7/12/2016

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New Directions in Aplastic Anemia:

What's on the Horizon?

Amy E. DeZern, MD; MHS

Assistant Professor

Hematologic Malignancies

Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins

Baltimore, MD

Objectives

• To provide information on new concepts

emerging in AA in somatic molecular

testing

• To review updates on markers of

response to therapy in AA

• To review newer data on emerging

therapies in aplastic anemia (AA)

TESTING

July 12, 2016 3

Better way to evaluate clonal

evolution?

• As survival is improving, we may see

more late development of MDS/AML in

≥15% of patients clonal evolution

• Extrapolation from MDS field somatic

mutational testing

• Goal: to use this testing to ID group of

AA pts more likely to get MDS

(treatment would be modified)

Kulasekararaj et al. Blood 2014

Yoshizato et al. NEJM 2015

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The Dawn of the Molecular Era of

the Myelodysplastic Syndromes• 51% of patients ≥1 mutation (including ~50% with

normal karyotype)

• FIVE genes (in ~30% of pts) independent

prognostic significance and predicted poor overall

survival

– EZH2 ETV6 RUNX1 ASXL1 P53

Bejar et al NEJM

2011

RUNX1

ETV6

WT1 PHF6

GATA2

DNMT3AEZH2

ASXL1

IDH1 & 2

UTX

TP53

Transcription FactorsTyrosine Kinase Pathway

Epigenetic Dysregulation

SF3B1

Splicing Factors

JAK2

NRAS

BRAFKRAS

RTKs

PTPN11

NOTCH?MAML?

ZSWIM4?UMODL1?

CBL

NPM1

ATRX

Others

SRSF2

U2AF1ZRSF2

SETBP1

SF1SF3A1

PRPF40BU2AF2

PRPF8

BCOR

TET2

Genes Recurrently Mutated in MDS

Courtesy of Bejar R.

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Retrospective from the UK

• From UK: looked at 150 pts with no

evidence (by microscope) of MDS

• Screen for mutations

– ASXL1, DNMT3A, BCOR, TET2, MPL at least

– 19% AA pts had mutations

– Pts with mutations had a longer disease

duration (37 vs. 8 months, p<0.04)

– AA patients with disease duration of > 6 mos

AND mutation40% risk of transformation to

MDS (p <0.0002) 7

Kulasekararaj et al. Blood 2014

Candidate gene mutations in acquired

aplastic anemia - correlation with survival

and clonal evolution to myelodysplastic

syndrome-courtesy of Dr. Dumitriu

Yoshizato et al. NEJM 2015

NIH SAA cohort

Time

De novo

MDS/AML

“Stable AA” – responders or

non-responders to

immunosuppressive therapySAA

6 months after IST

≈ 15% clonal evolution to MDS/AML

Clonal evolution

N = 256 patients (3 institutions)Yoshizato et al. NEJM 2015

ACQUIRED MUTATIONS IN SAA – NIH COHORT (n=256)

0 1 2 >2

Number mutations

per SAA patient

65%

23%

7%

5%

0%

25%

50%

75%

100%

Epigenesis Transcription

factor Signal

transduction Others

DNA

repair Receptor

Ribosomal

protein

AEBP2 ATM BRAF CDAN1 FANCA FLT3 RPL11 ASXL1 BCOR CSMD1 CDH23 FANCC KIT RPL35a ATRX BCORL1 GNAS DIS3 FANCD1 GCSFR RPL5 DNMT3A CEBPA GPRC5A DKC1 FANCD2 MPL RPS10 EED CTCF JAK1 ELANE FANCE RPS19 EZH1 CUX1 JAK2 ETNK1 FANCG RPS26 EZH2 DAXX JAK3 LAMB4 IDH1 Dido1 KRAS LUC7L2 Telomere Splicing Cohesin IDH2 ETV6 LNK PEG3 NHP2 DDX41 RAD21 JARID2 GATA1 MAP3K4 PIGA NOP10 PRPF8 SMC1A KDM6A GATA2 NF1 PRF1 POT1 SF3B1 SMC3 RBBP4 IRF1 NRAS SBDS RAP1 SRSF2 STAG2 RBBP7 NCOR2 PTPN11 SETBP1 RTEL1 U2AF1 SUZ12 NPM1 RIT1 UMODL1 TERC U2AF2 Ubiquitin TET2 PHF6 SRP72 ZSWIM4 TERF1 ZRSR2 BRCC3

Rb STAT3 TERF2 CBL RUNX1 TERT FBXW7 TP53 TINF2 WT1 TPP1

Targeted gene panel

ACQUIRED MUTATIONS IN SAA – NIH COHORT (n=256)

0.0%4.0%8.0%12.0%

PIGA

BCOR/BCORL1

DNMT3A

ASXL1

Splicing

cohesin

JAKs

RUNX1

TP53

TET2

SETBP1

GNAS

PRC2

CSMD1

LAMB4

WT1

TERF1/TERT

ATRX

PHF6

ATM

RIT1

CDAN1

IDH2

CUX1

RBBP4

CBL

PRPF8

KRAS

MPL

NF1

POT1

RAP1A

STAT3

PEG3

DIS3

SH2B3

77%% of patients

multiplemissense

nonsense

frameshiftsplicing

PIGA

BCOR/BCORL1

DNMT3A

ASXL1

ACQUIRED MUTATIONS IN SAA – STRONG AGE BIAS

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Odds ratio (95% CI) p value

ARC<25k/uL 1.09 (0.59, 2.07) 0.885

ANC<200/uL 1.46 (0.79, 2.68) 0.185

PNH+ 1.46 (0.80, 2.64) 0.202

Response to IST 1.42 (0.78, 2.62) 0.256

ACQUIRED MUTATIONS DO NOT CORRELATE WITH CYTOPENIAS,

PRESENCE OF PNH CLONE, OR RESPONSE TO IST

Odds ratio (95% CI) p value

Refractory to 2 rounds of IST 1.45 (0.49, 4.31) 0.498

Refractory to 2nd IST given for

relapse0.85 (0.22, 3.15) 0.805

HSCT (for

relapse/refractory/clonal

evolution)

0.51 (0.23, 1.10) 0.08

ACQUIRED MUTATIONS DO NOT CORRELATE WITH

REFRACTORY DISEASE

Odds ratio (95% CI) p value

BCOR/BCORL1 2.73 (1.05, 7.11) 0.038

DNMT3A 0.89 (0.31, 2.55) 0.835

ASXL1 0.68 (0.25, 1.83) 0.447

MUTATIONS IN BCOR/BCOL1 CORRELATE WITH BETTER

RESPONSE TO to IST

None of these mutations correlate with clonal evolution/refractory disease

OS

0.0

0.4

0.2

1.0

0.6

0.8

ACQUIRED MUTATIONS CORRELATE WITH PROGRESSION TO MDS

OS

0.0

0.4

0.2

1.0

0.6

0.8

ACQUIRED MUTATIONS CORRELATE WITH OVERALL SURVIVAL CONCLUSIONS

• Somatic mutations in 35% of cases

• PIGA, DNMT3A, ASXL1, and BCOR/BCORL1 were most frequently

mutated genes

• Presence and number of mutations correlated with age only

• BCOR/BCORL1 mutated clones associated with a better chance of

responding to IST

• Response to IST, clonal evolution and overall survival are associated with

acquired mutations

• Mutations remain independent predictors of clinical outcomes in

multivariate analysis

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Telomeres

• Telomeres: regions of repetitive nucleotides at the ends of chromosomes that are there to protect the chromosomes from damage and breakdown.

• Telomere length testing very helpful in inherited AA DKC (very short)

• Reports suggest that telomeres are shorter (not very short) in up to one-third of patients with acquired SAA

• At NIH, telomere lengths measured in the white blood cells of 183 patients treated with IST

• Shorter telomeres not found to predict who would have improved blood counts at 6 months after IST

• Shorter lengths may be associated with late effects such as relapse or clonal evolution to MDS

Scheinberg et al. JAMA, 304 (2010), 1358-64.July 12, 2016

DeZern and Armanios (unpublished)

PNH clones and telomeres predict

response to IST in Pediatric AA

• Prospective study of 113 children (Ages 0-16)

• All had PNH clones and telomeres done in CLIA certified

way before IST

• Response assessed based on PNH clone presence and

telomere length

– If PNH clone + and telomeres “long”- ~70% response

– If PNH clone neg and telomeres “short”- ~19%

response

• Suggestion for upfront HSCT if in this group

Narita et al. Haematolgica 201521

TREATMENTS

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Severe Aplastic Anemia 2015 Treatment Paradigm

Bone Marrow

Transplantation

Immunosuppressive

Therapy

No Response

~30%

~40% Relapse or

Clonal Evolution TRANSPLANTClinical

follow up

Response

Rate ~70%

Age < 40 years with

HLA matched sibling

Age > 40 years OR

No HLA matched sib

Diagnosis of Severe

Aplastic AnemiaTreatment based upon age and

donor availability

Alternative Donor transplants in

SAA

• Reserve for relapsed or refractory SAA– After failing ATG

• Should be done in a “specialist center with major experience in hematopoietic SCT procedures”

• Perform in setting of clinic trial “designed specifically to address the prevention of graft rejection and GVHD”

Ciceri et al BMT 2013

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Unrelated Donor or Alternative donor

BMT

• The sooner, the better after relapse/ refractoriness noted

• Bone marrow still the best source

• Similar conditioning regimens

• Often in setting of clinical trial

• Unrelated donor (NMDP- “MUDs”)

• Haplo-identical donor (half match)

• Umbilical cord donor

New Trial

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Primary Objective

Assess overall survival in 2 cohorts

(unrelated cord blood and haplo-

identical) at 1 year post-hematopoietic

stem cell transplantation in patients with

severe aplastic anemia

Hypothesis—both cohorts >75% 1yr OS27

Hopkins Haplo BMT for Acquired and

inherited SAA

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Age/

Sex59

Pre-BMT

Therapy

Degree of

HLA

match

Day of

engraftm

ent

(ANC

>1000)

Donor

chimerism

at day 100

aGVHD cGHVD ResponseFollow-

Up (mos)

35M ATG/ CsA 5/10 30 100 none none CR 50

52M ATG/ CsA 5/10 24 100 none none CR 27

45F ATG/ CsA 5/10 27 100 Gr 2 skin Gr 2 skin CR 22

27F ATG 5/10 24 100 none none CR 15

33M HiCY 5/10 16 100 none none CR 17

17M HiCY 5/10 17 100 none none CR 9

54M ATG/ CsA 5/10 15 100 none None CR 9

26F

ATG/

CsA/TPO 5/10 17 100 none None CR 6

59

ATG/

CsA/TPO 5/10 24

100 (Day

60 none None CR 3

21 Steroids 5/10 18 100 none none CR 33

38 Danazol 9/10 17 100 none Gr 2 skin CR 20

Mini-BMT for Refractory SAA

Treatment schema

Adult URD

• Survival now >75%

• Similar conditioning regimens- may add

TBI

Bacigalupo and Marsh BMT 2013

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Kaplan-Meier survival rate estimates (and 95%

confidence intervals) for recipients of an HLA-matched

sibling or unrelated donor HCT for SAA registered with

CIBMTR from 1990 through 2011, by donor type, age

group, and graft source HLA-Matched Sibling Donor Unrelated Donor

Age < 40y Age ≥ 40y Age < 40y Age ≥ 40y

Survival rate (95% CI), Graft Source: BM and PB 1 year 84 (82 – 85) 68 (64 – 72) -- -- 3 years 80 (79 – 82) 61 (57 – 65) -- -- 5 years 80 (78 – 81) 57 (52 – 62) -- -- 10 years 77 (75 – 79) 50 (45 – 56) -- -- Survival rate (95% CI), Graft Source: CB 1 year 79 (56 – 94) -- 52 (44 – 59) Not estimated* 3 years 72 (48 – 90) -- 44 (36 – 51) Not estimated* 5 years 72 (48 – 90) -- 40 (32 – 49) Not estimated* * CIBMTR requires a sample size of at least 20 for KM survival-rate estimations

The data presented here are preliminary and were obtained from the Statistical Center of the Center for International Blood and

Marrow Transplant Research. The analysis has not been reviewed or approved by the Advisory or Scientific Committee of the

CIBMTR.’

Umbilicord Transplants

• Survival is still lower ~40%

• Conditing regimens more varied

– CY/Flu/ TBI

– Melphalan/Flu/ TBI

• Japanese study

– 12 adult patients, 11/12 engrafted, survival

10/12 median 36 mos

Yamamoto et al Blood 2011

Peffault et all BMT 2013

Yoshimi et al BBMT 2008

URD in children

• 44 children in UK (40 s/p IST)

• Fludarabine, CY, Alemtuzumab

conditioning

• Overall survival and failure free survival

was 95%

Samarasinghe et al BJH 2012

2nd HSCT in AA

• Retrospective of 162 European pts

– 1998-2009: 1°or 2°in 14% of pts with 1 txp for AA

• Used same donor 81% of time

• Changed from BM to PBSC in 56%

– Excluded 2nd txp using cord blood

• Graft failure still occurred 26% of 2nd txp

• Follow up 3.5 years (median) 60% OS

Cesaro et al BJH 2015 34

ASH 2014: Transplants

• Abstract 256 Dufour et al

• Similar Outcome of Upfront

Unrelated and Matched

Sibling Donor Hematopoietic

Stem Cell Transplantation in

Idiopathic Aplastic Anaemia

of Childhood and

Adolescence

• 29 SAA children had unrelated

donor HSCT without prior IST in

UK

• Compares each with 3 matched

controls from the database of

the SAAWP of the EBMT with

MSD HSCT

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Androgens: Danazol

• Suggestion in literature that androgens may slow

telomere shortening in some pts

• Phase I/II at NIH in 27 pts (20 with mod AA) to take

danazol daily for 2 years

• Increased telomere lengths and hematologic

improvement seen

• No significant liver toxicity

• At publication 9 pts stopped drug prior to 2 years

Dumitriu et al. Blood

2014

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Iron Overload

• Iron burden increased in

patients with AA at

presentation and over

time with transfusions

– Follow ferritin (lab

measure of body’s iron

stores)

• Iron overload in other

marrow failure (MDS)

studied and problematic

– Deposition in liver

and heart

Jin et al Int J Hem 2015 37

Iron Chelation

• Deferasirox (Exjade oral) or

Desferoxamine (IV)

– To discuss with doctor as

meds have liver and

kidney side effects and

can lower platelets

• Recent study of 53 AA pts

showed deferasirox

improves ferritin and liver

iron overload when taken

daily

Cheong et al Transfusion

201538

THANK YOU!

July 12, 2016 39