bluuebunny/crossref_metadata_2025 huggingface dataset:
Apixaban, Dalteparin, in Active Cancer Associated Venous Thromboembolism, the ADAM VTE Trial
Authors: McBane Robert D. , Wysokinski Waldemar E. , Le-Rademacher Jennifer , Ashrani Aneel A. , Tafur Alfonso J , Gundabolu Krishna , Perez-Botero Juliana , Perepu Usha , Anderson Daniel M. , Kuzma Charles , leon Ferre Roberto , Henkin Stanislav , Lenz Charles , Loprinzi Charles
Published: October 2019

Background: Currently, low molecular weight heparin is the guideline endorsed treatment of patients with cancer associated venous thromboembolism (VTE). While apixaban is approved for the treatment of acute VTE, there are limited data supporting its use in cancer patients.

Methods: Patients with cancer associated acute VTE were randomly assigned to receive either apixaban 10 mg twice daily for 7 days followed by 5 mg twice daily or subcutaneous dalteparin (200 IU/kg for 1 month followed by 150 IU/kg once daily) for 6 months. The primary outcome was major bleeding. Secondary outcomes included VTE recurrence and a composite of major plus clinically relevant non-major bleeding.

Results: Of the 300 patients who underwent randomization, 287 were included in the primary analysis. Of these, metastatic disease was present in 65.5% of subjects and 74% were receiving concurrent systemic cancer therapy. Colorectal, lung, pancreas, and breast cancers were the four most prevalent cancer types. Major bleeding occurred in 0 of the 142 patients (0%) in the apixaban group as compared with 3 of the 145 patients (2.1%) in the dalteparin group (p=0.9956). Recurrent VTE occurred in 5 patients (3.4%) in the apixaban group and 20 patients (14.1%) in the dalteparin group (difference in risk -10.7 percentage points) with a Hazard Ratio (HR) 0.26, (95% CI, 0.09 - 0.80, p = 0.0182). Major plus clinically relevant non-major bleeding were similar at 9% for both groups. There were no mortality differences comparing apixaban (15.9%) and dalteparin (10.6%) groups at 6 months (HR 1.36, 95% CI 0.79 - 2.35). Monthly quality of life surveys favored apixaban therapy for many measures including: concern for excess bruising, stress, irritation, burden of delivery, and overall satisfaction with anticoagulant therapy (p<0.05). Monthly bruising questionnaire favored apixaban at each interval (p<0.002).

Conclusions: Oral apixaban therapy was associated with very low rates of bleeding and significantly lower VTE recurrence with superior quality of life outcome measures compared to parenteral dalteparin in the treatment of cancer associated VTE. These data support the clinical utility of apixaban for the acute treatment of VTE in this patient population.

Table. Table.

Disclosures

No relevant conflicts of interest to declare.
Reactivation of Hepatitis B Virus Infection in Aplastic Anemia Patients Receiving Immunosuppressive Therapy
Authors: Yin Hua , Wang Suli , Lu Xingyu , Shen Wenyi , Lu Ruinan , Zhu Yu , Miao Kourong , Hong Ming , Wang Shuai , Zhang Jianfu , Qiao Chun , Wu Yujie , Wu Xuemei , He Guangsheng , Li Jianyong
Published: October 2019

Objective: The aim of this study was to assess the risk of HBV reactivation in HBsAg-positive or negative, HBcAb-positive patients with aplastic anemia (AA) receiving immunosuppressive therapy.

Methods: We analyzed clinical data of 60 AA patients with HBV infection out of 201 cases. Entecavir or lamivudine therapy was initiated if HBV reactivation was encountered, or used as antiviral prophylaxis regimen for HBsAg-positive patients.

Result: Among 60 AA patients, 12 were chronically infected and 48 were previously exposed. There was no difference in clinical features in AA patients with or without HBV infection. The prevalence of non-severe AA (NSAA) progressed to severe AA (SAA) was similar in two groups (35.6% vs 42.7%, p=1.0). In NSAA group, the response rate to CsA, to ATG and CsA, and progression to SAA were similar in patients with or without HBV infection (35.7% vs 35.3%, p>0.05; 42.8% vs 58.8%, p= 1.0; 35.5% vs 42.7%, p= 0.414). In SAA group, patients with or without HBV infection responded to ATG and CsA therapy similarly (83.33% vs 59.0%, p = 0.252). HBV reactivation was occurred in all 5 HBsAg positive patients without any antiviral therapy, while no HBV reactivation happened in other 7 patients received antiviral therapy. Disease course (RR=1.012, p=0.036) and absolute reticulocyte count (RR=11.556, P=0.025) were the risk factors for HBV reactivation by univariate analysis. Logistic regression indicated that HBsAg positivity without preventive therapy was the only strong factor for HBV reactivation.

Conclusion: Antiviral prophylaxis is recommended for HBsAg-positive patients with AA who will receive IST because of high rate of HBV reactivation. HBV infection has no influence on the clinic course of AA, and antiviral therapy does not affect the efficacy of IST.

Disclosures

No relevant conflicts of interest to declare.
Assessment of the Application and Clinical Value of Next-Generation Sequencing for the Diagnosis of Inherited Thrombocytopenia
Authors: Jiang Miao , Wang Qi , Zhao Yiming , Yu Ziqiang , Chen Suning , Xia Lijun , Ruan Changgeng
Published: October 2019

Inherited thrombocytopenia is a group of hereditary diseases with a reduction in platelet count as the main clinical manifestation. Clinically, there is an urgent need for a convenient and rapid diagnosis method. We introduced a high-throughput next-generation sequencing (NGS) platform into the routine diagnosis of patients with unexplained thrombocytopenia and analyzed the gene sequencing results to evaluate the value of NGS technology in the screening and diagnosis of inherited thrombocytopenia.

From a cohort of 182 patients with thrombocytopenia, we screened 78 patients with hereditary features. For the blood samples of these 78 patients, a gene sequencing platform for hemorrhagic and thrombotic diseases comprising 89 genes was used to perform gene detection using NGS technology. When we combined the screening results with clinical features and other findings, 23 of 78 patients (29.5%) were diagnosed with inherited thrombocytopenia. In addition, 29 pathogenic variants, including 11 previously unreported variants, were identified in these patients.

In summary, NGS could play more important role in the molecular pathology diagnosis of inherited thrombocytopenia. Through the use of this detection platform, we expect to establish a more effective diagnostic approach to such disorders.

Disclosures

No relevant conflicts of interest to declare.
Impact of Mhealth and Ehealth Applications on Hemophilia Treatment Management
Authors: Santandreu Estelrich Maria Margalida , Sánchez-Raga José María , Massanet Antonio Palomero , Galmés Sureda Bernat , Delgado Olga , Sampol Antonia , Canaro Mariana
Published: October 2019

Objective:

To evaluate the effect of the implementation of a smart-phone based therapy management application over the monitoring of the hemophilia A (HA) and B (HB) patients in home-care setting.

Setting:

Since 2016 our hospital is using a mobile app and real time therapy management system for hemophilia patients (Haemoassist™, StatConsult) as a new tool of hemophilia patients care management complementing the existing health charts.

Methods:

A retrospective research conducted at one hemophilia treatment center covering four islands. HA and HB patients using the mobile app with at least 6-month follow-up period were included. Data on socio-demographics, clinical and therapy were collected before and after 6-month period of the app introduction. Sources of information were the electronic medical history (Millenium-Cerner™), pharmacy outpatient delivery program (Hospiwin™) and the above mentioned smart-phone app.

The adherence was estimated calculating real factor consumption divided by the theoretical factor consumption according to prescribed prophylactic regimen for each study period. The extra doses for bleeding episodes were collected only after the intervention, due to unavailable reliable reports for mild and moderate bleeding events before the incorporation of the app.

Results:

A total of 28 patients with severe and moderate HA and HB on prophylactic treatment were included. The median age was 25 years (range 3-57). The median of the first period adherence was 72.7 % (range 30.77-100%) and of the second was 100% (range 51.88-100%). The median of the difference between periods was 15% (see chart 1 for more detailed information). In the post-intervention period, 12 (43 %) patients had a median of 3 bleeding events (range 1 -7) and needed extra-infusions with a median of 7 doses (range 3-17).

Conclusions:

The adherence to prophylactic treatment is crucial to reduce joint bleedings (Manco-Johnson MJ et al. NEJM. 2007). The use of therapy management mobile app has contributed to increase adherence in our patients allowing a precise monitoring of the administered factor and bleeding events in real time.

Figure. Figure.

Disclosures

No relevant conflicts of interest to declare.
Enhancing a Specialized Nursing Care Guidelines Improves Acute Lymphoblastic Leukemia Patients' Outcome during Induction Phase; A Developing Country Experience
Authors: Hanafy Nesreen Fathy , Khedr Reham , Abd-Elwahab Eglal Ahmed , Abouelnaga Sherif
Published: October 2019

Introduction: Pediatric Cancer patients are treated with therapeutic research protocols that detail medical treatment in low- and middle-income countries (LMICs). Unfortunately, there is no precise definition of a structured nursing care plan that is mandatory to enhance the quality of care needed for these patients. Our study aimed to examine the impact of implementing a designed nursing care guidelines (NCG) on acute lymphoblastic leukemia (ALL) patient outcomes during the induction phase concerning; incidence, duration, and intensity of the patient's gastrointestinal tract GIT adverse events.

Methods: A Quasi-experimental research design was utilized in this study with posttest only control group conducted at the Hematology Units of Children Cancer Hospital Egypt 57357. Seventy-four oncology nurses received adequate education for the designed nursing care plan. A total of (132) ALL children in induction phase were enrolled in the study and were divided into two groups: group 1 (intervention group) was implemented the nursing care guidelines and group II (control group) who was left to the routine hospital care.

Tools: data collection instruments included; "patient outcomes audit chart" to assess the GIT adverse - events data: the incidence, duration, and intensity. The intensity grading of the adverse events Adopted from the NCI (National Cancer Institute) Common Terminology Criteria for Adverse Events v4.0 (CTCAE) Published on May 28, 2009.

Results: A significant positive correlation between implementing the NCG and GIT adverse events incidence, duration and severity were observed (Figure 1). Incidence was reported higher in the control group than the study group with a mean score of ±SD (2.48± .949) versus (0.67± 0.751) respectively, and a p-value (P<0.0001). The duration of incidence was (15.32± 5.920) versus (3.70± 5.108) in the intervention group (t =12.074) df (130) and a p-value (P<0.0001). The intensity grading of the adverse events was less in the study group than the control. (figure 2)

Mean scores for nurses' post-NCG knowledge in the study group were significantly higher than the nurse's knowledge scores in the control group. The intensity of incidence revealed that a significantly higher on the intervention group.

Conclusion: Designing and implementing NCG for all treatment protocols is essential for the enhancement of patients' outcomes. Developing a pediatric oncology nurse residency program for education and teaching of the required practical skills in LMIC is mandatory.

Figure 1 Figure 2

Disclosures

No relevant conflicts of interest to declare.
Utilizing Y Chromosome FISH to Determine the Origin of Post-Transplant Lymphoproliferative Disease in Solid Organ Transplant Recipients
Authors: Ford James B. , Jennifer Sanmann N , Erickson Kelly , Grant Wendy J , Althof Pamela A , Langnas Alan , Shostrom Valerie , Bast Martin , Greiner Timothy C. , Coccia Peter F.
Published: October 2019

Background: Post-Transplant Lymphoproliferative Disease (PTLD) is a heterogeneous disease that arises as a complication after solid organ transplants (SOT) and unusually after bone marrow transplants (BMT). PTLD is generally of recipient origin in SOT patients and donor origin in BMT patients. Knowing the cellular origin of PTLD may provide insight into tumorigenesis and potentially guide treatment options.

Design/Methods: We identified gender mismatched SOT patients from our institutional databases who had PTLD tumor tissue for FISH analysis to determine the tumor origin (donor vs. recipient). From these samples, lesional and normal (when present) tissue was delineated by a hematopathologist (TG), and subsequent XY FISH studies were performed according to standard protocols for detection of the Y chromosome.

Results: Thirty-one gender mismatched PTLD patients were examined (20 were pediatric patients <18 yrs old). Transplants were: 8 isolated liver (L), 7 kidney (K), 3 small bowel (SB), 6 L/SB, 4 L/SB/pancreas (P), 2 K/L and one L/K/P. Of the 31 patients: 25 were 100% recipient origin; 5/31 demonstrated mixed chimerism; and 1 was 100 % donor origin. Of the 6 patients with chimerism (3 children), the percentage of donor cells ranged between 23% and 100%. Three of 31 had PTLD in the allograft, with 2 of 3 demonstrating mixed chimerism. One was a 2 y.o. F 3 months after a SB transplant and the other a 10 m.o. M 12 months after a L/SB/P transplant. Of the 28 with tumor tissue at other sites, 3 had mixed chimerism: a 60 y.o. M 9 months after a K/L transplant; a 7 m.o. M 8 months after a L/SB transplant; and a 64 y.o. F 3 months after a L transplant. The single patient with 100 % donor chimerism was a 27 year old female 5 months after a L/SB transplant. The 6 chimeric patients developed PTLD on average earlier than the 25 patients of recipient origin (6.9 months vs. 18.1 months). Of the 20 pediatric patient, 12 had transplants including small bowel and 3/12 demonstrated mixed chimerism. Mortality rate was similar between pediatric and adult populations (40% and 45% respectively).

Conclusion: As expected, the majority of patients in our series had tumors of recipient origin. However, 3/20 pediatric patients (15%) and 3/11 (27%) adult patients were chimeric in 23% to 100% of their tumor cells. Chimerism was more common in patients who received transplants that included L (4/5) and SB (3/5).

Disclosures

Ford: Novartis: Consultancy, Honoraria.
4-1BB-Costimulated CAR-Mediated Non-Canonical NF-Kb Signaling Enhances CAR T Cell Survival and Suppresses Bim Expression
Authors: Milone Michael C. , OConnor Roddy , May Michael , Albelda Steven , Philipson Benjamin
Published: October 2019

Chimeric Antigen Receptor (CAR) T cell therapy induces deep and durable responses in a large percentage of patients with B-cell malignancies. These responses often correlate with CAR T cell persistence in patients. The first two FDA-approved CAR-T cell therapies employ 2nd generation CARs that use different costimulatory domains derived from either CD28 or 4-1BB. Data from pre-clinical studies as well as clinical trials suggest that 4-1BB CAR (BBz) T cells persist longer than CD28 CAR (28z) T cells.

One signal associated with cellular survival and activated by endogenous 4-1BB, but not CD28, is the non-canonical NF-kB (ncNF-kB) pathway. NcNF-kB is required for memory T cell persistence and enhances tumor cell survival by suppressing pro-apoptotic gene transcription. Therefore, we hypothesize that the BBz, but not the 28z CAR, activates ncNF-kB signaling, which promotes CAR T cell persistence by suppressing pro-apoptotic gene expression.

Using primary human T cells isolated from the apheresis products of anonymous healthy donors, we generated 28z or BBz T cells by lentiviral transduction following activation by CD3 and CD28. Induction of ncNF-kB signaling following CAR activation was assessed by western blot. NcNF-kB function was evaluated by concomitant expression of a dominant-negative mutant of NF-kB-inducing Kinase (dnNIK) to block the ncNF-kB pathway. In addition to pathway analysis by western blotting, T cell proliferation, immunophenotype and survival were assessed by bead-based counting via flow cytometry. To explore mechanisms affecting survival, pro- and anti-apoptotic gene expression was analyzed by qPCR and western blot over three weeks following restimulation through the CAR.

Following CAR activation, ncNF-kB signaling was detected in BBz but not 28z T cell lysates. Control mRFP BBz T cells expanded approximately 10 fold more than BBz T cells coexpressing dnNIK. DnNIK-expressing BBz T cells exhibited higher rates of cell death contributing to the observed differences apparent in ex vivo expansion. This cell death was associated with a 2 fold increase in the message and nearly 3 fold increase in the expression of the pro-apoptotic protein, Bim, in the dnNIK BBz T cells relative to control. In contrast, dnNIK 28z T cells had no appreciable difference in proliferation or survival compared with control.

Therefore, BBz, but not 28z signaling activates the ncNF-kB pathway, which protects BBz T cells from cell death likely by restricting the expression of the pro-apoptotic protein, Bim.

Disclosures

Milone: Novartis: Patents & Royalties.
Experience and Outcome of Patients with Nodular Lymphocyte Predominant Hodgkin Lymphoma (NLPHL) over 8 Years
Authors: Ali Syed S , George Reju
Published: October 2019

Introduction: NLPHL is an uncommon variant of Hodgkin lymphoma (HL) accounting for 5% incidence of all HL diagnoses. NLPHL represents a more indolent disease than classical HL, and is therefore managed uniquely. Unlike classical Hodgkin lymphoma (cHL), NLPHL shows CD20 immunoreactivity. Given the rarity of the disease, optimal management is unclear.

Here we present our retrospective clinical experience of nine cases of NLPHL diagnosed over the last 8 years at our institution.

Results: The median age at diagnosis was 45 years. Eight of the nine patients were males. The youngest patient was 21 years old and the oldest patient at diagnosis was 58 years old. One patient had Stage I, six had stage II and two patients had Stage-III disease. No patient had bone marrow involvement and only two patients had B symptoms. Interestingly, two sets of brothers diagnosed at different intervals were identified among this group of patients.

Three out of seven patients with Stage I/II disease received radiation as the primary modality of treatment. Four patients received chemotherapy only and two patients received combined modality treatment( chemotherapy followed by radiation). Only the youngest patient received R-CVP (rituximab, cyclophosphamide, vincristine, and prednisone) to avoid anthracycline related long term toxicity. A total of four patient received R-CHOP, two of these also received involved site radiation therapy (ISRT).One patient received six cycles of AVD (doxorubicin, vincristine and dacarbazine).

All the patients achieved complete response (CR) and durable remission except one patient. That particular patient had stage III NLPHL at diagnosis and was treated with R-CHOP initially. Three years later on relapse, he had T-cell rich large B cell lymphoma (TCRBCL) and is currently on a clinical trial with pembrolizumab and remains in complete remission.

Conclusions: As has been the experience with other institutions, the majority of the cases of NLPHL at our institution have presented with early stage disease. Treatments have included R-CHOP regimens in most of the cases with durable remission in the majority. Although R-CVP is not the standard regimen for NLPHL, the one young patient who had stage III disease at diagnosis and received R-CVP, achieved CR and remains disease free five years later. This highlights the importance of non-anthracycline chemotherapy regimens as an option for particularly young or older frail patients.

NLPHL occurs with higher than expected frequency among first-degree family members of patients with NLPHL as demonstrated in the Finnish Cancer Registry study reported in JCO 2013. Interestingly, in our small cohort, there were two sets of brothers identified with NLPHL, diagnosed metachronously. Unlike cHL, late relapse can occur as well as a propensity to transform to an aggressive B-cell Non-Hodgkin lymphoma.

Disclosures

No relevant conflicts of interest to declare.
Investigating the Role of C/Ebpδ-Deficiency in Radiation-Induced Bone Marrow Failure
Authors: Majumdar Debajyoti , Pietras Eric , Stumhofer Jason , Pawar Snehalata A
Published: October 2019

Background: Bone marrow (BM) failure is a common side-effect of toxicity to the hematopoietic tissue both in the clinical setting as well as in case of total body irradiation (TBI) exposure in the event of nuclear terrorism or disasters. Particularly IR-induced myelosuppression is considered a significant risk factor for infections and increased risk for long-term hematopoietic dysfunction and myelodysplasia.

Although a lot is known about the key regulatory proteins of steady-state hematopoiesis, not much is known about the regulatory factors involved in stress-induced hematopoiesis. Therefore delineating the mechanisms underlying the effects of IR stress-induced hematopoiesis is critical for the development of novel interventions with the potential to prevent or alleviate IR-induced BM injury/failure.

The transcription factor CCAAT/enhancer-binding protein delta (Cebpd; C/EBPδ) plays an important role in the regulation of inflammatory and stress responses, and in the innate and adaptive immune responses. We have previously reported that Cebpd-knockout (KO) mice display increased neutropenia, thrombocytopenia and myelotoxicity in response to IR exposure, which correlated with increased apoptosis of hematopoietic stem cells (HSCs) and hematopoietic progenitor cells (HPCs). In the present study, we further investigated the underlying mechanisms of IR-induced bone marrow failure in the absence of C/EBPδ.

Methods: Cebpd+/+and Cebpd-/- mice (C57BL/6J background) aged 3 months were exposed to 6 Gy TBI. Bone marrow mononuclear cells (BM-MNCs) were isolated from femurs and tibiae harvested at early time-points (1h, 4h and 24h) as well as 2 weeks post-irradiation. The presence of reactive oxygen species (ROS) was measured using MitoSOX and the extent of DNA damage was measured using an antibody specific to g-H2AX at the above time points. BM-MNCs were labelled with fluorophore-tagged antibodies and analyzed by flow cytometry to measure the absolute numbers of long term-HSCs, multipotent progenitors, common lymphoid progenitors and myeloid progenitors at 2 weeks post-6 Gy. The changes in cell cycle distribution in response to IR exposure will also be analyzed by flow cytometry using a DNA-binding dye in conjunction with Ki67.

Results: Preliminary results reveal: (a) reduced numbers of HSCs, HPCs, common myeloid progenitors, myeloid-erythroid progenitors and granulocyte-monocyte progenitors and (b) increased accumulation of ROS and the DNA damage marker, γ-H2AX in HSCs and HPCs in Cebpd-/- mice compared to Cebpd+/+ mice at 2 weeks post-irradiation.

These results suggest that C/EBPδ may play a protective role in radiation-induced bone marrow injury. Studies are underway to further examine changes in cell cycle, ROS and DNA damage in the various BM cell lineages post-TBI.

(Funding support by NIGMS P20GM109005 & Department of Defense W81XWH-15-1-0489 is gratefully acknowledged)

Disclosures

No relevant conflicts of interest to declare.
Assessment of Iron Overload in the Pediatric Allogeneic HSCT Recipient
Authors: DePriest Brittany Paige , Huang Mikey
Published: October 2019

Background: Owing to improved strategies in pediatric bone marrow transplantation, a larger number of transplanted children are now becoming long term survivors. These post-transplant patients remain at risk for late complications including iron overload, which has the potential to impair quality of life and adversely affect later outcomes. While literature has previously focused on iron overload in the adult sickle cell patient, there has been minimal research into its effect on the pediatric bone marrow transplant recipient. Thus, no current guidelines exist for screening, management or treatment of iron overload in this patient population. Our study focuses specifically on this population and reports the relationship between number of PRBC transfusions and current diagnostic tools.

Objectives: To identify the presence or absence of correlation between the number of red blood cell transfusions and indicators of iron overload via two different modalities: ferritin values and the T2* MRI liver iron concentration (Ferriscan).

Methods: A retrospective chart review of the allogeneic pediatric bone marrow transplant patients over the past 5 years at a single center (n = 32). Quantitative data obtained which included number of PRBC transfusions, ferritin, and T2* MRI LIC. Correlation analysis subsequently performed between pre-and post-transplant values.

Results: There was significant (p < 0.001) moderate correlation (r = 0.62) between the number of pre-transplant PRBC transfusions and the pre-transplant ferritin value. No significant (p >0.1) correlation between the number of pre-transplant PRBC transfusions and the pre-transplant T2* LIC. Also, no significant (p > 0.1) correlation between pre-transplant ferritin and T2* LIC. The total number of PRBC transfusions up to 100 days post-transplant did have significant (p = 0.008) moderate correlation (r= 0.62) with post-transplant ferritin values. There was significant (p = 0.01) strong correlation (r= 0.87) between the total number of PRBC transfusions up to 100 days post-transplant with post-transplant T2*LIC values. No significant correlation (p > 0.1) between post-transplant ferritin and T2* MRI LIC values.

Conclusions: In terms of modalities utilized for evaluation of iron overload in the pediatric allogeneic BMT population, no significant correlation exists between ferritin values and T2* MRI liver iron concentration values. While ferritin is an acceptable screening tool the post-transplant T2*MRI LIC is a more accurate diagnostic indicator of transfusion burden. Future studies will be used to explore associated adverse outcomes of patients diagnosed with iron overload.

Disclosures

No relevant conflicts of interest to declare.
Wnt5a Induces Association of ROR1 with Ca2+/Calmodulin-Dependent Protein Kinase II and ROR1-Dependent Calcium Influx in Chronic Lymphocytic Leukemia
Authors: Chen Liguang , Chen Yun , Yu Jian , Zhang Ling , Rassenti Laura Z. , Kipps Thomas J.
Published: October 2019

Receptor tyrosine kinase-like orphan receptor 1 (ROR1) is an oncoembryonic antigen that is expressed on CLL cells, but not on normal postpartum tissues. We found that ROR1 was a receptor for Wnt5a, which could enhance CLL-cell proliferation (Yu J, et al, JCI 126:585, 2016; Yu J, et al, Leukemia 31:2608, 2017; Hasan MK, et al, Blood 132:170, 2018). We performed mass spectrometry-based proteomics to interrogate immune-precipitates of Wnt5a-activated ROR1 and identified Ca2+/calmodulin-dependent protein kinase II (CaMKII), a serine/threonine-specific protein kinase. Recent studies demonstrated that high levels of different isoforms of CaMK, especially CaMKII, were expressed in several cancers. CaMKII phosphorylates nearly 40 different proteins, including enzymes, ion channels, kinases, and transcription factors and can play a critical role in the regulation of proliferation and survival of various cancer cells (Wang YY, et al, Oncotarget 20:11725, 2015; Chi M, et al, Sci Rep 6:33132, 2016; Hoffman A, et al, Cell Signal 26:748, 2014). We validated our mass spectrometry finings in co-immunoprecipitation studies and immunoblot analyses. These studies showed that Wnt5a could induce the specific phosphorylation and recruitment of CaMKII to ROR1. Moreover, these studies demonstrated that Wnt5a-induced recruitment of CaMKII to ROR1 could be blocked by cirmtuzumab, a first-in-class humanized anti-ROR1 mAb undergoing clinical testing in patients with CLL (Choi MY, et al, Cell Stem Cell 22:951, 2018). CaMKs serve as a ubiquitous intracellular receptor for Ca2+ and their activity are regulated through Ca2+ signaling. Therefore, we examined calcium influx in CLL cells by flow cytometry. Treatment of CLL cells cultured overnight in serum-free medium induced calcium influx within seconds. Moreover, the relative capacity of Wnt5a to induce calcium influx was associated with the relative expression level of ROR1 on CLL cells of different patients. Furthermore, Wnt5a could enhance calcium influx induced by treatment with anti-µ in CLL cells that expressed ROR1, but not in CLL cells that lacked expression of ROR1. Knockdown of ROR1 using ROR1 siRNA or treatment with cirmtuzumab inhibited the capacity of Wnt5a to enhance calcium influx induced by treatment with anti-µ. Collectively, these data demonstrate that Wnt5a-induced ROR1-signaling in CLL can influence BCR-signaling and activation of the Ca2+/calmodulin-dependent protein kinase II signaling pathway.

Disclosures

No relevant conflicts of interest to declare.
Low Relapse Rate after 2 Years in Patients with Diffuse Large B-Cell Lymphoma (DLBCL) Treated with R-CHOP and Achieved Complete Response
Authors: Kang Junho , Lee Kyoungmin , Hong Jung Yong , Yoon Dok Hyun , Kim Shin , Park Jung Sun , Lee Sang Wook , Park Chan-Sik , Ryu Jin-Sook , Huh Jooryung , Suh Cheolwon
Published: October 2019

Introduction : Patients with DLBCL usually relapse early after the first treatment but some relapse after 2 years (defined as late relapses). In a previous study, patients with DLBCL who achieved event free survival at 24 months had a subsequent overall survival equivalent to the general population. We analyzed the time of relapse and clinical characteristics of late relapse in patients with DLBCL who achieved complete response (CR) after frontline R-CHOP.

Methods: We retrospectively reviewed prospectively collected lymphoma registry of the Asan Medical Center in Seoul, Korea, between 2002 and 2015. We found 1,047 DLBCL patients who have been treated with R-CHOP as the first line modality. Among 1,047 patients, 859 (82.0%) patients achieved CR. Chi-square or Fisher's exact test was used for comparison of categorical variables and Student's t-test or Mann-Whitney U-test for continuous variables, as appropriate. Two-sided p-value of <0.05 was considered significant.

Results : Among 859 patients, 182 (21.2%) patients relapsed and 51 (5.9%) patients had late relapse after 2 years from the end of treatment evaluation that confirmed CR. For patients who had a late relapse, median time from diagnosis to relapse was 4.0 years (range, 2.0 to 10.0 years), median age was 61 years old (range, 39-78), and 27 (52.9%) patients were male. Twenty-six (51%) patients had stage I-II, and 36 (70.6%) patients had low/low-intermediate International Prognostic Index (IPI) score at diagnosis. Compared with early relapses (n=131, 12.5%), late relapses were associated with low IPI score (median, 2 vs. 3; p = 0.001), low LDH (median, 244 vs. 337 IU/L; p < 0.001), low beta-2-microglobulin (median, 2.4 vs. 2.6 mg/L p = 0.002), higher germinal center phenotype rate (30.6% vs. 15%; p=0.05). Median overall survival from the end of treatment evaluation that confirmed CR was significantly higher in the late relapse group compared with early relapse group [112.6 months (95% CI 73.1-152.0) vs. 19.9 months (95% CI 15.3-24.4); p<0.001 by log rank].

Conclusion: Our study demonstrated that relapse rate after 2 years was low (5.9%) in patients with DLBCL who achieved CR after R-CHOP. Patient with late relapse showed favorable clinical characteristics and survival outcomes compared with patients with early relapse.

Disclosures

No relevant conflicts of interest to declare.
Neutralizing IL-2 Early after HCT Specifically Prevents Expansion of Donor GM-CSF-Producing CD4+ T Cells That Initiate Acute Gut Gvhd
Authors: Song Qingxiao , Wang Xiaoning , Martin Paul J , Chen Yuanzhong , Zeng Defu
Published: October 2019

Acute graft versus host disease (GVHD) in gut has a critical impact on the outcome after allogenic hematopoietic cell transplantation (allo-HCT). It was recently reported that BATF-dependent GM-CSF-producing donor CD4+ T cells play a critical role in initiating acute gut GVHD (Ullrich et al: JCI 2018; Zeng: JCI; 2018). We recently reported that IL-2 from donor CD4+ T cells made infiltrating T cells resistant to host-tissue PD-L1-mediated tolerance (Ni & Song et al: JCI 2017). In the current studies, we tested whether in vivo neutralization of IL-2 early after allo-HCT regulates the expansion of GM-CSF-producing CD4+ T cells and the development of acute gut GVHD, and if so, whether host-tissue PD-L1 is required for this effect. We transplanted spleen (5x106) and BM cells (2.5x106) from C57BL/6 (H-2b) donors into irradiated wild-type (WT) or PD-L1-/- BALB/c (H-2d) recipients bearing BCL1 leukemia/lymphoma cells and into recipients without BCL1 cells. Recipients were treated with anti-IL-2 mAb IP (500 µg/mouse) on days 0, 2, 4 and 6, and controls were treated with isotype-matched IgG. We observed the following results. 1) Administration of anti-IL-2 fully prevented acute gut GVHD while preserving GVL activity in WT recipients. 2) Administration of anti-IL-2 did not prevent acute gut GVHD in PD-L1-/- recipients, indicating that GVHD prevention depends on expression of PD-L1 in recipient tissues. 3) Prevention of GVHD in WT recipients was associated with a marked reduction in the number of donor-derived GM-CSF-producing CD4+ T cells infiltrating gut tissue, together with decreased Paneth cell damage and bacterial translocation to the liver. These results indicate that neutralizing IL-2 early after allo-HCT specifically prevents expansion of acute gut GVHD-initiating GM-CSF-producing CD4+ T cells and prevents acute gut GVHD in a host-tissue PD-L1-dependent manner. These results also indicate that a short-term administration of anti-IL-2 following allo-HCT prevents induction of acute gut GVHD while preserving GVL effects. Current experiments are testing the molecular mechanisms whereby neutralizing IL-2 decreases the numbers of GM-CSF-producing CD4+ T cells in gut tissues via tissue expression of PD-L1. (Grant support: NIH 1R01CA228465-01 to Zeng).

Disclosures

No relevant conflicts of interest to declare.
Regulatory Reprogramming of Erythropoiesis By DNMT3A Mutation
Authors: Woo Janghee , Stehling-Sun Sandra , Deeg H. Joachim , Papayannopoulou Thalia , Urnov Fyodor D , Stamatoyannopoulos John A
Published: October 2019

DNA methyltransferase 3A (DNMT3A) regulates diverse epigenetic processes, and DNMT3A mutations occur frequently in myelodysplastic syndromes (MDS), including in founding clones of MDS samples. Most DNMT3A mutations affect Arg882 (R882) in the catalytic domain of DNMT3A, and are found almost exclusively in a heterozygous state. To resolve the relationship between the genetic and epigenetic architectures of R882H+ MDS, we engineered primary human CD34+ hematopoietic stem and progenitor cells (HSPCs) to carry heterozygous DNMT3A R882H and performed temporally resolved, genome-wide regulatory mapping via DNase-seq combined with RNA-seq during erythroid differentiation in vitro, and in an in vivo transplantation model.

Compared with isogenic controls, heterozygous R882H HSPCs cells exhibited markedly impaired erythroid differentiation, accumulation of early myeloid progenitors, and diverse maturation defects. Transplantation of R882H HSPCs into W41 NSG mice revealed both impaired erythroid differentiation and preferential survival of mutant alleles in multiple hematopoietic lineages compatible with an early progenitor defect.

Regulatory profiling of DNMT3A R882H heterozygous cells during differentiation via combined DNase- and RNA-seq revealed global and sequential alterations in the regulatory landscapes in mutant cells, most prominently decommissioning of thousands of regulatory regions normally found in primitive cells that mark gene loci destined for expression during later differentiation stages. Decommissioned regulatory elements in R882H heterozygotes were concentrated around genes involved in both regulation of erythropoiesis and cell-cycle control, biasing HSPC differentiation away from erythropoiesis. Similar findings were observed in CD34+-selected bone marrows from 33 patients with MDS, comparing heterozygous DNMT3A R882H and wild type.

Collectively, our results indicate that DNMT3A R882H mutation reprograms early myeloid regulatory landscapes by preferentially targeting elements that control genes destined to be expressed at later stages of differentiation, resulting in a combined phenotype of impaired myeloid differentiation, impaired erythroid maturation, and preferential survival of R882H+ cells. The results provide novel mechanistic insights into the chromatin programming of erythroid differentiation and its connection with MDS.

Disclosures

No relevant conflicts of interest to declare.
A Rare Case of Delirium: Acquired Thrombotic Thrombocytopenic Purpura in an HIV Patient
Authors: Solanki Kinjal , Pir Syed Haris A , Khoury Constantine , Cervantes Jose F.
Published: October 2019

Introduction

Thrombotic thrombocytopenic purpura (TTP) is a rare disorder with incidence of one in a million. Manifestations of TTP include fever, thrombocytopenia, thrombotic microangiopathy affecting the brain, heart and kidney causing neurological symptoms, and hemolytic anemia. Not all patients with TTP will have each and every manifestation, and therefore a high index of suspicion is necessary when managing a patient with microangiopathic hemolytic anemia and thrombocytopenia. In recent years, increased incidence of TTP has been reported in patients with coexisting Human immunodeficiency virus (HIV)infection .

Clinical Case

A 55 year old female with unknown past medical history presented with confusion and altered sensorium after she was found in the airport wandering. When questioned, she was oriented to self only, and gave single phrase answers.

Vitals on admission were significant only for tachycardia with HR of 125 beats per minute. Rest of physical exam was normal. Lab work revealed severe anemia (Hemoglobin 5.1), thrombocytopenia ( Platelet count 6), borderline renal function( BUN 30, serum Creatinine 1.1) and Schistocytes on peripheral smear. TTP was the presumptive diagnosis. Without evidence of sepsis, she was treated with intravenous fluids, systemic steroids, blood products (pure red cell concentrate and fresh frozen plasma) and plasmapheresis. Patient was found to be HIV positive, and had acquired immunodeficiency syndrome with CD4 count of 193. ADAMTS13 inhibitor was 1.3 (nl <0.4) and ADAMTS13 activity level was <3 (normal range 68-163%).

Patient's mental status improved to baseline over next 3 days and, renal failure and encephalopathy resolved. Upon further investigation, she recalled having a needle stick injury around 10 years ago. She was started on elvitegravir, cobicistat, emtricitabine, and tenofovir alafenamide (Genvoya) and prophylactic antibiotics prior to discharge.

Discussion

Despite its rare nature, TTP can be fatal if one fails to make a proper timely diagnosis. If left untreated, the mortality can reach up to 90% but with empiric treatment and therapeutic plasma exchange up to 85% survival rate can be achieved.

Through this case report, we hope to raise the awareness of this disorder with its particular association with HIV infection. The exact mechanism for HIV related TTP is unknown, but some proposed ones include the release of large amounts of von Willebrand factor and downregulation of ADAMTS13 and/or the production of antibodies against ADAMTS13. ADAMTS13 activity levels below 10% are seen in acquired and hereditary TTP, but not all patients with such exhibit low levels with this assay. Acquired TTP with low levels of ADAMTS13 has been increasingly reported in association with HIV infection, such as in this case.

Disclosures

No relevant conflicts of interest to declare.
Survival Analysis in Patients of AML with Myelodysplasia Related Changes
Authors: Ghimire Krishna , Nepal Mahesh , Rondelli Damiano
Published: October 2019

Introduction:

AML with myelodysplasia related changes (MRC) is a disease of elderly which has very poor outcome. There is limited data on survival disparities in AML with MRC by age and race.

Methods: We used SEER 18 registry to analyze relative survival (RS) rates among patients with AML with MRC diagnosed during 2000-2014. Patients were stratified by age (20-64 yrs, ≥65 yrs), sex and race (Caucasian, African American [ AA] and others). We used SEER Stat 8.3.4 for survival analysis.

Results: There were 2,071 patients; male 60%, median age of diagnosis 70 yrs; diagnosed with AML with MRC during 2000-2014. There were 1,742 Caucasian, 141 AA and 185 other races. The median overall survival of AML with MRC in Caucasian, AA and other races were 6.9, 6.1, 8.2 months respectively.

The RS for younger (20-64 yrs) patients was at 51.4% 1 yr , 32.8% 2 yr 27.9% and 3 yr . The RS for older patients was at 26.3% 1 yr , 12% 2 yr and 6.6% 3 yr .

When younger pts were analyzed by race, RS for Caucasian, AA, others were: 51.3%, 40.6%, 60.2% with p values 0.94, 0.104, 0.129 respectively at 1 yr ; 33.5%, 16.2%, 38.7% with p values 0.898, 0.017, 0.201 respectively at 3 years; 28.8%, 9.0%, 33.6% with p values 0.861, 0.005, 0.187 at 5 yrs respectively . There was no racial difference in RS in older patients.

When stratified by sex, RS for younger AA males vs all younger males were 33.4% vs 49.6% p: 0.05 at 1 yr; 11.6% vs 29.9% p 0.021 at 2 yrs ; and 3.9% vs 25% p 0.007 at 3 yrs respectively. There was no racial difference in RS in female sex both in younger and older patient population.

Conclusion:

Our study showed that young AA male diagnosed of AML with myelodysplasia related changes have poor outcome as compared to others. This difference is likely related to difference in disease biology and socio cultural differences and access to health care. Further studies are needed to identify potential areas of intervention.

Table. Table.

Disclosures

No relevant conflicts of interest to declare.
Relationship between Non-Prescribed Drug Use and Employment Status of Patients with Sickle Cell Disease
Authors: Idowu Modupe , Chung Tong Han , Yu Katherine
Published: October 2019

Introduction: Patients with sickle cell disease (SCD) suffer from recurrent episodes of acute vaso-occlusive crises that cause acute musculoskeletal pain and chronic pain due to complications such as avascular necrosis of the joints or bone infarcts. Most of these patients are on chronic opioid medications to manage their acute and chronic pain. Generally, patients with chronic pain syndrome are more prone to use illicit drugs more than the general population. In addition, patients with SCD have high rates of unemployment, which may put certain individuals at risk for negative coping behaviors such as illicit drug use. This study aim at investigating the relationship between the use of non-prescribed drug (illicit drug) and employment status of patients with SCD.

Patients and Methods: This was a pilot study of SCD patients at UT Physicians Comprehensive Sickle Cell Center from January 2012 to July 2018. We administered surveys during routine clinic visits and we reviewed clinical data in the electronic medical records. We used results of comprehensive urine drug screen (UDS) to evaluate for the use of non-prescribed drugs. UDS was done, on average every 3 to 6 months, on each patient. Descriptive analysis was performed with frequency distributions. Univariate logistic regression was conducted to investigate the association between non-prescribed drug use and employment status.

Results: A cohort of 78 SCD patients completed surveys about employment and non-prescribed drug use. In the survey, only ten patients (12.82%) reported using at least one non-prescribed drug. However, after the chart review for urine drug screens, twenty one out of seventy eight (26.92%) were using non-prescribed drugs. Most of the SCD patients using non-prescribed drug (71%) used Marijuana and three patients used multiple non-prescribed drugs. Seven out of twenty one (33.33%) of the non-prescribed drug users and 18 out of 57 (31.58%) of the non-drug users are employed. The univariate logistic regression analysis showed non-prescribed drug use is not statistically associated with employment status among SCD patients (P-value=0.8829).

Conclusions: In this sample, we concluded that there was no obvious relationship between non-prescribed drug use and employment status of patients with SCD. In our cohort, marijuana was the most commonly used non-prescribed drug, which might be partly due to its effect on chronic pain management. Non-prescribed drug use was quite common (26.92%), but was under-reported (13%) among users. It is important to note that only 3 out of 78 patients (3.85%) used multiple non-prescribed drugs; hence, polysubstance abuse was rare in our sample.

Disclosures

No relevant conflicts of interest to declare.
Aberrant regulation of superantigen responses during T-cell reconstitution and graft-versus-host disease in immunodeficient mice
Authors: Spaner David , Sheng-Tanner Xiaofang , Schuh Andre C.
Published: October 2019

Acute graft-versus-host disease (GVHD) after allogeneic stem cell transplantation is associated with impaired deletion and anergy of host-reactive T cells. To elucidate the immunoregulatory events that may contribute to such dysregulated T-cell responses in GVHD, we studied superantigen (SAg) responses after adoptive T-cell transfer into severe combined immunodeficient (SCID) mice. SAg responses are normally regulated by mechanisms involving deletion and anergy, with SAg-reactive T cells typically being deleted rapidly in vivo. In a SCID mouse model of GVHD, however, allogeneic host SAg-reactive T cells were not deleted rapidly, but rather persisted in increased numbers for several months. Moreover, depending on the timing of SAg stimulation and the numbers of T cells transferred, dysregulation (impaired deletion and anergy) of SAg responses could be demonstrated following the adoptive transfer of syngeneic T cells into SCID mice as well. Transgenic T-cell receptor-bearing KJ1-26.1+ T cells were then used to determine the fate of weakly reactive T cells after adoptive transfer and SAg stimulation. When transferred alone, KJ1-26.1+ T cells demonstrated impaired deletion and anergy. In the presence of more strongly staphylococcal enterotoxin B (SEB)–reactive T cells, however, KJ1-26.1+ T cells were regulated normally, in a manner that could be prevented by inhibiting the effects of more strongly SEB-reactive cells or by increasing the level of activation of the KJ1-26.1+ T cells themselves. We suggest that the control mechanisms that normally regulate strongly activated T cells in immunocompetent animals are lost following adoptive transfer into immunodeficient hosts, and that this impairment contributes to the development of GVHD.
Polymorphisms of the tumor necrosis factor-α gene promoter predict for outcome after thalidomide therapy in relapsed and refractory multiple myeloma
Authors: Neben Kai , Mytilineos Joannis , Moehler Thomas M. , Preiss Astrid , Kraemer Alwin , Ho Anthony D. , Opelz Gerhard , Goldschmidt Hartmut
Published: October 2019

Thalidomide (Thal) is a drug with antiangiogenic, anti-inflammatory, and immunomodulatory properties that was found to inhibit the production of tumor necrosis factor-α (TNF-α) in vitro. We studied single nucleotide polymorphisms at positions −308 and −238 of the TNF-α gene promoter and measured the corresponding TNF-α cytokine levels in 81 patients (pts) with refractory and relapsed multiple myeloma (MM) who were treated with Thal. In myeloma pts carrying the TNF-238A allele (n = 8), we found a correlation with higher pretreatment TNF-α levels in peripheral blood (P = .047). After Thal administration, this TNF-238A group had a prolonged 12-month progression-free and overall survival of 86% and 100% versus 44% and 84% (P = .003 andP = .07) in pts with the TNF-238G allele, respectively. These findings suggest that regulatory polymorphisms of the TNF-α gene can affect TNF-α production and predict the outcome after Thal therapy, particularly in those MM pts who are genetically defined as “high producers” of TNF-α.