ERK1/2 phosphorylation is an independent predictor of complete remission in newly diagnosed adult acute lymphoblastic leukemia

Abstract Extracellular signal-regulated kinase-1/2 (ERK1/2) is frequently found constitutively activated (p-ERK1/2) in hematopoietic diseases, suggesting a role in leukemogenesis. The aim of this study was to assess the expression and clinical role of p-ERK1/2 in adult acute lymphoblastic leukemia (ALL). In 131 primary samples from adult de novo ALL patients enrolled in the Gruppo Italiano per le Malattie Ematologiche dell'Adulto (GIMEMA) Leucemia Acute Linfoide (LAL) 2000 protocol and evaluated by flow cytometry, constitutive ERK1/2 activation was found in 34.5% of cases; these results were significantly associated with higher white blood cell (WBC) values (P = .013). In a multivariate analysis, p-ERK1/2 expression was an independent predictor of complete remission achievement (P = .027). Effective approaches toward MEK inhibition need to be explored in order to evaluate whether this may represent a new therapeutic strategy for adult ALL patients

Isolation of multidrug-resistant Enterobacter cloacae and comparison among clavulanate-tazobactam and sulbactam-synergy by using a double-disk synergy test

False negative results of double-disk synergy test with Enterobacter cloacae are common, as AmpC-enzymes may mask ESBLs elaboration. We increased the sensitivity of the method by using both clavulanate- and tazobactam/sulbactam; hence, we suggest to use all the three inhibitors to screen ESBLs in AmpC ß-lactamases producing organisms

AIDA 0493 protocol for newly diagnosed acute promyelocytic leukemia: very long-term results and role of maintenance

Abstract All-trans-retinoic acid (ATRA) has greatly modified the prognosis of acute promyelocytic leukemia; however, the role of maintenance in patients in molecular complete remission after consolidation treatment is still debated. From July 1993 to May 2000, 807 genetically proven newly diagnosed acute promyelocytic leukemia patients received ATRA plus idarubicin as induction, followed by 3 intensive consolidation courses. Thereafter, patients reverse-transcribed polymerase chain reaction–negative for the PML-RARA fusion gene were randomized into 4 arms: oral 6-mercaptopurine and intramuscular methotrexate (arm 1); ATRA alone (arm 2); 3 months of arm1 alternating to 15 days of arm 2 (arm 3); and no further therapy (arm 4). Starting from February 1997, randomization was limited to ATRA-containing arms only (arms 2 and 3). Complete remission was achieved in 761 of 807 (94.3%) patients, and 681 completed the consolidation program. Of these, 664 (97.5%) were evaluated for the PML-RARA fusion gene, and 586 of 646 (90.7%) who tested reverse-transcribed polymerase chain reaction–negative were randomized to maintenance. The event-free survival estimate at 12 years was 68.9% (95% confidence interval, 66.4%-71.4%), and no differences in disease-free survival at 12 years were observed among the maintenance arms

Treatment of Adolescents and Young Adults with Acute Lymphoblastic Leukemia (ALL): An Update of the GIMEMA Experience

Backgound: Adolescent and young (<30y) adults (AYAs) ALL represent a distinct population from both children and older adults. Recently it has been demonstrated that if AYA are treated according to pediatric schedules, Event Free Survival and Overall Survival (OS) can significantly improve (Ribera et al. 2008, Huguet et al. 2009). Nevertheless, which therapeutic strategy, a pediatric or an adult one, can, indeed, be the best approach in this cohort of pts it is still a matter of debate. (Usvasalo et al. 2008). We retrospectively reviewed the disease outcome of AYAs entered in a period over than 25 y in the 6 consecutive GIMEMA adult ALL trials in order to analyze the impact on Disease Free Survival(DFS) and OS of the different treatment strategies applied. Patients: Between 1982-2008, 1218 pts - median age 20.2 ys (range 12.0-30.0y)- were enrolled in the 6 GIMEMA studies; 30.4% of pts were 18y old, initial median WBC was 15.0x109/L (range 0.3-848.0), 72.9% of pts and 27.1% of pts were classified as B-lineage and T-ALL respectively, and 84 pts (13.1%) were Ph and/or BCR/ABL+ve. Results: Overall Remission Rate was 85.1% with no significant difference in terms of CR between the different protocols. From 1990, Ph and/or BCR/ABL+ve patients received a post-CR treatment including transplant and, since 2000, TKIs were also added. Comparing the studies, ALL0288 vs. ALL0183 and ALL0904, ALL2000 vs. ALL0183 and ALL0904, long-term DFS rate resulted significantly associated to protocol: (p=0.0078, p=0.0051, respectively) and (p=0.0044, p=0.0136, respectively), while OS resulted trend-associated to protocol (p=0.0891). One of the older study - ALL0288 - demonstrated a significantly lower Cumulative Incidence of Relapse (CIR) not only compared with the oldest ALL0183 (p<0.00001), but also with the following ALL0496 (p=0.0009), ALL2000 (0.0022) and ALL0904 (p=0.00002). Whether this was related to a more intensified treatment with reinduction cycles, both in consolidation and maintenance, foreseen in the ALL0288 study remains an open question; however, probably due to the less effective supportive care and, in particular, to the lack of growth factors, non-relapse mortality in CR was higher and the final outcome of ALL0288 did not significantly differed in terms of overall survival from other studies. Table 1 Protocol PDN Pretreat Induction Consolidation Maintenance pts. N. %OS (C.I. 95%) %DFS (C.I. 95%) %CIR (C.I. 95%) -------------------------------------------------------------------------------- ALL0183 - PVD + L-Asp PVD/L-VAMP/ VM-26+CA Standard (12 mths) 169 6y 35.6% (33.1-38.2) 6y 25.7% (23.9-27.6) 6y 69.4% (69.2-69.7) ALL0288 YES PVD + L-Asp ± Cy PV+Nov/L-VAMP/VM-26+CA Intensive vs. standard (24 mths) 456 6y 39.1% (37.4-41) 6y 37% (35.2-38.9) 6y 44.2% (44.1-44.3) ALL0394 - PV + Myeloid-like + L-Asp L-VAMP/VM-26+CA Standard (12 mths) 76 4y 50% (44.4-56.2) 4y 45.6% (40.1-51.9) 4y 45.9% (45-46.8) ALL0496 - PV + HD DNR + L-Asp VP-16+CA + Cy Standard + V-Cy/V-DNR Reinduction (36 mths) 231 6y 40.4% (37.8-43.2) 6y 36.1% (33.6-38.7) 6y 57.3% (57-57.6) ALL2000 YES PV + HD DNR + L-Asp VP-16+CA Standard + V-Cy/V-DN Reinduction (36 mths) 209 6y 44.4% (40.7-48.4) 6y 41.6% (38.3-45.2) 6y 55.9% (55.6-56.3) ALL0904 YES PV + HD DNR + L-Asp VP-16+CA Standard + V-Cy/V-DNR Reinduction (36 mths) 77 3y 47.6% (40.1-56.5) 3y 28.2% (23.9-33.4) 3y 66.4% (64.7-68.1) In conclusion, the overall results of the consecutive GIMEMA adult ALL trials conducted over the past 25 years show that only slight advances for specific subgroup of patients – i.e. Ph+ - have been obtained, mainly thanks to the introduction of targeted agents like TKIs. Also in the AYAs subgroup, the outcome remains dismal, and new approaches, possibly with more intensive pediatric-like regimens must be explored

Identification of DNA Rearrangements at the Retinoic Acid Receptor-a (RAR-a) Locus in all Patients With Acute Promyelocytic Leukemia (APL) and mapping of APL Breakpoints within the RAR-a second intron

Seventy patients with acute promyelocytic leukemia (APL) were characterized at the DNA level using genomic retinoic acid receptor-alpha (RAR-alpha) probes on Southern blot experiments. Sixty-two cases were defined as M3 according to the French-American-British (FAB) criteria, and eight had a diagnosis of microgranular or variant (M3v) APL. The use of two restriction enzymes and three probes exploring the second intron of the RAR-alpha gene allowed us to detect specific abnormal DNA fragments in every case, with clustering of rearrangements within the 20-kb intronic region between RAR-alpha exons II and III. A more detailed mapping of APL breakpoints was performed in 52 cases in which three EcoRI subregions of the RAR-alpha second intron were analyzed with corresponding probes. Comparison of clinical and hematological features in the three subgroups of patients with distinct RAR-alpha breakpoints did not show significant differences regarding age, peripheral blood (PB) counts, presence of coagulopathy, or FAB classification (M3 v M3v). Interestingly, a significant difference was observed in the M/F ratio of the three subgroups, with a higher incidence of rearrangements at the 5' end of the RAR-alpha second intron in female patients, and more frequent 3' breakpoints in males. The results of this study indicate that a unique genomic alteration consistently occurs on the 17q- derivative of the APL specific t(15;17) aberration. Moreover, the clinical relevance of RAR-alpha gene analysis both at diagnosis and in follow-up studies is further emphasized

Carfilzomib induction, consolidation, and maintenance with or without autologous stem-cell transplantation in patients with newly diagnosed multiple myeloma: pre-planned cytogenetic subgroup analysis of the randomised, phase 2 FORTE trial

Background: Patients with newly diagnosed multiple myeloma and high-risk cytogenetic abnormalities (HRCA) represent an unmet medical need. In the FORTE trial, lenalidomide and dexamethasone plus carfilzomib (KRd) induction resulted in a higher proportion of patients with at least a very good partial response as compared with carfilzomib, cyclophosphamide, and dexamethasone (KCd), and carfilzomib plus lenalidomide maintenance prolonged progression-free survival compared with lenalidomide maintenance. In this prespecified analysis of the FORTE trial, we described the outcomes of enrolled patients according to their cytogenetic risk. Methods: The UNITO-MM-01/FORTE was a randomised, open-label, phase 2 trial done at 42 Italian academic and community practice centres, which enrolled transplant-eligible patients with newly diagnosed multiple myeloma aged 18-65 years. Eligible patients had newly diagnosed multiple myeloma based on standard International Myeloma Working Group criteria, a Karnofsky performance status of at least 60%, and had not received any previous treatment with anti-myeloma therapy. At enrolment, patients were stratified according to International Staging System stage (I vs II/III) and age (&lt;60 years vs 60-65 years) and randomly assigned (1:1:1) to KRd plus autologous stem-cell transplantation (ASCT; four 28-day induction cycles with KRd, melphalan at 200 mg/m2 and ASCT [MEL200-ASCT], followed by four 28-day KRd consolidation cycles), 12 28-day KRd cycles, or KCd plus ASCT (four 28-day induction cycles with KCd, MEL200-ASCT, and four 28-day KCd consolidation cycles), using a web-based system (block randomisation, block size of 12). Carfilzomib was administered at 20 mg/m2 on days 1 and 2 of cycle 1, followed by 36 mg/m2 intravenously administered on days 8, 9, 15, and 16 of cycle 1, and then 36 mg/m2 intravenously administered for all subsequent doses on days 1, 2, 8, 9, 15, 16; lenalidomide 25 mg was administered orally on days 1-21; cyclophosphamide 300 mg/m2 was administered orally on days 1, 8, and 15; and dexamethasone 20 mg was administered orally or intravenously on days 1, 2, 8, 9, 15, 16, 22, and 23. After the consolidation phase, patients were stratified according to induction-consolidation treatment and randomly assigned (1:1; block size of 8) to maintenance treatment with carfilzomib plus lenalidomide or lenalidomide alone. Carfilzomib 36 mg/m2 was administered intravenously on days 1-2 and days 15-16, every 28 days for up to 2 years, and lenalidomide 10 mg was administered orally on days 1-21 every 28 days until progression or intolerance in both groups. The primary endpoints were the proportion of patients with at least a very good partial response after induction with KRd versus KCd and progression-free survival with carfilzomib plus lenalidomide versus lenalidomide alone as maintenance treatment. In this preplanned analysis, we included patients enrolled in the FORTE trial with complete cytogenetic data on del(17p), t(4;14), t(14;16), del(1p), gain(1q) (3 copies), and amp(1q) (≥4 copies) assessed by fluorescence in-situ hybridisation analysis on CD138-positive sorted cells. We assessed progression-free survival, overall survival, minimal residual disease negativity, and 1-year sustained minimal residual disease negativity according to the presence of zero, one, and two or more HRCA across treatment groups. The FORTE trial is ongoing, and registered with ClinicalTrials.gov, NCT02203643. Findings: Between Feb 23, 2015, and April 5, 2017, 477 patients were enrolled, of whom 396 (83%) had complete cytogenetic data and were analysed (176 [44%] of whom were women and 220 [56%] were men). The median follow-up from first randomisation was 51 months (IQR 46-56). 4-year progression-free survival was 71% (95% CI 64-78) in patients with zero HRCA, 60% (95% CI 52-69) in patients with one HRCA, and 39% (95% CI 30-50) in patients with two or more HRCA. Compared with patients with zero HRCA, the risk of progression or death was similar in patients with one HRCA (hazard ratio [HR] 1·33 [95% CI 0·90-1·97]; p=0·15) and higher in patients with two or more HRCA (HR 2·56 [95% CI 1·74-3·75]); p&lt;0·0001) across the induction-intensification-consolidation groups. Moreover, the risk of progression or death was also higher in patients with two or more HRCA versus those with one HRCA (HR 1·92 [95% CI 1·34-2·76]; p=0·0004). 4-year overall survival from the first randomisation was 94% (95% CI 91-98) in patients with zero HRCA, 83% (95% CI 76-90) in patients with one HRCA, and 63% (95% CI 54-74) in patients with two or more HRCA. Compared with patients with zero HRCA, the risk of death was significantly higher in patients with one HRCA (HR 2·55 [95% CI 1·22-5·36]; p=0·013) and two or more HRCA (HR 6·53 [95% CI 3·24-13·18]; p&lt;0·0001). Patients with two or more HRCA also had a significantly higher risk of death than those with one HRCA (HR 2·56 [95% CI 1·53-4·28]; p=0·0004). The rates of 1-year sustained minimal residual disease negativity were similar in patients with zero HRCA (53 [35%] of 153] and with one HRCA (57 [41%] of 138) and were lower in patients with two or more HRCA (25 [24%] of 105). The median duration of follow-up from second randomisation was 37 months (IQR 33-42). 3-year progression-free survival from the second randomisation was 80% (95% CI 74-88) in patients with zero HRCA, 68% (95% CI 59-78) in patients with one HRCA, and 53% (95% CI 42-67) in patients with two or more HRCA. The risk of progression or death was higher in patients with one HRCA (HR 1·68 [95% CI 1·01-2·80]; p=0·048) and two or more HRCA (2·74 [95% CI 1·60-4·69], p=0·0003) than in patients with zero HRCA. Interpretation: This preplanned analysis of the FORTE trial showed that carfilzomib-based induction-intensification-consolidation regimens are effective strategies in patients with standard risk (zero HRCA) and high-risk (one HRCA) myeloma, resulting in similar rates of progression-free survival and 1-year sustained minimal residual disease negativity. Despite promising progression-free survival, patients with ultra-high-risk disease (those with 2 or more HRCA) still have an increased risk of progression and death and therefore represent an unmet medical need. Funding: Amgen and Celgene/Bristol Myers Squibb