1. New APL Strategy for Children BFM-Recommendation
Ursula Creutzig
Nils von Neuhoff
Dirk Reinhardt
Medical High School Hannover
UK Essen

2. AML FAB M3 / AML FAB M3 variant
AML FAB M3v t(15;17)
Cantú Rajnoldi A, Biondi A, Jankovic M, Masera G, Rovelli A, Uderzo C, Head D, Raimondi S, Creutzig U, Ritter J. Diagnosis and incidence of acute promyelocytic leukemia (FAB M3 and M3 variant) in childhood. Blood 1993; 81: 2

3. 1. Frequency 7-8% of AML`s in < 18 years old in Germany
ca 8 pat. /year (G)
20% in Italy
Rare in infants < 2 years
Selten bei < 2 Jährigen

4. Standard treatment until 2012
Chemotherapy + ATRA
Standard treatment until 2012

5. Mechanismen of ATRA in APL
Normal
Mutation PML/RARa
The functional consequence of the PML-RARA fusion protein is a more difficult detachment of the co-repressor that can be overcome with higher concentrations of ATRA.
Die RARE verhindern/hemmen die Ablesung der DNA. Normalerweise reichen physiologische Konzentrationen von ATRA aus, den Co-repessor komplex abzulösen und so die Fortsetzung der DNA Ablesung zu ermöglichen und damit die weitere Differenzierung der Zelle.
Liegt das Fusionprotein PML/RARa vor, so ist die Ablösung des Corepressors erschwert. Erst höhere Konzentrationen von ATRA ermöglichen die weitere Transcription. Bei den selteneren anderen Mutation wie PLZF/RARa bewirken auch hohe ATRA-Konzentrastion keinen Effekt, die Zellen sind ATRA resistent.
Mutation PLZF/RARa
Abb. nach Guidez et al. Blood 1998; 91,

6. Chemotherapy + ATRA: AML-BFM 2004
KMP
Chemotherapy + ATRA: AML-BFM 2004
Tag -3 Tag ~ ~ Mo Mo Mo MRD MRD MRD MRD MRD MRD
12 Gy vs. 18 Gy1
HAE
Induktion 1
ADxE
haM
Erhaltungstherapie 1 Jahr und Cytarabin i.th.1
Intensivierung
A: ARA-C; Cytarabin Dx: liposomales Daunorubicin; L-DNR
I: Idarubicin E: Etoposid-Phosphat
HA: Hochdosis Cytarabin M: Mitoxantron
HAE: Hochdosis Cytarabin/ Etoposid-Phosphat R: Randomisierung SR: Standardrisikogruppe
HR: Hochrisikogruppe MRD: Minimal residual disease
KMP: Knochenmarkpunktion
Konsolidierung
AIE R1 R3 AI
ATRA
Tag –3 bis 11
Tag 18-31
Tag 38-51
AT RA
Parallel HAE 14 Tage
Alle 3 Monate je 14 Tage
FAB M3
Strategy APL children
no anthracycline-monotherapy
But limited cum. Anthracycline doses
and combination with Ara-C (+ ATRA)
Anthrazykline: 3x12mg IDR,
2x7 IDR, 2x10mg MITOX = (Faktor 5) = 350mg/m² DNR kum. Dosis

7. Results - APL Study 2004-2012 EFS (3 years)
1.0
OS 96% + 2% (4 events)
0.9
0.89, SE= 0.04
0.8
0.7
Results N %
Total pat. 77
100
Early death* 3 4
Relapse 5
Lfu in CCR
CCR 60 80
0.6
0.5 P
0.4
apl_2014.tab 15JUL14
0.3
0.2
*All ED were HR pts., died by cerbral bleeding, bleeding sepsis, 1x?,
at day 0, 9 and 10
0.1
Creutzig et al. BJH 2010
0.0 1 2 3 4 5 6 7 8 9
years
All Patients (N= 77, 7 events)
Testi et al BLOOD 2018

8. APL-Risk Groups Standard High Risk Early death and relapse WBC /µl
<10 000
>10 000
In addition: M3v
(associated with high WBC)
About 1/3 APL children
HR pts.

9. ATO = As2O3 Dosis dependend dual effect*
Apoptose: higher concentration
partial differentiation: lower concentration
Synergistic to ATRA by reduction of LICs (leukemia-initiating cells)**
ATO is licensed in Europe and US for relapsed/refractary APL and de novo SR-APL in in adults
ATO monoth. CR 80%
*Lallemand-Breitenbach , J Exp Med 1999
**Nasr, Nature Medicine 2008

10. Mode of Action of ATO and ATRA in APL
PML-RARa-Protein: Transkriptionfactor → dominant negative effect on myeloid differentiation, apoptosis, DNA-replication and DNA-repair
Synergististic effects: ATO/ATRA
Leukemia-inducing cells (LICs)
Mi et al. (2012) Leukemia 26:

11. Weight gain, fluid retention leukocytosis
Dynamic changes of peripheral WBC counts during As2O3 treatment in five patients presenting hyperleukocytosis.
Side effects ATO
Weight gain, fluid retention
leukocytosis
prolongation of the QT-interval.
ECG control at start of each ATO cycle
rare:
peripheral neuropathy
hyperglycemia
skin rash
Dynamic changes of peripheral WBC counts during As2O3 treatment in five patients presenting hyperleukocytosis.
Shen Z et al. Blood 1997;89:
©1997 by American Society of Hematology

12. Differentiation Syndrom after ATRA and ATO
Unexplained Fever
Respiratory distress
Interstitial pulmonary infiltrates
and pleural or pericardial effusion
weight gain (fluid retention)
hypotension
+/- hyperleukocytosis
Therapy
Stop ATRA and ATO
Dexamethason mg/m² iv in 2-3 doses/day for min. 3 days
No single feature
is diagnostic
of the syndrome,
but suggestive

13. APL-BFM recommendation Standard Risk
FAB M3 (PML/RARA): ATRA + ATO in pat. with WBC < /µl
Induction
maintenance CR
If PML/RARA remains positive, perform another cycle. If still posisive additional therapy is required
if NR consultation
molecular remission
from day 2-6 to day 42
4 weeks
4 Wochen
ATO
2 weeks
break
ATO
4 weeks
break
ATO
total 4x ATO following CR
ATRA 14 days, 14 days break
day 1 -14
day 21-42
day
day 84 – 98
day
day
total 7x ATRA following CR
ATRA
ATRA
ATRA
ATRA
ATRA
ATRA
BMP
i.th. starting day 10, every 4 weeks, in total 7x
i.th.
MRD monitoring from BM before the 4. ATO course and after the 5. ATO course (=end of therapy), afterwords from blood for 12 month (min. every 3-month)
MRD
Tag
MRD 1
MRD 28
MRD 56
MRD 84
MRD
112
In case of symptoms of differentiation syndrome immediately start dexamethason 10 to 15mg/m²
ATRA: All trans-retinoid acid 25mg/m²/day oral twice a day, each day for 14 days, followed by a break of 14 days, in total 7x following CR (exception 2. ATRA course!)
ATO: Arsentrioxid 0.15 mg/kg/day i.v.; 1-2 hours starting at day 2-6 until morphologic CR.
Concomitant prednison 0.5 mg/kg day 1 – day 15 as prophylaxis of the differentiation syndrome
After 2 weeks break: 4 cycles with ATO: Monday - Friday 0.15 mg/kg/day i.v. for 4 weeks – 4 weeks break
Side effects ATO:
Weight gain, fluid retention, leukocytosis,
prolongation of the QT-interval.
ECG control at start of each ATO cycle
rare: peripheral neuropathy, hyperglycemia, skin rash
CR: complete remission
MRD: minimal residual disease
BMP: bone marrow aspiration
i.th. intrathecal cytarabin age dependent
Modified from the adult protocol, see Lo-Coco et al, NEJM13
AML-BFM 05/2018

14. APL-BFM recommendation High Risk
FAB M3 (PML/RARA): ATRA + ATO in pat. with WBC > /µl
Induction
maintenance CR
If PML/RARA remains positive, perform another cycle. If still posisive additional therapy is required
if NR consultation
molecular remission
ICC APL study
2x GO
ADx
from day 2-6 to day 42
4 weeks
4 Wochen
ATO
2 weeks
break
ATO
4 weeks
break
ATO
total 4x ATO following CR
ATRA 14 days, 14 days break
day 1 -14
day 21-42
day
day 84 – 98
day
day
total 7x ATRA following CR
ATRA
ATRA
ATRA
ATRA
ATRA
ATRA
BMP
i.th. starting day 10, every 4 weeks, in total 7x
i.th.
MRD monitoring from BM before the 4. ATO course and after the 5. ATO course (=end of therapy), afterwords from blood for 18 month (min. every 3-month)
MRD
Tag
MRD 1
MRD 28
MRD 56
MRD 84
MRD
112
In case of symptoms of differentiation syndrome immediately start dexamethason 10 to 15mg/m²
ATRA: All trans-retinoid acid 25mg/m²/day oral twice a day, each day for 14 days, followed by a break of 14 days, in total 7x following CR (exception 2. ATRA course!)
ATO: Arsentrioxid 0.15 mg/kg/day i.v.; 1-2 hours starting at day 2-6 until morphologic CR.
Concomitant prednison 0.5 mg/kg day 1 – day 15 as prophylaxis of the differentiation syndrome
After 2 weeks break: 4 cycles with ATO: Monday - Friday 0.15 mg/kg/day i.v. for 4 weeks – 4 weeks break
Side effects ATO:
Weight gain, fluid retention, leukocytosis,
prolongation of the QT-interval.
ECG control at start of each ATO cycle
rare: peripheral neuropathy, hyperglycemia, skin rash
CR: complete remission
MRD: minimal residual disease
BMP: bone marrow aspiration
i.th. intrathecal cytarabin age dependent
AML-BFM 05/2018

15. SR WBC < 10 000/µl – PCR follow-up
ATRA – ATO Group (APL-BFM Recommendation)
SR WBC < /µl – PCR follow-up
PCR (Pos > 10 E -4)
Pos
Neg
1 6y 2m WBC 3.67
2 5 y 3m WBC 3.2
3 14y 11m WBC 1.3
4 3y 4m WBC 3.11
5 7y 8m WBC 4.2
6 1y 2m WBC 2.9
7 14y 2m WBC 0.79
8 16y 3m WBC 1.9
9 8y 6m WBC 1.9
10 11y 2m WBC 3.0
w16
11 1y 3m WBC 3.8
12 4y 6m WBC 2.0
13 14y 6m WBC 2.6
ATO
ATO
ATO
total 4* ATO
and 7 * ATRA from CR
ATRA
ATRA
ATRA
ATRA
ATRA
ATRA
Initial 4w
12w
16w
20w
28w 9m
12m
15m
18m 8w
Creutzig et al.(2017) First experience of the AML-BFM group in pediatric patients with standard-risk APL treated with ATO and ATRA. Pediatr Blood Cancer, 64.
9/2016

16. Course and Toxicity in SR APL Patients
WBC (/µl)
WBC increase
Therapeutic action
toxicity 1
3,7
48,6 (ATRA)
HU, Ara-C
Trans. thrombocytosis 1419,000/µl 2
3,2
79,0 (ATO)
Break of ATO, Ara-C
2x focal gen. seizure, posterior reversible encephalopathy syndrome (PRES), asept. Osteonecrosis 3
1,3
22,5 - 4
3,1
22,4
Skin reaction (facial), 5
4,2
135,0 (ATRA)
Ara-C (does escalation) * L-DNR
ATRA syndrome, knee pain, QTc time prolongation gr. 1 6
3,8
(AIE Ukraine)
Otitis media (4. ATO cycl.) 7
0,8
10,4 8
1,9
24,2 9
40,0 (ATO)
Break of ATO
double vision, congested papilla, abducens paresis 10
3,0
ADxE first (M2)
QTc time borderline 11
37,2 (infection)
Facial eczema 12
2,0
75,0 (ATO) HU 13
2,6
14,0 (ATO)
Stop of ATRA (diff. syndrome)
Deep vein thromb., after 2 yrs. hair loss

17. Increase of WBC until day 33
6 pat. with different. Syndrome
4x after ATO
WBC data are incomplete in patient (Pat) 4 and 6

18. Summary ATRA+ATO Leukemia can be cured without ChTH! (SR)
All 13 (in between 20 pts.) SR pts. are in molec. CR
Till now no difference in MRD kinetics – (time until PCR neg.) between ChTh. - and ATRA/ATO
All pts. achieved hyperleukocytosis after ATRA / ATO – (Pred. propylaxis and early HU needed)
After 1 week outpatient care!

19. Early Death in APL Summary of Findings
Bleeding and thrombosis are the leading causes (72%) of ED in child- hood APL –
CNS bleed: 85% chance ED
Higher ED rate in patients not receiving induction ATRA
Initial high WBC count, increased BMI and M3v morphology were independently associated with ED
Abla O. et al. – Predictors of thrombohemorrhagic early death… Ann. Hematol 2017
YOU ARE NOT SHOWING BLACK RACE – SO REMOVE FROM SUMMARYT

20. Early Death in APL Highest risik: Initially ED by bleeding/ DIC
Early diagnosis - Suspicion on APL – ATRA at once
Teaching – for pediatricians
Initial absolut nessessary - morphology!
WBC high risk > /µl
Bleeding? Coagulation - (Quick, PTT, Fibrinogen, D-Dimere)
Supportive Care Guidelines
intensive monitoring
Substitution of platelets
diagnostic LP after blast cell reduction

21. APL – to consider! ATRA always immediately
ATO as soon as possible (ATO leads besides differentiation also to apoptosis)
Because of danger of differentiation syndrome:
hydroxyurea (2x20mg / m² / day) already in case of WBC increase to 5 000/μl
At WBC increase to /μl, hydroxyurea (2x40mg/m²) + cytarabine (2x40mg/m²/day)

22. Concomitant therapies
Prednisone 0.5 mg/kg from day 1 until day 15 of induction to prevent differentiation syndrome. Dexamethasone if APL differentiation syndrome develops
Platelet concentrate transfusions to maintain platelets >50x109/l during the first 10 days.
After day 10, platelets transfusion when platelets count is <20x109/l or in presence of hemorrhagic symptoms.
Packed red cell concentrates must be transfused to maintain Hb levels > 8 g/dl.
Supplemental electrolytes administered i.v., to maintain potassium concentrations above 4 mEq/l and magnesium concentrations above 1.8 mg/dl (0.74 mmol/l)
in order to reduce the risk of cardiac arrhythmia

23. During follow-up In case of non-response – other fusion gene?
ZBTB16-RARA (past PLZF-RARA) – ChTh!
MRD (PCR) relapse diagnosis every 3 months
12 m. (SR) and 18 m. (HR) patients
After end of therapy from blood

24. Relapse treatment according to time of rel. </> 18->36 months
Algorithm for Early Relapse – Consensus Guideline COG/I-BFM
BJH 2016 Abla O. et al.
Relapse treatment according to time of rel. </> 18->36 months
or > 3 years
and the firstline treatment: ATRA + chemoth.
or ATRA + ATO
Early APL Relapse (<18 m)
Prior ATO?
Ind ATO/ATRA no
3x Consol
ATRA/ATO/GO
Auto SCT
PCR neg
Consol.: hAM, ATRA
PCR pos
Allo SCT
Ind ATO/ATRA/Ida
yes
Consol 1: HD-Ara-c, ATRA, GO
Consol 2: ATRA-ATO
Consol 3: hAM, ATRA
Consol.: HD-Ara-c ATRA
2x ITT

25. Algorithm for Late Relapse – Consensus Guideline COG/I-BFM
BJH 2016 Oussama A. et al.
APL Relapse (>18 m)
Prior ATO?
Ind ATO/ATRA no
3x Consol
ATRA/ATO/GO
4x ATRA/ATO
PCR neg
Consol.: hAM, ATRA
PCR pos
Allo SCT
Ind ATO/ATRA/Ida
yes
Consol 1: ATO/ ATRA, GO
Consol. 2: ATRA + ATO
Consol 3: hAM, ATRA
Auto SCT
Consol.: HD-Ara-c ATRA
2x ITT

26. Very Late Relapse (>3 yrs.)
ATO/ATRA regimen + GO (see de novo APL)
Persistent MRD after 3 courses – allo SCT
Thank`s for your attention!

27. Information for patients and their families – about the diseases and therapies ...

28. Risk Groups LR WBC <10 000 HR WBC >10 000 AIEOP/AIDA93* N=110
64 %
36 %
M3v
11 %
5 yrs. OS
>90 %
81 %
5 yrs. EFS
83 %
59 %
AML-BFM 93-04**
N=81
70 %
30 %
CNS pos.
5 %
(1 CNS rel)
86 %
more HR in children
vs adults (25%)
*Testis, BLOOD 2005
** Creutzig, BJH 2010