Search

Chemotherapy produces extended remissions, and potential cures, in a small minority of patients with acute myeloid leukemia (AML). We explored whether potentially cured patients were at increased risk of subsequent invasive cancer and were able to return to work. Potentially cured patients were defined as those in first or second complete remission (CR) for at least 3 years based on hazard rates for recurrence or death in CR, which declined sharply after this time. Patients who received allogeneic marrow transplant were excluded. We used questionnaires, phone contact, and chart review to obtain information about subsequent cancer and work status. The number of patients who developed invasive cancer was compared with the number expected based on age, gender, and years of follow-up using the Connecticut Tumor Registry. A total of 215 patients met our criteria for potential cure: 203 in first CR and 12 in second CR (of 1,663 treated between 1965 and December, 1992). At a median of 9.2 years from first or second CR, 163 (76%) remain alive in CR. Fifteen patients developed 18 invasive cancers (expected number of patients, 8.8; observed/expected, 1.70; 95% CI, 0.96 to 2.84; P = .06). Patients initially treated between 1973 to 1979, patients above the potentially cured cohort's median age of 40 years, and those who presented with abnormalities of chromosomes 5 and/or 7 were more likely to develop subsequent cancer, whereas the observed/expected ratio for younger patients was 1.05 (95% CI, 0.13 to 3.80; P = .56). Seventy-four percent of the patients who were working full-time and who were under age 50 at time of treatment for AML have been working full-time in the last 6 months. Only 17 of 56 patients who are currently not working cited physical limitation as the reason. Patients with potentially cured AML are likely to be able to return to work, and at least if younger do not, on average, have an increased risk of invasive cancer.

We performed a meta-analysis of 3 genome-wide association studies to identify additional common variants influencing chronic lymphocytic leukemia (CLL) risk. The discovery phase was composed of genome-wide association study data from 1121 cases and 3745 controls. Replication analysis was performed in 861 cases and 2033 controls. We identified a novel CLL risk locus at 6p21.33 (rs210142; intronic to the BAK1 gene, BCL2 antagonist killer 1; P = 9.47 × 10−16). A strong relationship between risk genotype and reduced BAK1 expression was shown in lymphoblastoid cell lines. This finding provides additional support for polygenic inheritance to CLL and provides further insight into the biologic basis of disease development.

Success of tyrosine kinase inhibitors (TKIs) in chronic myeloid leukemia (CML) has given patients hope for a long disease-free-survival. A longer survival raises the question of late effects, including development of another malignancy. Records of 1445 patients with CML/myeloproliferative neoplasm or other hematologic malignancies treated with TKIs were reviewed to investigate frequency and characteristics of second malignancies (other than acute myeloid leukemia, acute lymphocytic leukemia, or myelodysplastic syndrome). The number of second cancers was compared with the number expected from the Surveillance, Epidemiology, and End Results database. After a median follow-up of 107 months (range, 13-362 months) after CML/myeloproliferative neoplasm diagnosis, 66 patients (4.6%) developed 80 second cancers, including skin (31%), prostate (15%), melanoma (13%), digestive system (10%), kidney (4%), thyroid (4%), breast (3%), chronic lymphocytic leukemia (3%), hepatobiliary (3%), and other cancers (14%). Excluding nonmelanoma skin cancers, 55 second cancers were seen in 51 (3.5%) of all patients treated. The risk of second cancer was lower than expected (observed-to-expected ratio, 0.6; 95% confidence interval, 0.44-0.81). Second cancers occur in a small percentage of patients receiving therapy with TKIs for hematologic malignancies, mostly CML. No evidence at the moment suggests that exposure to TKIs increases the risk of developing second cancers.

Prior genome-wide association (GWA) studies have identified 10 susceptibility loci for risk of chronic lymphocytic leukemia (CLL). To identify additional loci, we performed a GWA study in 407 CLL cases (of which 102 had a family history of CLL) and 296 controls. Moreover, given the strong familial risk of CLL, we further subset our GWA analysis to the CLL cases with a family history of CLL to identify loci specific to these familial CLL cases. Our top hits from these analyses were evaluated in an additional sample of 252 familial CLL cases and 965 controls. Using all available data, we identified and confirmed an independent association of 4 single-nucleotide polymorphisms (SNPs) that met genome-wide statistical significance within the IRF8 (interferon regulatory factor 8) gene (combined P values ≤ 3.37 × 10−8), located in the previously identified 16q24.1 locus. Subsetting to familial CLL cases, we identified and confirmed a new locus on chromosome 6p21.3 (combined P value = 6.92 × 10−9). This novel region harbors the HLA-DQA1 and HLA-DRB5 genes. Finally, we evaluated the 10 previously reported SNPs in the overall sample and replicated 8 of them. Our findings support the hypothesis that familial CLL cases have additional genetic variants not seen in sporadic CLL. Additional loci among familial CLL cases may be identified through larger studies.

Reporting of myelodysplastic syndromes (MDSs) and chronic myeloproliferative disorders (CMDs) to population-based cancer registries in the United States was initiated in 2001. In this first analysis of data from the North American Association of Central Cancer Registries (NAACCR), encompassing 82% of the US population, we evaluated trends in MDS and CMD incidence, estimated case numbers for the entire United States, and assessed trends in diagnostic recognition and reporting. Based on more than 40 000 observations, average annual age-adjusted incidence rates of MDS and CMD for 2001 through 2003 were 3.3 and 2.1 per 100 000, respectively. Incidence rates increased with age for both MDS and CMD (P < .05) and were highest among whites and non-Hispanics. Based on follow-up data through 2004 from the Surveillance, Epidemiology, and End Results (SEER) Program, overall relative 3-year survival rates for MDS and CMD were 45% and 80%, respectively, with males experiencing poorer survival than females. Applying the observed age-specific incidence rates to US Census population estimates, approximately 9700 patients with MDS and 6300 patients with CMD were estimated for the entire United States in 2004. MDS incidence rates significantly increased with calendar year in 2001 through 2004, and only 4% of patients were reported to registries by physicians' offices. Thus, MDS disease burden in the United States may be underestimated.

To the editor: The recent article by Negro et al represents a thorough investigation into the effect of Lyp, the gene product of PTPN22 , on BCR signaling in the pathogenesis and progression of chronic lymphocytic leukemia (CLL).[1][1] This study shows that increased Lyp enhances Akt, a serine/

Introduction. The clinical course of chronic lymphocytic leukemia (CLL) is mostly indolent. About one third of the patients are managed with lifelong watch-and-wait (WW) and those who receive therapy often achieve a durable remission. As a result, the majority of patients with CLL will live with their disease for long periods of time, and be exposed to several complications, including the occurrence of other cancers (OC). Patients with CLL may have an increased incidence in OC. Published reports indicate an incidence of 3-27%, mostly in treated patients, however, very little is known on OC in patients with CLL not requiring therapy. Furthermore, observation time in published studies is limited to Methods. We reviewed our database and identified all patients with CLL untreated at the time of referral. We selected long-term survivors (LTS), defined as patients with a follow-up ≥10 years, and analyzed the incidence and prognostic impact of OC in this population. Non-melanoma skin cancers were excluded since these were diagnosed and treated promptly in virtually all cases and felt not to have prognostic impact. Standardized incidence ratios (SIR) were calculated for OC occurring after the diagnosis of CLL that were reportable to the Surveillance, Epidemiology and End Results program.The estimated overall survival (OS) according to the presence of OC was plotted considering OC as a time-dependent covariate. Results. We identified 797 LTS of CLL seen at our institution between 1957 and 2003. Median age was 56 years (24-88). 57% of patients were males. Median follow-up for the entire population is 154 months (120-485). We recorded 383 OC in 286 (36%) patients. 76/286 (26%) patients had >1 OC (62 had 2 OC, 10 had 3, 2 had 4, 1 had 5 and 1 had 6).The firstOC preceded or was diagnosed concomitantly with CLL in 100 patients (35%), while in the remaining 186 (65%) it occurred later during the course of the disease. 570 patients (71%) required treatment for CLL. Median time to treatment was 18 months (0-454). In treated patients, the cumulative frequency of OC was 205/570 (36%) and in WW patients 81/227 (36%). The SIR for all OC was 1.2 (p = .034). Males and patients younger than 60 years had a significantly higher incidence of OC (SIR 1.31 and 1.27, respectively). Among OC types, secondary leukemia, melanoma and head and neck cancers had the highest observed-to-expected ratio. Surprisingly, lung, digestive tract, and bladder cancer had a lower-than-expected incidence (table). 474 patients (59%) are alive. 222/570 (39%) treated patients and 101/227 (44%) WW patients have died. The median OS was longer in patients without OC (279 months) vs. those with OC (189 months). Independent predictors of shorter survival in multivariate analysis included higher creatinine, the presence of OC, and older age. Discussion. This is the first study to address the incidence of OC in LTS of CLL, including WW patients. In our population, the frequency of OC is similar in treated and WW patients. Although the incidence of OC in LTS of CLL is higher compared to matched general population, the incidence of lung, digestive and bladder cancer is lower than expected. Reasons of this finding remain to be identified.The occurrence of OC is an independent predictor of shorter survival, thus constituting a relevant competing risk of mortality in LTS of CLL. Variable Observed Expected Person-years SIR (O/E) 95% CI for O/E P -value Overall 148 123.34 10956 1.20 1.01 – 1.40 0.034 Male 96 73.4 5885 1.31 1.06 – 1.58 0.013 Female 52 49.93 5071 1.04 0.78 – 1.36 0.67 Age ≥60 years 60 54.33 3416 1.10 0.84 – 1.42 0.44 Age Disclosures No relevant conflicts of interest to declare.

Introduction: Patients who receive chemotherapy and/or radiation therapy for breast cancer (BCA) are at risk for developing therapy-related myeloid neoplasms (t-MN). In fact, BCA is one of the most common malignant solid tumors among patients with t-MN. Nonetheless, the association between t-MN features and the demographic, biologic, and therapeutic characteristics of patients with BCA remain poorly characterized. The aim of this study was to assess the factors associated with t-MN in BCA patients and determine the features and outcomes of t-MN in this patient group. Methods: We conducted a retrospective analysis of BCA patients who developed t-MN seen at The University of Texas M.D. Anderson Cancer Center between January 1997 and April 2013. As defined in the current WHO classification, t-MN includes therapy-related acute myeloid leukemia (t-AML), myelodysplastic syndrome (t-MDS), and myelodysplastic/myeloproliferative neoplasms (t-MDS/MPN). The study inclusion criteria included receipt of neoadjuvant or adjuvant chemotherapy and/or radiation therapy for BCA with subsequent development of t-MN. Results: All patients (n=150) were women with a median age of 57 years (range, 26-79 years) at the time of BCA diagnosis (64 at time of t-MN; range, 29-84 years). At presentation with BCA, stage ranged from 0 to 3. In addition to surgery, 93 (62%) patients were treated with combination chemotherapy and radiation therapy, 30 (20%) with radiation therapy alone, and 27 (18%) with chemotherapy alone. The median interval between BCA and t-MN was 57 months (range, 8-374 months); 54 months and 57 months respectively for patients who received chemotherapy alone or radiation therapy alone. At the time of t-MN diagnosis, 90 (60%) patients had t-AML, 56 (37%) t-MDS, and 4 (3%) t-MDS/MPN. Among patients with t-MDS and t-MDS/MPN, 26 (22%) developed t-AML after a median of 13.9 months (range, 2.3-69.6 months). Notably, development of t-MN among patients with BCA was associated with a body-mass index Conclusions: Patients with BCA who have a BMI Disclosures No relevant conflicts of interest to declare.

Introduction Tyrosine kinase inhibitors (TKIs) are effective treatments for chronic myeloid leukemia in chronic phase (CML-CP) in terms of response rates and clinical outcomes including overall survival (OS). The purpose of this study was to compare OS in each age group with newly diagnosed CML-CP compared to that of general population in the same age group in the era of multiple TKIs. Methods Response and survival data for 483 patients (pts) with newly diagnosed CML-CP who enrolled in five consecutive or parallel prospective clinical trials of imatinib at a dose of 400 mg or 800 mg daily, imatinib at a dose of 800 mg with pegylated interferon, dasatinib, or nilotinib were analyzed. The pts were divided into groups by age at diagnosis, as follows: 15-45 years; 45-65 years; 65-85 years; over 65 years. All pts, regardless of age, were divided into the following response groups within 1 year of treatment: complete cytogenetic response (CCyR); major molecular response (MMR); MR4.5 defined as more than or equal to 4.5 log reduction of BCR-ABL on the international scale; or complete molecular response (CMR). Pts also were assessed for OS, event-free survival (EFS), transformation-free survival (TFS), and failure-free survival (FFS). OS was dated from the start of therapy until death from any cause at any time. EFS was calculated from the start of therapy to loss of complete hematologic response, loss of major cytogenetic response, transformation to accelerated (AP) or blast phase (BP), or death from any cause during study therapy. TFS was calculated from the start of therapy to transformation to AP or BP, or death during study therapy. FFS was calculated from the start of imatinib, dasatinib or nilotinib to an event (as defined above), discontinuation for any reason, or death. The Kaplan-Meier method was used to calculate OS, EFS, TFS, and FFS. A log-rank test was used for univariate comparisons. Pvalues of less than 0.05 were considered statistically significant. Five-year relative survival rates were calculated from the five-year absolute OS divided by the estimated five-year OS in the general population. Estimated OS rates in the U.S. general population were obtained from national vital statistics reports for the year 2009. Results Of the 483 pts analyzed in the study, 271 were treated with imatinib, 101 with nilotinib, and 111 with dasatinib. The age breakdown was as follows: 15-45 years, 197 pts; 45-65 years, 222 pts; 65-85 years, 64 pts; over 65 years, 64 pts. No pts older than 85 years were enrolled in this study. Sokal risk score at diagnosis, and type of TKI treatment were analyzed by age group, cumulative best response, and five-year OS, EFS, TFS, and FFS, and the results are summarized in Table 1. Five-year OS in the general population, relative five-year OS in all age groups, and relative five-year OS by response group are also described in Table 1. As expected, 5-year OS decreased with increasing age groups, but for all age groups OS was similar to 5-year OS in the corresponding age group in the general population. 5-year OS in pts of ages 15-85 who achieved CCyR or better was similar to that in the general population. Conclusion In the era of TKIs, the OS rates in pts with newly diagnosed CML-CP in all age groups are only slightly lower to that of general population. However, the OS rates in pts who achieved CCyR or better within 1 year of treatment is similar to that of general population. Table 1. Patient Characteristics and Outcomes by Age Group Age 15-45 [n= 197] No. (%) Age 45-65 [n= 222] No. (%) Age 65-85 [n= 64] No. (%) P Sokal Risk Score .419 Low 129 (65) 158 (71) 48 (75) Intermediate 56 (28) 48 (22) 12 (19) High 12 (6) 16 (7) 4 (6) Type of TKIs .364 Imatinib 113 (57) 116 (52) 42 (66) Nilotinib 42 (21) 50 (23) 9 (14) Dasatinib 42 (21) 56 (25) 13 (20) Cumulative Best Response CMR 91 (46) 124 (56) 33 (52) .142 MR4.5 127 (64) 158 (71) 47 (73) .230 MMR 162 (82) 197 (89) 54 (84) .162 CCyR 171 (87) 208 (94) 59 (92) .048 5-y Outcome (%) FFS 77.9 74.5 60.6 .043 TFS 93.8 93.4 87.4 .224 EFS 81.0 89.2 78.9 .094 OS 96.2 93.5 80.1 < .001 5-y Absolute OS 5-y Relative OS 5-y OS in General Population Age Group (%) Ages 15-45 96.2 96.9 99.3 Ages 45-65 93.5 97.1 96.3 Ages 65-85 80.1 97.1 82.5 Ages 15-85 92.7 98.2 94.4 Ages 15-85 by Response (%) CCyR within 1 year 97.3 103.1 94.4 MMR within 1 year 97.9 103.7 94.4 MR4.5 within 1 year 97.1 102.9 94.4 CMR within 1 year 96.7 102.4 94.4 Disclosures Jabbour: Ariad, Novartis, BMS, Pfizer, and Teva : Consultancy. Kantarjian:ARIAD, Pfizer, Amgen: Research Funding.

Multiple myeloma (MM) is 2-3 times more common among African-Americans compared to non-Hispanic whites. The 2-3-fold increased risk among family members of cases suggests a genetic contribution to risk. Genome-wide association studies (GWAS) in populations of European ancestry have identified seven novel risk loci at 2p23.3 (rs6746082), 3q26.2 (rs10936599), 3p22.1 (rs1052501), 6p21.32 (rs2285803), 7p15.3 (rs4487645), 17p11.2 (rs4273077) and 22q13.1 (rs877529) (Broderick, et al. Nat Genet, 2011, Chubb, et al. Nat Genet, 2013), three of which were replicated in another European series (Martino et al., Br J Haematol, 2012). Here we examined the index signals and conducted fine-mapping for each locus in a case-control study of 1,049 multiple myeloma cases and 7,084 controls of African ancestry to identify better markers of risk and novel independent loci in seven previously reported regions in this high risk population. Incident cases were recruited from 10 clinical centers and SEER cancer registries from 2011 to 2013 and genotyped using the Illumina HumanCore GWAS array. Control data were obtained from previous genome-wide studies of breast and prostate cancer, genotyped using the Illumina 1M-Duo in 4425 male controls from the African Ancestry Prostate Cancer Consortium (consisting of 14 independent studies) and 2632 female controls from a breast cancer GWAS of African-American women (consisting of 9 independent studies). Imputation to 1000 Genomes (March 2012 release) was conducted for regions around six of the previously identified single nucleotide polymorphisms [SNPs] (the HLA region harboring rs2285803 is still being imputed, results will be presented). A case-control analysis of SNPs/indels >1% frequency within 250 kb of each index variant was conducted using unconditional multivariable logistic regression adjusting for age, sex and five leading principal components. Region-specific alpha levels were determined through permutation tests. The minimum alpha level across the six regions was α=0.002. All previously reported risk variants were common in African-Americans (minor allele frequency [MAF] >0.05). For five of the six SNPs, we had ≥94% power to detect the same effect observed in non-Hispanic whites, and 64% power for the less common variant rs10936599 (MAF=0.07). We observed directionally consistent effects (odds ratio [OR]>1) for the six risk variants tested, with three replicating at p≤0.05 (7p15.3, p=1.4x10-7; 17p11.2, p=0.05; 22q13.1, p=0.02). For three of the six regions, we observed better markers of risk in African-Americans that were correlated with the index SNP in Europeans (7p15.3, rs56333627, p=1.5x10-5, r2=0.89; 17p11.2, rs34562254, p=2.9x10-3, r2=0.90; 22q13.1, rs2092410, p=1.1x10-4 r2=.71). The missense variant identified in the 17p11.2 region (rs34562254, Pro251Leu) is located in TNFRSF13B, which encodes the protein TACI, a B cell surface receptor which plays a role in B cell maturation, apoptosis and antibody production by inducing activation of transcription factors including NFAT and NFκβ. In addition, there is evidence suggesting that TACI is involved in MM pathogenesis. Our results demonstrate that many of the risk loci for MM found in European ancestry populations are also risk loci in men and women of African ancestry and that by fine-mapping, we are able to identify variants that better capture risk in populations of African ancestry. Disclosures Terebelo: Celgene Corp: Membership on an entity's Board of Directors or advisory committees. Lonial:Millennium: The Takeda Oncology Company: Consultancy, Research Funding; Celgene: Consultancy, Research Funding; Novartis: Consultancy, Research Funding; Bristol-Myers Squibb: Consultancy, Research Funding; Onyx Pharmaceuticals: Consultancy, Research Funding.

Abstract 1785 Background: Chronic lymphocytic leukemia (CLL) is a malignant lymphoproliferative disorder characterized by the progressive clonal expansion of CD5+ B cells. Approximately 8–10% of CLL patients have a first degree relative with CLL, indicating that genetic factors can contribute to disease susceptibility. Genome wide association (GWA) studies have identified 16 “common variants,” single-nucleotide polymorphisms (SNPs) with a population prevalence of >5%, that confer risk for CLL. Among patients with CLL, the clinical course can be highly heterogeneous. Studies have defined disease-characteristics that vary among patients that can be used as markers to help predict clinical outcome. African American (AA) CLL patients have a poorer overall survival than Caucasians. However, there is little information on whether there are distinctive, ethnic-associated disease-characteristics that contribute to differences in clinical outcome. Moreover, studies of the genetics of CLL have involved primarily Caucasian patients. For these reasons, we examined for ethnic-related differences in the distribution and prevalence of CLL-associated SNPs and adverse disease-associated characteristics among AA with CLL relative to those of Caucasian patients with this disease. Methods: The clinical and biologic characteristics of 43 AA CLL patients ascertained at Duke University and the Durham VA Medical Center were tabulated and compared to Caucasian CLL patients at the same centers. Fifteen SNPs were genotyped in this “discovery” cohort of 43 AA CLL patients using TaqMan SNP genotyping assays. As a “validation” cohort, 70 AA CLL patients ascertained by the CLL Research Consortium (CRC) were assayed using the same platform. Three control groups were considered in analysis: (1) previously published Caucasian CLL patients, (2) control AA genotypes reported in the HapMap database and (3) control AA with no history of malignancy from other GWA studies. The 3' untranslated region of CPEB1 was sequenced in AA CLL patients using conventional Sanger sequencing. Results: Among the Duke/Durham VA CLL patients, no significant differences were observed in age, WBC count, platelet count, or hemoglobin at diagnosis; lymphocyte doubling time; Rai stage; ZAP70 expression; or CD38 expression between AA and Caucasian patients. AA had a larger proportion of trisomy 12 and fewer 13q.14 deletions than Caucasians: 40.0% of AA had trisomy 12 and 15.0% had del 13q, compared to 14.6% and 40.7% of Caucasians, respectively. IGHV mutation status also varied between races, with 62.2% of AA having unmutated IGHV, compared to 38.4% of Caucasians. Disparities in clinical outcomes were similar to that reported in the SEER database: overall survival was 8.8 years in AA patients and 17.8 years in Caucasians, and time to first treatment was 2.8 years among AAs and 4.5 years for Caucasians. Risk allele frequencies among 15 genotyped SNPs showed that 14 SNPs had risk allele frequencies that statistically differed between AA patients and Caucasian CLL patients. In 9 of 14 SNPs, the risk allele was less common in AA than in Caucasians but similar to that AA controls. In the other 5 SNPs, the risk allele was more common in AA CLL than Caucasian CLL, and similar to that of AA controls in 4 of the SNPs. A single SNP, rs783540 (CPEB1) was found to have an increased frequency in AA patients with CLL when compared to both Caucasian CLL and control AA. As an exploratory analysis to identify possible pathogenic variants, the 3' UTR of CPEB1 was sequenced as there are no common non-synonymous SNPs in CPEB1. Preliminary review of the sequencing data revealed that a G insertion SNP (rs34816185) that alters a predicted miRNA binding site is in linkage disequilibrium with rs783540 (D'= 0.978). Conclusions: Most SNPs associated with CLL risk are less frequent in AA than in Caucasian CLL patients. However, rs783540 (intron 2, CPEB1) risk allele was more frequent in AA CLL than that previously reported in Caucasian CLL or AA controls. Initial data suggests that rs783540 is linked to a SNP in the 3' UTR of CPEB1, which may have functional significance. Studies to better delineate the functional and clinical implications of these germline variants are underway. Our data provide the first evidence of differential genetic risk as a determinant of CLL biology among different ethnic groups. Disclosures: No relevant conflicts of interest to declare.

Abstract 2443 Background: There is strong and consistent evidence that a genetic component contributes to the etiology of chronic lymphocytic leukemia (CLL). A recent genome-wide association (GWA) study of CLL identified genetic variants located on chromosomes 2q13, 2q37.1, 6p25, 11q24, 15q23, and 19q13 that increased the risk of CLL within a European population. We replicated 5 of these 6 loci in an independent sample of CLL cases and controls from the United States. We now investigate whether these loci also influences MBL, a reported precursor condition of CLL. In addition, a follow-up analysis of the initial GWA study identified four more CLL-susceptibility loci on 2q37.3, 8q24.21, 15q21.3, and 16q24.1. Herein, we also evaluate the association of these four loci with risk of CLL. Methods: Peripheral blood samples were obtained from three ongoing studies: the Genetic Epidemiology CLL (GEC) Consortium, the Mayo Clinic non-Hodgkin lymphoma (NHL)/ CLL study, and the Mayo Clinic Biobank. We implemented rigorous genotyping quality-control measures, and successfully genotyped a total of 407 CLL patients, 965 controls, and 60 MBLs from these studies. Within each locus, the previously reported single nucleotide variants (SNPs) or variants in high linkage disequilibrium (LD) with the previously reported SNPs were evaluated with risk of MBL or CLL. Tests for association was done using the Cochran-Armitage trend test, and unconditional logistic regression was used to estimate odds ratios (ORs) and corresponding 95% confidence intervals (CIs) for CLL or MBL risk Results: In our evaluation of the six initially reported CLL-susceptibility loci (2q13, 2q37.1, 6p25, 11q24, 15q23, and 19q13) with MBL risk, we found three of the six had suggestive associations (p-value < 0.20) with ORs comparable to and in the same direction as those observed from CLL risk. Our strongest finding was with rs13397985 at locus 2q37.1 (OR= 1.56; 95% CI: 1.05, 2.31; p-trend = 0.041), followed by rs17483466 at locus 2q13 (OR= 1.49; 95% CI: 0.99, 2.24; p-trend = 0.074). As expected given our previously reported findings with CLL risk, the association between rs11083846 on chromosome 19q13 and MBL risk was not significant (p-trend = 0.70). Of the four recently reported CLL-susceptibility loci SNPs located on 2q37.3, 8q24.21, 15q21.3, and 16q24.1, we found all to be associated with CLL risk but one. Specifically, the strongest association was seen for locus 8q24.21 (best tagged SNP rs1021955; OR = 1.37; 95% CI: 1.10, 1.70; p-trend = 0.005), followed by locus 16q24.1 (best tagged SNP rs305065; OR= 0.77; 95% CI: 0.61, 0.97; p-trend = 0.024). However, we found no associations for locus 15q21.3 for the previously reported SNP nor for any SNPs in LD with the previously reported SNP. Conclusions: Our MBL results provide additional robust genetic evidence that MBL is a precursor to CLL and that it shares similar underlying genetic predisposition. Also our results confirm three of the four recently reported CLL-susceptibility loci and further support the role of a genetic basis in the etiology of CLL. More research is needed to elucidate the potential manner in which these genetic loci function in CLL or MBL. Disclosures: No relevant conflicts of interest to declare.

Abstract 1241 Poster Board I-263 Background and Significance Monoclonal B lymphocytosis (MBL) is a hematologic syndrome characterized by accumulations of clonal B lymphocytes in the peripheral blood. Most MBL have a CLL-like immunophenotype, though other, less common phenotypes are observed. Although some MBL, particularly those with MBL cell counts >1.9 × 109 / L, progress to CLL, “low count” MBL ( Methods Individuals with MBL were identified by flow cytometry screening of fresh and cyropreserved peripheral blood from unaffected members of CLL kindreds ascertained by Genetic Epidemiology of CLL Consortium (GEC) sites. We defined MBL as populations of CD5+, CD19+, CD20lo, CD23+ B cells that comprised at least 0.02% of the PBMC and did not exceed 5.0 × 109 MBL cells / L. Flow cytometry was used to determine the surface immunophenotype including prognostic parameters of CD38, intracellular ZAP-70, immunoglobulin isotype, CD49d, and the ratio of CD69:71. mRNA and genomic DNA from single MBL cells isolated by flow cytometric sorting were analyzed using PCR to determine immunoglobulin heavy and light chain sequences (IGVH status). MBL cells were sorted in bulk for FISH determination of genetic loci associated with clinical CLL. Results Fifty-four unaffected family members were found to have MBL, of these 48 (89%) showed a typical CLL immunophenotype (CLL-like MBL). We observed significant variability in the size of the MBL clone as a percentage of the CD19+ B cell compartment (mean 30%, median 16%; range 2% - 97%). CD38 positive (defined as CD38 surface expression in ≥ 30% of MBL cells) was observed in 6 of 38 (16%) subjects tested. ZAP-70 positive (defined as intracellular expression in ≥ 20% of MBL cells) was expressed in 5 of 28 (18%) participants. CD49d positive (defined as surface expression in ≥ 45% of MBL cells) was observed in 4 of 17 (24%) subjects. The ratio of surface expression of CD69:CD71, a measure of cellular activation that also correlates with an unmutated IGVH, was ≥2.0 in 3 of 34 (9%) subjects tested. Among 36 subjects tested, 9 (25%) MBL expressed both surface IgD and IgM (defined as surface expression ≥ 40% for both IgM and IgD), 12 (33%) expressed IgD only, 2 (6%) expressed IgM only, and 13 did not express IgD or IgM (36%). Analysis of IGVH status has been completed in 10 individuals. Both immunoglobulin heavy chain variable (IGVH) region mutated (n = 14) and unmutated (n = 5) sequences were observed. Six of 10 individuals had 2 or more unrelated MBL clones (range 2 - 4), including two individuals with both unmutated and mutated clones. Among the 19 MBL clones identified in these 8 subjects, VH3 or VH4 rearrangements were observed in all MBL clones. The most commonly rearranged IGVH genes were 3-07 (3 MBL clones), 3-15 (3), and 4-34 (3). No VH1 family gene rearrangements were observed. MBL cells were bulk sorted for FISH from 14 subjects. Mono or biallelic deletion of 13q14.3 was observed in 9 subjects, 4 were normal, and one showed trisomy 12. Conclusions Our data affirms that CLL-like MBL are commonly observed among the unaffected family members from CLL kindreds. We found that family associated MBL clones (most of which were small clones) express ZAP-70, CD38, and CD49d at an apparently lower frequency than observed in CLL. Unlike in CLL, the surface immunoglobulin isotype showed co-expression of IgM and IgD in only one third of cases. Moreover, small MBL clones are commonly oligoclonal and predominantly express mutated IGVH genes with an IGVH usage that also appears different from CLL. Taken together, these findings suggest that small MBL clones, though phenotypically similar to CLL, have important biologic differences from CLL that may explain the limited potential of these clones to progress to CLL. The clinical outcome of these MBL clones in relation to our baseline prognostic characterization will be of interest. In addition the further investigation of family associated MBL is being conducted and may clarify the genetics and immunobiology of familial CLL. Disclosures No relevant conflicts of interest to declare.

Abstract 1232 Poster Board I-254 B-Chronic Lymphocytic Leukemia (CLL) shows a strong familial risk and also co-aggregates with other indolent lymphomas. Monoclonal B-cell lymphocytosis (MBL) is an asymptomatic hematologic condition characterized by small B-cell clones, most with a surface phenotype similar to that of chronic lymphocytic leukemia (CLL). These clones are detectable at low absolute lymphocyte cell (ALC) numbers in otherwise healthy individuals using sensitive 6 or 8 color flow cytometry analysis and can be a precursor to CLL. In the general population, MBL increases with age with a prevalence of 5% in individuals over age 65. In contrast, the rate of MBL is 13-18% in first degree relatives of CLL patients in high risk families. In the largest study to date, we report the characteristics of MBL among 430 first-degree relatives of CLL patients (with no associated lymphoproliferative diseases [LPD]) in 132 high risk families. Patients and Methods Individuals studied came from “high risk” families (defined as those with two or more confirmed cases of CLL) that are participating in the Genetic Epidemiology of CLL Consortium. Multi-parameter flow cytometry analysis with a detection sensitivity of 0.02% was performed on either fresh or cryopreserved PBMC and MBL was classified according to previously published criteria (Marti et al, Br. J Haematol 130:325, 2005). Both the ALC and the absolute B cell count (B-ALC) were calculated for each individual. Survival analysis was used to compute the probability of developing MBL with age using the life table method. Results The overall rate of MBL was 17% (73/430) among first–degree relatives but the probability for developing MBL by age 90 was 51%. Males had a slightly higher (but non-significant) risk for MBL than females. MBL patients had significantly higher ALC and B-ALC than did those with normal immunophenotype. The mean ALC was 2.5×109/L among MBL patients, and 20% had an ALC greater than 3 ×109/L. The B-ALC count averaged 0.51 ×109/L. Ninety percent of the MBL cases had a CLL-like phenotype (CD20dim, CD5+, CD23+). Conclusions MBL is found at a very high rate in families selected for having 2 or more patients with CLL suggesting that MBL reflects inherited predisposition to CLL. Although most of the MBL cases in these families had low cell counts and thus have a presumed low likelihood of progressing to CLL or other LPD, a higher proportion of them had lymphocytosis compared to those with normal immunophenotype. We hypothesize that if MBL is an early step in the process of development of CLL, then germ line genes are likely to be acting early in carcinogenesis with more “hits” required before CLL develops. By looking for genes associated with MBL or CLL in families or in the population, we could substantially increase our power to identify germ line genes predisposing to CLL. Disclosures Kay: Biogenc-Idec, Celgene, Genentech, genmab: Membership on an entity's Board of Directors or advisory committees; Genentech, Celgene, Hospira, Polyphenon Pharma, Sanofi-Aventis: Research Funding.

Background and Significance : Chronic lymphocytic leukemia (CLL) is the most heritable hematologic malignancy; however, no common CLL predisposition genes are known. Monoclonal B lymphocytosis (MBL) is a hematologic syndrome characterized by small accumulations of B lymphocytes in the peripheral blood. MBL has a CLL-like immunophenotype, may progress to overt CLL, and is over represented in CLL families. Therefore, MBL observed in the context of familial CLL may be a marker of inherited risk for development of CLL. Detailed characterization of family-associated MBL may also provide mechanistic insights into the pathogenesis of familial CLL. Our strategy was to detail the biologic characteristics of CLL in family-associated MBL. Methods : Persons with MBL were identified by flow cytometric screening of peripheral blood from unaffected members of CLL kindreds ascertained by Genetic Epidemiology of CLL Consortium (GEC) sites. Flow cytometry was used to determine the surface immunophenotype including CD38 and intracellular ZAP-70. We defined MBL as populations of CD19+, CD5+, CD20lo, CD23+ B cells that comprised at least 2% of the CD19+ peripheral B cell compartment and did not exceed 5.0 × 109 MBL cells/L. RNA and genomic DNA from single MBL cells isolated by flow cytometric sorting were analyzed using PCR to determine immunoglobulin heavy and light chain sequences. MBL cells were sorted in bulk for FISH for loci associated with clinical CLL. Results : Twenty-two out of 190 (12%) unaffected family members were found to have MBL. We observed significant variability in the size of the MBL clone as a percentage of the CD19+ B cell compartment (mean 32%; range 2%–97%). Nonetheless, the absolute size of the MBL clone was small, 15 of 17 individuals had < 200 × 106 MBL cells/L. CD38 expression (defined as CD38 surface expression in ≥30% of MBL cells) was observed in 8 of 18 subjects tested. ZAP-70 (defined as intracellular expression in ≥ 20% of MBL cells) was expressed in 4 of 12 participants. Among 12 subjects tested, 5 MBL expressed both surface IgD and IgM, 3 expressed IgD only, 2 expressed IgM only, and 2 did not express IgD or IgM. Analysis of immunoglobulin heavy and light chains has been completed in 8 individuals. Both immunoglobulin heavy chain variable (IgVH) region mutated (n = 12) and unmutated (n = 4) sequences were observed. Four of 8 individuals had 2 or more unrelated MBL clones (range 2–5), including one individual with both unmutated and mutated clones. Among the 16 MBL clones identified in these 8 subjects, VH3 or VH4 rearrangements were observed in all MBL clones. The most commonly rearranged IgVH genes were 3–07 (3 MBL clones), 3–15 (3), and 4–34 (3). No VH1 family gene rearrangements were observed. In one individual, a VH3–07 MBL clone showed intraclonal diversification suggestive of antigen driven immunoglobulin sequence changes. Twenty productive light chain rearrangements were identified among the 16 MBL clones, with 11 Vλ and 9 Vκ genes used. We observed 6 productive rearrangements of Vλ1–51. MBL cells were bulk sorted for FISH from 9 subjects. Mono or biallelic deletion of 13q14.3 was observed in 5 subjects, the other 4 were normal. Conclusions : Our findings confirm that MBL is commonly observed among the unaffected family members from CLL kindreds. We found that some MBL clones express ZAP-70, CD38 or have unmutated IgVH genes and thus are similar to clinical CLL. The clinical outcome of these MBL clones in relation to our baseline prognostic characterization will be of interest. Small MBL clones are commonly oligoclonal. Importantly, although the immunoglobulin heavy and light chain genes rearranged in these MBL clones are all commonly used in CLL, the absence of VH1 and abundance of Vλ1–51 rearrangements do suggests differences in BCR usage between CLL and MBL. Further investigation of family associated MBL may clarify the genetics and immunobiology of familial CLL.

We have recently developed a risk model specific for patients with lower risk MDS that allows the identification of poor prognosis patients (Leukemia. 2008; 22:538-3). We showed that the majority of patients classified by IPSS as low risk actually have poor outcomes with respect to overall survival. The cause of death (COD) of these patients is not well understood. In order to guide early therapeutic intervention, it is important to identify whether the mortality in this group is attributable to causes related to MDS or whether death occurs due to age-related comorbidities. The aim of the present study was to examine the rate of disease-related deaths in a cohort of 269 deceased patients with low or intermediate-1 disease by IPSS at presentation to a tertiary care center from 1980 to 2006. Autopsy, final progress note, physician letter, or death certificate were used to determine COD. For each patient, we categorized the COD as disease-related vs. non-related. MDS-related death was defined as infection, bleeding, transformation to acute myeloid leukemia (AML), or disease progression. Non-related causes included accidents, coronary events, heart failure, respiratory and renal failure, non-hemorrhagic stroke, and chronic hepatitis. Median age at presentation and at time of death was 66 years (range 19–88) and 67 years (range 21–90), respectively. Overall median survival was 59 weeks (range = 1–831). By FAB classification, all subgroups were identified (RA = 41.3%, RARS = 5.8%, RAEB = 28.6%, RAEB-t = 12.3%, CMML = 12.0%). By IPSS score, most patients were Intermediate-1 (Int-1 = 79% and Low = 21%). Most patients had diploid cytogenetics (58.3%), and the most common cytogenetic abnormality was deletion of chromosome 5 (9.1%). Almost all patients received supportive care only. The COD was identified as MDS-related in 229 of 269 patients (85%). The most common disease-related COD was infection (39% of all deaths) followed by hemorrhage (34%) and transformation to AML (23%). The most frequent non-disease-related COD were cardiovascular events (19 of 40 patients). 8 of 269 patients died of a secondary neoplasm. Our data demonstrates that the majority of patients with low- or intermediate risk MDS will succumb to causes related to their underlying disease. Although these results need to be validated prospectively, early therapeutic intervention could be considered in the management of these patients to improve survival.

BACKGROUND: Incidence rates for myelodysplastic syndromes (MDS) and chronic myeloproliferative disorders (CMD) in the United States were unavailable prior to the addition of these stem cell malignancies to the National Cancer Institute’s Surveillance, Epidemiology, and End Results (SEER) Program and other central cancer registries in 2001. Description of national incidence rates for 2001–2003 will provide an important baseline for future studies of secular trends and allow for the examination of rates by selected demographic factors to define risk profiles of these malignancies in the American population. METHODS: Incidence rates of MDS and CMD were calculated for 18 SEER areas between 2001–2003. These rates were stratified by disease subtype using the FAB classification (including chronic myelomonocytic leukemia [CMML]) with the addition of the WHO deletion 5q category, sex, age at diagnosis and race. Based on the observed SEER incidence rates, counts were estimated for the entire U.S. population. RESULTS: In 2003, 2,538 cases of MDS and 1,421 cases of CMD were observed for all 18 SEER areas combined. Similar numbers of cases were observed in 2001 and 2002. Age-adjusted incidence rates for 2001–2003 were significantly higher among males than females for MDS (4.5 per 100,000 in males vs. 2.7 per 100,000 in females, p CONCLUSION: Male sex and advanced age are important risk factors for the development of CMD and MDS. Diagnostic recording differences may underestimate the total annual U.S. MDS and CMD case burden. Future prevention intervention and disease causality studies of MDS and CMD should target high-risk groups.

Little is known about the etiology of MDS. A hospital-based case control study was conducted to investigate the association between lifestyle characteristics and MDS risk. Cases included 354 newly diagnosed adult de novo MDS cases registered at M. D. Anderson Cancer Center (MDACC) between 1996 and 2003. Four hundred and fifty two age-, sex- and race-matched healthy controls were recruited among visitors to MDACC who accompanied patients to different clinics excluding the Leukemia clinic. A validated questionnaire was used to collect demographic and epidemiological information including lifetime history of smoking, alcohol drinking and occupational history. Multivariate logistic regression analysis adjusting for all variables simultaneously was used. The distribution by FAB type was 102 (29%) RA/RARS, 43 (12%) CMML and 209 (59%) RAEB/RAEB-T. The mean age of patients was 64 years (range: 24 to 89), the male to female ratio was 2.72, and 94% of cases were whites. Abnormal cytogenetics was found in 49% of the patients. Multivariate logistic regression analysis was performed among all MDS cases and among each FAB type. For all MDS combined, having a first degree relative diagnosed with a hematopoietic cancer (Odds ratio (OR)=1.92, 95% CI: 1.11–3.33), having ever smoked (OR=1.65, 95% CI: 1.19–2.29), having been exposed to agricultural chemicals (OR=4.57, 95% CI: 1.78–11.7) and solvents (OR=2.08, 95% CI: 1.22–3.54) were associated with MDS risk. Wine drinkers had a reduced risk of MDS as compared to those who never drank alcohol (OR=0.54, 95%: 0.37–0.79). For the RA/RARS type, smoking (OR=2.16, 95% CI: 1.3–3.6) and having been exposed to agricultural chemicals (OR=4.64, 95% CI: 1.27–16.9) were the only two risk factors identified. Wine drinkers were at reduced risk (OR=0.51, 95% CI: 0.29–0.91). For the RAEB/RAEBT type, a positive family history of hematopoietic cancer (OR=2.16, 95% CI: 1.17–3.98), smoking (OR=1.55, 95% CI: 1.05–2.30) and exposure to agricultural chemicals (OR=4.12, 95% CI: 1.51–11.3) or solvents (OR=2.83, 95% CI: 1.59–5.05) were independent risk factors. Also drinking wine seemed to reduce the risk by almost 50% (OR=0.51, 95% CI: 0.32–0.81). We also found a joint effect between smoking and chemical exposures with the largest OR found among smokers who were also exposed to solvents or agricultural chemicals as compared to never smokers without chemical exposures (OR=3.22, 95% CI: 2.11–4.92, Trend test: p

With the development of new treatment strategies, the survival of CLL patients has improved. Some reports indicate that CLL patients may be at increased risk of subsequent cancer. Patterns for the specific type of cancer may provide insights into possible causes associated with the development of secondary cancers. We evaluated the development of second cancer after diagnosis with CLL among 1069 patients diagnosed at M. D. Anderson Cancer Center between 1985 and 2001. Only patients with no prior invasive cancer and were followed-up for at least 1 year were included in the analysis. The mean age was 56 years (range: 16–89 years) and the male-to-female ratio was 1.47. During the mean follow-up of 6 years (range: 1–20 years), sixty six (6%) patients were diagnosed with secondary invasive cancers: breast (12), lung (11), colorectal (7), prostate (7), melanomas (6), Hodgkin’s disease (HD) (5), acute myelogenous leukemias (AML) (3), bladder cancers (3), myelodysplastic syndromes (MDS) (3), Merkel cell carcinomas (2), pancreatic (2), esophageal cancer (1), kidney (1), liver (1), endometrial (1) and appendix (1). The mean time to the development of secondary cancers was 4.7 years (range: 1 – 16 years). We compared the observed number (O) of second cancers to the expected number (E) calculated from the age-, sex- and calendar-year matched general US population using the Connecticut Tumor Registry data. Overall, no excess of second cancers was found, the standard incidence ratio (SIR) [O/E = 66/62 = 1.07 (95% CI: 0.84 – 1.37)]. When stratified by treatment, no significant increased risk of second cancer was observed among treated (SIR = 36/35.6 = 1.01, 95% CI: 0.71 – 1.40) and untreated patients (SIR = 30/25 = 1.20, 95% CI: 0.81 – 1.72) compared to the general population. However, when analyzing risks by cancer sites, higher risk of secondary melanoma (SIR = 4/0.85 = 4.71, 95% CI: 1.28 – 12.1) was observed among patients diagnosed with CLL at age older than 60 years. All five secondary Hodgkin’s disease were diagnosed in men, a significant excess of HD was found among both older (≥ 60 years) (SIR = 3/0.13 = 23.1, 95% CI: 4.75 – 67.4) and younger patients (< 60 years) (SIR = 2/0.15 = 13.3, 95% CI: (1.61 – 48.1). All three patients diagnosed with AML were men, and they had higher risk of developing AML (SIR = 3/0.33 = 9.09, 95% CI: 1.87 – 26.5). Two out of three patients who developed AML were treated with alkylating agents. Patients who received chemotherapy for CLL had an increased risk of developing AML (SIR = 3/0.27 = 11.1, 95% CI: 2.29 – 32.4) and HD (SIR = 4/0.16 = 25.0, 95% CI: 6.8 – 64.0). However, no increased risk of AML was found among those who received fludarabine alone and those never received any treatment for CLL. This large study confirmed that site-specific excesses of second cancers after CLL diagnosis did exist. The excess of AML among those treated with chemotherapy may due to alkylating agents. Monotherapy with new purine analog drug did not increase the risk of AML in this study. Further research is needed to investigate the causal relationship between CLL and second malignancies.