Hyperferritinemia at diagnosis predicts relapse and overall survival in younger AML patients with intermediate-risk cytogenetics

Leukemia Research 39 (2015) 818–821

Contents lists available at ScienceDirect

Leukemia Research journal homepage: www.elsevier.com/locate/leukres

Hyperferritinemia at diagnosis predicts relapse and overall survival in younger AML patients with intermediate-risk cytogenetics Delphine Lebon a,1 , Franc¸ois Vergez b,g,1 , Sarah Bertoli c , Véronique Harrivel d , Stéphane De Botton e , Jean-Baptiste Micol e , Jean-Pierre Marolleau f,∗∗,2 , Christian Récher c,g,∗,2 a

Service d’Hématologie Clinique, CHU Amiens, Amiens Cedex 1, France Laboratoire d’Hématologie, Centre Hospitalier Universitaire de Toulouse, Institut Universitaire du Cancer de Toulouse Oncopole, Toulouse, France c Service d’Hématologie, Centre Hospitalier Universitaire de Toulouse, Institut Universitaire du Cancer de Toulouse Oncopole, Toulouse, France d Laboratoire d’Hématologie, CHU Amiens, Amiens Cedex 1, France e Service d’Hématologie Clinique, Institut Gustave Roussy, Villejuif, France f Service d’Hématologie Clinique, Université de Picardie Jules Verne, CHU Amiens, Amiens Cedex 1, France g Université Toulouse III Paul Sabatier, Toulouse, France b

a r t i c l e

i n f o

Article history: Received 1 February 2015 Received in revised form 2 May 2015 Accepted 5 May 2015 Available online 14 May 2015 Keywords: Leukemia Acute myeloid leukemia Prognosis Ferritin

a b s t r a c t The prognostic value of ferritin level at diagnosis in AML patients is unknown. We studied 162 younger AML patients with intermediate-risk cytogenetics who received intensive chemotherapy. The median ferritin level at diagnosis was 633 ␮g/L and 128 (79%) patients had a ferritin level above the upper normal limit. Hyperferritinemia was significantly associated with a higher cumulative incidence of relapse as well as poorer disease-free and overall survival. In multivariate analysis, hyperferritinemia remained an independent poor prognosis factor. The level of ferritin at diagnosis has a major impact on relapse suggesting a link between inflammation, oxidative stress and chemoresistance in AML. © 2015 Elsevier Ltd. All rights reserved.

1. Introduction The prognostic impact of serum ferritin level, a well-known indicator of the body’s iron stores and inflammation, has been well established in patients with myelodysplastic syndromes (MDS) or acute myeloid leukemia (AML) in the context of allogeneic stemcell transplantation [1]. Several studies have indicated that high pre-transplantation ferritin levels were strongly associated with greater risk of relapse and lower overall survival [2–5]. In these patients, hyperferritinemia is mainly due to transfusion relatediron overload [6]. Much less is known about AML patients at

∗ Corresponding author at: Service d’Hématologie, Centre Hospitalier Universitaire de Toulouse, Institut Universitaire du Cancer Toulouse-Oncopole, 1 Avenue Irène Joliot-Curie – IUCTO – 31059 Toulouse Cedex 9, France. Tel.: +33 05 31 15 62 49; fax: +33 05 31 15 65 87. ∗∗ Corresponding author at: C.H.U d’Amiens – Hôpital Sud, Avenue René Laënnec, Salouel – 80054 AMIENS Cedex 1, France. Tel.: +33 03 22 45 59 14. E-mail addresses: [email protected] (J.-P. Marolleau), [email protected] (C. Récher). 1 These authors contributed equally to the work. 2 JPM and CR are co-senior author. http://dx.doi.org/10.1016/j.leukres.2015.05.001 0145-2126/© 2015 Elsevier Ltd. All rights reserved.

diagnosis who are, in most cases, free from red blood-cell transfusions. Interestingly, ferritin levels are frequently elevated in those patients at the time of disease onset [7]. We report here a retrospective study to determine the prognostic impact of ferritin level at diagnosis in younger AML patients with intermediate-risk cytogenetics treated by intensive chemotherapy. 2. Patients and methods 2.1. Patients We studied 162 patients (60 years or younger) with de novo AML and intermediate-risk cytogenetics who were treated between May 2007 and December 2011 by a “3+7-like” chemotherapy in three French centers according to GOELAMS (Toulouse University Hospital, n = 99), or ALFA (Amiens University Hospital n = 37, and Gustave Roussy Institute, n = 26) protocols [8,9]. Ferritin level, included in the diagnosis workup, was measured by spectrophotometry. Cytogenetic prognosis was defined according to the refined British MRC classification [10]. A favorable genotype was defined as NPM1 mutation in the absence of FLT3-ITD. This study was approved by the institutional review board of each center. 2.2. Statistical analysis Comparisons of patient characteristics were performed using the Mann–Whitney test for continuous variables and the Fisher’s exact test for

D. Lebon et al. / Leukemia Research 39 (2015) 818–821

819

Fig. 2. Disease-free survival (A) and overall survival (B) in AML patients with NPM1 mutation and without FLT3-ITD mutation according to the level of serum ferritin at diagnosis.

using the log-rank test. Survival-time data and covariates were analyzed using the backward method of Cox proportional hazards regression. All calculations were performed using STATA software, version 13.

3. Results

Fig. 1. Disease-free survival (A), overall survival (B) and cumulative incidence of relapse (C) in AML patients with intermediate-risk cytogenetics according to the level of serum ferritin at diagnosis.

categorical variables. When needed, the best thresholds for continuous variables were calculated using receiver operating characteristic (ROC) curves. Complete response (CR), disease-free (DFS) and overall (OS) survival rates were defined according to Cheson’s criteria [11]. Cumulative incidence was used to estimate the risk of relapse in patients having achieved first CR with death without evidence of disease recurrence considered as the competing risk. Patients still alive were censored at the time of last contact. The covariates associated with response to induction chemotherapy or outcome that were identified in univariate analysis with a p-value <0.2 or with borderline value but prognostic impact established from published data (e.g., FLT3-ITD), were included in the multivariable logistic model. OS and DFS were estimated by the Kaplan–Meier method and compared

We choose to select younger patients with intermediate-risk cytogenetics and de novo AML in order to reduce the proportion of patients who might have received a transfusion in the months prior to AML diagnosis (e.g., secondary AML) and thus have a biased ferritin level at diagnosis. Patients’ characteristics are shown in Table 1. In this series of patients with a median follow-up of 32 months, 3-year DFS and OS were 69% and 74%, respectively. The median ferritin level at diagnosis was 633 ␮g/L (range, 54–80,070 ␮g/L) and 128 (79%) patients had a ferritin level above the upper normal limit. ROC curve analyses were used to determine the best thresholds of ferritin to predict an adverse event (relapse or death). Two groups of patients were identified with a cut-off at four times the upper normal value (>4n). The 43 patients (27%) who had a ferritin level >4n at diagnosis were more likely to have higher white blood cell count (WBC) (36 vs 6.2 G/L), higher median c-reactive protein (CRP) levels (96.8 vs 8.4 mg/L) and NPM1 mutation (60% vs 38%) than patients with ferritin <4n. After induction chemotherapy, complete response was achieved in 146 patients (90%). In univariate analysis, WBC count, FLT3-ITD, ferritin >4n, CRP level >55 mg/L had no impact on response achievement whereas only NPM1 mutation had a positive impact (p = 0.05).

820

D. Lebon et al. / Leukemia Research 39 (2015) 818–821

Table 1 Characteristics of the 162 patients at diagnosis.

All patients, n (%) Male/female, n (%) Age (years), median (range) WBC count (G/L), median (range) WBC count >50 G/L CRP level (mg/L), median (range) CRP level >55 mg/L FAB subtypes, n (%) Total available M0 M1 M2 M4 M5 M6 M7 Cytogenetics, n (%) Normal karyotype Chromosomal aberrations Not available Molecular biology, n (%) FLT3-ITD+ve NPM1+ve Not available Allo-SCT, n (%) Complete response, n (%)

Total cohort

Serum ferritin >4n

Serum ferritin <4n

p

162 (100%) 94/68 (58%/42%) 49 (16–60) 10.7 (0.3–800) 45 (28%) 17 (0.2–334) 52 (32%)

43 (27%) 31/12 (72%/28%) 50 (16–60) 36 (0.3–236) 19 (44%) 96.8 (0.3–334) 27 (63%)

119 (73%) 63/56 (53%/47%) 49 (17–60) 6.2 (0.7–800) 26 (22%) 8.4 (0.2–284) 25 (21%)

– 0.03 0.63 0.001 0.009 <0.0001 <0.0001

159 (98%) 9 (6%) 34 (21%) 53 (33%) 34 (21%) 21 (14%) 5 (3%) 3 (2%)

41 (95%) 0 (0%) 6 (14%) 12 (28%) 12 (28%) 9 (21%) 0 (0%) 2 (5%)

118 (99%) 9 (8%) 28 (24%) 41 (34%) 22 (18%) 12 (10%) 5 (4%) 1 (1%)

111 (69%) 43 (26%) 8 (5%)

31 (72%) 11 (26%) 1 (2%)

80 (67%) 32 (27%) 7 (6%)

1.0 1.0 0.68

45 (28%) 71 (44%) 11 (7%) 65 (40%) 146 (90%)

16 (37%) 26 (60%) 5 (12%) 16 (37%) 38 (88%)

29 (24%) 45 (38%) 6 (5%) 49 (41%) 108 (91%)

0.11 0.006 0.15 0.86 1.0

0.12

Abbreviations: FAB, French American British classification; WBC: white blood cell count; CRP: C-reactive protein; Allo-SCT: allogeneic stem-cell transplantation. Fisher’s exact test for categorical variables and Mann–Whitney test for continue variables.

In logistic regression, NPM1 (OR: 4.94, CI: 1.19–20.6) and FLT3ITD (OR: 0.28, CI: 0.08–0.99) mutations retained significance for response achievement. Among complete responders, 65 received allogeneic stem-cell transplantation as post remission therapy, 16 patients (37%) in the group with ferritin >4n at diagnosis and 49 (41%) in the group with ferritin <4n. The median DFS was not reached in patients with ferritin <4n compared to 10.1 months in patients with ferritin >4n (Fig. 1A). Similarly, median OS was not reached in patients with ferritin <4n compared to 19.9 months in patients with ferritin >4n (Fig. 1B). Cox-regression analysis showed that ferritin >4n at diagnosis was a poor-risk factor for both DFS (HR: 3.45, 95%CI: 1.98–6.04; p < 0.0001) and OS (HR: 4.12, 95%CI: 2.29–7.42; p < 0.0001) (Table 2). The other independent prognostic factors for DFS and OS were allogeneic-stem cell transplantation as post-remission therapy, NPM1 and FLT3-ITD mutations. Hyperferritinemia may have affected survival through cardio-vascular or infectious adverse events in CR patients during post remission therapy. To better appreciate the impact of ferritin level on disease control in patients having achieved first CR, we assessed the risk of relapse through cumulative incidence of relapse analysis using deaths without evidence of disease recurrence as the competing event. As shown in Fig. 1C, patients in first CR with ferritin >4n at diagnosis (n = 38) had a higher cumulative incidence of relapse than those with ferritin <4n (n = 106) (HR 2.17, 95%CI: 1.23–3.83; p = 0.007). Interestingly, among the 41 patients with

favorable molecular prognosis (NPM1 mutation without FLT3-ITD), ferritin >4n was associated with shorter DFS (median 8.3 months vs not reached; p < 0.0001) (Fig. 2A) and shorter OS (median 22.1 months vs not reached; p = 0.0004) (Fig. 2B). 4. Discussion This study shows that, similar to other cancers, high levels of ferritin are detected in the sera of AML patients at diagnosis, and the higher levels correlate with poor clinical outcome [12]. As a marker of red blood cell transfusion burden, increased serum ferritin levels have been associated with poor outcome in MDS patients probably through the negative impact of iron overload on the function of vital organs such as the liver or heart. In addition, our study suggests that serum ferritin could also affect the prognosis in AML through other mechanisms, since younger AML patients are generally free or have received few transfusions at the time of diagnosis suggesting that the leukemia-associated elevation of ferritin is most likely due to an underlying inflammatory state rather than alterations in the body’s iron stores or liver damage. Indeed, ferritin has various functions unrelated to iron metabolism, such as proliferation, angiogenesis and immunosuppression [13]. We found a strong association between the level of ferritin and the risk of relapse even in patients with favorable molecular status (NPM1+ve /FLT3-ITD−ve ) indicating a possible link with the resistance of leukemic cells to

Table 2 Multivariate analysis. Complete response

Disease-free survival

Overall survival

Variables

OR

95% CI

p

HR

95% CI

p

HR

NPM1 mutation FLT3-ITD WBC >50 G/L CRP >55 mg/L Serum ferritin >4n Allo-SCT

4.94 0.28

1.19–20.6 0.08–0.99

0.049 0.028 >0.1 >0.1 >0.1

0.31 2.39

0.17–0.57 1.28–4.45

0.20 3.13 1.75

0.11–0.38 1.78–5.49 0.99–3.09

3.45 0.44

1.98–6.04 0.25–0.78

0.0002 0.006 >0.1 >0.1 <0.0001 0.006

95% CI

4.12 0.24

2.29–7.42 0.12–0.44

Abbreviations: OR: odds ratio; HR: hazard ratio; WBC: white blood cell count; CRP: C-reactive protein; Allo-SCT: allogeneic stem-cell transplantation.

p <0.0001 0.0001 0.06 >0.1 <0.0001 <0.0001

D. Lebon et al. / Leukemia Research 39 (2015) 818–821

intensive chemotherapy. Ferritin is a growth factor for AML cell lines and it is also possible that its antioxidant activity may decrease the efficacy of cytotoxic agents such as anthracyclines which induce cell death through the induction of oxidative stress [12,14]. Ferritin could thus represent a new therapeutic target in AML. In conclusion, although serum ferritin should be validated as a prognostic factor in a larger prospective study, we show for the first time that hyperferritinemia at diagnosis has a major impact on relapse suggesting a link between inflammatory response, oxidative stress and chemoresistance in AML. Author contributions D.L. and F.V. collected and analyzed data and wrote the paper; S.B. and V.H collected data; S.d B and JP.M treated patients, collected and analyzed data; C.R. treated patients, collected and analyzed data, and wrote the paper. All the authors checked the final version of the manuscript. Conflict of interest The authors declare no conflict of interest. Acknowledgments The authors thank Audrey Sarry for data collection and all the members of the G.A.E.L (Gaël Adolescent Espoir Leucémie) and A.G.M.O.M.P (Association des Greffés de Moelle Osseuse de MidiPyrénées) associations for their kind support to patients. References [1] Armand P, Kim HT, Cutler CS, et al. Prognostic impact of elevated pretransplantation serum ferritin in patients undergoing myeloablative stem cell transplantation. Blood 2007;109(10):4586–8.

821

[2] Armand P, Sainvil M-M, Kim HT, et al. Does iron overload really matter in stem cell transplantation? Am J Hematol 2012;87(6):569–72. [3] Bazuaye GN, Buser A, Gerull S, et al. Prognostic impact of iron parameters in patients undergoing allo-SCT. Bone Marrow Transplant 2012;47(1): 60–4. [4] Mahindra A, Bolwell B, Sobecks R, et al. Elevated pretransplant ferritin is associated with a lower incidence of chronic graft-versus-host disease and inferior survival after myeloablative allogeneic haematopoietic stem cell transplantation. Br J Haematol 2009;146(3):310–6. [5] Lim ZY, Fiaccadori V, Gandhi S, et al. Impact of pre-transplant serum ferritin on outcomes of patients with myelodysplastic syndromes or secondary acute myeloid leukaemia receiving reduced intensity conditioning allogeneic haematopoietic stem cell transplantation. Leuk Res 2010;34(6): 723–7. [6] Cazzola M, Della Porta MG, Malcovati L. Clinical relevance of anemia and transfusion iron overload in myelodysplastic syndromes. Hematology Am Soc Hematol Educ Program 2008:166–75. [7] Delavigne K, Berard E, Bertoli S, et al. Hemophagocytic syndrome in patients with acute myeloid leukemia undergoing intensive chemotherapy. Haematologica 2014;99(3):474–80. [8] Thomas X, Elhamri M, Raffoux E, et al. Comparison of high-dose cytarabine and timed-sequential chemotherapy as consolidation for younger adults with AML in first remission: the ALFA-9802 study. Blood 2011;118(7):1754–62. [9] Recher C, Bene MC, Lioure B, et al. Long-term results of a randomized phase 3 trial comparing idarubicin and daunorubicin in younger patients with acute myeloid leukaemia. Leukemia 2014;28(2):440–3. [10] Grimwade D, Hills RK, Moorman AV, et al. Refinement of cytogenetic classification in acute myeloid leukemia: determination of prognostic significance of rare recurring chromosomal abnormalities among 5876 younger adult patients treated in the United Kingdom Medical Research Council trials. Blood 2010;116(3):354–65. [11] Cheson BD, Bennett JM, Kopecky KJ, et al. Revised recommendations of the International Working Group for Diagnosis, Standardization of Response Criteria, Treatment Outcomes, and Reporting Standards for Therapeutic Trials in Acute Myeloid Leukemia. J Clin Oncol 2003;21(24):4642–9. [12] Alkhateeb AA, Connor JR. The significance of ferritin in cancer: anti-oxidation, inflammation and tumorigenesis. Biochim Biophys Acta 2013;1836(2): 245–54. [13] Arosio P, Ingrassia R, Cavadini P. Ferritins: a family of molecules for iron storage, antioxidation and more. Biochim Biophys Acta 2009;1790(7): 589–99. [14] Kikyo N, Hagiwara K, Yazaki Y, Okabe T. Growth stimulation of ferritin of human leukemia cells in vitro. J Cancer Res Clin Oncol 1995;121(2):76–8.