1. . Cytogentic & Molecular Risk Stratification based management of Pediatric AML in 2015 Brijesh Arora, Professor, Division of Pediatric Oncology, Tata Memorial Hospital, Mumbai

2. Synopsis.Molecular Pathogenesis.Molecular Pathogenesis Genomic abnormalities in Pediatric AML Genomic abnormalities in Pediatric AML Role of MRD Role of MRD Current risk stratification & recommendations Current risk stratification & recommendations Approach to Treatment Approach to Treatment

3. COG

5. Genomic subtypes in Pediatric AML

6. Integrative analysis( Type I & II abnormalities)

7. Genetics in Pediatric AML: Proven factors

8. Pediatric AML: Probable factors

9. Pediatric AML: Unproven factors

10. Cytogentic & Molecular factors used to classify good risk FactorSt Jude 08MRC 15/17COG 1031BFM2012 t(8;21), inv(16) YESYesYES t(1;11)No YES NPM/ BICEBPA NoYes YES

11. Cytogentic & Molecular factors for defining high risk FactorSt Jude 08MRC 15/17COG 1031BFM2012 FAB M0, M6 & M7without t(1:12) YESNo Secondary AMLYESYes -5, -7, del (5q), complex ktype YESYes t(4;11),t(5;11) t(6;11),t(10;11), t(9;22) NoYesNoYes t(7;12),12p t(6;9), t(8;16),t(16;21) YesNo Yes abn (3q),inv3,t(3:3), - 17,Abn 17p NoYesNo FLT3-ITD YES ( MRD+) Yes YES

12. FLT3-ITD:Allelic Ratio (AR)

13. AML outcome: leukemia, Host & Treatment MRD

14. AuthorTrial GroupNMRD level % Hazard ratio 95 % CI P value Multivariate Sievers 2003CCG 2941 & 2961 252> 0.54.82.8-8.4p <0.0001 independent Langebrake 2006AML BFM 98150> 0.12.01.0- 4.39 p=0.05 not independent Coustan-Smith 2003 Saint Judes AML 02 46> 0.13.79p 0.037 independent Results of MRD Studies in Paediatric AML

15. Impact OF MRD- COG studies

16. Probability of Relapse-free and Overall Survival According to MRD 94 children treated on MRC AML 12/DCOG ANLL 97 Independent of age, WCC, FLT3/ITD V.H.J. van Velden et al, 2010

17. Risk Stratification in 2015

18. COG 1031 risk stratification Low-Risk: Low-Risk: Inv(16), t(8;21), nucleophosmin (NPM) mutations, or CEBPA mutations with any MRD status. Standard-risk cytogenetics (defined by the absence of either low-risk or high-risk cytogenetic characteristics) with negative MRD at end of Induction I.

19. COG 1031 risk stratification High Risk: High Risk: High allelic ratio FLT3-ITD-positive with any MRD status. Monosomy 7 with any MRD status. del(5q) with any MRD status. Standard-risk cytogenetics with positive MRD at end of Induction I.

20. AML-BFM 2012

21. St Jude AML-08 Risk groups

23. Conventional Cytogentics & FISH Cytogentics Cytogentics

24. Molecular Cytogentics:

25. Impact on treatment

26. Induction Treatment Approach

27. CR & death rates in various Pediatric trials

28. DAT ADE MACEMidAC Allo BMT ABMT MRC AML 10 R1 ADE DAT DONOR NODONOR R2 NFT

29. MRC AML 12 R1 ADE MAE V RISK GROUP ASSIGNED ADE V MACE MidAC CLASPMidAC CLASPMidAC STANDARD + POOR Allo BMT CLASPAlloBMT MAE R2 DONOR NO DONOR R2 GOOD Mitoxantrone= Daunorubicin

30. MRC AML 15 Course 1 + LP Course 2 + LP Course 3 Course 4 Course 5 R ADE 3+10+5 ‘Good’, ‘Standard’ and ‘Poor’ risk without a donor in CR ADE 3+8+5 FLAG-IDA Risk group assessment CR R If no CR go to Relapse Protocol ‘Poor’ risk, but with a Matched donor and CR Ara-C 3 g/m 2 MACE Ara-C 3 g/m 2 MidAc E Sibling/UD allogeneic BMT R No further treatment Ara-C 1.5 g/m 2 R = Randomise E = Elect Non-APL Patients (At a later date there may be a further randomisation for Mylotarg at Course 1 and 3)

32. BFM 2004

33. St Jude AML02- Dose of AraC

34. Antharcycline dose intensity High dose Daunorubicin not tested in view of risk of cardiotoxicity High dose Daunorubicin not tested in view of risk of cardiotoxicity

35. Current approach

36. Post Induction regime

37. Number of courses

38. MRC AML 12 R1 ADE MAE V RISK GROUP ASSIGNED ADE V MACE MidAC CLASPMidAC CLASPMidAC STANDARD + POOR Allo BMT CLASPAlloBMT MAE R2 DONOR NO DONOR R2 GOOD 4 courses = 5 courses

39. MRC 15 Consolidation: MACE v Ara-C

40. CNS prophylaxis

41. St Jude AML-02: Impact of TIT.

42. Role of SCT?

43. AML-BFM 98 Intent-to-treat Analysis No donor HLA-id. donor OS Event-free survival No donor HLA-id. donor HR= standard +poor

44. AML 10 & 12 Survival from CR by Risk Group SCTNo SCT2P Value All patients57%65%0.3 Standard46%61%0.2 Poor28%47%0.2 Standard Poor 100 75 50 25 0 1 2 3 4 5 61 % 46% 47% 28% 0 1 2 3 4 5 100 75 2P = 0.2 49 10 49 240 No Allograft Allograft No Allograft Allograft Years from CR 2P = 0.2 50 25

45. BMT =480Chemotherapy = 893 Outcome%P value Favorable-risk disease Relapse21 300.06 Disease-free survival63610.58 Overall survival8373710.85 Intermediate-risk disease Relapse362654< 0.001 Disease-free survival5839< 0.001 Overall survival7062510.006 Poor-risk disease Relapse5367560.69 Disease-free survival33350.82 Overall survival3933350.80 Nonclassifiable Relapse32440.004 Disease-free survival52500.14 Overall survival60610.49 Risk Stratified Outcomes Comparing Matched Sibling BMT and Chemo Alone MRC 15% COG 40% with no cytogenetics Horan J, Journal of Clinical Oncology 2008, Vol 26, Issue 35

49. Role of Myelotarg

52. Role of TKIs Sorafinib- promising in FLT3-ITD mutated AML and some benefit in Non-mutated population Sorafinib- promising in FLT3-ITD mutated AML and some benefit in Non-mutated population

54. Heterogeneity within cytogenetic classes on GEP

55. Copy number Heatmap for Pediatric AML ( N-111)

56. Frequency of CNA & Mutations

57. Summary of AML Pathogenesis Less than 2.0 copy number per case ( ALL 7/case) Less than 2.0 copy number per case ( ALL 7/case) Deletion= amplification Deletion= amplification Recurrent focal lesion are rare Recurrent focal lesion are rare 30% with translocation had no CAN or point mutation 30% with translocation had no CAN or point mutation