bluuebunny/crossref_metadata_2025 huggingface dataset:
Inferior Long-Term Outcome of Front-Line Hypomethylating Agent Compared to Supportive Care in Patients with Lower Risk Myelodysplastic Syndrome: Prosensity Score Matched Analysis
Authors: Sohn Sang Kyun , Moon Joon Ho , Jae Sook Ahn , Kim Hyeoung Joon , Song Moo kon , Shin Ho-Jin , Lee Won Sik , Lee Sang Min , Joo Young Don , Lee Ho Sup , Kim Yang Soo , Cho Yoon Young , Bae Sung Hwa
Published: October 2019

Background

Supportive care (BSC) including hematopoietic cytokines still remains an important component of treatment for lower-risk myelodysplastic syndrome (LR-MDS) including low or intermediate-1 risk by International Prognostic Scoring System (IPSS) even in the era of hypomethylating agents (HMA). The role of front-line HMA for LR-MDS has not been clearly defined yet. In the current study, we evaluated the long-term outcomes of patients with LR-MDS treated with front-line HMA compared to those treated with supportive care.

Methods

The data of 353 patients diagnosed with LR-MDS from Oct 1992 to Jul 2013 were retrospectively evaluated. The prognostic factors affecting overall survival were evaluated within all population. Then, we performed a case-constrol study using 122 patients with propensity score matched (PSM) population.

Results

Initial patient population (n=353) included 110 patients treated with BSC and 243 treated with HMA. Patients characteristics (age, gender, IPSS risk groups, IPSS blast score, IPSS cytopenia score) were similar between two groups, however, ECOG performance status (PS) and IPSS cytogenetic score were biased between two groups. ECOG-PS 2-3 were 32 patients (29.1%) in BSC and 20 (9.3%) in HMA group (p<0.001) and IPSS cytogenetic score °Ã0.5 were 27 patients (25.2%) and 33 (14.6%) in HMA group (p=0.032). In the multivariate analysis, ECOG-PS 2-3 (HR 4.586, p<0.001), IPSS blast °Ã0.5% (HR 2.549, p<0.001) and front-line HMA therapy (HR 2.019, p=0.006) were unfavorable factors affecting OS. Using PSM population, we performed a case-control study comparing the outcomes of 61 patients in each group who treated with BSC and front-line HMA. Patient characteristics were well balanced between two group. In the multivariate analysis, ECOG-PS 2-3 (HR5.036, p<0.001), IPSS blast °Ã0.5% (HR 2.157, p=0.035), and first-line HMA therapy (HR 2.213, p=0.026) were still unfavorable factors for OS. The 5-year OS rate was 62.5±10.8% in BSC group and 41.0±7.4 in HMA group, respectively (p=0.049).

Conclusion

Front-line HMA for patient with LR-MDS showed inferior long-term outcomes compared to BSC in PSM population. The role of front-line HMA should be elucidated in prospective studies on LR-MDS patients.

Figure. Overall survival between BSC and HMA groups in propensity score matched population Figure. Overall survival between BSC and HMA groups in propensity score matched population

Disclosures

Off Label Use: Rituximab has been used as an off-label drug for adult ALL, and has been provided by Roche Inc. for scientific purpose. .
Multiple Myeloma Cells Induce Mitochondrial Stress Response in Bone Marrow Mesenchymal Stromal Cells
Authors: Berenstein Rimma , Blau Olga , Nogai Axel , Wächter Marlies , Schmidt-Hieber Martin , Pezzutto Antonio , Dörken Bernd , Blau Igor Wolfgang
Published: October 2019

Introduction: Interaction of multiple myeloma (MM) cells with the surrounding bone marrow mesenchymal stromal cells (BMMSCs) is crucial for MM proliferation and survival. We have previously reported that in vitro cultured MM-BMMSCs display premature stress-induced senescence and constitutive changes in gene expression (Blood, 2013). Because mitochondrial oxidative stress could be the reason for senescence in MM-BMMSCs we investigated the metabolic interplay between MM-BMMSCs and MM cells.

Methods: In this study we analyzed 51 patients with MM, 4 patients with monoclonal gammopathy of undetermined significance (MGUS) and 10 healthy donors. Investigations ofNAD-dependent deacetylase sirtuin-3 (SIRT3) expression and mitochondrial mass were performed with SYBR-Green Real-Time PCR and relative quantification by linear regression. In addition, 20 co-cultures of MM-BMMSCs and KMS12-PE MM cell line were carried out. After incubation for 72 h SIRT3 expression in MM-BMMSCs was analyzed. Moreover, reactive oxygen species (ROS) production and mitochondrial membrane potential (ΔΨM) in co-cultured KMS12-PE cells and MM-BMMSCs were investigated by FACS analysis.

Results: MM-BMMSCs displayed a 2-fold decrease in SIRT3 expression and a 2-fold increase in mitochondrial mass compared to healthy donor BMMSCs (HD-BMMSCs). These changes were not detected in MGUS-BMMSCs, suggesting an association with disease progression. Furthermore, the increase in mitochondrial mass could be induced by oxidative stress in MM-BMMSCs and is a feature of senescent cells. Because SIRT3 is a major regulator of the mitochondrial function, reduced expression could account for accumulation of reactive oxygen species in MM-BMMSCs cultured in vitro. Interestingly we found a 4-fold upregulation of SIRT3 expression in MM-BMMSCs when co-cultured with KMS12-PE myeloma cells. This indicates that cell-cell-contact to MM cells influences the mitochondrial function in MM-BMMSCs and induces mitochondrial stress response. Moreover, we found decreased levels of ROS and ΔΨM in co-cultured KMS12-PE myeloma cells and MM-BMMSCs compared to cells cultured alone. Therefore, MM cells seem to modify the mitochondrial function and induce expression of antioxidants in MM-BMMSCs aimed at reducing ROS levels and increasing cell proliferation and survival pathways in both cell types.

Conclusion: Our results indicate that MM cells influence the mitochondrial function of MM-BMMSCs. This interaction leads to reduced ROS levels in both cell types and could support their survival and growth. Moreover, the sustained induction of mitochondrial stress response could be the reason for premature senescence in MM-BMMSCs when separated from MM cells. Therefore, MM therapy outcome may be improved through the disabling of the metabolic interplay between MM cells and MM-BMMSCs.

Disclosures

No relevant conflicts of interest to declare.
Interferon Alpha May Improve the prognosis of Advanced Myeloproliferative Neoplasm Patients with JAK2V617F Mutations
Authors: Xiaoli Liu , Ding Li , Xu Na , Huang Bintao , Zhou Xuan , Qisi Lu , Huang Jixian
Published: October 2019

Objective Whetherinterferon alpha (IFN-α) has special therapeutic effect formyeloproliferative neoplasm (MPN) patients with JAK2V617F mutations was not widely confirmed. Our purpose was to evaluate the therapeutic effect of interferon alpha (IFN-α) in MPN patients with JAK2V617F mutations.

Methods A total of 99 advanced MPN patients (including 68 polycythemia vera (PV) patients with 34 JAK2V617F mutations and 68 essential thrombocytosis (ET) with JAK2V617F mutations) patients) were enrolled to the study during 2007 to 2013 with informed consent, then they were divided into two groups: the IFN-α group (patients received a standard dose of IFN-α with (30-50)ug/d ) and the Hydroxyurea (HU) group (patients received a a dose of (0.25-0.5)g/d for HU). The progression-free survival rate were analyzed for a median of 32.0 (6.0 to 60.0) months follow-up period.

Results The overall response rate between IFN-α and Hydroxyurea therapy groups of essential thrombocytosis (ET) patients with JAK2V617F mutations had no significant difference (88.2% vs 85.0%, P>0.05), but the 5-year progression-free survival rate of two groups showed significant difference (88.2% vs 55.0%, P<0.05). The overall response rate (78.6% vs 82.4% ) and 5-year progression-free survival rate (57.1% vs 58.8%) between IFN-α and Hydroxyurea therapy groups of ET patients without JAK2V617F mutations had no significant difference (P>0.05). The overall response rate between IFN-α and Hydroxyurea therapy groups of polycythemia vera (PV) patients with JAK2V617F mutations had no significant difference (80.0% vs 75%, P>0.05), but the 5-year progression-free survival rate of IFN-α and Hydroxyurea therapy groups showed significant difference (86.7% vs 50.0%, P<0.05). After the treatment of IFN-α and HU for six months, the ratio of Interferon-treated patients need to continue phlebotomy was significantly lower than hydroxyurea therapy group (8.3% vs 58.3%, P<0.05). The thromboembolic events,splenomegaly, bone marrow fibrosis of interferon treatment group were lower than hydroxyurea treatment group showed significant difference (P<0.05). The adverse reactions of IFN-α was moderate, most of the patients in this study could tolerate the therapy. The major side effect of hydroxyurea was hematologic adverse reactions (Grade 1-2) with mainly reduce of white blood cells and thrombocytopenia, which showed difference between IFN-α and hydroxyurea (P<0.05).

Conclusions IFN-α may improve the prognosis of ET and PV patients with JAK2V617F mutations. Moreover, patients with PV and JAK2V617F mutations may be benefit for the treatment of IFN-α and could be recommended for an effective choice.

Disclosures

No relevant conflicts of interest to declare.
Determination of Driver Mutations in JAK2, MPL, and Calreticulin in Coronary Patients with Suspected Essential Thrombocythemia
Authors: Gasser Klaus , Muendlein Axel , Kinz Elena , Leiherer Andreas , Steurer Michael , Fraunberger Peter , Drexel Heinz , Lang Alois
Published: October 2019

Patients with essential thrombocythemia (ET) are at increased risk towards atherothrombotic complications. The JAK2 V617F mutation is found in at least half of the patients with ET and screening for JAK2 V617F mutational status has been included in the World Health Organization diagnostic criteria for ET. Further somatic driver mutations including mutations in exon 12 of the JAK2 gene, MPL mutations W515L/W515K, as well as mutations in exon 9 of the calreticulin (CALR) gene have been suggested as diagnostic markers for ET. Due to the close relation of ET to thrombotic events, early diagnosis of ET is of high clinical relevance, especially in patients with increased cardiovascular risk, like coronary patients. However, elevated blood cell counts are often ascribed to a reactive genesis within an acute coronary event. For this reason mostly no further clarification concerning myeloproliferative neoplasms is done.

In the present study, therefore, we determined the prevalence of JAK2 V617F, JAK2 exon 12, MPL W515L, MPL W515K, and CALR exon 9 mutations in a cohort of patients undergoing coronary angiography for the evaluation of suspected or established stable coronary artery disease and suspected diagnosis of ET. We aimed at identifying those with occult ET proposing need for additional treatment.

From a total of 1,589 coronary patients, 12 patients had increased platelets (>450 x10 9/L) predisposing them to ET. Mutation analysis among these patients showed three individuals with the JAK2 V617F mutation and one with an ins/del mutation in exon 9 of the CALR gene confirming suspected diagnosis of ET. Consequently, frequency of ET was 0.25% among our coronary patients. For comparison, in the United States between 38 and 57 ET cases per 100,000 age-adjusted inhabitants have been reported. This corresponds to an up to 7-fold accumulation of ET cases in coronary patients compared to the general population.

We conclude that the prevalence of ET is increased in coronary patients compared to the general population. For this reason comprehensive mutation analysis should be considered in all cardiovascular risk patients with persistent elevation of thrombocytes, not only to identify patient subgroups at high risk but also to individualize therapeutic strategies.

Disclosures

No relevant conflicts of interest to declare.
Disparities in Utilization of Autologous Hematopoietic Progenitor Cell Transplantation for Multiple Myeloma in the US
Authors: Costa Luciano J , Huang Jia-Xing , Hari Parameswaran N.
Published: October 2019

Introduction: Autologous hematopoietic progenitor cell transplantation (AHPCT) is an established modality in the treatment of patients with multiple myeloma (MM) with impact in depth and duration of remission and, in some studies, overall survival. Utilization of AHPCT for treatment of MM in US is increasing but still low. Race-ethnicity, sex and age-disparities may affect AHPCT utilization, although they do not impact benefit from AHPCT.

Methods: MM incidence derived from Surveillance, Epidemiology and End Results (SEER-18) database and AHPCT for MM reported to the Center for International Blood and Marrow Transplant Research (CIBMTR) between 2005-2009 were analyzed. Cases were grouped in 4 racial-ethnic categories (REC): non-Hispanic Whites (NHW), non-Hispanic Blacks (NHB), Hispanics (irrespective of race) and Asians. We assessed utilization as the ratio between first AHPCT for MM and number of newly diagnosed cases in the period of interest and calculated the relative utilization ratio (RUR), as [utilization for a given category] / [utilization for the entire population].

Results: Data was obtained from 22,462 actual MM cases reported to SEER and 13,311 actual AHPCT reported to CIBMTR. NHW, NHB, Hispanics and Asians corresponded respectively to 72.0%, 18.7%, 6.7% and 2.6% of the new MM cases and 77.4%, 15.85, 5.2% and 1.6% of the AHPCT procedures. Median age at diagnosis of MM was higher in NHW (P=0.0002)and was higher in women than in men in all RECs. Age-adjusted RUR was 1.17 (95% C.I. 1.15-1.19) among NHW, higher than in NHB [0.69 (95% C.I. 0.67-0.72), P<0.0002], Hispanics [0.64 (95% C.I. 0.60-0.69), p<0.002] and Asians [0.65 (95% C.I. 0.58-0.73), P<0.0002]. There was higher utilization of AHPCT in men than in women detected among Hispanics (age adjusted RUR 0.72 vs 0.56, P=0.007), but not among NHW, NHB or Asians. Only 3.1% of the NHW patients younger than 65 were identified as uninsured vs. 8.1% of NHB, 11.9% of Hispanics and 3.2% of Asians (P<0.0001). Correction of sex disparity would lead to an overall increase of 1.3% in AHPCT for MM, higher among Hispanics (11.7%) but lower in the other categories (Figure, panel a). The hypothetical correction of racial-ethnic disparity would result in 15.9% increase in volume of AHPCT, with a pronounced increase among NHB, Hispanics and Asians (Figure, panel b). Increase in age at transplant will strongly affect AHPCT volumes with dissimilar impact in different RECs according to their age structure (Figure, panel c).

Conclusions: Race-ethnicity disparity greatly affects AHPCT utilization for management of MM in US. Sex disparity plays a much lesser role, except among Hispanics. The profound age disparity is decreasing over time and will likely continue to drive major increase of AHPCT activity.

Figure 1 Figure 1.

Disclosures

No relevant conflicts of interest to declare.
Familiar JAK2 G571S Variant Not Linked with Essential Trombocythemia
Authors: Panovska-Stavridis Irina , Eftimov Aleksandar , Pivkova-Veljanovska Aleksandra , Ivanovski Martin , Cevreska Lidija , Dimovski Aleksandar J
Published: October 2019

Somatic activating mutations in the JAK2 gene are one of the most important characteristics of the myeloproliferative neoplasams (MPNs). Moreover, JAK2 germline mutations occur in familiar MPN. However, the same JAK2 mutations are associated with different phenotypic MPNs and their exact role in the pathogenesis of the MPNs is not clear and well established.

Here, we report a family with a germline JAK2 G571S mutation associated with only one sporadic case of essential thrombocythaemia (ET). Our patient, male, born 1958, presented at the age of 54 with a marked and sustained thrombocythosis (platelets count higher than 1500x109per liter over a period of 3 months). The bone marrow biopsy sample revealed normocellular bone marrow with an increased number of megakaryocytes organized in clusters; the reticulin staining was negative. The molecular diagnostic work up towards MPNs included the analysis of BCR/ABL fusion transcript, JAK2, CALR and MPL mutations. These analyses showed that the patient had 2 variants which might account for the ET phenotype; a somatic CARL mutation (insertion p.K385fs*47) and a germline C-T substitution at codon 571 in exon 13 of the JAK2 gene. Extended family analysis showed that the G571 variant was also present in the patient’s father, brother and one daughter. All of them had normal hematological parameters and didn’t exhibit any abnormality in the serum ferritin, prolactin, lipids, fasting glucose levels, blood pressure, body mass index, skin and skeletal changes.

The JAK2 G571S mutation was already described in MPNs with a frequency <0.01 and was not recorded in the database of single nucleotide polymorphisam (SNP). Glycine at 571 is adjacent to Tyr570 which is one of the most important sites for autophosphorilation and downregulation of JAK2 signaling. The substitution of nonpolar Glycine for polar but non-charged Serine might affect this by altering the conformation of the protein and result in a constitutively active kinase. However, the absence of any hematological or other disorders in a wide age spectrum in carriers of this variant indicate that it is a silent nonfunctional polymorphism. Moreover, the ET phenotype present in the index case is reminiscent of other ET patients with somatic CALR p.K385fs*47 mutation, further demonstrating that the JAK2G571 variant is a non-functional silent polymorphism.

Our results support the need for routine screening for all mutations that might be involved in the pathogenesis of the MPNs since they are not always mutually exclusive and also not always responsible for the phenotypic expression of the MPNs.

Disclosures

No relevant conflicts of interest to declare.
Spectrum of Phenotypic Manifestations of a Novel c1339A>C, pS447R Germline GATA2 Mutation
Authors: Kochuparambil Samith T. , Jackson Amie E , Litzow Mark R. , Khan Shakila , Rodriguez Vilmarie , Hogan William J. , Abraham Roshini , Patnaik Mrinal M.
Published: October 2019

Background: Haploinsufficiency of GATA2 results in familial immunodeficiency and MDS/ AML. We identified a family with a novel c1339A>C, pS447R germline GATA2 mutation. Unlike most other disease-causing GATA2 mutations, this mutation occurred in the non-zinc finger domain. Methods: After due IRB approval, clinical and laboratory data were retrospectively abstracted.

Results: Seven family members with the mutation are being followed at our institution. (Table 1), of whom two have MDS, one MDS/AML and one with isolated neutropenia. At the time of diagnosis 5/7(71%) pt had decreased monocyte count. 4/7(57%) patients had decreased NK cell count and/or function. Only 1/7(14%) patient had decreased CD4 count. 3/7(42%) patients had reduced B cell numbers and 5/7(71%) patients had persistent HPV warts. Other infections include invasive Absidia sinusitis, infectious mononucleosis, pertussis, and blood stream infections with S. maltophilia and S.aureus. One patient had the Emberger's syndrome presenting with lymphedema and congenital pulmonary stenosis. Pulmonary manifestation included a patient each with decreased DCLO and hyperreactive airway disease. Genitourinary manifestations included pelvic kidney/dysplastic kidney, posterior urethral valve, dermoid cyst and hydrocele. Two female patients developed primary infertility. One patient had a history of appendicular carcinoid. 4/7(57%) patients have successfully undergone allogenic stem-cell transplantation.

Conclusion: Germline GATA2 mutations are associated with a high frequency of MDS/AML. We describe a family with a non-zinc finger GATA2 mutation causing MDS/AML, with a spectrum of hematological and non-hematological manifestations, once again, highlighting the heterogeneity of this syndrome and expanding the genotype-phenotype correlation in this disease. Abstract 5614. Table#Age/sexHemDAbso . MonoCount Abso. CD4 TCellNK cyto-toxicityAbso. NK CountAbso.B cell CountInfectiousDermCoag/VascularCVS/LungOthersNo.137/MAMLSeverely DecreasedNormalAbsentSeverely DecreasedAbsentAbsidia S.maltop- hilia S.aureusHPV WartsITP -Hydrocele 10 hyperparathyroidismNo.231/FMDSDecreasedNormalAbsentDecreasedNormalInfectious MonoHPV Warts-Hyper- reactive airwayInfertilityNo.317/FMDSSeverely DecreasedNormalUnknownDecreasedDecreasedHerpes stomatitisHPV Warts-Dec-DCLOPosterior urethral valveNo.49/MNeutropeniaSeverely DecreasedNormalNormalNormalNormalHSV-1HPV Warts Embergers syndrome Pul. Stenosis Congenital dysplastic Rt. Kidney Pelvic Lt. KidneyNo.531/F-DecreasedNormalDecreasedNormalNormal- -Qualitative platelet defectNoneInfertilityNo.635/F-NormalNormalDecreasedDecreasedDecreasedPertussisHPV Warts--Dermoid appendicular carcinoid No.756/F-NormalNormalNormalNormalNormalFrequent PNA----

Disclosures

No relevant conflicts of interest to declare.
Early Diagnosis of Multiple Myeloma - Project CRAB of Czech Myeloma Group(CMG)
Authors: Straub Jan , Hajek Roman , Scudla Vlastimil , Maisnar Vladimir , Gregora Evzen , Schutzova Miroslava , Adam Zdenek , Bacovsky Jaroslav , Spicka Ivan
Published: October 2019

Introduction: Multiple myeloma is one of the most frequent hematological malignancies. The prognosis of patients has substantially improved due to new treatment options. However, the early diagnosis is still a crucial factor for prognosis. First symptoms of myeloma are different and mostly unspecific - therefore many patients are diagnosed late with serious organ and/or tissue damage. Czech Myeloma Group initiated the program for early diagnosis of MM in 2007. Program (named due to educational reasons„CRAB“) was focused on general practitioners (GPs) and key specialists responsible for recognizing the symptoms related to MM (neurology, orthopedics, nephrology). We present results of the final analysis.

Methods: a/ telephonic survey for healthcare professionals, b/ written information for primary care providers, c/ brochures containing definition of clinical symptoms and recommended diagnostic methods, d/ patient questionnaire, e/ presentations at medical meetings in Czech republic, f/ presentation in non-hematological medical journals, g/ e-learning.

Primary objectives were: 1) decrease risk of late diagnosis ( > 3 month after first symptoms of myeloma) from 50% to 30% , 2) reduction of irreversible deterioration at the time of diagnosis from 20% to <10%. Secondary objectives were: 3) improve knowledge of the first-contact care providers about the initial symptoms of multiple myeloma 4) inform them about diagnostic methods applicable in first-contact care 5) inform them about new treatment modalities and improving prognosis of myeloma patiens.

Planned project duration was 7 years (2007-2013). The first interim analysis was done in 2010.

Results: 76,4% patients was diagnosed < 3 month after first contact with healthcare professionals according to the second analysis in 2013. Probability of early diagnosed patients increased from 53,5% in 2007 to 68,8%, ,i.e. by 29% , in 2013 However, incidence of the osteolytic lesions and renal failure at time of diagnosis remained similar.

Conclusion: The 7-year project leads to the increase of early diagnosis of MM by almost one third. Long-term analysis will show whether better knowledge of medical society about myeloma is transient (just during information campaign) or permanent.

Project was supported by Czech Myeloma Group and Jansen-Cillag.

Disclosures

Hajek: Merck: Consultancy, Honoraria; Celgene: Consultancy, Honoraria; Janssen: Honoraria.
Generation of a Predictive Score for Ixazomib Response in Multiple Myeloma
Authors: Mitra Amit Kumar , Dey Sanjoy , Hangsleben Andrew , Steinbach Michael , Kumar Vipin , Van Ness Brian
Published: October 2019

Multiple myeloma (MM) is the second-most common hematopoietic malignancy in the United States accounting for 1% of all cancers and 10% of all hematologic malignancies. Despite recent improvements in treatment strategies including the emergence of proteasome inhibitors (PIs) as effective chemotherapeutic agents, MM still remains difficult to cure with median survival rate of around 7 years, primarily due to wide inter-individual variation in response to treatment. We believe such heterogeneity in response to PIs is governed by the underlying molecular characteristics of the tumor including alterations in gene expression profile (GEP).

In the current study, we used a panel of Human Myeloma Cell Lines (HMCLs) representing the gamut of biological and genetic heterogeneity in MM to evaluate the gene expression signatures associated with response to the second-generation PI Ixazomib and produced a predictive score (PI score) for Ix response.

HMCLs (n=45) were treated with increasing concentrations of Ixazomib used as single agent and half maximal inhibitory concentration (IC50) values were determined using cell viability equation. Gene expression profiling data was obtained as publicly available data from the Keats lab website at TGen (http://www.keatslab.org/myeloma-cell-lines).

Genes with high expression value and high standard deviation beyond the median values were pre-filtered and log expression values were normalized by subtracting mean expression of individual genes across all the samples and the housekeeping genes (GAPDH). Subsequently, analysis of correlation between Ix IC50 data and GEP data and the False Discovery Rate (FDR) based on 1000 random permutations were performed to identify true patterns of genes that are highly predictive of Ix response and to look for the top genes that could discriminate between the top sensitive and top resistant cell lines. Gene clusters were identified that correlated with response and will be presented. Our results will demonstrate in vitro modeling of response using GEP approaches that may provide predictive scoring algorithms of a defined set of genes that will be useful in clinical evaluation of drug choice in treating individual patients.

Disclosures

No relevant conflicts of interest to declare.
CSF1R-Inhibition and Reduction of Macrophages Delays Multiple Myeloma Growth in a Non-T-Cell-Dependent Manner
Authors: Schjesvold Fredrik H. , Haabeth Ole Audun , Bogen Bjarne , Tveita Anders
Published: October 2019

Macrophages are important tumor-promoting cells, and can constitute up to half of the tumor mass, orchestrating remodeling, inducing angiogenesis and suppressing the immune system to terminate local inflammatory responses. Colony stimulating factor (CSF-1), also known as macrophage colony-stimulating factor (M-CSF), is the most important cytokine involved in survival, proliferation and differentiation of tissue macrophages and their precursors. Previous experiments from our group has shown that amount of CSF-1 in the tumor bed correlates with successful rejection of cancer cells in a TCR-transgenic model where CD4+ T cells recognize a tumor specific antigen produced by multiple myeloma cells. We therefore tested if reduced signaling via CSF-1R, and thereby a decrease in tumor infiltrating macrophages, would results in decreased growth of multiple myeloma cells. .

PLX3397, a tyrosine kinase inhibitor with specificity for CSF1R and KIT, has been demonstrated to delay tumor growth in a CD8+ T-cell-dependent manner after chemotherapeutic treatment in a murine model of mammary carcinogenesis. Here, we show that MOPC315 multiple myeloma cells implanted subcutaneously in matrigel plugs in SCID mice become infiltrated with M2 phenotype macrophages that enhances their growth. When given chow containing PLX3397, recruitment of macrophages is strikingly reduced, with significant delay in tumor growth. Importantly, this delay in tumor development is not T cell dependent, since the anti-tumor effect is seen in T cell deficient SCID-mice as well as in BALB/c mice. Importantly, treatment with PLX3397 does not abrogate efficient tumor killing, and does not affect survival, when tested in a TCR-transgenic model where CD4+ T cells via induction of M1 macrophages reject multiple myeloma.

In conclusion, PLX3397 delays tumor growth by reducing amounts of tumor infiltrating M2 macrophages, while rendering effective tumor killing by M1 macrophages uninhibited. Thus, drugs that inhibit signaling of CSF-1 could be of value in treatment of multiple myeloma.

Disclosures

No relevant conflicts of interest to declare.
Application of Hematopoietic Progenitor Cell Count: To Optimize Peripheral Blood Stem Cell Harvest
Authors: Takeshita Masataka , Hirai Risen , Tanimura Akira , Nakamura Miki , Hagiwara Shotaro , Miwa Akiyoshi
Published: October 2019

background.

High dose therapy and autogenic or allogeneic stem cell transplantation plays an important role in the treatment course of hematological malignancies. In some countries, major method of unrelated stem cell donation programs had shifted from bone marrow harvest (BM) to peripheral blood stem cell harvest (PBSCH). PBSCH is a heavy duty not only for donor or patient, also for medical staffs. In some cases, poor mobilization may cause poor collection of stem cells. Hemogram needs time for May-Giemsa stain, and CD34 count needs complicated technique and running cost. New simple tool to predict the count of mobilized stem cell is needed to optimize PBSCH.

methods.

Since 2009, we started measuring peripheral blood hematopoietic progenitor cell (HPC) with Sysmex XE-5000(R) blood cell counter. With IMI channel method, we could rapidly know the count of circulating stem cells. Daily HPC count and yielded CD 34 positive cell count were analyzed.

results.

189 samples were collected from 122 donors/patients. Diagnosis of patients: malignant lymphoma (n=29), leukemia (3), multiple myeloma (74), amyloidosis (5), cryoglobulinemia (1). 10 healthy donors were also included. Age: 18-66, Sex: male 82/female 40. Mobilization regimen: G-CSF 57, chemo+G-CSF 74, G-CSF+plerixafor 1

HPC count (cells/ul) and collected CD34 positive cells (106cells/kg) had positive correlation. When HPC count was above 25/ul, collected CD34 positive cells were above 1x106/kg (positive predictive value: 80.9%). Number of PBSCH operation was 1.59 in average. We also show three cases in which HPC count was useful to make clinical decision of initiating PBSCH.

discussion.

HPC and CD34 had positive correlation, and HPC >25/ul seems to be appropriate cut-off to start PBSCH. With our former threshold of PBSCH (G-CSF day>4, WBC >3000/ul), 241 operations were to be planned. Including HPC count, we could reduce PBSCH operation to 204.

Hematopoietic progenitor cell count is rapid and inexpensive method. Within 5 minutes, mobilized stem cells can be measured, and it may be also useful in outpatient-based harvest settings.

Figure 1 Figure 1.

Disclosures

No relevant conflicts of interest to declare.
Reduced Intensity Versus Myeloablative Conditioning for Allogeneic Stem Cell Transplantation in Acute Myeloid Leukemia
Authors: Fan Donna , Sabry Waleed , Stakiw Julie , MacKay Rebecca Ellyn , Bosch Mark , Sarker Sabuj , Elemary Mohamed
Published: October 2019

Introduction

Reduced intensity conditioning (RIC) regimens for allogeneic hematopoietic stem cell transplantation (SCT) offer a potential treatment for otherwise incurable cases of acute myelogenous leukemia (AML) with less associated toxicity compared to myeloablative conditioning (MAC). Eradication of malignant cells after RIC depends largely on the graft-versus leukemia effect (GVL). These regimens are becoming increasingly popular, particularly in older patients or those with comorbidities. They may also be offered to otherwise healthy patients based on personal or physician preference, as there is growing evidence that overall survival may be equivalent for both treatments. We retrospectively reviewed the charts of Saskatoon Cancer Centre patients receiving either RIC or MAC to compare the incidence and grade of graft versus host disease (GVHD), progression free survival (PFS), and overall survival (OS).

Methods

We identified 74 patients who underwent HSCT for AML in complete remission (CR) between January 2000- December 2013. Of these patients, 55 received MAC and 19 received RIC.

Median age at HSCT was 48 years (range 18-68). In the group receiving MAC, 36% of patients were >50 years, whereas 74% of patients receiving RIC were >50 yrs of age.

Results

Patients receiving RIC experienced greater incidence of chronic GVHD (63% vs 41%, p=.09) and relapse (54% vs 30%, p=.07). Incidence of acute GVHD was the same for either regimen (53%).

Median overall survival was similar (39 vs 38 months), with lower early mortality in RIC later overtaking MAC at 27 months. Progression free survival demonstrated a non-statistically significant advantage for MAC (median 43 vs 49 months).

Conclusion

RIC has been associated with greater incidence of chronic GVHD and relapse, with no difference in overall survival. Patients receiving RIC are more likely to be >50 years of age, making comparisons challenging. The results of this review suggest that MAC is the preferred regimen for patients who can tolerate its toxic effects due to reduced incidence of chronic GVHD and relapse, however the similarity in overall survival makes the choice of either conditioning regimen reasonable. Future studies to identify the best conditioning regimen are warranted.

Overall Survival

Figure 1 Figure 1.

Progression Free Survival

Figure 2 Figure 2.

Disclosures

No relevant conflicts of interest to declare.
Serem Ferritin Was the Only Prognostic Factor for Disease Free Survival in MDS Patients after Allo-HSCT: A Single Centre Study
Authors: Shi Jimin , Luo Yi , Tan Yamin , Lin Yu , Cai Zhen , Lin Maofang , Huang He
Published: October 2019

Introduction: Myelodysplastic syndrome (MDS) represents a heterogeneous group of hematopoietic stem cell disorders characterized by single-lineage or multi-lineage cytopenias and a risk of progression to acute myeloid leukemia (AML). Despite the development of new drugs, allogeneic hematopoietic stem cell transplantation (allo-HSCT) remains the only potential curative therapy. We have a retrospective analysis of the efficacy and security of the allo-HSCT therapy for MDS in our singal centre.

Method: Between June1999 and March 2012, 39 MDS patients with a median age of 32 years (range, 12-52) were transplanted with a matched related donor (n=10), unrelated donor (n=20) or haploidentical donor (n=9) in our centre. Of the patients, 62% were male; 44% had intermediate-1 risk, 13% intermediate-2 risk and 43% poor risk cytogenetics by the International Prognostic Scoring System criteria. The cell source was bone marrow (BM) in 36%, peripheral blood (PB) in 59% and BM+PB in 5%. 51% patients had received chemotherapy prior HSCT. Conditioning regimens were BUCY or BUCY plus ATG for matched related HSCT and unrelated transplants, AraC+BuCy+ATG+MeCCNU for haploidentical transplants. The median number of CD34+ cells/kg infusion was 5.52×106(range, 0.8×106-10.38×106).Graft-versus-host disease prophylaxis was employed by cyclosporine A (CsA), mycophenolate mofetil (MMF) and short-term methotrexate (MTX). 25 patients received serum ferritin measurement berore HSCT. The mediun level of serum ferritin was 1100ng/ml (range, 456-2318).

Result: The median follow-up was 27 months(range,1.5-154). The 3-year disease free survival(DFS) was 60.8%. Transplant related mortality(TRM) was assessed at 37% on the whole cohort. 5% has no engraftment for a total of 2 patients. A neutrophil count of >0.5 × 109/L was achieved at a median of 12 days (range, 9–24 days) and a platelet count of >20 × 109/L within 14 days (9–49 days) post-transplant. Acute GVDH grade 1-2 was documented in 49%, grade 3-4 in 5% and no GVDH in 46%. Chronic GVHD could be identified in 27 patients (69%), 5 of whom had extensive disease, while the other 22 had limited disease. Overall 14 patients (36%) died. Causes of death were Infection 57%,GVDH 8%, haemorrhage 14%, engraft failure 14% and “other causes” 7%. Only one patients died because of relapse of the disease.DFS according to donor source (matched related donor 87.5%, unrelated donor 51.6% and haploidentical donor 55.6%) was not significant (p =0.22 ). Likewise no significant difference was found on DFS among BM 57%, PB 66.4% and BM+PB 50% (p =0.65). A similar DFS was seen in different risk categories (56.7% in intermediate, 66.7% in high-risk; p=0.51). No difference was seen in DFS according to the CD34+ cell number and whether received chemotherapy prior to HSCT. Only the elevated serum ferritin is associated with inferior DFS after HSCT(p =0.018 ).

Disclosures

No relevant conflicts of interest to declare.
Safety and Outcomes of Extracorporeal Photopheresis with the Therakos Cellex System for Graft Versus Host Disease in Pediatric Patients
Authors: Uygun Vedat , Daloglu Hayriye , Karasu Gulsun , Hazar Volkan , Yesilipek M. Akif
Published: October 2019

Background: Graft-versus-host disease (GVHD) is a serious complication with a significant negative impact on survival following allogeneic hematopoietic stem cell transplantation (HSCT) in both adults and children. Immunosuppressants like steroids remain the mainstay of treatment which carries risks of increased infection frequency, a negative impact on the graft-versus-leukemia effect, and an increased probability of secondary malignancies. Extracorporeal photopheresis (ECP) treatment, seems to ameliorate GVHD by immunomodulation, rather than immunosuppression. However it is difficult to perform in pediatric population. This is a retrospective review of 17 pediatric patients who underwent photopheresis with the Therakos Cellex system for graft-versus-host disease (GVHD).

Procedure: Extracorporeal photopheresis regimen was same for all acute and chronic GVHD patients: initially every week (2 sessions/week) for two months, then every two weeks for two months; and finally, every month for at least one year. Demographic data, degree of GVHD before photopheresis, adverse reactions during photopheresis procedure, modification in immunosuppressive treatment, and response to photopheresis were recorded.

Results: Acute GVHD occurred in seven patients, overlap and chronic GVHD occurred in five patients in each group. The improvement observed in eleven of twelve patients who have acute GVHD (90%) and in seven of ten chronic GVHD patients (70%). Thirteen patients had skin involvement before ECP and eleven of them responded to treatment (84%). Gastrointestinal involvement occurred in ten patients and seven of them improved during ECP treatment (70%). All of the four patient´s liver involvements failed to respond. No serious adverse reactions occurred.

Conclusions: In conclusion, our study demonstrates that ECP with the Therakos Cellex system is a safe treatment option for GVHD in children.

Disclosures

No relevant conflicts of interest to declare.
Reduction in the Incidence and Severity of Graft Versus Host Disease in HLA-Matched and Haploidentical Bone Marrow Transplantation Using Posttrasplant Cyclophosphamide. Experience of Two Latino-American Institutions
Authors: Ovilla Roberto , Perez-Lozano Uendy , Calles-Payan Dannia , Reynolds-Ocampo Lucia A , Ruiz-Reyes Gabriela , Balderas-Delgado Carolina , Cabrera Garcia Alvaro
Published: October 2019

The Graft Versus Host Disease (GVHD) grades II-IV is present in up to 40% in Human Leucocyte Antigen (HLA) - identical related transplants and up to 80% of non-related. The HLA-haploidentical bone marrow transplantation (BMT) has been associated with significant risks of graft rejection and severe GVHD, as an excessive alloreactivity by host and donor T cells. High dose of Cyclofosfamide (Cy) after BMT inhibits both graft rejection and GVHD. We want to share our experience in preventing GVHD in HLA - haploidentical alloBMT and HLA-matched related BMT using the strategy of Cy post-Transplant. We evaluated 25 patients from March 2013 to June 2014, all of them were in advanced stages of the disease or they have characteristics of poor prognosis before transplantation. All patients received non-myeloablative conditioning and Cyclofosfamide (Cy) 50 mg/Kg postrasplant (on days 3 and 4 after transplantation), Mycophenolate mofetil (from day 5 to 35) and Tacrolimus (from day 5 to 180). The 64% (16) were male, mean age 30.6 years (range 2 – 67 years), with a average follow-up of 198 days (range 14-512 days). The 76% (19) were HLA-matched related alloBMT (7 patients) and HLA-haploidentical alloBMT (12 patients) in hematological malignancies, the rest of trasplants (24%) were HLA-haploidentical alloBMT in benign hematological diseases, overall survival (OS) at day 180 by type of transplant was 70%, 64%, and 67% respectively. 28% (7) had graft failure. 11 patients had no acute GVHD, 10 patients had GVHD grade I-II, and 3 patients had grade III, only 1 patient died because of grade IV (P = 0.005). Chronic GVHD occurred in 4 patients (16%). As a complication related to Cy therapy, hemorrhagic cystitis was observed 32%(8). Posttransplantation cyclophosphamide is able to reduce the likelihood of developing chronic GVHD and reduces the severity of acute GVHD, it plays an important role in the feasibility of a haploidentical transplant because the lower incidence of GVHD. Our results showed one of the most satisfactory and encouraging studies on the use of post-transplantation Cy performed in Latin America.

Disclosures

No relevant conflicts of interest to declare.
Donor KIR B Haplotype Is Associated with a Increased Rate of Leukemia Relapse and Worse Overall Survival after HLA Match Sibling Pediatric Stem Cell Transplantation
Authors: Pérez-Martínez Antonio , Martinez Isabel , Valentin Jaime , Fernandez Lucia , José Luis Vicario , Miguel Ángel Diaz
Published: October 2019

Introduction

Graft versus leukemia (GvL) effect after hemotopoietic stem cell transplantation (HSCT) is mediated by donor immune cells recovery. Natural Killer (NK) cell alloreactivity is controlled by the interaction of activatory receptors and inhibitory killer-immunoglobulin-like receptors (KIRs) with major histocompatibility locus class I antigens on the leukemia cells. Haploidentical setting is a plattform for NK cell alloreactivity however HLA identical setting remains unclear.

Methods and Patients

We performed KIR-genotyping of HLA-identical sibling donors in 35 pediatric CD34 selection peripheral blood stem cell transplantations to identify genetic factors affecting leukemia relapse and overall survival. Univariate analysis of leukemia relapse and KIR genotyping was performed in order to identify independent variables predictive of outocome for pediatric acute lymphoblastic leukemia (ALL), (n=20) and acute myeloblastic leukemia (AML), (n=15).

Results

Donor B haplotype was observed in 21 cases (60%). Statistical analysis shown that donor B haplotype was associated with significantly more relapse in leukemia pediatric patients (38% vs. 0%) and worse overall survival (40% vs. 7%). Further analysis revealed that 2DL5a, 2DS3 and 2DS5 were associated with an increased rate of leukemia relapse (47% vs. 6%, 54% vs. 10% and 58% vs. 13%, respectively) and 2DL5a, 2DS1 and 3DS1 were associated with a worse overall survival (48% vs. 6%, 64% vs. 10% and 58% vs. 13%, respectively). No difference was observed in patients KIR haplotype or donor-recipient KIR haplotype mismatch.

Conclusion

In our study, which included only reduced intensity conditioning without antithymocyte globulin followed by related peripheral blood stem cell transplantation, we found a significant worse impact of donor KIR B haplotype in stem cell transplantation outcome. Our results suggest that donor KIR B haplotype (2DL5a, 2DS3 and 2DS5) increases leukemia relapse and also donor KIR B haplotype (2DL5a, 2DS1 and 3DS1) confer significant survival damage to HLA-identical sibling HSCT.

Figure 1. Donor KIR genotyping (2DL5A, 2DS1 and 3DS1) impacts in overall survival. Figure 1. Donor KIR genotyping (2DL5A, 2DS1 and 3DS1) impacts in overall survival.

Disclosures

No relevant conflicts of interest to declare.
Evidence of Effect Modification of Graft-Versus-Leukemia Effect of Cytomegalovirus By Alemtuzumab in Myeloid Malignancies Undergoing Unrelated Donor Transplantation
Authors: Shanavas Mohamed , Uhm Jieun , Alam Naheed , Atenafu Eshetu G , Kuruvilla John , Lipton Jeffrey H. , Messner Hans A. , Seftel Matthew , Gupta Vikas , Kim Dennis
Published: October 2019

Several studies have suggested a beneficial effect of CMV seropositivity and or reactivation on relapse risk after allogeneic hematopoietic cell transplantation (HCT) in myeloid malignancies. Inability to replicate this finding in T cell depleted HCT is suggestive of a potential effect modification between TCD and CMV in this setting, but this has not been addressed in previously published studies.

We have retrospectively analyzed transplant outcomes in 192 patients with myeloid malignancies who have undergone unrelated donor HCT at our center during January 2006 –November 2013. Among this 111 patients received in vivo TCD with low dose (30 mg) alemtuzumab and 81 patients received non-TCD transplants. Recipients were CMV seropositive in 57% of TCD transplants and 59% of non-TCD transplants.

Analysis showed a significant effect modification (p=0.03 for interaction) between alemtuzumab and CMV serostatus on relapse risk, and stratified analysis based on recipient CMV status showed inferior outcomes with alemtuzumab in CMV seropositive recipients but not in CMV seronegative recipients. In CMV seropositive recipients alemtuzumab was an independent predictor of higher relapse (Hazard Ratio=13.95, p=0.008), inferior relapse free survival (HR=2.30, p=0.002), and inferior overall survival (HR= 2.04, p=0.008).

There was no difference in NRM between CMV seropositive and CMV seronegative groups, or between TCD and non-TCD transplants.

These findings suggest the presence of an effect modification by TCD on CMV's effect on relapse, resulting in inferior transplant outcomes with low dose Alemtuzumab in CMV seropositive recipients, but not in seronegative recipients.

Figure 1. CIR, NRM, RFS, and OS showing differential effects of T cell depletion between CMV seropositive and seronegative recipients (A-B) Cumulative incidence of relapse, (C-D) Non-relapse mortality, (E-F) Relapse free survival, and (G-H) Over all survival. Figure 1. CIR, NRM, RFS, and OS showing differential effects of T cell depletion between CMV seropositive and seronegative recipients. / (A-B) Cumulative incidence of relapse, (C-D) Non-relapse mortality, (E-F) Relapse free survival, and (G-H) Over all survival.

Disclosures

Off Label Use: Alemtuzumab for GVHD prophylaxis.