General

1
Leukemia Translational Research In Clinical
Oncology (TRACO) Course
Alan S. Wayne, M.D. Clinical Director, Pediatric
Oncology Branch National Cancer
Institute National Institutes of Health
2
Leukemia

• Leuk-emia White Blood (Virchow 1847)
• Acute rapid proliferation
• Chronic slow proliferation

• Acute Lymphoblastic Leukemia - ALL
• Acute Myelogenous Leukemia - AML

• Chronic Lymphocytic Leukemia - CLL
• Chronic Myelogenous Leukemia - CML

3
Normal Hematopoiesis
CD34, CD38-
( ) Hematopoietic Stem Cell
Modified from Dick ASH Education Program Book,
2001
4
Leukemic Transformation
CML ?
ALL ?
CLL ?
Modified from Dick ASH Education Program Book,
2001
5
5 year-old with ALL Diagnostic Evaluation

• Bone marrow
• Replaced with lymphoblasts
• Flow cytometry
• B-precursor phenotype CD10, CD19, Tdt, HLA-DR

6
5 year-old with ALL Diagnostic Evaluation

• Bone marrow
• Replaced with lymphoblasts
• Flow cytometry
• B-precursor phenotype CD10, CD19, Tdt, HLA-DR

• Chromosomes
• DNA index 1.15
• Hyperdiploid (52-54,X,4,6,10,17,21)

7
Leukemia Incidence in the USA

• Acute Leukemias
• Most common pediatric cancer
• 1 cause of cancer death lt35 years

Chronic Leukemias Most common adult leukemias
ALL 4,000 cases/year
CLL 10,000 cases/year

• AML
• 9,000 cases/year

CML 5,000 cases/year
8
Leukemia Incidence in the USA
(CLL, CML)
9
Incidence ALL AML
10
ALL Sites of Involvement

• Bone Marrow (100)
• Anterior Mediastinal Mass (10)
• Central Nervous System (5)
• Testes (2)
• Other Ocular, Epidural, Skin (Leukemia Cutis),
  Tonsils/Adenoids, Heart/Pericardium, Lungs,
  Liver, Kidney, Bladder, Breast, Ovary, Priapism,
  Appendix, Salivary Gland (Mikulicz Syndrome)

11
Acute Lymphoblastic Leukemia Presentation

• Symptoms and Signs
• 68 Hepatosplenomegaly
• 60 Fever
• 50 Fatigue
• 50 Lymphadenopathy
• 40 Bleeding
• 40 Bone or Joint Pain
• 20 Anorexia
• 10 Abdominal Pain

12
Acute Lymphoblastic Leukemia Laboratory Findings

• White Blood Cell Count (/mm3)
• lt 10,000 50
• 10,000-50,000 30
• 50,000-100,000 10
• gt 100,000 10
• Absolute Neutrophil Count (/mm3)
• lt 500 40
• Platelet Count (/mm3)
• lt 20,000 25
• 20,000-100,000 50
• gt 100,000 25
• Hemoglobin (g/dl)
• lt 7 40
• gt 10 20

13
Leukemia Pathogenesis

• Environmental
• Ionizing radiation
• Toxins
• Infectious (eg, HTLV-I, EBV)
• Immunodeficiency Syndromes (eg, AT, SD)
• Genetic
• Familial (eg, twin concordance, Li-Fraumeni)
• Congenital chromosomal (eg, Trisomy 21,
  instability syndromes)
• Acquired chromosomal

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Chromosomal Translocations in Leukemia

• CML
• t(922) BCR/ABL

• ALL
• t(1221) TEL/AML1
• t(119) E2A/PBX1
• 11q23 MLL
• t(922) BCR/ABL
• Mature B-Cell
• t(814) c-myc/IgH
• t(28) c-myc/Ig?
• t(822) c-myc/Ig?
• T-Cell
• 14q TCR-?/?
• 7q TCR-?

• AML
• t(821) AML1/ETO
• inv(16) MYH11/CBFB
• t(1517) PML/RAR? t(1117) PLZF/RAR? 7-, 7q-
• 11q23 MLL

• CLL
• t(1418) BCL2
• t(1419) BCL3
• 13q-

15
Numeric Chromosomal Changes in Childhood ALL
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Molecular Basis of Cancer

• Two classes of oncogenes
• Proto-oncogenes
• positive regulators of cell growth
• over expression ? tumorigenesis
• dominant oncogenes (require only 1 allele)
• Tumor suppressor genes
• negative regulators of cell growth
• loss of function ? tumorigenesis
• recessive oncogenes (require loss of both
  alleles)

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Molecular Basis of Leukemia

• Hyperdiploidy
• Gain of chromosomes, genes, function
• Hypodiploidy
• Loss of chromosomes, genes, function
• Deletion or Inactivation of Tumor Suppressor
  Genes
• Translocations
• Fusion genes
• Transformation
• Dysregulation of gene function (increase,
  decrease)

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t(922) Translocation and Leukemia
Ph Leukemia
19
t(1517) Translocation and APML
Modified from Grignani et al Nature 1998 391815
20
Greaves Blood 2003
21
Concordant acute leukemia in monozygotic
twins1984-2002
Greaves Blood 2003
22
Childhood ALL Treatment History

• 1865 Fowlers solution (arsenic)
• 1903 Irradiation
• 1943 Nitrogen mustard
• 1947 Farber folic acid ? antimetabolites
• 1949 Farber ACTH ? corticosteroids
• 1955 Pediatric oncology cooperative groups
• 1964 5-year disease-free survival (DFS) 3
• 1970 5-year DFS 50

23
Survival of Children with ALL St. Jude
Childrens Research Hospital, 1962-1997
Pui C-H, Evans WE NEJM, 1998
24
ALL Treatment Phases

• 1. Induction
• 2. Central Nervous System Prophylaxis
• 3. Consolidation
• 4. Maintenance

25
5-Year Survival of Children with ALLUSA,
1975-1994
Data from Ries NCI, SEER Program, NIH, 1999
26
Childhood ALL Cytogenetic Risk Groups
Pui C-H, Evans WE NEJM, 1998
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Pre-B ALL Prognostic Factors

• Lower Risk Higher Risk
• Age 1-9 years lt 1, gt 10 years
• WBC lt 50,000/mm3 gt 50,000/mm3
• CNS Negative Positive
• Chromosomes t(1221), T-10, T-4 t(922), 11q23,
  t(119)
• DNA Index gt1.16 lt 1.16
• Response Rapid Slow

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Relapsed Childhood ALLBMT vs. Chemotherapy
Barrett et al NEJM, 1994
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GVHD decreases the risk of relapse after
BMT(Acute leukemia in relapse)
Sullivan et al Blood, 1989
30
AML Treatment Phases

• Induction/Reinduction (70-85 CR)
• Dose intensity vs. Intensive timing
• Supportive care (3-9 Mortality)
• CNS Sterilization/Prophylaxis
• Intensification/Consolidation

31
AML Post-Remission Chemotherapy vs. BMT CCG 2891
Woods Blood, 2001
32
Acute Myelogenous Leukemia Chemotherapy vs. BMT
Zittoun New Engl J Med , 1995
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Acute Myelogenous Leukemia Chemotherapy vs. BMT
Zittoun New Engl J Med , 1995
34
AML Prognostic Factors

• Lower Risk Higher Risk
• Age gt 1, lt 60 years lt 1, gt 60 years
• WBC lt 100,000/mm3 gt 100,000/mm3
• CNS Negative Positive
• Chromosomes t(821), inv 16, t(1517) t(922),
  11q23, -7, -5
• Trisomy 21 Flt3/ITD, Secondary
• FAB M1, M2, M3 infant M4/5, M6, M7
• Response Rapid Slow

35
5-Year Survival of Children with AMLUSA,
1975-1994
Data from Ries NCI SEER Program, NIH, 1999
36
CMLBone Marrow Transplantation
(IFN?)
Modified from Radich ASH Education Program Book,
2002
37
Late Complications of Leukemia Therapy

• Endocrinopathies
• Neurodevelopmental Dysfunction
• Secondary Malignancy
• Cardiomyopathy
• Pulmonary Dysfunction
• Avascular Necrosis

38
Molecularly-Targeted Anticancer Drugs
Drugs that produce their effect through
interaction with cellular macromolecules (e.g.,
proteins) that contribute to malignant
transformation

• Signal transduction pathways (bcr-abl, ras, EGFR)
• Apoptotic pathways (bcl-2)
• Cell cycle regulatory proteins (p53)
• Differentiation pathways (retinoids)

39
Bcr/Abl Tyrosine Kinase Inhibitor in Ph Leukemia
Ph Leukemia
40
CMLImatinib Therapy
Modified from Hughes ASH Education Program Book,
2003
41
CMLImatinib Therapy
(IFN?)
Modified from Apperley ASH Education Program
Book, 2003
42
Retinoic Acid for APMLMechanism of Action
Modified from Grignani et al Nature 1998 391815
43
Leukemia Genotype
Armstrong et al Nature Genetics 2002 3041
44
FLT3 Mutations
Modified from Griffin ASH Education Program
Book, 2003
45
Childhood AML Risk Groups
Meshinchi, Blood, 2001
46
Leukemia New Therapeutic Modalities

• Oncogene inactivation
• Tyrosine kinase inhibitors
• Signal transduction inhibition
• Farnesyltransferase inhibitors
• Antisense oligonucleotides
• Gene therapy (tumor suppressors)
• Immunotherapy
• Monoclonal antibodies
• Tumor vaccines
• Allogeneic cell infusion
• Cytokines

47
Monoclonal Antibody Therapy
48
CLLAnti-CD20 MoAb Therapy
Modified from Keating ASH Education Program
Book, 2003
49
CLL Anti-CD20 MoAb Therapy
Modified from Keating ASH Education Program
Book, 2003
50
Conjugated Monoclonal Antibodies Immunotoxins
Anti-CD25 (LMB2)
Anti-CD22 (BL22)
Modified from Reiter, Pastan TIBTECH 199816513
51
NCI Phase I Trial of Anti-CD22 Immunotoxin (BL22)
for Adults with CD22 Leukemias and Lymphomas

• Response Rate
• 21/28 (75)
• 17 Complete (Hairy Cell Leukemia)
• 4 Partial
• Kreitman et al. N Engl J Med 345241-247, 2001

52
Cellular Immunotherapy
17-year-old with chronic myelogenous leukemia
(CML)
Relapse after sibling donor BMT
Remission after donor lymphocyte infusions

• Therapeutic graft-vs-leukemia (GVL) effect

53
Wilms Tumor 1 (wt1) GeneVaccine Target in Human
Leukemias
wt1 Gene 11p13
Tumor suppressor in Wilms Dominant oncogene in
leukemias, solid tumors
WT1 Protein Limited expression beyond
embryogenesis HLA-restricted CTL against WT1
oligomers High expression in heme malignancies