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The azanucleotide decitabine is used in the treatment of acute myeloid leukemia (AML). Studies have shown conflicting results with 10-day regimens used in previously untreated AML patients. Additionally, there is little data on 10-day decitabine regimens in the relapsed setting. This study investigated outcomes of 108 adult patients with AML in the upfront and relapsed setting treated with a 10-day decitabine regimen. In the upfront group, the overall response rate (ORR, CR + CRi) was 36.1% and the median overall survival (OS) was 6.6 months, while the relapsed/refractory group had an ORR of 25% with an OS of 4.8 months. When analyzed with respect to cytogenetics, the upfront group featured an ORR of 28.1% with an OS of 9.4 months in the intermediate cytogenetic cohort compared to a 40.5% ORR and an OS of 5.4 months in the unfavorable cytogenetic cohort. An analysis of the relapsed/refractory group demonstrated an ORR of 26.3% with an OS of 7.9 months for intermediate cytogenetics versus 25.0% with an OS of 1.8 months in the unfavorable cohort. While these response rates are similar to previously published data, the median OS appears shorter.

AML is a disease of older adults with the median age at diagnosis of 68. Elderly AML, generally defined as patients ≥60 years of age, is a clinically distinct disease highlighted by worse overall survival (OS), lower complete remission (CR) rates, and higher treatment related toxicity. Most elderly AML patients who achieve a CR will eventually relapse and require further chemotherapy. Despite the central role of relapsed disease in elderly patients few studies have reported on outcomes using salvage chemotherapy in patients over 60 years of age and no standard regimen has been established. We retrospectively examined data for 108 consecutive relapsed or refractory AML patients treated with the HAMA regimen at Wake Forest between May, 1999 and December, 2010. This regimen consists of high dose cytarabine (3gm/m2 in patients Of the 108 patients analyzed, 75 were ≥60 years old and 33 were younger than 60 at the time of HAMA treatment. The median age for the younger cohort was 51 (range 20-59) and for the elderly cohort was 68 (range 60-84). Older patients were more likely to have refractory disease (25% vs 6%), one or more comorbidities (47% vs 12%) and poor risk cytogenetics (23% vs 16%). Early all cause mortality (30 and 60 day) was 13% and 22% respectively for all patients and 17% and 28% for those ≥60. The percentage of patients that died during hospitalization or were discharged to hospice was 25% for all patients (12% 1 year (p=0.0005). Of the 16 patients in the cytogenetic poor risk group only 12% (2/16) achieved CR2 and none were alive more than 14 months from relapse. Median survival for patients with CR1 >1 year was 13.6 (5.9-19.7) months compared to 5.8 (3.3-7.2) months for patients with CR1 In conclusion, the HAMA salvage regimen when given to older patients results in a 37% complete remission rate with a median survival of almost one year in this subgroup, however only 12% went on to allogeneic HCT and only 3% were alive 24 months after relapse. Patients with poor risk cytogenetics regardless of age were not effectively salvaged with this regimen and should be offered experimental therapy when possible. Disclosures: No relevant conflicts of interest to declare.

Patients with Acute Myeloid Leukemia (AML) have compromised marrow function and chemotherapy causes further suppression. As a result complications are frequent, and patients may require admission to the intensive care unit (ICU). How codes status changes when these events occur and how those changes influence outcome are largely unknown. Outcomes for adult patients with AML, undergoing induction chemotherapy, and transferred to the ICU between January 2000 and December 2013 were analyzed. 94 patients were included. Median survival was 1.3 months. At 3 and 6 months overall survival (OS) was 27% and 18% respectively. Respiratory failure was the most common reason for transfer to ICU (88%), with 63% requiring mechanical ventilation at transfer. Other reasons included: cardiac arrest (18%), septic shock (17%), hypotension (9%), and acute renal failure (9%). The most frequent interventions were mechanical ventilation in 85%, vasopressors in 62%, and hemodialysis in 30%. Following transfer 55 patients (58%) had a change in code status. Overall, 46 patients (49%) changed from Full Code (FC) to Comfort Care (CC), 7 (7%) from FC to Do Not Resuscitate (DNR), and 2 (2%) from DNR to CC. For the entire cohort, ICU mortality (IM) was 61% and hospital mortality (HM) was 71%. For FC or DNR patients, IM was 30% and HM was 41%. For CC patients, IM was 90% and HM was 100%. Overall, 27 patients (29%) survived to discharge. Of those discharged, 22 (81%) were alive at 3 months and 17 (63%) were alive at 6 months. In conclusion, patients that required ICU admission during induction chemotherapy have a poor prognosis. Code status changed during the ICU stay for the majority of patients and always to a less aggressive status.

We conducted a retrospective study to define the significance of Philadelphia chromosome (Ph) in myelodysplastic syndrome and acute leukemia in the adults at this institution and the literature was reviewed. One hundred forty-eight cases of t(9;22)(q34;q11) were identified for the period September 1993 through August 2001. The presentation of 124 cases (84%) was that of typical CML in chronic phase. Nineteen cases (13%) presented as de novo ALL, two cases (1%) presented as de novo AML and three cases (2%) presented as myelodysplastic syndrome (MDS). The estimated incidences of t(9;22)(q34;q11) in ALL and AML are 21 and 0.6%, respectively. Ph+ AMLs are increasingly being reported with either M-BCR or m-BCR gene rearrangements, similar to those found with Ph+ ALL lending support to the notion that Ph+ AMLs are distinct entities and not merely blastic phases of undiagnosed CML. This is further supported by the existence of Ph+ MDS cases.

We retrospectively evaluated the prognostic significance of polypharmacy and inappropriate medication use among 150 patients >60 years of age receiving induction chemotherapy for acute myelogenous leukemia (AML). After adjustment for age and comorbidity, increased number of medications at diagnosis (≥ 4 versus ≤ 1) was associated with increased 30-day mortality (OR=9.98, 95% CI=1.18-84.13), lower odds of complete remission status (OR=0.20, 95% CI=0.06-0.65), and higher overall mortality (HR=2.13, 95% CI=1.15-3.92). Inappropriate medication use (classified according to Beers criteria) was not significantly associated with clinical outcomes. Polypharmacy warrants further study as a modifiable marker of vulnerability among older adults with AML.

The revised French-American-British (FAB) classification system for acute myeloid leukemia (AML) recommends the determination of serum lysozyme (SL) or urine lysozyme (UL) levels as an aid in distinguishing acute myeloblastic leukemia with maturation (FAB M2) from acute myelomonocytic leukemia (M4). We reviewed retrospectively 208 cases of adult leukemia in which SL and/or UL were obtained. Elevated lysozyme levels were not found in any of the M0, M3, or M7 cases, but were increased (false positive) in three (14%) M1 cases, 18 (19%) M2 cases and one (20%) M6 case. Although a UL value in excess of 3x normal was found in most cases of AML M4 and M5, only five (11%) M4 cases and three (20%) M5 cases had SL elevations of this magnitude. Lysozyme levels need to be interpreted in conjunction with other parameters for FAB classification.