Prognostication in MF: From CBC to cytogenetics to molecular markers

Alessandro M. VannucchiUniversity of Florence, Italy

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Pro

bab

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0 2 4 6 8 10 12 14 16 18 20 22 24 26Years

1980 - 1995 1996 - 2007

Whole series: actuarial survival (± 95% CI)according to period of diagnosis

p < 0.0001

Survival is Significantly Shortened in PMF

Cervantes F et al. JCO 2012; 24:2891-7.

Median survival: 4.6 versus 6.5 y

Why do we Need Accurate Prognostic Scores?

• Long term remissions with the potential of being cured have been described only in patients undergoing allogeneic HSCT

• However, HSCT approach to MF has several limitations, currently:

Disease related Procedure related

• Median age is 65 y (but changing…)

• Donor availability

• Age-related comorbidities • Only one prospective trial (+1 not yet fully reported)

• Fragile patients (splenomegaly, cytopenias, previous therapies…)

• High, and highly variable, TRM

• Rapid evolution to AML • Choice of fully ablative versus RIC

• Uncertainties about whom and when

• Poor information about long-term effects

Variable IPSS DIPSSAge >65 y

Constitutional symptoms

Hemoglobin <10 g/dL

Leukocyte count >25x109/L

Circulating blasts > 1%

Platelet count <100x109/L

RBC transfusion need

Unfavorable karyotype+8,-7/7q-,i(17q),inv(3), -5/5q-,12p-, 11q23 rearr.

Cervantes et al, Blood 2009;113:2895-901Passamonti et al, Blood 2010; 115:1703-8

Gangat N et al, J Clin Oncol 2011; 29:392-7

Risk Stratification in PMF

International Prognostic Scoring System-IPSS

Low

Int-1Int-2High

Cervantes F et al. Blood 2009;113:2895-901

Points Median survival

(mo)

Low 0 135

Int-1 1 95

Int-2 2 48

High >3 27

Impact of Anemia on Disease Progression

Passamonti F.et al, Blood 2010; 115:1703-8

• Disease-related anemia* has been associated with worse prognosis in all risk scoring systems (Lille, IPSS and derivatives)• RBC transfusional dependency is included in the DIPSS-plus score

* NOT treatment-related

Dynamic IPSS (DIPSS)

Passamonti F et al. Blood 2010;115:1703-8

Points Median survival

(mo)

Low 0 Not reach.

Int-1 1-2 170

Int-2 3-4 48

High 5-6 18

Survival by Cytogenetic Category in PMF

Tam C S et al. Blood 2009;113:4171-4178

At diagnosis Beyond initial diagnosis

CPX= complex (>3 abnormalities)

"Unfavorable" Karyotype in PMF: Effect on OS

Favorable KaryoM 5.2 yr5-yr survival: 51%

Unfavorable KaryoM 2.0 yr5-yr survival: 8%

UNFAVORABLE KARYO:- Complex karyo, - Sole or 2 abnormalities including:• Trisomy 8• -7/del(7q)• Del(5q)• Inv(3)• isochromosome 17q/17p-• 12p-• 11q23 abnormality

Caramazza D et al. Leukemia 2011; 25:82-88

"Unfavorable" Karyotype in PMF: Effect on LFS

Caramazza D et al. Leukemia 2011; 25:82-88

Favorable Karyo5-yr AML transformation rate: 7%

Unfavorable Karyo5-yr AML transformation rate: 46%

Variable IPSS DIPSS DIPSS-plusAge >65 y

Constitutional symptoms

Hemoglobin <10 g/dL

Leukocyte count >25x109/L

Circulating blasts > 1%

Platelet count <100x109/L

RBC transfusion need

Unfavorable karyotype+8,-7/7q-,i(17q),inv(3), -5/5q-,12p-, 11q23 rearr.

Cervantes et al, Blood 2009;113:2895-901Passamonti et al, Blood 2010; 115:1703-8

Gangat N et al, J Clin Oncol 2011; 29:392-7

Risk Stratification in PMF

Gangat et al. J Clin Oncol 2011;29:392-7

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Months

∆ Low risk (0 adverse points) n=66; median survival ~ 185 months

▲ Intermediate-1 risk (1 adverse point) n=174; median survival ~ 78 months

○ Intermediate-2 risk (2 or 3 adverse points) n=360; median survival ~ 35 months

High risk (4 or more adverse points) n=193; median survival ~ 16 months

Low risk (0 variable)M 185 mo

Int-1 risk (1 variable)M 78 mo

Int-2 risk (2-3 variables)M 35 mo

High risk (>4 variables)M 16 mo

Dynamic IPSS-plus (DIPSS-plus)

Vaidya R et al. Blood 2011;117:5612-15

Adverse Impact of Monosomal Karyotype

Normal karyoM 50 mo

Monosomal karyoM 6 mo

Sole +8M 20 mo

Complex karyoNo monosomalM 24 mo

“Very-High Risk” Patients: >80% MortalityAt 2 Years

Tefferi A et al. Blood 2011; 118:4595-8

Low (3%)

Int-1 (11%)

Int-2 (26%)High (53%)

Very High (82%)

Very-High risk variables

• monosomal karyotype

• inv(3)/i(17q)

or any 2 of the following:

• PB blasts >9%

• WBC >40x109/L

• other unfavorable karyotype

Novel Prognostic Variables

• Somatic Mutations

• Germline Characteristics

• Cytokines

• Other biomarkers (FLC, hepcidin & ferritin

levels)

P=0.198

WT

V617F

JAK2 V617F Mutation and Prognosis in PMF

JAK2 V617F JAK2 wt

89 (31.1%) 68 (34.5%)

103.4 mo (77.5-129.3)

137.6 mo(48.5-226.8)

N=483

Guglielmelli P et al, ASH2012

No Impact of JAK2V617F on Leukemia Risk

WT

V617F

P=0.839HR: 1.05 (95% CI, 0.7-1.7)

(Competitive risk analysis) Guglielmelli P et al, ASH2012

Blast transformation: Kaplan-Meier analysis

jak2=wt

jak2=heteroz

jak2=homoz

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0.25

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0.75

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145 101 58 37 23 15 12 6 1 1 0jak2=homoz223 118 56 36 19 13 9 6 4 4 2 jak2=heteroz225 130 83 60 42 27 19 9 5 2 0jak2=wt

Number at risk

0 36 72 108 144 180 216 252 288 324 360Months

Kaplan Meier estimates for JAK2Event=Leukemia-transformation

Barosi et al. PlosOne 2013, In press

IPSS prognostic score 4.33 (1.5-12.6) 0.007

JAK2 V617F wt or Homo vs. Hetero

2.43 (1.44-4) 0.02

Mutation Complexity in PMF 382 (79.1%) of patients presented at least one somatic mutation

• 154 pts (32.5%) had >2 mutations

• 31 pts (6.4%) had >3 mutationsGuglielmelli P et al, ASH2012

EZH2 ASXL1

SRSF2

P= 0.0008 P< 0.0001

P< 0.0001

Hazard Risk(95% CI range) P

EZH2 1.91 (1.08-3.36) 0.025

ASXL1 2.21 (1.57-3.11) <0.0001

SRSF2 2.60 (1.63-41.6) <0.0001

Mutations Associated with Reduced Overall Survival in Multivariate Analysis

WTMut

WTMut

WT

Mut

Guglielmelli P et al, ASH2012

EZH2 ASXL1

SRSF2 IDH1/2

P=.003HR=1.98 (95%CI: 0.88-4.46)

P<.0001HR=2.5 (95%CI: 1.51-4.13)

P=.007HR= 2.73 (95%CI: 1.34-5.55)

P<.0001HR= 2.66(95%CI: 1.10-6.47)

* Competitive Risk Analysis

Mutations Associated with Leukemiain Multivariate Analysis

WT

Mut

WTMut

WTMut

WTMut

Guglielmelli P et al, ASH2012

• In the “molecularly high-risk” category, overall survival was 81 months (range: 61.9-99.5) compared with 148 months (range: 52.5-243.2) in the “molecularly low-risk” category (P<0.0001). Mutivariate analysis.

Low Risk

High Risk

P<0.0001

HR= 2.29 (95%CI: 1.65-3.19)

A "Molecularly High-Risk" Status Associates with Reduced Overall Survival

• EZH2• ASXL1• SRSF2• IDH1/2

Guglielmelli P et al, ASH2012

P<0.0001

Low Risk

High Risk

HR 2.96 (95%CI:1.85-4.76)

• In the “molecularly high-risk” category, leukemia-free survival was 129 months (range: 90-168) compared with 323 months (range: 194-452) in the “molecularly low-risk” category (P<0.0001) – Competitive risk analysis

A "Molecularly High-Risk" Status Associates With Leukemia Transformation

• EZH2• ASXL1• SRSF2• IDH1/2

Guglielmelli P et al, ASH2012

P= 0.017 P= 0.002

IPSS (LOW-INT1) IPSS (INT2-HIGH)

Low Risk

High Risk

Low Risk

High Risk

Molecular Risk category

Median Overal Survival, months (range)

LOW 264.2 (184.7-343.6)

HIGH 125.6(77.4-173.8)

Molecular Risk category

Median Overal Survival, months (range)

LOW 71.5(59.2-23.7)

HIGH 32.4(26.6-38.3)

The "Molecularly High-Risk" Status Contributes to Refined IPSS Categorization

Guglielmelli P et al, ASH2012

P= 0.01 P= 0.001

IPSS (LOW-INT1) IPSS (INT2-HIGH)

Low Risk

High Risk

Low Risk

High Risk’

IPSS category Hazard Risk (95%CI,range)

LOW-INT1 2.28 (1.20-4.36)

INT2-HIGH 3.22 (1.52-6.83)

The "Molecularly High-Risk" Status Predicts for Leukemia Risk within IPSS Categories

Guglielmelli P et al, ASH2012

ABSTRACT #430

Prognostic Interactions Between SRSF2, ASXL1, and IDH Mutations in Primary Myelofibrosis and Determination of Added Value to Cytogenetic Risk Stratification and DIPSS-PlusTerra L Lasho, MT, (ASCP)1*, Naseema Gangat, MD1*, Christy Finke, BS1*, Rebecca R. Laborde, PhD1*, Curtis A Hanson, MD2*, Rhett P Ketterling, MD3*, Ryan A Knudson3*, Animesh Pardanani, MBBS, PhD1 and Ayalew Tefferi, MD1

Barosi G et al, Blood 2012; 120:3112-7*, restricted to JAK2V617Fpos pts, n=295

OS* BT*

The A3669G Polymorhism of Glucocorticoid Receptor Contributes to Blast Transformation in PMF

0.47 per 100 pt-yr

13.6 per 100 pt-yr77.6mo vs 298mo; P=0.049

76.7mo vs 261mo; P=0.018remained significant in multivariate

• The A3669G allele is a susceptibility allele for PMF (HR 1.6-1.8)

• The G/G allele associated with a «more-myeloproliferative» phenotype

N=21N=274

Tefferi A et al. JCO 2011;29:1356-1363

All (n=127)

Treatment naive (n=90)

Int-1 (n=27)

Int-2 (n=70)

Abnormally Increased IL-8 and IL2R Plasma Levels Are Prognostically Detrimental

Pardanani A et al. JCO 2012;30:1087-94

Plasma Free Light Chain (FLC) Levels Predict Survival in PMF

Levels above or below the ROC cutoff (3.78 mg/dL)

FCL FCL +/- IL-8 and/or IL-2R

Both normal

Either abnormal

Both abnormal

< 3.78 mg/dL

Both abnormal> 3.78 mg/dL

Conclusions

• Prognostic scores in OMF are needed for therapeutic choices

• At present, they are mainly reserved for HSCT decision• Most used scores are based on clinical and hematologic

variables• Cytogenetics has been show to add to clinical scores• Molecular characterization may help refine clinical

scores, be cost-effective and overcome technical limitations of conventional cytogenetics

Acknowledgments

Section of Hematology, University of Florence

Paola Guglielmelli Flavia BiamonteTiziana FanelliAmbra SpolveriniMaria Chiara SusiniGiada RotunnoAlessandro PancrazziLisa Pieri

Mario Cazzola - PaviaGianni Barosi - PaviaFrancisco Cervantes - BarcelonaAndrea Reiter - MannheimAndrew Duncombe - SouthamptonKaterine Zoe - AthensNick Cross - Salisbury

Contributors