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Primary Resistance to Azacytidine in MDS: Preliminary Data on the Potential Role of HIF-1A Expression – the Hellenic MDS Study Group
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Poster Presentations – 14th International Symposium on Myelodysplastic Syndromes / Leukemia Research 55 S1 (2017) S45–S167
of 6 cycles (range, 1–6 cycles) of decitabine. During the study 2 of 17 (12%) patients from the ITT group achieved ORR (CR + CRp). A total of 10 (59%) patients achieved an overall improvement rate (CR + PR + mCR) during the study, including 2 CR, 4 PR and 4 mCR. In total, 11 of 17 enrolled patients discontinued treatment (major reasons included disease progression, n = 8, patient withdrawal/lack of efficacy, n = 3). As expected, cytopenias were the most frequent complication. Grade 3 or 4 hematologic toxicities included anemia (18%), thrombocytopenia (18%) and agranulocytosis (6%). Grade 2 elevation of ALT and AST occurred in 1 patient (6%), grade 2 hyperbilirubinemia observed in 1 patient (6%). Conclusion: Decitabine treatment was efficacious in patients with intermediate- or high-risk MDS and its safety profile is comparable to the global studies of decitabine conducted to date.
113 PRIMARY RESISTANCE TO AZACYTIDINE IN MDS: PRELIMINARY DATA ON THE POTENTIAL ROLE OF HIF-1A EXPRESSION – THE HELLENIC MDS STUDY GROUP V. Mpakou1, A. Spathis2, F. Kontsioti1, A. Bouhla1, K. Gontopoulos1, G. Stavroulaki1, I. Glezou1, S. Papageorgiou1, E. Bazani1, D. Vasilatou1, P. Karakitsos2, E. Kontandreopoulou3, N. Viniou3, A. Galanopoulos4, K. Zafeiropoulou5, I. Kotsianidis6, A. Symeonidis5, G. Dimitriadis1, V. Pappa1 1 Second Department of Internal Medicine and Research Institute, Attikon University General Hospital, Athens, Greece; 2Department of Cytopathology, Attikon University General Hospital, Athens, Greece; 3 Department of Hematology, Laiko General Hospital of Athens, Athens, Greece; 4Hematology Unit, General Hospital of Athens “G. Gennimatas”, Athens, Greece; 5Hematology Unit, University General Hospital of Patras, Patra, Greece; 6Department of Haematology, Democritus University of Thrace, Alexandroupolis, Greece Background: The hypomethylating agent azacytidine is the standard of care for patients with high-risk myelodysplastic syndromes (MDS) (IPSS intermediate-2 or high) and patients with AML not candidate for treatment with intensive chemotherapy. Nevertheless, approximately 40% of patients fail to respond, whereas even responders will inevitably relapse. The exact mechanisms of azacytidine failure are largely unknown and there is no approach to circumvent azacytidine resistance. Hematopoietic and leukemia stem cells reside in a particularly hypoxic niche and several reports have demonstrated the significance of hypoxia in the regulation of both physiological and malignant hematopoiesis. Methods: Bone marrow samples from 43 de novo MDS patients, 3 CMML patients, 4 AML and 1 MPN (40 males and 11 females) with a median age of 78 (60–89) and 10 healthy donors were collected. MDS patients were classified according to WHO as RCMD (7/43), RAEB I (8/43) and RAEB II (28/43). All patients received treatment with azacytidine at the dose of 75 mg/m2 ×7 days SC. Before treatment, bone marrow mononuclear cells were isolated using the Ficol-paque method, followed by RNA extraction using TRIzol reagent and cDNA preparation using Superscript II reverse transcriptase. Hif-1α expression was estimated by real time PCR TaqMan gene expression assay, using the appropriate primers and probes. Relative gene expression was calculated by comparative threshold cycle (ΔΔCt) method. β-actin was used as a housekeeping gene. Results: Out of the 51 patients examined, 25 responded to azacytidine-treatment (including CR, PR and HI) while 26 failed to respond. Using real time PCR we found that the ΔΔCt ratio of Hif1α/β-Actin median expression for control samples was 0.82, for patients who responded to azacytidine- treatment 1.36, while for non-responders 0.83. Interestingly, in MDS patients, a trend towards increasing Hif-1α expression, although not statistically
significant, was observed across IPSS risk groups, with Hif-1α median expression varying from 1.09 in low risk group to 1.12 in inter-I, 1.31 in inter-II and 1.63 in high risk group of patients. Conclusions: Our data suggest that increased pretreatment expression of Hif-1α might be associated with better response to azacytidine, indicating a potential role of hypoxia signaling in azacytidine response. Moreover, our data indicate that Hif-1α expression levels gradually increase across IPSS scoring groups, suggesting an association with more aggressive disease.
114 AZACITIDINE INDUCED SIGNIFICANT HYPERKALEMIA AND MILD RENAL DYSFUNCTION S. Sadawarte1, S. Gundlapalli2, S. Kashimalla3 1 Haematology and Bone Marrow Transplant, CARE Hospital- Banjara Hills, Hyderbad, India; 2Nephrology, CARE Hospital- Banjara Hills, Hyderabad, India; 3Haematology and Bone marrow transplant, CARE Hospital- Banjara Hills, Hyderabad, India Introduction: Hypomethylating agents have changed the outlook for patients with MDS and AML not fit for intensive therapy. They have some peculiar side effects. Azacitidine is known to cause proximal renal dysfunction with hypokalemia. Case report: We report a case of 70 years old diabetic and hypertensive female who was diagnosed with Pure Red Cell Aplasia in August 2015. She had some response to cyclosporine after she failed steroid trial. She developed severe anaemia in March 2016 and a repeat haematological evaluation showed Myelodysplastic syndrome with multi-lineage dysplasia and had low IPSS. She had previously experienced side effects of cyclosporine with rise in creatinine and potassium which reverted to normal after dose reduction. She was initiated on Azacitidine 75 mg/m2 (120 mg) subcutaneous daily for 7 days every 4 weeks. She underwent first two cycles without major problems. Prior to third cycle she had normal serum creatinine of 0.96 mg/dL with eGFR of 64.8 mL/min/1.73 m2, serum potassium of 5.1 meq/L and serum bicarbonate of 21 mmol/L. After the first dose of cycle 3 she developed rise in creatinine which peaked to 1.34 mg/dL with eGFR of 40 mL/min/1.73 m2 and serum potassium of 5.9 meq/L. The Azacitidine therapy was with held. This was true hyperkalemia with ECG changes. There was drop in serum bicarbonate to 19.5 mmol/L. She had normal serum uric acid of 2.5 mg/dL, Calcium of 11.3 mg/dL and phosphates of 4.6 mg/dL. Her urine potassium creatinine ratio was 1.23. There was no significant glycosuria. She was not being treated with any nephrotoxic drug and was adequately hydrated precluding us from considering alternative diagnosis. She was treated with Intravenous hydration, Calcium polystearanate, dextrose insulin drip and salbutamol nebulisation for 4 days. After normalisation of these parameters she was restarted on reduced dose Azacytidine 100 mg daily for 6 days which was well tolerated.
Poster Presentations – 14th International Symposium on Myelodysplastic Syndromes / Leukemia Research 55 S1 (2017) S45–S167
of 6 cycles (range, 1–6 cycles) of decitabine. During the study 2 of 17 (12%) patients from the ITT group achieved ORR (CR + CRp). A total of 10 (59%) patients achieved an overall improvement rate (CR + PR + mCR) during the study, including 2 CR, 4 PR and 4 mCR. In total, 11 of 17 enrolled patients discontinued treatment (major reasons included disease progression, n = 8, patient withdrawal/lack of efficacy, n = 3). As expected, cytopenias were the most frequent complication. Grade 3 or 4 hematologic toxicities included anemia (18%), thrombocytopenia (18%) and agranulocytosis (6%). Grade 2 elevation of ALT and AST occurred in 1 patient (6%), grade 2 hyperbilirubinemia observed in 1 patient (6%). Conclusion: Decitabine treatment was efficacious in patients with intermediate- or high-risk MDS and its safety profile is comparable to the global studies of decitabine conducted to date.
113 PRIMARY RESISTANCE TO AZACYTIDINE IN MDS: PRELIMINARY DATA ON THE POTENTIAL ROLE OF HIF-1A EXPRESSION – THE HELLENIC MDS STUDY GROUP V. Mpakou1, A. Spathis2, F. Kontsioti1, A. Bouhla1, K. Gontopoulos1, G. Stavroulaki1, I. Glezou1, S. Papageorgiou1, E. Bazani1, D. Vasilatou1, P. Karakitsos2, E. Kontandreopoulou3, N. Viniou3, A. Galanopoulos4, K. Zafeiropoulou5, I. Kotsianidis6, A. Symeonidis5, G. Dimitriadis1, V. Pappa1 1 Second Department of Internal Medicine and Research Institute, Attikon University General Hospital, Athens, Greece; 2Department of Cytopathology, Attikon University General Hospital, Athens, Greece; 3 Department of Hematology, Laiko General Hospital of Athens, Athens, Greece; 4Hematology Unit, General Hospital of Athens “G. Gennimatas”, Athens, Greece; 5Hematology Unit, University General Hospital of Patras, Patra, Greece; 6Department of Haematology, Democritus University of Thrace, Alexandroupolis, Greece Background: The hypomethylating agent azacytidine is the standard of care for patients with high-risk myelodysplastic syndromes (MDS) (IPSS intermediate-2 or high) and patients with AML not candidate for treatment with intensive chemotherapy. Nevertheless, approximately 40% of patients fail to respond, whereas even responders will inevitably relapse. The exact mechanisms of azacytidine failure are largely unknown and there is no approach to circumvent azacytidine resistance. Hematopoietic and leukemia stem cells reside in a particularly hypoxic niche and several reports have demonstrated the significance of hypoxia in the regulation of both physiological and malignant hematopoiesis. Methods: Bone marrow samples from 43 de novo MDS patients, 3 CMML patients, 4 AML and 1 MPN (40 males and 11 females) with a median age of 78 (60–89) and 10 healthy donors were collected. MDS patients were classified according to WHO as RCMD (7/43), RAEB I (8/43) and RAEB II (28/43). All patients received treatment with azacytidine at the dose of 75 mg/m2 ×7 days SC. Before treatment, bone marrow mononuclear cells were isolated using the Ficol-paque method, followed by RNA extraction using TRIzol reagent and cDNA preparation using Superscript II reverse transcriptase. Hif-1α expression was estimated by real time PCR TaqMan gene expression assay, using the appropriate primers and probes. Relative gene expression was calculated by comparative threshold cycle (ΔΔCt) method. β-actin was used as a housekeeping gene. Results: Out of the 51 patients examined, 25 responded to azacytidine-treatment (including CR, PR and HI) while 26 failed to respond. Using real time PCR we found that the ΔΔCt ratio of Hif1α/β-Actin median expression for control samples was 0.82, for patients who responded to azacytidine- treatment 1.36, while for non-responders 0.83. Interestingly, in MDS patients, a trend towards increasing Hif-1α expression, although not statistically
significant, was observed across IPSS risk groups, with Hif-1α median expression varying from 1.09 in low risk group to 1.12 in inter-I, 1.31 in inter-II and 1.63 in high risk group of patients. Conclusions: Our data suggest that increased pretreatment expression of Hif-1α might be associated with better response to azacytidine, indicating a potential role of hypoxia signaling in azacytidine response. Moreover, our data indicate that Hif-1α expression levels gradually increase across IPSS scoring groups, suggesting an association with more aggressive disease.
114 AZACITIDINE INDUCED SIGNIFICANT HYPERKALEMIA AND MILD RENAL DYSFUNCTION S. Sadawarte1, S. Gundlapalli2, S. Kashimalla3 1 Haematology and Bone Marrow Transplant, CARE Hospital- Banjara Hills, Hyderbad, India; 2Nephrology, CARE Hospital- Banjara Hills, Hyderabad, India; 3Haematology and Bone marrow transplant, CARE Hospital- Banjara Hills, Hyderabad, India Introduction: Hypomethylating agents have changed the outlook for patients with MDS and AML not fit for intensive therapy. They have some peculiar side effects. Azacitidine is known to cause proximal renal dysfunction with hypokalemia. Case report: We report a case of 70 years old diabetic and hypertensive female who was diagnosed with Pure Red Cell Aplasia in August 2015. She had some response to cyclosporine after she failed steroid trial. She developed severe anaemia in March 2016 and a repeat haematological evaluation showed Myelodysplastic syndrome with multi-lineage dysplasia and had low IPSS. She had previously experienced side effects of cyclosporine with rise in creatinine and potassium which reverted to normal after dose reduction. She was initiated on Azacitidine 75 mg/m2 (120 mg) subcutaneous daily for 7 days every 4 weeks. She underwent first two cycles without major problems. Prior to third cycle she had normal serum creatinine of 0.96 mg/dL with eGFR of 64.8 mL/min/1.73 m2, serum potassium of 5.1 meq/L and serum bicarbonate of 21 mmol/L. After the first dose of cycle 3 she developed rise in creatinine which peaked to 1.34 mg/dL with eGFR of 40 mL/min/1.73 m2 and serum potassium of 5.9 meq/L. The Azacitidine therapy was with held. This was true hyperkalemia with ECG changes. There was drop in serum bicarbonate to 19.5 mmol/L. She had normal serum uric acid of 2.5 mg/dL, Calcium of 11.3 mg/dL and phosphates of 4.6 mg/dL. Her urine potassium creatinine ratio was 1.23. There was no significant glycosuria. She was not being treated with any nephrotoxic drug and was adequately hydrated precluding us from considering alternative diagnosis. She was treated with Intravenous hydration, Calcium polystearanate, dextrose insulin drip and salbutamol nebulisation for 4 days. After normalisation of these parameters she was restarted on reduced dose Azacytidine 100 mg daily for 6 days which was well tolerated.