bluuebunny/crossref_metadata_2025 huggingface dataset:
Rituximab Plus CHOP Given Every 15 Days with GM-CSF (sargramostim) In Patients Withnewly Diagnosed Diffuse Large B-Cell Lymphoma
Authors: Tulpule Anil , Berman Nancy , Ahmed Nazish , Boswell William , El-Masry Mary , Chaudhary Preet
Published: October 2019

Abstract 4886

Background:

The R-CHOP regimen administered every three weeks has become the standard of care for treatment of patients with diffuse large B-cell lymphomas. Previous studies have not shown an advantage of dose dense (cycles given every 2 weeks) R-CHOP therapy. Granulocyte-macrophage colony stimulating factor (GM-CSF), in addition to stimulating hematopoetic recovery augments dendritic cell numbers and promotes antigen presentation, induces immune recognition of tumor cells, causes antibody dependent cytotoxicity, and upregulates activity of rituximab. In a Phase II study, we analyze the efficacy and tolerability of R-CHOP given every 15 days with GM-CSF administered on days 3 through 13 of each cycle.

Methods:

All patients were treated with Rituximab, 375 mg/m2; Cyclophosphamide, 750 mg/m2; Doxorubicin, 50 mg/m2; Vincristine, 1.4 mg/m2, all given IV on day 1; oral prednisone 100 mg given orally on days 1–5 and subcutaneous GM-CSF, 250 mg/m2 on days 3–13. Chemotherapy cycles were repeated every 15 days.

Results:

In this mid-study evaluation, thus far 36 patients with a median age of 53 (range 22–81) have been accrued. All patients were previously untreated and had CD20+ diffuse large B cell lymphoma. 26 (72%) patients had stage III (8) or IV (18) disease. Thirteen (36%) patients had bone marrow involvement. Twenty eight (77%) had elevated serum LDH levels, and 16 (44%) patients had an intermediate or high risk IPI score. Toxicities have been primarily hematologic with transient grade 3 or 4 neutropenia in 27 (74%) patients; grade 3 anemia in 6 (16%) patients; and grade 3 or 4 thrombocytopenia in 4 (11%) patients. In addition, 4 patients experienced neutropenic fever. Non-hematologic side effects of note were grade 3 mucositis/stomatitis in 2 patients; grade 3(n=1) and grade 4 (n=1) cardiac dysfunction in 2 patients. IgG, IgA, IgM levels were all decreased after 2 cycles of chemotherapy. Further cycles did not affect immunoglobulin levels. Of the 34 patients evaluable for response, 24 (71%) achieved complete remission, 7 (21%) achieved partial remission, 1 (3%) had stable disease, and 2 (6%) had progression of disease.

Conclusion:

The mid study evaluation confirms that R-CHOP given every 15 days with GM-CSF (sargramostim) administered on days 3 through 13 of each cycle provides promising response rates with tolerable toxicity.

Disclosures:

Tulpule: Genzyme, I am the PI on this study funded by Genzyme.: Research Funding.
Carfilzomib (CFZ): A Novel Proteasome Inhibitor That Induces Cell Cycle Arrest and Cell Death In Rituximab-Chemotherapy Resistant Lymphoma and Potentiates the Anti-Tumor Activity of Chemotherapeutic Agents
Authors: Gu Juan , Hernandez-Ilizaliturri Francisco J. , Kaufman Gregory P. , Mavis Cory , Czuczman Myron S.
Published: October 2019

Abstract 4908

Rituximab-chemotherapy relapsed/refractory B-cell lymphomas represent an emerging clinical challenge that underlies the need to develop alternative therapeutic strategies. Targeting the ubiquitin-proteasome system using bortezomib (BTZ) has resulted in significant anti-tumor activity and potentiates the effects of chemotherapy/biologic agents in multiple myeloma, and to a lesser degree, B-cell lymphoma. CFZ is as a novel proteasome inhibitor which is selective and structurally distinct from BTZ. In an attempt to characterize the biological activity of CFZ, we evaluated its anti-tumor activity in several lymphoma pre-clinical models. Rituximab-chemotherapy sensitive cell lines (RSCL), rituximab-chemotherapy resistant cell lines (RRCL), as well as primary tumor cells derived from patients with de novo or relapsed/refractory B-cell lymphoma, were exposed to escalating doses of CFZ or BTZ (1-7.5nM) alone or in combination with doxorubicin, paclitaxel, or gemcitabine for 24, 48 and 72hours. Cell viability was determined by cell titer glow luminescent assay and cell cycle was analyzed by FASCan DNA methodology. Patient-derived lymphoma cells were isolated from fresh biopsy tissue via negative selection using magnetic beads. Western blots were performed using cell lysates from CFZ, BTZ or control-treated cells to detect PARP-cleavage and/or changes in Bcl-2 family members. CFZ was more active than BTZ and exhibited dose-dependent and time-dependent cytotoxicity against RSCL, RRCL, and primary tumor cells. We found a 10-fold concentration difference between CFZ and BTZ activity. In vitro exposure of RRCL or RSCL to CFZ resulted in G2/M phase cell cycle arrest. In addition, CFZ exposure resulted in the up-regulation of Bak and Noxa levels and subsequent PARP cleavage in RRCL. Finally, CFZ demonstrated the ability to overcome resistance to chemotherapy in RRCL and potentiated the anti-tumor activity of paclitaxel and gemcitabine in B-cell lymphoma cell lines. In summary, our data strongly suggest that CFZ is a novel and potent proteasome inhibitor which is able to: overcome resistance to some conventional chemotherapeutic agents, upregulate proapoptotic proteins to enhance cell death, and induce G2/M cell cycle arrest in lymphoma cells. Our preclinical data supports future clinical evaluation of CFZ in patients with refractory B-cell lymphoma. (Supported by USPHS grant R01 CA136907-01A1 from the National Cancer Institute).

Disclosures:

No relevant conflicts of interest to declare.
Effect of Denileukin Diftitox on Pruritus and Other Skin-Related Symptoms Vs Placebo In Patients with Cutaneous T-Cell Lymphoma
Authors: Pinter-Brown Lauren , Kozlovski Anna
Published: October 2019

Abstract 4922

Introduction.

Cutaneous T-cell lymphoma (CTCL) is a heterogeneous group of non-Hodgkin's lymphomas (NHLs) that develop primarily in the skin but may progress to involve lymph nodes, blood, and visceral organs. CTCL is characterized by skin patches, plaques, tumors, and erythroderma. Pruritus is frequently associated with skin lesions in CTCL and may be severe. Some treatments have been noted to produce improvements in pruritus that appears to be independent of the response rate. Denileukin diftitox (DD, Ontak), a recombinant fusion protein targeting IL-2-receptor-expressing T lymphocytes, has demonstrated a significant effect on overall response rate with minimal immunosuppression in patients with CD25 assay-positive CTCL. For this post-hoc analysis, we used data from a randomized, double-blind, placebo-controlled, phase III clinical trial to assess the effect of DD on pruritus and overall skin condition in patients with CTCL.

Patients and methods.

Patients with CD25 assay-positive, stage Ia to III CTCL were randomized to receive 9 μg/kg/d DD (n=45), 18 μg/kg/d DD (n=55), or placebo (n=45). Study medications were administered on the first 5 days of a 21-day cycle for up to 8 cycles. Four grading scales were used to assess clinical signs and symptoms (Table 1).

Results.

Higher percentages of DD-treated patients experienced clinically significant improvements in skin-related symptoms than did patients on placebo during treatment and follow-up (Table 2). The differences between the proportions of patients in the placebo group experiencing clinically significant improvement and the proportions of those in the 18 μg/kg/d and combined DD dose groups were statistically significant for all 4 assessments. Substantially more DD-treated patients had ≥20% and ≥50% improvement in pruritus (relative to baseline) at any time than those receiving placebo; improvements were maintained for ≥6 weeks. The global skin score improvement and pruritus score improvement in both high dose and low dose groups were significantly correlated, with higher correlation in high dose group compared to low dose group (p=0.0004 vs p=0.0381). There is no correlation in placebo group for the two scores (p=0.3798). Improvement in pruritis was to some extent independent of response, as demonstrated by the proportion of agreement between tumor response and significant pruritus improvement (27% and 19% for high dose and low dose, respectively, in DD groups), based on Kappa concordance coefficient.

Conclusion.

Patients treated with DD, particularly at the 18-μg/kg/d dose, were more likely to experience clinically significant improvements in pruritus and other skin-related symptoms than were patients receiving placebo. DD was observed to improve pruritus independent of response.

Disclosures:

Kozlovski: Eisai Inc.: Employment.
Human Monocytes and Monocyte-Like Cells Are Highly Sensitive to Plitidepsin-Induced Cell Death In In Vitro Assays
Authors: Morande Pablo E , Zanetti Samanta , Borge Mercedes , Nannini Paula , Jancic Carolina , Bezares Raimundo , Galmarini Carlos M. , Gamberale Romina , Giordano Mirta
Published: October 2019

Abstract 4942

Plitidepsin (Aplidin®) is a marine-derived cyclic depsipeptide with strong cytotoxic effects against a variety of cancer cell types. It is currently in Phase II/III clinical trials for solid and hematologic malignancies. We evaluated the cytotoxic effects of Plitidepsin on lymphoid and monocyte cells from healthy donors and analysed the mechanisms involved. We found that monocyte cells showed a markedly higher sensitivity to Plitidepsin compared to lymphoid subsets as determined by incorporation of 7-AAD and flow cytometry analysis. Plitidepsin induced a dose- and time-dependent cell death on freshly isolated monocytes (7-AAD+ cells at 24 h: control: 3±1% versus Plitidepsin 10 nM: 47±5%, mean±SEM, n=6) and on macrophages (5±2 vs 49±3, n=5) and dendritic cells (4±1 vs 21±4, n=5) differentiated in vitro. By contrast, resting or mitogen-activated lymphocytes were not affected by Plitidepsin at 10 nM. The mechanisms of induced cell death in monocytes involved the early exposure of phosphatidylserine to the outer leaflet of plasma membrane, activation of caspase-3 and subsequent PARP fragmentation, indicative of death via apoptosis. Incubation of monocytes with Plitidepsin (10 or 100 nM) for 30 minuntes induced ROS production. On the other hand, the cytotoxic effect of Plitidepsin was significantly diminished when monocytes were pre-incubated with the antioxidant reagent Ebselen, which acts as an scavenger of peroxynitrite. We also determined Plitidepsin activity on malignant cells from chronic myelomonocytic leukemia (CMML) and chronic lymphocytic leukemia (CLL) patients. Monocyte-like cells obtained from 3 CMML samples resulted sensitive to Plitidepsin, though to a different extent (viable CD14+ cells at 24 h: control 100%, incubated with Plitidepsin 10 nM: sample 1: 79%, sample 2: 82%, sample 3: 29%). Finally we evaluated the effects of Plitidepsin on nurse-like cells (NLC) from CLL patients. These cells represent a subset differentiated from monocytes that favours leukemic cell progression through pro-survival signals. NLC were very sensitive to Plitidepsin and, more importantly, their death indirectly decreased neoplasic clone viability (7-AAD+ leukemic B cells co-cultured with control NLC: 36±10 versus 7-AAD+ leukemic B cells co-cultured with NLC exposed to Plitidepsin 100 nM for 24 h: 47±6, n=5, p<0.05). Myeloid cells are present in tumor microenvironment and actively affect the malignant cells, both directly and indirectly via the suppression of host immunity. Given their relevance in supporting tumor growth, the sensitivity of monocyte-like cells to Plitidepsin may contribute to its antitumoral effects.

Disclosures:

Galmarini: PharmaMar: Employment, Equity Ownership. Giordano: PharmaMar: Research Funding.
Function and Clonality of T-Cells In Myelodysplasia
Authors: Davison Glenda , Novitzky Nicolas , Abdulla Rygana
Published: October 2019

Abstract 4972

Objective:

Myelodysplastic (MDS) syndromes are clonal disorders arising from haematopoietic multi-potential stem cells. Research has implied that cells of the immune system play a role in the disease process. The aim of this study was to examine the clonality, response to mitogens, effects of lymphocytes on bone marrow clonogenic progenitors and proliferative capacity of selected marrow progenitors in a well defined cohort of MDS patients.

Methodology:

Seventeen patients with MDS were accrued. The clonality of the T-cells was studied using the TCR Vβ repertoire kit. In order to assess in vitro function, the lymphocytes were activated using phorbol 12-myristate13 acetate (PMA) and thereafter analysed for expression of the activation antigen CD69 using standard flow cytometry. The results were compared to age matched controls. The effect of the autologous blood mononuclear cell populations on clonogenic growth was studied by culturing Li- selected CD34+ cells with both PMA activated and non-activated autologous lymphocytes using a non-contact double layer culture technique.

Results:

T-cells did not demonstrate monoclonality, although skewing of the T-cell repertoire was observed. The median percent of CD3+ T-cells expressing CD69 after activation was 30% (9.5 – 95.4%). This was reduced in comparison to age matched controls (p=0.025). The effect of the lymphocytes on clonogenic cell growth was heterogeneous however median values demonstrated a cell dose response in the colony numbers directly related to cultured lymphocyte numbers (p=0.04 compared to no lymphocytes added). In addition, the median CFU-GM scores were higher when cultured with PMA activated lymphocytes (p=0.05). This pattern was not significantly different to normal controls.

Background:

Our investigations suggest that in this cohort of MDS patients the T-cells were not clonal but had reduced activation capacity when stimulated with the mitogen PMA. However, their ability to stimulate colony growth of autologous bone marrow CD34+ cells was preserved. Furthermore, selected CD34+ MDS cells proliferated well, with clone numbers not different from control. These observations imply that the previously reported abnormal T-cell responses and poor clonogenic growth may be the result of complex interactions between T-cells, the malignant clone and accessory cells in the bone marrow stroma. Further study examining each of these cell populations is required to better understand the mechanism of marrow failure and progression to leukaemia.

Disclosures:

No relevant conflicts of interest to declare.
EVALUATION of the Intra-LABORATORY Reproducibility of Percentage of Blast Counting IN MYELODYSPLASIA
Authors: Wuilleme Soraya , Eveillard Marion , Barille Sophie , Accard Francoise , Lodé Laurence , Avet-Loiseau Hervé , Garrand Richard
Published: October 2019

Abstract 4981

Background.

In the two International Prognostic Scoring Systems of Myelodysplastic Syndrom (MDS), the percentage of BLAST cells in the Bone Marrow is the most important parameter implicated in score: either directly in the IPSS (International Prognostic Scoring System) (1) or indirectly in the WPSS (Who classification-based prognostic scoring system) (2). In these two systems, as in the recommendations of the WHO 2001 (3), the morphological criteria defining blasts cells compared to promyelocyte cells are not specified.

In 2005, the IWGM-MDS (International Working Group on Morphology of myelodysplastic syndrome) (4-6) has established morphological criteria defining Blasts cells.

PURPOSE OF THE WORK.

Our objective in this study is to evaluate the reproducibility, among five observers of our laboratory, of the counting of the marrow blasts of 73 myelodysplasia.

Materials and Methods.

This study was conducted in several stages. 1st step was to test the implementation of the MDS-Foundation (http://www.mds- foundation.org/virtualmicroscopy) by 5 observers. The 2nd step was to perform correlation test of the selected cells from RAEB (selected and stained in our laboratory conditions), for the 5 observers. Finally Step 3 was to assess the correlation of blast percentage of 73 bone marrow smears from MDS patients, selected due to the presence of an excess of blast cells in the first reading on the bone aspiration.

Results.

Our results show that the correlation on counting blasts is generally satisfactory (percentage agreement: Test 1 = 86% and test 2 = 94%), while the concordance on the counting blasts of bone marow smears of 73 MDS patients and concordance on the WHO classification seems less satisfactory (agreement 3/5 observers. = 95% but agreed to 4–5/5 observers = 64%). These results can be explained partly by the inter-observer variability and by the variability of some parameters specific to smear marrow (poor quality smears, the staining and/or poverty of smears).

Conclusion.

The evaluation of the blasts in the MDS must be achieved: (i) at least 500 cells counted (ii) by at least two different observers (iii) by a third observer in discordant case. Despite these recommendations, the assessment of the blasts in myelodysplasia is difficult to achieve in many cases.

Disclosures:

No relevant conflicts of interest to declare.
Severe Lenalidomide-Induced Hypersensitivity Pneumonitis
Authors: Dy Irene A. , Gamboa Eric O. , Frankel Etta
Published: October 2019

Abstract 4982

Lenalidomide is an immunomodulatory agent that stimulates T-cell activation, enhances natural killer cells and inhibits cytokines, as tumor necrosis factor-alpha. It is FDA-approved for use in both transfusion-dependent myelodysplastic syndrome, especially 5q deletion syndrome and refractory and relapsed multiple myeloma. The known side effects are myelosuppression, diarrhea/constipation, fever, fatigue, rash and thromboembolism, while pulmonary complications are rarely reported. We present a patient with myelodysplastic syndrome on lenalidomide with acute pulmonary toxicity.

A 63-year-old Caucasian man was diagnosed with low-intermediate risk myelodysplastic syndrome with 5q deletion after presenting with anemia and thrombocytopenia. He was started on lenalidomide at 21mg daily dose but after 5 days began to develop dyspnea on exertion, cough and fever. He was admitted for treatment of community acquired pneumonia. Physical examination revealed a middle aged man in respiratory distress. Oxygen saturation on room air was 86%. Chest examination revealed dry crackles. Heart sounds were regular without murmurs or gallops. Laboratory tests revealed hemoglobin of 8.6g/dl, normal white count at 10,000 and platelets of 7,000/uL. BNP and echocardiogram were normal and chest radiography was initially unremarkable.

He was started on antibiotics but developed respiratory failure requiring endotracheal intubation and mechanical ventilation. CT scan of the chest showed diffuse interstitial reticulonodular opacities most prominent at the apices with scattered ground glass attenuation. Cultures from blood, sputum, urine and stool and brochoalveolar lavage did not reveal an infectious source. Broad spectrum antibiotics and antifungals were withheld. Clinical and radiologic improvement was noted after withdrawal of lenalidomide and initiation of steroids.

He was persistently transfusion-dependent hence lenalidomide was reintroduced. Within 6 days of lenalidomide, respiratory symptoms recurred. He later improved after withdrawal of the offending drug.

Our myelodysplastic patient developed acute respiratory failure after lenalidomide introduction which improved with steroids and drug withdrawal. He had symptom recurrence after reintroduction of lenalidomide. The exposure history, clinical and radiological examination, positive challenge test with exclusion of other etiologies support the diagnosis of lenalidomide-induced hypersensitivity pneumonitis. This is the third reported case of lenalidomide-induced hypersensitivity pneumonitis and it is likely that this entity is underdiagnosed due to concurrent steroid use especially in myeloma patients. Clinicians should be aware of this potential complication in patients who present with fever, hypoxemia and diffuse pulmonary infiltrates unresponsive to broad spectrum antibiotics as this disease is reversible if diagnosed early.

Disclosures:

No relevant conflicts of interest to declare.
Comparison of Survival and Clinical Features In Different Age Cohorts of Patients with Multiple Myeloma: A Single Center Experience
Authors: Jeong Jae Ho , Yoon Shinkyo , Kim Dalyong , Kim Jeong Eun , Yoon Dok Hyun , Kim Shin , Suh Cheolwon
Published: October 2019

Abstract 4997

Purpose

This analysis was aimed to compare clinical features in different age cohorts of multiple myeloma (MM) patients and to identify the impact of the clinical characteristics on survival in the patients in a single center.

Patients and Methods

We retrospectively analyzed data from 513 patients between Sep 1995 and Feb 2010 in the Asan Medical Center. Correlation of baseline characteristics with survival was made by the following age strata: <45, 45–54, 55–64, and ≥65 years of age.

Results

Median observed overall survival (OS) in the entire cohort was 3.20 years (95% confidence interval: 2.71–3.68). Observed survival decreased steadily with ages from 4.56 years in patients younger than age 45 years to 2.50 years in patients ≥65 years (P=0.003). The patients in the oldest group (age 65 years or older) were more likely to have International Staging System (ISS) stage II or III than others (P=0.007). There were no significant differences in hypercalcemia (≥10 mg/dL), elevated serum creatinine (≥2 mg/dL), anemia (Hb <10 g/dL) and osteolytic bone lesion, so called CRAB among the different age cohorts. Prognostic factors including elevated C-reactive protein (CRP) (≥ 0.8mg/dL), lactate dehydrogenase (LDH), bone marrow plasma cell infiltration also did not differ significantly among 10-year age cohorts. However, hypoalbuminemia (<3.5 g/dL) and high serum β2-microglobulin (≥3.5 mg/dL) level were more frequent in patients ≥65 years of age (P=0.001 and P=0.046, respectively). Furthermore, higher proportion of patients underwent ASCT in the younger 10-year age cohorts (71.4%, 53.7%, 43.4%, 2.5% in < 45, 45–54, 55–64, and ≥ 65 years of age, respectively, P<0.001).

Conclusion

No significant differences in the myeloma related organ or tissue impairment and prognostic markers including CRP, LDH and bone marrow infiltration of myeloma cells were noted among different age groups. However, survival significantly declined in the higher age group, which might be related to higher ISS stage associated with hypoalbuminemia, high serum β2-microglobulin level and lower proportion of patients receiving ASCT.

Disclosures:

No relevant conflicts of interest to declare.
Comorbid Diabetes Does Not Impact the Survival of Patients with Multiple Myeloma
Authors: Hsiao Liang-Tsai , Chiou Tzeon-Jye , Hong Ying-Chung , Liu Chun-Yu , Yu Yuan-Bin , Teng Hao-Wei , Yang Sheng-Hsiang , Yang Ching-Fen , Gau Jyh-Pyng , Liu Jin-Hwang , Hsu Hui-Chi , Chen Po-Min , Tzeng Cheng-Hwai
Published: October 2019

Abstract 5003

Background & aims.

For patients with multiple myeloma (MM), comorbid type II diabetes mellitus (DM) has leaded additional consideration and complications. Preceding DM in MM patients may have lead to end-organ damage involving cardiovascular, renal and nervous systems, and the use of glucocorticoids - the mainstay of anti-myeloma agents - further impairs glycemic control. However, it is not well studied at present whether comorbid DM itself will influence clinical features and prognosis of MM patients. Methods. Patients who were newly diagnosed in Taipei Veterans General Hospital between 1996 and 2007 were enrolled. Data of clinical features, comorbidities, and laboratory tests at diagnosis, treatment modalities, and survival at last follow up were collected. MM patients with or without DM was compared in terms of clinical/laboratory tests and outcome. Results. There were 389 MM patients (M/F=288/101, 74% vs. 26%) with median age of 71 years, with the features summarized in the Table. The immunophenotypes consisted of IgG (194, 49.9%), IgA (113, 29%), and light chain diseases (LCD) (67, 17.2%). Clinical stages included Durie-Salmon (DS) stage I/II/III = 7.2%/20.1%/72.7% and International Staging System (ISS) stage I/II/III = 14.5%/29.3%/56.2%. Serum Cr > 2.0 mg/dL at diagnosis was noted in 34%. Sixty patients (15.4% of 389) had DM preceding the diagnosis of MM. There was no statistical difference of median age, gender distribution, DS stages, and renal impairment when comparing MM patients with or without comorbid DM.MM patients with comorbid DM were associated with a lower prevalence of IgA-type diseases (with vs. without DM= 17% vs. 32%, P=0.094), an elevated serum beta-2 microglobulin >5 mg/L (with vs. without DM = 75% vs. 52%, P=.006), and ISS-stage III disease (with vs. without DM = 75% vs. 53%, P=.005). In terms of anti-myeloma therapy, the proportion of MM patients with or without DM who once received thalidomide, bortezomib and high-dose chemotherapy plus stem cell transplantation (HDT and SCT), and bisphosphonates were similar. The median overall survival (OS) of all patients was 20.5 months. The OS was well correlated with ISS stages (I vs. II vs. III = 51.2 vs. 27.2 vs. 13.4 months, P<0.001) but was not with comorbid DM. Conclusions. Comorbid DM was present in up to 15% of MM patients, and was more frequently associated with elevated serum beta-2 microglobulin (>5 mg/L) and ISS-stage III diseases; however, comorbid DM did not significantly influence the OS. Therefore, comorbid DM itself should not be considered as a contraindication of aggressive anti-myeloma treatments at present.

Disclosures:

No relevant conflicts of interest to declare.
Effect of Imids on Gene Expression Profiles of Fresh Human Myeloma Cells
Authors: Tagoug Ines , Plesa Adriana , Vendrell Julie , Dumontet Charles
Published: October 2019

Abstract 5013

Immunomodulatory drugs represent a major therapeutic advance in the treatment of patients with multiple myeloma. While these agents appear to exert various effects on the microenvironment, including effect on immune cells and angiogenesis, a direct effect on the tumor cells themselves is also likely. To describe and compare the effect of the three clinically available agents (thalidomide, lenalidomide, pomalidomide) we analyzed the gene expression profiles of fresh human myeloma cells exposed to thalidomide, lenalidomide or pomalidomide, using high density DNA arrays. Fresh human myeloma samples were obtained from bone marrow aspirates of patients with myeloma, and myeloma cells were immunopurified using anti CD138 magnetic beads. Purified myeloma cells (1.106 cells/ml) were incubated for 24 hours in RPMI 1640 medium supplemented with 10% fetal calf serum under each of the four following conditions: 1) DMSO; 2) thalidomide 40 microM; 3) lenalidomide 1 microM; 4) pomalidomide 100 nM. These levels are achievable in the plasma of MM pts. Pangenomic array experiments were performed usingWhole Human Genome 4 × 44K Agilent one-color microarrays. Data were normalized using the quantile normalization method. Samples were analysed for differentially expressed genes, taking into account both the level of significance and the fold-change. Ten evaluable samples were processed. Exposure to thalidomide, lenalidomide and pomalidomide induced differential expression of 36, 50 and 75 genes, respectively, in comparison to DMSO-exposed controls, the total list including 101 genes. Twelve of these were found to be differentially expressed after exposure to all of the three agents, including trophoblast glycoprotein, WAS protein family member 1, dickkopf homolog 1, pentraxin-related gene, CD28, interleukin 12B, tissue factor pathway inhibitor 2, phospholipase A2, dehydrogenase/reductase (SDR family) member 9, hypothetical LOC145788 and betacellulin. These commonly altered genes could be mechanistically involved in themultiple activities of these agents in multiple myeloma or may represent epiphenoma mechanistically unrelated to drug-induced cell death. Genes differentially expressed between the treatment with each of these agents could be indicative of the different and non-overlapping actions these agents have in multiple myeloma. An example of this is the recent demonstration that pomalidomide is clinically active in lenalidomide refractory patients. These results suggest that exposure to IMIDs induce various intracellular signalization pathways in myeloma cells which might be involved in the cytotoxic activity of these compounds.

Disclosures:

Dumontet: Celgene: Research Funding.
Frontline Management of Myeloma with Bortezemib and Dexamethasone - Focus on Renal Failure - A Study From India
Authors: Aggarwal Shyam , Jauhri Mayank , Negi Anita , Kohli Sangeeta , Minhas Sachin
Published: October 2019

Abstract 5045

Introduction:

First line treatment of myeloma has witnessed significant changes and improvement in the last one decade. Bortezemib – proteasome inhibitor and lenalidomide – IMID, in combination with other drugs offers the best chances to achieve complete remission and or very good partial remission. These two agents also seem to have overcome the barrier of poor prognostic factors including 4:14 translocation, 13p deletion, renal failure.

Material and methods:

We analysed 21 patients of multiple myeloma treated at our hospital in 2008–2009 with bortezemib and dexamethasone. Median age at presentation was 62 years. There were sixteen males and five females. IgG Kappa monoclonal spike was seen in fourteen cases. Light chains alone were seen in urine in 4 cases. Sixteen patients had renal failure. Bone involvement was seen in fifteen patients, anemia in sixteen cases. B2 microglobulin levels were >2.5mg/L in fifteen cases. As per ISS staging, thirteen patients were stage 3, six were stage 2 and two were stage 1. All patients were treated with bortezemib 1.3 mg per sq.mt and dexamethasone 40 mg day 1, 4, 8, 11. Cycles were repeated every three weeks. Four such cycles were given. Hemodialysis was done as indicated.

Results:

Complete remission (negative IFE) was seen in five, VGPR in five, PR in five, stable disease in four and progressive disease in two cases. Improvement in renal failure and independence from dialysis was seen in twelve of sixteen cases. Out of 21 cases, eight developed peripheral neuropathy – four mild to moderate and four severe painful neuropathy. In the latter four bortezemib was discontinued. Five patients developed thrombocytopenia requiring dose reduction for bortezemib. Four patients developed herpes zoster.

Conclusions:

Bortezemib and dexamethsone combination is effective and safe in frontline management of myeloma patients especially with renal failure. Acyclovir prophylaxis should be considered for all patients and peripheral neuropathy should be closely monitored.

Disclosures:

No relevant conflicts of interest to declare.
Ibandronate and Renal Function In Myeloma Patients
Authors: Bergner Raoul , Breuer Jochen , Sandermann Andreas , Uppenkamp Michael J. , Hoffmann Martin
Published: October 2019

Abstract 5047

Introduction:

Treatment of myeloma bone disease with bisphosphonates (BP) is standard of care. However, renal toxicity due to BP treatment tends to be a major problem in myeloma patients, especially. At highest risk are patients with reduced renal function and patients who had switched the BP. Toxicity appears typically after few month of BP treatment.

We evaluated the renal safety of ibandronate (IBD) in myeloma patients, who were treated with IBD for myeloma bone disease. The patients were stratified according to pretreatment and kidney function.

Methods:

In a prospective noninterventional study about safety and efficacy of IBD in breast cancer patients it turned out that myeloma patients were also included unintentionally. Out of 3540 documented patients 105 myeloma patients were identified. The data from these myeloma patients were evaluated separately.

The patients were subdivided in 4 groups according to their glomerular filtration rate [GFR]: GFR>90 (1), 60–90 (2), 30–59 (3) and <30 (4) ml/min. Since pretreatment with other BP could be of influence, patients were analysed according to former pretreatment: no BP (I), IBD (II), and other BP (III). The renal function was calculated every month over a period of six month by the MDRD-formula.

Results:

105 patients were available for evaluation. In 99 patients RF was documented over a minimum of 5 months. The initial RF was (1) n=14, (2) n=36, (3) n=38 and (4) n=17, respectively. At baseline there were no differences in renal function according to their pretreatment. A total number of 692 infusions were documented. The IBD dosage was 6 mg in 90% of all infusions, 4 mg in 3,6%, 3 mg in 2% and 2 mg in 4.4%, respectively. The GFR (mean GFR+/−SD) was stable over time in the groups 1–3 and increased significantly in group 4;

The mean changes were similar in all groups irrespectively of the pretreatment. In 9 patients the treatment was terminated prematurely, due to disease progression (n=3), death due to myeloma during study period (n=3). Two patients were lost by follow up and one patient declined further treatment.

Discussion:

The data of this noninterventional study demonstrate, that there is no evidence for renal toxicity of IBD in myeloma patients in all stages of renal function. Quite in contrary to previous observations with other BP patients with worse kidney function (stage 4) had a significant improvement of GFR over the study period. The reason for this observation remains unclear, because parameters like hypercalcemia or burden of light chains are not recorded in this study.

Disclosures:

Off Label Use: Ibandronate is not approved for myeloma bone diease.
Thalidomide Based Regimens for Treatment of Unfit Patients with Relapsed and Refractory Multiple Myeloma: a Monocentric Experience
Authors: Moscetti Alessandro , Saltarelli Francesca , Bianchi Maria Paola , Monarca Bruno , La Verde Giacinto
Published: October 2019

Abstract 5048

Thalidomide, an immunomodulating drug with antiangiogenic activity, is an efficacious therapeutic option for unfit patients with multiple myeloma. Its efficacy may be increased by the addiction of steroids or other cytotoxic drugs such melphalan or cyclophosphamide. In this study we assessed the efficacy and toxicity of thalidomide based regimens as savage therapy in a series of elderly patients with relapsed/refractory multiple myeloma. Previous treatments included at least one therapy (range 1–4), such as high dose dexamethasone, alkylating agents, anthracyclines, IFN-α and autologous graft. Thalidomide 50–200 mg/die was administered orally in a total of 16 patients (median age 73.8 years, range 59–84) with relapsed/refractory multiple myeloma observed in our Hematology Department between May 2004 and January 2010. Oral dexamethasone or prednisone was added to the treatment. All patients continued therapy until relapse or progression and were prospectively followed-up including accurate monitoring of side effects. Response to thalidomide was assessed according to the European Group for Blood and Marrow Transplantation criteria. The median follow-up time was 25.6 months (range 8 – 68). Overall response rate was 81.2% (13/16 patients) with a median duration of response of 26.7 months (range 7 – 67): 3 patients showed a very good partial remission, 10 partial response, 1 stable disease and 2 progression of disease. During follow-up, 6 patients died (3 due to progression, 2 due to other neoplasm, 1 due to heart failure), 10 patients are still alive (2 VGPR and 7 PR in continuous therapy, 1 PD in third line therapy). No response was observed in 3/16 patients (18.7%). Despite the following side effects, mild to moderate bradycardia (25%, 1 needed PMK positioning and 1 dose reduction), peripheral sensitive polyneuropathy (18.7%) and constipation (6%), no patient discontinued therapy. This study shows that thalidomide based regimens are an effective therapy with a high response rate and manageable side effects when used in patient with multiple myeloma with relapsed/refractory disease.

Disclosures:

No relevant conflicts of interest to declare.
JAK2 V617F Mutation In Atypical Chronic Myeloid Leukemia
Authors: Nam Myung-Hyun , Kim Ju-Yeon , Yoon Soo-Young , Lim Chae Seung , Lee Chang Kyu , Cho Yunjung , Kim Young-Kee , Lee Kap No
Published: October 2019

Abstract 5069

Atypical chronic myeloid leukemia (aCML) is a rare leukemic disorder which shows myelodysplastic and myeloproliferative features simultaneously. Some cases of JAK2 V617F mutation in aCML were reported before WHO criteria introduced (Jelinek J et al. Blood 2005; Jones AV et al. Blood 2005; Levine RL et al. Blood 2005). However, Fend F et al observed no JAK2 V617F mutation in aCML as defined by WHO classification (Fend F et al. Leuk Res 2008), which result was refuted by a case report (Campiotti L et al. Leuk Res 2009). Here we analyzed JAK2 V617F mutation with amplification refractory mutation system (ARMS) and direct sequencing in three cases of aCML and found a case with JAK2 V617F mutation. All three cases were diagnosed as aCML according to WHO classification and showed significant myelodysplastic/myeloproliferative features in peripheral blood and bone marrow aspirates. Absence of BCR/ABL1 gene rearrangement was confirmed by FISH analysis, and conventional cytogenetic analysis revealed trisomy 8 in a case with no JAK2 V617F mutation. The patient with JAK2 V617F mutation poorly responds with hydroxyurea therapy and is showing prolonged leukocytosis.

Disclosures:

No relevant conflicts of interest to declare.
Posttransplant Lymphoproliferative Disorders (PTLD) After Renal Transplantation: Focus on HLA Antigens
Authors: Strandhave Charlotte , Jørgensen Kaj Anker , Bendix Knud , Jespersen Bente , Pedersen Robert Schou , Søndergaard Esben , Mortensen Leif Spange , d'Amore Francesco
Published: October 2019

Abstract 5074

Background:

PTLD is a lymphoid proliferation that develops as a consequence of immunosuppression. It represents monoclonal B-cell, or rarely T-cell, proliferations, occurring in a setting of decreased T-cell immune surveillance. It has been shown that HLA-B mismatching is associated with increased risk of skin cancer in recipients of renal transplants. An association between skin cancer related to human papillomavirus and HLA-A11 has also been established in this group of patients. Bakker et al has shown that HLA-B mismatching is a risk marker of PTLD. More specifically, Subklewe et al found that HLA-B18 and HLA-B21 were associated with increased risk of PTLD, whereas mismatch at HLA-A03 and HLA-DR7 level reduced the risk of PTLD. We therefore hypothesized that mismatch of certain HLA alleles may be risk predictors of PTLD after renal transplantation.

Methods:

According to the national renal transplantation database of the Danish Society of Nephrology, 872 renal transplantations in 793 patients were performed at Aarhus University Hospital between 1990 and 2005. A total of 11 cases of PTLD were retrospectively identified through the National Danish Pathology database and individually reviewed by an experienced hematopathologist (KB). PTLD patients were investigated according to transplantation procedure, clinicopathological patient characteristics, type of lymphoma, outcome and HLA haplotype of both donor and recipient.

Results:

Univariate Cox regression analysis showed no positive correlation between risk of PTLD and number of HLA-B mismatches, or with HLA-A or HLA-DR mismatches. Conversely, we found a decreased risk with one/two HLA-B mismatches compared to no mismatches (p<0.01). With regard to specific alleles, HLA-B37 showed a trend towards an association with PTLD (OR = 8.62; 95% CI 1.70–43.6; P<0.04), whereas the same association was significantly stronger for HLA-DR6 (OR= 30.7; 95% CI 4.97–189.8; p<0.005). Unlike earlier reports, no association with HLA-B18 and HLA-B21 mismatches was observed.

Conclusions:

Our data suggest not only that the risk of developing PTLD is unaffected by an increasing number of HLA-B mismatches, but that a low number of such mismatches may even protect against PTLD developement. In our analysis, we found a moderate correlation between PTLD and HLA-B37, and a stronger one with HLA-DR6. The latter observation has never been previously reported. Further analyses with larger cohorts of renal transplant patients are needed to clarify the role of HLA antigens as risk markers for PTLD in order to establish whether a pre-emptive PTLD monitoring of renal transplant patients expressing certain haplotypes/haplotype mismatches is justified.

Disclosures:

No relevant conflicts of interest to declare.
Demylinating Peripheral Neuropathy and Lymphoplasmacytic Lymphoma
Authors: Huff Carol Ann , Chaudhry Vinay , Sumner Charlotte , Cornblath David
Published: October 2019

Abstract 5090

Lymphoplasmacytic lymphoma (LPL) is a neoplasm of small B lymphocytes, plasmacytoid lymphocytes, and plasma cells, which does not fulfill criteria for any of the other small B-cell lymphoid neoplasms (WHO 2008). Neuropathy has been described in association with Waldenstrom's macroglobulinemia, but less so with LPL. We present 7 cases of neuropathy and LPL to highlight the variable presentations. 1) A 56 year old man developed sensory ataxia with an IgM kappa non-MAG paraprotein. CSF protein was 97. Stabilized on MMF, he slowly worsened. Plasma exchange (PE) was given with improvement. Bone marrow (BM) 4 years into his course revealed LPL. Rituximab was given, and his PE reduced. 2) A 49 year old woman developed progressive weakness with rapid decline in January 2010. NCS showed demyelinating polyneuropathy, and CSF protein was 179. An IgM kappa non-MAG paraprotein was found. BM was normal. PE was given with improvement but later prednisone, IVIg and rituximab twice did not help. Repeat BM revealed 2% clonal CD20+ CD5negCD10neg B cells by flow cytometry. PE was given with modest improvement. Cyclophosphamide 1 gm/m2 monthly was given with improvement. 3) A 53 year old man noted imbalance and distal weakness. NCS showed absent SAPs and prolonged distal and F wave latencies. An anti-MAG positive, IgM kappa paraprotein was found. In 2002 BM was normal. He received rituximab weekly × 4 doses. 7 years later, he developed anemia and worsening neuropathy. Repeat BM showed 0.5% CD20+CD5negCD10neg kappa-restricted B cells by flow cytometry and weekly rituximab was reinitiated. 4) A 62 year old man developed weakness and areflexia. NCS showed asymmetric demyelinating polyneuropathy. Biclonal gammopathy of IgM kappa and IgG kappa was found. BM showed LPL by histopathology. Prednisone was given with improvement. Later two courses of weekly rituximab were given. 5) A 55 year old woman developed asymmetric weakness. NCS showed asymmetric demyelinating polyneuropathy. MRI showed enlargement, abnormal signal intensity, and abnormal enhancement of bilateral radial, median, and ulnar nerves. She was found to have an IgG kappa paraprotein and LPL on BM biopsy. She was treated with rituximab, cyclophosphamide, fludarabine, and PE. In each case, the primary feature driving the need for therapy was the neuropathy and not the underlying hematologic process. Further, worsening neuropathy in 3 cases led to repeat bone marrow biopsies revealing a clonal B cell process and a diagnosis of lymphoplasmacytic lymphoma. Thus, in the presence of an IgM monoclonal gammopathy and peripheral neuropathy, we suggest bone marrow examination for LPL and then consideration of therapy directed toward the abnormal B cell clone.

Disclosures:

No relevant conflicts of interest to declare.
REFRACTORY Blastic Extramedullary Plasmacytoma
Authors: Trainor Sebastian , O'Briain D. S , Gillham Charles , O'Mahony Deirdre
Published: October 2019

Abstract 5102

Tumour classification defines clinically distinctive, non-overlapping disease entities that serve the basis for future investigation and therapeutic management. The World Health Organization committee for classification of haematological malignancies is truly one of the first worldwide group to provide a consensus approach encompassing morphology, immunophenotyping, genetic and clinical features. However, there are limitations. Not all diseases fit into specific categories. Attention to unique clinical presentations facilitates our continued education. We report a blastic variant of an extramedullary plasmacytoma.

A fit 61 year old Caucasian man presented with a progressive neck and right upper limb (RUL) pain. No other relevant past medical or family history. Examination revealed a sensory neuropathy involving the 7th cervical dermatome. MRI cervical spine revealed a 5cm right paravertebral mass extending from C5-T1, surrounding the right vertebral artery and the roots and trunks of the right brachial plexus. It extended into the right neural foramina at the C5-C6, C6-C7 and C7-T1 levels with more minimal invasion at the C4-C5 level. Over a two week period he complained of increasing RUL pain, a right Horner's syndrome and weakness of the small muscles of his hand. An excision biopsy of the mass was performed and staging investigations were completed including CT body, lumbar puncture, bone marrow aspirate/biopsy, serum and urine protein electrophoresis. A PET/CT showed the right sided paraspinal nodal mass with low to moderate metabolic activity.

A diffuse, monotonous population of medium size cells with average nuclear: cytoplasm ratios, blastic chromatin, round nuclei and smooth contours surrounding a relatively unremarkable reactive lymph node. Mitoses are readily apparent, along with 'starry sky' appearance imparted by numerous tangible-body macrophages within the infiltrate. An extensive immunohistochemical panel were performed. The cells of interest express CD45, Cd38, vs38, CD138, MUM1, CD4, CD15, p53, weak CD19 and lambda light chain. The proliferation rate by Ki-67 is high approximately 60%. The overall phenotype was consistent with plasma cell differentiation but the mitotic rate and morphological rate does not fit well.

An initial response to definitive radiotherapy (40Gy/20fr) was swiftly followed 6 weeks later with a profound C5 radiculopathy. MRI imaging confirmed an extra-axial lesion, lying partially within the radiation port. The patient is now receiving salvage chemotherapy.

The behaviour of this lesion both under the microscope at the bench and the bedside is at odds with that predicated for a plasmacytoma, highlighting the critical importance of interplay between different medical disciplines. While blastic variants have been described for many haematological malignancies, it has not been previously reported in this situation.

Disclosures:

No relevant conflicts of interest to declare.
Sideroblastic Anemias Associated with Marked Thrombocytosis, the Role of JAK2 (V616F) Mutation (exon 6 and 12)
Authors: Corinaldesi Giorgio
Published: October 2019

Abstract 5135

The refractory anemia with ringed sideroblasts (RARS) and multilineage dysplasia is often associated with marked thrombocytosis; the research of JAK2 (V617F) mutant alleles was positive, JAK2 mutation is present in patients with polycythaemia vera (70%-95%), essential throbocythemia (32%-58%), CIMF (36%-50%), resulting in a valine to phenylalanine substitution at position 617; the mutation increases the kinase activity of JAK2 and the auto-phosphorylation and hyperactivation of EPOR and TPOR these two causing eritroid cells hyperplasia, the increase of dysgranulocytopoiesis with small hypolobulated dysplastic form and megakaryocytopoiesis with cluster of giant cells and enhanced risk for thrombosis greater than 30% or recurrent thrombosis greater than 20%. Dysgranulocytopoiesis features includes hypogranulation of myeloid cells, pseudo Pelger form, ringed sideroblastosis, thrombocytosis (>600.000/nL) with refractory cytopenia, and signficantly higher levels of PF4.

We have studied 8 patients with RARS–T, and we have found that JAK2 mutation is present in 5 out of 8 patients; these patients had a significantly higher white cells count, an increase of the tyrosin-kinase 2, and an enhanced activation of downstream transcription factors such as STAT-3 and STAT-5 A/B signalling cytokines that induce FOXP3 up regulation in activated CD4+, CD25+ regulatory T cells. Several defects of aggregation are present and deficiency of ATIII, PC, PS, splenomegaly were associated with a mild bleeding tendency.

Disclosures:

No relevant conflicts of interest to declare.