1. Acute Myeloid Leukemia By Ahmed Refaat Abd Elzaher Assistant lecturer of Medical Oncology South Egypt Cancer Institute Assuit University

2. Heterogeneous  Heterogeneous clonal stem cell malignancy  Immature hematopoietic cells proliferate and accumulate in BM, PB & other tissues features of BM failure.  Recently, certain CyG abnormalities classified as AML irrespective of blast count : t(8;21), inv(16) and t(15;17) Definition & epidemiology  PB and/or BM blasts > 20 % of nucleated cell (NC) count  If the blasts in the BM are > 5% & < 20% MDS Roboz G & Sung L. ASH-SAP 2010; PP 475 Roboz G & Sung L. ASH-SAP 2010; PP 475

3. Acute myeloid leukemia Incidence – 2.7 per 100,000 –median age of presentation : 65 yo AML comprises 90% of all acute leukemias in adults More prevalent: –Males –European –Hispanic (promyelocytic leukemia (AML M3)

4. AML - Etiology Primary AML –Increased incidence Genetic fragility –Faconi anemia –Down syndrome tobacco use? herbicides?, pesticides? benzene exposure Secondary AML –XRT –Topoisomerase II inhibitors (e.g etopisode), alkylating agents –MDS –other cell proliferation disorders CML, polycythemia vera, primary thrombocytosis, PNH

6. ACUTE LEUKEMIA Diagnosis Clinical Morphological Immunophenotyping Molecular genetics Cytogenetics

7. Clinical presentation  Sign or symptoms related to pancytopenia:  WBC  infection.  Hb  anemia.  platelets  bleeding  Approximately 25% of AML patients present with white blood cell (WBC) counts > 50,000/mm³  Monocytic variants (M4 or M5) commonly display infiltration of gingivae, skin, soft tissues or meninges  DIC is a common presentation in AML M3  M2 : Chloroma:-presents as a mass lesion ‘tumor of leukemic cells’

8. Leukostasis Leukostasis – predominantly in those with WBC counts > 100,000 (10% of patients); can also be seen in patients with WBC > 50,000 –Most common in those with M4 or M5 leukemia Common symptoms –Pulmonary: dyspnea, chest pain –CNS: headaches, altered mentation, CN palsies, ocular symptoms –Priapism –Myocardial Infarction

9. Gingival Infiltration in Monocytic AML (M4) After tt !

10. Diagnosis  Previously >30% blasts on BM aspirate (per FAB criteria)¹  Recently changed to > 20% blasts in the peripheral blood or BM (per WHO criteria)²  Patients with certain cytogenic abnormalities are considered to have AML regardless of blast percentage² t(8;21) (q22;q22), inversion (16) (p13q22) t(16;16) (p13;q22), and t(15;17) (q22;q12) 1- Bennett et al, Br J Haematol 1976 2-Vardiman et al, blood 2002

11. FAB Classification of AML (1976) M 0 : minimally differentiated M 1 : without maturation M 2 : with maturationM 3 : hypergranular promyelocytic 30% 5%

12. M 4 : myelomonocyticM 5a : Monoblastic M 6 : erythroleukemiaM 7 : megakaryoblastic 20% 30% 2-4% M 5b : monocytic FAB Classification of AML (1976)

13. AML (WHO 2008) Cytogenetics & Moleculars FAB ! Excluding APL (M3) EXTREMELYIMPORTANT

14. (eg alklating agents, topoisom. II inhib., RT…) Therapy-related AML …. WHO classification (2008) (FAB excluding APL) Poor prognosis… BAD cytogenetics AML with MDS

15. “Therapy-related AML: Alkylating agents and radiotherapy Topoisomerase II inhibitors Onset5-6 years post- exposure 1-5 years post- exposure Ch abn.Of MDSRearrangements of ch 11 MM AML

16. ______________________ALL____________AML__________ Myeloperoxidase - + Suddan black - + Non-specific esterase - + in M4, M5 Periodic acid Schiff (PAS) + in B-ALL + in M6 Acid phosphatase + in T-ALL + in M6 Bennett et al, Br J Haematol 1976 Cytochemistry

17. Immunophenotype Based on blast surface antigen expression CD34 –Stem cell marker CD117, CD33, CD13, MPO –Myeloid markers CD14, CD64 –Monocytic marker Glycophorin A –Erythroid marker CD41, CD61 –Megakaryocytic markers

18. Qadir et al, Cytometry Part B: Clinical Cytometry,2006

19. Normal / t(9;11) Normal / t(9;11) Roboz G & Sung L. ASH-SAP 2010; 475-487 Jabbour E et al. Mayo Clin Proc. 2006; 81:247 Others: Complex (≥3 abnorm.), monosomal karyotype 5 or 7 (MK 5 / 7 seems to be of the worst !) t(9;22), t(6;11), abn(17). (Trisomy 8) (CBF)

20. Rowe JM et al. Blood 2010;116:3147 AML in pts less than 60 years of age: Survival, by karyotype, of de novo and therapy-related (t-AML) Grimwade D & Hills RK. Hematology ASH Educ Program 2009; 385–395.

21. Molecular genetics: The field of biology that studies the structure and function of genes at a molecular (atomic) level

22. “The most important prognostic indicators in AML are age, cytogenetics, and molecular genetics….”

23. & inv16 20-30% of t(8;21) & 30-40% of inv16 The WORST GOODGOOD (BAD) (Intermediate risk)

24. Frohling S et al. JCO 2004; 22:624 Preudhomme C et al. Blood 2002; 100:2717 OS for AML patients with NC according to CEBPA mutation status (similar results in two studies) (similar results in two studies)

25.  cytogenetic markers revolutionized therapeutic decisions favorable, intermediate & unfavorable. respond differently Molecular markers of AML.  However, patients tend to respond differently to a specific therapeutic approach within the same cytogenetic risk group`. Molecular markers of AML. Remember…  Both the NCCN and the ELN guidelines recommend: molecular genetics (mainly FLT3, NPM1, C-Kit and CEBPA) to further categorize cytogenetically normal patients…. More individualized decision making !

26. Cytogenetics and Molecular Abnormalities

28. DNMT3A Mutations Common in Intermediate-Risk AML Mutations in the DNA methyltransferase gene, DNMT3A, are also associated with poor prognosis and are highly recurrent in patients with intermediate-risk AML. Presence of any DNMT3A mutation, either alone or in combination with the FLT3 internal tandem duplication (ITD) mutation, is associated with significantly shorter overall survival Ley TJ, et al. ASH 2010. Abstract 99.

29. Isocitrate dehydrogenase (IDH ) :IDH1 and IDH2 mutations occur in 25–30% of patients with CN- AML, and in general predict for worse outcome in certain molecular (NPM1 wild-type) and clinical (older age) subsets of patients Molecular markers of AML

30. Evaluation ● Cytogenetics are critical. ● Molecular diagnostics mandatory for all patients including the elderly: at least FLT3-ITD, NPM1, CEBPA; also consider C-KIT in patients with core- binding factor AML. ● Post-remission monitoring of minimal residual disease using cytogenetics, PCR, and multicolor flow cytometry. ● Send HLA typing of patient and siblings at time of initial diagnosis.

32. Assessment of response to treatment CALGB Criteria Detection of minimal residual disease (MRD) Karyotyping FISH PCR Immunophenotyping CRPR Clinical PB BM MRD-MRD+

33. Criteria of response to treatment (CALGB) Definition of CR ClinicalPeripheral bloodBone marrow TLC= 2-10 X 10 9 /L –ANC > 1000 –No blasts HB > 11 (females) > 12 (males) PLT > 100 000/m 3 P.S. = 100% No organomegaly Normocelluar Blasts <5% The presence of Auer rods is not allowed in CR marrow NCCN Guidelines Version 2.2011

34. Essentially, routine practice nowadays for all AML pts ! for all AML pts ! previously !! …previously !!

35. Treatment of AML 5) Special considerations  Elderly AML  Concept of targeted therapy in AML 1) Supportive treatment (for all pts) 2) Induction therapy 3) Post-remission (consolidation) therapy 4) Treatment of Relapsed AML

36. Supportive treatment  Hydration and allopurinol to prevent tumor lysis syndrome… esp initial cyto-reduction with HU (if TLC)  Availability of “full” neutropenic precautions  Insertion of a central line to deliver chemotherapy.  Blood and platelets transfusion  Oral care and nutritional advice  Antimicrobials (prophylactic / therapeutic)  Sperm banking  Hormonal therapy to control menses during time of thrombocytopenia.

37. To begin with, till this very moment…. It is still the: “3 + 7” regimen (from the 1970s …..!!) Anthracycline X 3d (usually Daunorubicin) AraC (Cytarabine) X 7d Although AML…heterogeneous Same tt approach (except APL)… !

38. Induction Treatment Of AML Dauno 45mg/m 2 D 1-3 I.V 100 / 200 AraC 100 / 200 mg/m 2 D 1-7 C.I Standard DA (3+7) Initially No Difference in OS BUT …

39. (Fernandez HF et al. NEJM 2009; 361:1249)

40. IdarubicinOR Idarubicin (10 or 12mg/m 2 X 3d) OR Mitoxantrone Mitoxantrone 12mg/m 2 X 3d Which anthracycline ? NO advantage over the higher doses of Dauno (i.e 60 or 90)

42. Day 14 BM Day 14 BM  Blasts <5%  wait till CBC recovery initial blasts (if tolerable & NO active infection)  Blasts >5% & < 50% of initial blasts  2 nd 3+7 (if tolerable & NO active infection)  initial blasts  Blasts > 50% of initial blasts  Salvage (eg HAM / FLAG-M) Upon CBC recovery  BM Day 14 BM Day 14 BM  Blasts <5%  wait till CBC recovery initial blasts (if tolerable & NO active infection)  Blasts >5% & < 50% of initial blasts  2 nd 3+7 (if tolerable & NO active infection)  initial blasts  Blasts > 50% of initial blasts  Salvage (eg HAM / FLAG-M) Upon CBC recovery  BM Still with remission induction (Nadir)

43. Treatment of AML 5) Special considerations  Elderly AML  Concept of targeted therapy in AML 1) Supportive treatment (for all pts) 2) Induction therapy 3) Post-remission (consolidation) therapy 4) Treatment of Relapsed AML

44. Rational: eradicate residual Leukemic clone Consolidation therapy: “EXTREMELY” crucial…..

45. Consolidation after CR (exclusively… cytogenetics) AML (1 st CR) Good risk HiDAC x 3-4 Intermed. risk Allo-HSCT OR HiDAC Poor risk Allo-HSCT OR clinical trial Two meta analyses superiority of Allo in these risk groups: 1)Cornelissen J et al. Blood 2007; 109:3658 2)Koreth A. et al. JAMA 2009; 301:2349

46. Current facts The new era of molecular incorporation…. therapeutic map is changing (Few grey zones...!)

47. Favorable No role for HSCT, EXCEPT: Those with a mutation in c- KIT (eg with CBF t 8;21) or FLT3 45% of AML, mostly cytogenetically normal (CN) Intermediate Allo-HSCT for all EXCEPT mutant NPM1 but FLT3- ITD -ve OR CEBPA+ve Allo-HSCT for all Unfavorable

48. Post-remission therapy for adults with newly diagnosed AML (except APL) Induction by (3+7) irrespective of risk group CR Favorable risk Intermediate/unfavorable risk HD ARA-C containing regimen X 3 cycles Relapse 2 nd induction Donor presentNo donor Allo BMT in CR2ABMT in CR2 Donor presentNo donor Allo BMT in CR1 as soon as possible HD ARA-C containing regimen X 3 ABMT in CR1 Relapse Palliative therapy

50. Treatment of special forms of AML AML M5 High Risk Of CNS Disease After reaching CR by induction chemotherapy, give triple intrathecal prophylaxis: MTX 15 mg ARA-c 40 mg Dexamethazone 4 mg Every 8 weeks for a total of 6 injections.

51. Treatment of AML in Eldery

53. HAM Treatment of relapsed AML Mitoxantrone ARA-c 1 gm/m 2 (3hrs infusion) /12 hrs. 12 mg/m 2 I.V. short infusion. Days 3-5 1-3

54. HAM Treatment of relapsed AML - High dose ARA-c should not be given over a period shorter than 3 hours : - Prophylaxis ARA-C induced chemical conjunctivitis (excreted in tears) : Dexamethazone eye drops (e.g. Isoptodex): 2 drops in each eye qid day 1-7. Due to enteritis problem - Antiemetic ttt Zofran 16-32 mg C.I. or I.V. (2-4 amp.).

55. Treatment of relapsed AML AVVV V P 16 A RA-c 100 mg/m 2 C.I. 100 mg/m 2 I.V. Days 12 1-7 V incristine 2 mg...……I.V. 1-5 10 V elbe 10 mg …… I.V.

56. Treatment of relapsed AML FLAG Days A RA-c* Fl udarabine 25 mg/m 2 1gm/m 2 /12 hrs 1-5 G -CSF** 200  gm /m 2 1-5 D0  ANC >1000 1 hr inf. 3 hrs inf. S.C. *ARA-c should be given at least 4 hrs after Fludarabine to modulate pharmacokinetics of ARA-c (++ level of ARA-CTP in blast cells). ** Our experience is either to drop G-CSF or to start it on day +6

57. Epigenetic changes (Heritable modifications in gene function or activity without changes in DNA sequence) DNA hypermethylationDNA hypermethylation Histone deacetylationHistone deacetylation Gene silencing…”switching off” (tumor suppressor genes) Carcinogenesis REVERSIBLE ! HistoneDeacetylation Inhibitors (HDACi) Hypomethylating agents… AZA / DEC

58. It is easy to kill cancer cells, but the challenge is keeping the patient alive at the same time…..!

59. Thank You