THE LEUKEMIAS. ACUTE CHRONIC AML and ALL CLL and CML (any ages) (in the elderly)

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1 THE LEUKEMIAS Definition: malignant transformation of the pluripotent stem cell, successive expansion of the malignant clone from the bone marrow to the tissues

2 THE LEUKEMIAS Characteristics: maturation arrest and pancytopenia Classification: morphology, cytochemistry, cytogenetics, immunophenotype analysis, gene rearrangement

3 THE LEUKEMIAS ACUTE CHRONIC AML and ALL CLL and CML (any ages) (in the elderly) Etiology: genetic predisposition (twins,downs syndrome) Known environmental mutagens(ionizing radiation,atomic bomb survivors, chemical exposure like cytostatic agents) Viruses: HTLV I,II in adult T cell leukemias, EBV in L3

4 Secondary leukemias preceeded by preleukaemic phase/mds

5 FAB Classification of de novo AL

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7 Blasts in peripheral blood smear

8 AML

9 Auer rods

10 ALL

11 L3 type leukemia

12 AMoL

13 AMoL

14 AUL

15 POX positive AML

16 esteráze positive AML

17 PAS positivity in ALL

18 Acid phosphatase pozitiv AML

19 Cluster of Differentiation Subtype MO M1 M2 M3 M4 M5 M6 M7 L1 L2 L3 CD markers CD34,33,13 CD 34,33,13 CSD33,13,15 CD33,13, HLA DR - CD 34,33,15,14,13 CD33,15,14,13 CD33,glycophorin CD33,41 CD10,19,34,Tdt CD10,19,34,Tdt CD19,20,sIg

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21 Prognostic variables in AML factor favourable unfavourable age <45 yr >60 yr leukemia De novo Pre-MDS,MPS Surface markers Cytogenetics molecular markers CD34-,14-,13- T(15;17) t(8,21) inv (16) FLt-3 negatíve NPM: negatíve CD34+ -7/7q-,-5/5q-, complex FLt-3 pozitive NPM: pozitive 3.

22 Molecular markers of prognostic significance Core binding factor (CBF) transcription factor involved in the regulation of normal hematopoiesis. In t(8;12) the RUNX1 (AML1) gene encoding subunitαof CBF is fused to the RUNX1T1 (ETO) gene and in inv(16)/t(16;16), the CBFB gene, encoding subunitβof CBF, is fused to the MYH11 gene. Protein products of the CBF fusion genes act as dominant negative inhibitors of normal hematopoiesis and contribute to leukemogenesis.

23 Clinically relevant genes mutated and/or overexpressed in CBF AML Gene symbol KIT FLT3 MLL CEBPA NPM1 WT1 BAALC ERG MN1 Gene name Encodes for a member of receptor TK family Fms-related Tk3 Mixed lineage leukemia Enhancing binding protein alpha nucleophosmin Wilms tumor 1 Brain and AL gene Viral oncogene Meningeoma 1 Chromosome location 4q11-q12 13q12 11q23 19q13.1 5q35 11p13 8q q q11

24 Considering survival and relaps on chemotherapy only Good prognosis: balanced translocations associated with core binding factor, characteristic karyotypes: t(15;17), t(8,21), inv. Chr.16. [CR 80-90% ] but OS at 5 yr: 40% Intermedier prognosis: normal karyotype ( heterogenous group, +(poor)/- FLT-3 mutation, +(good)/- NPM (nucleo-cytoplasmic transport protein) mutation; + c-kit mutation: poor) [CR:70-80% ] Poor prognosis: inbalanced karyotypes: LOH, -7,7q-, - 5;5q-, t(9;22), 3q abn. complex karyotypes ( 3 or more) [CR: 50-60% ] but: OS at 5 yrs: 5-15% Therefore BMT is important!

25 Multiple step pathogenesis of AML Chromosome translocations result in disturbed differentiation ot the hemopoietic progenitors with the involvement of transcription molecules. point mutations occur frequently in cell division and signal transduction abnormalities. t(8:21) translocation resulting in AML1-ETO fusion protein (M2) Core binding factor (CBF) heterodimer transcription factors. In AML with t(8:21) fusion gene result from the fusion of RUNX1T1 (on chr 8) and RUNX1 (on chr 21). In AML (inv16) the fusion of CBF located on chr 16q22 and MYHII located on 16q13 will take place.(bjh 2006;135:165-73).

26 t(12,21) juxtaposes TEL and AML1 gene ( childhood leukemia) providing gain of function -P16 (INK4A) provide loss of suppressor gene, that is a mutant cell cycle regulator gene -t(9;22) abl/bcr provide Tk aktivation property - FLT-3 gene mutation in AML: code for Tk- signal transduction (ITD) -The mixed lineage leukemia gene, MLL. transcription factors that are involved in the specification of cell fate during development. In any defect of the gene will provide imortalized cell lines= leukemias

27 Disease Diagnostic / Followup Target Fusion Product Diagnostic Multiplex 28 fusion products (see below) t(1;11)(p32;q23) MLL / AF1p t(1;11)(q21;q23) MLL / AF1q t(1;19)(q23;p13) E2A / PBX1 t(3;21)(q26;q22) AML / EAP / MDS / EVI1 t(3;5)(q25.1;q34) NPM / MLF1 t(4;11)(q21;q23) MLL / AF4 t(5;12)(q33;p13) TEL / PDGFRB t(5;17)(q35;q21) NPM / RARA t(6:11)(q27;q23) MLL / AF6 t(6;9)(p23;q34) DEK / CAN t(8;21)(q22;q22) AML1 / MGT8

28 t(9;11)(p22;q23) MLL / AF9 t(9;12)(q34;p13) TEL / ABL t(9;22)(q34;q11)* BCR / ABL t(9;9)(q34;q34) SET / CAN t(10;11)(p12;q23) MLL / AF10 t(11;17)(q23;q21) MLL / AF17 t(11;17)(q23;q21) PLZF / RARA t(11;19)(q23;p13.1) MLL / ELL t(11;19)(q23;p13.3) MLL / ENL t(12;21)(p13;q22)* TEL / AML1 t(12;22)(p13;q11) TEL / MN1 t(15;17)(q22;q21) PML / RARA t(16;21)(q11;q22) TLS / ERG t(17;19)(q22;p13) E2A / HLF inv(16)(p13;q22) CBFb / MYH11

29 t(x;11)(q13;q23)mll / AFX TAL1deletion(p34) SIL / TAL1 AML Diagnostic t(1;22)(p13;q13)ott / MAL CML Diagnostic t(9;22)(q34;q11)* BCR / ABL CML t(9;22)(q34;q11)* BCR / ABL HYPEREOSINOPHILIC SYNDROME t(5;12)(q33;p13)tel / PDGFRB HYPEREOSINOPHILIC SYNDROME Diagnostic del(4)(q12q12) FIP1L1-PDGFRA CHRONIC EOSINOPHILIC LEUKEMIA LEUKEMIA Diagnostic t(8;9)(p21-23;p23-24) PCM1 / JAK2 LYMPHOMA Diagnostic t(14;18)(p32;q21) BCL-2 / JH LYMPHOMA t(14;18)(p32;q21) BCL-2 / JH

30 Disease Diagnostic / Target Comment Diagnostic & Activating mutation (Internal tandem duplication) of the FLT3 Responsiveness to Various FLT3 Inhibitors Diagnostic & Activating mutations in exon 14 of the FLT3 Responsiveness to Various FLT3 Inhibitors ACUTE MYELOID LEUKEMIA Diagnostic & Mutations in Exons 8, 11 AND 17 in KIT Gleevec/Imatinib Responsiveness ACUTE MYELOID LEUKEMIA Exon 20 Mutations in FLT3 (Including ASP835) Responsiveness to Various FLT3 Inhibitors BONE MARROW TRANSPLANT: ENGRAFTMENT CONTROL STR Markers Chimerism CHRONIC MYELOID LEUKEMIA AND Diagnostic & Mutations in Exons 4-10 of the ABL Gene (Including T315I) Gleevec/Imatinib Responsiveness CHRONIC MYELOMONOCYTIC LEUKEMIA (CMML) Diagnostic V617F Mutation in JAK2 ESSENTIAL THROMBOCYTHEMIA Diagnostic V617F Mutation in JAK2 HYPEREOSINOPHILIC SYNDROME Diagnostic V617F Mutation in JAK2 MAST CELL LEUKEMIA Diagnostic & Mutations in Exon 17 in KIT Gleevec/Imatinib Responsiveness MASTOCYTOSIS Diagnostic & Mutations in Exon 17 in KIT Gleevec/Imatinib Responsiveness MYELOID METAPLASIA WITH MYELOFIBROSIS Diagnostic V617F Mutation in JAK2 NEUTROPHILIC LEUKEMIA (CNL) Diagnostic V617F Mutation in JAK2 POLYCYTHEMIA VERA Diagnostic V617F Mutation in JAK2 SYSTEMIC MASTOCYTOSIS Diagnostic V617F Mutation in JAK2 THE MYELODYSPLASTIC SYNDROMES Diagnostic V617F Mutation in JAK2

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33 Protein kinases represent important target for drug therapy in leukemias. PKs contain an activation loop that controls the catalytic activity by switching between active (open) and inactive ( closed) conformation states in a phosphorylation dependent manner. Open conformations are generally stabilized by phosphorilation on a serine, threonine, or tyrosine residues within the activation loop, and in this conformation provides a platform for substrate binding. In CML the The TK activity is derived from the bcr/abl fusion protein resulting from a translocation of chromosome 22 and 9 t(22;9) commonly termed as Ph. Imatinib ir a potent TK INH

34 Chemotherapy Mechanisms

35 Novel therapies I. Gliveec *imatinib( for Ph + AML) For relapsed and/or refractory AML: -DNA demethylating Decitabine(iv:15 mg/m2/10d), -Histon deacetylase inhibitor: valopric acid ( p.os:35mg/ttkg). Consequence: CR:20% (because the so far repressed p15 suppressor gene deliberated by hypomethylation)(blood 2006; 108: ) For ALL: adding L-asparaginaze U/m2/10 d on d and in late intenzification, provided better results. To introduce children ALL protocol in adult ALL gives better cahnces for cur(higher dose MTX, without Etoposide)

36 Novel therpies II. Chemotherapy:Topotecan - topoizomeraze INH), clofarabin( purin nukleotid analog), rapamycin (mtor mammalian target of rapamycin-inh) Targeted therapy: BCL-2 antisense oligonucleotid, bevacizumab VEGF INH, FLT-3 INH:PKC412 Immunotherapy: gemtuzumab- CD33-ab, Wilms tu-ab BMT: autologous, allogenic: myeloablative, RIC

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39 BMT in AML in CR1- otherwise : 50-80% relapse Autolog SCT in CR1 MUD (HLA-matched unrelated donor) UC ( Umilical cord) RIC it is to be considered: Age, average condition,cr1 or CR2, refractory disease, In 57 register more than 10 million donor Finding donor takes mos, time elapsing to BMT: 4 mos. Problems: 1/ allogen SCT: high relapse rate- absence of good GVL effect, 2/MUD with myeloablative preconditioning: GVHD, high transplant related mortality (TRM), 3/ UMb.Cord:transplant insufficiency, long repopulation time, but: no CMV infection,low GVHD, easy access, no harm for the donor, 4/ RIC: reduced intenzitiy conditioning including TBI: for elderly not fit persons. For RIC OS at 2yrs 48%, 5/ haploidentic stem cell transplantation ( differernce in at least 3 HLA locus-relativ) How to choose donor: good preformance status, age<55-60: myeloablative MUD, elderly, comorbidities: RIC

40 Comparison of results BMT/conventional chemotherapy survival>3 yrs % Allo-BMT Acute Myelogenous Leukemia 1st remission nd remission rd remission Acute Lymphocytic Leukemia 1st remission nd remission rd remission Auto-BMT Chemoth < <10 0

41 CLL/low risk NHL

42 CML