bluuebunny/crossref_metadata_2025 huggingface dataset:
Acquired Factor XIII Deficiency in the Inpatient Setting: Clinical Suspicion, Impact and Treatment: Retrospective Case Series
Authors: Chuliber Fernando , Schutz Natalia Paola , Otero Victoria , Barrera Luis , Altuna Diana , Fantl Dorotea Beatriz , Martinuzzo Marta
Published: October 2019

Introduction: Activated factor XIII (FXIII) stabilizes fibrin clots at the end of the coagulation cascade by bridging fibrin molecules. Disproportionate surgery related bleeding has been reported in association with FXIII deficiency, in patients with normal coagulopathies screening tests, and without a history of previous bleedings.

Methods: Retrospective case series. We performed immunological factor XIIIA (FXIIIA) studies in the inpatient setting of the Hospital Italiano de Buenos Aires, between January 2014 and March 2016. FXIIIA below 50% were considered deficient. Patients with suspicion of congenital Factor XIII deficiency or 2 years old or less were excluded. Descriptive statistics were used. Populations were compared with chi-square, Fisher and T test, or Mann Whitney tests with Stata13 software.

Results: FXIII was studied in 52 patients; 37 of these (26 females and 11 males) met inclusion and exclusion criteria. Median age was 43 years (range 9-81). Twenty two patients were studied because of disproportionate surgery related bleeding, 11 because of spontaneous bleeding; and 4 not specified. All patients presented normal coagulopathies screening tests, normal Von Willebrand factor and ristocetine cofactor activity and normal platelet function tests. Eleven patients (30%) had FXIIIA less than 50%. Statistically significant differences between groups were found for median drop in hematocrit points [3.5 (IQR 3-10) vs 1.5 (IQR 0-2, p=0.02)] and median number of red cell units transfused [4 (IQR 0-6) vs 0 (0-2), p=0.01]. Differences in rates of minor and major bleedings were not statistically significant. Only one patient of eleven presented FXIII deficiency associated spontaneous bleeding vs 8 out of 20 patients in the postsurgical setting. FXIII concentrate was used in two patients to treat persistent bleeding, resolving in less than 24 hours. Three patients died, none because of bleeding. Five of the 11 patients with FXIII deficiency returned to normal values when FXIII assay was repeated away from acute setting.

Discussion: FXIII acquired deficiency is associated with disproportionate bleeding in postsurgical setting in patients without apparent coagulation defects. FXIII deficiency could be underdiagnosed. Patients with FXIII deficiency in our series had more hematocrit drop and more transfusion requirements. We found no association with spontaneous bleeding. Alltough deficiency could be transient, treatment with FXIII concentrate could be useful to manage serious, persistent or life threatening bleedings.

Disclosures

No relevant conflicts of interest to declare.
Targeting FVIII-Specific B Cells Using BAR-Transduced Regulatory T Cells
Authors: Zhang Ai-Hong , Yoon Jeong Heon , Kim Yong Chan , Scott David W.
Published: October 2019

Up to a third of hemophilia A (HA) patients receiving therapeutic FVIII develop neutralizing antibodies termed "inhibitors". Once inhibitors develop, clinical management of HA patients becomes extremely difficult. Thus, a rational solution would be to establish FVIII-specific immune tolerance to FVIII in high risk patients. To address this issue in a mouse model of human HA, we elected to use an antigen-specific regulatory T cell (Treg) approach. Analogous to the chimeric antigen receptor (CAR) strategy successfully used in cancer immunotherapy, we have created a chimeric receptor comprising a protein antigen or its domain, linked with the transmembrane and signal transduction domains, CD28-CD3ζ. We termed this receptor "BAR" for B-cell-targeting antibody receptor. Human Tregs (CD4+CD25hiCD127low) were retrovirally transduced with a BAR containing FVIII C2 domain (C2-BAR) or FVIII A2 domain (A2-BAR) and expanded successfully in vitro. These cells stained positively with anti-C2 and anti-A2 monoclonal antibodies, respectively, and maintained Treg phenotypic markers in terms of co-expression of Foxp3 and Helios. Control human Tregs were transduced with a BAR containing chicken ovalbumin (OVA-BAR). To test the hypothesis that BAR-transduced Tregs could directly and effectively suppress the activity of specific B cells, a xenogeneic model was employed. On day 0, FVIII-/- HA mice were injected intravenously with 106 transduced human Tregs. The mice were then immunized subcutaneously on day 1 with FVIII in incomplete Freund's adjuvant, and anti-FVIII antibody development was followed. By two weeks after immunization, anti-FVIII antibodies could be detected in the control mice (n = 4). However, in the experimental group (n = 5) that received a mixture of equal number of C2-and A2-BAR Tregs, anti-FVIII antibody development was reproducibly completely blocked for at least 8 weeks. To examine the possible mechanism of BAR Treg suppression, purified B cells and T cells from "tolerized" (A2+C2-BAR) or "control" (OVA-BAR) recipients were mixed and tested for recall responses to FVIII in vitro. The results suggested that the FVIII-specific B cells were directly tolerized while the T-cell response remained intact. Taken together, we report here a successful approach utilizing FVIII-specific BAR-Tregs to directly target FVIII-specific B cells, an approach which could be adapted to address other adverse immune response as well. (Supported in part by a NIH grant HL127495)

Disclosures

No relevant conflicts of interest to declare.
Disparities in the Upfront Use of Hematopoietic Stem Cell Transplant Among Patients with Acute Myeloid Leukemia
Authors: Mehmood Tahir , Bartley Adam C , Hashmi Shahrukh K. , Go Ronald S.
Published: October 2019

Background:

The incidence for acute myelogenous leukemia (AML) is on the rise in the United States (US). Roughly 20,000 new AML patients are expected to occur in 2016 in the US (data from Surveillance Epidemiology and End Results Program). It is mainly a disease of older individuals with median age of 67 years. Unfortunately, most patients are not cured. Recent data suggest that early referral for hematopoietic stem cell transplant (HSCT) leads to more favorable outcomes, particularly those with non-good risk cytogenetics compared to alternate therapies. The objective of our study was to assess the use of upfront HSCT among AML patients with a focus on patients with non-good risk cytogenetics and determine disparity in its access based on sociodemographic and regional considerations.

Methods:

We analyzed data obtained from National Cancer Data Base (NCDB) Participant User Files for patients diagnosed with AML between 2004 and 2013 using the International Classification of Diseases for Oncology version 3 (ICD-O-3) codes 9840-9861, 9865-9874, 9891-9931. The data is collected prospectively by joint program of Commission on Cancer (CoC) and American Cancer Society. It covers nationwide oncology outcome from more than 1,500 CoC-accredited hospitals. Over 70% of all newly diagnosed cancer cases in the US are captured by NCDB. Since unique ICD-O-3 codes exist for the good-risk but not for intermediate- or poor-risk AML, we categorized the AML subtypes as good risk or non-good risk for analytic purposes. We considered patients with t(15;17), inv(16) and t(8;21) with corresponding ICD-O codes of 9871, 9896, and 9866, as good-risk patients. All others were considered non-good risk. Proportion of HSCT usage was estimated in various subgroups with 95% confidence intervals calculated using robust estimates of standard error.

Results:

We identified 80,087 patients who were diagnosed with AML between 2004 and 2013. Majority of these patients were Whites (85.9%), males (53.8%) and between the ages of 40 and 79 years (71.5%). The overall use of upfront HSCT increased consistently over time. This occurred predominantly among the non-good risk AML from a rate of 6.5% in 2004 to 12.5% in 2013 (Figure). Non-good risk patients who were Black, had Medicare insurance, with lower annual household income, and treated at facilities located in the East, South and Central parts of US ( AL, KY, MS, TN) had less access to HSCT (Table).

Conclusion:

The use of upfront HSCT in AML has almost doubled in the past decade, predominantly among those with non-good risk cytogenetics. Nevertheless, we found substantial disparity among sociodemographic and geographic subgroups. Future studies should try to understand and address how to bridge this gap.

Disclosures

No relevant conflicts of interest to declare.
Mitochondrial Calcium Entry Is Essential in Agonist-Induced Procoagulant Platelet Formation
Authors: Kholmukhamedov Andaleb , Janecke Rae , Choo Hyojung , Jobe Shawn M
Published: October 2019

Procoagulant platelets are a subpopulation of activated platelets with high-level phosphatidylserine (PSer) externalization. When initiated by co-stimulation with thrombin (THR) and a GPVI agonist, such as convulxin (CVX) or collagen, both extracellular calcium entry and mitochondrial permeability transition pore (mPTP) formation are required to mediate the transition to the procoagulant platelet phenotype. The intracellular mechanisms coordinating these processes remain unclear. Here we investigated the role of the mitochondrial calcium uniporter in the regulation of procoagulant platelet formation.

The flux of calcium from the cytosol to the mitochondrial matrix is limited by the ion-impermeable inner mitochondrial membrane. Initially, a pharmacologic approach was utilized to investigate the importance of mitochondrial calcium entry and elevation. Washed human or murine platelets were stimulated with THR and/or CVX in physiologic buffer with 2 mM CaCl2. Mitochondrial transmembrane potential was evaluated using 0.5 μM tetramethylrhodamine methylester (TMRM). Limitation of mitochondrial calcium entry either through alteration of pre-stimulatory mitochondrial membrane potential (i.e. inhibition of F0F1 ATP-ase, mitochondrial uncoupling etc.) or using the ruthenium red analog (Ru360) abrogated both mPTP and procoagulant platelet formation consistent with the hypothesis that elevated calcium levels within the mitochondrial matrix drives these processes.

The molecular pathway mediating this rapid mechanism of calcium entry was investigated using mitochondrial calcium uniporter (MCU) null platelets. MCU is a transmembrane ion channel that allows the passage of Ca2+ from the cytosol into the mitochondrial matrix. Neither platelet aggregatory ability nor granule release was altered in response to single or dual-agonist stimulation. In contrast, procoagulant platelet formation in MCU null platelets was significantly decreased coincident with decreased mPTP formation as measured by loss of mitochondrial transmembrane potential. Whereas the number of annexin V positive platelets decreased from 60% in WT to 32% in MCU null (p<0.05, n=4). Thus, these results identify a key role of mitochondrial calcium uptake channel in the regulation of strong agonist-initiated procoagulant platelet formation and suggest a novel pharmacologic target that could be used the treatment of procoagulant-platelet related pathologies.

Disclosures

No relevant conflicts of interest to declare.
Over-Expression of RPS3 Promotes Acute Lymphoblastic Leukemia Growth and Progress By Down-Regulating COX-2 through NF-κb Pathway
Authors: Hua Wang , Yue Lu , Dingbo Shi
Published: October 2019

The Ribosome protein S3 (RPS3) is a component of 40S ribosomal subunit, which is important in ribosomal maturation.In addition, RPS3 plays a central role in the regulation of cell cycle,proliferation,migration,DNA repair,and apoptosis.Recent study has also been reported that RPS3 is secreted as a homodimer in cancer cells. The increased level of secreted RPS3 was detected in more malignant cells.These findings suggest that the RPS3 protein is an indicator of malignant tumors.Therefore, we studied the roles and the functions mechanisms of RPS3 in leukemia in order to understand whether RPS3could be a key target for leukemia therapy.

qRT-PCR and western blot analysis were carried out in a small cohort of acute lymphoblastic leukemia patients(ALL) and multiple leukemia cell lines to evaluate RPS3 mRNA and protein expression levels.To assess its biological functions relevance, its expression was down modulated by transient RNA interference in ALL cell lines.Our results show that RPS3 mRNA and protein expression is higher in both ALL patients and the ALL cell lines when compared to the healthy donors peripheral blood mononuclear cell or myeloid leukemia cell lines. Correspondence with this, the ALL patients with higher expression of RPS3 had shorter overall survival than those with lower expression of RPS3 (25.1% vs. 63.4%, P<0.001, for 5 year-OS).Furthermore,blocking RPS3 activity in four ALL cell lines, by either knockdown or treatment with the RPS3 inhibitor, causes significant decrease in their cell proliferation.This decrease in cell proliferation was coupled with both an induction of the G1/S cell cycle arrest and with an increase of apoptosis induced in the leukemia population. In vivo,we also found that knockdown of RPS3 significantly inhibited tumor growth in a ALL xenograft mouse model. Finally, mechanism studies showed that RPS3 knockdown in ALL cells triggered suppression of COX-2 expression and its down-stream targets PGE2 release,inhibited COX-2 promoter activity by decreased P50 /P65 Binding to cox2 promotor.

In conclusion,our results suggest that overexpression of RPS3 promotes acute lymphoblastic leukemia growth and progress by up-regulating COX-2 through NF-κB pathway. and that targeting RPS3could be an attractive strategy for ALL therapy.

Disclosures

No relevant conflicts of interest to declare.
the NADPH Oxidase Catalytic Subunit Nox2 Displays Differential Roles in Arterial Vs. Venous Thrombosis
Authors: Sonkar Vijay , Jensen Melissa J , Lentz Steven R. , Dayal Sanjana
Published: October 2019

NADPH oxidase is a major superoxide generating enzyme in vascular tissues. Deficiency of the Nox2 (gp91phox) catalytic subunit of NADPH oxidase is a genetic cause of X-linked chronic granulomatous disease. These patients are prone to infection due to loss of oxidant production by neutrophils, and recent evidence suggests they also have a defect in platelet adhesion to collagen. However, the role of Nox2 in thrombosis is controversial, with one study demonstrating no effect of murine Nox2 deficiency on platelet activation and another study implicating Nox2 in platelet aggregation as well as thrombosis in small vessels. Given that Nox2 may be important for both platelet activation as well as release of neutrophil extracellular traps (NETs, a mediator of venous thrombosis), we hypothesized that genetic deficiency in murine Nox2 leads to decreased susceptibility to experimental thrombosis in both arterial and venous systems. We studied male Nox2 deficient (Cybb-/y) mice and wild type (Cybb +/y) littermates at 10-14 weeks of age. There were no differences in platelet count (921.9±33.6 x103/µl vs. 978±85.2 x103/µl), hematocrit (36.5±0.6% vs. 38.7±0.8% ) or white blood cell count (5.5±0.3 x103/µl vs. 6.1±0.6 x103/µl) between Cybb+/y and Cybb-/y mice. We next, examined platelet activation in response to thrombin (0.05 and 0.2 U/ml) or collagen (80 and 320 ng/ml) using flow cytometry. We observed similar levels of integrin α2bβ3 activation, fibrinogen binding, and intra-platelet levels of H2O2 in platelets from Cybb+/y and Cybb-/y mice after activation with either agonist, which suggests no alteration in platelet inside-out signaling due to loss of Nox2. No significant difference in susceptibility to carotid artery thrombosis in a photochemical injury model was observed between Cybb+/y and Cybb-/- mice (time to stable occlusion 21.97±4.7 vs 27.6±4.2, P>0.4). In contrast, Cybb-/y mice demonstrated significant decreases in the weight and length of venous thrombi in the inferior vena cava after 48 hours of stenosis (P<0.05). Our findings suggest that Nox2 is not a major mediator of platelet activation or arterial thrombosis but contributes to the development of venous thrombi. Future studies are warranted to examine the role of NETs and the prothrombotic effects of Nox2 in association with other cardiovascular risk factors.

Disclosures

Lentz: Novo Nordisk: Consultancy, Research Funding; Celgene: Equity Ownership; Opko: Membership on an entity's Board of Directors or advisory committees.
Platelet-Induced T Cell Activation in Patients with Myocardial Infarction; The Role of miR155
Authors: Solomou Elena E. , Kalyvioti Elena , Verigou Evgenia , Katsanaki Katerina , Gogos Charalambos , Hahalis George , Alexopoulos Dimitrios
Published: October 2019

Specific aim: We have previously shown that platelets from patients with myocardial infarction (with ST elevation-STEMI) can activate T cells in vitro. In this study we wanted to expand our initial observation and explore the mechanism of this T cell activation.

Methods: After written informed consent was obtained, peripheral blood mononuclear cells (PBMCs) were isolated from heparinized venous blood obtained from 30 patients with STEMI (28 men and 2 women) at the time of hospital admission at diagnosis, before receiving any treatment, as well as 5 days and 30 days later. We also analyzed 15 healthy subjects (12 men and 3 women), and 7 patients with unstable angina who served as the disease control group. PBMCs were analyzed by flow cytometry with the following markers and their isotypic controls: CD4, CD25, CD127, FOXP3, and CD69. We also isolated platelet rich plasma or plasma alone from the patients and the healthy subjects, and used in mixed cultures with PBMCs. miR 155 levels were examined with real-time PCR.

Results: Initially, we incubated T cells with platelets from patients with STEMI and examined T cell activation by CD69 expression. These T cells showed increased expression of CD69 compared to T cells treated with platelets from healthy subjects (p<0.05). No T cell activation was observed following incubation with plasma alone from patients or healthy controls.

Next, the percentages of CD4+CD25+hi CD127low FOXP3+ (regulatory T cells, Tregs) were examined in all study subjects. Patients at presentation showed comparable Treg levels with the controls (healthy subjects and disease control group). Five days later, patients with STEMI displayed increased levels of Tregs compared with the controls (p<0.05) (Fig.2). To explore the mechanism of Treg up-regulation the miR155 levels through real time PCR were evaluated. Patients with STEMI showed comparable levels of miR155 at presentation, but five days later showed decreased miR155 levels compared to controls (p<0.001) (Fig. 1); we observed an inverse correlation between miR155 levels and Treg numbers in patients with STEMI. At re-evaluation, one month later, patients with STEMI displayed Treg numbers comparable to the initial presentation levels

Conclusion: Herein, we show that platelets from patients with STEMI can activate T cells in vitro. This platelet activation in patients with STEMI, results in an increase in Tregs through down-regulation of miR155, that return to normal levels a month later. This Treg increase reflects possibly an effort to suppress immune system activation secondary to platelet activation, shortly after the infarct.

Figure 1 Figure 1. Figure 2 Figure 2.

Disclosures

No relevant conflicts of interest to declare.
"Etiology of Non-Cirrhotic Portal Vein Thrombosis in Adults: Experience of 12 Years in a Chilean University Hospital"
Authors: Gonzalez Jaime A , Conte Guillermo F , Marin Arnaldo A
Published: October 2019

Introduction: Portal Vein Thrombosis (PVT) is a rare disease primarily caused by a thrombotic obstruction in the origin of portal vein in extrahepatic portion. PVT is a frequent complication in advanced chronic liver disease (CLD), but the etiology and complications of non-CLD PVT (nPVT) are not well understood. The etiology of nPVT is heterogeneous and involves both local and systemic prothrombotic factors such as abdominal inflammatory processes, inherited and acquired thrombophilia, and JAK 2 positive mieloproliferative neoplasm (MPN).

Methods: The aim of this study was to evaluate etiological and prognostic factors in nPVT patients in chilean population. All patients referred to University of Chile Clinical Hospital between January 2002 and January 2012 with nPTV diagnosis were included in this study, with no previous history of solid or hematologic malignancy or CLD. We studied demographic characteristics, risk factors and in-hospital mortality rate. Statistical tests were two-tailed with the level of significance set at p<0.05, and we use analysis multivariate. The presence of the JAK2 mutation was determined by polymerase chain reaction in patients from whom DNA was available. It was decided that CLD was not possible through clinical history, abdominal ultrasound and liver enzymes. Screening for Thrombophilia was made with C and S protein, prothrombin gene mutation, V Leyden factor mutation, hyperhomocysteinemia, AT-III deficit and screening for anti-phospholipid syndrome.

Results: 265.089 adult patients were hospitalized at Clinical Hospital, University of Chile between 2002 and 2012, and 119 had nPVT diagnoses (0.04%). Median age at the diagnosis was 56.8± 2.43 years, with 52.1% of female sex. 15.9% died at the hospital. Thrombophilia was diagnosed in 33 patients (27.73%), newly diagnosed solid tumors in 16 patients (13.44%) and JAK 2 positive MPN in 4 patients. In analysis multivariate, patients with nPVT and Thrombophilia diagnosis was significantly associated to previous deep venous thrombosis diagnosis (OR 7.78, p=0.0007), female sex (OR 3.06, p=0.01) and age below 50 years (OR 1.82, p=0.03)

Conclusions: nPTV is a rare disorder, and its development is associated to the presence of inflammatory intra-abdominal process, newly diagnosed solid tumors, MPN and Thrombophilia. The previous deep venous thrombosis diagnosis, female sex and age below 50 years are associated to thrombophilia diagnosis.

Disclosures

No relevant conflicts of interest to declare.
PPARγ Agonists Inhibit Adhesion Signal to Endothelial Cells in the Differentiation Induction of HL-60 Acute Promyelocytic Leukemia Cells
Authors: Park Jinny , Yoon JiWon , Yu Hong-Nu , Noh Eun-Mi , Hong On-Yoo , Kim Jong-Suk
Published: October 2019

All-trans retinoic acid (ATRA) has successfully been used in the treatment of acute promyelocytic leukemia (APL) patients, with a remission rate of greater than 90% . Despite the high cure rates, induction mortality is a still a problem in APL. One of the most common causes of death was the differentiation syndrome (DS) . The early administration of high-dose dexamethasone at the onset of the first signs or symptoms of DS is crucial, however specific biological therapies to counteract the syndrome are still not available. Peroxisome proliferator activated receptor gamma (PPARγ) is a ligand-dependent transcription factor and a member of the nuclear receptor superfamily, which is expressed in normal monocytes, various leukemias, and epithelial malignancies. PPARγ is highly induced in differentiating myeloid cells and subsequently contributes to their differentiation. Differentiation induction of APL cells is associated with increased expression of specific adhesion molecules and inflammatory cytokines, which may promote activation, migration, and adhesion of these cells. Here, we studied the effect of PPARγ agonists on the adhesion of a human leukemia cell line (HL-60) to endothelial cells. HL-60 cells were differentiated into macrophage-like cells by a PKC activator, 12-O-Tetradecanoylphorbol-13-acetate (TPA). Differentiation was determined by an increase in reactivity with the CD11b antibody. For the adhesion assay, the Matrigel transwell system was used. During the differentiation of HL-60 cells, PPARγ agonists acitvate TPA-induced CD11b expression. However, PPARγ agonists completely blocked TPA-induced ICAM-1 expression of endothelial cells, which resulted in the inhibition of adhesion of HL-60 cells to endothelial cells. These responses also were reversed by PPARγ antagonist (GW9662), indicating that PPARγ agonists inhibits the adhesion of the HL-60 cells to endothelial cells through a PPARγ dependent mechanism. These results suggest that PPARγ agonists inhibit TPA-induced adhesion signal in the between HL-60 cells and endothelial cells, and may control differentiation syndrome in APL patients.

Disclosures

No relevant conflicts of interest to declare.
Bridging to Second Allogeneic Peripheral Blood Stem Cell Transplantation with Nelarabine in a Patient with Multiply Relapsed/Refractory T-Cell ALL
Authors: Baptista Jacqueline , Tollkuci Eris , Nathan Sunita , Maciejewski John J. , Larson Melissa L. , Akpek Gorgun
Published: October 2019

T-cell acute lymphoblastic leukemia (ALL) is a very challenging disease to attain durable remission once relapses. We treated a 40 year-old female with T-cell ALL, normal cytogenetic who relapsed twice after her matched related donor allogeneic stem cell transplantation (allo-SCT) with Nelarabine achieving third complete remission prior to second allo-SCT. She was initially treated with HyperCVAD x 5 cycles with IT chemo (negative cytopathology). After achieving complete remission (CR), she received PK-directed IV Busulfan and Fludarabine myeloablative conditioning followed by 12/12 HLA-MRD allo-SCT with 11.06 x 106 CD34+cells/kg. GVHD prophylaxis was Tacrolimus and mini-Methotrexate (5 mg/m2/dose). She engrafted on time. She never had GVHD. On day+ 100, bone marrow biopsy revealed relapsed disease involving 60% of marrow space. Patient was treated with one cycle augmented HyperCVAD resulted in second CR. She developed elevated transaminases, liver biopsy was consistent with NASH and drug-induced liver injury, negative for GVHD. She was given alpha interferon 3 million units MWF in attempt to induce GVHD/GVL while pending insurance approval for donor lymphocyte infusion. She developed full donor chimerism as well as extensive chronic GVHD involving skin, liver, skin, lung, eyes, vagina, and mouth after interferon. She was treated only with topical steroid therapies and remained in CR until day+266. On Day+266, she was again found to have relapse of her disease with significant leukocytosis and circulating blasts. CT scan showed recurrent large anterior mediastinal mass. She was treated with Cytoxan (500 mg/m2) and Etoposide (100 mg/m2 x 5 days), complicated with neutropenic fevers before receiving outpatient Nelarabine. She recovered with progressive leukemia, which was treated with a single dose of Cytoxan 600mg/m2. She developed diffuse alveolar hemorrhage, treated in the MICU with high dose steroids and antimicrobials. She was discharged to outpatient clinic and given Nelarabine at 1500 mg/m2 on days +1, +3, +5, every 3 weeks for 2 cycles. Her clinical condition and peripheral counts improved with disappearing peripheral blasts after the initial cycle of Nelarabine. She received second cycle and subsequent restaging studies showed remission marrow (CR-3) with complete resolution of mediastinal mass on CT scan. She developed mild neuropathy after Nelarabine. She is currently inpatient receiving her for second MRD allo-SCT. This case is noteworthy and clearly illustrates lack of GVL effect in T-cell ALL and an efficacy of two cycles of Nelarabine even in the setting of refractory T-cell ALL relapsing twice after allogeneic SCT.

Disclosures

No relevant conflicts of interest to declare.
TP53 Mutations Determine Outcome of Patients (pts) with High-Risk Myelodysplastic Syndrome (HRMDS) and Acute Myelogenous Leukemia (AML) Regardless of Karyotype and ELN Risk Stratification
Authors: McCloskey James K. , McKenna Marshall , Koprivnikar Jamie L. , Depadova Samantha , Stanislaus Genique , Goldberg Stuart L. , Faderl Stefan
Published: October 2019

Background: Cytogenetic and molecular abnormalities are the backbone of risk stratification for pts with AML/MDS. Yet, the current stratification systems still fail to identify some pts at high risk for treatment failure. TP53 mutations have been linked to poor outcome and treatment resistance in many malignancies. We conducted a retrospective case-control study of pts with HRMDS and AML with TP53 mutations (TP53 m) to define disease characteristics, response, and outcome after transplant (HSCT).

Methods: Twenty-one consecutive pts with HRMDS or AML were treated between January 2014 and March 2016 who wereTP53 m. The pts were compared to a control cohort of 46 pts with wild type TP53 (TP53 wt). Mutation analysis was performed using next generation sequencing. All AML pts were treated with a standard 3+7 induction protocol. Pts were excluded for incomplete cytogenetic and molecular data.

Results: A total of 21 patients were identified with TP53 m (14 HRMDS, 11 AML). The median age of the 21 pts was 64 years (range 32-84). Pts with TP53 m were older (median age 64 vs 55 years, p=.0256) and exhibited a higher rate of adverse cytogenetics (71% vs 30.4%, p=.043) when compared to TP53 wt. Secondary AML was also more common with TP 53 m (57% vs 31%, p=.05). Pts with TP53 m were less likely to achieve CR (33% vs 74%, p=.009). Three pts with TP53 m proceeded to transplant (2 with HRMDS and 1 with AML).

With a median follow up of 3.4 months (range 0.3-73) the estimated PFS and OS at 18 months was superior in TP 53 wt compared to TP 53 m (17% vs 69%, p=.037 and 17% vs 50%, p=.0095 respectively). HSCST was associated with a 70% reduction in mortality, but this was not statistically significant (p=.067).

Conclusion: TP 53 mutations in pts with HRMDS and AML are associated with advanced age, high risk cytogenetic abnormalities, and secondary AML. Our findings demonstrate that TP53 m in HR MDS and AML is associated with poor clinical outcome including lower CR rates, and lower PFS and OS. Different treatment strategies need to be devised for these pts.

Disclosures

McCloskey: Incyte: Consultancy; Ariad: Consultancy, Speakers Bureau; Amgen: Speakers Bureau; Novartis: Speakers Bureau. Koprivnikar:Alexion: Consultancy, Speakers Bureau. Depadova:Amgen: Speakers Bureau. Stanislaus:Novartis: Consultancy, Speakers Bureau. Goldberg:COTA Inc: Employment; Bristol Myers Squibb, Novartis: Speakers Bureau; Neostem: Equity Ownership; Novartis: Consultancy; Pfizer: Honoraria. Faderl:Celgene: Consultancy, Research Funding; JW Pharma: Consultancy; BMS: Research Funding; Ambit Bioscience: Research Funding; Karyopharm: Consultancy, Research Funding; Celator Pharmaceuticals: Research Funding; Astellas: Research Funding; Pfizer: Research Funding; Seattle Genetics: Research Funding; Amgen: Speakers Bureau.
Adverse Hematological Effects of Benzene Exposure Among Elderly Subjects after a Flaring Disaster at the BP Refinery Plant in Texas City
Authors: D'Andrea Mark A , Reddy G. Kesava , Mitter Ajay
Published: October 2019

Objective: To evaluate the health risks associated with benzene exposure in elderly subjects following a flaring disaster at the BP refinery in Texas City, Texas.

Methods: Elderly subjects aged 60 years and older who had been exposed and unexposed to benzene were included. We reviewed medical charts and compared measures of white blood cells (WBC), platelets, hemoglobin, hematocrit, blood urea nitrogen (BUN), creatinine, alkaline phosphatase (ALP), aspartate amino transferase (AST), and alanine amino transferase (ALT) in exposed and unexposed elderly subjects.

Results: Records from 294 elderly subjects (benzene exposed, n=216 and unexposed, n=78) were reviewed. Benzene exposed subjects had significantly higher levels of WBC (X 103 per µL) (7.7±1.9 versus 6.3±1.5, P=0.0000) and platelet (X 103 per µL) counts (256.8 ± 51.6 versus 237.9 ± 41.9, P=0.0104) compared with the unexposed subjects. Serum creatinine levels (mg/dL) were also significantly increased in the exposed group compared with the unexposed group (1.1 ± 0.4 versus 0.9±0.2, P=0.000). Serum levels of ALP (IU/L) were significantly elevated in the exposed subjects compared with the unexposed subjects (87.5 ± 23.6 versus 72.5 ± 17.8, P=0.000). Similarly, benzene exposed subjects had significantly higher levels of AST (24.8 ± 6.2 versus 19.2 ± 5.1, IU/L, P=0.000) and ALT (24.2 ± 8.6 versus 19.1 ± 4.8, IU/L, P=0.000) compared with those unexposed to benzene.

Conclusion: Benzene exposure resulted in significant alterations in hematological and hepatic profiles among elderly subjects.

Disclosures

No relevant conflicts of interest to declare.
Impact of Previous Invasive Fungal Infections on the Outcome of Patients Undergoing Allogeneic Hematopoietic Stem Cells
Authors: Maffongelli Gaetano , Maffongelli Gaetano , Maffongelli Gaetano , Cudillo Laura , Di Piazza Fabio , Malagnino Vincenzo , de Santis Giovanna , Mariotti Benedetta , Ceresoli Eleonora , Cerretti Raffaella , Picardi Alessandra , Andreoni Massimo , Arcese William , Sarmati Loredana
Published: October 2019

Introduction: Outcome in allogeneic HSCT varies widely depending on disease type, stage, stem cell source, HLA-matched status and conditioning regimen. IFI is a possible complication of HSCT and a prior IFI increases the patient's risk for transplant related mortality due to the possibility of reactivation of the fungal infection. This study aimed to evaluate the impact of a previous IFI history on transplant outcome

Methods: We retrospectively collected the clinical data of patients considered eligible for allogeneic HSCT during 2014 at the Rome Transplant Network (RTN), a JACIE accredited metropolitan transplant program established in Rome since 2006. The observation of patients was continued until 31 December 2015. The diagnosis of IFI were defined as possible, probable and proven as established by European Organization for Research and treatment of Cancer.

Results: Twenty-one (37%) out of 57 eligible patients had an IFI episode before transplant: 6 of the episodes were proven, 4 probable and 11 possible. Overall, 10 (47%) pneumonia, 4 (19%) gastroenteritis, 3 sinusitis, 2 candida sepsis, 1 meningitis and 1 cutaneous abscess were registered. Five out of 21 patients (23%) died before HSCT versus 2 of 36 patients (5%) without previous documented IFI, [OR 5.31 95% CI 0.93- 30.40 , p value 0.06 Fisher Test], .

A larger percentage of patients with past IFI waited HSCT over 6 months from the date of eligibility in comparison with those without previous IFI [43% vs 30% ; OR 1.87 95% CI 0.54-6.40 , p value 0.5 Yates test]; Sixteen (57%) out of 28 dead patients in the pre-transplant period have had a previous IFI episode vs 5(17%) out of patients alive [OR 6.4, 95% CI 1.89-21.68, p value: 0.004 Yates Test].

In the post-transplant period, only 6% of patients with a past IFI, experienced an engraftment in a time of < 15 days, vs 30% of patients without past IFI [OR 4.86 CI 95% 0,5-43,2, p value 0,2 Yates test]. In the post-transplant period, a IFI was diagnosed in 13 (26%) patients; ten (76%) out of 13 patients had a past IFI versus 9 (24%) of the patients without IFI.. [OR 7.87, CI 95% 1,8-34,2, p value 0,005 Yates test].Among the dead HSCT patients, those who had a previous IFI had a lower median survival [160 days (range 22- 480)] compared to patients without a previous IFI who died [196.5 days period (range 20-820)].

Conclusions: A previous IFI episode in the pre transplant period slow the accessibility to the transplant, adversely affects the engraftment, and is significantly associated with increased post-transplant mortality

Disclosures

No relevant conflicts of interest to declare.
Durable Remission and Survival in Relapsed/Refractory Multiple Myeloma after Allogeneic Hematopoietic Stem Cell Transplantation
Authors: Cornelison A. Megan , Saliba Rima M , Ahmed Sairah , Nieto Yago , Bashir Qaiser , Shah Nina , Parmar Simrit , Patel Krina , Hosing Chitra , Popat Uday R. , Shpall Elizabeth J. , Champlin Richard E. , Qazilbash Muzaffar H.
Published: October 2019

Background: The role of allogeneic hematopoietic stem cell transplantation (allo-HSCT) in the setting of refractory multiple myeloma (MM) is still controversial. Although potentially curative in a subset of pts, concerns regarding treatment related mortality (TRM) and graft vs. host disease (GVHD) preclude its universal use. In this study, we evaluated the role of allo-HSCT for pts with relapsed MM.

Methods: 110 consecutive pts with relapsed MM underwent allo-HSCT at our institution between 2000 and 2014. The primary objective was to assess progression-free (PFS) and overall survival (OS).

Results: Median age at allo-HSCT was 54 (range, 32-71) years and median time from diagnosis to allo-HSCT was 35.7 (range, 8.6 to 228.8) months. Fifty-two (47%) and 49 (45%) pts had standard-risk (SR) and high-risk (HR) cytogenetics at the time of allo-HSCT, respectively. Pts received a median of 5 (range, 1-9) prior chemotherapy regimens and 99 (90%) pts had at least 1 (range, 0-3) prior auto-HSCTs. One hundred one (92%) pts received either a proteasome inhibitor (PI) or an immunomodulatory drug (IMiD) prior to allo-HSCT, with 65 (59%) receiving both. Sixty eight (62%) received allo-HSCT from matched related, 34 (31%) from matched unrelated, 5 (4%) from cord blood, and 3 (3%) from mismatched donors. Preparative regimen was fludarabine/melphalan-based in 88 (80%) and fludarabine/busulfan-based in 16 (15%) pts. Median time to neutrophil and platelet engraftment was 12 (range, 8-30) and 13 (range, 0-81) days, respectively. Ten pts died of non-relapse causes within 100 days (100-day TRM: 9%) and 21 (19%) within 1 year. Grade 1-4 acute GVHD was seen in 50 (45%) and cGVHD in 35 (32%) pts, respectively. Eighteen (16%) achieved a CR, 26 (23%) a VGPR and 38 (34%) achieved a PR, with an overall response rate of 73%. With a median follow up of 41.9 months (range, 6.4 to 172.9) in surviving pts, 1- and 2-year PFS were 23% and 15%, respectively (Fig 1). One and 2-year OS were 50% and 32%, respectively (Fig 2). HR cytogenetics at allo-HSCT were associated with a significantly shorter 2-year PFS (6% for HR vs. 23% for SR; p=0.007) and OS (p=0.01). A response <PR after allo-HSCT was also associated with significantly shorter 2-year PFS (p<0.001) and OS (p<0.001).

Conclusions: Allo-HSCT is associated with durable remission and survival in approximately 15% of heavily pretreated pts with relapsed/refractory MM. Novel, more effective approaches are needed for patients with HR cytogenetic abnormalities.

Figure 1 Progression-Free Survival Figure 1. Progression-Free Survival Figure 2 Overall Survival Figure 2. Overall Survival

Disclosures

No relevant conflicts of interest to declare.
hnRNP K Overexpression Drives AML Progression By Altering Pathways Critical for Myeloid Proliferation and Differentiation
Authors: Hornbaker Marisa J , Gallardo Miguel , Zhang Xiaorui , Ma Huaxian , Hu Peter , Khoury Joseph D , Kornblau Steven M. , Bueso-Ramos Carlos E , Post Sean M.
Published: October 2019

Acute myeloid leukemia (AML) is a disease largely defined by recurrent genetic and chromosomal abnormalities. As such, The Cancer Genome Atlas' recent detailed examination of the most common genetic abnormalities that drive AML uncovered relatively few novel alterations. However, within this list of recurrently mutated genes was heterogeneous nuclear ribonucleoprotein K (HNRNPK). While previously unknown to impact AML, we recently identified HNRNPK as a haploinsufficient tumor suppressor at the 9q21.32 locus. In contrast to its tumor suppressive roles, hnRNP K is most customarily overexpressed, rather than underexpressed, in several solid tumors.

In this study, we show through FISH analyses, RNA expression profiling, and reverse phase protein array analyses that the HNRNPK gene is amplified with corresponding mRNA and protein overexpression in a sizeable cohort of patients with AML that do not carry a 9q.21.32 deletion. Together, this indicates that hnRNP K may be an uncharacterized oncogene in this context. Increased hnRNP K correlated with decreased event-free and overall survival, increased WBC, and increased bone marrow and peripheral blood blast percentage. High hnRNP K levels also correlated with elevated expression of histone modifiers (e.g., ASH2L and TRIM24), regulators of ribogenesis (e.g., nucleolin and EBP1), and potent oncogenes, such as c-Myc. Together, these observations indicate that increased hnRNP K expression significantly alters the landscape of myeloid biology and may thus contribute to the etiology of AML.

To directly interrogate this possibility in vivo, we generated a Vav-Cre;HnrnpkTg mouse model. In addition to significant differences in hnRNP K expression compared to Vav-Cre mice, Vav-Cre;HnrnpkTg mice exhibited reduced survival, development of transplantable myeloid malignancies, and enhanced HSPC proliferation and differentiation potential. Reflecting data from our patients, Vav-Cre;HnrnpkTg mice also exhibited elevated expression of critical oncogenic pathways such as c-Myc.

Currently, we are examining pharmacologic methods to abrogate the effects of aberrant hnRNP K expression on various activated pathways. Transplant models using diseased bone marrow from Vav-Cre;HnrnpkTg mice are being utilized to evaluate the efficacy of specific pathway inhibitors (i.e., bromodomain inhibitors or bortezomib) in prolonging survival and decreasing leukemic burden. These studies will provide the rationale for potential clinical trails that employ these agents for patients with hnRNP K-overexpressing AML.

Disclosures

No relevant conflicts of interest to declare.
Validation of the Khorana Score in a Large Cohort of Cancer Patients with Venous Thromboembolism
Authors: Chaudhury Ateefa , Balakrishnan Asha , Thai Christy , Holmstrom Bjorn , Nanjappa Sowmya , Ma Zhenjun , Zhou Junmin , Patel Ankita , Visweshwar Nathan , Jaglal Michael V.
Published: October 2019

BACKGROUND:

Venous thromboembolism is a well-known complication of malignancy. The Khorana Risk Score (KRS) utilizes the type of cancer, blood counts, and body mass index to predict risk of thrombosis in cancer patients. Patients with a KRS of greater than 3 are considered high risk for developing blood clots and may benefit from prophylactic anticoagulation. We wanted to determine if the use of the KRS would have led to prophylactic anticoagulation (AC) in these cancer patients prior to their thrombotic events.

METHODS:

This study utilized a group of 286 patients treated at Moffitt Cancer Center between May 1, 2010 and June 30, 2015 with a wide variety of cancer diagnoses with known venous thromboembolic events (VTE) (pulmonary embolism or deep venous thrombosis). We aimed to validate the KRS by retrospective analysis to determine if the KRS would have predicted VTE in these patients on the day of their venous thromboembolic event. The demographics are summarized using descriptive statistics. Wilcoxon rank-sum test is used for testing the difference in continuous variables. Fisher exact test is used for testing the difference in categorical variables.

RESULTS:

We found that the majority of these cancer patients with known VTE (89%) would have been classified as low risk of having VTE. Only 11% would have been classified as high risk to where prophylactic anticoagulation might have been indicated.

CONCLUSIONS:

We found that in a diverse group of cancer patients who had thrombotic events, the KRS did not appropriately stratify patients at the highest risk of VTE. The majority of patients with VTE were actually found to be low risk which would not have led to improved awareness or medication prophylaxis. Improved risk stratification methods are needed for cancer patients to implement an effective prophylactic strategy.

Table Table.

Disclosures

No relevant conflicts of interest to declare.
Dissecting Antigen-Specific T-Cell Immunity in Human Cancer and Acquired Resistance to Immunotherapy
Authors: Restifo Nicholas
Published: October 2019

T lymphocytes are at the very center of the rapidly expanding universe of cancer immunotherapy. We now know that each T cell clonotype can in fact contain a stem cell-like system, which is capable of self-renewal and differentiation. We have described the identification of human T memory stem cells (TSCM). TSCM maintain robust replicative capacity and are multipotent in their ability to give rise to cytolytic effector and memory progeny. Stem-cell-like T cells are epigenetically distinct. From their poised epigenetic and metabolic states, TSCM efficiently can give rise to cells with a multiplicity of identities required for successful immune responses, and collectively provide protection against infections and cancer.

We have visualized the chromatin states of TSCM on a whole genome level. We have found that the transcription factor Bach2 is a repressor of T cell receptor-driven programs. These findings go a long way in identifying a molecular mechanism that enables T cells to maintain their stem cell-like state. We have direct evidence that sufficient T cell activation can overwhelm the repressive influence of Bach2 through the action of the Akt kinase. Akt mediates the core events of T cell differentiation and it is possible to selectively block the Akt pathway with an allosteric inhibitor enabling the creation of long-lived, less-differentiated T cells that are much more effective therapeutically in a mouse model of established tumor. These findings form the basis for a novel immunometabolomic approach to improve cell-intrinsic features of therapeutic T cells in the clinic.

Finally, we will describe how even the most effective T cells can be thwarted by mechanisms in place in the tumor microenvironment. Our recent and unpublished findings involve two elements from the periodic table - potassium and oxygen - that can be immunosuppressive under certain physiologic conditions. We have also described an internal T cell checkpoint mechanism called Cish. We furthermore seek to find ways of overcoming the powerful physiology that can enable tumors to grow and kill their hosts. These efforts can produce T cells that are capable of increased anti-tumor efficacy.

Disclosures

No relevant conflicts of interest to declare.
The Eosinophilia of Magnesium Deficiency
Authors: HUNGERFORD GERALD F. , KARSON EUGENE F.
Published: October 2019

Experimental magnesium deficiency has been produced by dietary means in intact and adrenalectomized rats. The numbers and distributions of eosinophiles and mast cells were studied.

1. Adrenal ablation produced a mild blood eosinophilia and the numbers of mast cells were reduced in peritoneal fluid. Tissue eosinophilia was not observed.

2. Magnesium deficiency in both intact and adrenalectomized rats is accompanied by an extremely high blood eosinophilia. Concurrently the numbers of peritoneal fluid eosinophiles increased while the numbers of peritoneal mast cells decreased.

3. Massive infiltration of eosinophiles into the lung, submaxillary gland and mesenteric lymph nodes were observed in all magnesium deficient groups. Mast cells were found in the liver sinusoids and spleen of adrenalectomized, magnesium deficient animals of the chronic phase where these cells are not normally present.
High Fetal—Hemoglobin C Disease: A New Syndrome
Authors: MCCORMICK WILLIAM F. , HUMPHREYS ELEANOR W.
Published: October 2019

A case of interaction of the genes for hemoglobin C and "high fetal" has been reported, with an incomplete family study. The "high F" gene seems to behave as a dominant one.

A discussion of the relationship, if any, with this disease to "classical" C-thalassemia was presented. The evidence is inconclusive, but this case does not fit the picture of C-thalassemia as previously reported and is considered to be a separate condition.