bluuebunny/crossref_metadata_2025 huggingface dataset:
Treatment of Red Cell Hypoplasia Following Fully Ablative Matched Related Allogeneic Transplant with Stem Cell Boost.
Authors: Essell James , Tierney Catherine , Alliston Mary , Broun Edward R.
Published: October 2019

Abstract 4530

We present the case of a 34 year old African American male with T-cell non-Hodgkin's Lymphoma who received a matched related allogeneic transplant using a preparative regimen of cyclophosphamide and TBI from his brother on 11/4/09. The patient's blood type was O+ and the donor's blood type was B+. The cell dose was 10.3 × 106 CD34/kg. His post transplant course was generally uncomplicated. Although he recovered his ANC on D+18 and he was platelet transfusion independent by D+28, he never became red cell transfusion independent. A bone marrow biopsy on day 33 showed no evidence of disease with minimal erythroid recovery. His engraftment studies were all 100% donor cells. His reticulocyte counts are detailed in the table below. On day 126 he had a positive qualitative PCR for parvovirus. He received IVIG (400 mg/kg) for 5 consecutive days beginning 3/15/10. Weekly surveillance for CMV by PCR remained non-detectable.

Repeat bone marrow biopsies on day 63 and 88 continued to show neutrophil engraftment, hypoplastic megakaryocytes and aplasia of red cells. His immune suppression was discontinued on day 99. A fourth bone marrow biopsy on day 155 again showed erythroid hypoplasia with neutrophil and megakaryocyte hypoplasia.

He received a second infusion of PBSC without a conditioning regimen. He received 2.5 × 106 G-CSF mobilized HPC-A from the original donor on day 205 post transplant. Tacrolimus was reinitiated on day 203. As noted in the table below, his reticulocyte count normalized three weeks post infusion. His last RBC transfusion was given two days prior to the stem cell infusion and he remains transfusion independent today. He continues on tapering doses of tacrolimus and has not experienced any graft versus disease.DateT+WBCHgbPLTANCreticParvo PCR12/7/09336.68.8632.412/9/09356.17.8692.50.68%negative2/25/101131.98.8691.10.10%3/10/101262.18.50.4positive3/25/101423.59.1732.20.10%negative4/1/101492.48.0491.2negative5/25/102032.77.0871.50.10%6/18/10227/233.18.31131.96.10%6/25/10234/303.68.41172.25.20%

Disclosures:

No relevant conflicts of interest to declare.
Incidence and Outcome of Auto/Alloimmune Hepatitis with Hepatic Graft-Versus-Host Disease After Hematopoietic Stem Cell Transplantation.
Authors: Koldehoff Michael , Elmaagacli Ahmet H , Klein Reinhild , Beelen Dietrich
Published: October 2019

Abstract 4534

Auto/alloimmune hepatitis (AIH) is an inflammatory liver disease characterized histological by a dense mononuclear cell infiltrate in the portal tract and serological by the presence of non-organ and liver-specific antibodies, high transaminases and increased levels of IgG. The relation between allogeneic hematopoietic stem cell transplantation (HSCT) and auto/alloimmune disease is complex. To examine this association, we retrospectively studied 1,636 allogeneic patients (median age 43, range 18–73 years) between May 1996 and December 2008. Among these patients, 311 (19%) developed hepatic graft-versus-host disease (GvHD) (162 pts had a hepatic GvHD of grade > II). We followed 25 patients (11 male, 14 female) in whom GvHD of the liver presented with marked elevation of serum aminotransferases, clinically resembling acute hepatitis and auto/antibodies characteristics for AIH. The median age at transplant was 35 (range, 18–54) years. Onset of liver dysfunction was at 286 days (range, 55–2766) after HSCT. Median peak serum was 312 (range 105–1750) U/L for alanine aminotransferase, 629 (133-2410) U/L for gamma-glutamyl transferase and 1.74 (0.5-23.4) mg/dl for bilirubin. The autoantibody profiles of AIH were 60% for anti-nuclear antibody, 44% for antibodies to liver-kidney microsomes, 24% for antibodies to smooth-muscle antigens, 28% for anti-mitochondrial antibody, 16% for antibodies to actin, 8% for antibodies to nucleoli, and 4% for other autoantibodies. AIH had a higher prevalence in younger and in female patients. AIH occurred in 92% in patients, who were transplanted with G-CSF mobilized and peripherally collected stem cells (PSC), but in only 8% in patients with bone marrow (BM) source (p<0.02), comparing all transplanted patients (1326 PSC, 310 BM). Stem cell grafts from matched sibling donor or matched unrelated donor were similar in the two groups. Acute GvHD of grade> II occurred more frequently in the groups with AIH (15/25 vs. 649/1636, p<0.002), and chronic GvHD (11 limited, 14 extensive) was ascertained in all AIH patients vs. 49.8% in all transplanted patients (p<0.0001). Three patients with AIH died from pulmonary bleeding, chronic GvHD, and relapse, whereas 22 patients with AIH are still alive (88%) at a median survival time of 2570 days. In conclusion, our evaluation confirms a strong association between G-CSF mobilized PSC, chronic GvHD and the development of AIH.

Disclosures:

No relevant conflicts of interest to declare.
Etanercept for Steroid-Refractory Acute Graft-Versus-Host Disease After Allogeneic Hematopoietic Stem Cell Transplantation.
Authors: Park Joon Seong , Jeong Seong Hyun
Published: October 2019

Abstract 4548

Background:

Treatment strategy for steroid-refractory acute graft versus host disease (aGvHD) after allogeneic hematopoietic stem cell transplantation (allo-HSCT) is to be standardized. We report our clinical experience of Etanercept, recombinant human soluble tumor necrosis factor receptor fusion protein, on steroid-refractory aGvHD, retrospectively.

Method:

A total of 18 patients who received allo-HSCT and presented with steroid-refractory aGvHD in Ajou University Hospital were studied retrospectively. Twenty five miligram of Etanercept was given subcutaneously twice weekly for 4 weeks. Clinical responses were checked with regard to the severity of aGvHD.

Results:

Median age was 43.5 years. Patients with AML, myeloma, ALL, aplastic anemia, myelodysplastic syndrome and idiopathic myelofibrosis were studied. The engraftment kinetics was adequate and no one failed to engraft. Before Etanercept, grade 4, grade 3, grade 2 and grade 1 of aGvHD occurred in 7, 6, 5, and zero patients, respectively however the number of patients were changed to 4, 5, 5, and 4 after Etanercept, respectively (p = .005). Eighty percent of grade II and 57% of grade IV patients showed partial response, so did in 14% of grade III patients. Skin and gut aGvHD was well controlled with Etanercept, whereas hepatic GvHD was not. Three patients died of severe infection. There was no factor affecting clinical outcome of Etanercept. All the non-responders died but 56.6% of the responders survived (p = 0.003).

Conclusion:

Etanercept can be one of the effective anti-aGvHD drugs for steroid-refractory cases after allo-HSCT considering tolerable side effects and tolerable cost.

Disclosures:

No relevant conflicts of interest to declare.
Allogeneic Stem Cell Transplantation (allo-SCT) for Isolated and Leukemic Myeloid Sarcoma (GS): a Survey on Behalf of the Acute Leukemia Working Party (ALWP) of EBMT.
Authors: Chevallier Patrice , Labopin Myriam , Cornelissen Jan J. , Socié Gérard , Ljungman Per T. , Lioure Bruno , Tilly Herve , Gratwohl Alois , Milpied Noel , Yakoub-Agha Ibrahim , Volin Liisa , Vernant Jean-Paul , Bay Jacques-Olivier , Michallet Mauricette , Buzyn Agnès , Samey Benedicte , Mohty Mohamad , Rocha Vanderson
Published: October 2019

Abstract 4558

Myeloid Sarcoma (MS) is a rare malignant disorder usually presenting as an extramedullary myeloid cell tumor proliferation. MS can be observed in 3 to 7% of AML cases (called “leukemic” MS, LMS hereinafter). MS prognosis is rather poor with overall survival (OS) not exceeding 2 years. We have previously shown, that allo-SCT following an AML-like chemotherapy is likely the best available therapeutic option for patients with LMS (J Clin Oncol 2008). However, it is still unclear whether allo-SCT is a valid therapeutic option for patients with isolated MS (IMS). The aim of this analysis was to assess the role of allo-SCT in patients with IMS as compared to patients with LMS.

We retrospectively analysed the outcome of 99 MS patients with a median age of 40 years (range: 18–70), including 30 cases of IMS and 69 cases of LMS, reported to the EBMT registry between January 1991 and June 2009. The majority of patients were in complete remission (CR) at time of transplant (IMS: first CR n=14, second CR or beyond n=7 vs. LMS: first CR n=38, second CR or beyond n=21, P=0.20). In this series, patients received either a standard (IMS, n=24 vs. LMS, n=55, P=NS) or a reduced-intensity conditioning regimen (IMS, n=6 vs. LMS, n=14, P=NS) prior to allo-SCT from a matched-related (IMS n=21 vs. LMS, n=48, P=NS) or unrelated donor (IMS, n=9 vs. LMS, n=21, P=NS).

After allo-SCT, engraftment was observed in all patients. The incidences of grade 2–4 and grade 3–4 acute GVHD were 32% and 9%, respectively. The incidence of chronic GVHD at 2 years was 45%. With a median follow-up of 48 (range: 6–213) months, the 5-years OS, and leukaemia-free survival (LFS), and the cumulative incidences of relapse (RI), and non-relapse mortality (NRM) were 48%, 36%, 40% and 19%, respectively. When comparing the two sub-groups (IMS vs. LMS), there were no significant differences in term of outcomes: neutrophils recovery (15 vs 18.5 days), grade 2–4 acute GVHD (27% vs 35%), chronic GVHD (54% vs 41% at 2 years), 5-year OS (33% vs. 48%), 5-year LFS (30% vs. 38%), 5-year RI (45% vs. 38%) and 5-year NRM (19% vs. 17%).

In all, we conclude that allo-SCT is an effective treatment for patients with MS. The current data suggest that patients with isolated or leukemic MS have similar outcome after allo-SCT. Therefore, allo-SCT is likely to be considered as the optimal therapy for both isolated and leukemic MS.

Disclosures:

Tilly: Amgen: Honoraria.
Haploidentical Stem Cell Transplantation for Children with High-Risk Leukemia In Chile: Report of the First 15 Cases.
Authors: Palma Julia I , Salas Lucia , Carrion Flavio , Sotomayor Cristián , Catalán Paula , Handgretinger Rupert , Rivera Gaston
Published: October 2019

Abstract 4581

The Chilean population is ethnically diverse, and more than 50% of the children referred for hematopoietic stem cell transplantation lack a suitable donor. To expand the donor pool we assessed the feasibility, tolerance, and efficacy of using a parental haploidentical (HI) donor and a reduced-intensity conditioning regimen for patients with high-risk leukemia; this study was preceded by 2 years of technology transfer from St. Jude Children's Research Hospital. Between March 2006 and November 2009 fifteen patients (median age, 9.6 years) received T cell-depleted grafts at Calvo Mackenna Hospital, from peripheral stem cells mobilized with G-CSF from parental donors. N° aphaeresis/patient = one; 6/15 products required a second depletion, final Log of depletion= 3, 11 (5, 05-1, 64). Median cell doses were CD34+: 9.5 × 106 cells/kg (range, 2.13 – 20.0), CD3+: 1.0 ×105cells/kg (0.11 – 1.59), and CD56+: 67, 9 × 106cells/kg (7, 6–131, 8). 14/15 patients engrafted one1ry primary engraftment failure and in 2 cases a 2ry engraftment failure (CMV and Toxoplasmosis treatment). Eight remain alive and clinically well at a median follow up of 12.4 months post-transplant (7.2 – 52.2). Four patients died after bone marrow relapse, while only one died of transplant-related causes. Virus reactivation was the main post-transplant complication: 9/15 had positive CMV PCR but none had CMV disease. One patient developed acute GvHD > grade II and one had chronic GvHD. In this setting, HI transplantation offers a rational option for children who lack suitable stem cell donors. This information is especially relevant for populations that are poorly represented in international donor registries. On the other hand HISCT with RIC with ATG and TNI permits a good OS and EFS in this especially high risk population low TRM. This approach is associated with low incidence of GvHD and high viral reactivation incidence but no lethal infection even without CD3+ lymphocyte recovery due probably to pre-emptive treatment and fast NK cell recovery.

Disclosures:

No relevant conflicts of interest to declare.
Faisability and Results of Autologous Stem Cell Transplantation In Lymphoma Patients Over 65 Years Old.
Authors: Tempescul Adrian , Ianotto Jean-Christophe , Eveillard Jean-Richard , Guillerm Gaelle , Bijou Fontanet Delices , Berthou Christian
Published: October 2019

Abstract 4593

Introduction:

The incidence of lymphoma is increasing in the western population. Autologous stem cell transplantation (ASCT) is the standard consolidation procedure in patients with lymphoma expressing bad features at the time of diagnosis or in patients relapsing after a first line of chemotherapy (or radiotherapy). It has already been proven that ASCT improves the overall survival and the disease free survival in younger patients. No data are available for the feasibility and the results of ABSCT in elderly patients (OMS defines elderly as age superior to 65 years).

Purpose:

We performed a retrospective study in our centre, comparing the feasibility and the results of ABSCT in elderly patients with lymphoma compare to patients younger than 65 years old.

Patients and Methods:

We identified 147 patients who underwent ASCT transplantation in Brest Transplantation Centre. Ninety-four patients were younger than 65 (mean51.44years) and 53 patients were older (mean 67.86 years).

Results:

Transplantation related mortality (TRM) (up to 100 days post ASCT) was similar for the two populations. There was no statistically significant difference between the two populations regarding the number of units of RBC and platelets transfused, the number of CD 34 reinjected and infectious complications. There was a statistically significant difference between the two populations regarding the duration of aplasia: 11.21 days in younger patients and 11.89 days in elderly population.

There was no statistically significant difference between the two populations regarding the overall survival (OS) and the disease free survival (DFS).

Conclusion:

Our retrospective, monocentric, comparative study showed that ACST could be performed in selected elderly patients (over 65 years old) with no significant difference regarding TRM, DFS and OS but a little bit longer period of aplasia: 11.21 days for young patients and 11.89 in elderly (p-0.0005).

Disclosures:

No relevant conflicts of interest to declare.
Nicotinamide Promotes Apoptosis In Chronic Lymphocytic Leukemia through Activation of the p53/Mir-34a/SIRT1 Tumor Suppressor Network
Authors: Audrito Valentina , Vaisitti Tiziana , Serra Sara , Rossi Davide , Gottardi Daniela , D’Arena Giovanni , Gaidano Gianluca , Malavasi Fabio , Deaglio Silvia
Published: October 2019

Abstract 4627

Nicotinamide (Nam), is the main precursor of nicotinamide adenine dinucleotide (NAD+). It regulates intracellular levels of NAD+ and consequently activities of four classes of NAD+-consuming enzymes, including NADases, mono-ADP-ribosyl transferases (ARTs), poly-ADP-ribose polymerases (PARPs) and sirtuins.

Pharmacological doses of Nam inhibit the physiological activation and proliferation of mouse B lymphocytes, suggesting that this agent might affect also human B cell homeostasis. We approaches this issue by comparing the effects of Nam on normal vs. leukemic B lymphocytes. Chronic lymphocytic leukemia (CLL) was selected as disease model, for testing in vitro the therapeutic potential of Nam, due its intrinsic resistance to apoptosis, mediated by an imbalance in the mechanisms regulating cell death, mainly regulated through the activities of NAD+-dependent enzymes.

This study shows that pharmacological doses of Nam (5-10 mM) significantly inhibit proliferation and induce apoptosis of CLL cells. At earlier time points, Nam markedly reduces phosphorylation of multiple intracellular substrates, including ERK1/2. Normal B lymphocytes, used as control, were significantly less sensitive to the action of Nam. We hypothesized that these effects could be explained at least in part as a consequence of the inhibitory effects of Nam on NAD+-consuming enzymes. Attention was focused on SIRT1, a deacetylase that plays a critical role in cancer and that acts as a longevity factor. The results demonstrate that Nam exposure inhibits the activity, and also the expression of SIRT1. This effect is apparent only in leukemic cells, where SIRT1 protein levels are significantly higher than in normal B lymphocytes, obtained from spleen or tonsils, markedly less sensitive to Nam effects. The functional block of SIRT1 induced by Nam is followed by activation of p53, transcription of miR-34a and translational repression of SIRT1 mRNA (p53/miR-34a/SIRT1 functional loop). The endpoint is the activation of apoptosis. The same loop is the target of conventional DNA-damaging drugs, such as etoposide. Thus, addition of Nam to conventional DNA-damaging chemotherapeutics agents, leads to an inhibition of SIRT1 through two independent and synergic pathways, resulting in additive effects on apoptosis.

In conclusion this work suggests that Nam represents a potentially useful non-chemotherapeutic agent, characterized by a known and established safety profile, to be associated to conventional cytotoxic drugs in the treatment of selected forms of CLL.

Disclosures:

No relevant conflicts of interest to declare.
DNA Methylation Profiling of Childhood Acute Lymphoblastic Leukaemia Using Illumina Infinium DNA Methylation27 Bead Arrays Identifies a Distinct DNA Methylation Signature Associated with Leukaemogenesis
Authors: Wong Nicholas C. , Chatterton Zac , Bell Katrina , Kowalcyk Adam , Bedo Justin , Wang Qiao , Haviv Izhak , Algar Elizabeth , Ashley David , Craig Jeff , Saffery Richard
Published: October 2019

Abstract 4650

Acute Lymphoblastic Leukaemia (ALL) is the most common form of cancer in children. Although up to 80% of cases can be characterised by either abnormal chromosome number (hyper- or hypo-diploidy) or a specific chromosome translocation, a significant proportion of cases do no exhibit any major chromosome abnormality. Indeed, no common gene mutation has been found to be associated with childhood leukaemia. This suggests that epigenetic modifications, in particular DNA methylation, may also play a significant role in ALL pathogenesis. Understanding the specific epigenetic changes associated with this disease is therefore of paramount importance for predicting onset and disease outcome and understanding disease aetiology.

From our cohort of over 450 cases of childhood leukaemia we analysed 12 cases of childhood ALL that carried the TEL/AML1 (RUNX1/ETV6) chromosome translocation using Illumina Infinium Human Methylation27K bead chip arrays. These interrogate 27,578 CpG methylation sites across the human genome covering 14,495 RefSeq gene promoters. We analysed matching leukaemia and remission bone marrow with the aim of identifying DNA methylation signatures associated with this leukaemia subtype.

We used a number of computational methods to determine the DNA methylation signatures associated with childhood ALL including LIMMA, Centroid Analysis and Support Vector Machine Modelling. This identified 16 probes sufficient to define a leukaemia sample from a remission sample based on methylation level.

We are currently validating our results using high throughput SEQUENOM and performing gene pathway and network analyses to look for commonly affected genes associated with leukaemia. These methylation changes we have identified may help refine the diagnosis of childhood ALL and identify cellular pathways subject to epigenetic disruption in ALL.

Disclosures:

No relevant conflicts of interest to declare.
Molecular, Epigenetic, and Phenotypic Repolarization of T Lymphocytes From Chronic Lymphocytic Leukemia Patients Using 5-Aza-2′-Deoxycytidine
Authors: Dubovsky Jason A , Powers John , Gao Yang , Mariusso Luis F , Sotomayor Eduardo M. , Pinilla-Ibarz Javier
Published: October 2019

Abstract 4651

The improper polarization of helper and cytotoxic T lymphocytes is a trademark immunosuppressive strategy employed by chronic lymphocytic leukemia (CLL). Mounting data implicates chromatin regulation, namely promoter methylation, in the plasticity of naïve human T cells. Very recent in-vitro evidence indicates that this plasticity may be phenotypically replicated by using methylation inhibitors which are approved for clinical use in certain types of cancer, however the longevity and therapeutic potential of repolarized cells remains to be elucidated. These results beg the question: can the ineffective polarization of T lymphocytes in the context of CLL be effectively modulated using methylation inhibitors in a sustainable therapeutic fashion? To answer this question our laboratory has focused on repolarizing helper and cytotoxic T lymphocytes using 5-aza-2′-deoxycytidine (5A2) tracking changes in well characterized molecular and epigenetic signaling pathways involved in effective polarization. Moreover, we sought to investigate the consequences of methylation inhibitor treatment on lymphocyte survival, activation intensity, and naïve cell polarization. Our studies relied upon intracellular staining, methylation specific PCR, western blot, and phosflow anlaysis. The data indicates that 5A2 treatment can repolarize Th2 cells to effectively secrete interferon gamma, signal via T-bet, and achieve demethylation of critical Th1 specific promoters. We also show that this repolarization can be maintained. Moreover, we demonstrate that 5A2 can force Th1 polarization of naïve T cells despite a strong IL-4 stimuli and a lack of IL-12. Finally, we have identified a cytotoxic threshold for 5A2 treatment which is above the concentration necessary to achieve effective and sustained molecular and epigenetic repolarization. All in all our data seeks to define a modality in which improper or ineffective T cell polarization can be altered ex post facto and continued immunotherapeutic intervention may benefit from the naïve polarization of anti-cancer responses.

Disclosures:

No relevant conflicts of interest to declare.
Functional Characterization of a Recombinant FVIIa Drug Candidate
Authors: Turecek Peter L , Varadi Katalin , Vejda Susanne , Boehm Ernst , Rottensteiner Hanspeter , Schwarz Hans Peter , Mitterer Artur , Mundt Wolfgang , Ehrlich Hartmut J. , Scheiflinger Friedrich
Published: October 2019

Abstract 4653

Human coagulation factor VII (FVII) is a vitamin-K-dependent protein with a molecular weight of 50 kDa. Activation of FVII occurs by cleavage of the arginine 152 – isoleucine 153 peptide bond resulting in two disulfide-linked peptide chains. The therapeutic utility of rFVIIa is based on its capacity to trigger hemostasis independently from factor VIII and factor IX and thus even in the presence of factor VIII or factor IX inhibitors.

Baxter has developed a recombinant FVIIa (rFVIIa) that is synthesized by a genetically engineered Chinese hamster ovary (CHO) cell line. No materials of human or animal origin are employed in the manufacture, purification, or formulation of the final product, thus reducing the risk of transmission of adventitious agents. The growth medium is a chemically defined medium, and the downstream process does not use monoclonal antibodies for the purification of rFVIIa.

The rFVIIa drug candidate was functionally characterized in vitro and its features were compared with those of a commercially available rFVIIa. The overall hemostatic potency of rFVIIa was assessed by its FVIII bypassing activity in a human FVIII-deficient plasma with high-titer inhibitor by measuring the kinetics of thrombin generation and fibrin formation. The thrombin-generating capacity of the rFVIIa drug candidate was similar to that of commercial rFVIIa. The time and rate of fibrin formation was measured by thromboelastography, where a dose-dependent normalization of the impaired clotting times and fibrin formation was observed. A similar FXa-generating potency was found for rFVIIa and commercial rFVIIa when measured on the surface of TF-expressing fibroblasts, suggesting a full capability to bind to TF-bearing cells and trigger hemostasis on their surfaces. rFVIIa could be inactivated by anti-thrombin III-heparin in solution with relipidated TF with no relevant difference to the comparator product. TF pathway inhibitor effectively inhibited FXa generation in a cell-based activity assay, with a similar IC50 for rFVIIa and the comparator.

In summary, the functional characteristics of the rFVIIa drug candidate were very similar to those of commercially available rFVIIa.

Disclosures:

Turecek: Baxter Innovations GmbH: Employment. Varadi:Baxter Innovations GmbH: Employment. Vejda:Baxter Innovations GmbH: Employment. Boehm:Baxter Innovations GmbH: Employment. Rottensteiner:Baxter Innovations GmbH: Employment. Schwarz:Baxter Innovations GmbH: Employment. Reiter:Baxter Innovations GmbH: Employment. Mitterer:Baxter Innovations GmbH: Employment. Mundt:Baxter Innovations GmbH: Employment. Ehrlich:Baxter Innovations GmbH: Employment. Scheiflinger:Baxter Innovations GmbH: Employment.
A Case of Clopidogrel Induced TTP Recurring After Four Years
Authors: Methuku Nanda K. , Chandra Abhinav B. , Belur Anuradha , Dabrowski Lech
Published: October 2019

Abstract 4678

Case description -

A 61 year old woman was started on clopidogrel after having PTCA with stent placement in February 2006. Four weeks after starting clopidogrel she developed thrombocytopenia with platelet nadir of 17,000. Her LDH was 700 IU/L and she was anemic with hemoglobin of 7.4 gm/dl with elevated reticulocyte count. Peripheral blood smear showed schistocytes and diagnosis of TTP secondary to clopidogrel was made. She did not have renal insufficiency. Clopidogrel was discontinued and patient was started on plasmapheresis with recovery of platelet counts. Early attempts in weaning plasmapheresis resulted in drop in platelet count and Rituximab was given to the patient weekly for four weeks. Subsequently, patient was weaned off plasmapheresis. For four years patient was followed periodically with CBC showing platelet counts greater than 250,000. In May 2010, four years after initial event patient was admitted to hospital for abdominal pain and found to have splenic infarcts. Subsequently, she also developed bilateral cerebral infarcts. Platelet count had decreased to less than 100,000. Her LDH was elevated at 419 IU/L. Reticulocyte count was 2.3%. Peripheral blood smear revealed significant number of schistocytes. There was no renal insufficiency or fever. Trans-esophageal echocardiogram (TEE) was done that did not reveal any vegetations. Patient was diagnosed as having recurrence of TTP and started on plasmapheresis with recovery in platelet counts. Pt was also treated with Rituximab.

Discussion-

We describe a case of TTP initially occurring within weeks of starting clopidogrel. Patient was treated with plasmapheresis and Rituximab and clopidogrel was discontinued. Patient had recurrence after four years as manifested by infarcts in multiple organs, with mild thrombocytopenia, elevated LDH and significant number of schistocytes on peripheral blood smear. It is very uncommon for clopidogrel associated TTP to recur after such a prolonged period of 4 years. Most cases of clopidogrel associated TTP have mild thrombocytopenia. This patient had severe thrombocytopenia on first presentation of TTP but had mild thrombocytopenia on recurrence. This case illustrates the importance of extended follow up and high index of suspicion for TTP as delays in initiation of plasmapheresis has a poor clinical outcome.

Disclosures:

No relevant conflicts of interest to declare.
Anagrelid In Essential Thrombocythaemia Treatment of a Patient Under 12 Months
Authors: Laguna Pawel , Romiszewski Michal , Klukowska Anna , Pawelec Katarzyna , Matysiak Michal
Published: October 2019

Abstract 4680

Essential thrombocythaemia (ET) is a chronic myeloproliferative disorder. It occurs mostly in adults and rarely in young children. We present the case of ET in an 8 –month- old girl, who was treated with Anagrelid for 13 months.

The girl was admitted to the hospital because of elevated platelet count. She had stomach pains periodically. On admission the child's condition was good but on palpation her stomach was sore and her spleen was enlarged. Laboratory investigations showed an elevated platelet count (1.5m) and hypercalaemia (6.3mEq/l). Thrombopoetin was normal.

Acesan was added to the treatment. A morphology performed after 1 month revealed further elevation of platelets (up to 2.65m). On the basis of the laboratory investigations, bone-marrow biopsy and trepanobiopsy, we eliminated an oncological disease and infectious diseases of connective tissues.

On bone-marrow investigation, acquired mutation of JAK2 (V617F) tyrosine kinase was diagnosed, which confirmed ET.

On account of the growing number of platelets, which was life - threatening, we decided to administer Anagrelid, starting with a dose of 0.25 mg per day. The number of platelets decreased to 1.4m, so the dose was increased to 0,25 mg twice daily after 3 weeks.

At present, after 13 months of Anagrelid treatment, the number of platelets in the child ranges between 400 and 650.

The patient comes to our, department for monthly check-up of morphology, biochemical tests, ECG and echocardiography.

In international literature there is no information on the use of Anagrelid in ET treatment of children under 12 months old. However, on the basis of our observations and initial results of treatment, it seems that the above protocol for Anagrelid administration is safe for infants of this age.

Disclosures:

No relevant conflicts of interest to declare.
Efficacy of Lower Dose Rituximab by Adding Fresh Frozen Plasma for the Treatment of Idiopathic Thrombocytopenic Purpura
Authors: Sun Mei , Gu JIan , He Bin , Xie Xiao-Yan , Chen Bao-An , Pei Xiao-Ping
Published: October 2019

Abstract 4682

OBJECTIVE:

To evaluate the effectiveness and safety of lower dose rituximab by adding fresh frozen plasma in the treatment of patients with idiopathic thrombocytopenic purpura (ITP).

METHODS:

A prospective study was performed at Subei People,Hospital Affiliated to Yang Zhou University involving the use of lower dose rituximab combining fresh frozen plasma in 15 patients who had previously been treated with steroids, intravenous immunoglobulin (IVIG) or splenectomy. Fifteen patients with refractory ITP which were unresponsive to or relapse after the above said treatment were treated with two hundreds millilitre of fresh frozen plasma (FFP) followed with rituximab (100 mg/m2 per week for four weeks) and oral Medrol (24mg per day). Whole blood cell count in all cases and B cells of CD19 (+)/CD20 (+) were detected in eight cases before and after rituximab therapy.

RESULTS:

Complete response (CR) was achieved in 7 patients (46.67%), response (R) in 13(86.67%), and non-response (NR) in 2 (13.33%). The median follow-up time was 4 weeks. The median response and CR time were 7 and 14 days, respectively. CD19 (+) CD20 (+) B cells significantly decreased (P < 0.01). There were no severe adverse effects during rituximab therapy.

CONCLUSION:

Lower dose rituximab by adding fresh frozen plasma is effective and safe for ITP. Our therapeutic regimen is superior to other relative studies; however, a randomized control trial is needed to confirm the results of our study.

Disclosures:

No relevant conflicts of interest to declare.
Thrombotic Thrombocytopenic Purpura Associated with Systemic Lupus Erythematosus and Antiphospholipid Syndrome: A Case Report
Authors: He Yang , Yang Weiwen , Ruan Changgeng
Published: October 2019

Abstract 4685

Background:

The occurrence of thrombotic thrombocytopenic purpura (TTP) in patients with systemic lupus erythematosus (SLE) is rare TTP frequence. In pregnancy women is increased. TTP with simultaneous SLE, and antiphospholipid syndrome (APS) occurring in the same patient is extremely rare.

Case report:

We described a 41-year-old Chinese female with TTP in her third trimester (33+4 gestational weeks) of pregnancy who suffered from SLE. and APS at the same time. The clinical features and positive laboratory abnormalities included fever, repeated abortion in first trimester, palpitation, dyspnea, orthopnea, hypertension (180/113mmHg), proteinuria, renal dysfunction, thrombocytopenia (platelets count 12×109/L), hemolytic anemia (Hb 67g/L), positive Coombs test, positive lupus test, positive antinuclear antibody, anti-Sm antibody, anti-insulin antibody, anti-ENA antibody and anti-RNP antibody. The level of plasma ADAMTS13 activity was below 5%, and ADAMTS13 inhibitor was present in the patient's plasma. This patient was treated with a combination of corticosteroids and plasma infusion and plasmapheresis. At 33+5 weeks of gestation she delivered a healthy infant via cesarean section. The patient improved quickly with these therapies.

Conclusion:

This is a rare TTP case with simultaneous SLE, APS and preeclampsia. Her overlaping clinical manifestations and laboratory abnormalities made the diagnosis very difficult. These data indicate that plasma therapy and corticosteroids can improve the prognosis of TTP associated with SLE and APS. In addition, the termination of pregnancy may be also helpful for controlling the development of the disease.

Disclosures:

No relevant conflicts of interest to declare.
Hematopoietic Reconstitution of Mice Cord Blood Transplantation Combined with Bone Marrow Transient Hematopoietic Progenitor Cell
Authors: Shi Jun , Ikeda Kazuma , Yosinobu Maeda , Yuan Yinghua , Yu Yehua , Tanimoto Mitsune
Published: October 2019

Abstract 4688

Umbilical cord blood has been increasingly used as a source of hematopoietic stem cells. However, fetal blood recipients had slower hematopoietic engraftment and impaired immune reconstitution. To accelerate myeloid and lymphoid recovery, we used an animal model of newborn blood modeled for cord blood (CB), along with transiently reconstituting progenitor cells from congenic bone marrow with recipients, as sources of stem cells. According to the previous reports that murine transiently reconstituting progenitor cells express the c-kit molecule, but not Sca-1 and lymphohematopoietic lineage markers, Lin-sca-1-c-kit+(c-kit+) were isolated by MACS method. c-kit+ cells population consisted of exclusively of medium- or large-sized blast-like cells, which displayed relatively low proliferative potential in vitro than Lin-sca-1+ (sca-1+) population. After transplantation of CB from DBA/2 mice (H-2d/d, CD45.2), with or without graded numbers of either c-kit+ or sca-1+ cells isolated from BDF1 mice (H-2d/b, CD45.1) bone marrow into lethally irradiated CD45.2 congenic BDF1 mice, hematopoietic engraftment were dynamic investigated. The intermingled transplantation of CB and c-kit+ cells or sca-1+ cells at the dosages of 1×104 or 2.5×104 or 5×104 to recipient mice leads to the quantity of white blood cells and platelets increased to 1×109/L and 1×1012/L at day12, whereas the injection of CB alone resulted in day17. By 2 weeks post-transplantation, congenic BM-derived cells were dominantly found in granulocytes and B lymphocytes, while host cells were dominantly found in T lymphocytes in CB transplantation combined either with c-kit+cells or sca-1+ cells. In cotransplantation with CB and c-kit+cells – engrafted surviving mice, the degree of donor CB cells in the peripheral blood increased progressively over time, while congenic donor BM-derived cells decreased gradually. After 60 weeks cotransplantation with CB and c-kit+ cells, a complete chimerism frequency of CB–derived cells continued to maintain in granulocytes and B lymphocytes, while T lymphocytes were dominantly derived from CB. On the other hand, congenic bone marrow or host-derived cells were the dominant population and CB-derived cells in the peripheral blood were less than 10% after 60 weeks cotransplantation with CB and sca-1+cells. In conclusion, the cotransplantation of CB and congenic c-kit+ cells was able to accelerate early hematopoietic recovery due to congenic marrow cells. But complete or main chimerism of cord blood was formed without or with fewer residual cells of host origin and congenic BM origin in long-term multilineage reconstitution. Thus, this cotransplant model in vivo may be to bring useful information for improving hematopoietic and immune reconstitution in fetal blood recipients.

Disclosures:

No relevant conflicts of interest to declare.
Cytokine Expressions In Peripheral Blood Mononuclear Cells During Graft-Versus-Host Disease After Allogeneic Hematopoietic Stem Cell Transplantation
Authors: Ye Fang , Qiao Zhenhua , Yang Tao , Zhang Li , Jia Ning
Published: October 2019

Abstract 4708

Objective

To investigate the relationship between cytokines and human graft-versus-host disease (GVHD) after allogeneic hematopoietic stem cell transplantation (allo-HSCT).

Methods

In 21 patients undergoing allo-HSCT, the plasma concentrations of cytokines (interleukin 2(IL-2), soluble interleukin 2 recepter (sIL-2R), interferon-gama (IFN-γ), interleukin 4(IL-4), transforming growth fator-beta1(TGF-β1)) were measured by using sandwich enzyme-linked immunological assay (ELISA) and the gene messanger RNA expressions of these five cytokines were analysed by using semi-quantitate reverse transcriptase-polymerase chain reaction (RT-PCR).

Results

1. The concentrations and gene messanger RNA expressions of IL-2, sIL-2R and IFN-γ in the patients with GVHD were significantly higher than those without GVHD (P<0.01); these three cytokines expression levels in the patients with aGVHD were higher than with cGVHD and without GVHD (P<0.05); The levels of IL-4 showed no difference between the patients with or without GVHD (P>0.05); the levels of TGF-β1 in the patients with GVHD were significantly declined (P<0.01) but in those without aGVHD were obviously increased (P<0.05). After effective treatment, unnormal IL-2, sIL-2R, IFN-γ and TGF-β1 expressions recovered to the levels before transplantation. 2. The results of multivariate logistic regression modles and Kaplan-Meier survival curves analyses showed: age, sex, infection, HLA-matched, blood type, conditioning regiment and the times of absolute neutrophil counts and platelets recovering to normal, had no association with the incidence of GVHD (P>0.05). A multivariate COX survival function modle analysis showed IL-2, sIL-2R and TGF-β1 are independent prognostic factors for GVHD (=11.149, P<0.0001). 3. The results of IL-2, sIL-2R, IFN-γ and TGF-β1 measured by RT-PCR and ELISA for detecting peripheral blood cytokines expression levels had no difference.

Conclusions

1. IL-2, sIL-2R, IFN-γ and TGF-β1 play important roles in the development of GVHD after allo-HSCT. Monitoring the changes of IL-2, sIL-2R, IFN-γ and TGF-β1 expression levels (especially IL-2, sIL-2R and TGF-β1) might provide predictive markers for GVHD, especially aGVHD. 2. Different conditioning regiments resultes in different IL-2, sIL-2R, IFN-γ and TGF-β1 expression levels. 3. IL-4 expression had no effect on the developing of GVHD after allo-HSCT. 4. The sensitivity between RT-PCR and ELISA for detecting peripheral blood cytokines expression levels had no difference.

Disclosures:

No relevant conflicts of interest to declare.
The Effect of Rhg-CSF on MDSC In Bone Marrow and Peripheral Blood Cells
Authors: Ling Yiwen , Liu Qifa , Fan Zhiping , Wu Xiuli , Liu Can , Li Xuan , Sun Jing
Published: October 2019

Abstract 4709

Objective:

As granulocyte colony-stimulating factor, recombinant human granulocyte colony stimulating factor (rhG-CSF) is widely used in neutropenic patients. In addition to stimulating the growth of granulocyte, rhG-CSF can promote hematopoietic stem cells from bone marrow (BM) to peripheral blood (PB) and has the effect of immune regulation. Myeloid-derived suppressor cells (MDSC) are a group of heterogeneous cells, derived from bone marrow progenitor cells and immature myeloid cells. Recently, MDSC is researched in the field of solid tumor, but not in the field of hematopoietic stem cell transplantation. Here, we investigate rhG-CSF's effect on MDSC in healthy donors’ BM, PB and the relationship between MDSC and graft-verse-host disease (GVHD).

Methods:

We obtained the BM and PB samples before mobilization and the BM APB and peripheral blood stem cell collection (PBSC) on the 5th day after the rhG-CSF mobilization from 12 healthy donors, respectively. Then we used the flow cytometry to check the absolute number of MDSC. Finally, we analyzed the relationship between the number of MDSC and the incidence of GVHD.

Results:

In normal physiological conditions, the MDSC could be detected in healthy donor's PB and BM. In PB, the proportion of MDSC in the mononuclear cells was 1.35 ± 0.35%. In BM, the proportion was 2.44 ± 1.11%. The proportion in BM is higher than that in PB, the difference was statistically significant (P=0.047). On the 5th day after the rhG-CSF mobilization, the MDSC ratio of mononuclear cell in PB were 4.01 ± 1.82%. In BM, the ratio was 4.38 ± 2.19%. The difference between the ratio of MDSC in BM and PB was no significant (P=0.076). The number of mobilized peripheral blood MDSC was significantly higher than that before mobilization (P=0.015), while the difference between the numbers of bone marrow MDSC cells before and after mobilization was not significant (P=0.083). The numbers of MDSC in collection and the incidence of GVHD had a significant negative correlation (P=0.048).

Conclusion:

MDSC could be detected in the healthy donors’ PB and BM, the numbers of MDSC in BM were higher than that in PB. The rhG-CSF could mobilize more MDSC from BM to the peripheral blood, and the increased s of MDSC in PB after rhG-CSF mobilization might be related to the low incidence of GVHD in hematopoietic stem cell transplantation.

Supported by National Natural Science Foundation of China (30971300), Science and Technology Planning Project of Guangdong Province of China (2009A030200007) and China Postdoctoral Science Foundation (200902332, 20080440776).

Disclosures:

No relevant conflicts of interest to declare.
Determinants of Persisting Thrombocytopenia In Patients with Type 1 Gaucher Disease Treated with Alglucerase/Imiglucerase for 4–5 Years
Authors: Cappellini Maria D. , Belmatoug Nadia , Cole Alex , Dahl Stephan vom , Deegan Patrick , Goldblatt Jack , Rosenbloom Barry E. , Tylki-Szymañska Anna , Weinreb Neal J. , Zimran Ari , Hollak Carla
Published: October 2019

Abstract 4719

Introduction:

Thrombocytopenia in type 1 Gaucher disease (GD) may result in surgical, obstetrical and spontaneous bleeding. Treatment with alglucerase/imiglucerase generally results in rapid improvement in platelet count but, in rare cases, the platelet response to therapy is slow or lacking. The factors underlying persisting thrombocytopenia despite treatment are poorly understood.

Aim:

To identify patient characteristics associated with (and potentially predictive of) persisting thrombocytopenia despite therapy by retrospective analysis of ICGG Gaucher Registry data.

Methods:

1,016 type 1 GD patients with an intact spleen, date of diagnosis and therapy initiation, no treatment breaks 4–5 years after therapy initiation, and known platelet counts, were classified into four groups by last platelet count 4–5 years after therapy initiation: >120 × 109/l (n = 772); >100 to <120 × 109/l (n = 94); >80 to <100 × 109/l (n = 80); and <80 × 109/l (n = 70, of which 20 had <60 × 109/platelets/l). Patients were characterized by demographics, BMI; platelet count; anemia; biomarkers; hepatomegaly; splenomegaly; and skeletal assessments at baseline (therapy initiation) and after 4–5 years of therapy. Initial enzyme dose and cumulative average dose were noted. Possible associations with persisting thrombocytopenia were tested using a multivariate analysis calculating odds ratios adjusted for age at diagnosis and therapy initiation, genotype, sex, year of diagnosis, and year of therapy initiation.

Results:

Of the 1,016 patients in this study, 20 (2%) had platelet counts <60 × 109/platelets/l after 4–5 years of therapy. These patients all had severe splenomegaly at baseline. Associations between persisting thrombocytopenia were found between baseline low platelet count (<80 × 109/l), splenomegaly and anemia (p <0.0001). After 4–5 years, persisting thrombocytopenia was associated with anemia (p <0.0001), reduced WBC (p = 0.049), splenomegaly (p <0.0001), hepatomegaly (p = 0.006), bone pain (p = 0.035) and cumulative enzyme dose (dose range 18.6–55.5 U/kg/2weeks; doses <25th percentile: p = 0.043). Too few data prevented reliable analysis of other bone parameters and biomarkers.

Discussion and conclusion:

Persisting thrombocytopenia despite therapy is rare (2% of patients with platelets <60 × 109/l). The strong association between splenomegaly, anemia and thrombocytopenia at therapy initiation and persisting thrombocytopenia after 4–5 years of treatment suggests that in a minority of cases extensive spleen involvement, possibly with fibrosis, may be predictive of thrombocytopenia that is refractory to treatment. Findings underline the importance of initiating treatment before irreversible complications have developed.

Disclosures:

Cole: Genzyme Corp: Employment.
Value of Survival Gains In Chronic Myelogenous Leukemia
Authors: Yin Wesley , Penrod John R , Maclean Ross , Humphrey Jeffrey , Bahceci Erkut , Lakdawalla Darius
Published: October 2019

Abstract 4736

Background:

Tyrosine Kinase Inhibitors (TKI) are the first line therapies for patients with chronic myelogenous leukemia (CML). The value of survival gains to patients associated with TKI treatment—in aggregate or relative to the cost of treatment—is unknown.

Methods:

Multivariate Cox proportional hazard models are used to construct real-world, community-based estimates of survival improvements in CML associated with the introduction of first-line TKI therapy, controlling for characteristics of patients which may independently affect survival. We then employ an economic framework following Becker, Philipson and Soares (2005) to calculate social value of infra-marginal improvements in survival gains due to treatment with TKIs. Finally, the value of community-based improvements in CML survival from treatment by newer TKIs used in second line is estimated by combining community-based survival data for first-line TKIs, along with clinical data on health improvements for CML patients receiving a TKI in second line.

Results:

Introduction of first-line TKIs in 2001 is associated with a real-world decrease in the all-cause mortality hazard rate of 0.183 (p < 0.01) for CML patients. A decrease of this magnitude is associated with an increase in life expectancy from 60 to 110 months for treated CML patients with median survival length in 2001. We estimate that patients place an annual value of $110,000 on first-line treatment with TKIs. This implies that for all patients in present and future CML cohorts, the present social value of first-line TKI therapy is $88bn. The present value of costs is estimated to be $8bn, suggesting that more than 90% of social value of TKIs in first line therapy is retained by patients. In second-line CML therapy, use of newer TKI agents is estimated to have created $47bn in social value, of which roughly 88% is retained by patients. This estimated value of the newer TKIs does not incorporate possible benefits in first-line therapy.

Conclusions:

In total, the TKI class in first and second-line theray has created over $135bn in social value. Approximately 90% of this value is retained by patients; approximately 10% is recouped by manufacturers. These estimates suggest that at current price levels, the vast majority of value created by new therapies in CML is appropriated by patients. In addition, since our estimates of survival community-based improvements are somewhat smaller than those contained in clinical trial estimates, this suggests the potential value of addressing real-world obstacles to efficacy, such as poor adherence.

Disclosures:

Yin: Precision Health Economics: Consultancy. Penrod:Bristol-Myers Squibb: Employment. Maclean:Bristol-Myers Squibb: Employment. Humphrey:Bristol-Myers Squibb: Employment. Bahceci:Bristol-Myers Squibb: Employment. Lakdawalla:Bristol-Myers Squibb: Consultancy; Precision Health Economics: Equity Ownership.