Acute Myeloid Leukemia With Myelodysplasia-Related Changes: A New Definition

CAPN1 is a novel biomaker of patients with AML based on comprehensive analysis

Acute myeloid leukemia (AML) is a common hematologic malignancy in adults. Recent studies investigating the potential pathogenesis of AML have significantly advanced our understanding of this disease. While cytogenetics and molecular abnormalities are crucial for confirming chemotherapy response and long-term outcomes, there are additional potential therapeutic targets and prognostic factors. The CAPN1 gene, which encodes a large subunit of the ubiquitous enzyme calpain, has not been extensively studied in hematological diseases. In this study, we used data from the TCGA public database to perform a bioinformatic analysis and found that CAPN1 is differentially expressed in multiple cancers and is associated with an unfavorable prognosis in AML. We employed R software and websites such as David and STRING to conduct differential analysis, GO and KEGG analysis, and explore the correlation between CAPN1 and physiological processes and key pathways. Our findings suggest that CAPN1 is significantly associated with the structure of the extracellular matrix and receptor-ligand interactions, indicating its potential role in disease progression. Additionally, we used CYBERSORT and ssGSEA to analyze the immune environment of CAPN1 and found that it is associated with most immune components, particularly CD56 cells and neutrophils. In conclusion, CAPN1 is a key prognostic gene in AML that is significantly correlated with disease progression, clinical features, and immune invasion.

Acute myeloid leukemia with myelodysplasia-related changes and blasts of the mixed T/myeloid phenotype: a case report

A rare but clinically important diagnostic dilemma arises when cases meet the criteria for both acute myeloid leukemia with myelodysplasia-related changes (AML-MRC) and mixed phenotype acute leukemia, especially those that evolve from myelodysplastic syndrome. We describe a 56-year-old male patient who presented with cytopenias and was initially diagnosed with myelodysplastic syndrome with single lineage dysplasia. Nearly 1 year later, this patient progressed to acute leukemia, and his blast cells simultaneously expressed T-lymphoid and myeloid antigens. Cytogenetic analysis showed a 20q deletion, and next-generation sequencing showed mutations of ASXL1, NRAS, PHF6, RUNX1, TP53, and PIGA. He was diagnosed with AML-MRC with blasts of the mixed T/myeloid phenotype according to the latest World Health Organization guidelines. In accordance with the treatment principles of AML-MRC, we chose an AML-like regimen for four cycles, but the patient did not achieve remission. Finally, we adhered to the treatment principles of mixed phenotype acute leukemia, and he achieved remission after a course of ALL-like regimen chemotherapy.

Advances in acute myeloid leukemia

Acute myeloid leukemia (AML) is an uncommon but potentially catastrophic diagnosis with historically high mortality rates. The standard of care treatment remained unchanged for decades; however, recent discoveries of molecular drivers of leukemogenesis and disease progression have led to novel therapies for AML. Ongoing research and clinical trials are actively seeking to personalize therapy by identifying molecular targets, discovering patient specific and disease specific risk factors, and identifying effective combinations of modalities and drugs. This review focuses on important updates in diagnostic and disease classifications that reflect new understanding of the biology of AML, its mutational heterogeneity, some important genetic and environmental risk factors, and new treatment options including cytotoxic chemotherapy, novel targeted agents, and cellular therapies.

Older adults with newly diagnosed high-risk/secondary AML who achieved remission with CPX-351: phase 3 post hoc analyses

CPX-351, a dual-drug liposomal encapsulation of daunorubicin/cytarabine in a synergistic 1:5 molar ratio, is approved for the treatment of adults with newly diagnosed, therapy-related acute myeloid leukemia (t-AML) or AML with myelodysplasia-related changes (AML-MRC). In a pivotal phase 3 study, patients aged 60 to 75 years with newly diagnosed, high-risk/secondary AML were randomized to receive CPX-351 or conventional 7+3 chemotherapy. In the primary endpoint analysis, CPX-351 demonstrated significantly prolonged median overall survival (OS) vs 7+3. These exploratory post hoc subgroup analyses evaluated the impact of achieving complete remission (CR) or CR with incomplete neutrophil or platelet recovery (CRi) with CPX-351 (73/153 [48%]) vs conventional 7+3 (52/56 [33%]) on outcomes. CPX-351 improved median OS vs 7+3 in patients who achieved CR or CRi (25.43 vs 10.41 months; hazard ratio = 0.49; 95% confidence interval, 0.31, 0.77). Improved median OS was seen across AML subtypes (t-AML, AML-MRC), age subgroups (60 to 69 vs 70 to 75 years), patients with prior hypomethylating agent exposure, and patients who did not undergo transplantation. Patients who achieved CR or CRi with CPX-351 also had a higher rate of transplantation, a longer median OS landmarked from the date of transplantation (not reached vs 11.65 months; hazard ratio = 0.43; 95% confidence interval, 0.21, 0.89), and a safety profile that was consistent with the known safety profile of 7+3. These results suggest deeper remissions may be achieved with CPX-351, leading to improved OS. This study was registered at www.clinicaltrials.gov as #NCT01696084.

Diagnosis and Treatment of Patients With Acute Myeloid Leukemia With Myelodysplasia-Related Changes (AML-MRC)

Objectives

Acute myeloid leukemia (AML) with myelodysplasia-related changes (AML-MRC) represents a high-risk and somewhat diverse subtype of AML, and substantial confusion exists about the pathologic evaluation needed for diagnosis, which can include the patient’s clinical history, cytogenetic analysis, mutational analysis, and/or morphologic evaluation. Treatment decisions based on incomplete or untimely pathology reports may result in the suboptimal treatment of patients with AML-MRC.

Methods

Using a PubMed search, diagnosis of and treatment options for AML-MRC were investigated.

Results

This article reviews the current diagnostic criteria for AML-MRC, provides guidance on assessments necessary for an AML-MRC diagnosis, summarizes clinical and prognostic features of AML-MRC, and discusses potential therapies for patients with AML-MRC. In addition to conventional chemotherapy, treatment options include CPX-351, a liposomal encapsulation of daunorubicin/cytarabine approved for treatment of adults with AML-MRC; targeted agents for patients with certain mutations/disease characteristics; and lower-intensity therapies for less fit patients.

Conclusions

Given the evolving and complex treatment landscape and the high-risk nature of the AML-MRC population, a clear understanding of the pathology information necessary for AML-MRC diagnosis has become increasingly important to help guide treatment decisions and thereby improve patient outcomes.

Genetic Factors in Acute Myeloid Leukemia With Myelodysplasia-Related Changes

OBJECTIVES

Acute myeloid leukemia with myelodysplasia-related changes (AML-MRC) is a heterogeneous category with a broad range of underlying genetic abnormalities. We investigated the significance of genetic factors in a large series of AML-MRC cases.

METHODS

The morphologic findings, genetic data, and patient outcomes were assessed in 186 AML-MRC cases.

RESULTS

The median overall survival (OS) was dismal in AML-MRC patients (median, 7.6 months; 95% confidence interval, 5-10.6 months). Karyotypically normal cases and cytogenetically abnormal cases without myelodysplastic syndrome (MDS)-related cytogenetic abnormalities showed similar OS, significantly better than cases carrying MDS-related cytogenetic abnormalities. MDS-related cytogenetic abnormalities, monosomal or complex karyotype, and history of MDS or myelodysplastic/myeloproliferative neoplasm were all associated with dismal outcome.

CONCLUSIONS

AML-MRC predicts a poor prognosis. Our study supports the finding that the genetic profile plays a key role in determining prognosis in AML-MRC as defined according to the World Health Organization revised fourth edition (2017) diagnostic criteria.

Secondary Acute Myeloid Leukemia: A Primary Challenge of Diagnosis and Treatment

Secondary acute myeloid leukemia (sAML) is a complex diagnosis that includes AML caused by either an antecedent hematologic disease (AML-AHD) or from previous treatment with chemotherapy or radiation. This disease carries a poor prognosis and is historically chemorefractory; additionally, often patients are ineligible for standard chemotherapy because of advanced age and other comorbidities. The advances of molecular diagnostics and reclassification of World Health Organization criteria have aided in the categorization of this disease. This article describes the etiology and pathophysiology of sAML, and delves into past successful treatments as well as promising new treatments.

[The clinical analysis of haploidentical stem cell transplantation in myelodysplastic syndrome-associated acute myeloid leukemia]

Objective: To investigate the prognosis of haploidentical hematopoietic stem cell transplantation (haplo-HSCT) in the treatment of acute myeloid leukemia with myelodysplasia-related changes (AML-MRC). Method: The data of 102 patients with high-risk AML in the first complete remission phase (CR1) who received haplo-HSCT from January 2009 to July 2015 in Peking University People's Hospital were retrospectively analyzed. Results: These 102 cases included 17 AML-MRC cases (AML-MRC group) and 85 other types of AML cases (control group). There were 8 males and 9 females in the AML-MRC group, and the median age was 35 (17-61) years. There were 52 males and 33 females in other high-risk AML group, and the median age was 31 (11-60) years. No difference was observed between the two groups after haploidentical stem cell transplantation in the rates of cytomegalovirus, EBV (Epstein-Barr virus), blood flow infection rate and hematopoietic reconstitution (P>0.05). The overall 2-year survival rate after transplantation was 80.8% (95%CI 51.6%-93.4%) and 72.5% (95%CI 62.8%-80.1%) (P=0.650), the disease-free survival rate was 79.4% (95%CI 48.8%-92.9%) and 65.9% (95%CI 54.3%-75.2%) (P=0.573), cumulative recurrence rate was 13.0%(95%CI 1.9%-34.7%) and 13.3%(95%CI 7.0%-21.5%) (P=0.623), and non-relapse mortality was 6.7% (95%CI 0.3%-27.0%) and 20.0% (95%CI 12.0%-29.4%) (P=0.436). Conclusion: The prognosis of haplo-HSCT in patients with AML-MRC in CR(1) is similar to that of other types of high-risk AML patients. Haplo-HSCT is an ideal choice for patients with AML-MRC in CR(1).

Accidental diagnosis: Aeromonas infection leading to discovery of acute myeloid leukemia with meylodysplastic syndrome

PATIENT

47-year-old African American man.

CHIEF COMPLAINT

Initially, serious finger abscess. The patient reported severe pain that was localized to that finger only.

HISTORY OF PRESENT ILLNESS

His finger had become sore and then progressively more painful and swollen.

PAST MEDICAL HISTORY

A few weeks earlier, the patient had had a similar abscess on his leg; he could not recall any specific injuries other than this. He had a past history of epilepsy that is totally unrelated to this case; he had not had any episodes in more than 10 years. Otherwise, the medical history of the patient was relatively healthy: he is a nonsmoker with no history of diabetes or steroid use.

SOCIAL HISTORY

Patient washed cars for a living.

FAMILY HISTORY

Noncontributory.

PHYSICAL EXAMINATION

Initially, the patient was sent home with a course of antibiotics (cephalexin and trimethoprim/sulfamethoxazole) and was asked to return to the hospital for follow up within two days. By the time of the follow-up visit, the antibiotic treatment had been unsuccessful, and the patient experienced more pain in the finger; the flesh of the finger was becoming black and necrotic. The patient tested positive for all myeloid markers: myeloperoxidase (MPO), CD34, CD33, CD13, CD45, human leukocyte antigen–DR subregion (HLA-DR), CD15, and CD11c. Trilinear dysplasia was indicated by the results of bone-marrow studies and peripheral blood smear testing.