bluuebunny/crossref_metadata_2025 huggingface dataset:
Determination of a Limited Sampling Strategy for IV Busulfan Dose Individualization in Children.
Authors: Sibbald Cathryn , Schecter Tal , Doyle John , Dupuis L. Lee
Published: October 2019

Busulfan doses are individualized in order to achieve an area under the plasma Busulfan concentration vs time curve (AUC) to ensure engraftment while preventing hepatic venous occlusive disease. We currently calculate AUC using 7 plasma Busulfan samples drawn after the first of 16 Busulfan doses given every 6 hours. The objective of this retrospective study was to evaluate the extent of agreement between the AUC calculated using 7 plasma Busulfan concentrations (AUC-7) and each possible limited sampling strategy (LSS) in children undergoing haematopoietic stem cell transplant. 44 children aged 0.3 to 16 years (median: 3.0 years) received IV Busulfan from April 1, 2003 through January 2006 at our institution. Busulfan doses given and subsequent plasma Busulfan concentrations were recorded for each patient. AUC-7 and AUC using all possible LSSs were calculated using non-compartmental and 1-compartmental methods (WinNonLin version 5.0.1). Based on a target AUC of 1300 micromole·min/L, a theoretical adjusted Busulfan dose was calculated using AUC-7 and all LSSs using 2 and 3 plasma Busulfan concentrations. Extent of agreement betweenthe AUC-7 values and the LSS AUC values andthe theoretical adjusted Busulfan dose based on the AUC-7 values and the 2 and 3 point LSS AUC values was assessed by determination of the intraclass correlation coefficient (ICC; parallel, one-way random effect model) and Bland-Altman (BA) analysis.

Agreement was observed between AUC-7 calculated using non-compartmental and 1-compartmental methods and LSSs using 2 and 3 plasma Busulfan concentrations. AUC values calculated using 6 LSSs each consisting of 3 plasma Busulfan concentrations achieved ICC values > 0.96 (p<0.001) and were within the BA limits of agreement. Agreement between the theoretical Busulfan adjusted doses (7-point vs 3-point strategies) was very strong when the Busulfan concentrations obtained at the following time points were used: end of the 2 hour infusion, 3, and 4 hours after completion of the infusion; or 0.25, 3, and 4 hours after completion of the infusion. We conclude that there is excellent agreement between AUC-7 and a LSS for calculation of Busulfan AUC using 3 time points andbetween theoretical adjusted Busulfan doses calculated using AUC-7 and using these strategies.

The LSSs described here must be validated in a prospective study.
Retransplantation with Stem Cells from Mismatched Related Donors after Graft Rejection in Pediatric Patients.
Authors: Lang Peter J. , Greil Johann , Müller Ingo , Bader Peter , Klingebiel Thomas , Heinzelmann Frank , Belka Claus , Kremens Bernhard , Reiter Alfred , Schlegel Paul G. , Handgretinger Rupert
Published: October 2019

Graft failure is a rare but life-threatening complication after transplantation of hematopoietic stem cells. Treatment comprises immunoablative reconditioning regimens and a second stem cell donation from the same or from a different donor as soon as possible to minimize the time of pancytopenia and its sequelae.

We report a cohort of 11 pediatric patients with leukemias (acute lymphatic n=4, acute or chronic myeloic/MDS n=4) and severe aplastic anemia (n=3) who experienced graft rejection after TBI, busulphan or melphalan based myeloablative transplantation from mismatched related donors (MMRD) (n=6) or after cord blood/matched unrelated donor (MUD) transplantation (n=5) between 2000 and 2006. In the latter the original donor was not available a second time. Thus, all patients were re-transplanted with CD34+ positive selected or CD3/CD19 depleted stem cells from a second, haploidentical parental donor (MACS method, Miltenyi Biotec). Median time span from diagnosis of graft rejection to second donation was 16 days. The reconditioning regimens consisted of total lymphoid irradiation or cyclophosphamide, thiotepa (5mg/kg), fludarabine (120 mg/m2) and ATG/OKT3. A median number of 25×106/kg of body weight stem cells with 60.000/kg residual T cells were infused. Mofetilmycophenolat was given as GvHD prophylaxis, if residual T cells exceeded 25 000/kg bw. Sustained engraftment was achieved in all patients (ANC>500/μl: 9 (11–32) days). No GvHD > grade II was observed. T cell recovery was delayed, however no lethal viral infection occurred. Severe organ toxicity was observed in 2 patients (BOOP, hemorrhagic cystits) and moderate mucositis in 11 patients. 8/11 patients are disease free (median follow up 1.5 (0.3–6.6) years; 1 year EFS=73%). Causes of death were: BOOP (n=1), infection (n=1); only one patient with refractory AML relapsed. Thus, transplantation of stem cells from haploidentical donors represents a realistic option to rescue patients with graft failure within a short time span and for whom a second donation of the original donor is not available. The use of a different donor may help to avoid a second rejection.
In Vitro Monitoring of Defibrotide Prophylaxis for Endothelial Complications Following Allogeneic Stem Cell Transplantation.
Authors: Eissner Gunther , Wiesner Julia , Hahn Nancy , Iacobelli Massimo , Haubitz Marion , Andreesen Reinhard , Holler Ernst
Published: October 2019

Defibrotide (DF) is a polydisperse mixture of 90 % single-stranded polydeoxyribonucleotides with anti-thrombotic, pro-fibrinolytic and anti-apoptotic functions. DF is already successfully used in the treatment of hepatic veno-occlusive disease in allogeneic stem cell transplantation (SCT). Our observation that DF can also protect endothelial cells (EC) from conditioning (fludarabine (F-Ara))-mediated apoptosis(1) prompted us to apply it prophylactically to patients (pts) at risk for endothelial complications. Pending on the magnitude of risk, pts received 200–800mg every 6h in 2h-infusions, usually from day (d) −7 until d+21 post SCT.

Circulating EC (CEC) as a marker of conditioning-mediated endothelial toxicity(2) were detected by magnetic bead separation of CD146+ cells from EDTA blood of 50 SCT pts (33 DF, 17 NO DF) and co-staining with Ulex Europaeus antigen lectin 1. CEC maxima until d+100 post SCT were compared between the two groups. DF pts showed significantly lower maxima of CEC than untreated pts (1085 [±1012] in the DF treatment group vs. 2595 [±1910] CEC/mL in non-DF pts, respectively, p=0.0007). Similarly, when CEC maxima were compared in the time period of DF prophylaxis, again, DF pts had less cell counts (562 [±794] vs. 1548 [±1575] CEC/mL in control pts, respectively, p=0.005). Interestingly, this observation also held true for the heavily pre-treated diagnostic subgroup of acute myeloid leukemia (AML) pts (683 [±807] DF vs. 3467 [±2664] non-DF, p=0.007). These preliminary analyses suggest the protective efficacy of DF prophylaxis in the course of SCT. The final proof of principle is to be validated in long-term clinical follow-ups.
Clinical Outcome of a Second Autologous Hematopoietic Stem Cell Transplant (HCT) for Non-Hodgkin (NHL) and Hodgkin Lymphoma (HL) Relapsing after a First Autotransplant.
Authors: Smith Sonali M. , van Besien Koen , Carreras Jeanette , Vose Julie M. , Lazarus Hillard M. , Hari Parameswaran
Published: October 2019

Autologous HCT (autoHCT) salvages many patients (pts) with relapsed lymphomas but few relapsing after an autoHCT are cured. We determined feasibility of stem cell collection, engraftment kinetics, treatment-related mortality (TRM), progression free survival (PFS), and overall survival (OS) for a second autoHCT (HCT2) for lymphoma relapsing after prior HCT (HCT1). We studied 35 pts, 20 with HL and 15 with diffuse or follicular large cell and immunoblastic NHL, receiving a HCT2 for relapse between 1986 and 2003 and reported to the CIBMTR. Median (range) age at HCT2 was 36 yrs (16–61); 61% had a performance score less than 90. HCT2 was performed >1 year after HCT1 in 80%. Median (range) time from diagnosis to HCT1 was 20 mo (4–162 mo), from HCT1 to relapse, 17 mo (3–68 mo), and from relapse to HCT2, 5 mo (1–40 mo). 83% underwent a 2nd stem cell / marrow harvest prior to HCT2. Median time to ANC >0.5 x 109/L was 11d. CBV or BEAM were the conditioning regimens for HCT1 in 80% and for HCT2 in 60%. The best response to HCT2 was complete remission in 22 pts and partial remission in 5; 8 pts had either no response or progressive disease. At a median follow up of 92 mo (32–124 mo) after HCT2, 26 pts (74%) have died with 17 (65%) dying of relapsed lymphoma. Two (6%) patients developed therapy-related MDS. The probability of TRM at day 100 was 12% (95% CI, 3–25%). The 1, 3 and 5 yr probability of PFS were 45% (95% CI, 29–62%), 33% (95% CI, 18–50%) and 30% (95% CI, 15–46%), respectively. The 1, 3 and 5 yr probability of OS were 63% (95% CI, 46–78%), 34% (95% CI, 19–50%) and 31% (95% CI, 17–47%), respectively. There were no differences in outcomes between HL or NHL. Pts relapsing >6mo after HCT1 appeared to have better OS (fig 1 and 2). In summary, HCT2 is feasible in pts with lymphoma after relapsing an HCT1. Stem cells harvested prior to HCT2 resulted in rapid engraftment with a day 100 TRM (12%) lower than that reported for alloHCT in this setting. Relapse is the primary reason for failure, but approximately one-third of pts enjoy long-term disease free survival. HCT2 should be considered for young pts with relapsed HL or NHL post-HCT1 without alternative transplant options.

HCT1 (%) HCT2 (%) Sensitive disease status pre-HCT 26 (79) 24 (75) Stem cell source BM 15 (43) 10 (29) PBSC 13 (37) 21 (60) Both 7 (20) 4 (11) Median days to platelet recovery ≥ 20 x 109 /L 17 (7–376) 20 (1–101) Stem cell harvest between HCT1 and HCT2 29 (83) Different conditioning regimen for HCT2 25 (74) Outcomes TRM @ 1 yr 21 (9–37) PFS @ 5yrs 30 (15–46) OS @ 5 yrs 31 (17–47) Figure 1 Figure 1. Figure 2 Figure 2.
Prior Therapy with Rituximab (R) in Patients (pts) with Diffuse Large B-Cell Lymphoma (DLBCL) Does Not Affect Disease-Free (DFS) or Overall Survival (OS) Following High Dose Therapy (HDT) and Autologous Stem Cell Transplantation (ASCT).
Authors: Thakkar Snehal G. , Sweetenham John William , Rybicki Lisa , Sobecks Ronald , Andresen Steven , Dean Robert M. , Pohlman Brad , Kang Tyler Y. , Kalaycio Matt , Brown Stacey , Bolwell Brian J.
Published: October 2019

The addition of R to first line chemotherapy regimens for DLBCL has resulted in improvements in DFS and OS. HDT and ASCT have been shown to improve outcome for pts with relapsed DLBCL compared with conventional dose salvage regimens. The effectiveness of HDT and ASCT in pts with DLBCL who have received prior therapy including R is unknown. We reviewed 257 consecutive pts with DLBCL treated with ASCT from 1/94–12/02. Of these, 161 (63%) had received R as part of their initial therapy and 65 (25%) had not received prior R. A third group (N = 31, 12%) who had been treated with R as part of salvage therapy prior to ASCT were excluded from further analysis.

Patient characteristics are shown in Table 1. All patients received a preparative regimen of Busulfan, Cyclophosphamide, and Etoposide. Greater than 75% of patients in both groups had evidence of disease at time of transplant. Univariable and multivariable analyses demonstrated no difference between the pts previously treated with R and those not treated with R. After median follow up of 76 months (13–142) no statistical difference in DFS or OS was observed between the two groups. Patients were then adjusted for age, gender, stage, prior chemotherapy/radiation, time from diagnosis to CR, IPI, and disease status and compared again. The matched propensity analysis also showed no significant difference in DFS (p=0.87) and OS (p=0.22) (Figures 1 and 2).

Despite concerns that pts with DLBCL previously treated with regimens containing R may have more resistant disease at relapse, our results suggest that HDT and ASCT is equally effective for these pts compared with those who have not received prior R. A prospective analysis is needed to confirm these results.

Table 1. Patient Characteristics Categories No Rituximab (n=65) Rituximab (n=161) Age-median (range) 48 (19–70) 53 (23–72) Gender (M/F) 42/23 93/68 Stage IV (n) 75% (49) 61% (98) Prior Chemo Regimens-median (range) 2 (1–4) 2 (1–6) Prior Radiation (n) 25% (16) 32% (51) IPI (Low/Low-Intermediate vs High-Intermediate/High) 66% vs 34% 55% vs 45% CD34 collection (x 10^6)-median (range) 8.3 (2.9–39.2) 4.4 (0–52.8) Time to Transplant (mos)-median (range) 14.7 (2.8–274.3) 14.5 (5.1–192.6) Diffuse Large B-cell Lymphoma - Matched Groups Diffuse Large B-cell Lymphoma - Matched Groups Diffuse Large B-cell Lymphoma - Matched Groups Diffuse Large B-cell Lymphoma - Matched Groups
The Influence of PET/Gallium (PET/Gal) Status and High-Dose Rituximab (HDR) in Patients with Aggressive, Large, B-Cell Lymphoma (LBCL) Receiving Autologous Stem Cell Transplants (ASCT).
Authors: Alousi Amin M. , Saliba Rima M. , Okoroji Grace-Julia , Hosing Chitra , Samuels Barry I. , Champlin Richard E. , Khouri Issa F.
Published: October 2019

Background: PET/Gal status has been reported to be an important predictor of outcome in patients with LBCL who receive an ASCT. Newer conditioning regimens which include high-dose rituximab (HDR) have been shown to improve results (Khouri, JCO, 2005). The impact of HDR on the outcome of patients based on PET/Gal status has not been determined.

Methods: A retrospective review of patients with chemo-sensitive, LBCL who received an ASCT on a research protocol at MD Anderson between 1995 and 2005 was performed. Factors that were considered for outcome included: Age, IPI, # of prior chemotherapies, B2-microglobulin, disease status at transplant, HDR and PET/Gal status. In patients who received HDR, it was given with stem cell mobilization and then again on days +1 and +8 following transplant.

Results: A total of 188 patients were identified. Median age was 49 years with 108 (57%) male patients. 147 patients (78%) had de novo LBCL and 41 (22%) had a LBCL of follicular origin (LBCL-F). 83 (39%) patients received HDR. At transplantation, 95 patients (50%) were in PR, 71 (38%) in CRU and 22 (12%) in CR. 142 (76%) patients were PET/Gal negative, 37 (20%) PET/Gal positive and 9 (4%) were unknown. Median follow-up was 47 months. On multivariate analysis, for patients with de novo LBCL, PET/Gal status and HDR were the only predictors for progression and progression free survival (PFS). Patients who were PET/Gal negative and those that received HDR had a hazard ratio (HR) of 0.3 (p<0.001) and 0.5 (p=0.02) for progression, respectively (see the table below for the cumulative incidence (CI) for progression and PFS at 54 months according to HDR and PET/Gal status for de novo LBCL undergoing ASCT). PET/Gal Status and HDR were also found to be predictive for patients with LBCL- F on univariate analysis, however due to the small numbers in this subset; multivariate analysis could not be performed. PFS at 54 months for patients with LBCL-F who were PET/Gal negative was 40% versus 17% in the PET/Gal positive group, (p=0.006). PFS for those LBCL-F patients who received HDR was 81% as compared to 23% for those who did not receive HDR, (p=0.007).

Conclusions: The two most important predictors of outcome following ASCT are PET/Gal status and whether HDR was given with the transplant regimen. The addition of HDR to the transplant regimen decreases the risk for progression irrespective of PET/Gal status; however the improvement is more significant in patients with a negative PET/Gal scan.

C.I. for progression and PFS at 54 months for de novo DLBCL PET/Gal Status HDR CI of Progression (%) Progression Free Survival Positive No 83 17 Positive Yes 54 45 Negative No 35 55 Negative Yes 22 75
S0204: Melphalan (MEL)-Based Tandem Autotransplants (TAT) for Multiple Myeloma (MM) with Thalidomide/Dexamethasone (TD) Induction and Thalidomide/Prednisone (TP) Maintenance: A Phase II Trial of the Southwest Oncology Group.
Authors: Hussein Mohamad A. , Jakubowiak Andrzej J. , Bolejack Vanessa , Zonder Jeff , Crowley John , Barlogie Bart
Published: October 2019

Background: TAT has recently been shown to double the 7-yr event-free (EFS) & overall survival (OS) rates achieved with a single AT (20% & 40%; IFM94). Completion of TAT in most randomized & phase II trials seldom exceeds 70%, due to toxicities encountered with prolonged induction chemotherapy & posed by the 1st AT. TD is effective salvage therapy &, when used up-front, effects high response rates including ~10% CR.

Patients and Methods: To reduce induction toxicities & thus deliver TAT in a timely fashion to the majority of pts, SWOG embarked on a trial of TD induction, modest-dose cyclophosphamide (CTX) for PBSC mobilization, melphalan (MEL)-based TAT & subsequent TP maintenance.

Results: Between July 2002 and December 2005, 147 newly diagnosed patients with MM were enrolled from 28 institutions. Among 138 eligible, analyzable patients, the median age was 56.5yr (range, 23.2–66.0), 83% were white, 62% male. Baseline prognostic features included serum levels of albumin <3.5g/dL in 21%, beta-2-microglobulin (B2M) >5.5mg/L in 21%, creatinine >=2mg/dL in 7%; ISS stage distribution I-48%, II-30%, III-22%. With a median follow-up of 14mo, 64 patients have come off protocol: 15 patients were removed from study due to adverse events, 10 refused further participation, 14 suffered progression or relapse, 1 died, 9 came off for other reasons, and 15 are presently under review. Therapy was well tolerated except for an increased incidence of hyper-coagulable events at the start of the protocol 27% (8/30); following an amendment to decrease the start dose of thalidomide to 50mg, the incidence of hyper-coagulable events decreased to 7% (7/101). Through the induction and PBSC mobilization phases, 4.4% achieved CR & 64.3% achieved Response (SWOG: >=75% M-protein reduction) or partial response (PR, >=50% M-protein reduction) pre-transplant for an overall response rate of 68.7%. 102 eligible patients proceeded to 1st transplant (74%) and 66 (47%) to 2nd transplant, with a median time to 2nd AT of 8mo and 96% of patients receiving 2nd AT within 4mo from 1st AT. Confirmed and unconfirmed CR after the transplant phase was 22%. Two-year OS from 1st transplant registration among 98 patients was 84% and 2-yr OS from TP maintenance among 62 patients was 87%.

Conclusion: Our data show that hyper-coagulable events with the TD regimen could be reduced by decreasing the starting dose of thalidomide from 100mg to 50mg/d. In a multi-institution setting, MEL200-based TAT could be performed safely. Timeliness of the 2nd AT was achieved where 96% of the patients were able to received the procedure within 4 months of the 1st AT. Response rates and quality are promising. Longer follow up should clarify the impact of the improved timeliness of 2nd AT, quality and response rate on PFS and OS.
Unrelated Allogeneic Stem Cell Transplantation with Myeloablative Preparative Regimen for Adult Patients with Acute Lymphoblastic Leukemia in CR: A Survey from the European Group for Blood and Marrow Transplantation (EBMT).
Authors: Basara Nadezda , Labopin Myriam , Ruutu Tapani , Zander Axel , Arnold Renate , Rocha Vanderson
Published: October 2019

Data from the EBMT indicate that approximately 46% of Unrelated Allogeneic Stem Cell Transplantation (UD-SCT) in Europe utilize peripheral blood (PB) and 54% bone marrow (BM) as a graft source for adult patients with ALL since January 1998. However, prospective randomized trials comparing the two stem cell sources are lacking. This study describes the results of 782 adult patients with ALL in remission (422 BM and 360 PB) transplanted in different centers affiliated with the EBMT from 1998 to 2004 with an HLA identical unrelated donor (HLA-A and -B low resolution and HLA-DRB1 allelic typing). Median age was 27 years for BM (range 16–63, male 60%) and 30 years for PB (range16–63, male 62%), respectively. Fifty four (54%) and 64% of patients were transplanted in first complete remission (CR1) in the BM and PB groups, respectively. The frequency of female donor to male recipient was 18% in the BM and 15% in the PB group. Total Body Irradiation (TBI)-based preparative regimens were given in 85% and 88% of patients in the BM and PB group respectively. Graft-versus-Host Disease (GvHD) prophylaxis consisted of cyclosporine A (CsA) (6% and 4%), CsA and methotrexate (77% and 58%) or in vitroT-cell depletion (17% and 38% in BM and PB group, respectively). With the median follow-up of 17 (range 1–92) and 11,3 (range 1–71) months, the incidence of GvHD grade II–IV was 37% in the BM group and 39% in the PB group (p=0.39). Probabilities of LFS, TRM and relapse were calculated using the Kaplan-Meier estimate. LFS was 45+/−3% vs 36+/−3% (p=0.04) transplant related mortality (TRM) was 33+/−2% and 39+/−3(p=0.29 while incidence of relapse was 32+/−3% and 41+/−4%(p=0.06), in the BM and PB groups respectively. Two years leukemia-free survival (LFS) for the patients transplanted in CR1 was 48% (BM) and 42% (PB, p=0.48). However, 2-years LFS for patients transplanted in CR2 or CR3 was significantly higher in the BM compared to the PB group (42% and 26%, p<0.004). The probability of relapse was significantly lower in BM compared to PB (32% vs 54%, p<0.001) without there being a detectable difference in TRM at 2 years (38% vs 43%, p= 0.31).

In conclusion, the results of this retrospective comparative study confirm that UD-SCT with BM and PB as a graft source have similar results for patients in CR1. However, patients transplanted in CR2 or CR3 with a bone marrow graft, have decreased relapse incidence and better LFS, probably reflecting disease and transplant related differences compared to PB transplants such as in vitro T cell depletion more used in those transplants.
Engraftment and Survival Following Hematopoietic Stem Cell Transplantation for Osteopetrosis Using a Reduced Intensity Conditioning Regimen.
Authors: Tolar Jakub , Bonfim Carmem , Grewal Satkiran , Orchard Paul
Published: October 2019

Autosomal recessive osteopetrosis (OP) is a disease characterized by osteoclast dysfunction, leading to multisystem morbidity and death of most affected children. Hematopoietic stem cell transplantation (HSCT) is the treatment of choice for OP, but this patient population is particularly prone to post-transplant complications and death after myeloablative conditioning. To determine the potential of achieving improved overall outcomes in these patients by decreasing pre-transplant mortality, we investigated engraftment and survival following a reduced intensity regimen including busulfan, fludarabine and total lymphoid irradiation. We report outcomes in 11 patients:

Age years Graft and HLA match NC dose (x108) CD34 dose (x106) Follow-up (years) Donor chimerism 1 2.1 URD BM 5/6 3 1.4 0.8 (dead) 100% 2 0.6 UCB 4/6 0.9 0.4 2.5 (dead) Transient partial 3 24 REL PBSC 6/6 12.1 9.2 3.25 (alive) 100% 4 1 URD PBSC 6/6 47 29.6 3 (alive) 100% 5 2.5 UCB 6/6 0.7 0.2 0.2 (dead) No donor engraftment 6 0.9 UCB 5/6 0.8 NK 2.25 (dead) No donor engraftment 7 0.6 UCB 5/6 0.9 0.2 4 (alive) No donor engraftment 8 1 URD PBSC 6/6 15  7.5  24.4 6  3  7 1.9 (alive) Transient partial  No donor engr.  78% donor 9 0.5 UCB 5/6, 4/6 3.5 5.3 0.75 (alive) Transient partial 10 4.4 UCB 4/6 1.1 0.7 0.6 (dead) 100% 11 2 URD BM 6/6 5 2.7 5.2 (alive) 100%

Legend: NC, nucleated cell; URD, unrelated donor; REL, related donor; BM, bone marrow; UCB, umbilical cord blood; PBSC, peripheral blood stem cells; engr., engraftment; NK, not known; HLA matching is reported for 6 antigens. All six patients who received a bone marrow or peripheral stem cell graft engrafted with > 75% donor chimerism. In contrast, all five recipients of unrelated cord blood as a stem cell source for a first graft failed to demonstrate donor hematopoietic chimerism. The day 100 and 6 month mortality was low at 9%. At 1-year after HSCT, 6 of 11 patients (55%) were surviving. Our data suggests that this regimen results in low peri-transplant mortality without compromising engraftment when a marrow or peripheral stem cell graft is used. An umbilical cord blood graft, however, should be used with caution for patients with OP when this or similar reduced intensity regimen is used.
Comparison of Results from a Phase 1/2 Study of Lumiliximab (Anti-CD23) in Combination with FCR for Patients with Relapsed CLL with Published FCR Results.
Authors: Byrd John C. , Castro Januario , O’Brien Susan , Flinn Ian W. , Forero-Torres Andres , Kipps Thomas J. , Heerema Nyla A. , Lin Thomas , Kheoh Thian , Wynnem Dee , Molina Arturo
Published: October 2019

Lumiliximab is a PRIMATIZED® anti-CD23 monoclonal antibody with human IgG1 constant regions and macaque variable regions. Preclinical data demonstrated that lumiliximab enhanced both fludarabine- and rituximab- mediated apoptosis in CLL cells. Thus, a Phase 1/2, open-label, dose-escalation, multicenter study (Study 152–30) evaluating lumiliximab + fludarabine, cyclophosphamide, and rituximab (L + FCR) for relapsed CD23+ B-cell CLL was initiated. Treatment has been completed and follow-up is ongoing. Thirty-one patients (pts) received either 375 mg/m2 (n=3) or 500 mg/m2 (n=28) of lumiliximab in combination with a 28-day cycle of FCR for up to 6 cycles. Median age at study entry was 58 yrs. The majority of pts (74%) were Rai Stage I/II. The most common adverse events included nausea (77%), pyrexia (61%), chills (55%), neutropenia (55%), and fatigue (48%). Twenty pts (65%) experienced a Grade 3 or 4 event. An overall response rate of 71% was demonstrated: 48% complete response (CR), 10% partial response (PR), and 13% unconfirmed PR. Currently, baseline cytogenetic data is available for 21 pts who received 500 mg/m2 of lumiliximab. Although preliminary, 1 of the 4 pts with del(17p13.1) responded; of the 6 pts with del(11q22.3), 5 responded with 4 attaining a CR. A comparison with published data from a study of FCR alone in 177 pts with relapsed or refractory CLL conducted at the M.D. Anderson Cancer Center (MDACC) (Wierda W, O’Brien S, Wen S, et al. J Clin Oncol.2005;23:4070–4078) demonstrated that L + FCR has an acceptable safety profile, does not appear to increase the toxicity (including myelosuppression) of the FCR regimen, and compares favorably with the CR rate of the FCR regimen alone, as displayed in Table 1. Most pt characteristics (age, gender, median number of prior therapies, and WHO performance status) were similar between the 2 studies; however, more pts in the MDACC study were Rai Stage III-IV (50% vs 22%) and were rituximab-naïve (88% vs 40%). Furthermore, there were no obvious differences in hematologic toxicity between the 2 studies and the tolerability of L + FCR was similar to that of FCR, with approximately 50% percent of pts completing 6 cycles of treatment in both studies. These data suggest that L + FCR may produce a higher complete response rate than FCR without additional toxicity. Based upon this data, a multicenter, global, randomized study of L + FCR vs. FCR alone is being initiated.

Table 1. Comparison of Responses in Study 152–30 and the MDACC Study Study 152–30, L + FCR (N=31), n (%) MDACC, FCR (N =177), n (%) 1CR and PR response criteria were the same in both studies. 2PRu is included in the OR. Overall Response 22 (71%) 130 (73%) Complete Response1 15 (48%) 45 (25%) Partial Response1 3 (10%) 85 (48%) Unconfirmed Partial Response2 4 (13%)
Noninvasive Approach to Detection of T-Cell Mediated Graft Rejection through Antibody-Tagged Nanoparticles Using SQUID Detection.
Authors: Jaetao Jason E. , Lovato Debbie M. , Sergatskov Dmitri A. , Bergemann Christian , Bryant Howard C. , Flynn Edward R. , Larson Richard S.
Published: October 2019

Organ transplantation is a life-saving procedure for patients. However, acute T-cell mediated graft rejection occurs in a significant quantity of recipients, which is a potentially life-threatening condition. Current diagnostic criteria for transplant rejection rely on invasive tissue biopsies and relatively non-specific clinical features. We hypothesized that nanoparticles could be developed that specifically bind to T-cells. Furthermore, we postulated that these nanoparticles could be detected non-invasively by a Superconducting Quantum Interference Device (SQUID). Nanoparticles were conjugated through either amino or carboxy termini to either anti-CD2 or anti-CD3 antibodies. All three cell types were found to bind exclusively to specifically targeted antibody-tagged nanoparticles as identified through light microscopy and SQUID detection. Using receptor site densities determined by flow cytometry and the magnetic moment per nanoparticle results, SQUID is capable of determining the number of labeled cells in a sample. Our results indicate that T-cells bind approximately 1×104 nanoparticles per cell. A SQUID sensor array also allows for in vitro localization of discrete sources of labeled T-cells. Using a phantom as a surrogate for organ or soft tissue, we also demonstrate that discrete signals of 105 T- cells can be detected at 10 cm from the SQUID detector. These results demonstrate the potential utility of antibody-tagged nanoparticles as a contrast agent and SQUID as a noninvasive and sensitive detection device in patients who may be undergoing T-cell mediated graft rejection. In addition, the extreme sensitivity of this technique may provide not only a means of early, non-invasive detection of impending T-cell mediated rejection, but also an approach to titrating chemotherapeutics for treating rejection.
Rapid Expansion of Acute Myeloid Leukemia-Reactive Cytotoxic T Cells from CD8+CD62L+ Blood Lymphocytes of HLA-Matched Healthy Donors In Vitro
Authors: Distler Eva , Woelfel Catherine , Pesth Sylvia , Kraus Nina , Wehler Thomas C. , Meyer Ralf G. , Nonn Marion , Huber Christoph , Woelfel Thomas , Herr Wolfgang
Published: October 2019

Allogeneic cytotoxic T-lymphocyte (CTL) therapy in acute myeloid leukemia (AML) is hampered by the poor efficiency of growing leukemia-reactive CTLs from healthy donors in vitro. We established an allogeneic mini-mixed lymphocyte-leukemia culture (MLLC) approach by stimulating comparably small numbers (104/well) of CD8+ T cells isolated from healthy donors against irradiated primary AML blasts in 96-well plates. Prior to use, CD8+ T cells were immunomagnetically separated into a CD62L(high)+ subset enriched for naive precursors and central memory cells as well as a CD62L(low)+/negative subset containing effector memory cells. The culture medium contained IL-7, IL-12, and IL-15. After 2 weeks, IL-12 was replaced by IL-2. Mini-MLLCs were performed in seven different healthy donor-AML pairs that were matched for HLA class I according to high-resolution molecular typing. Following 2 weekly re-stimulations with primary AML blasts, mini-MLLC responder populations were analyzed for reactivity on day 19 of culture using split-well IFN-gamma ELISPOT assays. AML-reactive CD8+ T-cell responders were obtained from all 7 donor-AML pairs. The majority of reactive cultures originated from the CD62L(high)+ subfractions. In 4 out of 7 pairs MLLC responder populations mainly recognized AML blasts, but not Epstein-Barr virus transformed B-lymphoblastoid cell lines of donor and patient origin. The AML-reactive CD8+ T cells were restricted by single HLA class I alleles as determined by blocking experiments using a panel of HLA allele-specific monoclonal antibodies. Representative mini-MLLC responders demonstrated strong cytotoxicity against primary AML blasts in 51Chromium-release assay. Cross-reactivity testing identified an HLA-A*0201-restricted CTL population that recognized AML blasts much stronger than non-malignant monocytes of the same patient. This CTL neither recognized recipient-derived primary fibroblasts nor other hematopoietic cells suggesting a leukemia-associated rather than a minor histocompatibility antigen as the target structure. Several MLLC-derived CTL populations expressed unique T cell receptor Vbeta chains consistent with clonal origin from AML-reactive precursors. Multiple CTL responders reached a cell yield exceeding 108 after 6 to 10 weekly re-stimulations with AML blasts. Our results suggest that in healthy individuals most AML-reactive CD8+ CTLs originate from the CD62L(high)+ peripheral blood subpopulation containing naive precursor and central memory T cells. This mini-MLLC approach allows the rapid expansion of AML-reactive CD8+ CTLs from HLA-matched healthy donors to cell numbers sufficient for antigen identification strategies or adoptive immunotherapy trials.
Vaccination with Host Dendritic Cells Induces Graft-Versus-Leukemia Responses without Severe Graft-Versus-Host Disease in a Preclinical Mouse Model for Allogeneic Stem Cell Transplantation.
Authors: van der Voort Robbert , Ruben Jurjen , Vos Annemieke , Philippens Marielle , de Witte T.M. , Dolstra Harry
Published: October 2019

Allogeneic stem cell transplantation is a potent treatment for patients with leukemia. This therapeutic effectiveness is largely attributed to the graft-versus-leukemia (GVL) response during which alloreactive donor CD8+ T cells eradicate minor histocompatibility antigens (MiHA)-expressing leukemic cells. Unfortunately, recognition of MiHA expressed in healthy tissues, including the liver, skin and gut, often results in morbidity and even mortality due to the development of graft-versus-host disease (GVHD). Antigen presenting cells (APC) play an essential role in the activation of alloreactive T cells and thus in the induction of GVL responses and GVHD. Using several in vivo models it has been suggested that host APC, which present endogenous MiHA to donor CD8+ T cells, are more potent inducers of alloreactive responses than donor APC. Here, we compared the ability of host APC versus donor APC to activate alloreactive T cells in vitro and to induce alloreactions in vivo. For this purpose, we isolated T cells and cultured bone marrow-derived dendritic cells (DC), the most potent APC, from B6.SJL ‘host’ mice and MHC (H-2b)-matched but MiHA-mismatched C3.SW ‘donor’ mice. Following their activation by the TLR4 ligand lipopolysaccharide for no longer than 5 hours, both host and donor DC showed a fully mature phenotype (MHCIhigh MHCIIhigh CD40+ CD80high CD86high), and comparable migratory behavior towards lymph node-specific chemokines. In primary mixed leukocyte reactions host DC were 2–3 times more potent than donor DC in inducing donor CD8+ T cell proliferation. To determine the role of host and donor DC in the development of GVL and GVHD, we established a preclinical mouse model (C3>B6) for allogeneic stem cell transplantation. Repopulation analyses demonstrated that T cells, B cells and myeloid cells from blood and spleen of transplanted mice were for more than 95% of donor origin. Transplanted mice were subsequently vaccinated intravenously with 3 weekly doses of 3 × 105 host or donor DC. DC vaccination, which did not lead to significant GVHD, was followed by an intravenous challenge with 106 GFP-expressing mouse AML (C1498) cells. While sham-vaccinated mice died quickly due to leukemia progression, vaccination with both host and donor DC resulted in diminished leukemia growth. However, only vaccination with host DC, and not donor DC, resulted in a (partial) rescue from challenge. These results suggest that host DC are the most potent inducers of GVL reactions without causing significant GVHD. We believe that these data will be instrumental in designing appropriate DC-based immunotherapies in transplanted leukemia patients.
BCR-ABL Specific Sequences Are Required To Prevent Ph+ Acute Lymphoblastic Leukemia in Syngeneic Mice by DNA Vaccination.
Authors: Köchling Joachim , Prada Javier , Bahrami Masoud , König Merediz Sven A. , Stripecke Renata , Seeger Karl , Henze Günter , Wittig Burghardt , Schmidt Manuel
Published: October 2019

Although 70 – 80 % of children with childhood acute lymphoblastic leukemia (ALL) can be cured by poly-chemo-therapy, the prognosis of patients with Philadelphia chromosome positive (Ph+) ALL remains poor. Therefore, new relapse prevention strategies are needed for patients with Ph+ ALL during remission. We have shown previously, that vaccination of mice with leukemia cell lines modified to express costimulatory molecules and cytokines induce a systemic immunity against the syngeneic BCR-ABLp185 expressing cell line BM185. However, the difficulties to culture and transfect human leukemia cells limit the clinical application of leukemia cell based vaccines. Thus, we evaluated the pre-immunization of mice with DNA based vaccines subsequently challenged by the cell line BM185. Ballistic transfer of minimalistic immunogenically defined gene expression (MIDGE) vectors encoding a BCR-ABLp185 fusion specific peptide or GM-CSF were used for in vivo transfection of murine skin. In addition, we used double stem-loop immunomodulators (dSLIM), containing three CpG-motifs as non-specific immune adjuvant. We provide survival data that shows specific immunization and protection of mice which received the complete vaccine BCR-ABL/GM-CSF/dSLIM. Mean tumor-free survival (p=0.019) and overall survival (p=0.008) were significantly longer compared to non-vaccinated mice and 26.7% survived and never developed leukemia. In contrast, tumor-free and overall survival of mice immunized with either dSLIM or GM-CSF alone or both dSLIM and GM-CSF was not significantly longer compared to non-vaccinated mice. Similarly, substitution of BCR-ABL by irrelevant TEL-AML1 sequences abolished the vaccine efficacy of the BCR-ABL/GM-CSF/dSLIM vaccine. The biometrical data were confirmed by CTL assays which showed that specific lysis was significantly higher after vaccination with BCR-ABL/GM-CSF/dSLIM compared to GM-CSF/dSLIM (p<0.05) and to naïve mice (p<0.005). Previously, we have shown in T-cell depletion studies that CD8+ T cells were the effector cells in the BM185 cell vaccine model and we suggest that CD8+ T cells also play an essential role in the BM185 DNA vaccine model. Together, we provide biometrical and functional data that DNA-based vaccination with BCR-ABLp185 fusion specific sequences, GM-CSF and dSLIM can protect mice against a lethal Ph+ ALL challenge.
Transduction of Macaque Hematopoietic Repopulating Cells with Lenti and Foamy Retroviral Vectors with MGMT Selection Cassettes To Evaluate AIDS Gene Therapy Strategies.
Authors: Trobridge Grant D. , Beard Brian C. , Dickerson David , Gooch Christina , Olsen Philip , Fletcher James , Li Ming-Jie , Hu Shiu-Lok , Rossi John J. , Kiem Hans-Peter
Published: October 2019

AIDS remains a significant health problem worldwide despite the advent of highly active antiretroviral therapy (HAART). Although substantial efforts have been made to develop a vaccine there is still no cure and alternative strategies are needed to treat HIV infection and to control its spread. Our goal is to evaluate lenti and foamy retroviral vectors that inhibit HIV replication by RNAi in a non-human primate SHIV model to develop a hematopoietic stem cell (HSC) gene therapy for AIDS. SHIV is a chimeric virus comprised of an SIV genome that contains the tat, rev and env genes of HIV and infects both T lymphocytes and macrophages. Infection of non-human primates with SHIV results in significant decreases in CD4+ T cells as early as 4 weeks post infection, and is currently the best large animal model available to test gene therapy strategies for AIDS. However inefficient gene delivery to hematopoietic stem cells has limited progress for AIDS gene therapy. We have developed both lenti and foamy retroviral vectors that contain methylguanine-DNA-methyltransferase (MGMT) expression cassettes to allow for in vivo selection, and have transduced macaque (M. nemestrina) long term repopulating cells with both vector systems. Following transplantation we observed rapid engraftment and levels of gene marking in the peripheral blood that should allow us to in vivo select both lenti and foamy-marked hematopoietic repopulating cells. In one animal transplanted with a lentiviral vector we obtained marking at 265 days post-transplant of over 30% in peripheral blood granulocytes and 20% in peripheral blood lymphocytes prior to in vivo selection. Anti-SHIV/HIV transgene cassettes targeting tat and rev that allow for potent inhibition of SHIV and HIV replication in vitro have been incorporated into both lenti and foamy vectors and we have transduced macaque long term repopulating cells with lenti vectors containing an anti-HIV cassette. We are currently developing protocols for efficient in vivo selection and future studies will investigate the ability of macaque hematopoietic repopulating cells transduced with lenti and foamy MGMT anti-HIV vectors to inhibit SHIV infection ex vivo and in vivo.
Current Practice of Testing for Hereditary Thrombophilia in the Netherlands.
Authors: Coppens Michiel , van Mourik Jan A. , Eckmann Carel M. , Middeldorp Saskia
Published: October 2019

Inherited thrombophilia is known to increase the risk for venous thromboembolism (VTE). Furthermore, an association between recurrent pregnancy loss and hypertensive pregnancy complications (including preeclampsia and HELLP syndrome) appears present. A relationship between thrombophilia and arterial cardiovascular disease could not be demonstrated in most studies. Since thrombophilia is prevalent in patients with VTE, testing for these abnormalities often reveals positive test results which may lead to widespread testing. This is also the case in patients with various other conditions. However, there is little convincing evidence about effectiveness of testing due to the uncertainty with respect to therapeutic consequences of a positive thrombophilia test results.

To assess the current practice of thrombophilia testing in The Netherlands and to get an impression of the therapeutic implications of testing for patients, simple questionnaires were sent out to physicians that ordered tests for protein S, C, or antithrombin activity, factor V Leiden (or APC resistance) or the prothrombin 20210A mutation in 1998 consecutive individuals who were investigated between November 2003 and March 2004. The tests were performed in a laboratory that serves as a diagnostic facility for mainly non-academic hospitals and general practitioners throughout the Netherlands. Of a total of 1265 returned questionnaires, 1130 were suitable for analysis (response rate 63%). Of the tested individuals, 64% were female (median age 38 years, inter-quartile-range [IQR] 30–50) and 35% were male (median age 51, IQR 41–59). Tests were ordered by internists (37%), gynaecologists (20%), neurologists (15%) and general practitioners (13%). Only 42% of the tested individuals had experienced VTE, 23% arterial cardiovascular disease, and 17% had had pregnancy complications. A known carrier or VTE in the family was the reason for testing in 180 asymptomatic individuals (16%). Testing had had no therapeutic consequences in 869 tests (77%). In 32% of these patients, physicians stated that had the test revealed a thrombophilic defect, this would not have altered management of the patient.

This study shows that testing for thrombophilia occurs very often in patients with various conditions. In the majority of cases, the results do not change therapeutic management of tested patients. Widespread thrombophilia testing is costly and may cause unnecessary concern in carriers. This study underscores the need to acquire high level evidence about its effectiveness that should include clinical outcomes as well as quality of life and costs.
Discrimination of Health States in Follicular Lymphoma with Utilities Derived from the EuroQOL EQ5D Instrument.
Authors: Friedlich Jessica D. , Cheung Matthew C. , Imrie Kevin R. , Hales Brigette , Mittmann Nicole , Buckstein Rena
Published: October 2019

Introduction: Health utilities (HU) elicited directly from patients have immediate application in facilitating medical decision-making and cost-effectiveness determinations. Collection of HU using generic health status scales enable comparisons across diseases, but may not be sensitive to variations in health states within a particular disease. The EuroQOL EQ5D is a generic scale that has never been used to generate utilities in a broad spectrum of follicular/indolent lymphoma patients and has not been validated in this context.

Methods: A consecutive, cross-sectional cohort of patients attending an outpatient malignant hematology clinic at a major cancer centre (Toronto, Canada) represented the eligible study population. Patients with a diagnosis of FL or other indolent NHL who consented to the study were asked to complete demographic and disease specific questionnaires in addition to the EuroQOL EQ-5D and Functional Assessment of Cancer Therapy (FACT)-Lymphoma quality of life assessment tools.

Results: Eighty-four patients completed the survey study (>95% response rate). Mean age was 58.7 (+/− 13.8 SD) and 55% were male. Diagnoses included FL (55%), CLL (25%), and other indolent NHL (20%). The majority of patients presented in advanced stage (stage III–IV; 65%) and had received some therapy to date, although 29% were still being observed at the time of survey administration. The mean utility score for the population was 0.84 (+/− 0.24; range 0–1). We evaluated the construct that patients receiving active treatment and those who were not in remission would have lower utility scores. Indeed, utilities were higher in patients being observed (0.91 +/− 0.16) compared to those in first remission (0.84 +/− 0.25), subsequent remissions (0.81 +/− 0.20), or those who were receiving active chemotherapy (0.75 +/− 0.27; p=0.049). Patients who were being followed in ongoing remission also trended to higher health status values (mean 0.88 +/− 0.21) compared to those who were not in remission (0.80 +/− 0.22; p=0.15). Utilities elicited from the EQ5D showed a moderate correlation with a criterion measure of quality of life, the FACT-Lymphoma scale (Spearman correlation coefficient 0.54, p<0.0001).

Conclusions: Utilities from the EQ5D are able to discriminate various health states in patients with follicular and other indolent lymphomas and the scale demonstrates construct and criterion validity in this population. HU scores are particularly sensitive to changes in patient remission and treatment status.