bluuebunny/crossref_metadata_2025 huggingface dataset:
Daily C - Reactive Protein (CRP) Levels Allow Early Identification of Patients with Severe Complications after Melphalan (MEL) and Autologous Stem Cell Transplantation (ASCT) for Multiple Myeloma (MM).
Authors: Anaissie Elias J. , Grazziutti Monica L. , Fassas Athanasios , Dong Li , Miceli Miceli H. , Van Rhee Frits , Hollmig Klaus A. , Talamo Giampaolo , Tricot Guido J. , Barlogie Bart
Published: April 2020

Background: CRP is an acute-phase reactant that increases rapidly in response to inflammation (including infection).

Objective: to assess the value of daily CRP level as a predictor of severe complications [pneumonia, bacteremia or severe mucositis (Grades 3–4, NCI Common Toxicity Criteria)] after MEL-ASCT for MM.

Patients and Methods: 199 MM patients (pts) who received a MEL-ASCT and had daily CRP levels on days 0–21 after ASCT.

Results: Median age was 58 years (32 – 77) and 60% were males. Mucositis was present in 89% of pts and was severe in 20%; bacteremia and pneumonia developed in 23 % and 13 % of pts respectively.Daily CRP levels (days 0-21): All pts with severe complications had higher daily CRP levels vs. those with mild or no complications (p< 0.0001). Higher CRP levels were observed among pts with pneumonia (p< 0.0001 vs. no pneumonia), bacteremia (p< 0.0001 vs. no bacteremia) and severe mucositis (p=0.002 vs. mild (grades 1–2) and no mucositis). When present among pts with mild mucositis, infection was associated with a higher CRP level (p< 0.0001 vs. no infection). CRP peak levels: Comparable CRP peak levels were observed among pts with various complications: pneumonia (n=27), bacteremia (n=46) or severe mucositis (n=41) [Mean and range in mg/dl: 16.6 (3.63 – 35.3); 17.18 (1.29 – 36.9); 17.81 (4.8 – 36.01) respectively; p= 0.95]. The presence of infection among pts with mild mucositis significantly increased CRP peak [mean and range 15.73 (1.29 – 36.9) vs. 11.59 (1.31 – 35.06) respectively, p= 0.0028].Rate of CRP increase: A significantly faster rate of CRP increase was observed among pts with severe complication vs. those with mild or no complications: mean and range of increase: 2.39 mg/dl/day (0.30 – 9.86) vs. 1.9 mg/dl/day (0.15 – 7.83). A model predictive of severe complications based on rate of CRP increase per day was developed based on the following formula:

p = exp(−0.6630 + 0.1837 * CRP slope (mg /dl/day))

1+ exp (−0.6630 + 0.1873 * CRP slope (mg/dl/day))

This model will now be prospectively validated.

Conclusions: Daily CRP levels provide an early identification of MM pts with severe complications after MEL-ASCT. Higher CRP levels correlate with severe mucositis and/or infection. Among pts with mild mucositis, a rapidly increasing and/or a high CRP level suggest the presence of severe infection.
Evaluation of Aprepitant for Treatment of Acute and Delayed Chemotherapy-Induced Nausea and Vomiting in Patients Undergoing Autologous Stem Cell Transplantation.
Authors: Barnett Chad M. , Oholendt Michael S. , Popat Uday , Carrum George , Heslop Helen E.
Published: April 2020

Autologous stem cell transplant (ASCT) requires therapy with very highly emetogenic chemotherapy regimens. Nausea and emesis are a major issue for patients undergoing ASCT. Aprepitant, a selective substance-P/neurokinin 1 (NK1) receptor antagonist, has been approved by the U.S. Food and Drug Administration for treatment of acute and delayed CINV in combination with a corticosteroid and 5-HT3 receptor antagonist. Due to little patient data in this area, a retrospective chart review was performed which evaluated 41 ASCT patients that had received standard therapy (control group, n=25) compared to aprepitant in addition to standard therapy (aprepitant group, n=16). Patients who underwent an ASCT and were greater than 18 years of age were eligible for inclusion in the study. Patients who underwent an allogeneic stem cell transplant were excluded. All data was collected from the hospital’s computerized nurse charting system. Episodes of nausea and emesis were collected from nursing notes while data for rescue medications was collected from the charted medications. Conditioning regimens given during the study included high dose (HD) melphalan, BEAM (carmustine, etoposide, cytarabine, and melphalan) or R-BEAM (rituximab, carmustine, etoposide, cytarabine, and melphalan). All patients evaluated in the aprepitant group had received aprepitant 125 mg orally once daily on the first day of chemotherapy administration and 80 mg orally once daily the following 2 days in the HD melphalan group (Day -1 through Day 0) and the following 5 days in the BEAM group (Day-6 through Day -1). Although aprepitant dosing was consistent, dosing was determined by the individual physician and prescribed on a patient-specific basis. The primary endpoint was the number of episodes of nausea and emesis after chemotherapy, while the secondary endpoint was the number of rescue medications that were used for nausea and emesis. For the primary endpoint of the study, the mean number of nausea episodes per patient was reduced in the aprepitant group compared to the control group in the acute phase (1.7 versus 2.2, p=0.51) and delayed phase (5.3 versus 5.6, p=0.83). Emetic episodes per patient were decreased in the aprepitant group compared to the control group in both the acute (0.06 versus 0.9, p=0.21) and delayed phases (0.9 versus 2.4, p=0.17). Use of rescue medication per patient was decreased in the aprepitant group compared to the control group in the acute phase (2.3 versus 3.6, p=0.40) but not in the delayed phases (8.1 versus 8.1, p=0.99). None of the results of this study were statistically significant, although the reduced number of emetic episodes with aprepitant may be clinically significant. The results of this study warrant consideration for a prospective evaluation of this therapy in ASCT patients to greater clarify the use of aprepitant in these patients.
Conditioning with Fludarabine (Flu)-Alkylator Is More Effective Cytoreduction Than Cyclophosphamide-Total Body Irradiation (Cy/TBI) for Refractory, Progressive Chronic Lymphatic Leukemia (CLL).
Authors: Grigg Andrew C. , Szer Jeffrey , Artz Andrew , Kline Justin , van Besien Koen
Published: April 2020

Allografting is becoming a more frequent therapeutic consideration for symptomatic CLL. The most frequently used preparative regimen historically has been Cy/TBI but flu-based conditioning is a recently reported alternative. Two cases in which Cy/TBI failed to impact on high pre-transplant peripheral blood (PB) lymphocyte counts prompted us to compare the outcome of stem cell allografts after TBI and non-TBI-based conditioning in 11 patients (pts) from two institutions. All pts had flu-refractory CLL. Five pts received flu 25mg/m2 with either melphalan 120mg/m2 (n=4) or Cy 120mg/kg; the other six received Cy 120mg/kg with fractionated TBI 12Gy. The two groups were comparable for age (median 50 yr overall; range 42–57), number of prior therapies (4; 2–6), extent of marrow involvement pre-transplant (90%; 65–99%) and incidence of cytogenetic abnormalities (abnormal in 8/9 evaluable). PB stem cells were used in 10 pts and marrow in one, with cyclosporine/methotrexate as GVHD prophylaxis in 8 and Campath/tacrolimus in 3. All patients receiving flu-alkylator conditioning had substantial initial cytoreduction with disappearance of PB lymphocytosis (including 2 with >30x109/L pre-transplant), reduction in marrow infiltration to 25%, 15% and <5% at days 30, 60 and 100 respectively. Three of 5 remain in complete remission (CR) at 12, 35 and 49 months; one relapsed at one year and one died of GVHD with minimal disease at 5 months. In contrast, 5 of 6 pts had no significant initial marrow cytoreduction, 2 of whom maintained PB lymphocyte counts >300 and 30x109/L during the first month. Median marrow CLL involvement was 93%, 80% and 77% at days 30, 60 and 100 post transplant in this group. Two pts subsequently experienced late onset cytoreduction in the context of chronic GVHD but have yet to achieve CR; three died of progressive disease and one of GVHD. In vitro studies in one patient demonstrated resistance of CLL cells to irradiation. These preliminary data demonstrate that advanced CLL may be resistant to TBI and despite prior resistance to single agent flu, a combination of melphalan and flu may be the optimal cytoreductive regimen in this context.
Low Incidence of Acute Graft-VS.-Host Disease (GVHD) Using Tacrolimus (TAC) and Mycophenolate Mofetil (MMF) after Matched Sibling Donor (MSD) Non-Myeloablative Stem-Cell Transplants (NST) Conditioned with Fludarabine (FLU) and Low-Dose Total Body Irradiation (TBI).
Authors: Nieto Yago , Patton Nigel , Hawkins Timothy , Spearing Ruth , Bearman Scott I. , Rabinovitch Rachel , Zeng Chan , Baron Anna , McSweeney Peter A.
Published: April 2020

Randomized studies after conventional allografting showed that in combination with methotrexate TAC was superior to cyclosporine for prevention of acute GVHD. Using the Seattle conditioning regimen of FLU/low-dose TBI we evaluated TAC/MMF as a substitute for cyclosporine/MMF as post-grafting immunosuppression after MSD PBPC NST. Thirty-two patients (median age 57, range 32–68 years), who were poor candidates for a conventional myeloablative transplant, were enrolled. Patient diagnoses included lymphoma (N=12) (7 follicular, 2 transformed, 1 mantle-cell, 1 diffuse large cell, 1 NK), myeloma (N=12), high-grade MDS (N=5), AML (N=2), Hodgkin’s (N=1). Patients were conditioned with FLU (30 mg/m2/d x 3), TBI (200 cGy), were infused donor PBPCs on day 0, and received GVHD prophylaxis with TAC (0.06 mg/kg PO b.i.d. from day −3), targeting initially 10–20 ng/mL, and MMF (15 mg/kg PO b.i.d., from day 0 to +27, discontinued without taper). TAC was tapered from day +100 to +180 and from day +35 to +56, in those patients with indolent (N=25) and aggressive malignancies (N=7), respectively. Regimen toxicities and myelosuppression were mild, allowing 75% of patients to have entirely outpatient transplantations. One patient (3%) experienced a non-fatal graft rejection. The % patients with mixed/donor T-cell chimerism were as follows: 1 month: 77%/23%, 3 mo: 86%/14%, and 1 yr: 20%/80%. Five patients (15.6%) experienced stage II–IV acute GVHD, presenting at median day +61. Eleven patients (34%) experienced chronic GVHD (1 limited, 10 extensive) at median onset day +190. In 6 of those patients (22%), chronic CVHD was not elicited by immunosuppression withdrawal or DLI upon tumor progression. Day+100 transplant-related mortality (TRM) was 0%. Overall TRM was 9%, with 3 deaths from GVHD-related multiorgan failure on days +105, +343, and +354, respectively. At median follow-up of 19 (2–41) months, 20 patients (62.5%) were alive, 17 patients (53%) remained progression-free, 13 of them (41%) in complete remission. Median progression-free and overall survival times were 21 and 33 months, respectively.

Conclusion: TAC/MMF after a MSD NST provides effective acute GVHD prophylaxis, and is associated with an excellent early safety profile. As compared to reported outcomes with cyclosporine/MMF, acute GVHD incidence appeared lower and onset was delayed.
Efficacy of Fluconazole Prophylaxis for Autologous Peripheral Blood Stem Cell Transplantation: Results of a Prospective, Randomized, Controlled, Multicenter, Open Label Study.
Authors: Walsh Tracey L. , Bachier Carlos , Shaughnessy Paul , Freytes Cesar O. , Callander Natalie , LeMaistre C. Fred , Grimley Michael , Bradshaw Patrick
Published: April 2020

Infection is the leading cause of morbidity and mortality among hematopoietic stem cell transplant (HSCT) recipients. Fungal infection is particularly a threat because of difficulty in both diagnosis and treatment. The frequency of fungal infection is largely dependent on the mode of transplantation and duration of neutropenia. While fluconazole prophylaxis in allogeneic and autologous BMT is well studied, a trial in autologous PBSCT is lacking.

Methods: The Texas Stem Cell Transplant Consortium initiated a phase III randomized study to evaluate the efficacy of fluconazole for prophylaxis of invasive fungal infections (IFI) following autologous PBSCT with an initial planned enrollment of 150 patients. Patients were randomized to receive either no prophylaxis or fluconazole 400mg/day (or 12mg/kg if <18 years of age) beginning on the day of stem cell re-infusion. The prophylaxis phase continued until the post-nadir absolute neutrophil count (ANC) reached 1000/μL or until the patient developed an IFI according to criteria developed by the IFI Cooperative Group of the EORTC. Primary endpoints measured included the comparative incidence of proven, probable or possible IFI through engraftment and through day 100 post-transplantation and IFI-related mortality through day 100. Overall survival and the comparative incidence of superficial fungal infection were also analyzed.

Results: Thirty patients have been enrolled to date (16 fluconazole, 14 without prophylaxis). The median stem cell dose received was 3.5 million CD34+ cells/kg for patients randomized to fluconazole versus 6.2 million CD34+ cells/kg for those that did not receive antifungal prophylaxis. The median duration of neutropenia, defined as an ANC <1000/μL, was 7.5 days versus 7 days with a median duration of fever ≥100.5°F of 2 days and 2.5 days respectively. Superficial fungal infection developed in none of the patients that received fluconazole versus 31.3% of patients that did not receive antifungal prophylaxis. Additionally, the incidence of proven IFI was 0% in the fluconazole group versus 18.8% in those that did not receive prophylaxis and mortality due to proven IFI was 0% and 16.7% respectively. Although the small numbers do not allow for statistical comparison, the study was terminated early as a result of the high incidence of IFI and IFI-related mortality in the patients randomized to receive no anti-fungal prophylaxis.

Conclusion: Results of this study suggest that fluconazole prophylaxis should be provided as standard of care in patients following autologous PBSCT.
Cytomegalovirus Infection after Unrelated Cord Blood Transplantation (CBT) for Adults with Hematological Diseases.
Authors: Myojo Tomohiro , Matsumura Tomoko , Narimatsu Hiroto , Masuoka Kazuhiro , Inokuchi Chiho , Kami Masahiro , Miura Yuji , Kato Daisuke , Kusumi Eiji , Yuji Koichiro , Wake Atsushi , Ueyama Junichi , Miyakoshi Shigesaburo , Yoneyama Akiko , Matsuzaki Michio , Morinaga Shinichi , Taniguchi Shuichi
Published: April 2020

Backgrounds: Cytomegalovirus (CMV) infection is a major complication after allogeneic transplantation; however clinical significance of CMV reactivation after cord blood transplantation remains unclear.

Objective: We retrospectively investigated the incidence of CMV antigenemia, and CMV diseases, and its prognosis in adult patients who underwent reduced-intensity cord blood transplantation (RI-CBT)

Patients/ Methods: We reviewed medical records of 77 patients who received RICBT at Toranomon Hospital between January 2002 and March 2004. Median age of the patients was 55 years (range 17–79). Underlying diseases were chemorefractory hematologic diseases (n=76) and severe aplastic anemia (n=4). Conditioning regimen comprised fludarabine (125 mg/m2), melphalan (80 mg/m2), and TBI 4-8Gy. GVHD prophylaxis was cyclosporine (n=69) or tacrolimus (n=11). Median total nucleated cells and CD34+ cells was 2.4×106 cells/kg (0.39–4.3), and 0.81×105 cells/kg (0.05–5.7) respectively. HLA disparity was 6/6 (n=3), 5/6 (n=12), 4/6 (n=63), and 3/6 (n=2). All patients were monitored CMV-antigenemia weekly and received pre-emptive gancyclovir or foscarnet.

Results

CMV antigenemia tested positive in 47 patients on a median of day 32 (range, 12–55) after RICBT. The cumulative incidence of CMV reactivation at day 100 was 0.70. Seven and 29 patients were treated with preemptive ganciclovir and foscarnet, respectively. Adverse events of them were myelosuppression in 3 patients given ganciclovir, and mild hyponatremia in a patient given foscarnet. CMV diseases developed in 15 patients on a median of day 39 (range 15–92); enterocolitis (n=13), pneumonia (n=1), and encephalitis (n=1). Seven of 15 patients were resolved with antiviral treatment, and the other patients were fatal with CMV infection. Univariate analysis showed any risk factors for CMV reactivation.

Discussion

CMV reactivation and diseases develop early after cord blood transplantation. Opitimal strategy for preventing CMV disease should be established in RICBT.
Reduced Intensity Conditioning Regimen for Allografting Following Autografting Is Feasible and Has a Strong Anti Multiple Myeloma Activity.
Authors: Carella A.M. , Beltrami Germana , Corsetti Maria T. , Scalzulli Potito , Cascavilla Nicola , Carella Michele , Nati Sandro , Greco Mario M. , Musto Pellegrino
Published: April 2020

The development of reduced intensity conditioning regimens (RICT) has renewed interest in allografting for patients with multiple myeloma (MM). Taking advantage of this new approach, we firstly postulated that combining maximal tumor reduction achieved with autografting and the benefits of RICT, we could achieve more cures of multiple myeloma (MM) with acceptable toxicity. Sixteen patients, 51 years of age (range, 36–63) with previously treated stage III MM were given melphalan 140 mg/m2 and autologous peripheral blood progenitor cells (PBPC) reinfusion. The regimen-related toxicities were moderate with a median of 8 and 11 days of neutropenia and thrombocitopenia, respectively. Forty-six to 156 days later (median, 79 days), the patients received fludarabine 30 mg/m2/d x 3 days plus 2 Gy TBI and HLA-identical donor mobilized PBPC. Postgrafting immunosuppression consisted of cyclosporine and mycophenolate mofetil. Donor lymphocyte infusions were given to eight patients with stable mixed chimerism or progressive disease who did not show signs of aGVHD. Engraftment occurred in 14 patients (87%). Ten patients (62%) are alive with 9 of them in continuous complete remission 11–36 months (median, 30 months) after transplants. All remitters patients achieved full chimerism and developed GVHD. Grade II–III acute GVHD occurred in 7 patients (43%) but no patient died of aGVHD. Three patients (18%) developed extensive chronic GVHD requiring intensive therapy. Six patients died; five of them of progressive disease and one of progressive disease combined with extensive cGVHD and interstitial pneumonitis. In conclusion, this 2-step approach is feasible and demonstrated to have a strong antimyeloma activity with reduced deaths due to acute toxicities.
Reduced-Intensity Stem Cell Transplantation (RIST) for Non-Hodgkin Lymphoma (NHL): A Single-Institute Experience of 52 Patients.
Authors: Sugimoto Kyoko , Onishi Yasushi , Kusumoto Shigeru , Kim Sung-Won , Kami Masahiro , Mori Shin-ichiro , Heike Yuji , Takaue Yoichi , Tobinai Kensei , Tanosaki Ryuji
Published: April 2020

Since allogeneic hematopoietic stem cell transplantation (HSCT) is reported to have a high mortality rate for advanced lymphoma patients, less toxic technique has been expected. We evaluated the safety and preliminary efficacy of RIST in patients with advanced NHL on the basis of the WHO classification. We retrospectively reviewed the medical records of 52 patients with NHL who underwent RIST from February 2000 to April 2004 at National Cancer Center Hospital. The median age of the patients at the time of RIST was 50 years (range, 26 to 67 years). Eighteen patients had indolent B-cell lymphoma (follicular 16, lymphoplasmacytic 1, chronic lymphocytic leukemia 1), 11 had aggressive B-cell lymphoma (diffuse large B cell 8, mediastinal large B cell 2, mantle cell 1), and 23 had T-cell and NK-cell lymphoma (adult T-cell leukemia/lymphoma 12, peripheral T-cell, unspecified 8, extranodal NK/T-cell 1, enteropathy-type T-cell 1, anaplastic large cell 1). The median number of prior chemotherapy regimens was 3 (range, 1–8), and 17 (33%) patients had experienced autologous HSCT before RIST. Thirty (58%) patients had progressive/refractory disease at the time of transplantation. The RIST regimens were fludarabine- (n=47) and cladribine-based (n=5), of whom 9 patients received additional anti-thymocyte globulin. Stem cell sources were related peripheral blood (n=36), unrelated bone marrow (n=8), and unrelated cord blood (n=8). GVHD prophylaxis was cyclosporin alone (n=36) or cyclosporin and short-term methotrexate (n=16). The median duration of follow-up after transplantation was 309 days (range, 2 to 1492 days). Except for one patient who died early on day 2, all patients showed sustained engraftment. Acute GVHD gradeII–IV developed in 32 patients (62%), gradeIII–IV developed in 12 (23%) and chronic GVHD developed in 29 (56%). The day-100 TRM rate was 6%, including sepsis (n=2) and liver failure (n=1). The estimated one-year overall-survival and estimated progression-free survival rates were 75% and 63%, respectively, for all patients; 94% and 94% for indolent B cell, 76% and 58% for T or NK cell and 42% and 21% for aggressive B cell, as shown in Figures 1 and 2. (P = 0.0037 and, 0.0004 by log-rank test). In our analysis, GVHD did not clearly affect the clinical response or survival. Sustained engraftment and the low TRM rate indicate that RIST is feasible in patients with relapsed or refractory NHL. Although this is a preliminary study with a heterogeneous population and a short follow-up, the results suggest that RIST might be a promising procedure in relapsed or refractory NHL, especially in indolent B-, T- and NK-NHL. Further large-scale prospective studies are warranted.
Allogeneic Hematopoietic Stem Cell Transplantation with Nonmyeloablative Conditioning in Patients with Myeloid Leukemias: Results of a Prospective Study of the Latin American Cooperative Onco Hematology Group (LACOHG).
Authors: Ruiz-Arguelles Guillermo J. , Gómez-Almaguer David , Gómez-Rangel José D. , Vela-Ojeda Jorge , Kardus Amado , Cantú-Rodríguez Olga G. , Jaime-Pérez José C. , González-Llano Oscar , Herrera-Garza José L.
Published: April 2020

Using a nonmyeloablative stem cell transplantation (NST) program previously shown to be effective in individuals receiving allografts in México, 29 patients with either acute myelogenous leukemia (AML, n = 12) or chronic myeloid leukemia (CML, n = 17) from the Latin American Cooperative Onco Hematology Group (LACOHG) were prospectively given allogeneic bone marrow allografts. Patients received a modified NST conditioning regimen consisting of oral busulphan 4 mg/kg on Days −6 and −5, IV cyclophosphamide 350 mg/m2 on Days −4, −3, and −2, IV fludarabine 30 mg/m2 on Days −4, −3, and −2, oral cyclosporine A 5 mg/kg twice daily starting on Day −1 (continuing until Day 180), and IV methotrexate 5 mg/m2 on Days +1, +3, +5, and +11. Median patient age was 43 years (range, 10–63). All patients engrafted; median time to achieve an absolute neutrophil count >0.5 x 109/L was 14 days (range, 0–21), whereas the median time to achieve a platelet count >20 x 109/L was 12 days (range, 0–21). Follow-up periods ranged between 39 and 519 days (median, 249). In patients with CML, the median overall post-transplant survival has not been reached, whereas the 519-day overall survival was 88%, and the 100-day mortality was 0%. In patients with AML, the median overall post-transplant survival has not been reached, the 459-day overall survival was 66%, and the 100-day mortality was 8%. The results from this multicenter, multinational study complement and further support the efficacy of our NST preparative regimen. The initial experience obtained from individuals with CML and AML receiving allografts in 2 institutions in México has now been extended into other Latin American countries, and the results are acceptable.
Successful Unrelated Umbilical Cord Blood Transplantation for Shwachman-Diamond Syndrome.
Authors: Vibhakar Rajeev , Rumelhart Stephen L. , Tatman David J. , Radhi Mohamed A. , Goldman Frederick D.
Published: April 2020

Shwachman-Diamond Syndrome (SDS) is an autosomal recessive disorder characterized by pancreatic insufficiency and variable degrees of neutropenia. Additional clinical features include short stature, skeletal abnormalities and bone marrow dysfunction. SDS patients are at increased risk of developing myelodysplasia, aplastic anemia and leukemic transformation. The role and timing of allogeneic hematopoietic stem cell transplantation (HSCT) in SDS remains controversial due to a poorly defined predisposition toward peri-transplant complications and overall poor survival. Here we report three SDS patients (age 13 mo, 16 mo and 8 yr) with severe aplasia successfully transplanted using 5/6 HLA matched unrelated umbilical cord blood. All patients received a previously described “cardiac sparing” conditioning regimen consisting of Melphalan (180 mg/m2), Etoposide (1200 mg/m2), anti-thymocyte globulin (90 mg/kg), and low dose total lymphoid irradiation (500 cGy) with graft versus host disease (GVHD) prophylaxis consisting of cyclosporine and prednisone. Patients received grafts containing 6.7 – 9.1 x 105 CD34+ cells/kg. Myeloid engraftment occurred promptly with the ANC > 500 cells/mm3 on day 15 ± 5. Platelet recovery (>20k without transfusion) occurred on day 20, 30 and 140 days post transplant. All patients displayed 100% donor chimerism by 2 months post transplant. Patients were discharged between 25 – 60 days post transplant without severe complications, though all patients displayed grade II or III acute GVHD, and one developed chronic GVHD. The patients are alive 85, 390 and 850 days post transplant. Factors that may be important in HSCT outcome for SDS include transplantation at a relatively young age prior to malignant transformation, avoidance of cyclophosphamide in the preparative regimen, and adequate GVHD prophylaxis. Importantly, these cases also suggest that unrelated umbilical cord blood, in the absence of a matched family member, should be considered as the preferred source of donor stem cells in SDS patients undergoing HSCT.
Gene Expression Analysis of Leukemic Blasts Persisting at Day 8 of Induction Therapy in Childhood ALL.
Authors: Rhein Peter , Ratei Richard , Scheid Stefanie , Hagemeier Christian , Seeger Karl , Kirschner Renate , Schrappe Martin , Spang Rainer , Ludwig Wolf-Dieter , Karawajew Leonid
Published: April 2020

In childhood acute lymphoblastic leukemia (ALL), early response to therapy is of crucial prognostic significance. In the frontline ALL-BFM (Berlin-Frankfurt-Münster) trial, treatment stratification is based on blast count estimation in peripheral blood at day 8 of induction prephase with prednisone and one dose of intrathecal methotrexate at day 1. To approach yet unknown mechanisms of therapy resistance and to characterize cells persisting under therapy on molecular level, we investigated gene expression profiles of leukemic blasts at day 8 of therapy (“day 8” cells) and their changes as compared with blast cells at initial diagnosis (“day 0” cells). To this end, an experimental procedure has been established including flow sorting of leukemic cells by their leukemia-associated immunophenotype and preparation of cRNA, starting from a small number of cells and using an additional amplification step. Experiments have shown that flow sorting procedure does not affect RNA quality, and this experimental approach facilitates investigation of patient samples with blast cell counts as low as 50 blast cells/μl. Blast cells from ten patients with B-cell precursor ALL were investigated using Affymetrix HG U133A microarrays, and gene expression data were processed by normalization procedure on probe level by variance stabilization. Genes commonly up- or downregulated in blast cells under therapy were identified in matched pairs of day 8 and day 0 samples using Significance Analysis of Microarrays (SAM) and a filtering criterion of at least two-fold mean change. By this procedure a group of 84 genes with a false discovery rate of less than 10 % was identified. In this group, 24 genes, reportedly involved at different levels of the cell cycle regulation, including cell cycle progression (CDC2, cyclin B2), DNA replication (e.g. thymidylate synthetase TYMS, ribonucleotide reductase RRM2, proteins MCM 4 and 6) and execution of mitosis (e.g. cell cycle checkpoint kinases CHEK1 and BUB1B, kinesin-like proteins 1 and 7, and MAD2L1), were found to be downregulated in the day 8 cells. In contrast, genes (n=7) encoding for proteins involved in survival signaling (e.g. IL-4/IL-13 common receptor chain, membrane-spanning 4-domains MS4A1 and CD20) showed increased expression in day 8 blasts. Taken together, the described experimental approach enabled gene expression analysis of ALL cells persisting under therapy and pointed to increased survival signaling in day 8 blasts and their preferential positioning in the G1 cell cycle phase.
CD11b Is a Therapy-Induced Marker for Monitoring Minimal Residual Disease in Childhood Acute Lymphoblastic Leukemia.
Authors: Rhein Peter , Ratei Richard , Mitlohner Rita , Schrappe Martin , Ludwig Wolf-Dieter , Karawajew Leonid
Published: April 2020

Assessment of minimal residual disease (MRD) has become central to the clinical management of patients with acute lymphoblastic leukemia (ALL). Among the methods available for MRD monitoring, flow cytometry (FCM), which relies on the presence of leukemia-associated aberrant immunophenotype, holds great promise for clinical application. However, the major antigens used for FCM-MRD identification (CD10, CD34, CD45, CD20, CD19, TdT) undergo expression changes during therapy. Moreover, the presence of normal hematopoietic progenitors, in particular in the regenerating bone marrow after treatment, negatively impacts the sensitivity and specificity of MRD detection. Recently, we analysed genome-wide gene expression in blasts isolated from peripheral blood of pediatric precursor B-cell (PBC)-ALL patients after one week of therapy (day 8 cells). Expression changes observed in the day 8 cells pointed to several cell surface molecules, whose expression has not been characteristic for B-lineage hematopoiesis. In particular CD11b surface antigen has been frequently up-regulated in the day 8 cells. In the present study, we addressed expression dynamics of CD11b in PBC-ALL at clinically significant MRD timepoints during induction therapy (days 15, 33 and 78; ALL-BFM protocol). To this end, a CD11b specific antibody has been included into a nine-color, single-tube panel (antibodies to CD19, CD20, CD10, CD34, CD45, CD58, CD3, and a nuclear stain Syto16), which has been applied in order to detect residual blasts among 106 cells in bone marrow specimens from patients with PBC-ALL. At day 15, mean expression of CD11b (in MESF units) has been significantly increased if compared with leukemic cells at diagnosis (9600+/−2800 vs 850+/−140; p=0.005). The up-regulation by more than 10-fold has been found in 8 of 24 cases (33%), and has reached, in part, very high levels (eg, 450 MESF vs 49500 MESF at diagnosis and day 15, respectively). This indicates that CD11b expression changes are due to a therapy-induced gene up-regulation rather than to a clonal selection during clinical treatment. At the later timepoints of induction therapy, 7 of 22 patients (day 33) and 2 of 18 patients (day 78) were MRD positive. CD11b expression, if increased at day 15, retained its high values on day 33 (7900+/− 3200 MESF, 6 patients) and on day 78 (15100 MESF, 1 patient). Importantly, in contrast to leukemic cells, their normal CD19+CD10+ counterparts in both, non-leukemic and ALL bone marrow samples, remained CD11b negative. This difference has facilitated a reliable discrimination of normal and leukemic blasts in the MRD positive cases with regenerating bone marrow at day 78. In conclusion, treatment-induced up-regulation of CD11b in PBC-ALL has a promising potential as a novel marker, which may considerably improve specificity of FCM-MRD detection in bone marrow samples with a complex hematopoietic background.
Late Relapses of Childhood T-ALL Are Frequently Second T-ALL.
Authors: Szczepanski Tomasz , van der Velden Vincent H.J. , Van Vlierberghe Pieter , Gruhn Bernd , Panzer-Grumayer Renate , Spinelli Monica , Cave Helene , Stadt Udo zur , Campana Dario , Schrauder Andre , van Wering Elisabeth , Meijerink Jules P.P. , van Dongen Jacques J.M.
Published: April 2020

The vast majority of relapses in childhood T-cell acute lymphoblastic leukemia (T-ALL) patients occur relatively early, usually within 2 years from diagnosis. Our previous comparative molecular analyses between diagnosis and relapse in all such “classical” T-ALL showed totally or at least partly identical T-cell receptor (TCR) gene rearrangement patterns at both disease phases. These results confirm that the relapse clone in these patients originated from the original diagnosis clone, which became resistant to the applied treatment. In contrast to these “classical” T-ALL, two patients experienced very late T-ALL recurrences and displayed completely different TCR gene rearrangement sequences between diagnosis and relapse. We hypothesized that such late “relapses” of T-ALL in fact might represent second malignancies in genetically predisposed persons. We investigated 16 T-ALL patients with late relapses, i.e. at least 2.5 years from initial diagnosis. The studies at the DNA level involved detailed comparison of TCR gene rearrangements between diagnosis and relapse (PCR-heteroduplex, sequencing and/or Southern blot analyses), the detection of gene fusions involving the TAL1 gene and/or TCR genes and comparative genomic hybridization (CGH) using high-resolution Agilent arrays. We found evidence of a common clonal origin between diagnosis and relapse in ten of the 16 patients. In one case, no clonal TCR rearrangements were detected neither at diagnosis nor at relapse. In the other five patients TCR gene rearrangement sequences had completely changed between diagnosis and relapse, suggesting a second T-ALL rather than a relapse. Moreover, three of these five patients remained in complete remission after second-line treatment, which is unusual for relapsed T-ALL. In three of the five patients with presumed second T-ALL, CGH arrays showed completely different patterns of genomic aberrations between diagnosis and relapse, while in the remaining two patients the patterns of genomic changes were vastly different, but some aberrations were similar at both disease phases. In eight patients with evidence of a common clonal origin between diagnosis and relapse at least 50% of genomic events revealed by CGH arrays were identical between diagnosis and relapse of T-ALL. We conclude that approximately one-third of late T-ALL “relapses” in fact represent second malignancies. We are currently performing further genomic analyses to identify common genetic events or common genomic features which might be related to predisposition for development of T-ALL.
Outcomes of MDS Patients with Chromosome 7 Abnormalities Treated with 5-Azacytidine.
Authors: Lim ZiYi , Ho Aloysius Y.L. , Samuel Jonathon , Hayden Janet , Garcia-Manero Guillermo , Mufti Ghulam J.
Published: April 2020

Chromosome 7 abnormalities occurring in isolation or as part of complex cytogenetics confer an adverse prognosis in patients with myelodysplastic syndromes (MDS). Preliminary clinical data from various groups has suggested that the use of 5-azacytidine, a DNA methyl transferase inhibitor, in this sub-group of poor risk patients may be associated with an improved clinical response. We report on a retrospective analysis on the outcomes of 31 MDS patients with chromosome 7 abnormalities treated with 5-azacytidine. 5-azacytidine was administered subcutaneously at 75mg/m2 daily for 7 days and each cycle was repeated every 28 days. The median age of the cohort was 61 years (range: 17–80). Based on the WHO classification, 4 patients (13%) were RCMD/RCMD-RS, 17 were RAEB I/II (55%), 8 patients had acute myeloid leukemia transformed from MDS (26%), an additional 2 patients had secondary MDS. The IPSS of the cohort was Int-1(n=1), Int-2(n=12), high-risk(n=18). 13(42%) patients had isolated chromosome 7 abnormalities, 8(58%) had chromosome 7 abnormalities as part of a more complex cytogenetic profile. 10 patients(33%) had previously been treated prior to therapy with 5 azacytidine. 5 patients were withdrawn from treatment after 1 cycle due to drug intolerance or disease progression and were excluded from further analysis. The remaining 26 patients received a median of 6 cycles of treatment (range: 2–28 cycles). Response criteria was based on the modified IWG response criteria for MDS (Cheson et al Blood 2007). 7 patients achieved a complete response (CR), 3 partial response (PR), with haematological improvement (HI) in a further patient. The median cycles of treatment before response was 2, with median response duration of 10.5 months (range: 4–20 months). Overall response rate (CR+PR+HI) was 6/12 (50%) for patients with isolated chromosome 7 abnormalities as compared with 5/14 (36%) for patients with complex cytogenetics (p=0.15). 7 patients had a complete cytogenetic response, with a further 2 patients achieving a partial cytogenetic response. These cytogenetic responses were observed in 4/12 patients with isolated chromosome 7, and 5/16 patients with complex cytogenetics. The median survival of the cohort was 19.8 months (95%CI: 16.3–23.3). Patients with isolated chromosome 7 abnormalities had median survival of 24.8 months (95%CI: 17.8–31.8) compared with those with complex cytogenetics (17.3 months, 95%CI: 8.3–26.3, p=0.10). In addition, patients achieving cytogenetic remission (complete or partial) had an improved overall survival when compared with non-responders (median OS: 24.8 vs 19.8 months, p=0.05). WHO classification, IPSS, patient age, and history of prior therapy were all not significant predictors of response or overall survival in this cohort. In summary, 5-azacytidine is able to induce high remission rates in a cohort of high risk MDS patients with chromosome 7 abnormalities.
Therapy of Myelodysplastic Syndrome (MDS) with Azacitidine Given in Combination with Etanercept: A Phase II Study.
Authors: Holsinger Aaron L. , Ramakrishnan Aravind , Storer Barry , Becker Pamela S. , Petersdorf Stephen , Deeg H. Joachim , Scott Bart L.
Published: April 2020

The heterogeneity of Myelodysplastic Syndrome (MDS) has spurred interest in combining agents with different mechanisms of action in an attempt to improve the frequency and robustness of responses. Laboratory studies in patients with MDS have shown a shift in the relative levels of TNF-α receptor 1 and 2 in favor of receptor 2 in patients with more advanced MDS. Receptor 2 conveys only proliferative (not apoptotic) signals, and blockade of TNF-α may thus interfere with disease progression, while possibly protecting normal hematopoietic precursors. Therefore, we combined an established regimen of azacitidine with administration of the soluble TNF receptor antagonist etanercept in patients with advanced MDS. Twenty-three patients were treated with azacitidine, 75mg/m2/day for 7 days combined with etanercept, 25mg sc twice a week for two weeks every 28 days. Eighteen patients with MDS (4 RAEB-1, 11 RAEB-2, 1 CMML-1, and 2 CMML-2) have completed at least 3 months of therapy and were considered evaluable. Five of these patients had intermediate-1 risk, seven intermediate-2 and six high risk MDS by IPSS. Using the revised International Working Group (IWG) criteria for MDS, 14 patients (78%) responded: 5 patients (28%) had complete remissions (CR), 8 patients (44%) had partial remissions (PR) and 1 patient (6%) had hematologic improvement of neutrophils. Three patients have been on therapy for two years with sustained responses. Two patients developed pneumonias. The most common grade ¾ adverse events were hematological toxicity (78%). This therapeutic combination may be superior to treatment with azacitidine alone and warrants further study.
XBP-1 Levels Predict Sensitivity of Myelomas to Proteasome Inhibitor Bortezomib.
Authors: Ling Silvia C. , Lau Edwin , Ho Lye L. , Ho Joy , Joshua Douglas E. , Allen John
Published: April 2020

Background: Proteasome inhibitors (PI) are remarkably effective in relapsed and refractory myeloma but the origin of this peculiar sensitivity remains unclear. Myeloma is dependent on the unfolded protein response (UPR) and its regulator, transcription factor XBP-1. PI perturbs the unfolded protein response (UPR) by inhibition of the 26S proteasome-the main pathway for protein degradation. We hypothesize that the dependence on the UPR and XBP-1 mediates sensitivity to PI and the level of XBP-1 correlates with sensitivity to PI. The aim of this study is to correlate Bortezomib sensitivity with XBP-1 in vitro and in myeloma patients; to check the effect of manipulating XBP-1 on Bortezomib sensitivity and develop Bortezomib-resistant myeloma cell lines to ascertain the effects on XBP-1 and the UPR.

Methods and Results: Sensitivity to Bortezomib was measured by growth inhibition assay. XBP-1 mRNA levels and its isoforms were measured by a two-step quantitative QPCR assay, in 6 myeloma cell lines and 17 other cancer cell lines. There is a strong inverse correlation in myeloma cell lines between total or unspliced XBP-1 with Bortezomib sensitivity (r = −0.9) but not in other cancer cell lines. 23 marrow biopsies from 11 Bortezomib-treated myeloma patients were analysed for XBP-1 expression. Myeloma cells (CD38 hi, CD14 lo, kappa or lambda light chain +ve) were purified by flow cytometry. XBP-1 levels in myeloma cell lines were manipulated by shRNA-mediated knockdown and overexpression by retroviral transduction and had little effect on Bortezomib sensitivity. Bortezomib-resistant myeloma lines were developed. The mechanism of resistance was elucidated (XBP-1, ATF6, P-EIF2a, P58 INK and immunogloblin production). Marked downregulation of XBP-1 was demonstrated.

Conclusion: XBP-1 is a surrogate marker of Bortezomib sensitivity and its clinical utility is being tested now. Sensitivity to PI is related to the dependence on the UPR, reflected in the level of XBP-1. Bortezomib resistance is mediated by downregulation of the UPR.
Gene Expression Profiling of Myeloma Cells To Predict Response to Primary Therapy with Thalidomide-Dexamethasone for Newly Diagnosed Multilple Myeloma.
Authors: Abdelkefi Abderrahman , de Vos John , Assou Said , Othman Tarek Ben , Rossi Jean-Francois , Ladeb Saloua , Safra Ines , Galai Yosr , Ahmed Malika Ben , Benkahla Alia , Jenhani Faouzi , Nasr Moufida Ben , Torjman Lamia , Lakhal Amel , Louzir Hechmi , Abdeladhim Abdeladhim Ben
Published: April 2020

Background: Thalidomide which represents an effective treatment strategy for relapsed/refractory multiple myeloma, actually represents a standard of care also for newly diagnosed multiple myeloma patients.

Methods: In the present study, we adopted a gene expression profiling (GEP) strategy in an attempt to predict response (> 50% reduction in serum M protein) to primary therapy with thalidomide-dexamethasone for newly diagnosed multiple myeloma. Plasma cells (CD138+) were purified from bone marrow aspirates from 17 patients at diagnosis, before initiation of treatment with thalidomide-dexamethasone. GEP was performed using the Affymetrix U133 Plus_2 microarray platform. The Affymetrix output (CEL files) was imported into Genespring 7.3 (Agilent technologies) microarray analysis software, where data files were normalized across chips using GCRMA and to the 50th percentile, followed by per gene normalization to median. Criteria of response were those established by Bladè et al.

Results: After sufficient follow-up, responders (n=9) and nonresponders (n=8) were identified, and gene expression differences in baselines samples were examined. Of the 11000 genes surveyed, Wilcoxon rank sum test identified 149 genes that distinguished response from non response. A multivariate step-wise discriminant analysis (MSDA) revealed that 14 of the 149 genes could be used in a response predictor model (see table). Of interest, the gene list encompasses WXSC1, known to be involved in the chromosomal translocation t(4;14) (p16.3;q32.3) in multiple myeloma.

Conclusion: These results could be the first step to adopt microfluidic cards, in an attempt to select at diagnosis patients who will respond favourably to a particular treatment strategy.

List of 14 genes able to predict response to primary therapy with thalidomide-dexamethasone for newly diagnosed multiple myeloma. Gene ID Gene Name Chromosomal location 212771_at C10orf38 10p13 229874_x_at LOC400741 1p36.13 219690_at U2AF1L4 19q13.12 202207_at ARL7 2q37.1 243819_at GNG2 14q21 203753_at TCF4 18q21.1 235400_at FCRLM1 1q23.3 211474_s_at SERPINB6 6p25 226785_at ATP11C Xq27.1 215440_s_at BEXL1 Xq22.1–q22.3 209054_s_at WXSC1 4p16.3 227168_at FLJ25967 22p12.1 213355_at ST3GAL6 3q12.1 223218_s_at NFKBIZ 3p12–q12
A Heparin-Based Inhibitor of Heparanase Blocks Myeloma Growth In Vivo by Targeting the Tumor Microenvironment.
Authors: Yang Yang , Swain Telisha , Naggi Annamaria , Torri Giangiacomo , Casu Benito , Vlodavsky Israel , Sanderson Ralph D.
Published: April 2020

Heparanase is an enzyme that cleaves heparan sulfate chains of proteoglycans and promotes the growth and metastasis of many types of human tumors. Our previous work demonstrates that enzymatically active heparanase

is present in the bone marrow of myeloma patients and is associated with a poor prognosis, substantially enhances tumor growth and spontaneous metastasis to bone in an animal model of myeloma, and increases the synthesis and shedding of syndecan-1 by myeloma cells,

this in turn contributes to myeloma progression by elevating levels of syndecan-1 in the tumor microenvironment. Thus, we hypothesized that inhibitors of heparanase activity would have a dramatic impact on the growth of myeloma tumors. To test this we used a chemically modified form of heparin that is 100% N-acetylated and 25% glycol-split (designated 100NA,RO-H). This form heparin is a potent inhibitor of heparanase enzyme activity but lacks anticoagulant activity thus enabling use of relatively high doses of the drug in vivo. Delivery of the 100NA,RO-H to animals bearing established myeloma tumors dramatically blocked tumor growth and progression in a dose-dependent manner(P<0.04). To understand the mechanism of action of 100NA,RO-H, a series of experiments were performed on tumor tissue harvested from the animals. Results demonstrate that the modified heparin significantly inhibits proliferation of cells within the tumor (33 ± 8/mm2 Ki-67 positive cells in treated vs. 688 ± 164/mm2 positive cells in controls, P = 0.002). 100NA,RO-H also dramatically inhibits angiogenesis as compared to controls as assessed by CD34 staining of tumor tissue. This anti-angiogenic effect may be due at least in part to its regulation of hepatocyte growth factor and/or vascular endothelial growth factor, two angiogenic factors that are detected by immunohistochemistry at high levels in controls but virtually absent from tumors of animals treated with 100NA,RO-H. In vitro studies demonstrate that 100NA,RO-H blocks syndecan-1 shedding from cells, consistent with the role of heparanase in promoting syndecan-1 shedding. In addition, in contrast to our finding that 100NA,RO-H blocks tumor growth in vivo, it only slightly inhibited proliferation, cell cycle progression and growth factor signaling in myeloma cells growing in vitro. Thus, the compound does not appear to have substantial direct effects on tumor cells. Although it is not yet clear if all of the effects of 100NA,RO-H are due to its anti-heparanase activity, we conclude that this modified heparin disrupts the myeloma tumor microenvironment thereby blocking in vivo growth and progression of the cancer. Therefore, its use as a single agent or in combination with agents having direct anti-tumor cell activity may constitute a potent new anti-myeloma therapy.