bluuebunny/crossref_metadata_2025 huggingface dataset:
Venetoclax Is Synergistic with Idelalisib or MK2206 Against Primary CLL Cells in an in Vitro Model of the Microenvironment
Authors: Shen Yandong , Crassini Kyle R , Fatima Narjis , Christopherson Richard , Mulligan Stephen P. , Best Oliver Giles
Published: November 2019

Background

The PI3-kinase signaling pathway and the Bcl-2-family of proteins play crucial roles in regulating the survival and proliferation of chronic lymphocytic leukemia (CLL) cells in the bone marrow and lymph nodes. Trials of ibrutinib, idelalisib and venetoclax illustrate the potential of targeting the B-cell receptor (BCR) signaling pathway and Bcl-2, however disease relapse is still common. Several pre-clinical studies and on-going clinical trials [Rogers et al., 2018, Jain et al., 2019] suggest that combinations of BCR inhibitors with venetoclax may be an effective treatment strategy for CLL patients with high risk disease. We sought to investigate the effects of combining idelalisib or the AKT inhibitor MK2206 with venetoclax against CLL cells under in vitro conditions that mimic the tumor microenvironment.

Methods

Primary CLL cells were co-cultured with CD40L-expressing mouse L-fibroblasts. Cell viability was assessed using the mitochondrial membrane potential dye DilC1(5), propidium iodide and flow cytometry (n = 6). Synergy between idelalisib or MK2206 and venetoclax was evaluated by calculating combination indices (CI) using the Compusyn software. The mechanisms of action of the drugs and synergies between the drugs were investigated by immunoblotting (n = 6).

Results

Venetoclax was highly synergistic in combination with idelalisib or MK2206 against CLL cells co-cultured with CD40L-fibroblasts, with CI values of 0.2 and 0.5 at a fractional effect of 0.9, respectively (Figure 1). This synergy was consistent with a significant (P < 0.05) reduction in the IC50 for venetoclax, idelalisib and MK2206.

Immunoblotting suggests that MK2206, as a single agent or in combination with venetoclax, was more effective than idelalisib in inhibiting the phosphorylation of AKT and NF-κB. Both MK2206 and idelalisib as single agents and in combination with venetoclax significantly reduced expression of Mcl-1 and Bfl-1, two pro-survival members of the Bcl-2 family of proteins in primary CLL cells co-cultured with CD40L-fibroblasts.

Conclusions

The synergy observed, which was associated with a significant decrease in the IC50s for idelalisib and MK2206, may mitigate some of the toxicities associated with PI3-kinase pathway inhibitors. Comparison of the two PI3-kinase-pathway inhibitors suggests that MK2206 may be more effective than idelalisib at blocking BCR-mediated signaling as a single agent and in combination with venetoclax. The mechanisms underlying the synergy include down-regulation of expression of Bcl-2 family proteins that are not targeted by venetoclax as a single agent. The data presented support the rationale for on-going and future clinical trials of combination therapies incorporating a PI3-kinase inhibitor with venetoclax for the treatment of high risk CLL.

Figure 1

Disclosures

No relevant conflicts of interest to declare.
Population Level Outcomes of Chronic Lymphocytic Leukemia in the Era of Targeted Agents- Analysis of Surveillance Epidemiology and End Results (SEER) Database
Authors: Narra Ravi Kishore , Atallah Ehab L. , Hamadani Mehdi , Guru Murthy Guru Subramanian Guru
Published: November 2019

Background:

The treatment paradigm of chronic lymphocytic leukemia (CLL) has changed significantly in the last decade with approval of multiple new targeted agents. Small molecule drugs such as ibrutinib, venetoclax, idelalisib and other targeted agents have improved the outcomes of patients with CLL treated in clinical trials. However, it is unclear if the population level outcomes of CLL have improved since the first approval of bruton tyrosine kinase (BTK) inhibitor Ibrutinib in February,2014.

Methods: Using SEER database, we identified patients aged ≥ 20 years with pathologically confirmed CLL (ICD-0-3 code 9823/3) diagnosed between 2011-2016 and actively followed. Patients were divided into two groups by the period of diagnosis - 2011-2013, 2014-2016, reflecting the period pre-and post-ibrutinib approval. Overall survival (OS) was compared between the two groups using Kaplan-Meier method and log rank test. Cox proportional hazard regression method was used to determine the influence of period and demographic factors on OS. Statistical analysis was performed with significant two-sided p< 0.05.

Results: A total of 30701 patients with a median age of 69 years (range 21-104) were included. Males (60.9%) and White race (80.8%) contributed to the majority as summarized in table 1. Median OS was not reached. OS at 30 months was significantly higher for patients diagnosed from 2014-2016 (83.3%) compared to those diagnosed from 2011-2013 (81.7%) (p=0.004) (figure 1). On multivariate analysis, diagnosis from 2014-2016 (HR 0.90, 95% CI 0.85-0.96, p: 0.002) and females (HR 0.74, 95% CI 0.70-0.78, p< 0.001) had lower mortality risk, whereas, increasing age (HR 1.07, 95% CI 1.07-1.08, p< 0.001), Hispanics (HR 1.18, 95% CI 1.05-1.32, p< 0.004), Non-Hispanic blacks (HR 1.41, 95% CI 1.28-1.54, p< 0.001) had higher risk of mortality.

Conclusions: Survival of patients with CLL at the population level is improving since approval of Ibrutinib. Non-biological factors such as age, gender and race/ethnicity continue to influence the survival even in the era of novel agents, highlighting the need for continued research to address these discrepancies.

Disclosures

Atallah: Jazz: Consultancy; Jazz: Consultancy; Novartis: Consultancy; Pfizer: Consultancy; Helsinn: Consultancy; Helsinn: Consultancy; Takeda: Consultancy, Research Funding. Hamadani:Janssen: Consultancy; Merck: Research Funding; ADC Therapeutics: Consultancy, Research Funding; Pharmacyclics: Consultancy; Takeda: Research Funding; Celgene: Consultancy; Sanofi Genzyme: Research Funding, Speakers Bureau; Medimmune: Consultancy, Research Funding; Otsuka: Research Funding. Guru Murthy:Cardinal Health Inc.: Honoraria.
Sarcopenia As a Significant Prognostic Factor in Acute Myeloid Leukemia: Validation of a Novel Scoring System
Authors: Sun Qian , Ming Hong , Qian Sixuan , Li Jian-Yong
Published: November 2019

Background: Acute myeloid leukemia (AML) is a malignant hematologic disease mainly occurs in the elderly. Sarcopenia is a muscle disease (muscle failure) common among adults of older age but can also occur earlier in life. This study indicates to investigate the prognostic value of sarcopenia in AML patients.

Methods: From January 2014 to April 2019, a total of 100 patients diagnosed with de novo AML according to the WHO classification were included in this study. Clinical data and biological characteristics were collected. Giemsa R-banding method was used to detect the karyotype of metaphase bone marrow cells. Targeted gene sequencing was taken to test a total of 23 gene mutations including DNMT3A, IDH1, IDH2, ASXL1, RUNX1, NPM1, CEBPA, FLT3, KIT, and TP53, etc. Bioelectrical impedance analysis (BIA) of human body before treatment was used to calculate the Body Mass Index (BMI), Appendicular Skeletal Muscle Mass (ASM), SMI (ASM/height2), Fat Mass (FM), Fat-free Mass (FFM), and FFMI (FFM/height2), etc. The diagnosis of sarcopenia was based on the consensus report of the Asian Working Group for Sarcopenia.

Results: Sixteen AML patients were diagnosed as sarcopenia. Patients with sarcopenia had significantly lower weight (P=0.049), BMI (P=0.039), ASM (P=0.002), SMI (P<0.001) and FFMI (P=0.005) than non-sarcopenia ones (Figure 1A~E). With a median follow-up time of 25 months, the overall survival (OS) of patients with sarcopenia was shorter than non-sarcopenia patients (median 7 vs. 28 months, P=0.054, Figure 2A). When stratified by age (≥60 yrs vs. <60 yrs), elderly patients with sarcopenia showed a significantly inferior OS to normal elder ones (median 3 vs. 12 months, P=0.008, Figure 2B). Receiver operator characteristic curves suggested that sarcopenia as one additional point to the 2017 European Leukemia Net risk stratification by genetics obtained superior area under the curve (AUC) in predicting AML OS than the latter alone (AUC 0.67 vs. 0.649, P=0.3305, Kaplan-Meier plotting see Figure 2C~D).

Conclusion: Sarcopenia is common in AML patients, and BIA offers a useful objective tool for identifying these patients. We illustrated a marked clinical impact of sarcopenia on patients with AML, and presented a novel prognostic scoring system. In elderly patients, the presence of sarcopenia before treatment may offer a useful factor for avoiding intensive therapeutic strategies for AML.

Disclosures

No relevant conflicts of interest to declare.
ATG4A is a Novel Regulator of Mitophagy during Human Erythropoiesis
Authors: Stolla Massiel Chavez , Thom Neele , Reilly Andreea , Clough Courtnee , Abkowitz Janis L. , Doulatov Sergei
Published: November 2019

Autophagy is a highly conserved pathway that degrades and recycles intracellular components. While autophagy is activated in response to cellular stress, it also contributes to hematopoietic cell differentiation. Previous studies in mice lacking core autophagy proteins have identified mitochondrial clearance as a critical function of autophagy in erythroid differentiation and maturation. Impaired autophagy results in anemia, retained mitochondria and elevated levels of reactive oxygen species in mice. However, the kinetics and regulation of mitophagy in human erythropoiesis have not been investigated. To better understand the kinetics of mitophagy in human erythropoiesis we have developed a lentiviral mitophagy reporter (MT-Keima) and used it to monitor mitochondrial clearance during erythroid differentiation of primary human CD34+ hematopoietic stem and progenitor cells (HSPCs). Measurement of mitophagy during erythroid differentiation revealed active mitochondrial clearance during early and late stages of erythropoiesis culminating with total clearance of mitochondria at the terminal stages of differentiation. Gene expression analysis during human erythroid differentiation identified the upregulation of the core autophagy program including ATG4A encoding a cysteine protease, which was restricted to the erythroid lineage. Knockdown of ATG4A in primary human HSPCs significantly reduced mitophagy in early and late erythroid cells and resulted in increased mitochondrial mass in terminally differentiated reticulocytes. Furthermore decreased expression of ATG4A, but not its paralog ATG4B, reduced the (i) expansion of erythroid progenitors, (ii) total number of erythroblasts (iii) and significantly reduced enucleation relative to luciferase controls. Finally significantly fewer erythroid colonies were found in methylcellulose culture only in HSPCs with ATG4A KD when compared to luciferase controls, while numbers of myeloid colonies were preserved, supporting a role for ATG4A selectively in the human erythroid lineage. Together these results identify ATG4A as a novel erythroid-specific regulator of mitophagy and a new potential target for the therapeutic modulation of autophagy in human erythropoiesis.

Disclosures

No relevant conflicts of interest to declare.
Impact of ABO Blood Group Incompatibility on Outcomes after Single-Unit Umbilical Cord Blood Transplantation for Malignant Hematological Disease
Authors: Siqi Cheng , Tang Baolin , Zhu Xiaoyu , Liu Huilan , Song Kaidi , Wan Xiang , Yao Wen , Wang Jian , Sun Zimin
Published: November 2019

Objective

In contrast to solid organ transplantation, ABO blood group incompatibility was acceptable in allogeneic hematopoietic stem cell transplantation (allo-HSCT). However, reports of the effect of donor-recipient ABO incompatibility on long-time survival, graft-versus-host disease (GVHD), and relapse after allo-HSCT were controversial. Relatively few reports existed on the effects of ABO incompatibility after umbilical cord blood transplantation (UCBT). The aim of this study was to investigate the role of major ABO incompatibility on RBC transfusion burden, hematologic recovery, GVHD, transplant-related mortality (TRM), relapse, and overall survival (OS) in UCBT for malignant disease.

Methods

This retrospective study included 587 malignant hematonosis patients who received myeloablative single-unit unrelated donor UCBT at our center between May 2008 and June 2018. Median follow-up time of the patients alive was 40.7 months (range: 12.0-134.6 months). A total of 230 (39.2%) patients received an ABO-identical transplant, and 357 (60.8%) received ABO-mismatched transplants, including 161 (27.4%) minor, 141 (24.0%) major, and 55 (9.4%) bidirectional ABO-incompatible UCBTs. All patients received myeloablative conditioning regimens and cyclosporine A (CsA) combined with mycophenolate mofetil (MMF) as a GVHD prophylaxis.

Results

A comparison of ABO compatibility and incompatibility demonstrated no significant differences (P>0.05) in the cumulative incidence of neutrophil, platelet, and red blood cell engraftment . There was no significant difference in the cumulative incidence of grades Ⅱ to Ⅳ aGVHD (P= .527) and Ⅲ to Ⅳ aGVHD (P= .949) among the 4 groups (Figure A , B). In univariate analysis, ABO blood group incompatibility was not associated with cumulative incidence of 180d TRM (Figure C, P= .602). The overall 3-year survival had no statistically significant differences among the 4 groups (Figure D; P= .384). Further, 11 patients were excluded from the analysis of post-UCBT RBC transfusion burden because of missing data and non-red blood cell engraftment. Of the remaining 576 patients, the median number of RBC transfusions during transplant days 0 to 60 was 4 (range, 0 to 106). There was no significant difference in the transfusion burden among all ABO blood type mismatch groups (Table 1, P = .069). Furthermore, none of the patients developed pure red aplastic anemia (PRCA) after UCBT.

Conclusion

The results showed that ABO blood group incompatibility had no significant impact on hematologic engraftment, the occurrence of GVHD, and the survival of malignant hemoblastosis. Patients with myeloablative single-unit UCBT may not develop PRCA; Donor-recipient ABO incompatibility may not be the major consideration in the selection of umbilical cord blood.

Disclosures

No relevant conflicts of interest to declare.
May Tigit (T cell Ig and ITIM domain) Expression be a New Target for Hodgkin Lymphoma?
Authors: Annibali Ombretta , Bianchi Antonella , Grifoni Alba , Tomarchio Valeria , Tafuri Mariantonietta , Verri Martina , Avvisati Giuseppe , Crescenzi Anna
Published: November 2019

Introduction: The use of immune-checkpoints (anti PD-1/PD-L1) resulted very effective in the treatment of relapsed/refractory classical Hodgkin Lymphoma (cHL). T cell Ig and ITIM domains (TIGIT) is another immune checkpoint receptor known to negatively regulate T cell functions.

Methods: In this study, we investigated the expression of TIGIT in cHL microenvironment in order to find a potential new target for inhibitor therapy. TIGIT, PD-1 and PD-L1 expression was evaluated in 34 consecutive patients with cHL referred to Campus Bio-Medico University Hospital for diagnosis and treatment during the last eight years.

Results: TIGIT positivity was observed in 19/34 patients (56%), of these 11 (58%) had advanced stages and 10 (52%) B symptoms. Among the 8 patients with IPS ≥ 4, 6 (75%) were TIGIT +.

Out of the 19 TIGIT + (score 1 to 3) peritumoral T lymphocytes, 16 (84%) were also PD-1+. While out of 15 TIGIT- peritumoral T lymphocytes only 4 (27%) were PD-1+ and 11 (73%) were PD1- (P=0.001). Moreover all 15 TIGIT- patients were PD-L1+ (100%) while out of 19 TIGIT + patients, 11 (58%) were PD-L1+ and 8 (42%) PD-L1- (P=0.004).

Conclusion: This study indicate that the great majority of TIGIT+ patients are also PD-1+, while those who are TIGIT- are all PD-L1+. These results may offer a new therapeutic possibility in the treatment of Relapsed/Refractory (R/R) cHL by the use of anti-TIGIT monoclonal antibodies.

Figure
Low Dose of Eltrombopag with Long-Term Response in Children with Severe Aplastic Anemia, Less Morbi-Mortality Better Quality of Life
Authors: Lopez-Santiago Norma C , Paredes Aguilera Rogelio a , Monsivais Orozco Angelica Cecilia , Gonzalez Pedroza Maria De Lourdes , Tavera Rodriguez Gabriela , Toscano Mara
Published: November 2019

Refractory severe aplastic anemia (RSAA) has poor prognosis. Eltrombopag is a therapeutic option in patients that failed to ATG+CyA; in countries with poor outcomes their use is limited. Described experience with low doses of Eltrombopag 25mg/d.

CASE 1. Female 4 yo diagnosis SAA not responded after 2 cycles ATG, the first one with mesterolone for 6 months, continued pancytopenic with multiple transfusions (every 2/3 weeks) complicated by iron overload, and serious infections; presented CNS infection with secondary spastic paralysis, due chelation therapy development 2 cholestasis outbreak. Eltrombopag was started 25mg/d, after the first month, no more transfusion was needed with increase of neutrophils and platelet counts. After 7 months Eltrombopag for economic reasons was stopped with partial response. Hb >10g/dL, CAN >1000 m3 & platelets 99 X103. For 4 years; until now; she is doing well, no infections and no transfusions needed.

CASE 2. Male 2 yo, SAA not responded ATG course, he was inpatient during 8 months with multiple infections, bleeding complications and consequence transfusion was needed. Iron overload required iron chelation therapy, the medical orders and CyA was irregularly administrated, the parents not accept considered BMT, so Eltrombopag 25mg/d was started, 6 weeks later no more transfusion was required, the bleeding stopped and no mores infections were observed; after 7 months had a partial response Hb > 11g/dL CAN > 1000m3 & platelets 45 x103, and Eltrombopag was stopped.

This two patients use Eltrombopag as compassionate use, with good clinical results, in spite of low dose to get a partial hematological response.

Low dose of Eltrombopag is useful to induce partial response rapidily with an excellent clinical results even when it is discontinued.

Actually all patients with new SAA diagnostic are register in our Institution in a prospective protocol to receive ATG+CyA and start Eltrombopag 50mg/d with increase according to the response.

The low dose could be a good option for patients with refractory aplastic anemia to get a partial response in development countries with less morbidity-mortality and a better quality of life.

Disclosures

No relevant conflicts of interest to declare.
The Magnitude of Lactate Dehydrogenase Elevation As a Predictive Factor for Central Nervous System Relapse in Diffuse Large B-Cell Lymphoma
Authors: Vieira Iolanda , Quintela Miguel , Moreira Cláudia , Chacim Sérgio , Domingues Nelson , Oliveira Isabel , Espirito Santo Ana , Moreira Maria Ilidia , Martins Ângelo , Viterbo Maria Luisa , Pereira Dulcineia , Mariz Jose Mario
Published: November 2019

Introduction: The incidence of central nervous system (CNS) relapse in diffuse large B-cell lymphoma (DLBCL) is approximately 5%. Although the introduction of rituximab for the treatment of DLBCL has reduced the risk of CNS relapse, the median overall survival of these patients remains only few months, emphasizing the need to accurately identify at-risk patients, screen for CNS disease, and develop effective therapeutic/prophylactic strategies.

Aim: To identify risk factors for CNS relapse in patients with DLBCL.

Methods: Retrospective analysis of patients with DLBCL diagnosed from January 2012 to December 2017 at a Cancer Institute. Patients with exclusive extranodal (EN) disease were excluded. Factors associated with CNS relapse were evaluated using Chi-square, Fisher's Exact Test, Mann-Withney U or T-Test, according to variable types and distributions. Survival was evaluated by Kaplan-Meier method and groups were compared by Log-rank test. Independent predictive factors were identified using Logistic Regression. A p value < 0.05 was considered statistically significant.

Results: Four hundred and seventy-nine patients were identified, 122 were excluded due to exclusive EN disease, and 357 patients were included in the study. With a median follow-up of 33 months, there were 10 (3%) CNS relapses. According to International Prognostic Index (IPI) factors in addition to involvement of kidneys and/or adrenal glands (CNS-IPI), 5 (50%) of these patients were classified as high risk, 4 (40%) intermediate risk and 1 (10%) low risk. Patients who development CNS involvement were significantly younger (57 vs. 65 years, p=0.036), presented higher levels of lactate dehydrogenase (LDH) (median 738 vs. 282 U/L, p<0.001) and lower levels of hemoglobin (median 10,3 vs. 12,1 g/dL, p=0.010) at diagnosis. No differences were found regarding to performance status, stage or number of EN areas. Two patients (18%) in the CNS relapse group had done CNS prophylaxis versus twenty two (6,3%) patients in the group without CNS relapse. In multivariate analysis, LDH >600 was the only independent predictive factor (HR 15.3, CI 95% 3.5 - 65.8, p<0.001). Overall survival in CNS relapse group was 22 months, versus not reached (p<0.001).

Conclusion: Although CNS-IPI is a robust model to estimate the risk of CNS relapse, it does not capture the full spectrum of those at high risk. Other clinical risk factors and biomarkers beyond this model might play an important role in this setting, such as the magnitude of LDH elevation

Disclosures

No relevant conflicts of interest to declare.
Managing Sickle Cell Disease Patients with Acute Pain Crisis in the Most Appropriate Setting
Authors: Gowhari Michel , Hughes-Dillard Tiesa , Ryan Catherine , Johnson Alexia
Published: November 2019

Introduction: Pain is the top concern of individuals with sickle cell disease (SCD). Acute painful vaso-occlusive episodes in SCD are the leading cause of emergency department (ED) encounters and frequent hospital admissions. Well-documented disparities include significant delay and under treatment of SCD patients with acute pain crisis in the ED. An acute care observation unit (ACOU) staffed with SCD specialists can help to address these disparities. SCD patients treated in a dedicated ACOU have a 40% lower admission rate than patients treated in the ED. An expedited transfer and treatment program at our dedicated sickle ACOU at the University of Illinois Hospital (UIH) was implemented with the goal of improving overall care and decreasing the hospital admission rate for SCD patients.

Method: This is an outcome study of individuals with SCD >16 years of age who presented with an acute painful episode to UIH. A quality improvement project used the Plan-Do-Study-Act translation method. The following key areas were identified for intervention: 1) established criteria for direct ACOU admission, 2) expedited transfer to the ACOU from the ED, 3) addition of a third provider to expand hours, and 4) establishing a consistent but individualized pain treatment plan across the ED and ACOU. The number of admissions to hospital of patients with SCD was examined from September 2018 through August 2019. Applying the Donabedian triad of Structure, Process, and Outcomes, we demonstrated improved outcome and decrease hospitalization.

Results: There were 877 admissions to the ACOU from January to July of 2019, which is an increase of 37% compared to the same period in 2018. Of the 877 admissions, 793 were discharged home (90.4%) as compared to 88.6 % in 2018. The average time to first dose of opioids in the ACOU in 2019 was 55 minutes with and average decrease in the pain score of 2.62 during an average length of stay of 4:18 hours.

Conclusions: Expedited care and treatment with a focus on improving quality and improving access resulted in increased volume of patients treated and decreased rate of admission to the hospital. Allocating resources to a dedicated sickle acute care observation unit can significantly decrease inpatient hospitalizations.

Table.

Disclosures

No relevant conflicts of interest to declare.
Pretreatment Risk Factors Is a Strong Predictor of Outcome in Pediatric Hodgkin Lymphoma
Authors: Khedr Reham , Rashad Hanaa , Hamoda Asmaa Mohammed , Elwakeel Madeha , Khorshed Eman , Saad Mohamed , Mohamed Engy , Moussa Emad
Published: November 2019

Background: During the last decades, the prognosis of Hodgkin lymphoma (HL) has been improved significantly with the introduction of effective chemotherapy and the implementation of risk-adapted treatment approaches. Identification of reliable risk factors is crucial to guide treatment throughout the disease. Objectives: We aimed to identify independent predictors of event-free survival (EFS) in pediatric/ adolescent HL using clinical data known at diagnosis and treated with the ABVD regimen at our hospital. Design/Method: This is a retrospective study done at Children's cancer hospital Egypt from July 2007 to December 2017. ALL Patients with Classical HL were enrolled in the analysis. The chemotherapy backbone was ABVD +/- RTH. Data analysis included all pretreatment Demographics, clinicopathological characteristics, and Laboratory findings. PET scan was performed at baseline and after two cycles of chemotherapy. Treatment was not changed according to the results of the interim scan. Results: A total of 737 patients were eligible for analysis.The Five-years OS 94.9% and the EFS 87.8% in these patients. Pretreatment Significant univariate predictive factors for the EFS were: Age<9.5 (HR 0.421; p = 0.002),, ESR (HR 0.421; p = 0.002), Hemoglobin <10.5 (HR 1.373; p = 0.014), TLC >11,000 (HR 0.368; p = 0.000), Stage IV( p = 0.000) and treatment groups (HR 0.180; p = 0.000). Although the pathological subtypes has a diverse EFS;NS: 86.6% MS: 92.9% Lymphocyte rich: 87.5% and Lymphocyte depleted: 41.7%, Histology has shown to be a powerful independent predictor of outcome ( p = 0.000).In the multiple regression model, NS Histology and stage remained strong predictive factors with a p-value of 0.011and 0.026 respectively, In addition to the significance of the Albumin level (HR 0.047, p= 0.011). The interim PET, as well as RTH, were highly significant on both univariate (p= 0.000 and 0.0002 respectively) as well as multivariate analysis (p= 0.001and 0.000 respectively). Conclusion: Age; stage IV disease; white blood cell count, and hemoglobin level are independent predictors of survival that can significantly impact survival. Optimizing initial therapy may improve overall EFS for these patients. Although CHL pathology is a significant independent predictor of EFS, its subtypes have different EFS and OS, which should be translated into changes in the treatment approach.

Disclosures

No relevant conflicts of interest to declare.
The Efficacy and Safety of Decitabine in Combination with ATRA, G-CSF and Low Dose Cytarabine(Dlaag Regimen)in Relapsed/Refractory Acute Myeloid Leukemia Not Suitable for Strong Chemotherapy : A Phase 2, Prospective, Single-Arm, Multicenter Study
Authors: Yang Li , Liu Ligen , Zhao Limin , Lu Yingting , Zhang Jing , Sun Lihua
Published: November 2019

Background.

Patients with relapsed or refractory acute myeloid leukemia (R/R AML)who are intolerant of strong regimen chemotherapy have poor responsibility to chemotherapy and clinic remission is lower. The DNMT is depleted to reactivate the silencing tumor suppressor gene to exert anti-tumor effects. Vitro experiments confirmed that ATRA has an anti-leukemia effect on non-M3-AML cell lines. We perform the 2 phase, single-arm, multicenter study of Decitabine in Combination with ATRA, G-CSF and low dose cytarabine(DLAAG Regimen)in R/R AML not suitable for strong chemotherapy (NCT03356080).

Methods.

R/R AML patients aged more than 18 years not suitable for strong chemotherapy were eligible to enroll on this study. The objective was to assess the responses and safety of this therapy. All patients received subcutaneous decitabine injection 0.1-0.2mg/kg on days 1-3 ,8-10,15-17 .ATRA was taken orally at 45mg/m2 on day 4-6 and 15mg/m2on days 7-20. Subcutaneous injection cytarabine 15mg/m2 every 12 hours on days 1-10 and G-CSF 300ug/d on day 0 until disease remission or absolute neutrophils count ≥ 0.5×109/L were administered. The FLT3 inhibitor, arsenious acid, and the JAK-2 inhibitor, rotectinib, were allowed to be combined.All patients received one or two courses of induction treatments.

Results.

During the period from December 1, 2017 to July 2019, a total of 33 patients were recruited, including 17 women and 16 men. The median age is 64 years (range 46-82). In 33 patients, the overall response rate (ORR = CR + PR) was 36.3%, and the complete response rate (CRR = CR + CRi) was 33.3%. The early treatment-related mortality rate was 6.0%. One died of infection and one died of organ bleeding. Of the 26 patients with karyotype data, 11 received CR. Seven patients (63.6%) in CR showed normal karyotype, 2 patients (18.1%) in CR, and 1 patient (9.0%) in PR showed other moderate karyotypes. One case (9.0%) of the CR group had a poor karyotype. Statistical analysis showed that there was a statistically significant difference between the different karyotype groups (P < 0.05). Only 2 of the 10 FLT3 mutant patients achieved CR (20%). Two patients with abnormal MLL gene did not receive CR.

Conclusions

DLAAG regimen is effective and tolerated in patients with R/R AML who are not suitable for intensive therapy and could be as a bridging therapy regimen followed by HSCT.

Disclosures

No relevant conflicts of interest to declare.
Targeting Homologous Recombination in Lymphoid Malignancies: Evaluation of Four Small Molecule Inhibitors of RAD51
Authors: Day Melinda , Maclay Tyler , Cyr Amber , Hasham Muneer G , Chow Kin-hoe , Keniston ED , Mills Kevin
Published: November 2019

Genomic instability is recognized as a driver of tumorigenesis and cancer progression. Loss of tumor suppressors or activation of oncogenes can induce DNA damage stress, promoting genomic instability and creating dependencies upon key DNA repair pathways. These dependencies can be targeted therapeutically to induce synthetic lethality. The homologous recombination (HR) repair pathway is an attractive target. HR deficient cancers are hypersensitive to numerous anticancer drugs, and tumors will often induce expression of HR genes to promote drug resistance. RAD51 is a key component of the HR pathway. RAD51 forms nucleoprotein filaments at sites of DNA damage and replication fork stalls, mediating homologous DNA strand exchange to promote recombinational repair of breaks and damaged replication forks. We utilized four small molecule inhibitors of RAD51-mediated HR for evaluation of RAD51 as a potential therapeutic target. Compounds CYT-0851, CYT-0853, CYT-1027, and CYT-1127 were evaluated for anti-cancer activity in vitro and in vivo. To determine the impact of the small molecules on RAD51 and HR, all four were tested for effects on RAD51 focus formation and sister chromatid exchange (SCE) activity. All the compounds showed a reduction in SCE activity, however only CYT-0851 and CYT-0853 produced a measurable reduction in RAD51 foci. We have previously shown that that RAD51 inhibition leads to accumulation of DNA breaks, and ultimately cell death, in cells expressing the DNA mutator protein Activation Induced Cytidine deaminase (AICDA/AID). Cytotoxicity assays were performed in an AID+ (Daudi, Burkitt's Lymphoma) and AID- (WI-38, fibroblast) cell lines. All four compounds were preferentially active in AID+ cells with little to no cytotoxicity observed in the AID-negative WI-38 cell line. CYT-0853 was the most potent in the Daudi cell line with an EC50 of 8nM. All four compounds were orally bioavailable in all preclinical species tested but showed differences in pharmacokinetics. Preclinical cell line derived xenograft models of AID-high Burkitt's lymphoma (Daudi) and B-cell acute lymphoblastic leukemia (CCRF-SB) were used to determine the in vivo anti-tumor activity of the compounds in lymphoid cancer models. CYT-0851 and CYT-0853 both showed significant anti-tumor activity with tumor growth inhibition of greater than 50% in both models. Further analysis showed drug exposure with CYT-0851 was more consistent in the CDX models than CYT-0853. Overall, these data indicate that RAD51 and HR are attractive therapeutic targets for the treatment of lymphoid malignancies and that CYT-0851 is a viable clinical development candidate.

Disclosures

Day: Cyteir Therapeutics: Employment. Maclay:Cyteir Therapeutics: Employment. Cyr:Cyteir Therapeutics: Employment. Mills:Cyteir Therapeutics: Employment, Equity Ownership.
Targeting AML: The Development of Two Functionally and Mechanistically Distinct Classes of Cereblon-Mediated Protein Homeostatic Modulators
Authors: Chourasia Aparajita Hoskote , Fung Leah , McElwee Brooke , Richard Normand , Lam Imelda , Torres Eduardo , Erdman Paul , Sullivan Robert , Hecht David , Chan Kyle WH , Mercurio Frank , Stirling David I
Published: November 2019

Targeting disease-relevant proteins by exploiting the cells' very own protein homeostasis machinery is the next generation drug discovery platform that has come center stage for treatment of hematological malignancies. We present our novel and unique Protein Homeostatic Modulators (PHMsTM) - that promote ubiquitination and subsequent proteasomal degradation of known substrates as well as neosubstrates via Cereblon - as therapeutic candidates for acute myeloid leukemia (AML). Specifically, we report the discovery of two functionally and mechanistically distinct classes of Cereblon-mediated PHMsTM from phenotypic screens of our proprietary PHM®library. Unlike classical IMiDs, our oncology candidates, BTX508 and BTX1119 demonstrate significant cytotoxicity with IC50s in low-nanomolar range in a panel of AML cell lines. BTX508 is a purely cytotoxic compound that does not display immune modulatory activity. In contrast, BTX1119 is not only cytotoxic, but is also immunomodulatory in that it inhibits inflammatory cytokines such as IL-1β, IL-6 and TNF-α as well as induces IL-2, an indicator of T cell activation. BTX1119's immune modulatory activity is a 100-fold more potent when compared to Pomalidomide. The distinct functional activities exhibited by BTX508 and BTX1119 is a result of strategically engineered substrate degradation profiles. Importantly, BTX508 and BTX1119 exhibit a large safety window wherein the concentrations at which they target AML cells do not affect normal healthy cells such as liver epithelial cells or lung fibroblasts. To further establish BTX508 as a clinical candidate for AML, we performed in vivo efficacy studies in the MV-4-11 human AML xenograft model using athymic nude mice. A single daily dose of BTX508 results in a significant reduction in tumor volume. BTX508 exhibits significant oral bioavailability, thus making it a promising clinical candidate for treatment of AML as well as other potential hematological malignancies. With regard to BTX1119, we believe that incorporation of both the potent cytotoxic and immunomodulatory properties into a single molecule holds great therapeutic promise; however, to evaluate the synergistic potential of this combination will require use of a humanized mouse model - this work is ongoing.

Disclosures

No relevant conflicts of interest to declare.
Small Molecule Screening Identifies Rho-Associate Protein Kinase (ROCK) As a Regulator of NK Cell Cytotoxicity Against Cancer
Authors: Lee Grace , Karunanithi Sheela , Jackson Zachary , Wald David
Published: November 2019

NK cells are a subset of lymphocytes that directly recognize and lyse tumor cells without the limitation of antigen specific receptor recognition. In addition to behaving as cytotoxic effector cells, NK cells unlike T cells are not thought to elicit graft versus host disease. The combination of these characteristics makes NK cells a powerful tool for adoptive cell therapy. Despite the promise of NK cell therapy, key hurdles in achieving significant clinical efficacy include both generating sufficient numbers of highly tumoricidal NK cells and maintaining the cytotoxic activity of these cells in vivo despite the immunosuppressive tumor microenvironment.

Our lab and others have developed several feeder cell line-based expansion modules that robustly stimulate the ex vivo proliferation of NK cells. However, strategies to enhance and sustain the activity of NK cells once administered in vivo are still limited. In order to identify strategies to enhance the cytotoxic activity of NK cells, we developed a high-throughput small molecule screen (Figure 1A) that involved a calcein-based cytotoxicity assay of ex vivo expanded and treated NK cells against ovarian cancer cells (OVCAR-3). 20,000 compounds were screened and the screen was found to be highly robust (Z'>0.59). We identified 29 hits that led to at least a 25% increase in cytotoxicity as compared to DMSO control-treated NK cells. One of the most promising hits was the pan-ROCK inhibitor, Y-27632 that led to an 30% increase in NK killing of the OVCAR-3 cells. We validated that ROCK inhibition leads to enhanced NK cell cytotoxic activity using Y-27632 (Figure 1B) as well as other well-established ROCK inhibitors such as Fasudil using a flow cytometry based killing assay. Y-27632 increased NK cell cytotoxicity in a dose- and time- dependent manner. ROCK inhibition consistently led to ~10-25% increase in NK cell cytotoxic activity directed against a variety of ovarian (Figure 1C) and other solid tumor cell lines (Figure 1D). Interestingly, we found that the NK hyperactivation persists for up to 48hrs after washing off the drug that may enable ex vivo stimulation before NK cell infusion. Our preliminary results showed that ROCK inhibition activates PI3K-dependent Akt activation (Figure 1E). We hypothesize that ROCK inhibition restores Akt activation which may be critical for NK cell activating receptor pathways and our current investigations will test these hypotheses.

ROCK inhibitors, such as Y-27632 and Fasudil have been utilized in both preclinical and clinical studies for a variety of diseases such as atherosclerosis, neurodegenerative disorders, and ocular diseases. However, the consequences of ROCK inhibition in NK cells has not been thoroughly investigated. Our work shows a promising novel strategy to significantly enhance NK cell therapy against cancer that has high translational potential.

Disclosures

No relevant conflicts of interest to declare.
Angioimmunoblastic T-Cell Lymphoma: Patient Characteristics and Survival Outcomes
Authors: Ermann Daniel A. , Vardell Victoria A. , Silberstein Peter T.
Published: November 2019

Background

Angioimmunoblastic T-cell lymphoma (AITL) is a rare and aggressive malignancy, representing approximately 18.5% of Peripheral T-cell lymphomas. The clinical presentation varies greatly, and literature describing this disease is limited. In this study we utilized the National Cancer Database (NCDB) to describe the patient characteristics, demographics, and overall survival of AITL.

Methods

The NCDB for non-Hodgkin's lymphoma was used to identify 3,708 patients diagnosed with AITL between 2004 and 2016. We examined demographic information including age, race, gender, stage, and treatment modality. Kaplan-Meier analysis was used to analyze overall survival and compare survival by patient age, stage, and year of diagnosis. Bivariate and multivariate analysis was used to obtain hazard ratios and assess the association of patient characteristics and treatment methods with survival.

Results

The majority of AITL patients were white 87.8%, males 53%, with an average age of 67 years. 90% of patients received treatment, with 77.4% receiving chemotherapy, 10.8% receiving hematopoietic transplant, and 2.6% receiving radiation. B symptoms were present in 57% of patients. 43% were diagnosed with Stage III disease and 43.5% at Stage IV.

Median survival was 22 months (CI 19.7-24.4), with a five- and ten-year survival of 30% and 22%. Median survival for patients aged 35-50 was 74 months, 50-65 was 37.7 months, 65-80 was 20.5 months, and for patients aged >80 years old median survival was 6.4 months. Patients with Stage I disease survived 35.1 months whereas those with Stage IV disease survived 17.2 months. On multivariate analysis black race, increasing age, charleson-deyo comorbidity score, and stage at diagnoses were significantly associated with increased mortality risk. All forms of treatment, including chemotherapy, hematopoietic transplant, and radiation were all associated with improved survival.

Discussion

Our study found that the majority of AITL patients present with late stage disease, often with B symptoms, and have poor prognosis. We found a five-year survival of 30% for this malignancy when all stages of disease were combined. Knowledge of the patient characteristics, treatment modalities, and overall survival in AITL can serve to enhance the care of providers who encounter this uncommon diagnosis.

Disclosures

No relevant conflicts of interest to declare.
Hemoglobin Levels Vary in Infants in Relation in Occurrence of Influenza Virus Infections
Authors: Adamkiewicz Tom , Dada Omolaya , O'Neil Patrick , Wong Erica , Tran McKinley
Published: November 2019

Iron deficiency anemia (IDA) screening in children, and its treatment is standard in general pediatrics. IDA has been linked to developmental concerns. However, iron supplementation recently has been shown to have risks in resource limited environments as it seems to be associated with increased risks of infections. The role of iron in bacterial survival is well established. However more difficult to explain are reports linking iron supplementation to higher rates of respiratory illness in children. Recent studies have identified hepcidin as an important mediator between inflammation from common infections, and iron repletion status (Prentice et al 2019). In the current study we hypothesized that overall hemoglobin levels in infants may fluctuate depending on birth cohorts, as 1) exposure to respiratory illnesses peaks in winter months, and 2) children aged 6-12 months have the highest incidence of respiratory illness of all age groups (up to 6-8 upper respiratory infections per year). Institutional review board permission (Children Health Care of Atlanta), was obtained and the billing registry, laboratory and patient records from an multiethinic urban clinic (n= 7,616) were reviewed. Influenzas' infection was defined as a patient presenting with an acute illness and a positive rapid influenza test. Hemoglobin was obtained at 9 to 12 months routine visit by capillary draw and point of care measure (HemoCue hb). A total of 1236 patient files were reviewed from 2007 until 2018. Each year was examined separately and then overlapped. Influenza rates were lowest in the summer, rose starting September, and peaked during the winter months. In the first year of life, hemoglobin levels peaked in March, with lowest levels observed in July and December. Infants with a diagnosis of influenza had lower hemoglobin levels and more pronounced fluctuations. At age 7-9 months, medial hemoglobin was 12.1 (95% confidence interval [CI] ±0.026) g/dl and for those infected with influenza 9.8% 95% CI ±0.138). These observations have implications regarding screening, lower limits of normal may vary during the year. supplement. Other viruses also occur during the winter months and could play a role. These results require further validations.

Figure

Disclosures

No relevant conflicts of interest to declare.
Copper Deficiency and Cytopenia: A Systematic Review
Authors: Kharel Prakash , Gnanapandithan Karthik , Pandey Ramesh Kumar , Jha Samir , Grimshaw Alyssa , Giri Smith
Published: November 2019

Copper Deficiency and Cytopenia: A Systematic Review

Prakash Kharel, Karthik Gnanapandithan, Ramesh Kumar Pandey, Samir Jha, Alyssa Grimshaw, Smith Giri

Introduction: Copper deficiency is rare in humans unless there is a condition that affects either copper uptake or metabolism, or dietary deficiency. However, the incidence appears to be rising due to increasing gastric bypass surgery and total parenteral nutrition (TPN) use. Published data on hematological manifestations due to copper deficiency are limited to case reports, case series and small retrospective studies, creating confusion among clinicians and hematologists. We performed a systematic review of all published case reports and series to characterize hematological manifestations associated copper deficiency with a focus on risk factors, clinical manifestations, treatments and outcomes.

Methods:

Using a combination of free text and controlled vocabulary, a systematic search of the electronic literature using MEDLINE and EMBASE for published material from inception to March 2019 was performed. Two authors independently screened the titles, abstracts, and the full text of the selected papers. Subsequently, the full text of each article was assessed for eligibility and details. From the 97 reports, we included 116 cases in which the clinical course, management and outcomes were described.

Results: Of 5374 articles screened, a total of 268 articles were selected for full text review and a total of 97 reports describing 116 cases met our eligibility criteria. The median age at the time of presentation was 44 (interquartile range (IQR) 25-57) year, and 64 (55%) were males. Total of 37(32 %) had coexisting neurological symptoms. The median Hb was 7.7 gm/dl (IQR 6.2-9.5) and median WBC 2.3 (1.6-3.1). 94 (81%) of the patients had hemoglobin (Hb)< 10, 41(35%) had severe anemia Hb <7 at presentation. 80(69%) had leukopenia with white blood cell (WBC) <4K, of them only one patient had lymphopenia (1.28%), rest had neutropenia (98.72 %). Nearly half of these patients had macrocytic anemia (38, 55%) and only 3 cases had microcytic anemia. Of 78 patients with available data, 23(29%) had low platelet counts and 8 (10 %) had elevated platelet count. Zinc excess was implicated in almost half of these cases (39/87, 45%) and total parenteral nutrition (TPN) in 9 out of 87 cases (10%)

Conclusion:

Copper deficiency should be one of the reflexes in evaluation of patient who is at risk of copper deficiency specially as there is rise of bariatric surgery, survivors of significant bowel surgery patient requiring total parenteral nutrition or jejunal feed along with the baby boomers who will be the high number of patients using dentures and patient on zinc supplementation. There should always be a high degree of suspicion among clinicians when dealing with at-risk individuals to prevent irreversible complications and morbidity.

Disclosures

No relevant conflicts of interest to declare.