q26.2); RPN1-EVI1AML (megakaryoblastic) with t(1;22)(p13;q13); RBM15-MKL1Provisional entities: AML with mutated NPM1 or CEBPA AnyAnyAny≥20% in PB or BM≥20% in PB or BM≥20% in PB or BM≥20% in PB or BMNot specified AML with myelodysplasia-related changes ≥20% in PB or BM Therapy-related myeloid neoplasms ≥20% in PB or BM AML, not otherwise specified AML, minimally differentiated AML without maturation AML with maturation Acute myelomonocytic leukaemia Acute monoblastic/acute monocytic leukaemia Acute erythroid leukaemiaPure erythroid leukaemia / erythroleukaemia, erythroid/myeloid Acute megakaryoblastic leukaemia Acute basophilic leukaemia Acute panmyelosis with myelofibrosis ≥20% in PB or BM≥20% in PB or BM≥20% in PB or BM≥20% in PB or BM≥20% in PB or BM≥20% in PB or BM≥20% in PB or BM≥20% in PB or BM≥20% in PB or BM *red text denotes amendments from the 2001 WHO classification Vardiman JW, et al. Blood 2009;114:937–51

13. Cytogenetics Patients with AML can be divided into prognostic subgroups based on cytogenetics Foran JM. Hematology Am Soc Hematol Educ Program 2010;2010:47‒55

14. Genetic mutations The most commonly mutated genes in patients with AML CBF-AML = core binding factor acute myeloid leukaemia; EFS = event-free survival PTD = partial tandem duplication; RFS = relapse-free survival TD = internal tandem duplication ; TKD = tyrosine kinase domain Marcucci G, et al. J Clin Oncol 2011;29:475–86

15. Genetic mutations ELN system proposed for grouping genetic abnormalities in AML* Genetic abnormalities can be incorporated into cytogenetic categories to refine risk assessment *Correlating data from cytogenetic and mutational analyses of NPM1, CEBPA and FLT3 with clinical outcome; n number not specified; †≥3 abnormalities in the absence of t(15;17), t(8;21), inv(16) or t(16;16), t(9;11), t(v;11)(v;q23), t(6;9), inv(3) or t(3;3); ELN = European LeukemiaNet Dohner H, et al. Blood 2010;115:453–74

16. Current standard of intensive treatment for patients with AML1 Induction therapyWith the aim to eradicate the leukaemic clone Consolidation therapyWith the aim to maintain remission Standard-dose chemotherapy (1–4 cycles) Standard dose chemotherapy 7 days of cytarabine + 3 days of anthracycline (7+3) Ultimate goal: CR* Autologous HSCT Allogeneic HSCT *Definition of CR according to the ELN: BM blasts <5%; absence of blasts with Auer rods; absence of extramedullary disease ANC >1.0x109/L; platelets >100x109/L; independent of RBC transfusions2ANC = absolute neutrophil count 1. Roboz GJ. Curr Opin Oncol 2012;24:711–9 2. Dohner H, et al. Blood 2010;115:453–74

17. Allogeneic HSCT can be used for patients with AML and intermediate- or poor-risk cytogenetics Allogeneic transplant using an HLA-matched sibling donor is an established practice for younger patients with AML.1 However, recent studies have called for transplant eligibility to be determined based on cytogenetics rather than age alone1 Meta-analysis of trials evaluating allo-HSCT versus no allo-HSCT according to cytogenetic risk*2 N HSCT N no HSCT HR (95% CI) Overall OS benefit in AML-CR1 1768 3021 0.90 (0.82–0.97) 15 Trials OS benefit for good-risk AML-CR1 188 359 1.07 (0.83–1.38) 10 Trials OS benefit for intermediate-risk AML-CR1 864 1635 0.83 (0.74–0.93) 14 Trials p=0.071 OS benefit for poor-risk AML-CR1 226 366 0.73 (0.59–0.90) 14 Trials 0.1 0.5 1 5 10 Favours HSCT Favours no HSCT Hazard ratio of death Significant OS benefit was observed with allo-HSCT compared with no allo-HSCT; benefit could be seen in patients with poor-risk and intermediate-risk karyotypes, but not good-risk AML *Median age was ~30 years, all trails included patients ≤60 years CR1 = in first CR 1. Dohner H, et al. Blood 2010;115:453–74 2. Koreth J, et al. JAMA 2009;301:2349–61

18. Treatment of AML patients > 60 years old • In elderly patients – worsegeneralcondition, co-morbidities, worsecytogeneticsresults • In patients in goodcondition, without co-morbidities: induction and consolidationchemotherapy, allo-HSCT with reduceintensityconditioning • Demethylatingagents (decytabine, azacytydine) in patients with 20-30 % blastscells • Clinical trials with novelagents

19. Supportive care options for patients with AML During treatment, most AML patients will receive supportive care to protect against periods of very low blood counts Anti-infectious treatment Myeloid growth factors Transfusions Antibiotics and anti-fungals are used prophylactically to treat bacterial and fungal infections which can occur due to low WBC counts1 Transfusion of RBC and/or platelets can be used to correct anaemia and prevent bleeding1 Myeloid growth factors can shorten the duration of neutropenia and reduce the incidence and severity of infections2 RBC = red blood cells 1. http://www.ucsfhealth.org/conditions/acute_myeloid_leukemia/treatment.html2. Dohner H, et al. Blood 2010;115:453–74

20. APL: acute promyelocytic leukemia • 5-10% of AML • Pathogenesis: translocation of chromosomes 15 and 17, this causes parts of a gene from each of these chromosomes to join and create a fusion gene called PML/RARA • Symptoms of APL: unexplainedbleedingorbruising, abnormalities of clotting system (DIC), persistent tiredness, dizziness, paleness, or shortness of breath • The treatment of acute promyelocytic leukemia (APL) is verydifferent than that of other types of acute leukemia.ATRA plus anthracycline-based chemotherapy for induction and consolidation followed by maintenance ATRA with low-dose chemotherapy is currently the standard of care. • Patients must start treatment quickly after being diagnosed.