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2964 Intensive Induction Chemotherapy Vs Hypomethylating Agents + Venetoclax (HMA/VEN) in NPM1-Mutant Newly Diagnosed Acute Myeloid Leukemia (AML) - a Multicenter Cohort StudyClinically Relevant Abstract

Program: Oral and Poster Abstracts
Session: 617. Acute Myeloid Leukemias: Biomarkers, Molecular Markers and Minimal Residual Disease in Diagnosis and Prognosis: Poster II
Hematology Disease Topics & Pathways:
AML, Acute Myeloid Malignancies, Research, Clinical Research, Diseases, real-world evidence, Myeloid Malignancies
Sunday, December 10, 2023, 6:00 PM-8:00 PM

Jan Philipp Bewersdorf, MD1, Shai Shimony, MD2*, Rory M. Shallis, MD3, Yiwen Liu, MS4*, Eva Johanna Schaefer, MD5*, Amer M. Zeidan, MBBS, MHS6, Aaron D. Goldberg, MD, PhD7, Eytan M. Stein1, Guido Marcucci, MD8, R. Coleman Lindsley9, Evan C. Chen, MD5, Jorge Ramos, MD10*, Anthony Selwyn Stein, MD11, Daniel J. DeAngelo12, Donna S. Neuberg, ScD4, Richard M Stone, MD12, Brian J. Ball, MD10 and Maximilian Stahl, MD13

1Memorial Sloan Kettering Cancer Center, New York, NY
2Department of Medical Oncology, Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA
3Section of Hematology, Department of Internal Medicine, Yale School of Medicine, Yale University, New Haven, CT
4Department of Data Science, Dana-Farber Cancer Institute, Boston, MA
5Medical Oncology, Dana Farber Cancer Institute, Boston, MA
6Department of Internal Medicine, Yale School of Medicine and Yale Cancer Center, Yale University, New Haven, CT
7Memorial Sloan Kettering Cancer Center, New York City, NY
8Department of Hematologic Malignancies Translational Science, Gehr Family Center for Leukemia Research, City of Hope National Medical Center and Beckman Research Institute, Duarte, CA
9Department of Medical Oncology, Dana Farber Cancer Institute, Boston, MA
10City of Hope Cancer Center, Duarte, CA
11City of Hope National Medical Center, Duarte, CA
12Dana-Farber Cancer Institute, Boston, MA
13Dana Farber Institute, Boston, MA


Intensive induction chemotherapy (IC) with cytarabine + anthracycline remains the standard of care for younger and fit patients (pts) with acute myeloid leukemia (AML). Post-hoc analyses from clinical trials evaluating venetoclax (VEN)-based therapies in AML have identified mutations in NPM1 as being associated with high rates of durable responses. However, these trials were conducted in pts age ≥75 years or unfit for IC. Thus, it is unknown whether IC or hypomethylating agent (HMA)+VEN is the optimal frontline treatment for pts with NPM1-mutant AML. We performed a large multicenter retrospective cohort study dedicated to pts with newly diagnosed AML with NPM1 mutations, comparing treatment modalities and assessing the impact of clinical and molecular characteristics on response and survival.


We included pts with newly diagnosed, NPM1-mutant AML who were treated at 4 large academic centers with IC (either conventional 7+3 or liposomal cytarabine/daunorubicin [CPX-351]) or HMA+VEN. Detection of NPM1 mutations was performed at the participating sites either by polymerase chain reaction (PCR) or next-generation sequencing (NGS) per local standards. Composite complete response (cCR) was defined as complete response (CR) + CRi (CR with incomplete count recovery) per European LeukemiaNet 2017 criteria. Overall survival (OS) was compared between groups by log-rank test. Cox regression multivariable model for OS was fitted using a stepwise backward selection to evaluate the effect of treatment, allogeneic stem cell transplantation (allo-SCT) as a time-varying covariate and additional covariates with a p<0.1 in the univariate model.


We reviewed 1132 pts with AML and included 225 pts with NPM1-mutant AML in the final analysis (Table 1). Among these pts, 71% (n=160) and 29% (n=65) received IC and HMA+VEN, respectively. Some pts (22%) in the IC group also received midostaurin compared to 0% in the HMA+VEN group. Pts who received IC for NPM1-mutant AML were younger (median age 61 years [Range: 22 -76] vs 74 years [33 -89]; p<0.001) when compared to HMA+VEN and less likely to have prior myelodysplastic syndrome (MDS) or myeloproliferative neoplasms (MPN; 10% vs 20%, p=0.042), and SF3B1 mutations (3.1% vs 15%; p=0.002). There was no difference in the rate of FLT3-ITD mutations between groups (36% vs 29%; p=0.36).

Rates of cCR and CR were higher for IC than HMA+VEN-treated pts (cCR: 87% vs 74%; p=0.018; CR: 83% vs 52%; p<0.001), as well as rates of allo-SCT (56% vs 23%; p<0.001). Median OS was 31 months (95% CI: 24 months [mo] – not reached [NR]) for the total cohort of pts with NPM1-mutant AML and was better in pts treated with IC vs HMA+VEN (IC: 24 mo OS 65% [95% CI: 57 – 74%] vs HMA+VEN: 24 mo OS 38% [95% CI: 26 – 55%]; p<0.001).

While the median OS remained favorable for IC among pts age > 60 years with NPM1-mutant AML (34 mo [95% CI: 24 mo – NR] vs 15 mo [13 mo – 28 mo]; p=0.015), there was no difference in OS by treatment type among the pts undergoing allo-SCT (IC: median OS not reached; 24 mo OS: 72% [95% CI: 63-83%] vs HMA+VEN: median OS 29 mo; 24 mo OS 69% [95% CI: 48-100%]; p=0.55).

In the univariate analysis, treatment (HMA+VEN vs IC), age, prior chemotherapy exposure, abnormal cytogenetics, SF3B1, TET2 and RNA splicing mutations were associated with worse outcomes (Table 2). Of note, neither the presence of concurrent FLT3 or IDH1/2 mutations nor allo-SCT as a time-varying covariate had a statistically significant impact on OS. In the multivariable analysis, treatment with HMA+VEN vs. IC retained its predictive value (hazard ratio: 2.00; 95% CI: 0.92 – 3.03; p=0.006), as well as prior chemotherapy and abnormal cytogenetics (Table 2).


In pts with newly diagnosed NPM1-mutant AML, treatment with IC was associated with higher cCR rates and favorable OS when compared with HMA+VEN in multivariable regression analysis. However, as residual confounding cannot be excluded given the significant differences in baseline patient and disease characteristics between the two groups, a randomized clinical trial is needed to definitively verify the potential superiority of IC vs HMA+VEN in pts with newly diagnosed NPM1-mutant AML.

Disclosures: Shallis: Servier: Consultancy; Rigel: Consultancy; Gilead Sciences: Consultancy; Bristol Myers Squibb: Consultancy; Curio Science: Consultancy. Zeidan: Ionis: Consultancy, Honoraria; Schrödinger: Consultancy, Honoraria; Seattle Genetics: Consultancy, Honoraria; Otsuka: Consultancy, Honoraria; Pfizer: Consultancy, Honoraria; Agios: Consultancy, Honoraria; Chiesi: Consultancy, Honoraria; Astellas: Consultancy, Honoraria; Syndax: Consultancy, Honoraria; Shattuck Labs: Research Funding; Astex: Research Funding; Geron: Consultancy, Honoraria; Kura: Consultancy, Honoraria; Regeneron: Consultancy, Honoraria; Amgen: Consultancy, Honoraria; Taiho: Consultancy, Honoraria; Takeda: Consultancy, Honoraria; ALX Oncology: Consultancy, Honoraria; Janssen: Consultancy, Honoraria; BioCryst: Consultancy, Honoraria; Genentech: Consultancy, Honoraria; Jazz: Consultancy, Honoraria; Incyte: Consultancy, Honoraria; Gilead: Consultancy, Honoraria; Syros: Consultancy, Honoraria; Epizyme: Consultancy, Honoraria; Foran: Consultancy, Research Funding; Orum: Consultancy, Honoraria; Mendus: Consultancy, Honoraria; Notable: Consultancy, Honoraria; Zentalis: Consultancy, Honoraria; Servier: Consultancy, Honoraria; Tyme: Consultancy, Honoraria; Daiichi Sankyo: Consultancy, Honoraria; AbbVie: Consultancy, Honoraria; Novartis: Consultancy, Honoraria; Lox Oncology: Consultancy, Honoraria; Boehringer-Ingelheim: Consultancy, Honoraria; Celgene/BMS: Consultancy, Honoraria; BeyondSpring: Consultancy, Honoraria. Goldberg: Aptose: Research Funding; Aprea: Research Funding; DAVA Oncology: Honoraria; Prelude: Research Funding; Trillium: Research Funding; Celularity: Research Funding; AROG: Research Funding; Pfizer: Research Funding; ADC Therapeutics: Research Funding; Daiichi Sankyo: Consultancy, Research Funding; Astellas Pharma: Consultancy; Genentech: Consultancy; Abbvie: Consultancy, Research Funding. Stein: OnCusp: Consultancy; Jazz: Consultancy; Genentech: Consultancy; Abbvie: Consultancy; Genesis: Consultancy; Gilead: Consultancy; Neoleukin: Consultancy; Agios: Consultancy; Servier: Consultancy; Calithera: Consultancy; Daiichi: Consultancy; Foghorn: Consultancy; Menarini: Consultancy; Janssen: Consultancy; PinotBio: Consultancy; CTI Biopharma: Consultancy; Syros: Consultancy; Aptose: Consultancy; Syndax: Consultancy; Novartis: Consultancy; Bristol Myers Squib: Consultancy, Research Funding; Eisai: Research Funding; Astellas: Consultancy; Ono Pharma: Consultancy; Blueprint: Consultancy. Marcucci: Ostentus Therapeutics: Current equity holder in private company, Research Funding. Lindsley: Qiagen: Consultancy; Sarepta Therapuetics: Consultancy; Verve Therapuetics: Consultancy; Jazz Pharmaceuticals: Consultancy; Vertex Pharmaceuticals: Consultancy; Bluebird bio: Consultancy, Membership on an entity's Board of Directors or advisory committees; Takeda Pharmaceuticals: Consultancy. Chen: Rigel Pharmaceuticals: Consultancy, Honoraria; Abbvie Pharmaceuticals: Research Funding. Stein: Amgen: Speakers Bureau. DeAngelo: Jazz: Honoraria; GlycoMimetics: Research Funding; Novartis: Honoraria; Kite: Honoraria; Novartis: Research Funding; Gilead: Honoraria; Amgen: Honoraria; Autolus: Honoraria; Incyte: Honoraria; Blueprint: Honoraria; Blueprint: Research Funding; Takeda: Honoraria; Servier: Honoraria; AbbVie: Research Funding; Pfizer: Honoraria. Neuberg: Madrigal Pharmaceuticals: Current equity holder in private company. Stone: Rigel: Consultancy; Syntrix: Other: DSMB; Aptevo: Other: DSMB; Cellularity: Consultancy; Jazz: Consultancy; Epizyme: Other: DSMB; GSK: Consultancy; Hermavant: Consultancy; CTI Biopharma: Consultancy; BerGenBio: Consultancy; Abbvie: Consultancy; Kura One: Consultancy; AvenCell: Consultancy; Amgen: Consultancy; Takeda: Other: DSMB; Lava Therapeutics: Consultancy; Ligand Pharma: Consultancy. Stahl: Curis Oncology: Other: GME activity ; Haymarket Media: Other: GME activity ; Kymera: Membership on an entity's Board of Directors or advisory committees; Dedham group: Consultancy; Rigel: Membership on an entity's Board of Directors or advisory committees; Boston Consulting: Consultancy; Novartis: Membership on an entity's Board of Directors or advisory committees, Other: GME activity ; Clinical care options: Other: GME activity ; GSK: Membership on an entity's Board of Directors or advisory committees; Sierra Oncology: Membership on an entity's Board of Directors or advisory committees.

*signifies non-member of ASH