1. Society for Hematopathology/ European Association for Haematopathology 2013 Workshop Case 145 Nidhi Aggarwal, M.D.; Robert L. Redner, MD; Fiona E. Craig, M.D. University of Pittsburgh Medical Center

2. Clinical History 73 year-old male with history of a high-grade sarcoma of the thigh diagnosed January 2012, status post chemotherapy [Adjuvant Adriamycin (Doxorubicin) and Ifosfamide). Acute myeloid leukemia diagnosed November 2012. Enrolled in phase 1 trial ATRA plus Dasatinib (UPCI 08- 160). Bone marrow obtained day 28 status post chemotherapy.

3. Peripheral smear Patient valueReference range WBC0.5X10^9/l3.8-10.6 Hemoglobin9.7g/dl12.9-16.9 Platelet9X10^9/l156-369 Polys16% (0.08X10^9/l)2.24-7.68 Lymphocytes82% (0.41X10^9/l)0.8-3.65 Monocytes2% (0.01X10^9/l)0.3-0.9

4. Bone marrow aspirate: 84% blasts

5. CD14 - CD36,CD64 + CD15,CD33 + HLA-DR + CD117 - CD34 - SSC CD4 + MPO +

6. Butyrate esteraseButyrate esterase with fluoride

7. t(8;16)(p11;p13)

8. Bone marrow biopsy day 28 status post therapy Bone marrow biopsy at the start of therapy

9. SH/ EAHP Case 145: Persistent therapy-related AML with t(8;16) (p11;p13). Receiving novel therapy (protocol UPCI 08-160) with ATRA and escalating doses of Dasatinib Started on Decitabine therapy on 01/28/2013 The patient died on 03/11/2013. Follow-up:

10. AML with t(8;16) (p11;p13) Rare distinct subtype of AML (<1% of all AML). Atlas of Genetic and Cytogenetics in Oncology and Haematology Translocation inhibits RUNX1 regulated transcription, leading to differentiation block. Chr 8: MYST3/ MOZ Chr 16: CERBBP/ CBP

11. Younger patients including infants More common in women (?) More frequent in therapy related AML than de novo AML – Short latency (6-23months) – Absence of preceding MDS Extramedullary disease especially skin – may precede bone marrow involvement. Relatively high rate of DIC Extremely poor prognosis – Disease free survival very short ~3-4 months & overall survival 8-9 months – Rare spontaneous remission in infants AML with t(8;16) - Clinical features

12. AML with t(8;16) - Pathologic features Monocytoid/ myelomonocytoid differentiation Morphologic features can overlap with Acute promyelocytic leukemia Erythrophagocytosis Immunophenotype shows myeloid and monocytic markers, and usually CD34 negative and CD117 negative A few known collaborating somatic genetic alterations. J Clin Oncol (1993)11:2370-2379; Leukemia Research (2013) 37:32-36; Leukemia (2009) 23:934–943

13. ATRA classically used to induce differentiation in APL EGFR inhibitors (Erlotinib/ Gefitinib) combined with naturally occurring pro-differentiation agents (ATRA or Vitamin D) helps differentiation of AML [Cell Cycle. 2013;(12):18]. Epigenetic modification [Clin Epigenetics. 2013;5(1):12] – Histone deacetylase inhibitor: Valproic acid – DNA methylation inhibitors Furazolidone has been investigated as a differentiation agent for AML [PLoS One. 2013;8(8):e72335. doi: 10.1371/ journal.pone.0072335. eCollection 2013]. Therapeutic induction of differentiation.

14. Patient with AML-M5CD11b: Marker for differentiation Induction of differentiation with ATRA & Dasatinib Src family kinase (SFK), overexpressed in AML, is a negative regulator of ATRA-induced differentiation Dasatinib inhibits ABL and Src family kinase (SFK)

15. UPCI 08-160 protocol: Dasatinib and All-Trans Retinoic Acid for Relapsed/Refractory and/or Elderly Patients with Acute Myeloid Leukemia (AML) Non induction candidate elderly male (>65yrs). Relapsed/Refractory AML: – Failed 2 inductions, or relapsed within 6months. If relapse after >6 months - failed 2 inductions. – AML after MDS/MPN and after chemotherapy also considered). Fixed dose ATRA with escalating doses of Dasatinib.

16. Diagnosis Proposed Diagnosis – Persistent acute myeloid leukemia with monocytic differentiation and t(8;16), likely therapy related. Consensus Diagnosis – Therapy-related myeloid leukemia, acute myeloid leukemia (monocytic) with t(8;16)(p11;p13)