bluuebunny/crossref_metadata_2025 huggingface dataset:
The Oral Mtor Inhibitor Everolimus in Relapsed and Refractory Hodgkin Lymphoma- Compassionate Use in 8 Centers in Brazil
Authors: Da Rocha Talita Silveira , Fortier Sergio Costa , de Castro Nelson Siqueira , Delamain Marcia T , Oliveira José Salvador , Perini Guilherme , Buccheri Valeria , Gaiolla Rafael Dezen , Fogliato Laura , Laranja Andressa , Pinto Maeva , Chiattone Carlos
Published: October 2019

Purpose- Everolimus is an oral antineoplastic agent that targets the raptor mammalian target of rapamycin (mTORC1). The phosphatidylinositol 3-kinase/mTOR signal transduction pathway has been demonstrated to be activated in tumor samples from patients with Hodgkin Lymphoma (HL). The goal of this study was to evaluate the response, time of response, toxicity and overall survival in patients with refractory disease using everolimus out of clinical trial, in a compassionate use.

Patients and Methods- Patients were eligible if they had refractory and active Hodgkin disease. Patients received everolimus 10 mg PO daily. Dose reductions were allowed. Time to response assessement was defined by each center until progression (this was defined by each doctor, some have considered to keep the drug until clinical progression and not radiological progression of the disease). Patients could remain on drug until progression or toxicity.

Results- Thirty three patients were enrolled. Median age at the time of everolimus start was 29 years (range, 20-70). Patients had received a median of 5 prior therapies (range, 3-7) , 81% had undergone prior autologous stem cell transplant and 4 patients had undergone alogenic trasnplantation. The ORR was 51% (95% CI: 24-71%) with 14 patients achieving a PR, 3 patient achieving a CR and 10 with stable disease. Thirteen patients used the drug for more than 1 year. Patients received a median of 14 cycles of therapy and 3 remains on therappy at 36 months showing a great tolerability of the drug. The median DR for the responders (CR/PR) was 10 months. The most commons site effects were trombocitopenia and hypercholesterolemia. Three patients had pulmonar toxicity. The adverse events grade III and IV ocurred in 30% of the patients.

Conclusions- Everolimus has single-agent activity in relapsed/refractory HL, even in real lyfe and clinical practice and provides proof-of-concept that targeting the mTOR pathway in HL is clinically relevant.

Disclosures

Off Label Use: everolimus for refractory hodgkin lymphoma.
Clinical and Haematological Features of Genetic Mutations in MPN Patients with Diagnosis of Prefibrotic Idiopathic Myelofibrosis (MF0)
Authors: Martino Bruno , Labate Claudia , Greve Bruna , Ielo Domenica , Rotilio Domenico , Mammì Corrado , Laganà Carmelo , Ronco Francesca
Published: October 2019

Background: Diagnosis of a prefibrotic state (MF0) presents histological diagnostic difficulties. MF0 has a worst prognostic impact than Essential Thrombocythemia (TE) as regard the thrombotic risk and a higher risk towards Idiopathic Myelofibrosis (MI) and acute leukemia evolution. For this reason it is very useful to identify this group of patients.

Aims: The aim of this study was to evaluate clinical and hematological impact of the mutational status in patients with an MF0 diagnosis.

Methods: A retrospective chart review was performed from January 2010 to July 2015 in a single center in 317 patients affected by Ph negative chronic myeloproliferative neoplasms. Polycythemia vera cases were excluded. Thirty-three patients have been classified as MF0 on the base of the bone marrow histological examination. Onset features include cytogenetics, blood counts, peripheral CD34-positive cells, spleen and liver size, thrombotic events (prior to and post-diagnosis) and thrombotic risk. Fragment analysis was performed to study exon 9 CALR mutation, Real-time PCR was applied for exon 14 JAK2 V617F mutation and Sanger sequencing was used to identify exon 10 MPL mutations for 505 and 515 codons. According to genetic results, patients were identified into four groups according to a positivity for JAK2, MPL, CALR and for triple negativity.

Results: The 33 patients with MF0 were: 11 (33%) JAK2 positive, 10 (30%) CALR positive, (10) 30% triple negative and 2 (7%) MPL positive. The latter group was not further considered for analysis due to the low number of cases. Eighty percent of CALR positive patients had a deletion on the exon 9 of the gene (8 del52bp and 2 del46bp), while 20% had the type 2 mutation (ins5bp). The average of JAK2 allelic burden was 20%. The 3 groups of patients were comparable for age, white blood counts and hemoglobin values. There was a female prevalence (23 vs 10 males). Platelet count was higher (median 875.500 103 µl, interquartile range 303.000 103 µl , p = 0.008) in CALR positive patients compared to JAK2 positive (median 569.000 103 µl, interquartile range 433.000 103 µl) and to triple negative patients (median PLT count 629.500 103 µl, interquartile range 378.250 103 µl). Noteworthy, bone marrow cytogenetic exam was normal in all patients. JAK2 positive patients had a larger spleen compared to the other two groups. Pre-diagnosis thrombotic events were exclusive for JAK2 positive patients and absent in the other groups. Triple negative patients do not have a negative prognostic impact for the thrombotic risk.

Conclusions: CALR deletion could be considered as an MF0 marker and should be included in diagnostic work-up. JAK2 positivity in MF0 is associated with a high thrombotic risk.

Disclosures

No relevant conflicts of interest to declare.
United Kingdom Experience of Intracranial Bleeds in Childhood Immune Thrombocytopenia
Authors: Grainger John D. , Harrison Louise , Bolton-Maggs Paula H. B
Published: October 2019

Childhood immune thrombocytopenia (ITP) is an uncommon disease that is usually self-limiting and resolves spontaneously without treatment. Less than 1% of children with ITP will develop an intracranial haemorrhage (ICH). The aim of this project was to review data from all available cases of ICH and identify features associated with an increased risk of intracranial bleeding. The data were obtained from three main resources: patient notes, the UK ITP Registry and surveys sent out to centres across the UK. 19 cases were reviewed, occurring over a period of 12 years from 2004 to 2016.

Platelet counts below 20x109/L were associated with severe bleeding, as were moderate or severe bleeding manifestations beyond cutaneous bleeding in the 28 days leading up to an ICH. Patient comorbidity was also reviewed and a significant number of patients had co-existing issues, including positive autoantibody tests. Presentations of ICH varied. In 10 patients, headache was a presenting feature. 3 patients presented with seizures, and 5 with vomiting. The majority of patients also had at least one active bleeding site in the 28 days before the episode of ICH. The mouth and nose were the most common bleeding sites. The mortality rate was 4/19, 21%. Neurological disability on discharge was present in 4/15, 27% of the patients who survived. Most identified risk factors for ICH were consistent with previous research, however none had an arteriovenous malformation and only three of 19 cases were documented to have experienced head trauma prior to ICH. Based on UK ITP registry data the incidence of ICH is estimated to bet 0.14-0.57% of paediatric ITP patients.

Disclosures

Grainger: Amgen: Consultancy, Honoraria, Speakers Bureau; GSK: Consultancy, Honoraria, Membership on an entity's Board of Directors or advisory committees, Speakers Bureau; Novartis: Consultancy, Honoraria, Membership on an entity's Board of Directors or advisory committees, Speakers Bureau. Bolton-Maggs:Novartis: Honoraria; Grifols: Honoraria.
Clinicopathologic Comparison of Plasmablastic Lymphoma in HIV-Positive Versus HIV-Negative Patients: Single-Center Experience
Authors: Vasquez Jule , Huamanchumo Jorge , Quintana Shirley
Published: October 2019

Background: Plasmablastic lymphoma (PBL) is an aggressive lymphoma associated mainly to HIV infection, although cases in immunocompetent patients are described as well.

Objective: To describe the prevalence, the clinicopathologic features and determine the overall survival of lymphoma patients according human immunodeficiency virus (HIV) status.

Methods: We reviewed the pathology database at Instituto Nacional de Enfermedades Neoplasicas (INEN), the leading cancer center of Peru from 2005 to 2014. 6218 cases were lymphomas, 5031 cases were Non-Hodgkin lymphoma and 3905 cases were B-cell lineage. 22 met diagnosis of PBL, 4 patients were excluded (1 prior treatment, 1 synchronous malignancy and 2 incomplete medical records). Finally, we had 18 cases for evaluation. Survival curves were estimated by Kaplan Meier. Statistical analysis was based on SPSS Program version 22.

Results: The prevalence of PBL was 0.004% of all Non-Hodgkin lymphomas and 0.005% of B-cell lymphomas. 13 of 18 cases (72.2%) were HIV-positive patients (PBL-HIV+). The median age for PBL-HIV+ was 37 years (range 22-67 years) and 58 years (range 53-74 years) for HIV-negative patients (PBL-HIV-).The extra-oral primary was the most frequent primary site in both groups. The advanced stage was 80% in PBL-HIV- patients. Presence of B-symptoms and Ki-67>80% were greater in PBL-HIV- patients. CHOP or CHOP-like regimen was the common treatment in both groups, only one patient received DA-EPOCH (PBL-HIV+ group). HAART-naïve patients were 77%. The median OS time was 43 months (range 1-84 months) in PBL-HIV+ patients and 13 months (range 0-15 months) in PBL-VIH- patients, the 5-yrs-OS was 26.9% y 0% respectively.

Conclusions: Plasmablastic lymphoma is a rare lymphoma, either associated or not to HIV infection. Advanced and aggressive disease is a distinctive feature in both lymphomas. The PBL-HIV- has a worse prognosis with shorter overall survival compared to the PBL-HIV+ patients.

Disclosures

No relevant conflicts of interest to declare.
Impact of Additional Chromosomal Abnormalities in Philadelphia-Positive Clone on Prognosis of CML Patients Treated with Tyrosine Kinase Inhibitors
Authors: Liu Bingcheng , Wang Ying , Wei Hui , Liu Kaiqi , Lin Dong , Zhou Chunlin , Mi Yingchang , Wang Jianxiang
Published: October 2019

Background: To investigate the impact of additional chromosomal abnormalities(ACA) in Philadelphia-positive clone on response to TKIs and long-term survival of CML patients treated with tyrosine kinase inhibitors (TKIs) in the real world.

Methods:In this retrospective study, patients with chronic myelogenous leukemia (CML) in chronic phase treated with TKIs were recruited. The chromosome banding analysis was performed on bone marrow cells at baseline and during the TKIs therapy.The clinic response to TKIs was evaluated according to the recommendation of ELN2013. The overall survival (OS), events free survival (EFS) and progression free survival (PFS) were analyzed. Events were defined as treatment failure, progression to accelerate phase or blast crisis and death. The progression was defined according to criteria of ELN2013 CML recommendation.

Results:

The characters and cytogenetic analysis of the patients:A total of 451 patients (281 males and 170 females) were enrolled from Jun 2004 to March 2015.The median age was 42 (range 18-79) years old. 414 subjects hadevaluable information of karyotypeat baseline.351 patients (84.4%) had the standard Philadelphia chromosome (Ph), 8(1.9%) showed variant translocation of Ph, 19 had ACA in Ph+ cells (Ph+ACA), only 2(0.5%) showed ACA in Ph- cells (Ph-ACA)£¬11(2.7%) had normal karyotype. 29 patients (6.4%) developed Ph+ACA during the TKIs treatment. Ph-ACA occurred in 8 subjects (6.4%).The response to TKIs: Comparing to the patients without Ph+ACA at baseline, the patients with Ph+ACA had lower cumulative rate of complete cytogenetic response (CCyR) (92.4% vs 68.4%, P=0.038) and prolonger median time to achieving CCyR (19 vs 7 months, P=0.016).The Ph+ACA at diagnosis had no effect on achieving major molecular response (MMR). The OS, EFS and PFS at 7 years for the whole cohort were 91%¡¢54% and 83% respectively. The patients with baseline Ph+ACA had significant inferior survival comparing to the subjects without Ph+ACA (Figure 1). The median time of OS, EFS, PFS for Ph+ACA patients were 108, 50 and 91 months, whereas the patients without Ph+ACA were not reached ( P=0.003 for OS, P<0.001 for EFS, and P=0.004 for PFS). The patients developed Ph+ACA during treatment had similar OS comparing to the subjects with Ph-ACA or without ACA (P=0.115), but they had significant shorter EFS (31 vs 90 months vs not reached£¬P<0.001)and PFS(59 vs 120 months vs not reached£¬P<0.001).

Conclusion: The Ph+ACA emergence at diagnosis and during treatment had negative impact on prognosis of CML patients treated with TKIs.

Disclosures

No relevant conflicts of interest to declare.
Retrospective Case Series Study of Hypomethylating Therapy in IPSS Lower-Risk Myelodysplastic Syndrome
Authors: Park Han-Seung , Lee Je-Hwan , Kim Yoo-Jin , Sohn Sang Kyun , Yoon Sung-Soo , Kim Hawk , Cheong June-Won , Lee Won-Sik , Lee Gyeong-Won , Joo Young-Don , Kim Min Kyoung , Kim Yang Soo , Kim Hyeoung-Joon
Published: October 2019

Introduction: The IPSS has been widely used for risk stratification in myelodysplastic syndromes (MDS), and patients with IPSS low and intermediate-1 scores are designated as having lower-risk (LR) MDS. Despite its utility, the outcomes of patients with LR disease defined by IPSS are variable and a subset of patients experience inferior than expected outcomes. Treatment with hypomethylating agents is the standard of care in higher-risk MDS, but there have been little data for hypomethylating therapy in LR MDS. We retrospectively collected and analyzed the data related to hypomethylating therapy in IPSS LR MDS from 12 Korean institutes.

Patients and Methods: A total of 610 patients, who were treated with azacitidine or decitabine for IPSS LR MDS, were included in this retrospective case series study. All patients received azacitidine (7-day) or decitabine (5-day). Both regimens were repeated every 4 weeks. The overall response rate (ORR) included rates for complete response (CR), partial response (PR), marrow CR (mCR), and stable disease (SD) with hematologic improvements (HI). For 139 patients who underwent allogeneic hematopoietic cell transplantation (HCT), all survival data were censored at the time of HCT.

Results: Median age was 63 (19-84) years. IPSS category was low in 44 and intermediate-1 in 566. The patients were reclassified with other scoring systems including revised IPSS (R-IPSS), WPSS, and LR-PSS, and between 21.8% and 37.7% of patients were identified as having high or very high risk features by the other prognostic indices. Patients received azacitidine (n=436) or decitabine (n=174) for a median of 5 (1-46) courses. ORR was 51.3% (CR 78, PR 12, mCR with HI 27, mCR without HI 20, and SD with HI 176). 294 patients (48.2%) showed any HI. Median OS was 2.35 years and patients with HI had significantly longer OS than those without HI (P=0.001). Our case series patients were well stratified in terms of OS by R-IPSS (P=0.001), WPSS (P<0.001), and LR-PSS (P<0.001).

Conclusion: IPSS LR MDS included a broad range of prognostic implications. Hypomethylating therapy brought varying degrees of response in about half of the patients with IPSS LR MDS. The patients who had high risk features with other prognostic indices showed poor OS and allogeneic HCT should be considered during the course of hypomethylating therapy in these patients.

Disclosures

No relevant conflicts of interest to declare.
Nicotinamide N-Methyltransferase Expression Decreases in Iron Overload Exacerbating Iron-Induced Hepatotoxicity
Authors: Koppe Tiago De Bone , Patchen Bonnie , Cheng Aaron , Bhasin Manoj , Vulpe Chris D. , Fernandez-Real Jose M. , Schwartz Robert K. , Pissios Pavlos , Fraenkel Paula G.
Published: October 2019

Iron overload causes the generation of reactive oxygen species, which can lead to liver failure, particularly when it occurs in conjunction with nonalcoholic fatty liver disease (NAFLD) or viral hepatitis. Previously, we studied the effects of iron deficiency and iron overload on the hepatic transcriptional and metabolomic profile in mice. We found that iron overload induced significant changes in the expression of genes and metabolites involved in glucose and nicotinamide metabolism in both a dietary model, high iron diet, and a genetic model, hemojuvelin knockout mice. In particular, we discovered that the transcript, Nicotinamide N-methyltransferase (NNMT), was significantly downregulated in both models of iron overload. NNMT methylates nicotinamide, a form of vitamin B3, and has recently been shown to play a critical role in hepatic glucose and cholesterol metabolism by stabilizing Sirtuin 1, a nicotinamide-dependent deacetylase. For the current study, we evaluated 63 morbidly obese human subjects who gave written informed consent, validated and approved by the ethical committee of the Hospital Universitari Dr. Josep Trueta (Comitè d'Ètica d'Investigació Clínica, approval number 2009046), for the collection of liver biopsy samples and sera at the time of bariatric surgery after 8 hours of fasting. In these subjects, we found that log hepatic transcript levels of NNMT negatively correlated with measures of body iron stores, including log serum ferritin levels (R=-0.39, p=0.002) and log percent transferrin saturation (R=-0.21, p=0.02). We then performed experiments in primary hepatocytes to evaluate the interaction of iron overload and NNMT. We found that treatment with ferric ammonium citrate significantly decreased NNMT transcript levels in either primary human or mouse hepatocytes. We manipulated NNMT expression in primary mouse hepatocytes using adenoviral vectors and discovered that NNMT knockdown exacerbated iron-induced cytotoxicity and enhanced iron-induced expression of transcriptional markers of oxidative and endoplasmic reticulum stress, while NNMT overexpression protected against iron-induced cytotoxicity. In future studies, we would like to elucidate the mechanisms by which NNMT modulates hepatocyte sensitivity to iron overload. A deeper understanding of the relationship of the pathways involved in maintaining iron and energy homeostasis may reveal new therapeutic targets for patients with iron overload disorders, obesity, and NAFLD.

Disclosures

No relevant conflicts of interest to declare.
Geophagia: A Scientific Approach to a Historical Practice to Sustainably Treat Endemic Iron Deficiency in a Rural Community in Nepal
Authors: Lama Binay , Jones Rachael , Barlow Nicola , Keenan Russell D
Published: October 2019

Geophagia is the practice of eating earth or clay and is nearly universal around the world in traditional rural societies. Many animals across genera are known to eat mineral rich soil. Some animals travel long distances to seek specific soils that are rich in minerals that they are deficient. According to the WHO dietary iron deficiency is a documented threat to public health in Nepal and iron deficiency anaemia affects 60-85% in the general population. Iron deficiency holds developing communities back with reduced growth, reduced academic achievement and reduced physical productivity. While it would be possible to simply provide iron medications, the long term delivery to remote areas would make this logistically difficult to be sustainable and in our view would provide the wrong sort of aid.

We analysed local Nepalise hill clays in Kavre District to assess feasibility of use as an iron supplement. Providing a manual pill press would allow communities to make their own clay iron tablets facilitating more precise dosing in a truly sustainable way at ongoing zero cost. 23 mineral elements were measured by Inductively Coupled Mass Spectrometry in the two common clays, white and red, following a protocol based on the UK Environmental Protection Agency method "Acid digestion of sediments, sludges and soils (Method 3050B)".

Iron was present in useful amounts in both white and red clays; 33,485 μg/g and 35,091 μg/g respectively. All other mineral elements were present at low levels and unlikely to pose a health threat, with the exception of aluminium. Aluminium was present at 20,577 μg/g in white clay and 53,125 μg/g in red clay, which is above UK recommended dietary intake levels. However, in the absence of dialysis dependant renal failure, excess aluminium is excreted in urine and there are no documented cases of environmental aluminium toxicity. Aluminium levels in antacid tablets can be 20% with no toxicity documented even with chronic use.

This is a project with local Nepali community leaders working together with UK laboratories and haematologists. Further work will assess the homogeneity of the clay composition over a wider area. We are currently developing methods to facilitate the production of clay pills with a hand press alongside developing a school based education and iron supplementation programme. Iron deficiency is a worldwide problem in developing countries. We believe this approach could be used to empower communities to improve iron nutrition across the globe.

Disclosures

No relevant conflicts of interest to declare.
Iron Metabolism before Allo-HSCT in Patients with Acute Leukemia and Impact of Iron Overload on Transplantation
Authors: Shi Jimin , Pei Xuying , Luo Yi , Tan Yamin , Zhao Yanmin , He Jingsong , Zheng Weiyan , Lai Xiaoyu , Zheng Gaofeng , Zhang Jie , Lin Maofang , Cai Zhen , Huang He
Published: October 2019

Objective: Iron overload is common in patients with acute leukemia who undergoing allogenic hematopoietic stem cell transplantation (allo-HSCT). We performed a comprehensive analysis of iron parameters to assess these patients' iron metabolism, and studied the prognostic impact of pretransplant iron overload on the outcome of transplantation.

Methods: In this retrospective study, we studied 124 patients undergoing myeloablative allo-HSCT between 2012 and 2014. Serum iron (SI), serum ferritin (SF), hepcidin (Hepc) and soluble transferrin receptor (sTfR) were measured before transplant. We analyzed the effect of elevated pretransplant ferritin on acute graft versus host disease (aGVHD), infectious complications, overall survival (OS) and non-relapse mortality (NRM).

Results: Date of 124 patients (including 56 cases of acute lymphocytic leukemia and 68 cases of acute myeloid leukemia) were analyzed. Median SI, SF, Hepc and sTfR values were 12.15 umol/L, 667.05 ng/ml, 369.50 ng/L and 7.69 ng/ml, respectively. Iron overload (defined as SF>1000 ng/ml) were observed in 27.42% of patients. Pretransplant iron overload was significantly associated with increased risk of bacterial infections during the early post-transplant period, and with reduced risk of aGVHD. Pretransplant iron overload increased NRM and reduced OS, but there were no significant differences.

Conclusion: Patients with acute leukemia regularly develop iron overload before they undergoing allo-HSCT. Pretransplant iron overload was correlated with transplantation outcome.

Disclosures

No relevant conflicts of interest to declare.
In Vivo Efficacy of Bcl11a Erythroid-Enhancer Deletion in Humanized Mouse Models of Anemia
Authors: Ryan Thomas M , Fontenard Suean Daimia , Liu Shanrun , Lockhart Jonathan , Berlett Michael
Published: October 2019

Autologous cell therapy holds great promise for the treatment of beta thalassemia major and hemoglobinopathies like sickle cell anemia. Gene editing of a patient's own stem cells to reactivate the silenced gamma globin gene is one approach under active development. Prior to directly testing these new therapies in patients, we can answer some basic questions about their in vivo efficiency and efficacy in humanized mouse models of anemia. These models have their endogenous adult alpha and beta globin genes replaced with human alpha, gamma, and beta globin genes. These mice synthesize high level of human fetal hemoglobin during fetal life and complete their fetal-to-adult hemoglobin switch after birth. Experimental strategies designed to reactivate the silenced fetal gamma globin genes in adult erythroid cells are easily tested in vivo in these humanized hemoglobin switching mouse models. The silenced human fetal gamma globin genes can be activated by mutating the erythroid-specific enhancer of Bcl11a by gene editing. CRISPR sgRNAs, designed to target the +62 kb DNase I hypersensitive site in the second intron of Bcl11a, were microinjected along with Cas9 mRNA, into fertilized mouse embryos collected from humanized hemoglobin (Hb A) mice. The indel mutations that were generated in the founder animals were characterized and bred to homozygosity. The data demonstrates that the sgRNAs tested were successful in creating multiple unique mutations at the erythroid enhancer target sites. These mutations were transmitted through the germline allowing the effect of individual edited alleles to be analyzed. The majority of the mutations showed marginal increases in the number of F-cells over control animals. Significantly, despite having homozygous mutation of the erythroid-enhancer in all cells, fetal hemoglobin expression remains heterocellular. Importantly, the therapeutic efficacy of reactivating fetal hemoglobin with specific Bcl11a erythroid-enhancer mutations for the treatment of beta thalassemia major and sickle cell anemia was directly measured in vivo in these humanized models of disease. The reactivation of gamma globin in these humanized mouse models provides us with an opportunity to further interrogate the Bcl11a enhancer element, identify additional factors involved in hemoglobin switching and elucidate the mechanism driving pancellular vs heterocellular fetal hemoglobin expression.

Disclosures

No relevant conflicts of interest to declare.
Structural and Functional Insight of Sphingosine 1-Phosphate-Mediated Pathogenic Metabolic Reprogramming in Sickle Cell Disease
Authors: Sun Kaiqi , Xia Yang , D'Alessandro Angelo , Ahmed Mostafa H , Zhang Yujin , Song Anren , KO Tzu-Ping , Nemkov Travis , Haines Julie , Wu Hongyu , Adebiyi Morayo G. , Liu Hong , Huang Aji , Peng Zhangzhe , Wen Yuan Edward , Wen Alexander , Berka Vladimir , Bogdanov Mikhail , Abdulmalik Osheiza , Kato Gregory J , Tsai Ah-lim , Idowu Modupe , Juneja Harinder S. , Kellems Rodney E. , Hansen Kirk C , Safo Martin K.
Published: October 2019

Sphingosine 1-phosphate (S1P) is a bioactive signaling lipid highly enriched in mature erythrocytes. Previous study has revealed that levels of S1P are significantly elevated in patients and mice with Sickle Cell Disease (SCD), a devastating and highly prevalent genetic hemolytic disorder that causes life-threatening hemolysis, tissue damage, and organ dysfunction with very limited treatment. Moreover, the activity of S1P generating enzyme-Sphingosine Kinase 1 (SphK1) is increased in human and mouse SCD erythrocytes, and inhibition of SphK1 decreased erythrocyte sickling. However, the structural and functional basis for the pathogenic nature of S1P in SCD remains obscure. Here, we report that increased erythrocyte S1P promotes pathogenic metabolic reprogramming coupled to increased channeling of glucose to glycolysis rather than through the pentose phosphate pathway (PPP). Suppressed PPP causes compromised glutathione homeostasis and increased oxidative stress, while enhanced glycolysis induces production of 2,3-bisphosphoglycerate (2,3-BPG) and thus increasing deoxygenated sickle Hb (deoxyHbS), deoxyHbS polymerization, sickling, hemolysis and disease progression. S1P functioning intracellularly binds to deoxyHbS, facilitates deoxyHbS anchoring to the membrane, induces release of membrane-bound glycolytic enzymes and in turn switches glucose flux towards glycolysis relative to the PPP. Extending from SCD, we unexpectedly found that S1P and 2,3-BPG work synergistically to decrease both HbA and HbS oxygen binding affinity. The crystal structure of HbA complexed with S1P alone or in combination with 2,3-BPG at 1.9 Å resolution revealed the overall architecture and unique features of S1P-2,3-BPG-deoxyHbA complex. In the presence of 2,3-BPG, S1P binds to the surface of 2,3-BPG-deoxyHbA and causes additional conformation changes to the T-state Hb. Phosphate moiety of the surface bound S1P engages in a highly positive region close to a1-heme while its aliphatic chain snakes along a shallow cavity making hydrophobic interactions in the "switch region", as well as with b2-heme like a molecular "sticky tape" with the last 3-4 carbon atoms sticking out into bulk solvent. Altogether, our findings provide functional and structural bases underlying pathogenic consequences of elevated S1P in SCD and its potential role in normal erythrocyte physiology.

Disclosures

Kato: Mast Therapeutics: Consultancy; Bayer: Research Funding.
VWF Multimer Quantitation for Assessment of Cardiac Lesion Severity and Bleeding Risk
Authors: Bryan Justin , Austin Christopher , Thomas Colleen , Safford Robert E. , Chen Dong , Blackshear Joseph
Published: October 2019

Introduction: Recent reports have utilized von Willebrand factor (VWF) multimerquantitation in the assessment of native cardiac lesions and prosthetic valve dysfunction. However there is no standardized method for quantitation. We compared 3 methods of assessment which utilized a normal plasma control.

Methods: We analyzed 476 samples and their control plasma from 395 patients including normal subjects, patients with aortic stenosis, hypertrophic cardiomyopathy, mitral or aortic regurgitation, normal and abnormal left cardiac valve prostheses, and left ventricular assist device therapy (LVAD). VWF multimers were assessed as normal or abnormal, or as normalized (patient / normal plasma) VWF multimerratios of gel bands >15/2-15 (NMR 15) or gel bands > 10/2-10 (NMR 10). We tested whether one technique was more strongly associated with hemodynamic severity of the cardiac lesion, with a history of acquired bleeding, and compared the results to a separate test of VWF function, platelet function analyzer 15 00 (PFA).

Results: Two hundred seventeen patient samples reflected normal or mildly abnormal hemodynamics, 111 moderate, and 113 severely abnormal hemodynamics. Abnormal multimers were present in only 19% of samples with normal or mildly abnormal hemodynamics compared to 79% abnormal in the presence of moderate to severe hemodynamic abnormality. The distinction between moderate and severe hemodynamic abnormality was less striking, 65% versus 88% (figure, left). Quantitative NMR values declined with increasing cardiac lesion severity (figure, middle). The two quantitative multimermethods showed similar relationships to lesion severity by ANOVA, r=0.40 (NMR 15) versus r=0.36 (NMR 10), and by Spearman correlation, r=0.68 for NMR 15, and r=0.66 for NMR 10, and PFA results were comparable (all p< 0.001). Bleeding rates were associated with NMR 15, 10 and PFA (Mann-Whitney p<0.001, figure, right).

Conclusion: The dichotomous normal / abnormal VWF multimer method appears to distinguish ≥ moderate hemodynamic disruption, whereas there is a continuous relationship between hemodynamic severity and quantitative multimer methods, which may be clinically useful in circumstances in which clinical estimation of lesion severity is challenging, such as with dysfunctional prosthetic valves. Progressive loss of VWF multimersappears to be associated with bleeding, suggesting that quantitative measures may provide incremental value over the dichotomous normal / abnormal designation.

Figure Figure.

Disclosures

Blackshear: Baxalta, Inc: Consultancy, Research Funding.
Incidence and Risk Factors of Venous Thromboembolism in Patients with Multiple Myeloma Receiving Immunomodulatory Agents
Authors: Kimpton Miriam , Buyting Ryan , Corsi Daniel J , Rupani Natasha , Carrier Marc , McCurdy Arleigh
Published: October 2019

Multiple myeloma (MM) is an incurable plasma cell disorder representing 10% of all hematologic malignancies. Cancer is a known risk factor for venous thromboembolism (VTE). Patients with MM are at a particularly high risk of developing VTE owing to patient characteristics (e.g. previous history of VTE), disease characteristics, and treatment characteristics including use of the immunomodulatory agents (IMIDs). Unfortunately, standard criteria to identify the patients most at risk for developing VTE in MM while receiving IMIDs are unknown. We sought to assess the incidence of VTE and its associated risk factors in MM patients receiving IMID therapy.

A retrospective cohort study including 1680 consecutive patients with multiple myeloma treated at our centre between January 01, 1995 and January 26, 2016 was conducted. The annual incidence of VTE on immunomodulatory agents including thalidomide, lenalidomide, and pomalidomide was derived. Univariate incidence ratio analyses of VTE for different risk factors was performed including: previous history of VTE, concomitant use of dexamethasone, and ≥/< 6 months after IMID initiation.

A total of 309 MM patients treated with an immunomodulatory agent were identified. Nineteen patients were excluded (incomplete data, lost to follow). Of the remaining 290 patients, the mean age was 67.9 and 42.4% were female. Twenty-seven VTE events were recorded. The overall risk ratio was 6.1 for the development of VTE. Patients with a personal history of VTE had an increased risk of suffering a VTE while on IMID therapy (IRR 5.4; CI, 1.9-13.6). The time from the initiation of the IMID therapy (less than 6 months) also increased the risk of developing a VTE (IRR 51.7; CI,19.4-160.1). The concomitant use of dexamethasone was not associated with a statistically significant increased risk (IRR 1.7; CI, 0.3-69.5). Incidence risk ratios for these risk factors are depicted in Table 1.

Our results suggest that a personal history of VTE and the time from the initiation of the IMID (less than 6 months) are associated with an increased risk of VTE in MM patients receiving IMID therapy. This may be helpful in determining which multiple myeloma patients treated with an IMID agent warrant more aggressive thromboprophylaxis. Further prospective studies are needed to determine the optimal agent, intensity, and duration of thromboprophylaxis in patients with MM on IMID therapy.

Disclosures

McCurdy: Celgene: Honoraria.
Myelodysplastic/Myeloproliferative Neoplasms Unclassified (MDS/MPN-U) Overlap: Can We Alter the Natural History?
Authors: Hendrix Kaitlin , Alali Najla , Padron Eric , Sallman David , List Alan F. , Lancet Jeffrey E. , Komrokji Rami S.
Published: October 2019

Introduction:

The 2008 World Health Organization classification recognized a unique overlap category that combines features of myelodysplastic syndromes (MDS) and myeloproliferative neoplasms (MPN). The least well characterized of the 4 overlap diseases is a rare entity known as MDS/MPN Unclassifiable (MDS/MPN-U), comprising <5% of myeloid disorders. The outcome of this subtype has been reported to be poor. The response to and impact of hypomethylating agents (HMA) on outcome is not well studied.

Methods:

We identified MDS/MPN-U patients within the Moffitt MDS database, baseline characteristics were reviewed, and responses to HMA utilizing IWG 2006 response criteria were assessed. The Kaplan-Meier method was applied to estimate overall survival (OS).

Results:

Among 127 patients with MDS/MPN-U, 62 patients received HMA treatment. There was no difference in baseline characteristics among those who received HMA or not, except that those treated with HMA were less likely to have low risk disease by IPSS, MD Anderson model or very low risk by revised IPSS (R-IPSS). Among 16 patients who had NextGen sequencing data, the 5 most common mutations were ASXL-1 (56%), TET2 (31%), JAK2 (33%), SRSF2 (25%), as well as SETBP1, DNMT3A, and EZH2(19%). The best overall response to HMA (hematological improvement [HI] or better) according to the International Working Group (IWG) 2006 criteria was 26%. Only 11 patients (low risk) underwent allogeneic stem cell transplant (allo-SCT) with no improvement or decrease in OS.

The median OS was 33 months (mo). Among patients with IPSS low/int-1 risk disease, the median OS was 39 and 33 mo respectively for those treated with HMA vs. HMA untreated. (p=0.50). For Int-2/high risk IPSS, the median OS was 11 and 5 mo for those who received HMA and those who did not. (p=0.02). Based on R-IPSS the median OS for very low/low risk was 47 and 39 mo respectively for those treated with HMA and without (p=0.96), for intermediate risk, the median OS was 39 and 25 mo respectively (p 0.75), and for high and very high risk the median OS was 13 and 5 mo respectively for those treated with HMA and those who did not. (p < 0.005). The median OS for patients with HI+, stable disease or progressive disease was 68, 59, and 36 mo respectively (p=0.08).

Conclusions:

Treatment with HMA is associated with modest improvement in OS among higher risk MDS/MPN-U, reinforcing the unmet need to improve outcomes in this group. Targeted therapy may prove to be of benefit as allo-SCT does not appear to be beneficial for patients even with low risk disease. Furthermore, these data demonstrate the need for prospective analysis of the outcomes of allo-SCT in patients with MDS/MPN-U to determine potential benefit to high risk patients.

Disclosures

Komrokji: Novartis: Consultancy, Speakers Bureau; Celgene: Membership on an entity's Board of Directors or advisory committees, Research Funding.
Dual Deficiency of mDia1 and Mir-146a in an Age-Related Inflammatory Bone Marrow Microenvironment Induces Ineffective Erythropoiesis in Del(5q) MDS
Authors: Mei Yang , Basiorka Ashley , Zhao Baobing , Yang Jing , List Alan F , Ji Peng
Published: October 2019

Myelodysplastic syndromes (MDS) are a group of age-related clonal hematologic diseases characterized by anemia, neutropenia, and thromobocytopenia. The mechanisms of anemia in MDS are unclear, which is partially due to the heterogeneity of MDS involving many cytogenetic and molecular abnormalities. Using a mouse genetic approach, here we show that dual deficiency of mDia1 and miR-146a, two genes located at chromosome 5q that is commonly deleted in MDS, causes an aged-related anemia and ineffective erythropoiesis that closely mimics human MDS. Bone marrow erythropoiesis at various stages was dramatically affected in mDia1/miR-146a double knockout mice, which induced a massive splenomegaly with potent extramedullary erythropoiesis. Old (> 1 year of age), but not young (2-4 months of age), wild type recipient mice that were transplanted with bone marrow cells from mDia1/miR-146a double knockout mice, exhibited severe anemia and rapid lethality, which indicates that the aged microenvironment is important for the development of ineffective erythropoiesis. Consistent with the roles of mDia1 and miR-146a in the innate immune response, the serum levels of TNFα and IL-6 were significantly elevated in mDia1/miR-146a double knockout mice. Pathogen-associated molecular pattern proteins (PAMPs), or damage-associated molecular pattern proteins (DAMPs), whose levels increase in aged microenvironment, both induced TNFα and IL-6 upregulation in mDia1/miR-146a double knockout granulocytes and T cells. Mechanistically, we demonstrated that the anemia and ineffective erythropoiesis was independent of hepcidin expression in mDia1/miR-146a double knockout mice. Instead, pathologic levels of TNFα and IL-6 inhibit erythroid colony formation and differentially affect terminal erythropoiesis through reactive oxygen species-induced caspase-3 activation and cell apoptosis. Our study highlights the dual roles of age-related microenvironment and cytogenetic abnormalities in the pathogenesis of ineffective erythropoiesis in MDS.

Disclosures

No relevant conflicts of interest to declare.
BKV Disease during the First 100 Days after Allogeneic Hematopoietic Stem Cell Transplantation - Results of a Screening Program and Retrospective Analysis
Authors: Posdzich Philip , Herling Marco , Leitzke Silke , Hamacher Laura , Di Christanziano Veronica , Hoeller Konstantin , Kaiser Rolf , Chemnitz Jens , Scheid Christof , Holtick Udo
Published: October 2019

BK virus (BKV) is a human polyomavirus often acquired in childhood which can reactivate after allogeneic hematopoietic stem cell transplantation (HSCT). BKV reactivation may present indifferent ways from asymptomatic viruria to hemorrhagic cystitis or nephritis.

Methods

We evaluated 377 patients (159 male, 218 female, median age 52 years) who were transplanted at the University of Cologne between 2008 and 2013 to assess incidence and risk factors for BKV disease after allogeneic HSCT. All 377 patients were screened routinely for BKV in urine and serum. We defined BKV disease as hemorrhagic cystitis (HC) with BK virus >100.000/ml in urine, hematuria (2+ until 4+ in dipstick test) and negative urine microbiology. To find risk factors for BKV disease, the impact of conditioning, CMV status, graft-versus-host disease (GvHD), underlying disease, donor mismatch and stem cell source was analyzed.

Results

According to our definition, BKV cystitis occurred in 37 of 377 patients (9,8%) in the first 100 days after HSCT. In 14 of these 37 patients (37,8%) BKV was also detected in serum. BKV was detected in the urine of 194 patients (51,4%) at any time during the screening program, but only 19,1% developed hemorrhagic cystitis. Sixty-two percent of patients suffering from BKV disease were female, 37,8% male. BKV disease was diagnosed in 13,3% of patients not in complete remission as opposed to 5,4 % of patients in complete remission prior to conditioning (p = 0,010). BKV disease was less common in matched related or unrelated (7,7%) as compared to mismatched or haplo-identical donors (16,7%; p=0,012). Acute GvHD grade II to IV was described in 122 of 377 patients (32,36%). Of them, 13,9% suffered from BKV cystitis in comparison to 7,84% with no or grade I acute GvHD, which did not reach statistical significance. We could not detect any correlation between BKV disease and administration of cyclophosphamide, total body irradiation or anti-thymocyte globuline. There was no association with the graft source. BKV disease was no predictor for non-relapse mortality, overall and relapse-free survival.

Conclusion

BKV disease is a common complication after allogeneic HSCT. The virus can be found in the urine of about half of our transplanted patients, but only a small proportion developed an HC. State of remission before conditioning and donor mismatch are associated with the development of BKV disease, which had no impact on survival in our cohort.

Disclosures

Scheid: Novartis: Other: funding outside this work; Celgene: Other: funding outside this work; Janssen: Other: funding outside this work.
Optimal Dose of Antithymocyte Globulin in Conditioning Regimens for Unmanipulated Haploidentical Haematopoietic Stem Cell Transplantation: Long-Term Outcomes of a Prospective Randomised Trial
Authors: Chang Yingjun , Wang Yu , Mo Xiao-Dong , Zhang Xiao-Hui , Xu Lan-Ping , Yan Chen-Hua , Chen Huan , Chen Yu-Hong , Chen Yao , Han Wei , Wang Feng-Rong , Wang Jing-Zhi , Liu Kai-Yan , Huang Xiao-Jun
Published: October 2019

Background: Antithymocyte globulin (ATG) is an important component of conditioning regimens to prevent severe GVHD in patients undergoing unmanipulated haploidentical stem cell transplantation (haplo-SCT). However, the optimal dose of ATG is unknown.

Methods: In this open-label extension of a prospective, randomised trial, we compared the long-term outcomes of two ATG doses used in myeloablative conditioning before unmanipulated haplo-HSCT. Patients were randomly assigned (1:1) to 10 mg/kg (ATG-10) or 6 mg/kg (ATG-6) ATG. Patients and individuals assessing outcomes were masked to treatment allocation. Analysis of disease-free survival (DFS), GVHD-free/relapse-free survival (GRFS), relapse, non-relapse mortality (NRM), and chronic GVHD (cGVHD) included the entire population. Late effects were assessed in disease-free patients who had survived for at least 6 months and had received regular follow-up evaluations.

Results: Between December 2010 and May 2012, 224 patients were recruited. The median follow-up period was 1614 days (28-1929 days). The 5-year cumulative incidence was comparable between the ATG-6 and ATG-10 groups for relapse (12·8% vs. 13·4%, p=0·832) and NRM (11·6% vs. 17·0%, p=0·263). The 5-year probability of DFS was comparable between groups (75·6% vs. 69·6%, p=0·283). The 5-year cumulative incidence was higher with ATG-6 for cGVHD (75·0% vs. 56·3%, p=0·007; moderate-to-severe cGVHD: 56·3% vs. 30·4%, p<0·0001) and late effects (71·2% vs. 56·9%, p=0·043). The 5-year probability of GRFS was higher with ATG-10 (41·0% vs. 26·8%, p=0·008). In the multivariate analysis, ATG-10 was associated with lower cGVHD risk and improved GRFS.

Conclusions: ATG 10 mg/kg may be the optimal dose for conditioning regimens before unmanipulated haplo-SCT.

Disclosures

No relevant conflicts of interest to declare.
Pharmacovigilance of a Rituximab Biosimilar (Novex) in Argentina
Authors: Milone Gustavo , Fernandez Francisco , Penna Maria Ines , Gomez Roberto
Published: October 2019

INTRODUCTION

Novex is a rituximab biosimilar approved in Argentina. From January 2015 to June 2016 as part of the Risk Management Plan approved by ANMAT, every treatment detected was recorded and a follow up was implemented in order to obtain safety information.

The aim of this communication is to present the information gathered during this pharmacovigilance program.

MATERIALS AND METHODS

All treatments with at least 1 follow up point were selected and reviewed.

Treatment duration until last follow up checkpoint or date of treatment finalization was recorded.

We summarized demographic data (age, gender), indication distribution, treatment exposition (duration expressed in days and number of cycles received), adverse event frequency (cumulative incidence and incidence density) and distribution.

RESULTS

We collected 345 treatment notifications with at least 1 follow up point.

Gender distribution: 53.2 % of patients were male patients. Age range was 10 to 90 years old, with a mean of 63.9 years.

The indications distribution is summarized in table 1. More than 90% of them were hematological.

Average treatment duration was of 235 days with a median duration of 210 days (IQR = 152 - 311).

Mean number of cycles 5.5; range (1-12).During the reported period a total of 12 Individual Case Safety Reports (ICSR) were received. This represents a cumulative incidence of 3.5 %, an incidence density of 0.015 ICSR notifications per 100 days of treatment and 0.99 per 100 administered cycles.

These 12 ICSR totalized 14 different diagnoses. Of them, the most frequent was Acute Infusion Related Reaction (AIRR), as expected.

All AE but 1 were classified as serious (SAE) because they had at least 1 manifestation that prolonged hospitalization or endangered life.

As expected, the most frequent AE notified was AIRR (5 cases), followed by cardiovascular manifestations (2 arrhythmia, 1 cardiac failure and 1 ischemic stroke), infections (1 pneumonia, 1 progressive multifocal leukoencephalopathy), neurologic (1 paresthesia), cytopenias (1 pancytopenia) and cutaneous (1 bullous dermatitis).

Most of the acute manifestations occurred within the 2 initial infusions of Rituximab, as described.

CONCLUSION

The observed AE frequency and distribution was consistent with product specifications.

No AE notified were unlisted or were notified with greater frequency than expected.

Treatments registry resulted in a suitable way to detect AE that complements spontaneous reporting.

Disclosures

Fernandez: Laboratorio ELEA S.A.C.I.F y A: Employment. Penna:Laboratorio ELEA S.A.C.I.F y A: Employment. Gomez:Laboratorio ELEA S.A.C.I.F y A: Employment.