bluuebunny/crossref_metadata_2025 huggingface dataset:
Acquired Pure Red Cell Aplasia Associated with Alemtuzumab, Mycophenolate, and Daclizumab Immunosuppression after Pancreas Transplant.
Authors: Elimelakh Milena , Dayton Vanessa , Park Katharine S. , Gruessner Rainer W. , Gruessner Angelika C. , Sutherland David E. , Bland Barbara , Howe Robert B. , van Burik Jo-Anne , Asraani Aneel A. , Reding Mark T. , Singleton Tim P. , Key Nigel S.
Published: April 2020

Acquired pure red cell aplasia (PRCA) is a rare disorder that may be associated with malignancy, infections, connective tissue disorders, pregnancy and drugs. Recently, we observed PRCA in pancreas transplant patients treated with a new immunosuppressive regimen. Since 1966, the University of Minnesota Medical Center (UMMC) has performed 1577 pancreas transplants. Since February 2003, 280 pancreas transplants were treated with a new immunosuppressive protocol involving induction and maintenance with (n=190) or conversion to (n=90) alemtuzumab (humanized anti-CD52) and mycophenolate mofetil (MMF). Daclizumab (humanized anti-CD25, IL-2 receptor) was added when MMF dosing was limited by neutropenia. Between September 2004 and July 2005, 12 patients receiving the triple drug combination were diagnosed with PRCA. All 12 had prolonged exposure to MMF and/or a calcineurin inhibitor (cyclosporine, tacrolimus) prior to induction with [n=8] or conversion to [n=4] the above protocol. Eight subjects had bone marrow biopsies performed and reviewed at UMMC, and 4 additional patients received the diagnosis of PRCA at other institutions. All cases showed similar morphologic features, including dysgranulopoiesis, erythroid aplasia or marked hypoplasia with evidence of maturation, megakaryocytic hyperplasia with normal or low peripheral platelet counts, and atypical lymphoid aggregates in bone marrow trephine sections. Cytogenetic studies showed normal karyotypes. Severe reticulocytopenia was present in all subjects. In one subject, an extramedullary post-transplant lymphoproliferative disorder was diagnosed simultaneously. Another patient developed atypical reactive lymphadenopathy. Acute parvovirus infection was excluded by serology or polymerase chain reaction in 11 cases. Erythropoietin, when used, was started after the diagnosis or maintained through recovery of PRCA. Two patients died, one (post conversion) of PRCA associated with autoimmune hemolytic anemia and one (post induction) of ischemic heart disease. MMF was either discontinued (n=8) or dose reduced (n=2) in the remaining 10 subjects, with improvement in hemoglobin or decreased transfusion requirements in 8 patients. The single patient in whom a follow-up bone marrow biopsy was obtained after clinical recovery showed normal erythropoiesis. Ten patients developed infections with cytomegalovirus (n=7), BK virus (n=3), Zygomyces (n=1), Aspergillus versicolor (n=1), and Mycobacteria Simiae/Interjectum (n= 1). Hypogammaglobulinemia was a common finding. We conclude that reversible PRCA is associated with the immunosuppressive protocol including alemtuzumab, MMF, and daclizumab.
Analysis of Expanded Human Cytokine Induced Killer Cells for Cellular Therapy.
Authors: Baker Jeanette , Sheehan Kevin , Monterola Gina , Staines Nancy , Negrin Robert S.
Published: April 2020

We have previously reported on the ex vivo expansion of cytotoxic effector T cells termed Cytokine Induced Killer (CIK) cells. CIK cells demonstrate both in vivo and in vitro anti-tumor activity in murine models with limited potential for GVHD induction. Human CIK cells are readily expanded from peripheral blood mononuclear cells (PBMC) when cultured with IFNg, CD3 and IL-2 and show cytotoxic activity against a variety of tumor cell lines and fresh autologous tumor cells through an NKG2D dependent mechanism. Clinical application of CIK cells requires expansion of effector cells in GMP-compliant manner. In this study, PBMC were collected by apheresis from 9 healthy non-mobilized donors and placed in closed, continuous perfusion cultures using Aastrom RepliCell@biochambers for 21–28 days. Cultures were inoculated with 3x108–7.5x108 nucleated cells containing a median of 46% CD3+ cells (range 29%–71%). At culture harvest, the median cell count was > 4x109 (range 2.6x109–8.7x109) with 97% CD3+ (86%–99%) and an average cell viability of 84.8% (range, 75%–99.6%). The average expansion of CD3+ cells in culture was > 30-fold (range13–91). CD3+CD56+ are the subpopulation of cells that demonstrated the highest cytotoxicity against tumor cell lines in culture. The mean percentage of these cells was 1.8% however at harvest, the mean CD3+CD56+ was 14% representing an average 34-fold expansion (range 19–515). The majority of CD3+ cells were CD8+ (range, 33–82%), NKG2D was predominately expressed by cells recovered from most cultures (range 47–76%). CD56+ was expressed by 1% – 36% of cells in different cultures and CD8+NKG2D+ expression ranged from 21%–50% of harvested cells. There was a moderate up-regulation of the activation markers CD25 and CD69 and the NK markers CD16, CD161 and CD94. In all cultures, the majority of CD8+ and CD56+ cells co-expressed the selectin marker a4b7. Furthermore the majority of the CD3+CD8+ cells were effector memory cells expressing CD62L−CD44+ (50%–71%) while the central memory cells CD62L+CD44+ ranged from 10%–40%, almost no naïve cells were detected in time of harvest. Cytotoxicity assays against a panel of tumor cell lines (B and T cell lymphomas, uterine cancer, erythroleukemia, ovarian cancer and plasmacytoma) showed significant yet variable killing. This system allows for the rapid expansion of cytotoxic cell in GMP-compliant manner suitable for clinical application.
A Randomized Trial of High-Dose (HD) Imatinib Mesylate (IM) with or without Peg-Interferon (PEG-IFN) and GM-CSF as Frontline Therapy for Patients with Chronic Myeloid Leukemia (CML) in Early Chronic Phase (CP).
Authors: Cortes Jorge , Talpaz Moshe , O’Brien Susan , Ravandi Farhad , Verstovsek Srdan , Garcia-Manero Guillermo , Koller Charles , Andreeff Michael , Estrov Zeev , Kantarjian Hagop
Published: April 2020

Some studies suggest that HD IM may be more effective than standard dose in CP CML. Still, only a minority of patients (pts) may reach undetectable levels of Bcr-Abl transcripts, and the use of single agent therapy may eventually result in development of resistance. IFN is thought to be effective in CML due to its immunomodulatory properties and may be valuable for management of minimal residual disease. Pre-clinical studies suggest synergy with imatinib. GM-CSF combined with IFN is a potent stimulator of dendritic cells. We designed this randomized phase II study to investigate if adding PEG-IFN to imatinib may improve the rate of complete molecular responses and prolong remission duration. Pts with previously untreated CP CML started treatment with imatinib 800mg daily and randomized after 6 months (mo) of therapy to either continue HD IM alone or add PEG-IFN 0.5mcg/kg/week and GM-CSF 125 mg/m2 three times weekly. Pts were monitored with real-time PCR and cytogenetics (CG) every 3 mo for the 1st year and every 6 mo thereafter. Ninety-four pts have been registered to date: 49 randomized to IM alone and 45 to IM + PEG-IFN+GM. 70 (75%) have been followed for at least 6 months and 49 (52%) for 12 months. (First interim analysis done when 30 pts evaluable at 12 mo). Ten pts randomized to PEG-IFN did not start therapy (2 refused, 2 physicians decision, 6 off study before 6 mo because of noncompliance n=3, melanoma n=1, financial n=1, progressive disease n=1). Patient characteristics and response (intention to treat) are as follows:

No./No. Evaluable (%) p value Overall IM alone IM+PEGIFN+GM Median age (range), y 48 (19–73) 46 (19–73) 50 (19–73) 0.12 Sokal (% low/int/high) 71/20/9 63/25/12 79/16/5 0.17 CG CR Overall 73/84 (87) 40/45 (89) 33/39 (85) 0.74 @ 12 mo 44/49 (90) 27/31 (87) 17/18 (94) 0.63 12 mo BCR-ABL/ABL <0.05% 20/49 (41) 10/31 (32) 10/18 (55) 0.13 Undetectable 5/49 (10) 3/31 (10) 2/18 (11) 1.0 Median (range) 0.1 (0–79.3) 0.12 (0–79.3) 0.04 (0–21.9) 0.51

Toxicity with HD imatinib was similar to previous reports. The most common grade ≥3 toxicity associated with PEG-IFN in the 26 pts included fatigue (n=7, 27%), rash (n=5, 19%), depression (n=3, 11%), and headache (n=2, 7%). Twelve pts have required dose reductions of PEG-IFN and 3 (13%) permanently discontinued it. The actual median (range) dose of IM at 12 months was 800 mg (600–800 mg) for IM alone and 800 mg (400–800 mg) for combination arm. Among pts randomized to PEG-IFN arm, the dose of IM had to be reduced after 6 mo (i.e., after start of PEG-IM) in 4 (16%) pts. We conclude that the combination of IM and PEG-IM as done here is associated with acceptable toxicity profile. There is a trend for improved response after 12 months with the combination.
Combination Treatment with Imatinib and Mitoxantrone/Etoposide Is a Suitable Preparative Regimen before Allogeneic Transplantation in Patients with Myeloid Blast Crisis of Chronic Myeloid Leukemia.
Authors: Fruehauf Stefan , Topaly Julian , Buss Eike C. , Lahaye Tanja , Ottmann Oliver G. , Fischer Thomas , Emmerich Bertold , Haus Ulrike , Hehlmann Rudiger , Ho Anthony D. , Hochhaus Andreas
Published: April 2020

In advanced BCR-ABL-positive leukemia, combination of chemotherapy with imatinib is expected to result in better reduction of leukemia cell load and may delay or offset clonal selection of resistant leukemia cells, thus improving the survival. We carried out a prospective phase I/II combination trial for patients (pts) with myeloid blast crisis of chronic myelogenous leukemia (CML). Pts were treated with imatinib+mitoxantrone/etoposide in four cohorts starting from mitoxantrone 10mg/m2/d and etoposide 100 mg/m2/d for 2 or 3 consecutive days and start of imatinib 600mg/d from day 15 (coh. 1 and 2) or from day 1 (coh. 3 and 4, respectively). After hematologic reconstitution following the cytopenic phase, cytarabine was administered at a dose of 10mg/m2/d s.c. in addition to imatinib as maintenance treatment.

A total of 16 pts (8 m, 8 f) are available for analysis, median age 59 years (range 37–74). All pts who received more intensive induction treatment (coh. 3 and 4, n=7) achieved a hematologic response (HR). In contrast, HR was achieved in 6 of 9 pts treated in coh. 1 and 2. The induction treatment was well tolerated with a treatment-related mortality rate of 12.5% (1 intracranial hemorrhage in coh. 1, and 1 pneumonia in coh. 4).

A median of 8 (2–18) red blood cell concentrates and a median of 5 (1–8) platelet concentrates were required. Antibiotic treatment for febrile episodes was administered for a median of 10d (0–38). Of note, CTC grade 3 or grade 4 mucositis did not occur. Pts who received imatinib on day 1 (coh. 3–4) had a longer duration of severe leukopenia (WBC <1/nl) with a median of 19 days (0–23) vs. 2 (0–14) but without increase of infection incidence.

Six pts who achieved HR received an allogeneic stem cell transplantation with myeloablative conditioning. Three of 6 transplanted patients are alive and in complete cytogenetic remission at 735, 723, and 279 days after initiation of study treatment. Two patients died of transplant-related complications (GvHD and sepsis), 1 patient died from hematologic relapse. Of 10 pts who received only conventional treatment, 1 (coh. 1) is still alive and in a complete cytogenetic remission at day 1280 after initiation of study treatment. Median survival of transplanted pts was 486 days, and 142 days in the group with conventional treatment only (p=0.078).

We conclude that the combination of mitoxantrone/etoposide and imatinib is a well tolerated induction protocol with mild non-hematological toxicity even in older patients. Eligible pts have an advantage from an allogeneic stem cell transplantation following response to the induction treatment.
Emerging Marrow Fibrosis Is an Early Indicator of Imatinib Failure and Shortened Survival Time in CML Independent of Hematologic, Cytogenetic and Molecular Response.
Authors: Buesche Guntram , Hehlmann Ruediger , Ganser Arnold , Hecker Hartmut , Freund Mathias , Heimpel Hermann , Heinze Barbara , Gadzicki Dorothea , Schlegelberger Brigitte , Fonatsch Christa , Frye Bernd , Tobler Andreas , Georgii Axel , Kreipe Hans H.
Published: April 2020

In chronic myeloid leukemia (CML), imatinib may reverse bone marrow fibrosis (MF) that has occurred before start of therapy. The risk and prognostic relevance of MF evolving during imatinib treatment are unclear as yet. Bone marrow biopsies (n = 1509) taken prospectively from Ph+ CML patients (n = 605) were examined for MF before and during therapy. 107 patients were treated with 400 mg imatinib / day, 208 with interferon-alpha +/− cytosine arabinoside, 154 with hydroxyurea and 136 with busulfan.

Imatinib and interferon-alpha +/− cytosine arabinoside were significantly more effective than the other types of therapy regarding reversal of initial MF (P < 0.000005). During the follow-up period of 3 years, imatinib monotherapy was not superior to interferon-alpha or hydroxyurea in preventing evolution of MF: MF affected more than 20 % of patients and developed from small foci with increased fiber deposition to full-stage fibrosis within 1 – 2 years. Hematologic, cytogenetic and molecular response did not protect against evolution of MF as long as a complete molecular remission (i.e. bcr/abl negativity) was not achieved. Evolving MF was an independent significant predictor of therapy resistance and shortened survival time of patients irrespective of the type of treatment (P < 0.00005).

Conclusion: Although imatinib reverses initial MF in CML, MF may evolve during imatinib monotherapy indicating an unfavorable course of disease independent of hematologic, cytogenetic and molecular response.
A Phase I, Multi-Center, Dose Escalation Study of Atiprimod in Patients with Refractory or Relapsed Multiple Myeloma (MM).
Authors: Wang Michael , Talpaz Moshe , Jagannath Sundar , Chanan-Khan Asher Alban , Alexanian Raymond , Weber Donna M. , Gavino Maria , Estrov Zeev , Harris Pamela J. , Picker Donald , Schlossman Robert L. , Tassone Pierfrancesco , Anderson Kenneth C. , Munshi Nikhil C.
Published: April 2020

Atiprimod (N-N-diethl-8, 8-dipropyl-2-azaspiro [4,5] decane-2-propanamine) is an orally bioavailable cationic amphilic compound that inhibited STAT 3 activation in MM cells. It effectively blocked the signaling pathway of interleukin-6, resulting in activation of caspase 3 and apoptosis (Amit-Vazina et al, Br J Cancer, 2005). Atiprimod has also induced cytotoxicity in dexamethasone, doxorubicin, and melphalan resistant MM cell lines (Hamasaki et al, Blood, 2005). Based on these encouraging in vitro data, we initiated a multi-center, phase I trial of atiprimod for patients (pts) with refractory or relapsed MM who had 2 prior lines of therapy and serum creatinine less than 2 mg/dl. Primary objectives were to evaluate the safety of atiprimod in MM pts and to identify the maximum tolerated dose (MTD). Each cycle of treatment consisted of 14 consecutive days of oral atiprimod followed by 14 consecutive days without treatment. A standard phase I dose escalation was used to determine MTD with atiprimod dose levels at 30 mg, 60 mg, 90 mg, 120 mg, and 180 mg. To date, 14 pts from 4 centers have been enrolled with evaluable data in 12 patients. Median age was 60 (range 44–64); median prior lines of therapy were 4 (range 3–7); median duration from initial treatment to registration to this trial was 36 months (range 19–76). Cohorts of 3 patients have been treated at 30, 60, 90,120 mg/day and 2 patients have been enrolled at the 180 mg/day level; no cohorts have been expanded because of dose-limiting toxicity. Median number of cycles received by MM pts was 2 (range 1–5). Common Grade 1 toxicity events included diarrhea, liver enzyme elevation and dyspepsia. There were two Grade 2 toxicity events with 1 neutropenia at the 90 mg/day level and 1 diarrhea at the 120 mg/day level. One pt had Grade 3 transaminase elevation (peak AST 402, ALT 469 units/L, bilirubin 0.5 mg/dl) during the second cycle that resolved on its own during the 14 day period off treatment. Two patients with rapidly rising serum M proteins prior to enrollment had a transient but clear reduction of their M proteins (30% and 80%) after the first 14 days of atiprimod. Two pts at higher dose levels noted subjective improvement in their bone pain. Atiprimod was generally well tolerated in this heavily treated group of MM pts. The MTD has not been reached. Although there has been no response to date, clinical activity is not expected until higher dose levels are evaluated (240 mg/day, 300 mg/day, and 360 mg/day). After the MTD has been established, the study of atiprimod combinations should be considered based on the in vitro assessment of synergy with other active agents.
Pulmonary Function Abnormalities 5 Years or More Following Myeloablative and Non-Myeloablative Allogeneic Stem Cell Transplantation for Hematological Disorders - Impact of Chronic GVHD.
Authors: Savani Bipin N. , Srinivasan Ramaprasad , Montero Aldemar , Singh Anurag , Shenoy Aarthi , Kamipour Shervin , Childs Richard , Barrett A. John
Published: April 2020

Pulmonary function was studied in sixty nine consecutive patients with hematological diseases (65 malignant; 4 benign) 5–12 (median 7.5) years following allogeneic stem cell transplantation from HLA-matched siblings. Fifty-six (81%) patients received total body irradiation-(TBI) based myeloablative bone marrow or peripheral blood stem cell transplantation (MST) for hematological malignancies and 13 (19%) received a fludarabine/cyclophosphamide non-myeloablative peripheral blood stem cell transplantation (NST) for malignant (9) or benign (4) hematological disease. Median age of cohort was 37 years (MST 37, range 10–55; NST 34, range 15–68 years). Thirty nine patients were male. Eleven were smokers. Baseline pulmonary function tests (PFT) showed a median DLCO of 90% predicted (range 59–156%) and FEV1 of 97% predicted (range 64 to132%). Significant pre-transplantation PFT abnormality occurred in 19 (27.5%) patients (DLCO and/or FEV1 <80% of predicted). Twenty five (36%) patients developed acute graft versus host disease (aGVHD) and 43(62%) developed chronic GVHD (cGVHD). At long-term follow-up at a median of 7.5 years after transplant, 32 (42%) patients had PFT abnormalities, 26 with a predominantly restrictive pattern and 6 with a predominantly obstructive pattern. Twenty-two (32%) patients had a mild to moderate decline in PFT (compared with pre-transplant values DLCO/FEV1 value). Of the 32 patients with PFT abnormalities none required supplemental oxygen and only 12 (17.4%) were symptomatic, which included 10 (14.5%) with the most severely depressed pulmonary function (all with predominantly restrictive lung function). In univariate analysis, development of cGVHD (p <0.0001); pre-transplant PFT abnormality (p<0.0001) and a history of smoking (p=0.03); was associated with increased incidence of late PFT abnormality. In multivariate regression analysis, cGVHD (relative risk 36.1; 95% CI 4.1–320) and pre-transplant DLCO/FEV1 of less than 80% of predicted (relative risk 5.5; 95% CI 1.07–29) were independently associated with late decline in PFT. When analyzed for symptomatic PFT abnormality beyond 5 year post-transplant similar results were obtained. The incidence of late PFT abnormality was comparable in both MST (24/56) and NST (5/13) (p=0.51). Our result indicates that a significant proportion of patients developed late PFT abnormality after transplantation, however only a minority are symptomatic. In this series of patients receiving conditioning regimens of different intensity, cGVHD was the only transplant-related risk factor predictive for late pulmonary function defects.
PKC δ Inhibition Restores PTEN Activity in Myeloma Cells and Prolongs Survival of GFP+ Myeloma SCID/NOD Mice In Vivo.
Authors: Bahlis Nizar J. , Starovic Maya , Raedschelders Koen , Gratton Kathy , Bathe Oliver , Belch Andrew
Published: April 2020

PTEN, a cellular phosphatase involved in the regulation of phosphatidylinositol phosphates (PIPs), is often inactivated in myeloma cells either through gene mutation or via phosphorylation of serine and threonine residues in the PTEN C-terminal domain that also results in loss of its activity and stability. The loss of PTEN function results in a failure to de-phosphorylate PIPs with a corresponding increase in Akt kinase activity. We have recently reported that PKCδ inhibition with Rottlerin (3 μM) induces cell death in sensitive and resistant myeloma cell lines (MM1S, MM1R, 8226S and U266) (Blood2002,100,11,393a). In addition Rottlerin blocked constitutive as well as IGF-1 induced phosphorylation of Akt abrogating its kinase activity and suppresses the phosphorylation of FKHR, GSK 3α/β and Bad, downstream substrates of Akt, triggerring activation of the intrinsic apoptotic pathway with loss of the mitochondrial membrane potential (Δψ) and cleavage of caspases 9, 3 and PARP. PKCδ inhibition also suppressed, upstream of Akt, ser 241-PDK1 phosphorylation by PIPs. These findings led us to investigate the PTEN status in human myeloma cell lines (MM1S, 8226S and U266). While normal PTEN expression was detected in these cell lines, PTEN was universally phosphorylated on ser 380 in its C-terminal domain, resulting in loss of its activity. Rottlerin completely suppressed the phosphorylation of this serine residue, restoring PTEN function and dephosphorylating PIPs. In order to verify that Rottlerin exhibited its effects by inhibiting PKCδ, we first stably overexpressed PKCδ in the 8226S cells. PKCδ overexpression partially protected these cells against rotttlerin cytotoxicity and abrogated rottlerin induced AKT inhibition and PTEN activation. Furthermore transfection of 8226S cells with a mammalian PKCδ siRNA expression plasmid (sense strand of shRNA: 5′_AAGAACGCTTCAACATCGACATTCAAGATGCGATGTTGAAGCGTTCTTTTTTTG_3′expression plasmid) reduced PKCδ expression by nearly 90% and more importantly it reduced PTEN, Akt and GSK 3α/β phosphorylation. Finally, we examined the effect of Rottlerin on the viability of GFP+ myeloma SCID/NOD mice in vivo. 4 to 6 weeks old SCID/NOD mice were irradiated (300 rads) and 24 h later received tail vein injections of 5 x 106 RPMI-8226/S-GFP+ cells. Treatment with Rottlerin (3mg/kg ip) every other day was effective in slowing tumor growth as monitored by whole-body real-time fluorescence imaging and prolonged median survival of GFP+ myeloma SCID/NOD mice compared to a non-treated control cohort. In summary, our work provides evidence that PKCδ inhibition restores PTEN function in wild type PTEN expressing myeloma cells and is a valid biological target for the treatment of multiple myeloma.
Allogeneic Transplantation after an Alemtuzumab-Containing Myeloablative Conditioning Regimen for CD52 Positive Acute Lymphoblastic Leukemia (ALL).
Authors: Kebriaei Partow , Saliba Rima M. , Ma Carrie , Ippoliti Cindy , Couriel Daniel R. , de Lima Marcos , Giralt Sergio , Qazilbash Muzaffar H. , Gajewski James L. , Ha Chul S. , Champlin Richard E. , Khouri Issa F.
Published: April 2020

Alemtuzumab is an effective agent in the treatment of various B- and T-cell malignancies that express CD52. Patients with advanced or refractory ALL have poor outcome after allogeneic stem cell transplantation (SCT). We investigated whether the addition of alemtuzumab to a standard myeloablative conditioning regimen would have any additional therapeutic effect and improve outcome after SCT in CD52+ ALL.

Patients and Methods: Patients were eligible if their disease expressed CD52 in >20% blasts by flow cytometry. The conditioning regimen consisted of cyclophosphamide (Cy, 60 mg/kg daily x 2 doses) and total body irradiation (TBI, 12 Gy in four daily fractions). Alemtuzumab at 10 mg was intravenously administered daily on days -6 to -2 prior to day of stem cell infusion. Patients received additional graft versus host disease (GVHD) prophylaxis with tacrolimus and methotrexate.

Results: Fifteen patients (9 M/6 F) with median age 33 years (range 22–57) were studied. Twelve patients had B-lineage and 3 had T-lineage disease. Cytogenetic data were available for 12 patients; all had high-risk cytogenetics, including 5 with Ph+ disease. The median number of prior chemotherapy regimens was 3 (range 1–6). At time of study entry, 3 patients were in CR1, 3 were in ≥ CR1, and 9 were in primary or refractory relapse. Five patients received a matched related donor transplant and 10 received an unrelated donor graft. The source of stem cells was bone marrow (n=7) or peripheral blood (n=8). The median CD34+ cell dose infused was 4.67 x 106/kg (range 1.85–6.43). Median time to ANC ≥ 0.5 x 109/L was 15 days (range 11–20). Median time to platelet count ≥ 20 x 109/L was 19 days (range 13–34). The cumulative incidence of non-relapse mortality at 2 years was 13% (95% CI, 4%–43%). The incidence of grade II-IV acute GVHD was 7% (95% CI, 1%–38%); no grade III/IV acute GVHD was observed. The incidence of chronic extensive GVHD was 20%. Overall survival at 2 years was 16% (95% CI, 3%–40%). Failure was related mainly to progression; thirteen of 15 patients had disease progression at a median time of 4 months (range 1–22).

Conclusion: These data suggest that alemtuzumab can be safely added to the standard transplant conditioning regimen for ALL without delayed engraftment or increased regimen-related toxicity. However, any potential direct antileukemia effect in CD52+ ALL patients with advanced disease appears to be negated by in-vivo T-cell depletion of the donor graft. Strategies to restore the graft-versus-leukemia effect in this setting are needed.
Comparison of HLA-Identical Sibling Hematopoietic Stem Cell Transplant (HCT) Versus Chemotherapy as Postremission Therapy in t(8;21) Acute Myeloid Leukemia (AML).
Authors: Pasquini Marcelo C. , Perez Waleska , Zhang Mei-Jie , Schlenk Richard F. , Ganser Arnold
Published: April 2020

The t(8;21) is associated with high complete remission (CR) rates and high survival rates after cytarabine-containing postremission therapy for AML. However, patients with leukocytosis and additional cytogenetic abnormalities, such as loss of sex chromosome (LOS), have worse outcomes. We compared patients ages 16 to 60 years with t(8;21) AML in first CR, comparing 132 patients receiving postremission chemotherapy (chemo) with 118 receiving HLA-identical sibling HCT. The chemo cohort included patients treated with double induction followed by cytarabine-containing regimens in one of eight different German AML Intergroup clinical trials (SHG-Hannover-AML-2/95, SHG-Hannover-AML-1/99, SHG-Dresden-AML-96, AMLHD93, AMLHD98A, AMLCG92, AMLCG99, OSHO-AML-96) between 1993 and 2002. HCT recipients were registered with the CIBMTR from 1990 to 2000. To adjust for potential bias caused by delayed entry in the transplant cohort, left-truncated univariate analysis and Cox multivariate models were used. The median age of patients undergoing chemo and HCT were 42 and 32 years of age, respectively (p<0.001). The table below shows five-year outcomes in months, including relapse rate, treatment related mortality (TRM), adjusted leukemia free survival (LFS) and adjusted overall survival (OS) according to multivariate analysis (Table). WBC > 25.4×109/L was associated with higher relapse risk (RR=2.09, P=0.03), shorter LFS (RR=1.9, P=0.008) and shorter survival (RR=1.91, P=0.012), independent of postremission treatment. Neither year of treatment nor specific chemotherapy protocols were significantly associated with outcomes. HCT and chemotherapy had similar overall survival in patients with LOS and leukocytosis; in those without LOS, survival was significantly higher with chemotherapy. In this cohort of patients with t(8;21) treated in the 1990s, high transplant related mortality offset the antileukemia benefit of HCT, suggesting that HCT be reserved for patients who fail postremission chemotherapy.

TRM (95% CI) Relapse (95% CI) LFS (95% CI) OS (95% CI) LOS No LOS *From multivariate models Chemo 6 (2–11) 29 (21–37) 64 (55–73) 55 (41–69) 84 (74–92) HCT 32 (22–44) 14 (8–21) 55 (45–65) 64 (50–77) 53 (39–67) P-value* < 0.001 0.01 0.24 0.74 0.002
Total Therapy 1 (TT1): Status Report of the First Tandem Autotransplant (TAT) Trial for Multiple Myeloma (MM) - 15 Years Later.
Authors: Barlogie Bart , Tricot Guido , Fassas Athanasios , Desikan Raman , Anaissie Elias , Jagannath Sundar , Crowley John
Published: April 2020

Background: Melphalan-based high-dose therapy (HDT) with autologous peripheral blood stem cell support has become the standard of care for newly diagnosed patients with MM, based on IMF90 and MRC7 trial results of single HDT vs. standard-dose therapy and on IMF94 data demonstrating superior EFS and OS with TAT over single HDT. The aim of this report is to provide a detailed account of the long-term outcome of all 231 patients originally enrolled in TT1 between 8/1990 and 6/1995 of whom 63 remain alive.

Patients and Methods: Outcome data on TT1 have been reported previously (Blood93, 1999; 101, 2003). Here we give final account of patient status with a median follow-up of 12 years (range, 9–15).

Results: Of 231 patients, 195 had received at least 1 and 165 the 2 scheduled transplants; 7 without insurance coverage were given intermediate dose melphalan 70mg/sqm. Of 87 (38%) initially achieving CR (median, 27 mo), 17 (20%) remain in uninterrupted 1st CR. The median EFS duration was 31mo, and 32 (14%) remain continuously event-free. The median OS duration is 68 mo with a 12-yr estimate of almost 30%. Of all 63 survivors, 19% had cytogenetic abnormalities (CA) prior to therapy, and 38% had CA intermittently. Of the 17 patients in continuous CR, 10 never had CA at any time, 4 developed CA subsequently with resolution in 3; of 3 with baseline CA, 2 normalized and 1 persisted. A detailed account of CA type and frequency as well as salvage therapies such as thalidomide, bortezomib and further auto- or allotransplants will be provided.

Conclusion: TT1 was the first tandem autotransplant protocol applied to 231 newly diagnosed patients MM that yielded an unprecedented positive outcome with 12-yr rates of CCR, EFS and OS of 20%, 14%, and 30%, respectively. The Figure displays a 3-phasic relapse pattern: an initial steep slope spanning years 1-3, a more shallow slope between years 4 to 10, merging into a cure-consistent “hockey-stick”.

Event-Free Survival- TT1 Patients Event-Free Survival- TT1 Patients Overall Survival- TT1 Patients Overall Survival- TT1 Patients
Molecular Pathogenesis of Polycythemia Induced in Mice by JAK2 V617F.
Authors: Zaleskas Virginia M. , Krause Daniela S. , Lazarides Katherine , Patel Nihal , Hu Yiguo , Li Shaoguang , Van Etten Richard A.
Published: April 2020

A somatic mutation (V617F) in the JH2 pseudokinase domain of the JAK2 tyrosine kinase is found in the majority of patients with polycythemia vera (PV), and some patients with essential thrombocythemia (ET) and chronic idiopathic myelofibrosis (CIMF). The JAK2 V617F mutant is constitutively active and induces polycythemia in mice after retroviral expression in transplanted bone marrow (James et al., Nature2005; 434:1144). We expressed murine JAK2 wild-type (WT) or a JAK2 V617F mutant in bone marrow (BM) using retroviral transduction and transplantation in two different strains of inbred mice, C57Bl/6 (B6) and Balb/c. In both B6 and Balb/c mice, JAK2 V671F induced non-fatal polycythemia characterized by increased hematocrit and hemoglobin, reticulocytosis, and splenomegaly that were manifest by 3 weeks post-transplantation and were sustained for months. JAK2 V617F also induced significant leukocytosis and neutrophilia that was much more pronounced in Balb/c mice than in B6. Platelet counts were not significantly increased in either strain, despite expression of the mutant JAK2 kinase in megakaryocytes. By contrast, peripheral blood counts in recipients of BM transduced with JAK2 WT were normal and not significantly different from recipients of vector-transduced BM. We also employed BM from donor mice with mutations in erythropoiesis signaling pathways to analyze the pathogenesis of PV. Mice lacking the Src family kinase Lyn or with deficiency of both Stat5a and Stat5b have normal hematopoiesis as adults, but exhibit defects in stress and fetal erythropoiesis. JAK2 V617F efficiently induced polycythemia in BM from mice lacking the Src kinases Lyn, Hck and Fgr. By contrast, deficiency of both Stat5a and Stat5b in the donor BM attenuated the polycythemia and reticulocytosis induced by JAK2 V617F. These results demonstrate that the principal effect of expression of JAK2 V617F in hematopoietic stem/progenitor cells is expansion of the erythroid lineage through a Stat5-dependent, Src kinase-independent pathway. The strain-dependent leukocytosis suggests that genetic modifiers affect the hematopoietic phenotype of this activated JAK2 mutation. The lack of thrombocytosis implies that additional events may be required for JAK2 V617F to cause essential thrombocythemia.
Cyclophosphamide Mobilization Does Not Improve Outcome in Patients Transplanted for Multiple Myeloma.
Authors: Dingli David , Nowakowski Grzegorz S. , Dispenzieri Angela , Lacy Martha Q. , Hayman Suzanne , Litzow Mark R. , Gastineau Dennis A. , Gertz Morie A.
Published: April 2020

Patients with multiple myeloma (MM) who undergo high dose therapy (HDT) followed by autologous stem cell transplantation (ASCT) and achieve a complete response (CR) have a superior overall survival (OS) and time to progression (TTP). Thus achieving a CR is an important goal of therapy with ASCT. Cyclophosphamide has significant activity against MM and is often used in high doses prior to ASCT for mobilization of hematopoietic stem cells. We hypothesized that high dose cyclophosphamide (HDC) may further improve CR rates in patients undergoing ASCT.

Methods: The Mayo Clinic myeloma transplant database was searched for patients without circulating myeloma cells who had stem cell mobilization with hematopoietic growth factor (HGF) alone or HDC followed by HGF. Relevant demographic, clinical and laboratory characteristics were abstracted. The main outcome studied was the impact of HDC on CR rates and time to progression (TTP) to myeloma.

Results: We identified 201 patients without circulating myeloma cells. Of these, 127 were mobilized with HDC and HGF and 74 with HGF alone. The two cohorts were similar with respect to age, gender, isotype, B2M, plasma cell labeling index, cytogenetics, conditioning regimen, disease status at time of transplant with no statistically significant differences between the two cohorts. CR rates were 37.4 and 41.3% (p=0.6115) for patients mobilized with HDC/HGF and HGF respectively. TTP was 19.9 and 17.6 months (p=0.6039) respectively. The median number of collection sessions for patients mobilized with HDC/HGF was 2 (1–10) and those mobilized with HGF was 4 (1–10) (p<0.0001). In a multivariate analysis for TTP, cytogenetics and achieving a CR were the only independent variables (p=0.0012 and p<0.0001).

Conclusion: HDC for autologous hematopoietic stem cell collection reduces the number of collections necessary to support HDT/ASCT. However, HDC does not increase CR rates or improve on TTP for patients undergoing ASCT.
Thalidomide and Dexamethasone Induction Therapy Is Associated with Superior Progression-Free Survival after Autotransplant for Myeloma.
Authors: Vogl Dan T. , Luger Selina , Porter David L. , Chong Elise A. , Schuster Stephen J. , Tsai Donald E. , Perl Alexander , Loren Alison W. , Goldstein Stephen , Nasta Sunita D. , Andreadis Charalambos , Mangan Patricia A. , Hummel Kimberly , Siegel Donald L. , Glatstein Eli , Stadtmauer Edward A.
Published: April 2020

BACKGROUND: High-dose melphalan with autologous stem cell support improves survival when incorporated in the initial treatment of multiple myeloma. Published data show that induction thalidomide and dexamethasone (Thal/Dex) has a higher response rate than dexamethasone alone (Dex) or anthracycline induction (VAD or DVD), but the effect of initial induction therapy on outcomes after autologous transplant remains unclear.

PATIENTS: We reviewed the records of 164 patients who received high-dose melphalan with autologous stem cell support as part of initial therapy for multiple myeloma at the University of Pennsylvania. Median age was 55 years (range 25 – 72). Durie-Salmon stage at diagnosis was II in 27% and III in 70% of patients. Induction regimens included VAD (62%), DVD (12%), Thal/Dex (11%), Dex (5%), and more than one regimen (10%). Post-transplant therapies for consolidation or maintenance included thalidomide (7%), interferon (23%), tandem autologous transplant (4%), non-myeloablative allogeneic transplant (7%), autologous co-stimulated T-cell infusion (14%), or observation until progression (45%). Patients who received Thal/Dex initial therapy were not significantly different than those receiving anthracycline-containing induction regimens (VAD/DVD), except for lower serum creatinine (median 0.9 vs 1.1 mg/dl; p=0.01), with a trend toward lower beta-2 microglobulin (B2M) and correspondingly lower ISS stage.

RESULTS: Median overall follow-up is 29 months (range 7–120). Thal/Dex induction trended towards a higher Very Good Partial Response (VGPR) rate than anthracycline induction (29% vs 14%, p=NS) and a higher overall response rate (76% vs 68%, p=NS). All of the patients who received Thal/Dex as induction therapy are alive, with a median follow-up of 23 months (range 13 – 34), while overall survival in the anthracycline induction group is 85% at 2 years. Progression-free survival at 2 years is 93% for Thal/Dex induction and 58% for VAD/DVD (HR 0.12, p=0.039). The improvement in progression-free survival persists in Cox regression models that include creatinine and either B2M or ISS stage.

CONCLUSION: In myeloma patients who undergo autologous stem cell transplant, thalidomide and dexamethasone induction may result in improved progression-free survival compared with VAD or DVD. Further studies of initial therapies for myeloma should assess long-term outcomes after autologous transplant.

Progression Free Survival, By Initial Treatment Progression Free Survival, By Initial Treatment
Molecular Progenitor Profiling in Human Myeloproliferative Disorders.
Authors: Jamieson Catriona H.M. , Gotlib Jason , Chao Mark , Mariappan M Rajan , LayRaj Marla , Jones Carol , Zehnder James , Durocher Jeffrey , Lilleberg Stan , Coutre Steven , Weissman Irving L.
Published: April 2020

Myeloproliferative disorders (MPD) are clonal hematopoietic disorders characterized by a hypercellular marrow, an overabundance of distinct lineages of terminally differentiated progeny and a propensity to transform to acute myelogenous leukemia (AML). Recent reports revealed that a specific (V617F) mutation in JAK2 resulted in constitutive cytokine signaling and increased sensitivity to cytokines in a large proportion of patients with MPD. However, the stage of hematopoiesis at which this mutation occurs and whether additional mutations contribute to the evolution of MPD into AML has yet to be determined. We performed phenotypic and functional analyses of hematopoeitic stem cells (HSC), common myeloid progenitors (CMP), granulocyte-macrophage progenitors (GMP) and megakaryocyte-erythroid progenitors (MEP) in 63 MPD peripheral blood or bone marrow samples donated by patients with PV (n=15), essential thrombocythemia (ET; n=8), post-polycythemic myeloid metaplasia/myelofibrosis (PPMM/MF; n=5), chronic myelogenous leukemia (CML; n=7), atypical CML/myeloproliferative disease unspecified (aCML/UMPD; n=2), chronic eosinophilic leukemia (CEL; n=1), chronic myelomonocytic leukemia (CMML; n=13) and AML (n=12) in order to identify the stage of hematopoiesis at which mutations arose as well as to provide prognostic information on patients with a propensity to transform to AML. Of the MPD mononuclear cells sequenced, 12 of 15 PV, 2 of 5 ET, 3 of 3 post-polycythemic myeloid metaplasia, and 2 of 2 aCML samples were positive for the JAK2 V617F mutation. With regard to phenotypic changes in progenitor profiles, PV samples had an increase in CMP together with a distinctive IL-3Ra high population that distinguished it from all other MPD. Conversely, aCML, AML and proliferative CMML had a preponderance of GMP. Functional changes in progenitors were assessed using hematopoietic progenitor assays (Figure 1A and B). This methodology demonstrated that the differentiation potential of PV was already skewed toward the erythroid lineage at the HSC level in contrast to CMML, CML, aCML and AML HSC which produced a preponderance of myeloid colonies. In addition, the aberrant erythroid potential of PV HSC could be potently inhibited with a specific JAK2 inhibitor - AG490 suggesting that JAK2 plays a role in enhancing the erythroid differentiation potential of PV at the stem cell level. Finally, other molecular abnormalities were detected at the progenitor level in MPD including changes in GATA-1 and PU.1 expression, bcl-2 overexpression and beta-catenin activation that were associated with progression to AML. Thus, molecular progenitor profiling may provide prognostic information in a variety of MPD and could be a useful adjunct to current diagnostic methods.

NBM versus MPD Colonies NBM versus MPD Colonies Normal BM vs PV Progenitor Colonies Normal BM vs PV Progenitor Colonies
A Screening and Intervention Program Reducing Mortality and Serious Morbidity Associated with Neonatal Alloimmune Thrombocytopenia.
Authors: Kjeldsen-Kragh Jens , Killie Mette K. , Tomter Geir , Golebiowska Elzbieta , Pedersen Helene , Randen Ingrid , Hauge Reidun , Aune Berit , Oian Pal , Dahl Lauritz B. , Pirhonen Jouko , Svenningsen Leif , Wergeland Hakon , Lindeman Rolf , Husby Henrik , Gronn Morten , Skogen Bjorn , Husebekk Anne
Published: April 2020

Background: Neonatal alloimmune thrombocytopenia (NAIT) is most frequently caused by antibodies against the human platelet antigen (HPA) 1a. The objective of the present study was to identify HPA 1a negative women, and to offer them an intervention program aimed to reduce morbidity and mortality of NAIT.

Methods: A total of 100,448 pregnant women were HPA 1 typed. The HPA 1a negative women were screened for anti-HPA 1a, which was quantified when present. Immunized women were referred to a university hospital for clinical follow-up, including ultrasonographic examination of the fetal brain. Caesarean section was performed 2–4 weeks prior to term with platelets from HPA 1bb donors reserved for immediate transfusion if petechiae were present and/or if platelet count was < 35 × 109/L.

Results: Of all women typed 2.1% were HPA 1a negative. Anti-HPA 1a was detected in 210 of 1,990 HPA 1a negative women. A total of 170 pregnancies in 154 HPA 1a negative women were managed according to the intervention program. These women gave birth to 161 HPA 1a positive children of whom 55 had severe thrombocytopenia (<50 × 109/L) including two with ICH. There were no intrauterine deaths. In 13 previously published prospective studies comprising 131,465 women of whom 2,290 were HPA 1a negative, there were 10 cases with severe NAIT-related complications (3 intrauterine deaths and 7 neonates with ICH), which are significantly higher than in our study (p < 0.05).

Conclusions: The screening and intervention program seems to reduce mortality and serious morbidity associated with NAIT.
Immune-Mediated Thrombocytopenia in Patients Treated with Vancomycin.
Authors: von Drygalski Annette , Curtis Brian , Bougie Dan , Ahl Scott , Baker Kelty , Aster Richard H.
Published: April 2020

Numerous drugs are known to cause immune thrombocytopenia (TP) mediated by antibodies (abs) that bind to platelets only when the sensitizing drug is present in soluble form. The widely used antibiotic, vancomycin, has been implicated as a cause of TP only in 8 case reports and little is known about antibodies possibly responsible for this complication. We characterized clinical and serologic aspects of TP occurring in 39 patients during treatment with vancomycin. In this group, TP developed after 1–27 days of treatment (median 6 days) and plt nadirs ranged from 1,000 to 60,000 plts/uL (median 14,000 plts/uL). Bleeding occurred in 14 patients and contributed to a fatal outcome in 3. TP persisted for 1–17 days after discontinuing vancomycin (median 7 days). Platelets eventually returned to baseline in all surviving patients. Serum obtained after the onset of TP was studied for vancomycin-dependent, platelet-reactive abs by flow cytometry and by solid phase ELISA using immobilized plt glycoproteins (GP) as targets.

Vancomycin-dependent antibodies detected in patients and normal subjects IgG only IgM only IgG + IgM No antibody Total Patients with TP 21 (54%) 5 (13%) 13 (33%) (0)%) 39 Normal individuals 58 (21%) 4 (1%) 1 (0%) 210 (77%) 273

Results of flow cytometric studies are summarized above. All patients had IgG and/or IgM abs that reacted with normal plts in the presence, but not in the absence of vancomycin. The IgG mean fluorescence intensity (MFI) signal in the presence of drug was 1.6 to 32.0 times stronger (mean ratio 5.7) than that obtained in the absence of drug. Vancomycin-dependent IgG abs were also identified in 59 of 273 normal individuals but were much weaker than abs detected in patients (p = 0.004). IgM abs (mean ratio 5.7, range 1.6 – 34) were found in 18 of 39 patients (46%). Weaker IgM abs were found in only 5 of 273 normal subjects (1.8%) (p = 0.001). Two patient abs studied in ELISA reacted preferentially with GPIIb/IIIa. Studies to determine the frequency of abs in patients given vancomycin who do not develop TP are in progress.

These findings provide evidence that TP in patients given vancomycin can be caused by drug-dependent abs specific for GPIIb/IIIa that are stimulated by vancomycin exposure. IgG and IgM abs in patients with TP are generally much stronger than drug-dependent, platelet-reactive immunoglobulins found in some normal subjects. The significance of the latter abs is presently unknown. Drug-dependent IgM abs are found almost exclusively in patients with vancomycin-associated TP and may be diagnostic. Patients treated with vancomycin often have life-threatening bacterial sepsis and may have various reasons for developing TP. Serologic testing for drug-dependent, platelet-reactive IgG and IgM abs may provide a means of identifying those in whom vancomycin should be discontinued.