Kurzfassung: Purpose Mutations of the isocitrate dehydrogenase-1 (IDH1) and IDH2 genes are one of the most frequent alterations in acute myeloid leukemia (AML) and can be found in ~20% of patients at diagnosis. Several IDH inhibitors are currently in late stage clinical development with Enasidenib, an IDH2 inhibitor, being recently approved by the FDA. Previous analyses have reported differential impact on response to chemotherapy and outcome, depending on the IDH-mutation type, co-occurring mutations and cytogenetic abnormalities, as well as the variant allele frequency (VAF) of IDH mutations. In order to better understand its prognostic role, we analyzed newly diagnosed AML patients enrolled in prospective trials of the Study Alliance Leukemia (SAL) to investigate the impact of IDH1/2 mutations on outcome. Patients and Methods All AML patients consecutively enrolled into intensive AML treatment protocols of the SAL or into the SAL registry were included in this analysis. Next-generation sequencing (NGS) on an Illumina MiSeq-system was performed to detect IDH1/2 mutations using pre-treatment samples. Overall survival (OS) and response to therapy were analyzed for all patients with intensive treatment and according to the mutational status. Results Overall, samples of 3898 patients were analyzed. The median follow-up was 91 months (95% CI 87.2 - 93.9). Patients' characteristics are shown in Tbl.1. Three-hundred twenty-nine patients (8.4%) had IDH1 mutations and 423 (11%) had IDH2 mutations; both mutations were found in 12 pts, so the overall mutation rate in IDH1 and 2 was 19% (740/3898 patients). Of the IDH1 variants, the most common ones were the R132C found in 143 patients (43%) and R132H in 137 patients (42%). For IDH2, 324 patients had the R140Q (77%) and 80 patients the R172K (19%) variant. According to the two main variants of the more common IDH2 mutations, as reported before, the IDH2 R172K was mutually exclusive with NPM1 and/or FLT3-ITD mutations. Overall, there was a trend for increased OS for patients with IDH2 R172K (26 vs. 15 months) as compared to those with R140Q. Considering only patients with a normal karyotype and no NPM1/FLT3-ITD mutation, these patients (n=27) had a highly significant better OS than patients with IDH2 R140Q (46.3 vs. 13.1 months, p=.012), supporting the findings published by Papaemmanuil et al. (NEJM 2016). In IDH1-mutated patients, we observed statistically significant differences in baseline characteristics between the two most common mutation types, IDH1 R132C and R132H. Patients carrying the R132C mutation were older (62 vs. 55 years, p=.001), had lower WBC (3.6 vs. 21 Gpt/L, p≤.001) and were less likely to have a normal karyotype (43% vs. 66%, p=.002), NPM1 (23% vs. 66%, p= 〈 .001), and FLT3-ITD mutations (8% vs. 27%, p 〈 .001) than those with the R132H variant. In univariate testing, the CR rate was also statistically significant lower in patients with IDH1 R132C (53% vs. 72%, p≤.001), with a median OS of 12.9 months compared to 17.4 months for patients with R132H variant (p=.08). In multivariate analysis including age, WBC, NPM1 and FLT3 status, and ELN risk, the CR rate was significantly lower in patients with the IDH1 R132C variant (p=.038). The median IDH VAF was 38% (range, 0.1 - 58) with no difference according to the different types of mutation. Patients with a VAF 〉 30% had a significantly higher BM blast count (73% vs 40% for VAF≤5%) and WBC (21.2 Gpt/L vs. 3.7 Gpt/L) at baseline, but there was no clear impact on CR rate or OS found in multivariate analysis. Conclusion In this large cohort of AML patients with IDH1/2 mutations, we found significant and so far not reported differences for one of the two most prominent mutations types of IDH1. The R132C variant was associated with increased age, lower WBC, and lower NPM1 and/or FLT3 co-mutation rate. Further, these patients had lower CR rates and a trend for shorter OS. For IDH2 we were able to reproduce findings on co-mutations and showed a favorable outcome for intensively treated patients with a normal karyotype and no NPM1/FLT3-ITD mutation and the IDH2 R172K variant, providing additional evidence for classification as a separate AML entity. Disclosures Middeke: Roche: Membership on an entity's Board of Directors or advisory committees; Janssen: Membership on an entity's Board of Directors or advisory committees, Research Funding; Abbvie: Membership on an entity's Board of Directors or advisory committees. Rollig:Bayer: Research Funding; Janssen: Research Funding. Kramer:Roche: Consultancy, Honoraria, Membership on an entity's Board of Directors or advisory committees; Bayer: Research Funding; Daiichi Sankyo: Consultancy. Scholl:Alexion: Other: Travel support; Abbivie: Other: Travel support; Novartis: Other: Travel support; Deutsche Krebshilfe: Research Funding; Carreras Foundation: Research Funding; Pfizer: Membership on an entity's Board of Directors or advisory committees; MDS: Other: Travel support; Jazz Pharma: Membership on an entity's Board of Directors or advisory committees. Hochhaus:Incyte: Research Funding; Pfizer: Research Funding; Takeda: Research Funding; Bristol-Myers Squibb: Research Funding; Novartis: Research Funding. Brümmendorf:Takeda: Consultancy; Pfizer: Consultancy, Research Funding; Janssen: Consultancy; Merck: Consultancy; Novartis: Consultancy, Research Funding. Burchert:Novartis: Research Funding; Pfizer: Honoraria; Bristol Myers Squibb: Honoraria, Research Funding; AOP Orphan: Honoraria, Research Funding; Bayer: Research Funding. Krause:Novartis: Research Funding. Hänel:Amgen: Honoraria; Novartis: Honoraria; Roche: Honoraria; Takeda: Honoraria. Platzbecker:Celgene: Research Funding. Mayer:Johnson & Johnson: Research Funding; Roche: Research Funding; Eisai: Research Funding; Affimed: Research Funding; Novartis: Research Funding. Serve:Bayer: Research Funding. Ehninger:Cellex Gesellschaft fuer Zellgewinnung mbH: Employment, Equity Ownership; Bayer: Research Funding; GEMoaB Monoclonals GmbH: Employment, Equity Ownership. Schetelig:Gilead: Consultancy, Honoraria, Research Funding; Abbvie: Honoraria; Janssen: Consultancy, Honoraria; Roche: Honoraria; Sanofi: Consultancy, Research Funding; Novartis: Consultancy, Honoraria, Research Funding. Thiede:AgenDix: Other: Ownership; Novartis: Honoraria, Research Funding. Stoelzel:Neovii: Speakers Bureau.

Kurzfassung: The presence of a mutated nucleophosmin-1 gene (NPM1 mut ) in acute myeloid leukemia (AML) is associated with a favorable prognosis. To assess the predictive value with regard to allogeneic stem-cell transplantation (SCT), we compared the clinical course of patients with NPM1 mut AML eligible for allogeneic SCT in a donor versus no-donor analysis. Patients and Methods Of 1,179 patients with AML (age 18 to 60 years) treated in the Study Alliance Leukemia AML 2003 trial, we identified all NPM1 mut patients with an intermediate-risk karyotype. According to the trial protocol, patients were intended to receive an allogeneic SCT if an HLA-identical sibling donor was available. Patients with no available donor received consolidation or autologous SCT. We compared relapse-free survival (RFS) and overall survival (OS) depending on the availability of a suitable donor. Results Of 304 eligible patients, 77 patients had a sibling donor and 227 had no available matched family donor. The 3-year RFS rates in the donor and no-donor groups were 71% and 47%, respectively (P = .005); OS rates were 70% and 60%, respectively (P = .114). In patients with normal karyotype and no FLT3 internal tandem duplication (n = 148), the 3-year RFS rates in the donor and no-donor groups were 83% and 53%, respectively (P = .004); and the 3-year OS rates were 81% and 75%, respectively (P = .300). Conclusion Allogeneic SCT led to a significantly prolonged RFS in patients with NPM1 mut AML. The absence of a statistically significant difference in OS is most likely a result of the fact that NPM1 mut patients who experienced relapse responded well to salvage treatment. Allogeneic SCT in first remission has potent antileukemic efficacy and is a valuable treatment option in patients with NPM1 mut AML with a sibling donor.

Kurzfassung: Biallelic mutations of the CEBPA gene (CEBPAbi) define a distinct entity associated with favorable prognosis; however, the role of monoallelic mutations (CEBPAsm) is poorly understood. We retrospectively analyzed 4708 adults with acute myeloid leukemia (AML) who had been recruited into the Study Alliance Leukemia trials, to investigate the prognostic impact of CEBPAsm. CEBPA mutations were identified in 240 patients (5.1%): 131 CEBPAbi and 109 CEBPAsm (60 affecting the N-terminal transactivation domains [CEBPAsmTAD] and 49 the C-terminal DNA-binding or basic leucine zipper region [CEBPAsmbZIP] ). Interestingly, patients carrying CEBPAbi or CEBPAsmbZIP shared several clinical factors: they were significantly younger (median, 46 and 50 years, respectively) and had higher white blood cell (WBC) counts at diagnosis (median, 23.7 × 109/L and 35.7 × 109/L) than patients with CEBPAsmTAD (median age, 63 years, median WBC 13.1 × 109/L; P & lt; .001). Co-mutations were similar in both groups: GATA2 mutations (35.1% CEBPAbi; 36.7% CEBPAsmbZIP vs 6.7% CEBPAsmTAD; P & lt; .001) or NPM1 mutations (3.1% CEBPAbi; 8.2% CEBPAsmbZIP vs 38.3% CEBPAsmTAD; P & lt; .001). CEBPAbi and CEBPAsmbZIP, but not CEBPAsmTAD were associated with significantly improved overall (OS; median 103 and 63 vs 13 months) and event-free survival (EFS; median, 20.7 and 17.1 months vs 5.7 months), in univariate and multivariable analyses. Additional analyses revealed that the clinical and molecular features as well as the favorable survival were confined to patients with in-frame mutations in bZIP (CEBPAbZIP-inf). When patients were classified according to CEBPAbZIP-inf and CEBPAother (including CEBPAsmTAD and non-CEBPAbZIP-inf), only patients bearing CEBPAbZIP-inf showed superior complete remission rates and the longest median OS and EFS, arguing for a previously undefined prognostic role of this type of mutation.

Kurzfassung: Mutations of the key myeloid transcription factor CCAAT/enhancer binding protein alpha (C/EBPa) are found in 5-10% of patients with acute myeloid leukemia (AML). Two mutational clusters exist, in the aminoterminal transcription activation domains (TAD1 or 2) and in the basic leucine zipper domain (bZIP) located at the carboxyterminal-part of the protein. Biallelic mutations (biCEBPA) have been found to be associated with improved outcome and are now included as an independent entity in the WHO-classification. In contrast, monoallelic CEBPA-mutations (moCEBPA) do not appear to provide prognostic information. We characterized a large cohort of AML patients for CEBPA mutations and further analyzed the mutational spectrum of mono- and biallelic CEBPA-mutant AML patients to better understand potential differences in the biology of these groups. Patients and Methods: Patients (including all age groups) analyzed had a newly diagnosed AML and were registered in clinical protocols of the Study Alliance Leukemia (SAL)(AML96, AML2003 or AML60+, SORAML) or the SAL-register. Screening for CEBPA mutations was done using PCR and capillary electrophoresis. All identified CEBPA mutations were confirmed using conventional Sanger sequencing and the samples were further analyzed using next generation sequencing (Trusight Myeloid Panel, Illumina) for the presence of associated alterations. Results: In the 4578 patients analyzed, 228 (5%) with CEBPA-mutations were identified. An initial analysis revealed substantial clinical differences between the different mutation subtypes. Patients with biCEBPA (n=111) were significantly younger (median age 46 yrs) than wt-CEBPA patients (median 57 yrs; p 〈 .001). Interestingly, single bZIP mutant patients (n=64) had a similar median age (50 yrs.) as biCEBPA, whereas single TAD mutant patients (n=53) were significantly older (median 63 yrs.). In addition, WBC counts, CD34 positivity as well as the history of prior MDS differed between the subgroups (single TAD mutant had significantly lower WBC counts, lower rate of CD34 positivity and had a higher rate of prior MDS than biCEBPA and single bZIP mutant patients). Along with this, the distribution of co-mutations differed significantly between the subgroups, especially GATA2 mutations were more common in biCEBPA and single bZIP mutant patients (37% and 34%, respectively) compared to only 3% (single TAD)(p=.001). A similar pattern was seen for mutations in DNMT3A (8% biCEBPA, 20% single bZIP vs. 36% single TAD; p=.001), and NPM1 (3% biCEBPA, 8% single bZIP, 32% single TAD; p 〈 .001). In 2897 patients, the different CEBPA mutations were correlated with outcome. This analysis indicated a differential effect of the individual mutations on outcome, with an improved rate of complete remission (CR), overall survival (OS) and event free survival (EFS) for biCEBPA and single bZIP mutations in univariate and multivariate analyses (shown for OS in Figure 1a). Given the similarity of single bZIP and biCEBPA mutations, it appears reasonable to speculate on a common mechanistical background, since most of the biCEBPA mutants include a bZIP alteration. Recent experimental evidence generated by several groups indeed supports a specific role of these bZIP missense mutations. To address this in the clinical context, we regrouped patients with mutant CEBPA into patients with (n=157) or without bZIP mutations (n=71), irrespective of the biallelic status. As illustrated in Figure 1b, the bZIP mutant group had a significantly better OS, similar results were obtained for EFS and CR. In multivariate analysis, the presence of a bZIP mutation was the strongest indicator for achievement of CR (HR 7.5, 95% CI: 3-19; p 〈 .001), and together with favorable cytogenetics the factor associated with best OS (HR: .48; 95% CI .36-.64; p 〈 .001). In conclusion, our results obtained in one of the largest cohorts of AML patients analyzed for CEBPA mutations indicate that especially the presence of a missense bZIP mutation is associated with a favorable outcome in AML patients. These data point to substantial differences in prognostic implications of individual CEBPA mutations and support the major functional divergence of these alterations. If confirmed, these results might necessitate further refinement of their use in AML-classification. Disclosures Middeke: Sanofi: Honoraria. Platzbecker:Janssen-Cilag: Honoraria, Research Funding; Celgene Corporation: Honoraria, Research Funding; TEVA Pharmaceutical Industries: Honoraria, Research Funding; Amgen: Honoraria, Research Funding; Novartis: Honoraria, Research Funding. Thiede:AgenDix: Employment, Other: Ownership.

Kurzfassung: Background: So called triple-negative acute myeloid leukemias (AML) form a heterogeneous subgroup of intermediate-risk AML according to ELN criteria. Molecularly this group can be defined by the absence of internal tandem duplications (ITDs) in the fms related tyrosine kinase 3 gene (FLT3), wild type (wt) nucleophosmin gene (NPM1) and wt or single (homozygously or heterozygously) mutated CCAAT/enhancer binding protein α gene (CEBPA). To date, it remains unclear whether this group of patients benefits from allogeneic stem cell transplantation (alloSCT) as consolidation strategy in first complete remission (CR1). Aims: To evaluate the impact of alloSCT on the overall (OS) and relapse free survival (RFS) in patients with triple negative AML in first remission in comparison to post remission chemotherapy (PRT). Methods: We performed a subgroup analysis of 3041 AML patients aged 16-60 years who were enrolled into the AML 96 and the AML 2003 trials of the Study Alliance Leukemia (SAL). Selection criteria for this subgroup were NPM1 wt, negativity for FLT3-ITD and CEPBA double mutations, a karyotype that does not define the AML as favorable or adverse according to ELN criteria and the accomplishment of CR1. Status of molecular markers was evaluated with standard PCR techniques. Within the AML2003 trial, donor status was evaluated at study entry, making these data eligible for a donor-versus-no-donor analysis. Kaplan-Meier estimates were used to report on point estimates for survival probabilities. Multivariate Cox models were fitted to analyze the impact of alloSCT as time-dependent covariate. Age, gender, white blood cell count, lactate dehydrogenase, AML type (de novo, secondary AML following MDS or MPN, or therapy-related myeloid neoplasms) and ECOG performance status at diagnosis were selected as adjusting covariables. As-treated analyses used data from both trials, AML96 and AML2003. For these analyses alloSCT or PRT were entered as time-dependent covariates into extended Cox regression models. Survival outcomes were displayed with Simon-Makuch-plots. Results: In total, 497 patients (AML96: 217, AML2003: 280) with a median age of 47 years were evaluable for the analysis of OS from diagnosis. A total of 302 patients had reached CR1 and could be evaluated for RFS. In a multivariate donor-versus-no-donor analysis, OS of patients with a sibling donor was not significantly different to patients without a donor (HR 0.79, 95%CI 0.53 to 1.16, p=.2). Irrespective of whether the patient actually received alloSCT in CR1, the probability of OS at 5 years from study enrollment was 55% (95%CI, 45% to 67%) for patients with a sibling donor and 47% (95%CI, 40% to 54%) for patients without a donor. For RFS, the hazard ratio was 0.72 (95%CI, 0.5 to 1.05, p=0.09), with a trend in favor of better remission-control for patients with a sibling donor. At five years from CR1, RFS of patients with sibling donor was 48% (95%CI, 38% to 61%) compared to 36% (95%CI, 30% to 44%). However, the transplantation rate in the donor group was only 53% and 15% of patients in the no-donor group actually received alloSCT. Therefore, 'cross-over' effects lowered the power of donor-versus-no-donor analysis. In the multivariable as-treated analysis including patients from AML96 and AML 2003, OS and RFS of patients with alloSCT were significantly longer (OS: HR 0.58, 95%CI, 0.37 to 0.9, p=.02, RFS: 0.51, 95%CI, 0.34 to 0.76, p=0.001) compared to the PRT group. The probability of OS at 5 years from initiation of consolidation treatment (alloSCT vs. PRT) was 66% (95%CI, 57% to 76%) for patients who received alloSCT compared to 46% (95%CI, 38% to 55%) for PRT patients. The probability of RFS at 5 years from initiation of consolidation treatment was 55% (95%CI, 46% to 67%) for alloSCT patients and 31% (95%CI, 24% to 39%) for PRT patients. Conclusions: Due to cross-over effects which limit the power of the donor-versus-no-donor analysis we give more weight to the results of the as-treated analysis. This analysis suggests that eligible intermediate-risk AML patients with NPM1 wt and absent FLT3-ITD benefit from alloSCT in CR1. However, bias introduced by selection and confounding factors cannot be excluded for this type of analysis and could only be circumvented in randomized controlled trials. Disclosures Thiede: AgenDix: Employment, Other: Ownership. Rösler:Janssen: Consultancy, Other: Travel/Accommodation/Expenses. Middeke:Sanofi: Honoraria. Schetelig:Sanofi: Honoraria.

Kurzfassung: FLT3 -ITD mutations are common druggable alterations in patients with acute myeloid leukemia (AML) and associated with poor prognosis. Beside typical ITD mutations, point mutations and deletions in the juxtamembrane domain (JMD) have been observed. However, due to the low frequency of these alterations, there is only limited information on molecular and clinical associations. To evaluate the prognostic impact of non-ITD mutations in the FLT3 JMD region, we analyzed a large cohort of 1,539 adult AML patients treated in different protocols of the Study Alliance Leukemia, using next-generation sequencing. Non-ITD point mutations and deletions within the FLT3 JMD were identified with a prevalence of ~1.23% (n = 19). Both FLT3 -ITD and non-ITD mutations were associated with a higher rate of NPM1 (42%–61%; p & lt; 0.001) and DNMT3A mutations (37%–43%; p & lt; 0.001), as well as an increased percentage of peripheral blood (54%–65%) and bone marrow blast cells (74%; p & lt; 0.001), compared to FLT3 -wild-type patients. Most significantly, AML patients with FLT3 non-ITD mutations had a higher rate of concomitant KMT2A -PTD mutations (37.5%; p & lt; 0.001) as compared to FLT3 -ITD (7%) or FLT3 -wild-type cases (4.5%). In a multivariable analysis, FLT3 non-ITD mutations were not an independent prognostic factor. However, patients with dual FLT3 non-ITD and KMT2A -PTD mutations showed a trend for inferior outcome, which points at a functional interaction in this subset of AML.

Kurzfassung: Acute myeloid leukemia (AML) is characterized by recurrent genetic events. The BCL6 corepressor (BCOR) and its homolog, the BCL6 corepressor-like 1 (BCORL1), have been reported to be rare but recurrent mutations in AML. Previously, smaller studies have reported conflicting results regarding impacts on outcomes. Here, we retrospectively analyzed a large cohort of 1529 patients with newly diagnosed and intensively treated AML. BCOR and BCORL1 mutations were found in 71 (4.6%) and 53 patients (3.5%), respectively. Frequently co-mutated genes were DNTM3A, TET2 and RUNX1. Mutated BCORL1 and loss-of-function mutations of BCOR were significantly more common in the ELN2017 intermediate-risk group. Patients harboring loss-of-function mutations of BCOR had a significantly reduced median event-free survival (HR = 1.464 (95%-Confidence Interval (CI): 1.005–2.134), p = 0.047), relapse-free survival (HR = 1.904 (95%-CI: 1.163–3.117), p = 0.01), and trend for reduced overall survival (HR = 1.495 (95%-CI: 0.990–2.258), p = 0.056) in multivariable analysis. Our study establishes a novel role for loss-of-function mutations of BCOR regarding risk stratification in AML, which may influence treatment allocation.