bluuebunny/crossref_metadata_2025 huggingface dataset:
Biosimilar Erythropoietin Alpha Is Effective As Originator Erythropoietin Alpha Plus Liposomial Iron and B12 and Folates in Patients with Refractory Anemia: A Retrospective Real-Life Approach
Authors: Giordano Giulio , Mondello Patrizia , Tambaro Rosa , Perrotta Nicola , D'amico Fabio , Berardi Giuseppe , Carabellese Bruno , Equitani Francesco
Published: October 2019

Background

Biosimilar drugs have a similar, but usually not inferior although not hidentical effects of old registred drugs. Safety is hidentical to old registred drug.

Aims

Aim of this study is to verify if in MDS patient with refractory anemia biosimilar erythropoietin alpha is not inferior to erythropoietin alpha in terms of safety, efficacy and costs.

Methods

This study is a dicentric, nonrandomized, retrospective study.

Between july 2008 and june 2012, 92 patients affected by refractory anemia were studied.

Median follow-up was 22 months (R3-34). Patients received in group A erythropoietin alpha 40000 IU sc/weekly. In group B patient received biosimilar erythropoietin alpha 40000 IU sc/weekly. In both groups patients received liposomal iron (Sideral®) 14 mg, 2 tablets orally/day calcium levofolinate 7.5 mg/day orally + Vitamin B12: 400 mg/day orally.

In group A median age was 70 years (R63-75), M/F: 18/28; in group B median age was 64 years (R60-70), M/F: 25/21. IPSS was low in 30 patients and int-1 in 13 patients in group A, and low in 32 patients and int-1 in 11 patients, in group B.

Patients with 5q- were excluded from this study.

Median level of haemoglobin was 8.5 g/dl in group A (R8-11) and 9.2 g/dl (R8.5-11.5) in group B.

Results

Group A patients increased Hb level of 1 g/dl after a median time of 5 weeks (R4-9) and after a median time of 4 weeks (R3-8) in group B. No relevant side effects were observed in both groups.

Erythropoietin alpha was reduced in group A because Hb achieved a level > 12g/dl after a median of 12 weeks (R 4-18). Biosimilar erythropoietin alpha was reduced in group B because Hb achieved a level > 12g/dl after a median of 10.5 weeks (R 3-16). In group A maintenance dose was administered with a median of every two weeks (2-4), In group B maintenance dose was administered with a median of every three weeks (2-5). Median cost for every month of erythropoietic therapy was 1536 euros/month (R1240-1850) in group A and 1354 euros/month (R954-1550) in group B. Five patients need transfusion support in group A and seven patients need transfusion support in group B

Summary/conclusion

Biosimilar erythropoietin alpha plus liposomal iron (Sideral®) and B12 and folates support seems to be safe, feasible, probably equally cost-effective and substantially not inferior to classical erythropoietin alpha support in patients affected by refractory anemia. This study needs confifrmation on a larger cohort of patients.

Disclosures

No relevant conflicts of interest to declare.
DNA Methylation-Based Subtype Prediction for Pediatric Acute Lymphoblastic Leukemia (ALL)
Authors: Nordlund Jessica , Bäcklin Christofer , Zachariadis Vasilios , Cavelier Lucia , Dahlberg Johan , Öfverholm Ingegerd , Barbany Gisela , Nordgren Ann , Övernäs Elin , Abrahamsson Jonas , Flaegstad Trond , Heyman Mats , Jónsson Ólafur G , Kanerva Jukka A. , Larsson Rolf , Palle Josefine , Schmiegelow Kjeld , Gustafsson Mats G , Lönnerholm Gudmar , Forestier Erik , Syvänen Ann-Christine
Published: October 2019

We present a method that utilizes DNA methylation profiling for prediction of the cytogenetic subtypes of acute lymphoblastic leukemia (ALL) cells from pediatric ALL patients. We used the methylation status of ~450,000 CpG sites from 546 well-characterized patients with T-ALL or B-cell precursor ALL with the cytogenetic subtypes high hyperdiploidy (HeH), t(12;21)(p13;q22)[ETV6/RUNX1], t(1;19)(q23;p13.3)[TCF3/PBX1], 11q23/MLL-rearrangements, t(9;22)(q34;q11)[BCR/ABL1], dic(9;20)(p13.2;q11.2), and intrachromosomal amplification of chromosome 21 iAMP21[RUNX1 x >3], to design and validate sensitive and accurate DNA methylation classifiers. After repeated cross-validation, a final classifier was derived consisting of only 246 CpG sites that accurately predicted the subtype of >96% of the patients with known subtype. The mean sensitivity and specificity across the subtypes was 0.90 and 0.99, respectively. We then used the DNA methylation classifier to screen for subtype membership of 210 patients with undefined karyotype (normal or no result) or non-recurrent cytogenetic aberrations (“other” subtype). Nearly half (n=106) of the patients lacking cytogenetic subgrouping displayed highly similar methylation profiles as the patients in the known recurrent groups. We verified the subtype of 20% of the newly classified patients by examination of diagnostic karyotypes, array-based copy number analysis, and detection of fusion genes by quantitative PCR and RNA-sequencing (RNA-seq). Using RNA-seq data from ALL patients where cytogenetic subtype and DNA methylation classification did not agree, we discovered several novel fusion genes involving ETV6, RUNX1, and PAX5. The CpG sites constituting the classifiers highlight relevant biological characteristics of otherwise unclassified ALL patients and provide clues to the origin and development of leukemic transformation. Together with response to induction therapy, genetic aberrations are among the most important prognostic factors in pediatric ALL. Our findings indicate that DNA methylation profiling can help clarify some of the heterogeneity in cytogenetically undefined ALL patient groups and can potentially be implemented for diagnostics of ALL and other types of hematological cancers.

Disclosures

No relevant conflicts of interest to declare.
Gallstones in Sickle Cell Disease: A Single Institution Experience
Authors: Coats Thomas , Gardner Kate , Thein Swee Lay
Published: October 2019

Background: There is an increased incidence of gallstones in patients with sickle cell disease (SCD), due to haemolysis. Complications of gallstones include cholecystitis, pancreatitis and cholangiopathy and gallstones can trigger an acute sickle cell crisis. It is not known whether patients with asymptomatic gallstones would benefit from elective cholecystectomy to avoid such complications.

Method: Electronic patient records of all 767 adult SCD patients attending clinic at King’s College Hospital, London between 1st Jan 2003 and 31st Dec 2013 were retrospectively reviewed to identify cases of gallstones. Medical records and steady state blood values were analysed in all those patients with an ultrasound of the biliary tree during this time period.

Results: Amongst the cohort of 767 patients with SCD, 481 (62.7%) were HbSS, 244 (31.8%) HbSC, 35 (4.6%) HbSB+, 6 (0.8%) HbSB0 and 1 (0.1%) HbSHFPH genotype. 43% were male. Mean age at the end of the study period was 36.6 +/- 12.5 years. 344 patients had an ultrasound scan of the biliary tree during the time period of the study. 38 of the 344 patients scanned had had a cholecystectomy prior to 2003. Of the remaining 306 patients with an ultrasound scan, 134 had gallstones identified within the gallbladder. The 134 patients with gallstones comprised 119 (88.8%) HbSS, 12 (9.0%) HbSC, 2 (1.5%) HbSB+ and 1 (0.7%) HbSB0. 39.6% were male. Mean age at the end of the study period was 35.4 +/- 12.2 years.

Of the 134 patients with gallstones identified during the study, 35 developed serious complications directly relating to cholelithiasis (5 pancreatitis, 4 acute cholangitis, 8 choledocholithiasis and 18 isolated cholecystitis) and 8 of these patients required sphincterotomies +/- stone removal with endoscopic retrograde cholangio-pancreatogram.

34 of the 134 patients with gallstones went on to have a cholecystectomy during the 11 year study period. Of these 34, 3 had recorded surgical complications following cholecystectomy (2 bile leaks, 1 hepatic injury). All 3 cases had gallstone-related complications prior to the cholecystectomy.

Discussion: Our findings of cholelithiasis in 134 of the 306 of sickle cell disease patients scanned, is similar to incidence reported in the literature. Notably, we documented a high incidence of complications associated with cholelithiasis. Furthermore, there were higher than expected rates of surgical complications in cholecystectomy undertaken following the development of a complication relating to gallstones. These findings make routine screening for cholelithiasis followed by elective cholecystectomy for positive cases an attractive approach.

Disclosures

No relevant conflicts of interest to declare.
Rivaroxaban Safety Threshold at 30 Ng/ml: Are a PT and/or a Aptt an Alternative to a Specific Test in the Real World?
Authors: Cauchie Philippe , Dierge Laurine , Isabelle Courtois , Alewaeters Alain , Chatelain Bernard
Published: October 2019

The French Working Group on Perioperative Haemostasis (GIHP) published in March 2013 proposals for the management of major bleeding complications and emergency surgery in patients treated with direct oral anticoagulants, and especially the Rivaroxaban. This Direct Oral Anticoagulant (DOA) induces most of clotting tests, including Prothrombin Time (PT) and APTT. This led the GIHP to a degraded proposition for the institutions who does not propose the specific dosage of the molecule. This proposal assumes that the normality of the PT and aPTT exclude most patients with Rivaroxaban level >30 ng/ml. The aim of our evaluation is to verify the real-life practicability of this proposal.

Samples from Rivaroxaban treated patients have been tested with 4 PT reagents: STA Neoplastine R (NeoR), STA Neoplastine CI+, Recombiplastine and Innovin. Four APTT reagents were also tested: STA-PTT automate, STA Cephascreen, Synthasil, Pathrontin SL. All reagents were tested on their specific analysers (STA-R, ACL TOP500, BCS XP). PT reagents were calibrated following manufacturer’s instructions (Stago, Instrumentation Laboratory, Siemens).

Rivaroxaban prolongs PT but reagent’s sensitivity varies considerably and we observed a major individual variability, and this even at low Rivaroxaban concentrations. The NeoR presents the greatest sensitivity, the Innovin the lowest. For a normal PT (>70%), the NeoR alone can validly identify patients with Rivaroxaban level > 30ng/ml (sensitivity 93%). With the other reagents, from 42 to 51% of our patients with normal PT has Rivaroxaban level > 30 ng/ml. Two patients with Rivaroxaban > 150 ng/ml had normal PT with these 3 reagents. None of the APTT reagents has sufficient sensitivity to validly exclude these patients.

In conclusion, none of the PT reagents can estimate Rivaroxaban concentration. The NeoR is the only reagent that allows distinguishing patients with residual Rivaroxaban level. For all other situations, specific test seems mandatory and the development of point-of-care system should be encouraged.

Disclosures

No relevant conflicts of interest to declare.
Anticoagulation Clinic Protocol and Electronic Medical Records in Patients Treated with Warfarin: Do They Increase the Likelihood of Achieving Therapeutic INR?
Authors: Patel Urmeel H , Galooshian Liya , Fontem Franklin , Kalavazoff Nadine , Klein Jordan , Agbonavbare Patience , Wert Yijin , Cheriyath Pramil
Published: October 2019

Introduction

Managing patients on warfarin therapy is known to be a challenging task in the outpatient setting. One of the methods used to improve warfarin therapy in the outpatient setting and increase patient compliance and time in therapeutic range (TTR) has been to refer the patient to an anticoagulation clinic. Anticoagulation clinics are used to achieve a higher TTR by using a protocol to standardize the management of warfarin therapy. This study looks into whether the implementation of a protocol to manage warfarin therapy and electronic medical records (EMR) to record the management have any effect on the patients’ TTR.   

Method

A retrospective study was completed on patients being managed on warfarin therapy and were a part of an anticoagulation clinic. A chart review was done on ninety-one patients. All INR results were collected on the patients prior to and after the interventions were implemented and included their therapeutic range. The number of days until the INR became therapeutic and the dosage of warfarin required for patients to remain in the therapeutic range were also collected. Chi-square tests were done to analyze the data to determine whether the interventions improved patients’ TTR.

Results

Prior to EMR implementation 62.76% of tests were found to be within therapeutic range; after EMR implementation 58.96% of tests were found to be within therapeutic range with a p-value of 0.0604. Prior to the protocol implementation, 65.41% of tests were within therapeutic range compared to 59.75% of tests within therapeutic range after protocol implementation with a p-value of 0.0409.   

Conclusion

Our results showed EMR implementation did not have any effect on the TTR for patients on warfarin therapy. Furthermore, when a protocol was implemented to standardize warfarin therapy and management in the anticoagulation clinic setting, study results revealed the TTR decreased with the standardized protocol with a p-value found to be statistically significant. In conclusion, the data suggests the management of warfarin therapy should be done on an individual patient case-by-case basis rather than a standardized approach to increase TTR.

Disclosures

No relevant conflicts of interest to declare.
A Restrictive Strategy Reduces the Number of Transfused Packed Red Blood Cells in Allograft Recipients
Authors: Mear Jean-Baptiste , Chantepie Sylvain , Gac Anne-Claire , Bazin Agnes , Reman Oumedaly
Published: October 2019

Objectives. The number of transfusion is increasing faster than the rate of new blood donations. Further more, a transfusion excess, causing iron overload may have a deleterious effect on long term survival of patient with a malignant blood disease. We therefore tried to reduce the number of Packed Red Blood Cells (PRBC) by transfusing only one PRBC per transfusion instead of two.

Material and methods. We conducted a prospective monocentric study between January and December 2013, with an historic comparative arm (from January 2010 to December 2012). We compared the number of PRBC transfused per hospital stay between two cohorts receiving only one PRBC per transfusion (Experimental arm or 1PRBC arm) or two PRBC per transfusion (Historical or 2PRBC arm). All patients admitted for remission-inducing therapy for acute leukemia or allogenic hematopoietic stem cell transplant (alloHSCT) aged ≥ 18 were eligible. The study was approved by local ethical committee. Transfusion triggers were hemoglobin lower than 80g/l or symptomatic anemia. Data analysis was performed in intention to treat. Results are mean ± standard deviation.

Results. Seventy-five patients were included in the 1PRBC arm and 194 in the 2PRBC arm. Population distribution for sex, age, pathology and treatment was comparable between the two arms. There was no significant difference of transfused PRBC per hospital stay between the two groups. (7,92±5,39 vs. 9,27±7,42, 15% decrease. p=0,18). However, the restrictive strategy saved 1PRBC per hospital stay (estimated mean of 75 PRBC/year in our center). In the subgroup analysis, alloHSCT recipients from the 1PRBC arm (N=23) received significantly less PRBC than the 2PRBC ones (N=81) (4,13±4,34 vs. 7,51±8,96, 45% decrease. p=0,0058). Savings in this arm is 3 PRBC by hospital stay (estimated mean of 69 PRBC/year in our center). The number of adverse events and symptomatic anemia did not significantly differ between the two arms.

Conclusion. A restrictive transfusion strategy is not inferior to a standard 2PRBC transfusion strategy and saves 1 CGR per hospital stay. This effect is especially patent in alloHSCT recipients. A prospective randomized multicentric study is ongoing to confirm these preliminary results.

Disclosures

No relevant conflicts of interest to declare.
Understanding the Role of Erythrocyte Adenosine Deaminase in the Ribosomopathies
Authors: Narla Anupama , Glader Bertil , Wong Carolyn
Published: October 2019

Diamond Blackfan anemia (DBA) is congenital bone marrow failure syndrome characterized by red cell aplasia and a predisposition to cancer. It was the first disease linked to ribosomal dysfunction with 70% of patients having haploinsufficiency of a ribosomal protein (RP) gene with RPS19 being the most frequently mutated. The 5q- syndrome is a subtype of myelodysplastic syndrome (MDS) also characterized by a severe anemia that is caused by heterozygous loss of RPS14 on chromosome 5q. These patients also have a predisposition to cancer. The reciprocal relationship between these two diseases, which are now collectively known as the ribosomopathies, has spurred interest in how we may be able to better understand the pathophysiology of these ribosomopathies to broaden therapeutic options, and to improve diagnosis.

Erythrocyte adenosine deaminase (eADA) levels have been used for last three decades in the diagnosis of Diamond Blackfan anemia based on the finding in 1983 that eADA enzyme levels are significantly elevated in patients with DBA. It is now known the eADA levels are elevated in >75% of patients with DBA. Furthermore, it has a sensitivity of 84%, specificity of 95% and positive and negative predictive values of 91% for the diagnosis of DBA compared with other inherited bone marrow failure syndromes. Our goal was to study the levels of eADA in patients with the 5q- syndrome to determine whether they were elevated (suggesting that eADA may be specific to ribosomal haploinsufficiency in general) or normal (suggesting that eADA may be specific to DBA).

Under a Stanford approved IRB, we are testing adult patients with the 5q syndrome who have not been transfused in the previous 3 months (which would affect the results of the test) and who have a confirmed deletion of the 5q- region by cytogenetics. To date, all of the 4 MDS samples, sent to us from collaborating hematologists, have had a normal eADA level. These findings suggest that elevation of eADA may be specific to DBA and not a general feature of ribosomal haploinsufficiency although our sample size is small and we plan to test additional samples.

Disclosures

No relevant conflicts of interest to declare.
Hydrocortisone does Not Influence in Vitro Glucocorticoid Sensitivity of Acute Lymphoblastic Leukemia Blasts
Authors: Warris Lidewij T. , van den Heuvel-Eibrink Marry M. , Ariës Ingrid M. , Pieters Rob , van den Akker Erica L.T. , Den Boer Monique L.
Published: October 2019

Introduction: Dexamethasone-induced neuropsychological side effects on mood, behavior and cognition seriously affect quality of life in children with acute lymphoblastic leukemia (ALL) during a long treatment period. Based on recent studies in animals, we hypothesized that these neuropsychological side effects are mediated by dexamethasone-induced cortisol depletion of the mineralocorticoid receptor (MR) in the brain. Therefore, we hypothesize that these side effects could be ameliorated by an intervention with hydrocortisone. For clinical application settings however, an absolute prerequisite is that MR activation does not interfere with the efficacy of the glucocorticoids, dexamethasone and prednisolone, on ALL cells.

Materials and Methods: To investigate responsiveness of leukemic cell lines and fresh patients’ leukemic cells to dexamethasone and prednisolone in the presence of hydrocortisone, MTT-assays were performed. In addition MR and the glucocorticoid receptor (GR) expression on leukemic cells of different ALL subtypes was studied with a microarray-based gene expression profiling and validated by quantitative real-time PCR.

Results: Leukemic cells expressed the MR at a very low level with a significantly higher (P≤0.001) expression in ETV6-RUNX1+ patients (median: 160.7 [AU] of fluorescence intensity, range: 38.1 - 760.6 [AU]) versus other ALL subtypes (median: 41.8 [AU] of fluorescence intensity, range: 25.1 - 276.2 [AU]). MR expression did not differ between glucocorticoid resistant and sensitive patients’ cells. Hydrocortisone addition did not affect glucocorticoid sensitivity of leukemic cell lines and patients’ leukemic cells of different leukemic subtypes also including ETV6-RUNX1+. Glucocorticoid sensitive patients’ cells became significantly more sensitive by hydrocortisone addition (prednisolone: P≤0.01, dexamethasone: P≤0.05).

Conclusion: This present study shows that hydrocortisone does not interfere with efficacy of dexamethasone and prednisolone in vitro. These findings support a clinical randomized trial to study whether addition of hydrocortisone decreases the neuropsychological side effects of dexamethasone in children with ALL.

Acknowledgments: The financial support of the KiKa® (Kinderen Kankervrij) foundation is highly appreciated.

Disclosures

No relevant conflicts of interest to declare.
Established Standards of Minimal Residual Disease Detected By Multiparametric Flow Cytometry in Acute Leukemia
Authors: Jing Hui , Huang Fen , Yi Zhengshan , Zheng Zhongxin , Wei Xiaolei , Xie Muchen , Hao Xiaoxiao , Feng Ru
Published: October 2019

Purpose

To establish a method for detecting minimal residual disease (MRD) by eight color flow cytometry which is stable, repeatable and accurate quantitation.

Method

According to the ratio of 10%, 1%, 0.1%, 0.01% and 0.001%,to analyze sensitivity of the method by successively mixing the cell lines (Kasumi, KG-1a) and primary acute leukemic bone marrow cell were mixed with normal bone marrow cells. In order to ensure the specificity of the test results, we increased antibody number to eight color combinations of antibodies to adjust fluorescence compensation value after labeling antibody separately in each channel. To verify the feasibility of standardization, standardized test were in 25 bone marrow samples of acute leukemia.

Result

In standard conditions of detection and sensitivity of 10-5could be detected by eight color flow cytometry. In our study there were 25 cases of acute leukemia, including 14 patients with acute myeloid leukemia and 11 patients with acute B-lymphoblastic leukemia. 23 of 25 cases were detected specific leukemia associated immunophenotypes (LAIP) at diagnosis. 20 patients could be detected the original LAIP, and LAIP of 3 patients changed after remission induction therapy. To analyze the relationship between the clinical data and MRD level, the result showed that the type of LAIP had significant influence on level of MRD. After remission the level of MRD in patients who expressed cross lineage and non-synchronous antigens at diagnosis was significantly higher than those who did not express (P=0.003, P=0.006).

Conclusion

We established the standardized conditions of minimal residual disease detected by multiparametric flow cytometry to ensure the accuracy and specificity of the test results. It has important significance to confirm that manifestations of LAIP were consistent with the outcome in patients with acute leukemia.

Disclosures

No relevant conflicts of interest to declare.
Paired Analyses of Diagnostic and Relapse Samples of MLL rearranged Infant Acute Lymphoblastic Leukemia Reveals Potential Therapy-Resistant Genomic Alterations
Authors: Buijs Arjan , Stevens-Kroef Marian JPL , Sonneveld Edwin , van der Veken Lars T.
Published: October 2019

Infant acute lymphoblastic leukemia (ALL) (less than one-year-old) is a rare, aggressive disease, with unique biological and clinical features. It is associated with 11q23 MLL rearrangements (MLL-R), and a high relapse risk. In contrast, in childhood ALL (age 1-18 years) the majority survives beyond 5 years, and only 15-20% of patients relapse. The genomic landscape in the latter group has been investigated quite extensively, and is has proven to be of diagnostic and prognostic significance. Paired diagnostic and relapse samples have identified frequent microdeletions in B-cell differentiation and cell cycle regulating genes IKZF1, EBF1 and CDKN2A/B. Alterations in these genes, either at diagnosis or relapse are linked to therapy-resistance. In contrast, data on copy-number alterations in infant ALL, particularly at relapse, are very limited. Therefore, we investigated two infant ALL at diagnosis and relapse by molecular cytogenetic analyses including high-density SNP array.

A six-months-old boy was diagnosed with pro B-ALL. Molecular cytogenetic analyses revealed a t(4;11) MLL-AFF1 positive karyotype. SNP array resulted in a balanced profile. After a MUD-SCT the ALL relapsed at age 1.1-years. Cytogenetics demonstrated the t(4;11) stemline, and evolution with two related sidelines, one with a dic(1;19) and another with an unbalanced t(1;18), both resulting in 1q gain. In addition, SNP array analysis revealed homozygous loss of 7p12.2 IKZF1 due to an overlapping and an intragenic exon 2-3 deletion.

The second case, a 3-months-old boy with pre B-ALL, showed a complex t(11;19) MLL-MLLT1 positive karyotype. Microarray analysis resulted in a balanced profile. At age one-year the ALL relapsed after a sibling-SCT, with the complex karyotype. SNP array showed a chimeric profile with only two small heterozygous 19p13.3 deletions, one including TCF3.

In childhood ALL drug resistant blasts at relapse are probably subclonal at diagnosis, or develop during therapy, with frequent microdeletions of B-cell differentiation regulating genes IKZF1 and EBF1. These alterations are found particularly in MLL-wt ALL, whereas MLL-R ALL is associated with epigenetic perturbations. Interestingly, in our two cases of infant MLL-R ALL we observe, at relapse only, microdeletions of B-cell differentiation regulating genes IKZF1 and TCF3. It is of importance to study more paired cases to further define the mutational landscape of this unique, but ill-fated subtype of ALL.

Disclosures

No relevant conflicts of interest to declare.
Defining Criteria for Diagnosis of Occult Lymphomatous Involvement in Cerebrospinal Fluid
Authors: Mocikova Heidi , Klanova Magdalena , Spacek Martin , Pytlik Robert , Kozak Tomas , Trneny Marek , Pospisil Vit
Published: October 2019

Introduction: Currently, there is no consensus regarding diagnosis and treatment of occult lymphomatous menigeal involvement of cerebrospinal fluid (CSF) in patients with systemic non-Hodgkin lymphomas (NHL), especially in patients with minimal number of clonal cells detected by flow cytometry (FCM) or by cytology.

Aim of the study: To describe a cohort of patients with occult lymphomatous involvement in cerebrospinal fluid including the diagnostic methods as well as management.

Patients and methods: CSF at diagnosis of B-NHL was examined by FCM, cytology, biochemistry and microRNA analysis in a cohort of 62 patients (systemic DLBCL N=45, MCL N=15, Burkitt lymphoma N=2) between 2010 and 2013. Occult meningeal involvement was defined by: a/ FCM: absolute positive number of clonal cells <20 and concomitant negative finding by cytology; b/ FCM negative for clonal cells and concomitant positive finding by cytology; c/ by abundance of increased levels (≥ 200% of the threshold levels) of oncogenic microRNAs (members of miR-17-92 cluster and miR-21, evaulated by Taq-Man RT PCR) in cerebrospinal fluid in patients either passing a/ or b/. The threshold of individual microRNA abundance was defined by statistical analysis of patients with or without CNS involvement. The patients qualified for occult meningeal involvement were considered to be at high risk of CNS relaps. As a control group, the patients with elevated oncogenic microRNAs and negative FCM or cytology of CSF (N=10), were used. All patients received some form of CNS prophylaxis as a part of standard first line treatment.

Results and conclusions: According to described criteria we identified 8 patients with occult meningeal involvement at diagnosis (systemic DLBCL N=4, MCL N=3, Burkitt lymphoma N=1) out of 62 patients: 3 with negative FCM and positive cytology (2-14 cells/ul); and 5 with positive FCM <20 clonal cells and negative cytology, 3 out of them with positive microRNAs. None of these patients with occult meningeal involvement relapsed/progressed into CNS within 12 months. In contrast three out of ten control patients (characterized by elevated oncogenic microRNAs in CSF, but negative for FCM and cytology) relapsed to CNS within 6 months after diagnosis. None of ”triple” negative (FCM, cytology, microRNA) patients (N=44) developed clinically manifest CNS involvement.

These results suggest that examination of oncogenic microRNA in CSF at diagnosis is more sensitive method than FCM and cytology of CSF to detect the patients with occult CNS involvement and higher risk of CNS involvement and this should be reflected in treatment strategy in further clinical trials.

Grants: GACR305 13-12449P, UNCE204021, PRVOUK: P24/LF1/3, P27/LF1/1, P 27/2012 LF3

Disclosures

Spacek: Roche: Consultancy, Travel grants Other.
Low Blood Absolute CD4 Counts Is Associated with Inferior Progression Free Survival in Diffuse Large B-Cell Lymphoma Independent of Age and IPI
Authors: Al-Saleem Tahseen I. , Dulaimi Essel , Millenson Michael M. , Smith Mitchell R. , Judd Julia , Li Tianyu , Borghaei Hossein
Published: October 2019

Tumor-infiltrating immune cells influence diffuse large B-cell lymphoma (DLBCL) outcome. Relatively little is known about the significance of peripheral blood immune cell counts (obtained by generally available flow cytometry) on DLBCL behavior

Patients and methods: 45 newly diagnosed DLBCL patients enrolled in an institutional protocol had blood pretreatment multicolor flow cytometry performed and immune cell counts recorded. The M/F ratio was 24/21, age 19-88, median 64; stage I: 11, II: 13, III: 6 and IV: 15. Thirty two had low/ intermediate International Prognostic Index (IPI) score (0-2) and 13 had 3+ IPI. One patient was HIV+. Thirty seven (82%) received immuno-chemotherapy and 8 had chemotherapy and/or irradiation.

Statistical Methods: The outcomes of the study were progression free survival (PFS) and overall survival (OS). Kaplan-Meier estimation method and Log-rank test were used in the univariate analysis. The Cox proportional hazard model was used for multivariable analysis (MVA). All analyses were done via SAS 9.2.

Results: Mean absolute CD4 cell count (ACD4C) was 450/c.mm and the median about 400. After follow up of 0.8 to 152 months (median: 73), 25 (56%) were still alive.

Univariate analysis: significant predictors to PFS were: age (HR=1.05, 95%CI: 1.02-1.09, p=0.005), ACD4C (HR= 0.998, 95% CI: 0.966-1.000, p= 0.023] and IPI (HR=0.05, 95%CI: 0.995-1.89, p= 0.054). But for OS ACD4C was only marginally significant (p= 0.083). Absolute lymphocyte count (ALC), CD8 and [CD3-C56+ (NK)] counts did not correlate with OS or PFS.

When analyzed as a binary variable with cutoff of 450/cmm, the 18 patients with high ACD4C had better 5 year PFS, 88% vs. 52% (p= 0. 023), figure (1), and OS, 88% vs. 59% (0.054) than the 27 with low ACD4C. Age, IPI groups (low /intermediate versus high) and ALC also correlated with PFS and OS, but not the CD8 or NK cell counts.

MVA with age as a continuous variable, IPI groups and ACD4C of 450/cmm; age and ACD4C only were significant for PFS, (p= 0.008 and 0.036 respectively). For OS age was the only significant variable (p=0.017). ALC, CD8 and NK cell counts did not correlate with PFS or OS.

Conclusion: Though the series contains more early stage patients than usual, blood ACD4C seems to be a predictor of PFS and to a lesser extent OS in DLBCL independent of age and IPI. If confirmed in a larger prospective study of uniformly treated patients ACD4C may serve as an immunological marker for DLBCL biological behavior.

Figure1: Progression Free Survival Figure1:. Progression Free Survival

Disclosures

No relevant conflicts of interest to declare.
Is Radiation Therapy Effective for DLBCL As a Salvage after Chemotherapy?: A Study of 180 Diffuse Large B Cell Lymphoma (DLBCL) Cases at a Single Institution
Authors: Ouchi Aya , Masahiro Yokoyama , Oguchi Masahiko , Takeuchi Kengo , Kusano Yoshiharu , Nitta Hideaki , Ueda Kyoko , Nishimura Noriko , Tsuyama Naoko , Terui Yasuhito , Usui Noriko , Aiba Keisuke , Hatake Kiyohiko
Published: October 2019

Introduction: Radiation therapy (RT) for localized- refractory or relapsed diffuse large B cell lymphoma (DLBCL) after chemotherapy is a standard therapy. Though some cases achieve complete remission (CR) after RT for local residual disease, others reveal disease progression after RT.

Methods: We analyzed DLBCL receiving RT on the purpose of achieving remission after chemotherapy at Cancer Institute Hospital from October 2005 to January 2014. All patients (pts.)’ histopathology samples were reviewed by expert hematopathologists, according to the WHO classification. All RT regimens were planned by expert lymphoma radiotherapists.

Results: A total of 180 pts. were included in this study. Baseline pts.’ characteristics were a median age of 65.2 years (range, 17.3-88.1 years), 105 male and 75 female, 87 pts. (48.3%) receiving radiation therapy as an adjuvant therapy after 3 cycles of R-CHOP therapy, 43 pts. (23.9%) receiving RT for low SUV max (1.2-7.94) residual disease at positron emission tomography-computed tomography (PET-CT) evaluation after chemotherapy, 38 pts. (21.1%) receiving for primary refractory, and 12 pts. (6.7%) for localized relapsed DLBCL after previous chemotherapy. A median total dose of RT was 30.6Gy (range, 16.0Gy-50.4Gy). After RT, 5 pts. (5.7%) of adjuvant therapy were progressive, 5 pts. (11.6%) of the pts. with low SUVmax at PET-CT, 25 pts. (65.8%) of primary refractory, and 11 pts. (91.7%) of relapsed DLBCL. Disease progressions outside of the radiation fields were recognized at 5 pts. (100.0%) of adjuvant therapy, 5 pts. (100.0%) of low SUV max cases, 12 pts. (48.0%) of primary refractory, and 10 pts. (90.9%) of localized relapsed DLBCL. There was no treatment related mortality during RT. At a median follow-up time of 33.3 months (range, 6.5-74.0), the 2 year progression free survival (PFS) after RT and overall survival (OS) rates are 74.4%, 76.7%, respectively. In Adjuvant group, PFS and OS were 94.5%, 93.1%, respectively. In low SUV max group, 70.1%, 83.7%, primary refractory group, 34.2%, 39.5%, and relapsed group, 8.3%, 50.0%, respectively.

Conclusions: RT as adjuvant therapy and for low SUV max residual disease after chemotherapy resulted in a good prognosis. High rates of disease progression outside the RT field were outstanding and they might indicate the limitation of local treatment for DLBCL. Because RT triggers few severe adverse events, it is tolerable even for elderly people and patients with long history of chemotherapy. However, it may be desirable for primary refractory and relapsed DLBCL as localized disease after chemotherapy to treat with chemotherapy as a systematic therapy.

Disclosures

Masahiro: Chugai Pharmaceutical co.,LTD: Consultancy. Nishimura:Chugai Pharmaceutical Co., LTD: Consultancy.
The Impact of Early Molecular Response in Event Free Survival in Patients with Chronic Myeloid Leukemia Treated with Imatinib
Authors: Fogliatto Laura , Capra Marcelo Eduardo Zanella , Shaan Mariza , Costa Tito Vanelli , Torriani Mayde Seadi , Contin Luis Carlos Zanandrea , Breunig Raquel , Fassina Katia , Fernandes Mario Sérgio , Almeida Denise , Schilling Marco Antônio , Hellwig Tânia , Daltoe Tiago , Zardo Adriana , Moschen Mariangela , Nene Moema , Silveira Juarez Fontoura , Soares Tahiane Brum , Daudt Liane Esteves , Friedrisch João , Silla Lucia
Published: October 2019

Background

Monitoring response to TKI therapy is one of the key management strategies of chronic myeloid leukemia (CML). Early molecular response to first-line TKI therapy is emerging as an effective prognostic factor indicator of long-term durable response and survival.

Objectives

We conducted a study to evaluate the importance of the early molecular response (EMR) at 3, 6 and 12 months (mo), and 3-year event free survival (EFS).

Methods

This is a retrospective study in a cohort of pts with chronic myeloid leukemia chronic phase (CP) enrolled in 14 Hematology centers in South Brazil. All pts received imatinib 400mg as first or second-line therapy. Patient evaluation and response criteria followed the ELN recommendations. EFS was measured from the start of imatinib to the date of any of the following events while on therapy: death from any cause, loss of complete hematologic response, loss of complete cytogenetic response, discontinuation of therapy for toxicity or lack of efficacy, or progression to accelerated phase or blastic phase.

Results

We analyzed data from 517 pts with CML-CP diagnosed since 1990. After a median observation time of 46 months, 5-year overall survival (OS) was 86% and 5-year event-free-survival was 53%. At 3 mo, EFS was 72,5% for 46 pts with BCR-ABLIS ≤10% compared to 58% for 14 pts with BCR-ABLIS >10% (p<0,07). Similarly, when EMR was analysed at 6 mo, the EFS was 81% for 75 pts with BCR-ABLIS ≤1%, while 31% of EFS was achieved for 38 pts with BCR-ABLIS >1% (p<0,001). At 12 mo, the 3-year EFS was 86% for 65 pts with with BCR-ABLIS ≤0,1% compared to 54% for pts with BCR-ABLIS>0,1% (p<0,001).

Conclusions

A significant proportion of pts achieve ERM after 3,6 and 12 mo of imatinib therapy with better 3-year EFS. ERM may could identify those pts more likely to have a favorable outcome.

Disclosures

No relevant conflicts of interest to declare.
Parvovirus B19 Infection Associated with Silent Cerebral Infarcts: A Secondary Analysis of the Silent Cerebral Infarct Trial Cohort
Authors: Ogunsile Foluso Joy , DeBaun Michael R. , Currie Kelli , Rodeghier Mark J.
Published: October 2019

Introduction:

Silent cerebral infarcts (SCI) are the major cause of neurological injury occurring in almost 40% of the population in children with sickle cell anemia (SCA); and are associated with a Full-Scale IQ decrease of approximately 5 points. Acute anemic events, defined as hemoglobin< 6.0 g/dl, is associated with an increase odds ratio (OR) of SCI (OR 2.72; 95% CI, 1.13-6.54; P = .025; Bernaudin et al. Blood. 2015 Mar 5; 125(10):1653-61). Infection with parvovirus B19 (B19V) causes a transient reticulocytopenia and an acute drop in hemoglobin levels in children with SCA. We tested the hypothesis that a history of B19V infection was associated with increased odds ratio of SCIs.

Methods:

In this retrospective cross-sectional study design, we performed a secondary analysis on the Silent Cerebral Infarct Multi-Center Clinical Trial (SIT Trial). Children with SCA between 5 and 15 years of age, with no history of overt strokes or seizures, were screened for SCIs with MRIs of the brain. Research personnel reviewed medical records to determine a history of B19V infection. Based on prior evidence from the SIT Trial cohort demonstrating that lower hemoglobin levels divided into tertiles are associated with an increase odds of SCI (DeBaun et al. Blood. 2012 Apr 19;119(16):3684-90), three analyses were performed. We stratified by hemoglobin levels into tertiles (<7.6g/dL, ³7.6 and ²8.4 g/dL, and >8.4 g/dL), to determine an association between SCI status and history of B19V infection. Chi squared statistic was used as the measure of association. As a secondary analysis of the original SIT trial cohort, the level of strong significance associated with an increased odds ratio of SCI was determined to be <0.01, with values <0.05 considered moderate significance.

Results:

A total of 814 of the SIT Trial participants had their SCI status adjudicated (present or absent) and a recorded history of B19V status (yes or no). In the cohort, 30% had a SCI and 17% had a history of B19V infection. Prior B19V infection with baseline hemoglobin levels <7.6 g/dL were associated with increase OR of SCI (OR 2.20; 95% CI, 1.22 to 3.97; p=0.008). Prior B19V infection with a baseline hemoglobin levels in the middle (³7.6 to²8.4 g/dL) and upper tertiles (> 8.4 g/dl) were not associated with an increased OR of SCI (OR 0.88; 95% CI, 0.47 to 1.66; p=0.695; and ³8.5 g/dL OR 1.39; 95% CI, 0.72 to 2.69; p=0.328; respectively).

Conclusion:

Children with SCA, a history of B19V and a low baseline hemoglobin level <7.6 g/dL have an increased OR of SCIs. Future efforts in developing a vaccine for B19V may provide an opportunity for decreasing the incidence of SCIs in children with SCA.

Disclosures

No relevant conflicts of interest to declare.
Natural Killer Cells Display an Activated Phenotype but Reduced Effector Functions in Obese Patients
Authors: Viel Sebastien , Besson Laurie , Charrier Emily , Bienvenu Jacques , Disse Emmanuel , Walzer Thierry , Dumontet Charles
Published: October 2019

The impact of adiposity on the immune system remains largely unexplored. While obesity has been suggested to be a predisposing or adverse prognostic factor in certain neoplastic diseases it is not yet clear to what extent this may involve the innate or adaptative immune systems. Adipose tissue produces a large number of secreted molecules, or adipocytokines, which may have immunomodulatory functions. This project aimed to determine whether phenotypical and/or functional properties of circulating natural killer (NK) cells were influenced by body mass index (BMI). In a preliminary study, 47 patients with no history of hematological malignancy were included, including 14 healthy volunteers with a normal BMI (18.5-25), 10 patients considered to be overweight (25 < BMI < 30), 11 patients considered as obese (BMI > 30) and 12 patients who were previously obese and had lost weight. Peripheral blood was analyzed by flow cytometry for the following markers: activating receptors (CD16, C161, DNAM-1, 2B4, NKG2C, NKG2D, NKp46, NKp30), inhibitor receptors (NKG2A, KIR2DL1, KIR2DL2, KIR3DL1), activation markers (CD69, granzyme B, NKG2C), maturation markers (CD56, CD57, CD94, CX3CR1) and cytotoxicity markers (perforin, NKG7). Moreover the capacity of NK cells to degranulate and to produce several cytokines (TNF, IFN-g) or chemokines (MIP1-b) in response to stimulation by K562 cells or Rituximab coated -tumor B cells was evaluated.

Results showed a positive correlation between BMI and total number of circulating NK cells, with a significant difference between lean patients and obese patients. Immunophenotypic analyses showed that NKp46 and CD94 expression (measured by Mean Fluorescence Intensity) were both significantly reduced with increased BMI. NK cells from obese patients also show signs of activation, characterized by an elevation of the expression of CD69 and granzyme B and a reduction of the expression of CD16. The ability of NK cells to be activated in the presence of cell lines was also reduced in obese patients: NK cell secretion of IFN-g and MIP-1b in the presence of Granta cells or MIP-1b in the presence of K562 decreased linearly with increasing BMI. NK cell degranulation upon co-culture with K562 cells was also negatively correlated with BMI. In these different assays pre-obese and ex-obese patients scored intermediate between lean and obese patients. Overall these results suggest in vivo activation and exhaustion of NK cells in obese patients. These cells are thus potentially less likely to participate as effector cells in immunotherapeutic regimens.

Disclosures

No relevant conflicts of interest to declare.
Characterization of a High-Affinity Fully Human IgG2 Antibody Against Tissue Factor Pathway Inhibitor As a Bypass Agent for the Treatment of Hemophilia
Authors: Bauzon Maxine , Liu Bing , Grudzinska-Goebel Joanna , Tebbe Jan , Pan Junliang , Cifrese Jill , Wang Zhuozhi , Sim Derek
Published: October 2019

The tissue factor initiated coagulation pathway is intact in patients with hemophilia; however, this pathway is normally inhibited by tissue factor pathway inhibitor (TFPI), resulting in insufficient thrombin generation to stop bleeding and prevent recurrence of bleeding. Antagonizing this natural inhibition through anti-TFPI antibodies is a potential mechanism to effectively restore hemostasis in patients with hemophilia.

A human phage-displayed antibody library was used to identify optimal anti-TFPI antibodies. From the panning campaign, unique antibodies were identified that bound to human TFPI and were cross-reactive to murine TFPI. In vitro characterization demonstrated that 6 of the antibodies could block TFPI activity, partially or completely restoring factor Xa activity. These 6 antibodies also shortened clotting time of hemophilic human (Hem A) plasma in a diluted prothrombin assay. When the ROTEM assay (Tem International GmbH, Basel, Switzerland) was used to measure clotting in human Hem A plasma from congenitally deficient individuals (factor VIII [FVIII] levels <0.38%), anti-TFPI antibodies significantly shortened clotting time, alone or in combination with FVIII or activated factor VII. In addition, the antibodies were effective in shortening clotting time in human blood containing anti-FVIII antibodies, indicating that anti-TFPI antibodies can be applied to inhibitor patients. One of the identified anti-TFPI antibodies was tested in a hemophilia A mice tail vein transection model and improved survival rate to 60%, significantly higher than the 10% survival rate of mice treated with an isotype control antibody. Additionally, combined with low-dose FVIII, this antibody could further increase the survival rate in hemophilic mice, and it was selected for further optimization.

Optimization covered 2 different aspects: (1) affinity maturation to increase its affinity to human and murine TFPI; and (2) sequence optimization to reduce sequence deviation from germ-line sequences and to remove critical residues prone to undergo unwanted chemical modifications during production and/or storage. Both processes consisted of 2 rounds of sequence optimization and screening. Following affinity maturation, target affinity was increased by >200-fold on human and >500-fold on murine TFPI. Sequence optimization was performed on the backbone of the final affinity-matured variant. BAY 1093884, the final optimized variant, is a fully human IgG2 antibody with <10 pM binding affinity to human and murine TFPI.

Disclosures

Bauzon: Bayer: Employment. Liu:Bayer: Employment. Grudzinska-Goebel:Bayer: Employment. Tebbe:Bayer: Employment. Pan:Bayer: Employment. Cifrese:Bayer: Employment. Wang:Bayer: Employment. Sim:Bayer HealthCare LLC: Employment.