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A. Gating strategy applied for flow cytometry analysis of NK cell panel. Phenotype of NK cell (CD56dim CD16+ ) activation was quantified using expression of cell surface markers CD69, CD107a, CD45RA, and CD45RO based on the indicated gates. B. NK cell frequency before and after the treatment analyzed in PBMCs from 18 patient samples and grouped according long-and short-survivors. C. Frequency of NK cells expressing cell surface activation markers CD69, CD107a, and CD45RA and CD45RO measured in short-and long-survival groups before and after the treatment.

Specific genes sequenced in bone marrow mononuclear cells.

Grade 3 or Higher Toxicities or Toxicities Observed in 10% or More Patients – Excluding Those Defined as Unrelated or Unlikely Related to Protocol Treatment.

Representativeness of Study Participants

Isolation and DNA extraction of bone marrow cell populations; Targeted DNA sequencing; Peripheral blood mononuclear cell (PBMC) staining and flow cytometry analysis

Purpose:We hypothesized that resistance to hypomethylating agents (HMA) among patients with myelodysplastic syndrome (MDS) and chronic myelomonocytic leukemia (CMML) would be overcome by combining a programmed death-ligand 1 antibody with an HMA.Patients and Methods:We conducted a Phase I/II, multicenter clinical trial for patients with MDS not achieving an International Working Group response after at least 4 cycles of an HMA (“refractory”) or progressing after a response (“relapsed”) with 3+ or higher risk MDS by the revised International Prognostic Scoring System (IPSS-R) and CMML-1 or -2. Phase I consisted of a 3+3 dose-escalation design beginning with guadecitabine at 30 mg/m2 and escalating to 60 mg/m2 Days 1 to 5 with fixed-dose atezolizumab: 840 mg intravenously Days 8 and 22 of a 28-day cycle. Primary endpoints were safety and tolerability; secondary endpoints were overall response rate (ORR) and survival.Results:Thirty-three patients, median age 73 (range 54–85), were treated. Thirty patients had MDS and 3 had CMML, with 30% relapsed and 70% refractory. No dose-limiting toxicities were observed in Phase I. There were 3 (9%) deaths in ≤ 30 days. Five patients (16%) came off study for drug-related toxicity. Immune-related adverse events (IRAE) occurred in 12 (36%) patients (4 grade 3, 3 grade 2, and 5 grade1). ORR was 33% [95% confidence interval (CI), 19%–52%] with 2 complete remission (CR), 3 hematologic improvement, 5 marrow CR, and 1 partial remission. Median overall survival was 15.1 (95% CI, 8.5–25.3) months.Conclusions:Guadecitabine with atezolizumab has modest efficacy with manageable IRAEs and typical cytopenia-related safety concerns for patients with relapsed or refractory MDS and CMML.

List of Patients Who Experienced Immune-related Adverse Events AEs.

A. Gating strategy applied on PBMCs samples evaluated by flow cytometry. CD8+ T cell memory was defined based on the expression of CD45RA and CCR7 (CD197). Cell surface phenotype (PD-1, CD39, and CD69) and intracellular activation (Ki-67) markers were quantified on CD8+ effector T cell (TEFF) based on indicated gates. B, CD8+ naïve and memory T cells in long-and short-survivors quantified before and after the treatment. C, Representative flow cytometry plots showing CD8+ T cells activation in PBMC samples from a short survivor. PD-1+ Ki-67+ expression on CD8+ T cells compared before and after the treatment.

Median overall survival was longer among patients whose T cells harbored ASXL1 mutations (green) than for those without the mutation (red) or with only myeloid mutations (blue), but ASXL1 mutation status was not associated with survival in a univariate analysis by the logrank test (p=0.11). In a multivariate analysis using a Cox proportional model and adjusted by age at study entry, gender, diagnosis, and the number of prior treatment regimens, ASXL1 was significantly associated with survival (p=0.001 based on likelihood ratio test).

A& B. Frequency (A) and intensity (B) of PD-1+ CD8+ T cells by gender) before (PRE), after second treatment cycle (C2D1 or C2D8; EARLY), and after third or fourth treatment cycle (C4D1, C4D8 or C5D1; LATE). CD8+ T cell expressing CD39 (C) and CD69 (D). F: females, M: males

Summary Background Guadecitabine is a next-generation hypomethylating agent whose active metabolite decitabine has a longer in-vivo exposure time than intravenous decitabine. More effective hypomethylating agents are needed for the treatment of myelodysplastic syndromes. In the present study, we aimed to compare the activity and safety of two doses of guadecitabine in hypomethylating agent treatment-naive or relapsed or refractory patients with intermediate-risk or high-risk myelodysplastic syndromes. Methods This phase 2 part of the phase 1/2, randomised, open-label study enrolled patients aged 18 years or older from 14 North American medical centres with International Prognostic Scoring System intermediate-1-risk, intermediate-2-risk, or high-risk myelodysplastic syndromes, or chronic myelomonocytic leukaemia. They were either hypomethylating agent treatment-naive or had relapsed or refractory disease after previous hypomethylating agent treatment as determined by the investigators' judgment. Eligible patients had Eastern Cooperative Oncology Group performance status of 0–2. Patients were randomly assigned (1:1) using a computer algorithm for dynamic randomisation to subcutaneous guadecitabine 60 or 90 mg/m2 on days 1–5 of a 28-day treatment cycle. Treatment was stratified by previous treatment with hypomethylating agents and neither patients nor investigators were masked. The primary endpoint was overall response (a composite of complete response, partial response, marrow complete response, and haematological improvement) assessed in all patients who received at least one dose of study drug. This study is registered with ClinicalTrials.gov, number NCT01261312. Findings Between July 9, 2012, and April 7, 2014, 105 patients were enrolled: 55 (52%) were allocated to guadecitabine 60 mg/m2 (28 patients were treatment-naive and 27 had relapsed or refractory disease after previous hypomethylating agent treatment) and 50 (48%) patients to 90 mg/m2 (23 patients were treatment-naive and 27 had relapsed or refractory disease). Three (3%) patients of 105 did not receive study treatment and were excluded from analyses. Median follow-up was 3·2 years (IQR 2·8–3·5). The proportion of patients achieving an overall response did not significantly differ between dose groups (21 of 53 [40%, 95% CI 27–54] with 60 mg/m2 and 27 of 49 [55%, 95% CI 40–69] with 90 mg/m2; p=0·16). 25 of 49 (51%, 95% CI 36–66) patients who were treatment-naive and 23 of 53 (43%, 30–58) patients with relapsed or refractory disease achieved an overall response. The most common grade 3 or worse adverse events in both groups, regardless of relationship to treatment, were thrombocytopenia (22 [41%] of 53 patients in the 60 mg/m2 group and 28 [57%] of 49 in the 90 mg/m2 group), neutropaenia (21 [40%] and 25 [51%]), anaemia (25 [47%] and 24 [49%]), febrile neutropaenia (17 [32%] and 21 [43%]), and pneumonia (13 [25%] and 15 [31%]). Seven (7%) of 102 patients died due to adverse events (three with 90 mg/m2 and four with 60 mg/m2), and all except one were in the relapsed or refractory cohort. Two deaths were deemed treatment related (septic shock with 60 mg/m2; pneumonia with 90 mg/m2). Interpretation Guadecitabine was clinically active with acceptable tolerability in patients with intermediate-risk and high-risk myelodysplastic syndromes. Responses and overall survival in the relapsed or refractory cohort offer the potential of a new therapeutic option for patients for whom currently available hypomethylating agents are not successful. We therefore recommend guadecitabine at a dose of 60 mg/m2 on a 5-day schedule for these patients. Funding Astex Pharmaceuticals and Stand Up To Cancer.

The implementation of targeted therapies for acute myeloid leukaemia (AML) has been challenging because of the complex mutational patterns within and across patients as well as a dearth of pharmacologic agents for most mutational events. Here we report initial findings from the Beat AML programme on a cohort of 672 tumour specimens collected from 562 patients. We assessed these specimens using whole-exome sequencing, RNA sequencing and analyses of ex vivo drug sensitivity. Our data reveal mutational events that have not previously been detected in AML. We show that the response to drugs is associated with mutational status, including instances of drug sensitivity that are specific to combinatorial mutational events. Integration with RNA sequencing also revealed gene expression signatures, which predict a role for specific gene networks in the drug response. Collectively, we have generated a dataset—accessible through the Beat AML data viewer (Vizome)—that can be leveraged to address clinical, genomic, transcriptomic and functional analyses of the biology of AML. Analyses of samples from patients with acute myeloid leukaemia reveal that drug response is associated with mutational status and gene expression; the generated dataset provides a basis for future clinical and functional studies of this disease.

Src family kinases (SFKs) are hyperactivated in acute myeloid leukemia (AML). SFKs impede the retinoic acid receptor, and SFK inhibitors enhance all-trans retinoic acid (ATRA)-mediated cellular differentiation in AML cell lines and primary blasts. To translate these findings into the clinic, we undertook a phase I dose-escalation study of the combination of the SFK inhibitor dasatinib and ATRA in patients with high-risk myeloid neoplasms. Nine subjects were enrolled: six received 70 mg dasatinib plus 45 mg/m(2) ATRA daily, and three received 100 mg dasatinib plus 45 mg/m(2) ATRA daily for 28 days. Headache and QTc prolongations were the only two grade 3 adverse events observed. No significant clinical responses were observed. We conclude that the combination of 70 mg dasatinib and 45 mg/m(2) ATRA daily is safe with acceptable toxicity. Our results provide the safety profile for further investigations into the clinical efficacy of this combination therapy in myeloid malignancies.

Acute myeloid leukemia (AML) often harbors mutations in epigenetic regulators, and also has frequent DNA hypermethylation, including the presence of CpG island methylator phenotypes (CIMPs). Although global hypomethylation is well known in cancer, the question of whether distinct demethylator phenotypes (DMPs) exist remains unanswered. Using Illumina 450k arrays for 194 patients from The Cancer Genome Atlas, we identified two distinct DMPs by hierarchical clustering: DMP.1 and DMP.2. DMP.1 cases harbored mutations in NPM1 (94%), FLT3 (71%) and DNMT3A (61%). Surprisingly, only 40% of patients with DNMT3A mutations were DMP.1, which has implications for mechanisms of transformation by this mutation. In contrast, DMP.2 AML was comprised of patients with t(8;21), inv(16) or t(15;17), suggesting common methylation defects connect these disparate rearrangements. RNA-seq revealed upregulated genes functioning in immune response (DMP.1) and development (DMP.2). We confirmed these findings by integrating independent 450k data sets (236 additional cases), and found prognostic effects by DMP status, independent of age and cytogenetics. The existence of DMPs has implications for AML pathogenesis and may augment existing tools in risk stratification.

Background Outcomes for patients with relapsed or refractory acute myeloid leukemia (AML) are poor. Guadecitabine, a next-generation hypomethylating agent, could be useful in treating such patients. Methods In this multicenter, open-label, phase 2 dose-expansion study, AML patients from 10 North American medical centers were first randomized (1:1) to receive subcutaneous guadecitabine at 60 or 90 mg/m2 on 5 consecutive days in each 28-day cycle (5-day regimen). Subsequently, another cohort was treated for 10 days with 60 mg/m2 (10-day regimen). Results Between June 15, 2012, and August 19, 2013, 108 patients with previously treated AML consented to enroll in the study, and 103 of these patients were treated; 5 patients did not receive the study treatment. A total of 103 patients were included in the safety and efficacy analyses (24 and 26 patients who were randomly assigned to 60 and 90 mg/m2 /d, respectively [5-day regimen] and 53 patients who were assigned to 60 mg/m2 /d [10-day regimen]). The 90 mg/m2 dose showed no benefit in clinical outcomes in comparison with 60 mg/m2 in the randomized cohort. Composite complete response (CRc) and complete response (CR) rates were higher with the 10-day regimen versus the 5-day regimen (CRc, 30.2% vs 16.0%; P = .1061; CR, 18.9% vs 8%; P = .15). Adverse events (grade ≥ 3) were mainly hematologic, with a higher incidence on the 10-day regimen. Early all-cause mortality was low and similar between regimens. Twenty patients (8 on the 5-day regimen and 12 on the 10-day regimen) were bridged to hematopoietic cell transplantation. Conclusions Guadecitabine has promising clinical activity and an acceptable safety profile and thus warrants further development in this population. Cancer 2018;124:325-34. © 2017 The Authors. Cancer published by Wiley Periodicals, Inc. on behalf of American Cancer Society. This is an open access article under the terms of the Creative Commons Attribution NonCommercial License, which permits use, distribution and reproduction in any medium, provided the original work is properly cited and is not used for commercial purposes.

Summary Background The hypomethylating drugs azacitidine and decitabine have shown efficacy in myelodysplastic syndromes and acute myeloid leukaemia, but complete tumour responses are infrequent and of short duration, possibly because of the short half-lives and suboptimal bone marrow exposure of the drugs. Guadecitabine, a next-generation hypomethylating drug, has a longer half-life and exposure than its active metabolite decitabine. A phase 1 study established 60 mg/m 2 guadecitabine for 5 days as an effective treatment schedule. In this phase 2 study, we aimed to assess the safety and activity of two doses and schedules of guadecitabine in older (≥65 years) patients with treatment-naive acute myeloid leukaemia who were not candidates for intensive chemotherapy. Methods We did a multicentre, randomised, open-label, phase 1/2 study of guadecitabine in cohorts of patients with treatment-naive acute myeloid leukaemia, relapsed or refractory acute myeloid leukaemia, and myelodysplastic syndromes; here we report the phase 2 results from the cohort of treatment-naive patients with acute myeloid leukaemia. We included patients aged at least 65 years from 14 US medical centres (hospitals and specialist cancer clinics) who were not candidates for intensive chemotherapy and randomly assigned them (1:1) using a computer algorithm (for dynamic randomisation) to guadecitabine 60 or 90 mg/m 2 on days 1–5 (5-day schedule) of a 28-day treatment cycle. Treatment allocation was not masked. We also assigned additional patients to guadecitabine 60 mg/m 2 in a 10-day schedule in a 28-day treatment cycle after a protocol amendment. The primary endpoint was composite complete response (complete response, complete response with incomplete platelet recovery, or complete response with incomplete neutrophil recovery regardless of platelets). Response was assessed in all patients (as-treated) who received at least one dose of guadecitabine. We present the final analysis, although at the time of the database lock, 15 patients were still in follow-up for overall survival. This study is registered with ClinicalTrials.gov, number NCT01261312. Findings Between Aug 24, 2012, and Sept 15, 2014, 107 patients were enrolled: 54 on the 5-day schedule (26 randomly assigned to 60 mg/m 2 and 28 to 90 mg/m 2 ) and 53 were assigned to the 10-day schedule. Median age was 77 years (range 62–92), and median follow-up was 953 days (IQR 721–1040). All treated patients were assessable for a response. The number of patients who achieved a composite complete response did not differ between dose groups or schedules (13 [54%, 95% CI 32·8–74·4] with 60 mg/m 2 on the 5-day schedule; 16 [59%; 38·8–77·6] with 90 mg/m 2 on the 5-day schedule; and 26 [50%, 35·8–64·2] with 60 mg/m 2 on the 10-day schedule). The most frequent grade 3 or worse adverse events, regardless of relationship to treatment, were febrile neutropenia (31 [61%] of 51 patients on the 5-day schedule vs 36 [69%] of 52 patients on the 10-day schedule), thrombocytopenia (25 [49%] vs 22 [42%]), neutropenia (20 [39%] vs 18 [35%]), pneumonia (15 [29%] vs 19 [37%]), anaemia (15 [29%] vs 12 [23%]), and sepsis (eight [16%] vs 14 [27%]). The most common serious adverse events, regardless of relationship to treatment, for the 5-day and 10-day schedules, respectively, were febrile neutropenia (27 [53%] vs 25 [48%]), pneumonia (14 [27%] vs 16 [31%]), and sepsis (eight [16%] vs 14 [27%]). 23 (22%) patients died because of adverse events (mainly from sepsis, eight [8%]; and pneumonia, five [5%]); four deaths were from adverse events deemed treatment-related (pneumonia, two [2%]; multiorgan failure, one [1%]; and sepsis, one [1%], all in the 10-day cohort). Interpretation More than half of older treatment-naive patients with acute myeloid leukaemia achieved a composite complete response with guadecitabine at all drug doses and schedules investigated, with tolerable toxicity. The recommended guadecitabine regimen for this population is 60 mg/m 2 in a 5-day schedule. A phase 3 study in this patient population is ongoing (NCT02348489) to assess guadecitabine 60 mg/m 2 in a 5-day schedule versus standard of care. Funding Astex Pharmaceuticals and Stand Up To Cancer.

Acute myeloid leukemia (AML) is the most common form of acute leukemia among adults and accounts for the largest number of annual deaths due to leukemias in the United States. Recent advances have resulted in an expansion of treatment options for AML, especially concerning targeted therapies and low-intensity regimens. This portion of the NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines) for AML focuses on the management of AML and provides recommendations on the workup, diagnostic evaluation and treatment options for younger (age

Splenic irradiation (SI) is a palliative treatment option for symptomatic splenomegaly (i.e. for pain, early satiety, pancytopenia from sequestration) secondary to hematologic malignancies and disorders. The purpose of the current article is to review the literature on SI for hematologic malignancies and disorders, including: (1) patient selection and optimal technique; (2) efficacy of SI; and (3) toxicities of SI. PICOS/PRISMA methods are used to select 27 articles including 766 courses of SI for 486 patients from 1960 to 2016. The most common cancers treated included chronic lymphocytic leukemia and myeloproliferative disorders; the most common regimen was 10Gy in 1Gy fractions over two weeks, and 27% of patients received retreatment. A partial or complete response (for symptoms, lab abnormalities) was obtained in 85-90% of treated patients, and 30% were retreated within 6-12months. There was no correlation between biologically equivalent dose of radiation therapy and response duration, pain relief, spleen reduction, or cytopenia improvement (r2 all

Background Guadecitabine is a novel DNA methyltransferase (DNMT) inhibitor with improved pharmacokinetics and clinical activity in a subset of patients with relapsed/refractory acute myeloid leukemia (r/r AML), but identification of this subset remains difficult. Methods To search for biomarkers of response, we measured genome-wide DNA methylation, mutations of 54 genes, and expression of a panel of 7 genes in pre-treatment samples from 128 patients treated at therapeutic doses in a phase I/II study. Results Response rate to guadecitabine was 17% (2 complete remission (CR), 3 CR with incomplete blood count recovery (CRi), or CR with incomplete platelets recovery (CRp)) in the phase I component and 23% (14 CR, 9 CRi/CRp) in phase II. There were no strong mutation or methylation predictors of response. Gene expression clustering defined a subset of patients (~ 20%) that had (i) high DNMT3B and low CDKN2B, CTCF, and CDA expression; (ii) enrichment for KRAS/NRAS mutations; (iii) frequent CpG island hypermethylation; (iv) low long interspersed nuclear element 1 (LINE-1) hypomethylation after treatment; and (v) resistance to guadecitabine in both phase I (response rate 0% vs. 33%, p = 0.07) and phase II components of the study (response rate 5% vs. 30%, p = 0.02). Multivariate analysis identified peripheral blood (PB) blasts and hemoglobin as predictors of response and cytogenetics, gene expression, RAS mutations, and hemoglobin as predictors of survival. Conclusions A subset of patients (~ 20%) with r/r AML is unlikely to benefit from guadecitabine as a single agent. In the remaining 80%, guadecitabine is a viable option with a median survival of 8 months and a 2-year survival rate of 21%. Trial registration NCT01261312. Electronic supplementary material The online version of this article (10.1186/s13148-019-0704-3) contains supplementary material, which is available to authorized users.

Patients with relapsed or refractory (R/R) cancers have a poor prognosis and limited treatment options. The recent approval of 2 chimeric antigen receptor (CAR) autologous T-cell products for R/R B-cell acute lymphoblastic leukemia and non-Hodgkin's lymphoma treatment is setting the stage for what is possible in other diseases. However, there are important factors that must be considered, including patient selection, toxicity management, and costs associated with CAR T-cell therapy. To begin to address these issues, NCCN organized a task force consisting of a multidisciplinary panel of experts in oncology, cancer center administration, and health policy, which met for the first time in March 2018. This report describes the current state of CAR T-cell therapy and future strategies that should be considered as the application of this novel immunotherapy expands and evolves.

Aberrant DNA methylation is a critically important modification in cancer cells, which, through promoter and enhancer DNA methylation changes, use this mechanism to activate oncogenes and silence of tumor-suppressor genes. Targeting DNA methylation in cancer using DNA hypomethylating drugs reprograms tumor cells to a more normal-like state by affecting multiple pathways, and also sensitizes these cells to chemotherapy and immunotherapy. The first generation hypomethylating drugs azacitidine and decitabine are routinely used for the treatment of myeloid leukemias and a next-generation drug (guadecitabine) is currently in clinical trials. This review will summarize preclinical and clinical data on DNA hypomethylating drugs as a cancer therapy.

Background: Guadecitabine (G) is a next generation subcutaneous (SC) hypomethylating agent (HMA) resistant to degradation by cytidine deaminase which results in prolonged in vivo exposure to the active metabolite decitabine. We conducted a large global randomized phase 3 study of G vs Treatment Choice (TC) with azacitidine (AZA), decitabine (DEC), or low dose Ara-C (LDAC) in 815 TN AML patients unfit for IC (ASTRAL-1 study). The primary ITT results were previously presented (Fenaux et al, EHA abstract S879, 2019). Clinical guidelines for single agent HMAs recommend a minimum of 4 to 6 treatment cycles for maximum benefit. We describe here the results of the study based on number of treatment cycles administered. M ethods: TN-AML patients ineligible for IC due to age ≥ 75 y, or coexisting morbidities, or ECOG PS 2-3 were randomized 1:1 to either G (60 mg/m2/d SC for 5-days Q28 days) or a preselected TC of AZA, DEC, or LDAC at their standard dose/schedule. AML diagnosis and response status were assessed by an independent central pathologist blinded to randomization assignment. Complete response (CR) and overall survival (OS) were co-primary endpoints. We analyzed patients' characteristics, number of treatment cycles, reasons for treatment discontinuation, CR, and OS including analyses by number of cycles received including prospective subgroups, and OS analyses of responders and non-responders. Results: 815 patients were randomized to G (408) or TC (407). Preselected TCs prior to randomization were DEC (43%), AZA (42%), and LDAC (15%). Baseline variables were well balanced across the 2 treatment arms. For G vs TC respectively, age ≥75 y in 62% vs 62.4%, PS 2-3 in 50.5% vs 50.4% (including 10.8% vs 8.8% PS 3), and poor risk cytogenetics in 34.3% vs 34.6%. Most patients were assigned to an HMA at randomization (759, 93%) with only 56 patients (7%) randomized to receive LDAC. Both CR (19.4% for G and 17.4% for TC), and OS Hazard Ratio (0.97; 95% CI 0.83-1.14) were similar and not significantly different between G and TC. Many patients in both arms did not receive the recommended minimum of 4 cycles (42.4% vs 40.8% for G vs TC respectively), or 6 cycles (54.2% vs 53.8% for G vs TC). The proportions were well balanced between the 2 treatment arms. Characteristics of patients who received at least 4 or 6 cycles were also well balanced between the 2 treatment arms for age, PS 2-3, secondary AML, poor risk cytogenetics, BM blasts >30%, and proliferative AML (total white cell count ≥20,000/uL). The primary reasons and proportions for treatment discontinuation were similar for the 2 treatments arms. For patients with Summary/Conclusions: In a large global 815-patient randomized study of G vs TC composed mainly of first generation HMAs, G was at least as effective as TC based on the primary ITT analysis of CR and the narrow 95% CI of OS HR (0.83-1.14). Analyses of patients by number of treatment cycles showed that those who received at least 4 or 6 cycles achieved longer OS in G vs TC with the largest benefit in those who received at least 6 cycles. The benefit was observed in all subgroups, and in both responders and non-responders. Treatment with single agent guadecitabine should continue as long as the patient can still benefit and for at least 6 cycles to gain the maximum survival benefit. Disclosures Roboz: Trovagene: Consultancy, Membership on an entity's Board of Directors or advisory committees; Takeda: Consultancy, Membership on an entity's Board of Directors or advisory committees; Sandoz: Consultancy, Membership on an entity's Board of Directors or advisory committees; AbbVie: Consultancy, Membership on an entity's Board of Directors or advisory committees; Actinium: Consultancy, Membership on an entity's Board of Directors or advisory committees; Agios: Consultancy, Membership on an entity's Board of Directors or advisory committees; Amphivena: Consultancy, Membership on an entity's Board of Directors or advisory committees; Argenx: Consultancy, Membership on an entity's Board of Directors or advisory committees; Astex: Consultancy, Membership on an entity's Board of Directors or advisory committees; Astellas: Consultancy, Membership on an entity's Board of Directors or advisory committees; Bayer: Consultancy, Membership on an entity's Board of Directors or advisory committees; Celgene: Consultancy, Membership on an entity's Board of Directors or advisory committees; Celltrion: Consultancy, Membership on an entity's Board of Directors or advisory committees; Daiichi Sankyo: Consultancy, Membership on an entity's Board of Directors or advisory committees; Eisai: Consultancy, Membership on an entity's Board of Directors or advisory committees; Janssen: Consultancy, Membership on an entity's Board of Directors or advisory committees; Jazz: Consultancy, Membership on an entity's Board of Directors or advisory committees; Novartis: Consultancy, Membership on an entity's Board of Directors or advisory committees; MEI Pharma: Consultancy, Membership on an entity's Board of Directors or advisory committees; Orsenix: Consultancy, Membership on an entity's Board of Directors or advisory committees; Otsuka: Consultancy, Membership on an entity's Board of Directors or advisory committees; Pfizer: Consultancy, Membership on an entity's Board of Directors or advisory committees; Roche/Genentech: Consultancy, Membership on an entity's Board of Directors or advisory committees. Döhner:Celgene, Novartis, Sunesis: Honoraria, Research Funding; AbbVie, Agios, Amgen, Astellas, Astex, Celator, Janssen, Jazz, Seattle Genetics: Consultancy, Honoraria; AROG, Bristol Myers Squibb, Pfizer: Research Funding. Mayer:AOP Orphan Pharmaceuticals AG: Research Funding. Krauter:Pfizer: Honoraria. Robak:Takeda: Consultancy, Research Funding; UCB: Honoraria, Research Funding; Janssen: Consultancy, Honoraria, Other: Travel grant, Research Funding; Amgen: Consultancy, Other: Travel grant; Roche: Consultancy, Other: Travel grant, Research Funding; Abbvie: Consultancy, Honoraria, Other: Travel grant, Research Funding; Gilead: Consultancy, Research Funding; BeiGene: Consultancy, Research Funding; Acerta: Research Funding; Morphosys AG: Research Funding. Kantarjian:Agios: Honoraria, Research Funding; Astex: Research Funding; Jazz Pharma: Research Funding; Amgen: Honoraria, Research Funding; BMS: Research Funding; Novartis: Research Funding; Actinium: Honoraria, Membership on an entity's Board of Directors or advisory committees; Immunogen: Research Funding; AbbVie: Honoraria, Research Funding; Takeda: Honoraria; Cyclacel: Research Funding; Pfizer: Honoraria, Research Funding; Daiichi-Sankyo: Research Funding; Ariad: Research Funding. Novak:Novartis: Consultancy, Membership on an entity's Board of Directors or advisory committees; Roche: Consultancy, Membership on an entity's Board of Directors or advisory committees; Pfizer: Consultancy, Membership on an entity's Board of Directors or advisory committees; Amgen: Consultancy, Membership on an entity's Board of Directors or advisory committees, Other: Travel,Accommodations; Takeda: Consultancy, Membership on an entity's Board of Directors or advisory committees; Janssen: Other: Travel,Accommodations. Jedrzejczak:Takeda: Consultancy; Amgen: Consultancy, Other: travel support for hematology meetings; Celgene: Other: travel support for hematology meetings; Novartis: Research Funding; Roche: Other: travel support for hematology meetings. Thomas:PFIZER: Honoraria; ABBVIE: Honoraria; DAICHI: Honoraria; INCYTE: Honoraria. Miyazaki:Chugai: Research Funding; Otsuka: Honoraria; Novartis: Honoraria; Nippon-Shinyaku: Honoraria; Dainippon-Sumitomo: Honoraria; Kyowa-Kirin: Honoraria. Brandwein:Jazz Pharma: Consultancy, Honoraria; Otsuka: Honoraria; Pfizer: Consultancy, Honoraria, Research Funding; Celgene: Consultancy, Honoraria, Research Funding; Roche: Research Funding; Novartis: Consultancy, Honoraria. Demeter:Angelini: Other: Advisory Board; Pfizer: Other: Advisory Board; Novartis: Other: Advisory Board; Bristol Myers Squibb: Other: Advisory Board; Amicus: Other: Advisory Board; Amgen: Other: Advisory Board; Roche: Other: Advisory Board. Griffiths:Astex Phramaceuticals/Otsuka Pharmaceuticals: Consultancy, Research Funding; Persimmune: Consultancy; Persimmune: Consultancy; Genentech, Inc.: Research Funding; Appelis Pharmaceuticals: Other: PI on a clinical trial; New Link Genetics: Consultancy; Novartis Inc.: Consultancy; Novartis Inc.: Consultancy; Onconova Therapeutics: Other: PI on a clinical trial; Partner Therapeutics: Consultancy; Appelis Pharmaceuticals: Other: PI on a clinical trial; Boston Scientific: Consultancy; Boston Scientific: Consultancy; Genentech, Inc.: Research Funding; Abbvie, Inc.: Consultancy; Celgene, Inc: Consultancy, Research Funding; Celgene, Inc: Consultancy, Research Funding; New Link Genetics: Consultancy; Onconova Therapeutics: Other: PI on a clinical trial; Partner Therapeutics: Consultancy; Astex Phramaceuticals/Otsuka Pharmaceuticals: Consultancy, Research Funding; Abbvie, Inc.: Consultancy, PI on a clinical trial. Yee:Agensys, Astex, Hoffman La Roche, MedImmune, Merck, Millenium, Roche/Genentech: Research Funding; Novartis, Pfizer: Honoraria, Membership on an entity's Board of Directors or advisory committees; Astellas, Celgene, Otsuka, Shire, Takeda: Membership on an entity's Board of Directors or advisory committees. Hao:Astex Pharmaceuticals, Inc.: Employment. Azab:Astex Pharmaceuticals, Inc.: Employment. Fenaux:Celgene Corporation: Honoraria, Research Funding; Aprea: Research Funding; Astex: Honoraria, Research Funding; Jazz: Honoraria, Research Funding.

The 2014 NCCN Clinical Practice Guidelines in Oncology for Chronic Myelogenous Leukemia recommend quantitative reverse-transcription polymerase chain reaction (QPCR) standardized to International Scale (IS) as the preferred method for monitoring molecular response to tyrosine kinase inhibitor (TKI) therapy. A BCR-ABL1 transcript level of 10% or less (IS) is now included as the response milestone at 3 and 6 months. Change of therapy to an alternate TKI is recommended for patients with BCR-ABL1 transcript levels greater than 10% (IS) at 3 months after primary treatment with imatinib. Continuing the same dose of TKI or switching to an alternate TKI are options for patients with BCR-ABL1 transcript levels greater than 10% (IS) at 3 months after primary treatment with dasatinib or nilotinib. The guidelines recommend 6-month evaluation with QPCR (IS) for patients with BCR-ABL1 transcript levels greater than 10% at 3 months. Monitoring with QPCR (IS) every 3 months is recommended for all patients, including those who meet response milestones at 3, 6, 12, and 18 months (BCR-ABL1 transcript level ≤10% [IS] at 3 and 6 months, complete cytogenetic response at 12 and 18 months).

Myelofibrosis (MF), polycythemia vera (PV), and essential thrombocythemia (ET) are a group of heterogeneous disorders of the hematopoietic system collectively known as Philadelphia chromosome-negative myeloproliferative neoplasms (MPNs). The diagnosis and the management of patients with MPNs have evolved since the identification of mutations that activate the JAK pathway (JAK2, CALR, and MPL mutations) and the development of targeted therapies has resulted in significant improvements in disease-related symptoms and quality of life. This manuscript discusses the recommendations outlined in the NCCN Guidelines for the diagnostic workup of MPN (MF, PV, and ET), risk stratification, treatment, and supportive care strategies for the management of MF.

The NCCN Guidelines for Chronic Myeloid Leukemia (CML) provide recommendations for the management of chronic-phase and advanced-phase CML in adult patients. The median age of disease onset is 67 years. However, because CML occurs in all age groups, clinical care teams should be prepared to address issues relating to fertility and pregnancy with patients who are of reproductive age at the time of diagnosis. CML is relatively rare in children and there are no evidence-based recommendations for the management of CML in pediatric population. These NCCN Guidelines Insights discuss special considerations for the management of CML during pregnancy and for the management of CML in the pediatric population.

Background: Guadecitabine SC (SGI-110) is a dinucleotide next generation HMA resistant to degradation by cytidine deaminase resulting in extended in vivo exposure to its active metabolite decitabine. A Phase 1 established 60 mg/m2 QDx5 as the biologically effective dose (BED), and 90 mg/m2 QDx5 as the Maximum tolerated dose (MTD) in MDS patients given in 28-day cycles (Issa et al, 2015, Lancet Oncology). Phase 2 is conducted to evaluate dose response between the BED and MTD in both untreated MDS patients, and patients previously treated with other HMAs. M ethods: Int, or HR MDS, and CMML patients who were either treatment-naïve (TN) or relapsed/refractory to other HMAs (r/r) were randomized to either 60 mg/m2 or 90 mg/m2 QDx5 every 28 days. Efficacy was evaluated by the clinical responses of CR, PR, marrow CR (mCR), and Hematological Improvement (HI) based on the International Working Group Criteria 2006, as well as transfusion-independence, and overall survival (OS). Adverse events (AEs) were graded by the CTCAE v4 criteria. Results: The study completed target enrolment with 102 patients: 53 r/r MDS, and 49 TN MDS. Fifty three patients were randomized to 60 mg/m2 and 49 patients to 90 mg/m2 QDx5 with a median follow up of 3.2 years (IQR 2.8-3.5 years). Median age was 72 and 71 years for r/r and TN MDS respectively. Most baseline patient characteristics were well balanced between the 2 treatment dose groups except that more CMML patients were randomized to the 60 mg/m2 group (28%) vs. 14% in the 90 mg/m2 group, and more patients with baseline BM blasts >5% were in the 90 mg/m2 group (67%) vs. 38% in the 60 mg/m2 group. Most patients were RBC transfusion-dependent at baseline (57%). In the r/r MDS cohort, most patients (58%) received their last HMA treatment Median number of treatment cycles was 5 for both r/r and TN MDS (range 1-37 in r/r MDS and 1-49 in TN MDS). In the TN MDS cohort CR was achieved in 11 (22%) of patients with no major difference between the 2 dose groups (19% in the 60 mg/m2 group vs 27% in the 90 mg/m2 group). Overall CR+mCR was achieved in 18 patients (37%) in TN MDS patients and median OS was 23.4 months. In the r/r MDS cohort, CR was achieved in 4% of patients in each of the 2 dose groups. Overall CR+mCR in the r/r MDS cohort was achieved in 17 patients (32%), with a median duration of response of 7.9 months, and median OS of 11.7 months. No significant difference in response or OS between the 2 dose groups was observed. In patients who were RBC transfusion-dependent at baseline, transfusion independence for at least 8 weeks was achieved in 42% of TN MDS, and 15% in r/r MDS patients. In the overall population of 102 TN and r/r MDS patients there were no major differences in OS based on DNMT3A or TET2 mutation status while patients with TP53 mutations had worse median OS (7.4 months) compared to those without TP53 mutations (22.6 months). Other baseline prognostic factors for worse OS were BM blasts >5%; RBC transfusion-dependence; IPSS High Risk; and ECOG Performance Status of >1. Overall incidence of Grade ≥3 AEs regardless of relationship to treatment was reported in 83 vs. 96% for 60 and 90 mg/m2 dose groups respectively. There was a slightly higher but non-significant difference in Grade ≥3 thrombocytopenia (57 vs 41.5%); neutropenia (51 vs 39.6%); febrile neutropenia (43% vs 32%); and pneumonia (32.7 vs. 26.4%) for the 90 mg/m2 compared to 60 mg/m2 dose group. Early 30, 60, and 90-day all-cause mortality was observed in 0, 3.7%, and 5.7% in the 60 mg/m2 dose group respectively; and in 2%, 4%, and 12% in the 90 mg/m2 dose group respectively. Conclusions: Guadecitabine at both dose groups is a well-tolerated novel HMA with clinical activity in the treatment of both TN and r/r Int and HR MDS, and CMML patients. In TN MDS patient CR rate of 22% and median OS of 23.4 months compare well with first generation HMA efficacy (Fenaux et al, 2009, Lancet Oncology). Activity in r/r MDS who previously failed prior HMAs is particularly promising (CR+mCR in 32% of patients with median duration of response and overall survival of almost 8 and 12 months respectively). A phase 3 trial (ASTRAL-3) of guadecitabine vs Physician Treatment Choice in r/r MDS and CMML patients previously treated with azacitidine or decitabine is actively enrolling (ClinicalTrials.gov ID: NCT02907359). Disclosures Ritchie: NS Pharma: Research Funding; Bristol-Myers Squibb: Research Funding; Novartis: Consultancy, Other: Travel, Accommodations, Expenses, Research Funding, Speakers Bureau; Incyte: Consultancy, Speakers Bureau; Celgene: Consultancy, Other: Travel, Accommodations, Expenses, Speakers Bureau; Pfizer: Consultancy, Research Funding; ARIAD Pharmaceuticals: Speakers Bureau; Astellas Pharma: Research Funding. Savona:Boehringer Ingelheim: Consultancy; Celgene: Consultancy, Membership on an entity's Board of Directors or advisory committees; Incyte: Membership on an entity's Board of Directors or advisory committees, Research Funding. Kropf:Celegene: Consultancy; Takeda: Consultancy. Daver:Pfizer: Consultancy; Sunesis: Consultancy; Pfizer: Research Funding; ImmunoGen: Consultancy; ARIAD: Research Funding; Novartis: Research Funding; Incyte: Research Funding; Otsuka: Consultancy; Novartis: Consultancy; Karyopharm: Consultancy; Alexion: Consultancy; Incyte: Consultancy; Karyopharm: Research Funding; BMS: Research Funding; Kiromic: Research Funding; Daiichi-Sankyo: Research Funding; Sunesis: Research Funding. Jabbour:Pfizer: Consultancy, Research Funding; Novartis: Research Funding; Abbvie: Research Funding; Takeda: Consultancy, Research Funding; Bristol-Myers Squibb: Consultancy, Research Funding. Yee:Celgene, Novartis, Otsuka: Membership on an entity's Board of Directors or advisory committees; Agensys, Astex, GSK, Onconova, Genentech/Roche: Research Funding. Stock:Jazz Pharmaceuticals: Consultancy. Griffiths:Alexion Inc.: Honoraria, Research Funding; Astex/Otsuka Pharmaceuticals: Honoraria, Research Funding; Celgene, Inc: Honoraria, Research Funding; Novartis, Inc.: Research Funding; Pfizer, Inc.: Research Funding. Podoltsev:Astex Pharmaceuticals: Research Funding; LAM Therapeutics: Research Funding; Sunesis Pharmaceuticals: Research Funding; Genentech: Research Funding; Boehringer Ingelheim: Research Funding; Daiichi Snakyo: Research Funding; Astellas Pharma: Research Funding; Pfizer: Research Funding; Celator: Research Funding; Pfizer: Membership on an entity's Board of Directors or advisory committees; Celgene: Research Funding. Berdeja:Genentech: Research Funding; Bluebird: Research Funding; Amgen: Research Funding; Novartis: Research Funding; Glenmark: Research Funding; Takeda: Research Funding; Bristol-Myers Squibb: Research Funding; Teva: Research Funding; Sanofi: Research Funding; Poseida Therapeutics, Inc.: Research Funding; Celgene: Research Funding; Janssen: Research Funding. Naim:Astex Pharmaceuticals, Inc.: Employment. Hao:Astex Pharmaceuticals, Inc.: Employment. Azab:Astex Pharmaceuticals, Inc.: Employment. Roboz:Orsenix: Consultancy; Roche/Genentech: Consultancy; Roche/Genentech: Consultancy; Otsuka: Consultancy; Bayer: Consultancy; Pfizer: Consultancy; Jazz Pharmaceuticals: Consultancy; Argenx: Consultancy; Sandoz: Consultancy; Celltrion: Consultancy; Bayer: Consultancy; Orsenix: Consultancy; Pfizer: Consultancy; Astex Pharmaceuticals: Consultancy; Daiichi Sankyo: Consultancy; Sandoz: Consultancy; Daiichi Sankyo: Consultancy; Novartis: Consultancy; Janssen Pharmaceuticals: Consultancy; Cellectis: Research Funding; Eisai: Consultancy; Celgene Corporation: Consultancy; Jazz Pharmaceuticals: Consultancy; Celgene Corporation: Consultancy; Janssen Pharmaceuticals: Consultancy; Eisai: Consultancy; Novartis: Consultancy; Otsuka: Consultancy; Argenx: Consultancy; Celltrion: Consultancy; Astex Pharmaceuticals: Consultancy; Aphivena Therapeutics: Consultancy; AbbVie: Consultancy; Aphivena Therapeutics: Consultancy; AbbVie: Consultancy; Cellectis: Research Funding.

Background: There are no FDA-approved therapies for patients with myelodysplastic syndrome (MDS) in whom hypomethylating agents (HMAs) fail, and mechanisms of resistance are not well-characterized. Preclinical and clinical data suggest that some myeloblasts express PDL-1 and that HMAs can induce expression of PD-1 on T cells, which may result in resistance through immune tolerance. We hypothesized that the addition of the PDL1-inhibitor atezolizumab to guadecitabine, a next generation HMA which has a longer in vivo exposure time, would induce or restore HMA sensitivity in patients with relapsed or refractory (R/R) MDS. Overlapping toxicities were not expected given atezolizumab is not myelosuppressive and guadecitabine does not appear to induce autoimmune or inflammatory conditions. Methods: We are conducting a phase I/II, multicenter clinical trial for adult patients with R/R, intermediate (3+) or high-risk MDS by the revised international scoring system, including chronic myelomonocytic leukemia (CMML). A 3x3 dose escalation design for guadecitabine was used for Phase I, beginning with 30 mg/m2 (Dose level -1) days 1-5 along with a fixed dose of atezolizumab 840mg IV days 8 and 22 of a 28-day cycle. The plan was to escalate to the recommended dose of guadecitabine, 60mg/m2 (Dose Level 1) if no dose limiting toxicities (DLTs) were identified during Dose Level -1. If ≥2/6 DLTs were observed during the Dose Level 1, de-escalation to 45mg/m2 (Dose Level -1.5) would occur. The primary endpoint of phase I was safety and tolerability of the combination. Overall survival (OS) from the on-study date and overall response rates (ORR), based on the 2006 Modified IWG Response Criteria for MDS, were secondary endpoints. Results: Nine patients (5M, 4F, median age 73) with intermediate or higher risk were treated during phase I. Three patients were treated at Dose Level -1 and sustained no DLTs. Similarly, no DLTs were observed among 6 patients treated at Dose Level 1. There were 17 grade 3 or 4 events considered possibly or probably related to the study treatments, the most common of which were: neutropenia (4), thrombocytopenia (4), and leukopenia (4). The median number of treatment cycles was 5 and the treatment duration for each patient is illustrated in Figure 1. Two patients achieved hematologic improvement (HI) and 1 patient achieved CR. Two patients died after coming off of the study (at 4.5 and 9 months respectively) and the median OS has not been reached. Discussion: The combination of guadecitabine at the recommended dose of 60mg/m2 D1-D5 along with atezolizumab 840mg IV d8, 22 was found to be safe with an acceptable toxicity profile in patients with R/R MDS. The ORR was 33% and a phase II study is ongoing. Disclosures Kropf: Celegene: Consultancy; Takeda: Consultancy. Grønbæk:Otsuka Pharma: Membership on an entity's Board of Directors or advisory committees; Celgene: Membership on an entity's Board of Directors or advisory committees; Janssen Pharma: Membership on an entity's Board of Directors or advisory committees.

Differences in healthcare utilization and costs were examined in chronic myeloid leukemia (CML) patients experiencing first-, second- and third-line tyrosine kinase inhibitor (TKI) therapy. Three CML cohorts were identified from the Truven Health MarketScan® database: No-Switch Cohort (NSc) = did not switch from first-line; One-Switch Cohort (OSc) = switched from first- to second-line only; Two-Switch Cohort (TSc) = switched to second- and then third-line. A total of 3510 patients were identified (mean = 54%; age = 55.8 years). NSc comprised 81% of the sample, OSc comprised 15% and 4% were in the TSc. First-line utilization/costs were significantly higher in the OSc/TSc compared to the NSc. Second-line hospital/outpatient visits and costs were higher in TSc compared to OSc. TSc experienced a significant cost increase from first- to second-line ($4226.46), twice that of OSc ($2488.03). TKI switching is associated with a substantial increase in healthcare utilization and costs, particularly for patients who switch twice.

Background Donor lymphocyte infusion (DLI) has been used with variable success in a variety of hematologic malignancies. Patients and Methods We conducted a retrospective analysis of all patients who were treated with DLI for persistent or relapsed disease at the Temple University Bone Marrow Transplant Unit from July 1, 1993 to December 31, 2013 to evaluate the effect of the type of DLI (fresh vs. cryopreserved) on event-free survival (EFS) and overall survival (OS). Median follow-up was 64.8 months (range, 0.3-142.6 months). Results We found that EFS and OS were similar between patients receiving cryopreserved cells and those receiving fresh DLI (median OS for cryopreserved cells, 0.39 years; median OS for fresh cells, 0.32 years; P = .793; median EFS for cryopreserved cells, 0.410 years; median EFS for fresh cells, 0.420 years; P = .4264). In the setting of relapsed disease, treatment with any chemotherapy regimen before receiving DLI did not significantly impact OS (n = 63; P = .2203) or EFS (n = 40; P = .542). A subgroup analysis limited to patients with acute myeloid leukemia (AML)/myelodysplastic syndrome (MDS) (32 patients) showed that differences in OS and EFS between cryopreserved and fresh DLI approached significance (median OS for cryopreserved cells, 0.34 years; median OS for fresh cells, 0.17 years; P = .16; median EFS for cryopreserved cells, 0.37 years; median EFS for fresh cells, 0.094 years; P = 0.11). Conclusion We conclude that the use of fresh cells versus cryopreserved cells does not have an impact on outcomes, and selected patients can achieve long-term survival with DLI for treatment of relapse after transplantation, although the overall outcomes remain dismal.

The classical Philadelphia chromosome–negative myeloproliferative neoplasms (MPN), which include essential thrombocythemia, polycythemia vera, and myelofibrosis (MF), are in a new era of molecular diagnosis, ushered in by the identification of the JAK2(V617F) and cMPL mutations in 2005 and 2006, respectively, and the CALR mutations in 2013. Coupled with increased knowledge of disease pathogenesis and refined diagnostic criteria and prognostic scoring systems, a more nuanced appreciation has emerged of the burden of MPN in the United States, including the prevalence, symptom burden, and impact on quality of life. Biological advances in MPN have translated into the rapid development of novel therapeutics, culminating in the approval of the first treatment for MF, the JAK1/JAK2 inhibitor ruxolitinib. However, certain practical aspects of care, such as those regarding diagnosis, prevention of vascular events, choice of cytoreductive agent, and planning for therapies, present challenges for hematologists/oncologists, and are discussed in this article.

Background: Acute myeloid leukemia (AML) causes the most leukemia-related deaths in the United States, and has frequent mutations in epigenetic regulators, including DNMT3A, IDH, and TET2. Such aberrations have been proposed to transform the epigenetic state in cancer, often involving DNA hypomethylation, however, the genomic specificity, causes, and clinical consequences of such methylation changes in AML remain unclear. Methods: We queried genome-wide CpG methylation using The Cancer Genome Atlas (TCGA) AML samples (n=194) run on Illumina 450k arrays. We used RNA-seq data to study gene expression changes associated with hypomethylator phenotypes (HP). Analysis was done using R. Results: Genome-wide analysis of CpG sites that are highly methylated in normal blood, and variably methylated in AML (β-value standard deviation in AML > 0.2; average β-value in normal blood > 0.8) revealed two distinct HPs by hierarchical clustering: Good-risk (GR) HP which included favorable cytogenetics, and DNMT-HP, which was enriched for DNMT3A mutations. We refined DNA methylation signatures of each HP cluster by differential methylation analysis and re-classified patients accordingly. Strikingly, all patients with t(8;21), inv(16), or t(15;17) belonged to the GR-HP+ group, suggesting that a common epigenetic thread connects these otherwise disparate genetic aberrations. From a clinical perspective GR-HP+ patients were younger than GR-HP- patients, and had significantly longer overall survival (median OS, years: GR-HP+ = Not reached; GR-HP- = 1.00; P < 0.001). In contrast, DNMT-HP+ cases were statistically equivalent to DNMT-HP- except for an enrichment for higher WBC counts, including no difference in survival (median OS, years: DNMT-HP+ = 0.92; DNMT-HP- = 1.34; P = 0.27). From an epigenetic perspective the two HP clusters harbored distinct DNA methylation changes; although both favored hypomethylation within non-CpG islands relative to CpG islands, the enrichment was more pronounced for DNMT-HP (Odds ratio: hypomethylated CpG islands/hypomethylated non-CpG islands, GR-HP = 0.64; DNMT-HP = 0.18). Genetic analysis revealed that GR-HP+ leukemia had wild-type IDH, DNMT3A, and NPM1 genes. In contrast, DNMT-HP+ AML had significantly more FLT3, NPM1, and DNMT3A mutations compared to DNMT-HP- patients. RNA-seq revealed significant up-regulation of genes in both HP phenotypes (216, and 150 genes for GR-HP and DNMT-HP, respectively at FDR < 0.01 and FC > 2). Pathway analysis of these genes revealed enrichments for ion channels and the complement pathway in DNMT-HP, and for nervous system and developmental genes in GR-HP. Conclusions: Our data suggest that two HPs exist in AML with unique epigenetic and transcriptomic signatures. The striking association between GR-HP and different favorable cytogenetic changes suggests that a common set of epigenetic features may contribute to improved survival in these patients. Citation Format: Andrew D. Kelly, Jozef Madzo, Priyanka Madireddi, Patricia Kropf, Charly R. Good, Jaroslav Jelinek, Jean-Pierre J. Issa. A DNMT3A-independent hypomethylator phenotype is a unifying epigenetic signature of AML with good risk cytogenetics [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2017; 2017 Apr 1-5; Washington, DC. Philadelphia (PA): AACR; Cancer Res 2017;77(13 Suppl):Abstract nr 5382. doi:10.1158/1538-7445.AM2017-5382

Epigenetic patterns of DNA methylation are frequently altered in acute myeloid leukemia (AML). Guadecitabine is a novel next generation hypomethylating drug with a demonstrated clinical activity in elderly AML. In our previous study of guadecitabine, we identified in relapsed/refractory (r/r) AML patients a gene expression signature (high DNMT3B, low P15, and low CDA) associated with reduced LINE-1 demethylation and resistance to the drug. Since pharmacodynamics only explains a small portion of the variability in response to guadecitabine, we suggest that intrinsic genetic and epigenetic characteristics can distinguish responders from non-responders. We analyzed genome-wide methylation patterns and screened 54 genes frequently mutated in leukemia in DNA from pre-treatment blood or bone marrow from 119 patients with r/r AML enrolled in guadecitabine phase I/II trials. Blood samples from 49 healthy donors were used as controls. We also examined expression of a panel of genes (CDA, P15, P21, DNMT3B, DNMT3A, DNMT1, and CTCF) at baseline by quantitative RT-PCR. Global DNA methylation at pre/post treatment was estimated by bisulfite-pyrosequencing of the LINE-1 repetitive sequence. For comparing methylation profiles at CpG islands (CGI), we performed hierarchical clustering analysis of differentially methylated 2794 CGI sites in 119 r/r AML and 49 healthy controls. Hierarchical clustering split them into 3 main groups of normal-like cluster (n=36), intermediate (n=41) and CpG island methylator phenotype (CIMP) like cluster (n=42). Normal-like cluster had a higher response rate (39 %) compared to intermediate (17%) and CIMP- like cluster (15%) (p=0.025, Fisher’s exact test). Demethylation rate of LINE-1 was lower in CIMP-like cluster than in normal-like and intermediate cluster (average demethylation -19 ± 2 % in CIMP-like cluster vs. -31 ± 2 % in normal-like vs. -23 ± 2 % in intermediate cluster, p=0.0007, One-way ANOVA). Mutation screening revealed frequent alterations affecting signaling pathways (CSF3R, KIT, KRAS, NRAS and FLT3) in the CIMP-like cluster (62%) compared to normal-like (11%) and intermediate cluster (13%) (p Citation Format: Woonbok Chung, Andrew D. Kelly, Patricia Kropf, Pietro Taverna, Sue Naim, Mohammad Azab, Jaroslav Jelinek, Hagop M. Kantarjian, Jean-Pierre J. Issa. Integrated molecular profiles and guadecitabine response in relapsed/refractory acute myeloid leukemia [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2017; 2017 Apr 1-5; Washington, DC. Philadelphia (PA): AACR; Cancer Res 2017;77(13 Suppl):Abstract nr 4677. doi:10.1158/1538-7445.AM2017-4677

Background: Guadecitabine is a second generation hypomethylating drug with improved pharmacokinetics and pharmacodynamics compared to decitabine and demonstrated clinical activity in both treatment naïve (tn) and relapsed-refractory (rr) AML. Previous studies reported similar response rates to guadecitabine in different cytogenetic subsets but it remains unknown whether this extends to genetic changes. Methods: Pre-treatment blood or bone marrow derived DNA was available for analysis from a total of 220 patients with AML enrolled on guadecitabine phase I-II trials (121 rrAML and 99 tnAML). We included only patients treated at therapeutic doses. Mutations in a panel of 54 genes was studied by the TruSight Myeloid Sequencing Panel (Illumina) and deep sequencingon the Illumina HiSeq platform. FLT3 mutations were separately determined by PCR analysis. The sequence data was analyzed for mutations using the TruSeq Amplicon Application in the Illumina BaseSpace Suite. Putative mutation calls were further filtered by sequencing read quality, minimum variant allelic fraction, and presence in the dbSNP and COSMIC databases. Results: In aggregate, responses to guadecitabine in rrAML were 15 CR (12%), 12 PR/CRi/CRp and 94 non responders (NR) and in tnAML, responses were 34 CR (34%), 21 PR/CRi/CRp and 44 NR. Overall, a median of 1 (range 0 - 5) mutation was present in each patient, with no significant differences between tn and rr AML. The most frequently mutated genes were ASXL1 (16.8%), TET2 (14.1%), IDH2 (10.9%), NPM1 (10%), RUNX1 (9.5%), DNMT3A (9.1%), NRAS (9.1%), FLT3-ITD (8.6%), U2AF1 (8.2%), IDH1 (6.8%), TP53 (5%), and KRAS (4.5%). The distribution of mutations was as expected for a group of patients with rrAML and elderly tnAML. We used Fisher's exact tests to compare mutation frequencies between patients who achieved CR and those who did not achieve CR. When we evaluated rrAML and tnAML separately, none of the genes showed a significantly different mutation rate between response subgroups. We then examined the population as a whole (N=220) and found that mutations in NRAS were significantly lower in patients who achieved CR (0/49) compared to those who did not (20/171, p=0.009). NRAS and KRAS mutations were inversely correlated, and when we considered the two genes together, mutations were present in 1/49 CR patients compared to 28/171 non-CR patients (p=0.007). Overall, CR rate was 3.4% in patients with RAS mutations compared to 25.1% in patients without such mutations. There was a similar significant trend for IDH2 mutations to be lower in CR patients (1/48) compared to non-CR patients (23/172, p=0.02) but this was not seen for IDH1. None of the mutations in other epigenetic regulators (DNMT3A, ASXL1, EZH2, TET2, U2AF1 or WT1) were significantly different between CR and non-CR patients individually or when we considered mutations in any of 8 epigenetic regulators (mutated in 22/49 CR patients vs. 93/171 non-CR patients, p=0.26). RAS mutations were higher in rrAML (22/121, 18.2%) than in tnAML (7/99, 7.1%, p=0.017) which may explain the lower CR rate in this group. Patients with PR/CRi/CRp were genetically similar to NR. Conclusions: In patients with AML treated with guadecitabine, RAS pathway mutations and IDH2 mutations are associated with a lower likelihood of achieving a CR. Disclosures Kropf: Celgene: Consultancy; Takeda: Consultancy. Roboz:Cellectis: Research Funding; Agios, Amgen, Amphivena, Astex, AstraZeneca, Boehringer Ingelheim, Celator, Celgene, Genoptix, Janssen, Juno, MEI Pharma, MedImmune, Novartis, Onconova, Pfizer, Roche/Genentech, Sunesis, Teva: Consultancy. Yee:Novartis Canada: Membership on an entity's Board of Directors or advisory committees, Research Funding. Taverna:Astex Pharmaceuticals: Employment. Naim:Astex Pharmaceuticals: Employment. Azab:Astex Pharmaceuticals, Inc.: Employment. Issa:Teva Pharmaceutical Industries: Consultancy; Astex Pharmaceuticals: Consultancy.

Introduction: DAC is a hypomethylating agent FDA approved for the treatment of advanced myelodysplastic syndromes (MDS) and chronic myelomonocytic leukemia (CMML).Despite its clinical activity, the duration of response is limited and prognosis at relapse is poor. In pre-clinical studies, we identified potent epigenetic effects of ATO alone and in combination with DAC, and also found that carboplatin (Carbo) can enhance gene reactivation in combination with DAC. We therefore initiated a randomized phase 2 clinical trial (NCT02188706) to compare the safety and efficacy of DAC in combination with either Carbo or ATO as compared to single agent DAC in patients with MDS/CMML and Acute Myeloid Leukemia. Here we present updated results for the MDS/CMML cohort. Methods: Patients with MDS/CMML INT-1 were randomized to one of three regimens: DAC 20 mg/m2 days 1-5, (DAC), DAC as above and Carbo AUC 5 on day 8 (DAC/Carbo), or DAC as above and ATO 0.15 mg/kg days 1-5 (DAC/ATO). We used adaptive randomization based on response rate which started after 10 patients were equally randomized to each arm. Cycles were scheduled every 28 days for a minimum of 4 cycles. Dose reductions/delays were allowed based on response and tolerability. Patients remained on treatment as long as they continued to benefit without toxicity. The primary endpoint was the composite response rate: the complete response (CR: complete response, mCR: marrow complete response and CRi: complete response with incomplete blood count recovery) and partial response (PR) rates using the modified IWG 2006 criteria. Secondary endpoints included median overall survival (OS) and safety. DNA methylation changes were measured using LINE1 bisulfite/pyrosequencing. Results: As of July 2016, 42 patients (MDS = 40, CMML=2) have been enrolled on study. Median age was 71 years (range, 35 to 84 years). There was no statistically significant difference in patients' characteristics between the three arms. Median number of cycles for the treatment arms was 4 (range, 1-15). Response data was evaluable for 36 patients (8 on DAC alone, 5 on DAC/Carbo and 23 on DAC/ATO). Composite responses were seen in 3/8 patients on DAC (37.5%), 0/5 patients on DAC/Carbo (0%, p=0.23 compared to DAC alone) and 12/23 patients on DAC/ATO (52.2%, p=0.69 compared to DAC alone). Median OS among MDS/CMML patients receiving DAC/ATO (17.8 months) was improved compared to the DAC/Carbo (3.9 months) and DAC (9.8 months) arms (p=0.01) [Figure 1]. There was not a significant difference in high-grade (≥ grade 3) toxicity between the three arms, with grade 3 neutropenia and thrombocytopenia as the most common side effects. DNA methylation analysis showed equivalent demethylation in all the arms, suggesting that the epigenetic effects of ATO were independent of DNA methylation, which was consistent with pre-clinical studies. Conclusion: Our results demonstrate higher response rates and a significant survival benefit with the combination of DAC and ATO in comparison to DAC alone in patients with MDS/CMML. Disclosures Kropf: Celgene: Consultancy; Takeda: Consultancy. Fung:Amgen: Consultancy; Genzyme: Consultancy. Kantarjian:ARIAD: Research Funding; Bristol-Myers Squibb: Research Funding; Amgen: Research Funding; Pfizer Inc: Research Funding; Delta-Fly Pharma: Research Funding; Novartis: Research Funding. Issa:Astex Pharmaceuticals: Consultancy; Teva Pharmaceutical Industries: Consultancy.

e19022Background: Outcomes of secondary DLBCL (sDLBCL) in patients with a prior diagnosis of a solid malignancy compared to de novo DLBCL (dnDLBCL) are not well understood. We sought to determine f...

To the editor: Chemoimmunotherapy with fludarabine (F), cyclophosphamide (C), and rituximab (R) is currently considered the gold standard first-line therapy for chronic lymphocytic leukemia (CLL).[1][1] In an attempt to reduce the neutropenia and maintain the high response rate of standard-dose FCR

Graft versus host disease (GVHD) is a common complication of allogeneic transplant. Acute GVHD primarily affects the skin, liver, and GI tract generally within the first 100 days after transplant. GVHD following an allogeneic transplant occurs as a result of donor T-cell recognition of host alloantigens. In contrast, patients undergoing ASCT are not subjected to the genetic disparity that occurs with allogeneic transplant, and in principal, should not develop this proinflammatory response. A clinical syndrome, however, has been described in patients following autologous transplant that shares the same features as GVHD occurring in recipients post-allogeneic transplant [1-3]. Previously reported cases have described skin, liver, and GI tract manifestations consistent with what is seen in allogeneic GVHD. Biopsies of the skin and GI tract mucosa have demonstrated similar histological features as well. Interestingly, the majority of reported cases seem to occur in patients with multiple myeloma undergoing consolidative ASCT. Historically, however, these patients have been described as having a relatively benign course with mild skin rash, nausea, vomiting, and/or diarrhea that is responsive to immunosuppression. In this article, we present a case of fatal, spontaneous GVHD in a patient with multiple myeloma following ASCT.

Src family kinase gene targets during myeloid differentiation: identification of the EGR-1 gene as a direct target

Introduction: Guadecitabine (SGI-110) is a novel subcutaneous (SC) next generation hypomethylating agent (HMA) designed as a dinucleotide of decitabine (DAC) and deoxyguanosine that is resistant to degradation by cytidine deaminase (CDA) and results in prolonged in vivo exposure to its active moiety DAC. The differentiated pharmacokinetic profile offers the potential of improved biological and clinical activity and safety over currently available HMAs. In the Phase 1 study, patients with r/r AML were treated at escalating doses of guadecitabine. In the phase 2 study, r/r AML patients were randomized to receive guadecitabine at 60 mg/m2 or 90 mg/m2 SC daily for 5 days (dailyx5). In a separate cohort, patients were treated with 60 mg/m2 SC daily for 10 days (dailyx10: days 1-5 and 8-12) for up to 4 cycles followed by subsequent cycles of the dailyx5 regimen. All regimens were dosed with a 28 day treatment cycle. We have reported the clinical efficacy and safety results from the Phase 1 dose-escalation study in AML and MDS (Issa et al, Lancet Oncology 2015) and the Phase 2 randomized dose-response study in r/r AML at 2 doses (60 and 90 mg/m2) in a 5-day regimen (Kantarjian et al, ASH 2013) and 60 mg/m2 in the 10-day regimen (Griffiths et al, ASCO 2014). Here, we report the associations between clinical responses and global DNA demethylation assessed by LINE1 assay, baseline expression of a panel of 7 genes (CDA, P15, P21, DNMT3B, DNMT3A, DNMT1 and CTCF) assessed by qRT-PCR, and FLT3-ITD/NMP1 mutations. Methods: Samples from 122 patients with r/r AML were analyzed (27 from phase 1 study treated at 36 m/m2/d or higher, 47 from the dailyx5 and 48 from the dailyx10 regimen of the phase 2). Global DNA methylation at baseline and after treatment, were estimated using bisulphite-pyrosequencing on the LINE-1 repetitive sequence for assessing guadecitabine pharmacodynamic (PD) effects. LINE-1 methylation time-course profiles were available in 117 out of 122 analyzed patients. Multivariate analysis was performed using nonlinear ensemble decision tree-based classification algorithms (Random Forests and Gradient Boosting Trees); the algorithms were applied to rank demographic features, treatment schedule features, baseline expression of 7 genes, FLT3-ITD and NPM1 mutations, LINE-1 methylation profiles and baseline hematological features as predictors of clinical response and to measure their directionality. All reported percentages are a measure of the average relative contribution of each feature in predicting response across boosted trees and are normalized across features. Results: In the 122 patients analyzed, the median age was 59.6 (range, 23-86), 75 were males (61.5%). Overall, peak LINE-1 demethylation generally occurred on day 8 after daily x 5 treatment or on day 8 or 15 after daily x 10 treatment. Overall, the maximum peak LINE-1 demethylation was -23.8 % ± 1.24. In 122 r/r AML patients, 28 showed Complete Response (23%, 14 CR and 14 CRi/CRp). High baseline CDA gene expression in peripheral blood was consistently ranked the main predictor of clinical response (mean for responders~1.76 and non-responders~0.12) irrespective of patient gender, dose and dosing cycles, and contributed for 22% of the model accuracy in predicting responses to guadecitabine. Expression of the genes CTCF (11%), DNMT3B (7%) and P21 (6%) were other genes that contributed > 5% in predicting clinical response. Age (8%) was also a significant predictor of response. FLT3-ITD mutations and NPM1 mutations were not significant predictors of response. In an integrated analysis, where methylation levels and gene expression were ranked together on their power to predict clinical response, LINE-1 methylation percent change from baseline on days 8(6%) and 22(19%), age (16%), CTCF (9%), CDA(7%), P21(6.5%) gene expression at baseline had greater than 5% contribution in predicting clinical response. A similar analysis was then performed to rank features on their power to predict day 8 methylation; CDA (28%), DNMT1 (8.5%), P15 (7.5%), and CTCF (7%) gene expression at baseline and age (7%) had greater than 5% predictive power. Conclusions: In conclusion, in r/r AML patients, global DNA demethylation was strongly associated with clinical responses to guadecitabine and analysis of baseline gene expression can identify trends that might enrich for r/r AML patients more likely to respond to HMA therapy with guadecitabine. Disclosures Gottipati: Otsuka Pharmaceutical Development & Commercialization, Inc.: Employment. Rohatagi:Otsuka Pharmaceutical Development & Commercialization, Inc.: Employment. Chung:Astex Pharmaceuticals, Inc.: Research Funding. Taverna:Astex Pharmaceuticals, Inc.: Employment. Kropf:Teva Pharmaceuticals: Consultancy. Azab:Astex Pharmaceuticals, Inc.: Employment. Issa:Astex Pharmaceuticals, Inc.: Consultancy; Janssen: Consultancy.