bluuebunny/crossref_metadata_2025 huggingface dataset:
Characterization of Waldenström Macroglobulinemia Subtypes using Global Gene Expression Profiling.
Authors: Chung Tae-Hoon , Kim Seungchan , Baker Angela S. , Price-Troska Tammy , Xu Ruifang , Ghobrial Irene , Greipp Philip R. , Rajkumar S. Vincent , Gertz Morie A. , Van Wier Scott A. , Ahmann Gregory J. , Carpten John , Fonseca Rafael
Published: October 2019

Waldenström macroglobulinemia (WM) is a lymphoid neoplasm associated with accumulation of lymphoplasmacytic cells in the bone marrow and an elevated monoclonal IgM in the serum. Although the genetic and molecular mechanisms behind the pathogenesis of WM are not well understood, losses of the long arm of chromosome 6 have been found as the only recurrent genomic aberration. These deletions, mostly starting at 6q21, are observed in upwards of 50% of patients and involve the majority of the clonal cells. To better characterize pathologic gene expression signatures in different types of WM at the molecular level (6q deleted versus not), we examined gene expression level changes of more than 20000 human gene probes in bone marrow tissues of clinically proven WM patients. We used Affymetrix HG-U133A v2 chips (n = 24). Clonal cells were purified using a combination of anti-CD138 and anti-CD19 Miltenyi™ magnetic microbeads. Based on cIgM-FISH results, we classified samples into two groups - 6q normal (ND) group and 6q deletion (D) group. We then proceeded to identify genes that showed differential expression between the two groups. We selected 165 differentially expressed genes (DEG) using SAM, and underwent further investigation of biological annotations of them using Gene Ontology™ (GO) terms. Among165 DEG, only 32 showed high level of expression in ND group compared to D group while 133 showed high level of expression in D group. As expected, all genes that reside in 6q region showed under-expression in D group, constituting 53% (17 genes) of genes under-expressed in D group (32 genes). According to GO analysis, the 6q-deletion-induced under-expression affects many biological processes, and is associated with a transcriptional upregulation of downstream genetic cascades. This likely indicates release of regulatory control by a tumor suppressor gene. Genes involved in cell growth and maintenance, cell communication and morphogenesis are also over-expressed in D group. Interestingly, a gene that is involved in innate immune response and inflammatory response shows under-expression in D group but is not accounted for by other mechanisms. In similar vein, a gene that is involved in negative regulation of cytokine biosynthesis showed over-expression in D group. We think these transcriptional characteristics can provide basic framework for differentiating subtypes of WM and search for genes associated with WM pathogenesis
The Antithrombotic Activity of Kininogen Is Mediated by Inhibitory Effects of Domain 3 on Thrombin-Induced Platelet Activation, In Vivo.
Authors: Hassan Sarmina , Khan Mohammad M. , Isordia-Salas Irma , Sainz Irma , Kashem Sakeen W. , Liu Bo , Sartor R. Balfour , Colman Robert W.
Published: October 2019

Background: High molecular weight kininogen (HK) exhibits anticoagulant and profibrinolytic properties and can inhibit platelet activation at low thrombin concentrations. HK acting through domain 3 (D3) is antithrombotic by interfering with the ability of thrombin to bind to the platelet GPIb complex in vitro. We hypothesize that rapid occlusive thrombosis due to de-endothelization of the aorta is due to enhanced platelet activation by thrombin and will be reversed by infusion of D3 or D3-derived peptides.

Methods: F6HKd (deficient in HK) and F6WT (wild-type) strains were produced from offspring of kininogen-deficient Brown-Norway rats by backcrossing to Lewis rats for 6 generations to ensure homogenous genetic background. In the present study, we have expressed kininogen domain 3 (D3) and a fragment of D3, coded for by exon 7, E7P (aaG235-Q292), in E. Coli as glutathione S-transferase (GST) fusion proteins. GST-D3 and either GST-E7P or GST alone was infused intravenously 10 min before inducing the endothelial injury to the abdominal aorta. (Each group n = 5)

Results: Despite an equivalent vascular injury, the mean time (± SEM) for a 90% decrease in flow measured by an ultrasonic probe was 28±5.2 minutes in GST-treated F6HKd rats compared with >240 minutes in the GST-D3 and 233±6.7 in GST-E7P-treated animals. Differences between GST and either GST-D3 or GST-E7P pretreatments were highly significant (p<0.0002). F6WT showed no occlusion at 240 min after injury. In F6HKd rats, TAT concentrations were increased from 32±5.1 to 52±4.1 ng/ml (p<0.007). Similarly D-dimer concentrations were increased from 94±16.3 to 145±9.6 ng/ml (p<0.01) after endothelial injury with only GST pretreatment. With GST-E7P pretreatment, TAT and D-dimer levels were significantly decreased from the GST-treated group (TAT from 52±4.1 to 36±4 ng/ml, p<0.01 and D-dimer from 145±9.6 to 69±11.9 ng/ml, p<0.0007). No significant difference was observed between the GST-E7P pretreated injured and non-injured F6HKd rats or between the F6WT rats which were injured and non-injured.

Conclusions: The results suggest that F6HKd rats are prothrombotic. After endothelial injury thrombotic occlusion occurs and is characterized by thrombin formation with secondary fibrinolysis. Moreover, thrombin-induced platelet activation is inhibited by D3 or the polypeptide coded for by exon 7 product in vivo. These results indicate the importance of HK in modulating arterial thrombosis and the possibility of therapy with HK fragments.
Activated Peripheral Mononuclear Cells Plus Soluble Plasma Tissue Factor Activate Factors VII and X in Cardiac Surgical Wounds.
Authors: Colman Robert W. , Khan Mohammad M.H. , Hattori Takashi , Edmunds4 L. Henry
Published: October 2019

Objectives: This study examines the role of pericardial wound monocytes in thrombin generation during clinical cardiac surgery with cardiopulmonary bypass (CPB).

Background: The mechanism by which wound mononuclear cells rapidly express procoagulant activity is unexplained.

Methods: Factor VII activation (FVIIa) was measured using recombinant, truncated, soluble tissue factor (rsTF) and various blood cells in vitro. FVIIa was also measured with monocytes and soluble plasma tissue factor taken before CPB and simultaneously from the pericardial wound and perfusion circuit during CPB in thirteen patients.

Results: RsTF in combination with monocytes, but not platelets, neutrophils or red cells, accelerates activation of FVII beginning at 1 pmole/L rsTF. Less than 1% rsTF is bound, yet catalytic activity peaks at 7 minutes and decays afterwards. In wound plasma, monocytes are activated (MCP-1 = 29.5 ± 2.1 pmoles/L) and wound plasma tissue factor (wpTF) is substantially elevated (3.64 ± 0.45 pmoles/L) with 81.7% in the supernatant and 18.3% in microparticles. By Western blot all forms of plasma TF migrate at Mr 65 kDa [TF/FVII(FVIIa) complex]. Wound monocytes and C5a activated prebypass or perfusate monocytes plus wpTF convert all available FVII to FVIIa. Activated monocytes plus supernatant TF/FVII(VIIa) more efficiently activate factor X than microparticle TF/FVII(FVIIa). The correlation coefficient (r) between wound thrombin generation (F1.2) and wpTF is 0.944 (p = 0.0004).

Conclusions: During clinical cardiac surgery with CPB wound monocytes plus wpTF or microparticle-free, protein fragments of wound tissue factor preferentially accelerate activation of FVII and FX. This system represents a new mechanism of thrombin generation.
CALGB 90003: Adoptive Immunotherapy by Allogeneic Stem Cell Transplantation for Metastatic Renal Cell Carcinoma: An Intergroup Phase II Study.
Authors: Rini Brian I. , Halabi Susan , Barrier Robert , Margolin Kim A. , Avigan David , Logan Theodore , McCarthy Philip L. , Small Eric S. , Linker Charles A.
Published: October 2019

A graft-versus-tumor effect mediated by non-myeloablative allogeneic stem cell transplantation has been reported for patients with cytokine-refractory, metastatic renal cell carcinoma (RCC). An Intergroup phase II trial was undertaken to further define the feasibility, toxicity and efficacy of this approach in a multi-institutional setting. The conditioning regimen was fludarabine 30mg/m2/d, days −7 to −3, and cyclophosphamide 60mg/kg/d, −4 and −3. Patients received 2 to 8 x 106 G-CSF-mobilized CD34+ cells/kg from a 6/6 HLA-matched sibling donor. Graft-versus-host disease (GVHD) prophylaxis included tacrolimus (target level 5–10 ng/ml) starting day −1 and methotrexate 5 mg/m2 days +1, +3, +6. Tacrolimus was tapered to zero between days +60 and +90. Twenty-two patients were enrolled at 14 different institutions. Patient characteristics included median age of 53, (range, 39–60) and a performance status of 0 in 14 patients and 1 in 8 patients. Prior systemic therapies included 1 regimen in 13 patients, 2 regimens in 5 patients and 3 regimens in 1 patient. One patient failed to engraft and had autologous recovery. Greater than 95% donor T cell chimerism was seen in 10 of 13 patients (77%) by 120 days after BMT. The day 100 regimen-related mortality was 0 of 22 (0%). Acute GVHD was observed in 7 patients (41%). Chronic GVHD was observed in 11 patients (65%) with one patient death from liver failure secondary to chronic GVHD. Eleven patients have died: 7 from disease progression; 1, renal failure (not treatment related); 1, sepsis (pseudomonas); 1, liver failure secondary to chronic GVHD (treatment related); 1, unknown. No objective response has been reported in the 17 patients with follow-up data available. Progressive disease was reported for 14 patients. Median progression-free survival is 4.1 months (95% C.I.: 3.9 – 4.4 months). Median overall survival is 5.6 months (95% C.I.: 4.3 – 12.3 months). Non-myeloablative allogeneic stem cell transplant for metastatic RCC is feasible in a multi-institutional setting. Significant morbidity limits the eligible patient population. Lack of anti-tumor effect highlights the need for stringent patient selection and for further manipulation of the current approach. Non-myeloablative allogeneic stem cell transplantation in metastatic RCC remains investigational.
The Mechanism of Transfusion-Related Immunomodulation Is Related to the Transfusion of Dendritic Cells Expressing the CD200 (OX-2) Tolerance Signal and Alloantigen: Evidence from a Murine Tumor Model.
Authors: Blajchman Morris A. , Gorczynski Reginald M. , Clark David A.
Published: October 2019

Background: The transfusion of blood products containing allogeneic leukocytes can alter recipient resistance to infection and stimulate the growth of some types of tumors in animal models of transfusion-induced tumor growth. Transfusion related immunomodulation (TRIM) represents a credible mechanism for the altered resistance to infection seen clinically, but cannot explain the growth of non-immunogenic tumors in syngeneic hosts seen regularly in the various transfusion-related animal models of tumor growth.

Methods and Results: In this study the transfusion of 50–200 μL of unmodified anticoagulated allogeneic BALB/c (H-2d) mouse blood into C57B1/6 (H-2b) mice, four days before being intravenously injected with syngeneic (H-2b) FSL10 fibrosarcoma cells (1–2 x 106 cells per mouse) resulted in a significant increase in the number of pulmonary nodules observed at 3 weeks compared to that seen in control mice. The median number of pulmonary nodules increased in an allogeneic blood transfusion dose-dependent manner, as did the proportion of mice without pulmonary nodules. This tumor growth-promoting effect of the allogeneic blood transfusions required the presence in the transfused blood of allogeneic CD11c+ dendritic cells bearing the CD200 co-stimulatory tolerance signal. This tumor growth-promoting effect of allogeneic blood could be blocked by specific monoclonal antibodies to either CD11c or to CD200. CD200 receptor-mediated signaling alone, in the absence of alloantigen, failed to augment the number of TRIM-induced pulmonary tumor nodules. Physiological concentrations of TGFβ, but not IL-10, were shown to stimulate proliferation of FSL10 cells in vitro in these studies. In this context, it is known that CD200 together with alloantigens are known to stimulate development of suppressor cells acting via IL-10 and TGFβ in vivo. Allogeneic blood also caused a significant CD200-dependent accumulation of TGFβ+ suppressor cells in the spleen, 12 days after transfusion, when the spleen cells could be shown to adoptively transfer the TRIM effect to naive animals.

Conclusions: These data support the hypothesis that allogeneic transfusions in an allogeneic blood transfusion mouse tumor model results in tumor growth promotion in recipient mice. This effect appears to result in both the induction of TGFβ-producing suppressor cells as well as requiring the transfusion of allogeneic CD11c+ dendritic cells, bearing both CD200 tolerance signaling molecules and alloantigens.
Nitrosylation of Platelet MHC Class I Molecules Directs Their Movement into the Immunosuppressive MHC Class I Processing Pathway within Antigen Presenting Cells.
Authors: Semple John W. , Speck Edwin R. , Freedman John
Published: October 2019

Previous studies have demonstrated that recipient mice require the production of nitric oxide (NO) within their antigen presenting cells (APC) in order to generate IgG anti-donor immunity against allogeneic platelet transfusions. NO has a complex biochemistry and several of its conjurors could be involved in this response; the most obvious is peroxynitrite (ONOO-) generated by the spontaneous combination of NO and superoxide (O2•−). ONOO- is a potent oxidant that can spontaneously nitrosylate lysine and tyrosine residues in proteins within the phagolysosome. To address the role of ONOO- in platelet immunity, we transfused GP91 PHOX knockout mice that lack the ability to produce O2•− and thus ONOO-. Results show that when wild type C57BL/6 mice were transfused with allogeneic BALB/c platelets, they developed a weak IgG anti-donor antibody response by the fifth transfusion. In contrast, PHOX KO mice generated IgG anti-donor antibodies by the 2nd transfusion and their IgG anti-donor antibody titres were significantly higher than the WT recipients. This suggested that ONOO- and protein nitrosylation may be linked with an immunosuppressive event within the recipient. This was confirmed by demonstrating that in vitro nitrosylation of platelet antigens with the ONOO- donor SIN-1 inhibited the ability of the platelets to mount an IgG immune response when transfused into allogeneic recipients. Nitrosylated platelet antigen trafficking within recipient APC was assessed by using adherent macrophages and various inhibitors of processing. When adherent APC were pulsed with nitrosylated platelet antigens in the presence of either Brefeldin A or proteosome inhibitors, IgG anti-platelet immunity against the platelets was restored. Furthermore, the IgG immunity could also be rescued against the nitrsosylated platelets if the recipients were first depleted of CD8+ T cells by injection of a monoclonal antibody. These results suggest that if platelet antigens are nitrosylated within antigen presenting cells, they are preferentially shunted to the MHC class I processing pathway and presented to CD8+ T cells that suppress the IgG immune response. Thus, it appears that reactive oxygen species act as intracellular regulators that determine whether a productive IgG immune response against platelet transfusions will occur.
Therapeutic Plasma Exchange (TPE) for Thrombotic Thrombocytopenic Purpura (TTP) Using Plasma Prepared with Photochemical Treatment (INTERCEPT Plasma).
Authors: Mintz Paul D. , Neff A. , MacKenzie M. , Hillyer C. , Goodnough L. T. , Kessler C. , McCrae K. , Menitove J. , Damon L. , Lopez I. , Roualt C. , Crookston K. , Benjamin R. J. , George J. , Van Doren S. , Lin J. S. , Corash L.
Published: October 2019

INTERCEPT Plasma (I-FFP) uses amotosalen (S-59, 150μM ) and UVA light (3 J/cm2 to inactivate pathogens in single plasma units. TPE is the mainstay therapy for TTP. Efficacy and safety of I-FFP for TPE of TTP were evaluated in a double-blinded, randomized, controlled trial. Eligible patients (pts) with TTP unrelated to cancer, cancer therapy, transplantation, AIDS, HUS, or SLE received daily TPE (1.0 to 1.5 blood volumes) with either I-FFP or conventional plasma (C-FFP) for up to 2 TPE cycles, each with a maximum of 35 days (d) of TPE. Treated pts were followed for 7 d after the last TPE to detect overall adverse events (AE) and for 60 d after achieving remission to detect relapse and serious adverse events (SAE). The primary endpoint was the proportion of pts in remission (platelet count ≥ 150,000/μL for 2 consecutive d without neurologic progression) within 30 d after the 1st TPE. Secondary endpoints were: time to 1st remission, volume of plasma used, number of TPEs, relapse rates after remission, vWF cleaving protease (vWF-CP) activity and inhibitor levels, antibodies to potential S-59 neoantigens, and safety. 35 pts (17 I-FFP, 18 C-FFP), mean age of 40 yr, 80% female were treated. TPE with I-FFP was comparable to C-FFP in remission rates (82% I-FFP, 89% C-FFP:p=0.66), median time to remission (6 d I-FFP, 6 d C-FFP:p=0.58), mean total volume of plasma exchanged (40.6 L I-FFP, 41.3 L C-FFP:p=0.86), mean number TPEs (11.3 I-FFP, 10.3 C-FFP:p=0.68), and relapse rates (36% I-FFP, 38% C-FFP:p=1.00). Baseline and post TPE vWF-CP activity and inhibitor levels were similar between groups. Overall AEs, serious AEs, deaths (1 I-FFP and 1 C-FFP: neither attributed to TPE), rates of discontinuation from study, laboratory abnormalities, and vital signs (VS) during TPE were comparable between groups. 1 C-FFP pt had TRALI. Five I-FFP pts had AEs coded to the cardiac system organ class compared to no C-FFP pts (p=0.02). In 4 of the I-FFP pts, these AEs were non-serious and did not interrupt TPE. One I-FFP pt with relapsing TTP had a serious AE after 12d of TPE, recovered without sequelae, was withdrawn from study, and continued on non-study FFP TPE with recurrent relapse. No antibodies to potential S-59 neoantigens were detected in any pts. In this trial, efficacy endpoints and safety profiles of TTP pts treated with I-FFP TPE were similar to those for TTP pts treated with C-FFP TPE.
High Shear Stress and Immobilization of Von Willebrand Factor Promotes the VWF-Cleaving Protease Activity as Assessed by the Cone and Plate(let) Analyzer.
Authors: Varon David , Shenkman Boris , Budde Ulrich , Angerhaus Dorothea , Schneppenheim Reinhard , Savion Naphtali , Seligsohn Uri
Published: October 2019

The metalloprotease ADAMTS-13 cleaves von Willebrand factor (VWF) that is released from endothelial cells as a large multimeric protein. However, the specific physiological conditions required for the function of this von Willebrand factor-cleaving protease (VWF-CP) are not yet established. In this study we determined the optimal conditions for the VWF-CP activity using the Cone and Plate(let) Analyzer (CPA). Proteolysis of a soluble recombinant VWF by a recombinant VWF-CP in the absence or the presence of BaCl2 (for induction of VWF-CP) was performed under static and flow (2050 s−1) conditions. The resulted fragments of the soluble VWF were immobilized on a polystyrene surface and non-adhering sites were blocked with 1% BSA. In parallel, polystyrene surface immobilized VWF was similarly treated by VWF-CP. The immobilized cleaved VWF fragments by the above protocols served as a substrate for citrated whole blood platelet adhesion under flow (2050 s−1). Reduction of platelet adhesion (surface coverage, SC) in BaCl2 treated compared to untrerated sample reflects the degree of VWF-CP activity.

Platelet adhesion (SC, %) to VWF proteolytic products generated under the indicated conditions:

Static w/o BaCl2 Static + BaCl2 Flow w/o BaCl2 Flow + BaCl2 Soluble VWF 15.0 ± 3.4 11.1 ± 2.7 13.6 ± 2.2 8.0 ± 2.1 Immobil. VWF 19.1 ± 3.0 12.0 ± 4.1 6.5 ± 1.1 1.0 ± 0.6

Maximal VWF-CP activity as reflected by maximal reduction (85%) of platelet adhesion was observed when immobilized VWF was treated by VWF-CP under flow. Minimal effect of VWF-CP activity was observed when soluble VWF was treated under static condition (26% reduction). Intermediate effect was observed with soluble VWF under flow (41%) and with immobilized VWF under static condition (37%). It should be noted that in the case of immobilized VWF application of flow alone (without BaCl2) was sufficient to induce a remarkable decrease of platelet adhesion (66%). In conclusion, both immobilization of VWF and high shear stress are important conditions for VWF-CP function, suggesting that stretching of immobilized VWF under flow exposes the VWF-cleavage site and thereby may serve as a control mechanism of platelet adhesion at the site of thrombus formation.
A Multicentre, Double-Blind, Randomized, Phase 2 Trial Comparing Pegfilgrastim with Filgrastim as an Adjunct to Chemotherapy for Acute Myeloid Leukaemia (AML).
Authors: Bosi Alberto , Szer Jeffrey , Kassis Jeannine , Sierra Jorge , Desborough Claire , Buchanan Karen
Published: October 2019

BACKGROUND: Heil et al (Blood ‘97) demonstrated that the duration of neutropenia and its clinical consequences following induction chemotherapy for AML were significantly reduced by the addition of filgrastim, with no increased risk of death, second malignancy or relapse (ASH ‘99). A single injection of pegfilgrastim has been shown to be comparable to daily injections of filgrastim in the management of chemotherapy-induced neutropenia. The primary aim of this trial was to estimate the difference in time to recovery from severe neutropenia (SN, ANC < 0.5 x109/L) in the first induction chemotherapy cycle (Induction 1) in AML subjects treated with pegfilgrastim or filgrastim.

METHODS: Subjects with de novo AML received 1 or 2 courses of induction chemotherapy (idarubicin 12mg/m2 IV days 1–3, cytarabine 100mg/m2 IV 12 hourly days 1–7 [IA 3+7]) then, if in remission, consolidation chemotherapy (cytarabine 2 [subjects < 55 years] or 3g/m2 [subjects ≥ 55 years] IV 12 hourly days 1, 3, 5). Subjects received either single administration 6μg pegfilgrastim or daily 5μg/kg filgrastim starting 24 hours after completion of chemotherapy until neutrophil recovery. Time to recovery from SN was defined as the number of days from the first day of chemotherapy until the first of two ANC consecutive values after the nadir that were ≥ 0.5 x 109/L whereas duration of SN was defined as the total number of days during the cycle with an ANC < 0.5 x 109/L.

RESULTS: Of 84 subjects randomised into the study, 83 received study drug (42 pegfilgrastim, 41 filgrastim). The treatment groups were generally well balanced for demographics and baseline characteristics. The median time to recovery from SN (ANC < 0.5 x109/L) in Induction 1 was 22 days in both treatment groups (95% CI for treatment difference: −1.9, 1.9). There was also no statistically significant difference in the median duration of SN between the 2 groups (21 days pegfilgrastim, 20 days filgrastim). Subjects in the filgrastim group required a median of 16 daily injections compared to a single administration of pegfilgrastim in the second group. Median serum concentration of pegfilgrastim in Induction 1 remained above clinically relevant concentrations until 21 days after the start of chemotherapy, results that are consistent with the neutrophil-mediated clearance of pegfilgrastim. The incidence of serious adverse events was comparable between the 2 groups except for infectious complications, which were higher in the filgrastim group (5 subjects [12%] pegfilgrastim versus 9 subjects [22%] filgrastim).

CONCLUSION: In the setting of the first cycle of IA 3+7 induction chemotherapy in AML patients, once per cycle administration of 6 mg pegfilgrastim or daily administration of 5mg/kg filgrastim result in similar median time to recovery to ANC ≥ 0.5 x109/L. Pegfilgrastim is safe and well tolerated in this subject population.
Clofarabine Plus Cytarabine (ARA-C) Combination Is Active in Newly Diagnosed Patients (PTS) ≥ Age 50 with Acute Myeloid Leukemia (AML) and Myelodysplastic Syndrome (MDS).
Authors: Faderl Stefan , Gandhi Varsha , Verstovsek Srdan , Cortes Jorge , Ravandi-Kashani Farhad , Beran Miloslav , Garcia-Manero Guillermo , Koller Charles , O’Brien Susan , Ferrajoli Alessandra , Estrov Zeev , Kwari Monica , Plunkett William , Kantarjian Hagop M.
Published: October 2019

Clofarabine is a next-generation deoxynucleoside analog with activity in acute leukemias. As clofarabine effectively inhibits ribonucleotide reductase, it is also suited for biochemical modulation strategies with other nucleoside analogs. In a previous study of clofarabine plus ara-C in pts with relapsed/refractory AML/MDS, we reported a CR rate of 24% (41% OR) (Blood 102:615a, 2003). Cellular pharmacology studies suggested that accumulation of intracellular clofarabine triphosphate resulted in higher ara-CTP accumulation of the leukemia blasts. We conducted a phase II study to investigate the efficacy and safety of clofarabine plus ara-C in pts ≥ 50 yrs with newly diagnosed AML and MDS (≥ 10% marrow blasts). Pts were excluded for ECOG PS > 2, age ≥ 75, and good prognosis karyotypes [t(8;21), inv(16), t(15;17)]. Clofarabine was given at 40mg/m2/d over 1-hour (hr) i.v. daily for 5 days (d2-6) followed 4 hrs later by ara-C at 1g/m2/d over 2-hrs i.v. daily for 5 days (d1-5). Sixty pts (53 AML, 7 RAEB-2 incl. 1 CMML-2) were enrolled and are evaluable. Median age: 61 yrs (range 50–74). Twenty-eight pts (47%) had secondary AML (17 AHD, 11 other malignancies) and 30 pts (50%) had abnormal cytogenetics (−5/−7 in 15, +8 in 10, del(11)(q23) in 3). 31 pts (52%) achieved CR; another 5 pts (8%) achieved CRp. Of 11 pts who received a second induction course, 4 pts (36%) responded (2 CR, 2 CRp). The CR rate was 60% (18/30 pts) in the diploid and 43% (13/30) in the abnormal karyotype group. Median time to CR: 29 days (20–98). 9 deaths (15%) occurred on study of which 4 pts (7%) died during the first course (d10 to d42). Adverse events included transient facial flushing and headaches (< gr. 3) during the infusion, and hyperbilirubinemia (gr. 3 in 3 pts), skin rashes, ↑ SGPT/SGOT, palmoplantar dyserysthesias, pancreatitis (1 pt) and renal failure (1 pt). Our data suggest that clofarabine + ara-C is active in older pts with newly diagnosed AML/high-risk MDS. The toxicity profile is acceptable. An update of time-to-event parameters will be presented.
Ann Arbor Stage Is the Most Important Predictor of Survival for Refractory and Relapsed HIV-Associated Lymphoma Enrolled in a Program of High Dose Therapy and Autologous Peripheral Blood Stem Cell Transplantation.
Authors: Re Alessandro , Cattaneo Chiara , Michieli MariaGrazia , Casari Salvatore , Spina Michele , Rupolo Maurizio , Allione Bernardino , Ferremi Piero , Lanfranchi Arnalda , Mazzuccato Mauro , Carosi Gianpiero , Tirelli Umberto , Rossi Giuseppe
Published: October 2019

The recent introduction of highly active antiretroviral therapy (HAART) has allowed an aggressive treatment approach in the management of HIV-associated lymphoma (HIV-Ly). Within the Italian Cooperative Group on AIDS and Tumors (GICAT) in 2000 we started a multiinstitutional program of high dose therapy (HDT) and autologous peripheral blood stem cell transplantation (PBSCT) for HIV + patients (pts) with refractory or relapsed lymphoma. CNS lymphoma were excluded. So far, 26 pts entered the study: 10 HD (five 1st relapse, two 2nd relapse, three refractory) and 16 NHL (eight 1st relapse, one 2nd relapse, two partial remission (PR), five refractory). Median age was 38 (28–56); CD4 count 207/cmm (17–506); detectable HIV viremia: 6 pts (23%). Performance status (PS): 0–1, 7 pts (27%); 2, 19 pts (73%). Ann Arbor stage of lymphoma: II, 4 pts (15%); III, 8 pts (31%), IV, 14 pts (54%); B symptoms: 9 pts (35%); bone marrow involvement: 7 pts (27%). Median duration of last remission was 6 months (mo) (1–53). Pts received 2nd line standard dose chemotherapy as debulking treatment. Six pts were refractory and 5 died for disease progression (one is on treatment); 17 of 20 pts with chemosensitive disease successfully mobilized an adequate number of CD34+ after Cyclophosphamide + G-CSF or G-CSF-supported CT. Two pts had early disease progression, and 15 pts received the BEAM regimen and PBSCT, according to the protocol. Engraftment was prompt in all. Pts received HAART during the entire program. Neither treatment-related death nor HIV related death were registered. Fourteen pts achieved complete remission and 1 partial remission. Relapse occurred in 3 (mo +5, +8, +12); 13 are alive and 11 disease-free at 12 mo (2–28) after transplant. The median survival of the entire series (26 pts) from the study entry was 17 mo with 51% of the pts alive after a median f-up of 17 mo. From the analysis of prognostic factor, PS, Ann Arbor stage IV, B symptoms and CD4 count at study entry showed a correlation with survival by univariate, but stage IV disease was the only factor proved to correlate independently with survival on multivariate analysis. The projected overall survival for pts entering the study with stage IV disease (12 pts) or less than stage IV (14 pts) was respectively 90% vs 12% at 2 years (P < 0.001). Our data showed encouraging overall results with an intensive treatment strategy as salvage therapy for HIV-Ly. Ann Arbor stage was the most important predictor of survival. Pts with stage IV disease had poor prognosis, mainly because of chemoresistent disease, suggesting that these pts might benefit from the use of dose intensification earlier in the course of their disease.
Autologous vs Allogeneic Cell Transplantation for Mantle Cell Lymphoma (MCL): Outcomes over a 10-Year Period at City of Hope.
Authors: Popplewell Leslie L. , Nademanee A. , Carter Nora , Zain Jasmine , Krishnan Amrita , Rodriguez Roberto , Kogut Neil M. , Vora Nayana , Molina Arturo , Forman Stephen J.
Published: October 2019

Mantle cell lymphoma (MCL) carries a poor prognosis with standard therapy. Both allogeneic (ALLO) and autologous stem cell transplant (ASCT) approaches have been used to intensify therapy in an attempt to achieve lasting remissions. 77 patients were transplanted at City of Hope over a 10-year period (1994–2003), including 13 ALLO and 64 ASCT.

Demographics: The majority of patients were male (92% ALLO, and 73% ASCT). Median age was significantly younger for the ALLO, 47 years vs. 55 years for ASCT (p=0.003). ALLO patients had received more prior regimens than ASCTs-- avg 3 in ALLO and 1 in ASCT (p-value 0.0031). Median time from diagnosis to transplantation was 1.3 years for ALLO, 0.81 for ASCT. For ALLO patients, 8% were in first complete remission (CR1), 62% in second or subsequent remission, 23% in relapse, and 8% in unknown status. For ASCT patients, 47% were in CR1, 31% in second or subsequent remission, 14% in relapse, 2% in unknown status.

Methods: Conditioning regimens for ASCT include FTBI/VP16/CTX (36), BCNU/VP16/CY (14), BEAM (2), Zevalin/BEAM (4), and other (8). One patient received an ASCT transplant, then received a reduced intensity ALLO transplant at the time of second relapse. Conditioning for ALLO included FTBI/CTX (9), Flu/Mel (3), or BU/CY (1),

Results: Median follow-up was 57 months for ALLO, and 26 months for ASCT. 3-year Overall Survival (OS), progression free survival (PFS), and relapse rate was 51%, 53%, and 14% , respectively, for ALLO, and 66%, 57%, and 27% for ASCT. Patients transplanted in 1st CR had a significantly higher 3-year OS (85% vs. 52%, p = 0.0153) and PFS (78% vs. 44%, p = 0.027) a trend to a lower RR than patients transplanted in more advanced disease status.

Conclusions: MCL patients transplanted in CR1 fared better than those transplanted with more advanced disease status, regardless of transplant approach. While relapse rates were lower in ALLO patients, this did not translate into improvement in OS or PFS, possibly due to a higher transplant related mortality (TRM). Analysis of PFS curves suggests no plateau on the ASCT curve, while late relapses were uncommon in ALLO patients.
Intense Immunochemotherapy (IC) and Autologous Stem Cell Transplant (ASCT) for Untreated Patients (pts) with Mantle Cell Lymphoma (MCL): CALGB 59909. A Preliminary Report.
Authors: Damon Lloyd , Niedzwiecki Donna , Johnson Jeff , Cheson Bruce , Hurd David , Barlett Nancy , Kelly Michael , Linker Charles , Canellos George
Published: October 2019

We evaluated the feasibility, safety, and effectiveness of an intense IC regimen including ASCT in pts with untreated MCL up to age 70. Pts with MCL confirmed by central pathology review plus one additional feature (compatible immunophenotype, cyclin D1 over-expression, t(11;14) or Bcl-1/IgH rearrangement) were treated with 2–3 cycles of R-M-augmented CHOP (Rituximab [R] 375 mg/m2 d1, Methotrexate 3000 or 300 mg/m2 d2, CHOP d3 [cyclophosphamide {C} 2 g/m2]) followed by consolidation and stem cell collection with EAR (Etoposide [E] 40 mg/kg continuous d1-4, Cytarabine 2 g/m2 Q12h d1-4, R d6 and d13, and filgrastim 10 mcg/kg/d beginning d14 until completion of stem cell collection). EAR was followed by ASCT using CBV (Carmustine 15 mg/kg d-6, E 60 mg/kg d-4, C 100 mg/kg d-2) followed by R 6 and 7 weeks after ASCT. 69 pts have been enrolled in 36 months.

Patient demographics: median age 57 (38–68); 84% stage IV; 47% serum LDH elevated; 78% bone marrow (+); 5% cerebrospinal fluid (+). To date, 38 pts have completed all therapy, 6 have completed EAR, and10 are still receiving RM-CHOP. Stem cell collection was excellent, with a median CD34+ cell dose of 11.8x106/kg in median1 apheresis. 4 pts were unable to receive the full intended therapy due to adverse events (2 treatment related deaths, 2 early progressions). 5 pts withdrew from study because of personal preference (2), lack of insurance approval (2) or allogeneic stem cell transplant (1). With a median follow-up of 7 months, the projected 2-year progression-free survival is 70±21%. We conclude that intense IC plus ASCT is feasible and safe in pts with MCL up to age 70 with a high percentage of pts able to receive the planned therapy.
Early Dose Intensity Is Critical in Patients with Aggressive Lymphoma: A Randomized study Comparing Identical Doses of Cyclophosphamide, Adriamycin, Vincristine, Etoposide, and Prednisolone given as 4 or 6 cycles followed by Repetitive Transplantation of Stem Cells (Mega-CHOEP).
Authors: Glass Bertram , Kloess Marita , Reiser Marcel , Berdel Wolfgang E. , Ho Anthony D. , Truemper Lorenz , Loeffler Marcus , Pfreundschuh Michael , Schmitz Norbert
Published: October 2019

The German Study Group for High-Grade NHL (DSHNHL) investigated the efficacy of CHOP + Etoposide (Mega-CHOEP) at high doses for treatment of younger patients (pts) (<60y) with aggressive NHL and LDH > N. Autologous stem cells (ASC) were administered after the last 3 courses of therapy for hematopoietic rescue. At dose level (DL) 1 and 2 four courses of treatment were given: while doses of adriamycin (70 mg/m²), vincristine (2 mg), and prednisolon remained identical at all dose levels, the doses of Cyclophosphamide (C) and Etoposid (E) were set at 1500, 4500, 4500 6000 mg/m² (C), and 600, 600 (960), 600 (960), 1480 mg/m² (E) during courses 1, 2, 3 and 4 of therapy at DL1 (2). At DL 3 pts were randomized to receive either 4 (DL 3/4) or 6 courses of therapy (DL 3/6). While the cumulative doses of C and E were highest at DL 3 (C 19.5 g/m²; E 5.04 g/m²) as compared to DL 1 (C 16.5 g/m²; E 2.8 g/m²) or DL 2 (C 16.5 g/m²; E 4.0 g/m²) the administration of Mega-CHOEP with 6 courses of chemotherapy resulted in substantial prolongation of treatment (65 to 124 days) and thus loss of dose intensity (Table). From February 1997 to June 2001, 208 consecutive pts. were enrolled at DL 1–3, 31 of whom were excluded mostly due to incorrect histopathologie diagnosis. Therapy was given as per protocol in 81.8 % of pts. at DL 1 and 2, 90.2 % at DL 3/4 , and 69.2 % at DL 3/6, respectively, with treatment delays at DL 3/6 mostly due to extramedullary toxicity and, or poor performance status. Results were as follows: see table 1.

Late events were very rare with 5 relapses beyond 2 years in the whole population. Dose escalation without higher dose intensity (DL1+2 vs DL3/4) did not improve results. Dose escalation with loss of dose intensity (DL1+2 and DL 3/4 vs DL3/6) resulted in loss of efficacy. Mega-CHOEP DL2 was selected for comparison with non-transplant therapy in an ongoing phase III trial. These data underscore the importance of early dose intensity for successful treatment of aggressive NHL with high risk features.

Table 1

Therapy n IPI1/2/3(%) Duration of therapy (days) CRandCRu (%) TTTF2y (%) OS2y (%) DL 1+2 110 31/49/20 65 74 67 75 DL 3/4 41 20/46/34 80 68 53 70 DL 3/6 26 15/62/23 124 50 23 46
Autologous Transplantation for Diffuse Large B Cell Lymphoma: Pre-Transplant Hypogammaglobulinemia Is a Predictor for Early Toxicities.
Authors: Bolwell Brian J. , Kalaycio Matt , Sobecks Ronald , Andresen Steven , Rybicki Lisa , Kuczkowski Elizabeth , Bates Jennifer , Summers Kristie , Bernhard Laura , Cherni Kelly , Baker Janet , Brown Stacey , Pohlman Brad
Published: October 2019

Response to chemotherapy and LDH level at the time of transplant are generally accepted as two variables predictive of clinical outcome in autologous peripheral blood progenitor cell (PBPC) transplantation (ABMT) for diffuse large B cell lymphoma (DLBCL). Several years ago we anecdotally noted that some patients suffered ongoing hypogammaglobulinemia after ABMT. We therefore embarked on a study examining pre and post ABMT IgG levels to determine possible prognostic volume of immunoglobulin levels. This study focuses on 68 patients with relapsed/refractory chemosensitive DLBCL undergoing autologous transplant from 4/2000 to 1/2004. All received PBPCs alone for hematopoietic support, and all received a preparative regimen consisting of Bu/Cy/VP. Median age was 55; patients received a median of 2 courses of prior chemotherapy; 44% received prior radiation therapy; 60% were male; 25% had tumor bulk greater than 10 cm in greatest diameter; 22% had elevated LDH at the time of transplant. Median PBPC dose infused was 7.5 x 106 CD34+ cells/kg. Median pre-transplant IgG level was 689 mg/dL (institutional normal range 717–1411 mg/dL). Six weeks post transplant the median IgG level had fallen to 587 mg/dL. There is a statistically significant difference in survival stratified by baseline IgG: 43% of patients with an IgG level less than 600 mg/dL were alive 18 months post transplant, as compared with 72% with a baseline IgG greater than 600 mg/dL (p=0.011). This is shown graphically below:

Figure Figure

18 month relapse-free survival was 44% in the less than 600 mg/dL group versus 63% in the greater than 600 mg/dL group. 13 of 24 in the less than 600 mg/dL group have died (54%) versus 13 of 44 (30%) in the greater than 600 mg/dL group. The majority of these deaths are from disease relapse, however, the relapses occurred faster in the less than 600 mg/dL group. 5 of 7 relapse related deaths occurred by day +200 in the less than 600 mg/dL group, compared to 1 of 10 in the greater than 600 mg/dL group (p=0.009). Additionally, 4 patients in the less than 600 mg/dL group died of diffuse interstitial pulmonary toxicity between day 100 and 165 post chemotherapy. We conclude that pre-transplant hypogammaglobulinemia may be related to a more refractory underlying disease and is associated with the potential for rapid relapse after ABMT. Additionally, those patients entering an autologous transplant with hypogammaglobulinemia are at risk for later non-specific pulmonary toxicity.
mTOR Activation Is Necessary for Primary AML Cells to Survive Genotoxic Stress.
Authors: Xu Qing , Thompson J. , Carroll Martin
Published: October 2019

The signaling pathways that regulate the survival of AML cells and whether those pathways can be targeted therapeutically are still poorly defined. We have previously demonstrated that AML cells require PI3 kinase activation for survival but clinical targeting of PI3 kinase itself is not currently feasible. Therefore, we have chosen to study the role of the mammalian target of rapamycin or mTOR protein in the survival of leukemic cells. mTOR mediates the effects of PI3 kinase and can be inhibited by the immunosuppressant, rapamycin. For these studies, patient samples were collected from patients seen at the Hospital of the University of Pennsylvania and we selected samples with greater than 75% blast cells for analysis. Here we show that mTOR is activated in over 90% of patient samples examined as shown by constitutive phosphorylation of the mTOR target protein, p70 S6 kinase (p70S6K). A second substrate, 4EBP1, is phosphorylated in the majority of AML samples but less consistently than p70S6K. Inhibition of mTOR with rapamycin caused only a modest 20% decrease in cell survival based on a 48 hour in vitro assay. Strikingly, however, when AML blasts were incubated with a combination of a topoisomerase II inhibitor, etoposide, and rapamycin, the dose response to etoposide was shifted to the left with the ED50 decreased by at least one log in each of 5 tested samples. Rapamycin inhibited mTOR as shown by inhibition of p70S6K phosphorylation and this inhibition was not altered in the presence of etoposide. To determine if combinations of rapamycin and etoposide would have combined effects on leukemic stem cells, AML cells were incubated in etoposide alone or etoposide with rapamycin for 16 hours and then transplanted into NOD/SCID mice for analysis of stem cell survival. Engraftment of AML cells into NOD/SCID animals was decreased by etoposide and this inhibition was increased by the combination of etoposide and rapamycin. These studies suggest that mTOR regulates a critical cell survival pathway in AML stem cells and this pathway is necessary for survival in the presence of a distinct apoptotic signal. Furthermore, these studies suggest that combinations of rapamycin with chemotherapy may enhance the efficacy of chemotherapeutic agents in the treatment of AML and, therefore, we have recently initiated a Phase I trial of rapamycin in combination with MEC chemotherapy for the treatment of relapsed AML.
Lower Relapse Incidence after Non-Cryopreserved Autologous Bone Marrow Transplantation Compared to Peripheral Blood Stem Cell Transplantation for High-Risk Hodgkin’s Lymphoma.
Authors: Holowiecki Jerzy , Giebel Sebastian , Krawczyk-Kulis Malgorzata , Wojnar Jerzy , Kachel Lucja , Sadus-Wojciechowska Maria , Stella-Holowiecka Beata , Grosicki Sebastian , Czerw Tomasz
Published: October 2019

In a number of studies on Hodgkin’s lymphoma (HL), autologous transplantation of peripheral blood hematopoietic stem cells (autoPBSCT) was proved to result in faster hematopoietic recovery compared to bone marrow transplantation (autoBMT), however, no difference regarding long-term outcome has been demonstrated so far. In Katowice transplant centre we developed a new method of autoBMT with bone morrow not-cryopreserved but stored for 3 days in 40C and reinfused 24 hours after completion of CBV conditioning. In this study we analyzed outcome of 40 HL patients treated with this method in comparison with 125 patients given autoPBSCT between 1993–2004. In this setting patients were treated with CBV (n=32), BEAM+/− procarbazine (n=63) or other preparative regimens (n=30). In the autoBMT group patients were transplanted in high-risk CR1 (achieved after >1 line of therapy) (25%), CR>=2 (22.5%), PR1 (35%), PR>=2 (5%), and primary or secondary refractoriness (12.5%). The indications for autoPBSCT were comparable. As well, both groups did not differ in terms of age, histological subtype, disease stage at diagnosis, organ involvement or preceding therapy.

At six years, the overall- and progression-free survival for autoBMT and autoPBSCT group equaled 88% vs. 72% (p=0.1) and 69% vs. 54% (p=0.08), respectively. The relapse incidence was significantly lower for patients given autoBMT compared with autoPBSCT (23% vs. 41%, p=0.03). In a univariate analysis, among other analyzed factors (age, disease stage at diagnosis and at transplantation, organ involvement, histological subtype, conditioning regimen, preceding therapy), the only factor influencing the risk of relapse was disease status at transplantation (CR or PR vs. NR - 32% vs. 62%, p=0.001). In a multivariate analysis the impact of both disease status (p=0.001) and the source of stem cells (p=0.04) remained statistically significant. The 100 days incidence of non-relapse mortality equaled 2.5% for autoBMT and 1% for autoPBSCT (p=NS). The neutrophil >0.5 G/L recovery was faster in the autoPBSCT group compared with autoBMT (14.7 vs. 17 d., p=0.006) whereas the difference regarding platelet >50 G/L recovery was not significant (17.5 vs. 19 d., p=NS). Both procedures did not differ in terms of severe adverse events as well as the need for blood products substitution, iv antibiotic therapy, cytokine tharapy or the time of hospital stay. CONCLUSION: AutoBMT without cryopreservation results in lower relapse rate in high-risk HL patients compared with autoPBSCT. Although the neutrophil recovery is longer by 2.5 days, the toxicity of both procedures as well as the need for supportive treatment is comparable.
A Prospective Phase II Comparison of Stem Cell Source Using Rituximab, Ifosfamide, Carboplatin, Etoposide (RICE) RE—Induction, Then High Dose Fludarabine, Busulfan (FLUBU) and Autologous (ASCT) or Allogeneic (AlloSCT) Hematopoietic Blood Stem Cell Transplantation for Mantle Cell (MCL) and Relapsed Low-Grade B-Cell Non-Hodgkin’s Lymphoma (NHL).
Authors: Stewart Douglas A. , Voralia Michael , Chaudhry Ahsan , Jeje Oluyemi , Morris Donald , Savoie Lynn , Brown Chris , Hasagawa Wanda , Bahlis Nizar , Russell James R.
Published: October 2019

Introduction: A “genetically-randomized” prospective phase II study was designed to compare stem cell source following novel, uniform, and expected low toxicity re-induction and high dose chemotherapy for indolent B-cell NHL.

Patients and Methods: Pts with MCL in 1st remission or 1st relapse, or other indolent B-cell lymphoma in 1st or 2nd relapse were eligible providing adequate organ function and age <65 years. Pts received RICE (Rituximab 375mg/m2 d1,8,15,22, Ifosfamide 1.67g/m2 d16-18, Carboplatin AUC=5 d17, Etoposide 100mg/m2 d16-18), with G-CSF d22-30, and apheresis d29-31 if ASCT, then FluBu (Fludarabine 50mg/m² d-6to-2, Busulfan 3.2 mg/kg IV daily d-5to-2) and SCT d0. GVHD prophylaxis for AlloSCT involved ATG 4.5mg/kg, MTX and CSA.

Results: The initial 43 pts accrued from 06/2001-03/2004 included Follicular=30, MCL=7, SLL=4, other histology=2. Disease status was 1st remission=2, 1st relapse=18, 2nd relapse=12, 10 refractory=11. The median EFS following most recent prior chemotherapy was 7 mos. RICE resulted in an overall RR of 72%. Blood stem cell source was ASCT=27, donor SCT=16 (related=14, unrelated=1, syngeneic=1). For ASCT, a median of 5.9 (1–14.5) x106 CD34+ cells/kg were collected from 1 (n=17) or 2 (n=10) 15-25L aphereses. Three pts required a second mobilization procedure. 16/24 pts converted from positive to negative marrow biopsies post-RICE. Two pts had NHL detected in the autograft. FluBu resulted in no acute Bearman grade 3-4 RRT(overall 100d non-relapse mortality (NRM)=0% for both ASCT and donor SCT). Median engraftment times were slightly longer post AlloSCT than ASCT (ANC>0.5 = 15 vs 11d, and platelets>20 = 12 vs 9d, respectively). Of 15 AlloSCT pts, grade 3–4 aGVHD occurred in 5 (33%), cGVHD occurred in 64%, and death from extensive cGVHD + infection occurred in 5 pts from 7-13mo post-AlloSCT (overall NRM=33% for AlloSCT). With a median follow-up of 22mo, the 2 year projected outcome of ASCT vs Allo/Syngeneic-SCT for relapse-free survival (RFS) was 64% vs 87% (logrank p=0.48), event-free survival (EFS) 63% vs 52% (logrank p=0.38), and overall survival (OS) 86% vs 46% (logrank p=0.0018), respectively. For relapsed follicular lymphoma only, the 2yr EFS was 61% vs 59% (logrank p=0.49) and OS 100% vs 51% (logrank p=0.0009) for ASCT (n=19) vs Allo/Syngeneic SCT (n=11), respectively.

Conclusion: These preliminary results suggest that RICE can "in-vivo" purge autografts but mobilizes blood stem cells only moderately well. RICE-FluBu/ASCT may result in prolonged EFS with significantly less NRM than AlloSCT.