Acute Myeloid Leukemia - 2015 Olga Frankfurt, MD Robert H. Lurie Comprehensive Cancer Center Northwestern University Chicago, IL

Acute Myeloid Leukemia (AML) AML is a group of blood cancers in which the bone marrow makes abnormal immature blood cells These cells also prevent the normal blood cells from maturation

Normally, the bone marrow makes blood stem cells (immature cells) that become mature blood cells over time. A blood stem cell may become a myeloid stem cell or a lymphoid stem cell. A lymphoid stem cell becomes a white blood cell. In AML, the myeloid stem cells usually become a type of immature white blood cell called myeloblasts (or myeloid blasts). The myeloblasts in AML are abnormal and do not become healthy white blood cells. Sometimes in AML, too many stem cells become abnormal red blood cells or platelets. These abnormal white blood cells, red blood cells, or platelets are also called leukemia cells or blasts. Leukemia cells can build up in the bone marrow and blood so there is less room for healthy white blood cells, red blood cells, and platelets. When this happens, infection, anemia, or easy bleeding may occur. The leukemia cells can spread outside the blood to other parts of the body, including the central nervous system (brain and spinal cord), skin, and gums.

Acute Myeloid Leukemia (AML) New patients/deaths in 2014: 18,860/10,460 Median age: 66 -72 years Heterogeneity in genetics, clinical features and outcome Outcome improved among age <60 with intensive post-remission strategies and transplantation Prognostic factors exist; many new, molecular Role of transplantation continues to be refined Myriad of new agents available

AML Age-Specific Incidence Rates 24 Incidence/100,000 22 20 18 16 14 12 10 8 6 4 2 0-4 5-9 85+ 10-14 15-19 20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65-69 70-74 75-79 80-84 Age (y) NCI-SEER Program

Risk Factors for Developing AML Previous exposure to radiation Environmental factors : tobacco, benzene Genetic factors Down’s syndrome Fanconi’s anemia, Bloom syndrome Ataxia telangectasia Bnezene is the best-documented environmental leukemogens. Patients vary in their ability to metabolize benzene, suggesting that genetic and environmental factor predispose to the development of AML TMPD; 20% AML Primarily megakaryocytic (M7) associated with GATA1 mutation GATA 1 zink finger transcription factor important for the erythro and thrombopoesis Bloom syndrome also known as Bloom–Torre–Machacek syndrome is a rare autosomal recessive chromosomal disorder characterized by a high frequency of breaks and rearrangements in an affected person's chromosomes. The condition was discovered and first described by dermatologist Dr. David Bloom in 1954.

Risk Factors for Developing AML Previous chemotherapy Alkylating agents del 5 and del 7 5 - 10 years latency Epipodophyllotoxins (etoposide, anthracyclines) Monocytic differentiation 11q23 1-3 years after exposure Evolving from the prior antecedent hematologic disorder Some alkylating agents are active under conditions present in cells; and the same mechanism that makes them toxic allows them to be used as anti-cancer drugs. They stop tumor growth by crosslinking guanine nucleobases in DNA double-helix strands, directly attacking DNA. This makes the strands unable to uncoil and separate. As this is necessary in DNA replication, the cells can no longer divide. These drugs act nonspecifically. Nitrogen mustards[7] Cyclophosphamide Mechlorethamine or mustine (HN2) Uramustine or uracil mustard Melphalan Chlorambucil Ifosfamide Nitrosoureas Carmustine Lomustine Streptozocin Alkyl sulfonates Busulfan Anthracycline has three mechanisms of action: Inhibits DNA and RNA synthesis by intercalating between base pairs of the DNA/RNA strand, thus preventing the replication of rapidly-growing cancer cells.[6] Inhibits topoiosomerase II enzyme, preventing the relaxing of supercoiled DNA and thus blocking DNA transcription and replication. Creates iron-mediated free oxygen radicals that damage the DNA and cell membranes

Molecular Pathogenesis of AML Class I mutations – activating mutations Class II mutations – inducing differentiation stop confers proliferative and/or survival advantage aberrant activation of signal transduction pathways Ras, RTK KIT and FLT3, loss of function of NF-1, gain of function SHP-2 mutations in the transcription factors or transcriptional co-activators CBF transcription complex [inv16/t(16;16) and t(8;21)], PML-RARα t(15;17) AML, like other human cancers, is consequence of more than one mutation. Epidemiologic and genotypic data have shown that many AML cells have more than once recurring mutation, either as point mutation, gene rearrangements and/or chromosomal translocations. Data from animal models of leukemia strongly support a multistep pathogenesis of the disease. It was demonstrated that different fusion transcript types that are specific for diverse AML subtypes cal already originate in utero. The AML-ETO, PML-RAR alpha, and MLL rearrangements were retrospectively detected in the blood from Guthrie cards that have been preserved from children who had developed the respective AMLe at young age. The long interval between birth and the clinical manifestation of leukemia ( up to 10 years) indicates that above fusion transcripts are not able to cause leukemia on their own but need a cooperation with additional secondary genetic alterations. The concept that capillary blood, obtained from pricking the heel or finger and blotted onto filter paper, could be used to screen for metabolic diseases in large populations of neonates was introduced in Scotland by Robert Guthrie in 1963. Neonatal screening for phenylketonuria became nationwide in 1969-70. Since then, Guthrie card samples have been collected routinely from infants in over 20 countries to screen for phenylketonuria and more recently for congenital hypothyroidism, sickle cell disorders and HIV infection. The limitations of sensitivity and specificity when screening such small volumes of blood restricted the use of dried blood spots for many years. However, recent advances such as the production of monoclonal antibodies, expression of synthetic proteins, and the introduction of the polymerase chain reaction have overcome many of these problems.[1] This type of blood testing is now available for use at home by consumers in the U.S. Available blood tests include Vitamin D, estrogen, testosterone, cortisol, TSH and lipids. New York is the only state that prohibits home blood spot testing.

Clinical Features of AML Constitutional symptoms Infections Abnormal blood counts Complications related to the high WBC Coagulation abnormalities Metabolic abnormalities Extramedullary tissue The clinical manifestations of AML reflect a maturation arrest of normal marrow precursors or their replacement by AML cells.

Morphology peripheral blood smear bone marrow core biopsy

Evaluation of Patient with AML History and Physical Examination CBC with differential and platelet, peripheral smear, CMP, uric acid, DIC panel, pregnancy test Bone marrow aspirate and biopsy/ Flow cytometry Cytogenetics Molecular studies: FLT3, NPM1, c-kit, CEBPα, IDH1, IDH2, k-RAS, n- RAS Next generation sequencing HLA typing and eligibility for stem cell transplant Serologies: hepatitis, HIV, CMV Study specific correlative laboratory studies

Evolution of Prognostic Factors in AML Prior to 1980s Age, performance status, WBC, antecedent hematologic disorder 1980s – 1990s Cytogenetics Favorable Intermediate Unfavorable 1990s – 2010s Molecular genetics (FLT3, MLL, NPM1, CEBPα, c-KIT, IDH1,2, TET2) and growing 2010- 2015 Next Generation Sequencing Over the last decades, our understanding of the prognosis of AML has grown substantially. Prior to the 1980s – age, WBC, and antecedent hematologic disorder were the only known prognostic factors with older age, higher WBC ct at dx, and antecedent hematologic disorder being negative. From the 1980s-1990s – cytogenetics became prognostically relevant And in the 1990s and early 2000s, the role of molecular genetics hit the forefront; predominantly to further characterize prognosis in those cases of normal karyotype; what we traditionally considered intermediate prognosis. We now understand that there are interactions between genes. As new mutations are identified and their interactions are recognized, our understanding of their role in prognosis will be further refined.

Cytogenetic Risk Groups Favorable inv(16); t(15;17) with any abn; t(8;21) lacking del(9q) or complex karyotype Intermediate Normal or +8 or +21 or others Unfavorable -5/del(5q), -7/del(7q), inv(3q), abn of 11q, 20q, 21q, 17p, del(9q), t(6;9), t(9;22), complex karyotypes with  3 abn Slovak ML, et al. Blood. 2000;96(13):4015-4083.

Overall Survival by Cytogenetic Group Years After Entering Study 20 40 60 80 100 2 Cumulative Percentage 8 4 6 Favorable 121 53 55% Intermediate 278 168 38% Unfavorable 184 162 11% Estimate At Risk Deaths at 5 Years Heterogeneity of 3 Groups: P < 0.0001 Favorable Intermediate Unfavorable Slovak ML, et al. Blood. 2000;96(13):4015-4083.

Therapy for AML- Principles Without therapy AML is fatal – days-months The therapy for AML: Induction and Consolidation Chemotherapy may cure selected patients and prolong survival in responding patients Chemotherapy is toxic and can cause substantial morbidity and mortality

Current AMLTherapy-2015 Younger Adults Induction: dauno 60-90 mg/m2/d x 3d + ara-C 100/200 mg/m2/d x 7d CI. Consolidation: high- or intermediate-dose ara-C (1-4 cycles) Allogeneic HCT for intermediate- and high-risk Consider in CBF with c-KIT, FLT3 Not done in FLT3-/NPM1+ , CEBP+(double mutation) Paschka J Clin Oncol, 2006; Schlenk N Engl J Med, 2008; Green J Clin Oncol, 2010; Dohner Blood, 2010

Current AMLTherapy-2015 Older Adults Decision: chemotherapy vs. hypomethylating agent Intensive Chemotherapy Induction: dauno 60-90 mg/m2/d x 3d + ara-C 100 mg/m2/d x 7d Consolidation: intermediate-dose ara-C (1-4 cycles); no clear role in older adults Low dose Chemotherapy Hypomethylating agents: Dacogen:5 days course or 10 days course Vidaza : 7 days course Reduced intensity HSCT

Investigational Approaches AMLTherapy-2015 Autologous HSCT is not a standard of care; being studied Maintenance is not a standard of care; being studied Maintenance after allo HSCT is not a standard of care for AML; being studied; many use hypomethylating agents Adding stem cells to expedite count recovery after the chemotherapy ; being studied Adding agents that stimulate platelet recovery after chemotherapy is being studied Altering the immune system to fight leukemia ( CAR-T cells) Chimeric antigen receptor therapy

Selected Agents in Clinical Trials Chemotherapy - Clofarabine, CPX-351, Vosaroxin, Elacytarabine Hypomethylating agents – Decitabine, Azacitidine FLT3 inhibitors – Sorafenib, Quizartinib, Crenolanib, ASP2215 MLL inhibitors – EPZ-5676 IDH1 and IDH2 inhibitors, pan IDH inhibitor Glutaminase inhibitor CB-839 Exportin 1 inhibitor - Selinexor Polo-like kinase inhibitor - Volasertib C-kit inhibitors – Dasatinib mTOR inhibitors – Temsirolimus Histone deacetylase inhibitors – Vorinostat, Panobinostat Antibody conjugates Cycline-dependent kinase inhibitor – Flavoperidol Hedgehog inhibitors MEK1/2 inhibitors – Trametinib Aminopeptidase inhibitors – Tosedostat

312 695-6180 Academic Office 312 695-0990 Cancer Center Olga Frankfurt, MD Co-director - Leukemia Program Director - Chronic Leukemia/MDS Associate Director for Umbilical Cord Blood Transplantation Robert H. Lurie Comprehensive Cancer Center, Northwestern Medicine