bluuebunny/crossref_metadata_2025 huggingface dataset:
Combination of the hyperCVAD Regimen with Dasatinib Is Effective in Patients with Relapsed Philadelphia Chromosome (Ph) Positive Acute Lymphoblastic Leukemia (ALL) and Lymphoid Blast Phase Chronic Meyloid Leukemia (CML-LB)
Authors: Jabbour Elias , O’Brien Susan , Thomas Deborah A. , Faderl Stefan , Koller Charles Asa , Dara Samuel , Garris Rebecca , Cortes Jorge , Kantarjian Hagop M , Ravandi Farhad
Published: April 2020

The dual Src and Abl inhibitor dasatinib is ~325 times more potent in vitro against BCR-ABL kinase activity and has significant clinical activity in patients with imatinibresistant lymphoid blast phase CML (CML-LB) and Ph+ ALL. In this study, patients with relapsed Ph+ ALL or CML-LB received dasatinib 50 mg po bid (or 100 mg daily) for the first 14 days of each of 8 cycles of alternating hyperCVAD and high dose cytarabine and methotrexate. Patients in CR continued to receive dasatinib 50 mg po bid (or 100 mg daily) and vincristine and prednisone monthly for 2 years followed by dasatinib indefinitely. To date 14 patients with relapsed Ph+ ALL or CML-LB have received a median of 3 cycles (range 1–8); 1 patient in complete remission (CR) is receiving maintenance therapy. Median age was 43 years (range 21–69); 4 (29%) patients were older than 50 years. Median WBC at start of treatment was 6.8 × 109/L (range, 0.4 – 27.2 × 109/L). Median blast percentage was 45% (range 0–96%) Three patients had CNS involvement. Median number of previous therapies was 1 (range, 1–4) including hyperCVAD and imatinib, tyrosine kinase inhibitor monotherapy, investigational agents and transplantation. All patients were evaluable for response. 10 patients (71%) achieved CR and 4 patients (29%) achieved CR with incomplete platelet recovery (CRp). Twelve of 14 (86%) patients achieved a major cytogenetic response, complete in 11, 1 (7%) had insufficient metaphases, and 1 (7%) had no response. Overall, 9 (64%) patients had achieved a major molecular response, complete in 5. Median time to neutrophil and platelet recovery during the first course was 18 and 22 days and 18 and 26 days, respectively after subsequent courses. Four patients relapsed after median response duration of 19 weeks (range, 9–38); two of them had acquired ABL kinase domain mutations: One patient lost his baseline mutation, Y253H, and acquired T315I and E450G; the second lost his 3 baseline mutations, Y253H, F359V, and E459K, and acquired T315I.Two patients received an allogeneic transplantation and one patient received a donor lymphocyte infusion. Grade 3 and 4 toxicities included 7 episodes of bleeding (4 GI, 1 GU, and 2 subdural hematomas), 4 episodes of pleural effusions, 2 episodes of pericardial effusions, infections, diarrhea, hypophosphatemia, hypocalcemia, elevated transaminases, and hyperbilirubinemia. With a median follow up of 6 months (range, 1–13 months), 9 patients are alive; 7 in CR/CRp. Two patients died after disease relapse, 1 died post transplant and 2 died in CR/CRp from infections. In conclusion, the hyperCVAD regimen with dasatinib is feasible and effective in patients with relapsed Phpositive ALL and CML-LB.
Stapled Peptides: Leveraging the BH3 α-Helix to Create a New Class of Drugs to Treat Hematological Malignancies
Authors: Kapeller Rosana , Han Jiawen , Sun Kaiming , Gangurde Pranoti , Kawahata Nori , Iadanza Matt , Guerlevais Vincent , Horstick Jim , Noehre Justin , Annis Allen , Licklider Larry , Nash Huw M. , Kung Andrew , Sawyer Tomi K.
Published: April 2020

AILERON is developing a selective approach to restore programmed cell death in cancer cells by borrowing from nature the BH3 domain alpha-helical “keys” from pro-apoptotic members of the BCL-2 family that fit into the “locks” of other anti- and pro-apoptotic BCL-2 proteins. AILERON has applied its proprietary chemical strategy termed hydrocarbon stapling (J. Am. Chem. Soc., 2000 122:5891) to generate cell-permeable BH3 stapled peptides that modulate the intracellular protein-protein interactions of BCL-2 family members and selectively kill cancer cells both in vitro and in vivo (Science, 2004 305:1466). The lead compounds possess the innate characteristics of the endogenous peptides they mimic, including mechanism of action and target specificity. BID BH3 and BIM BH3 stapled peptides have recently been shown to directly activate the pro-death molecule BAX, a unique property that differentiates BH3 stapled peptides from all BCL-2 small molecule antagonists (Mol. Cell, 2006 24:199). BID BH3 and BIM BH3 stapled peptides were tested for their ability to induce programmed cell death in a panel of 12 lymphoid-derived tumor cell lines. T-ALL derived cell lines were the most sensitive to the compounds, followed by multiple myeloma lines. CML-derived cell lines were the least sensitive. Resting human peripheral blood lymphocytes (hPBLs) and normal human embryonic lung fibroblasts (WI-38) were found to be resistant to BH3 stapled peptides, indicating that the compound may target only cells that are “primed to die” and not normal “resting” cells. The anti-cancer activity of BH3 stapled peptides was further investigated in orthotopic xenograft models and shown to dramatically suppress tumor growth. In a mixed lineage leukemia model (SEMK2), a tumor over control (T/C) of 27% was observed after 13 days of treatment at 30 mg/Kg IV q.d. We also investigated whether BH3 stapled peptides elicit an antibody response in rodents. No antibody titer was detected, indicating that BH3 stapled peptides are non-antigenic in rodents. While peptides are oftentimes unstable in vivo, with half-lives typically in the range of a few minutes, BH3 stapled peptides were 100% stable in both mouse and human plasma ex vivo, and exhibited excellent PK profiles in rats with half-lives greater than three hours. BH3 stapled peptides were well tolerated in all animal models tested to date. In conclusion, we show that BH3 stapled peptides exhibit promising pharmacological properties and represent a novel class of drugs for the treatment of hematological malignancies.
CXCR4 as a Predictor of Response in Acute Myeloid Leukemia
Authors: Pastore Domenico , Mestice Anna , Giannoccaro Margherita , Liso Arcangelo , Martelli Maria Paola , Carluccio Paola , Albano Francesco , Delia Mario , Rossi Antonella Russo , Leo Manuela , Pannunzio Alessandra , Liso Vincenzo , Falini Brunangelo , Specchia Giorgina
Published: April 2020

The expression of CXCR4 (CD184) has been associated with poor prognosis in Acute Myeloid Leukemia (AML) and it has also been suggested that the CXCL12(SDF-1a)/CXCR4 interaction contributes to the resistance of leukemia cells to chemotherapy-induced apoptosis. Inhibition of CXCR4 was found to enhance chemotherapy-induced apoptosis in a subset of leukemic myeloblasts that carry Flt3 mutations and to overcome chemoresistance associated with stromal activity. NPM variants with a cytoplasmic localization represent the most common mutation detected in myeloid malignancies and are associated with a favourable clinical outcome. A recent study provides biological evidence for a novel role for NPM as a negative regulator of CXCR4 signalling induced by CXCL12: suppression of NPM expression enhanced chemotactic responses to CXCL12, and conversely, over-expression of a cytosolic NPM mutant reduced chemotaxis induced by CXCL12. We investigated whether CD184 expression is a negative predictor factor for response to chemotherapy and if there is clinical evidence that NPM mutations could overcome chemoresistance to induction therapy in this subset of patients. The expression of CD184 was analyzed by flow cytometric methods in a group of 70 cases of adult AML at onset of disease, diagnosed at our Institution since January 2006. The diagnosis was performed according to FAB/WHO criteria; all patients received intensive chemotherapy according to institutional protocols. There were 34 males and 36 females and median age was 46 years (range 18–65). AML cells were gated based upon their CD45 expression and samples were considered positive if CD184 was expressed by more than 20% of blasts. CD184 was positive in 45 and negative in 25 cases. There was no significant difference between the two groups in terms of sex, age, Hb level, WBC and Plt counts, percentage of blasts, and occurrence of the NPM mutation. The CR rate was 45% in CD184+ and 82% in CD184- (p=0.03); among CD184+ cases, the CR rate was significantly higher in NPMc+ cases, (p=0.03). Our results show that CD184 expression is associated with a lower rate of CR after induction therapy and this association is stronger in NPM unmutated cases, suggesting that CD184 expression is a negative predictive factor for response to chemotherapy. Further data are needed to verify if the biological role of the cytosolic NPM mutant as a negative regulator of CXCR4 signalling induced by CXCL12 could have a clinical role contributing to overcome the resistance of leukemic cells to induction chemotherapy.
Sequential Cytarabine and Alpha-Particle Immunotherapy with Bismuth-213 (213Bi)-Labeled-HuM195 (Lintuzumab) for Acute Myeloid Leukemia (AML)
Authors: Rosenblat Todd , McDevitt Michael R. , Mulford Deborah A. , Pandit-Taskar Neeta , Weiss Mark A. , Heaney Mark L. , Chanel Suzanne , Morgenstern Alfred , Larson Steven M. , Scheinberg David A. , Jurcic Joseph G.
Published: April 2020

HuM195, a humanized anti-CD33 monoclonal antibody, targets myeloid leukemia cells and has single-agent activity against acute myeloid leukemia (AML). To enhance the potency of native HuM195 and avoid nonspecific cytotoxicity seen with β-emitting radioimmunoconjugates, the α-emitting radiometal 213Bi was conjugated to HuM195. The feasibility, safety, and antileukemic activity of 213Bi-HuM195 were shown in a phase I trial (Jurcic et al. Blood 2002). Because of the short-range (50–80 μm) and high linear energy transfer (8400 keV) of α particles, radioimmunotherapy with 213Bi is ideally suited for the treatment of residual disease. To determine the effects of 213Bi-HuM195 against cytoreduced disease, we treated 31 patients (median age, 67 years; range, 37–80) with cytarabine 200 mg/m2/day for 5 days followed by 213Bi-HuM195 in a phase I/II trial. Thirteen patients had untreated AML (5 with de novo AML; 8 with secondary AML). Eight patients had AML in untreated first relapse, and ten patients had heavily pretreated relapsed AML (n=7) or primary refractory AML (n=3). Nine patients had poor-risk cytogenetics. During the phase I portion of the study, cohorts of 3–6 patients were treated with 18.5, 27.75, 37, and 46.25 MBq/kg. Prolonged myelosuppression with grade 4 leukopenia > 35 days was the most common dose-limiting toxicity. The maximum tolerated dose (MTD) was 37 MBq/kg. Extramedullary toxicity was primarily limited to ≤ grade 2 events, including infusion-related reactions; however, grade 3/4 liver function abnormalities were seen in four patients (13%). Treatment-related deaths occurred in two of 21 patients (10%) who received the MTD. Significant reductions in marrow blasts were seen at all dose levels, and clinical responses were observed in 6 of the 25 patients (24%) who received doses of at least 37 MBq/kg (2 CR, 2 CRp, 2 PR). The median response duration was 7.7 months (range, 2–12). Pharmacokinetic and biodistribution studies suggested that saturation of all available CD33 sites by 213Bi-HuM195 was possible after cytoreduction with cytarabine. Sequential administration of cytarabine and 213Bi-HuM195 is tolerable and can produce complete remissions in patients with AML.
Impact of CRi on the Outcome of Elderly Patients with Untreated Acute Myeloid Leukemia (AML)
Authors: Etienne Anne , Charbonnier Aude , Prebet Thomas , Coso Diane , D’Incan Evelyne , Doglio Marie-Francoise , Sainty Daniele , Mozziconacci Marie-Joelle , Rey Jerome , Vey Norbert
Published: April 2020

New international recommendations of response for treatment of AML include morphologic complete remission with incomplete blood count recovery (CRi). This response criteria was defined following evaluation of new drugs used for the treatment of AML in first relapse (Sievers et al., JCO2001;19:3244–3254). The objective of our study was to evaluate this criterion in elderly patients with AML who are in first line of treatment. Between 1995 and 2006, 454 patients aged 55 years or older with previously untreated acute non promyelocytic leukemia received a conventional anthracycline and cytarabine induction chemotherapy in our institution. Ages were between 55 and 85 years (median 65 years). Two hundred and fourty-eight patients achieved a complete response (CR) (55%), 37 patients achieved CRi (8%), 104 patients had persisting leukemia (23%), and 49 died during remission induction therapy (13%). Multilineage dysplasia, secondary AML and blasts expressing CD34 were significantly more frequent in patients achieving CRi than CR (58% versus 29%, p=0.001, 33% versus 15%, p=0.007, and 79% versus 54%, p=0.01, respectively). No favorable prognostic karyotype was found in the CRi group but cytogenetic distribution did not differ statistically between the two groups. All patients who reached CR or CRi were scheduled to receive consolidation. Only 24 patients (65%) in CRi actually received this consolidation chemotherapy course and 11 patients (30%) had intensification (intermediate-dose cytarabine and/or autologous stem cell transplantation) whereas for patients achieving CR, 233 (94%) and 214 patients (86%) received consolidation and intensification, respectively (p<0,001 for both). None of the patients in CRi received an allogenic stem cell transplantation whereas 18 (7%) of CR patients had one (p=0,2). Disease-free survival (DFS) and remission duration were significantly different between patients in CRi and CR, with a median of 4 and 12 months, and 5 and 9 months respectively (p<0,001 and 0,03). The median overall survival (OS) was also significantly lower for patients in CRi versus CR, respectively 8 and 23 months (p<0,001). By landmark analysis, there was no difference in OS between patients in CRi and a group of 98 patients with induction failure surviving at least 60 days (p=0,4). We also noted that OS was better, in the group of patients in CRi, for those who finally achieved CR criteria after 1 or more course of post-remission chemotherapy (median 16 months, against 7 months for patients still in CRi, p=0,03). Our results show that the CRi criterion is not equivalent to CR in elderly patients who received intensive chemotherapy as the first line treatment of AML. This should be kept in mind when the results of new agents used in this setting are compared to historical data.
Age and Prognosis in Pediatric AML
Authors: Edslev Pernille Wendtland , Abrahamsson Jonas , Clausen Niels , Forestier Erik , Gustafsson Göran , Heldrup Jesper , Hovi Liisa , Jahnukainen Kirsi , Jonmundsson Gudmundur , Palle Josefine , Zeller Bem , Hasle Henrik
Published: April 2020

Introduction. Results from St. Jude and M. D. Anderson, USA, suggested that AML children < 10 years have significantly better outcome than patients aged 10–21 years. Similarly, the Medical Research Council, UK, showed superior survival in children < 10 years due to a lower relapse rate compared to 10 – 15 year olds. We describe the AML outcome by age in the Nordic countries.

Patients. Within the population based NOPHO AML protocols (NOPHO-AML 93 and NOPHO-AML 2004) we treated 403 patients aged 0 – 18 years from 1993 – 2007. Patients with Down syndrome and AML-M3 were excluded. The children were divided into three age groups; 0 –1 year (27%), 2 –9 years (41%) and 10+ years (32%). The oldest age group had a male preponderance. MLL-aberrations were more common among the youngest and t(8;21) among the oldest. FAB-type M5 was seen in 35% of 0–1 year olds versus only in 16% of children aged 10+.

0 – 1 year  n= 109 2 –9 years  n = 165 10 – 18 years  n = 129 Boys/girls 44/67 = 0.67 80/87 = 0.94 80/49 = 1.63 p = 0.01 WBC>100×109/L 18 (17%) 14 (9%) 18 (14%) p = 0.10 Cytogenetics  t(8;21)   t(9;11)   Other MLL 1 (1%)  14 (13%)  21 (19%) 24 (15%)  12 (7%)  16 (10%) 15 (12%)  9 (7%)  9 (7%) p = 0.01  p = 0.39  p = 0.03 FAB type  M4  M5 22 (20%)  38 (35%) 32 (19%)  31 (19%) 26 (20%)  21 (16%) p = 0.96  p = 0.00 Protocol  NOPHO-AML 93  NOPHO-AML 04 75 (25%)  34 (32%) 125 (42%)  40 (37%) 96 (32%)  33 (31%) p = 0.4

Results. Almost half of the patients experienced events during follow-up. Types of events, event-free survival (EFS), and overall survival (OS) are shown in the table.

0 – 1 year n= 109 2 –9 years n = 165 10 – 18 years n = 129 Induction death 2 (2%) 4 (2%) 3 (2%) p = 0.9 Resistant disease 2 (2%) 2 (1%) 9 (7%) p = 0.01 Death in CR 6 (6%) 4 (2%) 8 (6%) p = 0.2 Relapse 34 (31%) 64 (39%) 42 (33%) p = 0.4 5-year EFS 57% 54% 48% p = 0.5 5-year OS 68% 68% 64% p = 0.7

Conclusion. Older children are more often male, more frequently have t(8;21) and less often M5-subtype or MLL-aberrations. The OS and EFS are similar among all ages. However, older children more often have resistant disease. The risk of death during induction and relapse is similar.
The Comparison Between Matched Related Donor and Alternative Donor for Allogeneic Hematopoietic Stem Cell Transplantation in Patients with Acquired Aplastic Anemia: KSBMT2007-02 Study
Authors: Kim Hawk , Koo Hong Hoe , Kook Hoon , Kim Byung Soo , Kim Sung Hyun , Kim Hack-Ki , Kim Hyeoung Joon , Bae Sung Hwa , Sohn Sang Kyun , Shin Ho-Jin , Ahn Hyo Seop , Won Jong-Ho , Yoon Sung-Soo , Lee Young-Ho , Jeong Dae-Chul , Jo Deog-Yeon , Joo Young-Don , Kim Min Kyoung , Hyun Myung Soo , Lee Kyoo Hyung
Published: April 2020

Backgound; Although allogeneic hematopoietic stem cell transplantation (alloSCT) from matched related donor (MRD) is a standard therapy for severe acquired aplastic anemia (AA), alternative donor (AD) alloSCT is increasing and the survival of alloSCT from AD improves nowadays.

Aims: We planned this study to review the recent result of alloSCT survival and to compare AD with MRD.

Methods: A retrospective study comparing MRD and AD for alloSCT in patients with AA was conducted by Korean Society of Blood and Marrow Transplantation (KSBMT2007-02 study).

Results: The patient population was AA, pure red cell aplasia, paroxysmal nocturnal hemoglobinuria, and they underwent alloHSCT from 1997 and 2007. Total 336 patients were enrolled in 24 Korean alloSCT centers. Survival analysis was done in 331 patients because data were not available in 5 patients. Two hundred five adult patients with AA were also analyzed to define the characteristics of adult AA patients. AA was 97.3% and median age at alloSCT was 20.4 (1–62) years old. Median time from diagnosis to alloSCT was 6.2 (0.2–248.4) months. Male was 48.9%. Seventy nine percent patients received bone marrow (BM) as a stem cell source. AD had longer time from diagnosis to alloSCT (p=0.049) and received more peripheral blood (PB) or cord blood (CB) as a stem cell source (16.3% vs. 31.7%, p=0.004). Univeriate analysis showed MSD (p<0.001), age less than 15 years (p=0.010), BM as stem cell source (p=0.036) and disease duration less than 12 months (p=0.007) were significant predictor for better survival. However, multivariate analysis revealed that donor type was not significant factor (p=0.087) whereas age and BM was predictors for better survival. When 205 adult AA patients were analyzed, AD had more graft failure (p=0.005), delayed neutrophil engraftment (p=0.035), more acute graft versus host disease (GvHD; p=0.009). However, there were no different between AD and MRD in terms of platelet engraftment (p=0.618), incidence of SOS (p=0.735) and relapse rate (p=0.360). MRD (p=0.011), age less than 30Y (p=0.001), disease duration less than 12M (p=0.003), no prior immune suppression therapy, (p=0.007) and platelet transfusion less than 90U (p=0.010) significantly affected survival. Only age and platelet transfusion were significant factor for better survival in multivariate analysis.

Summary: In conclusion, our study showed that donor type was not a significant factor for survival. Therefore, AD should be considered earlier when there is no MRD in patients with AA.
The Effect of the CASP8 -6526N Del Promoter Polymorphism on Outcome in T-Cell Depleted Unrelated Donor Haemopoetic Stem Cell Transplants (HSCT)
Authors: Krishnamurthy Suchitra , Shaw Bronwen E. , Byrne J. L , Seedhouse C. , Mayor Neema P , Madrigal A. J , Russell Nigel H.
Published: April 2020

The 6 nucleotide insertion-deletion polymorphism (-6526N del) in the CASP8 promoter has been demonstrated to destroy an Sp1 binding site, resulting in reduced caspase-8 activity and expression and a reduced susceptibility of 652 6N del/del T-lymphocytes to undergo apoptosis in response to anti-FAS and to tumour infiltrating lymphocytes. As the susceptibility of T-lymphocytes to undergo apoptosis could affect outcome following allogeneic HSCT we have investigated the impact of the CASP8-652 6N del polymorphism in both donors and recipients on the outcomes of patients undergoing unrelated donor HSCT.

Genotyping was performed on 186 donor/recipient pairs who underwent an HSCT from a donor from the Anthony Nolan Trust in one of 25 transplant centres in the United Kingdom between 1997 and 2006. All patients were transplanted for a haematological malignancy and had long term clinical data collated. Diagnoses were CML: 40.3%; MDS: 4.3%, ALL: 16.6%; AML: 23.6 %, lymphoproliferative disorders: 10.4 %, multiple myeloma: 4.8%. The frequency of the 3 genotypes in the Caspase 8 promoter region was as follows: RECIPIENTS: WT/WT=0.26; WT/del=0.49; del/del=0.24 and DONORS: WT/WT=0.33; WT/del=0.40; del/del=0.25. Frequencies in both the donor and recipient populations were in Hardy-Weinberg equilibrium.

Our findings show that the overall survival (OS) in recipients who received a transplant from a donor with a WT/WT genotype was significantly better as compared to donors with WT/del or del/del genotype (52% v 34% at 5 years; p=0.03). The disease free survival (DFS) at 3 years was also significantly better (39% v 18%; p=0.03). In addition, we found a significant reduction in grade II-IV acute GVHD (17% v 30%; p=0.04) and a trend towards lower incidence of chronic GVHD (42% v 63%; p=0.06) and transplant related mortality (TRM) (19% v 35%; p=0.06) in these patients. No significant difference in disease relapse was seen.

The results were particularly striking in the subgroup of recipients where one or two deletions were present (WT/del or del/del genotype). The OS was 62% in those who received a graft from a donor with WT/WT genotype compared to 36% with other donors (p=0.01). This remained significant in multivariate analysis (HR 0.53; CI 0.29, 0.98; p=0.04). This subgroup also had a lower risk of relapse (p=0.02).

In this cohort, the majority (156/186) of recipients had in-vivo T-cell depletion using Alemtuzumab. As Alemtuzumab depletes T-cells in part by apoptosis induced via a caspase 8 dependent pathway, we hypothesize that recipients who receive a transplant from a donor with WT/WT genotype are likely to get more effective T-cell depletion and hence less acute GVHD and reduced TRM resulting in improved survival. The mechanism of interaction between donor and recipient genotypes remains to be explored.

Figure Figure
Mismatching at HLA-DPB1 Is Not Associated with Survival in Patients with Acquired Aplastic Anemia Who Receive Unrelated Bone Marrow Transplantation
Authors: Yagasaki Hiroshi , Kojima Seiji , Kato Shunichi , Kato Koji , Yabe Hiromasa , Sakamaki Hisashi , Kawase Takakazu , Tsuchida Masahiro , Kigasawa Hisato , Morishima Yasuo , Kodera Yoshihisa
Published: April 2020

DNA typing for HLA-A, -B, -C, -DQB1 and -DRB1 determines outcome in patients with severe aplastic anemia (SAA) who receive unrelated bone marrow transplantation (U-BMT). Based on our previous study of 300 subjects, complete matched (10/10) donors are preferable, but 1-allele-mismatched (9/10) donors are also acceptable. Several studies have addressed the additive effects of HLA-DPB1 for patients with hematological malignancies. In recent reports, HLA-DPB1 mismatching decreased the incidence of relapse, but increased the incidence of acute GVHD. However, the impact of matching for HLA-DPB1 remains unknown in SAA patients. To explore the impact of HLA-DPB1 on the outcome, we analyzed outcomes in 169 recipients with SAA who received U-BMT from an HLA complete matched or 1-allele mismatched donor through the Japan Marrow Donor Program. Median patient age was 17 years (range: 1 to 64 years), and 102 males and 67 females were included. Among 169 pairs, 101 were matched for 10/10 alleles and 68 matched for 9/10 alleles. Although the overall survival was comparable between the groups (10/10 matched group; 75.2%, 9/10 matched group; 64.5%, p=0.633), the incidence of acute GVHD (II–IV) was significantly higher in the 9/10 matched group (15.3%) than in 10/10 matched group (32.2%) (p=0.012). Therefore the impact of HLA-DPB1 matching was analyzed independently in each group. In the 10/10 matched group, 30 of 101 pairs (30%) were matched for HLA-DPB1, whereas 71 pairs (70%) were mismatched for HLA-DPB1. In the 9/10 matched group, 21 of 68 pairs (30%) were matched for HLA-DPB1, whereas 47 pairs (70%) were mismatched for HLA-DPB1. In the 10/10 matched transplants, the survival rate was comparable between the HLA-DPB1 matched group (74.4%) and the HLA-DPB1 mismatched group (75.7%) (p=0.894). The incidence of acute GVHD (II-IV) was lower in the HLA-DPB1 matched group (8.0%) than in the HLA-DPB1 mismatched group (18.1%), but this difference was not significant (p=0.193). In 9/10 matched transplants, the survival rate was comparable between the HLA-DPB1 matched group (71.4%) and the HLA-DPB1 mismatched group (61.7%) (p=0.826). The incidence of acute GVHD (II-IV) was also lower in the HLADPB1 matched group (21.0%) than in the HLA-DPB1 mismatched group (37.2%), but this difference was not significant (p=0.169). The incidence of chronic GVHD and rejection rate were not associated with HLA-DPB1 matching. In conclusion, HLA-DPB1 matching is not essential for U-BMT recipients with SAA when 10/10 or 9/10 allele-matched donors are available.
A Higher Prevalence of HIT Antibodies in Patients May Be Due to Contaminated Heparin
Authors: Bansal Vinod , Cunanan Josephine , Adiguzel Cafer , Litinas Evangelos , Nelson Kelly , Fareed Jawed
Published: April 2020

During the period of November 2007-January 2008, an increased prevalence of adverse reactions to heparin in hemodialysis patients was noted. These adverse events were attributed to the presence of purposeful contaminant, namely oversulfated chondroitin sulfate (OSCS). The OSCS exhibited a molecular profile similar to heparin (14–16 KDA) and was a weaker anticoagulant (30–40 USP U/mg), however when mixed with heparin it produced super-additive anticoagulant effects. Similar to heparin, the OSCS also produced HIT antibody mediated aggregation of platelets and serotonin release. The contaminated heparin was reportedly used in dialysis globally during the period March 2007–May 2008. Since dialysis patients have been exposed to contaminated heparin, the OSCS may have triggered the generation of anti-heparin platelet factor 4 antibodies (HIT abs). Earlier analysis of dialysis patients plasma obtained in 2006 and 2007, consistently showed a very low prevalence of HIT abs in these patients (5 %). To test the hypothesis that maintenance hemodialysis patients exposed to potentially contaminated heparin may have a greater prevalence of HIT abs, blood from 80 patients on maintenance hemodialysis for the past several weeks, was drawn in June 2008. Plasma samples were analyzed for the presence of HIT abs using a commercially available ELISA kit from GTI (Brookfield, WI). While there was no change in the platelet count, the prevalence of HIT abs in these patients was markedly higher 15/78 (19.2%). Subtyping of the antibody also showed a higher prevalence of IgG subtype in contrast to the previously determined abs which were mainly IgA and IgM. The OSCS was also found to strongly complex with platelet factor 4 and initiate heparin induced platelet aggregation responses. These observations suggest that OSCS contaminant in recalled heparin is capable of triggering a differential immunogenic response in comparison to contaminant free heparin. Regardless of the increased generation of HIT abs no reports on any adverse events and/or thrombocytopenia were apparent from the site where the blood samples were drawn.
Comparative Antithrombotic and Antihemostatic Effects of the Direct Factor Xa Inhibitors, Apixaban and Rivaroxaban, and the Direct Thrombin Inhibitors, Dabigatran and Lepirudin, in Rabbit Models of Venous Thrombosis and Bleeding Time
Authors: Wong Pancras C. , Crain Earl , Watson Carol
Published: April 2020

Background: Apixaban is an oral, direct and highly selective factor Xa (FXa) inhibitor in late-stage clinical development for the prevention and treatment of venous thromboembolism, stroke prevention in patients with atrial fibrillation, and secondary prevention in patients with acute coronary syndrome. The objective of this study was to assess the antithrombotic and antihemostatic effects of apixaban in rabbits, compared to the direct FXa inhibitor, rivaroxaban, and thrombin inhibitors, dabigatran and lepirudin.

Methods: We induced the formation of non-occlusive thrombus in venous thrombosis (VT) models by placing threads in the vena cava, and induced bleeding by the incision of cuticles in anesthetized rabbits. Apixaban, rivaroxaban, dabigatran and lepirudin were given as a bolus injection and supplemented with a constant IV infusion to achieve a stable plasma level.

Results: Control thrombus weight in the prevention VT model ranged from 65±3 to 88±5 mg, and in the VT treatment model ranged from 76±5 to 90±5 mg. Control bleeding time (BT) ranged from 163±5 s to 173±8 s (n=6 per group). In the prevention VT model, apixaban, rivaroxaban, dabigatran and lepirudin (infusion started at 30 min before VT initiation) exhibited dose-related efficacy in preventing VT with ED50s (doses for 50% reduction of control thrombus weight; mg/kg) of 0.17±0.003, 0.15±0.03, 0.37±0.04 and 0.24±0.07 mg/kg, respectively. Apixaban, rivaroxaban and dabigatran, at doses for 80% reduction of control thrombus weight, prolonged BT by 13±2, 91±9*, 343±38* and 505±12%*, respectively (*P<0.05, vs. apixaban, n=6 per group). In the treatment VT model, these inhibitors (infusion started at 30 min after VT initiation) were equally effective in preventing growth of a preformed thrombus. Clot regression was observed following administration of apixaban, rivaroxaban and dabigatran at 2.7 mg/kg, and lepirudin at 3.5 mg/kg. The preformed thrombus decreased from an initial weight of 38±2 mg to 26±4*, 17±2*, 20±3* and 25±1* mg, respectively (*P<0.05, vs. control, n=6 per group).

Conclusion: In summary, apixaban was as efficacious as rivaroxaban, dabigatran and lepirudin in the prevention and treatment VT models in rabbits. At equivalent antithrombotic doses, apixaban preserved hemostasis better than the other three agents in the rabbit cuticle BT model. Clinical studies will be required to assess the therapeutic windows in humans.
Case Fatality Rates of Recurrent Venous Thromboembolism during and Following Anticoagulation Therapy
Authors: Carrier Marc , Le Gal Gregoire , Wells Philip , Rodger Marc
Published: April 2020

Background: The optimal duration of anticoagulation treatment in patients with unprovoked VTE is unknown. In order to counsel VTE patients on the risks and benefits of discontinuing anticoagulants, clinicians need to balance the long-term risk of recurrent VTE with major bleeding on anticoagulants. For all VTE patients on oral anticoagulant, the case-fatality rate of major bleeding was previously reported to be 13.4% (95% confidence intervals (CI): 9.4% to 17.4%). A major knowledge gap exists regarding the case-fatality rate of recurrent pulmonary embolism (PE) during and following anticoagulation therapy for VTE.

Purpose: To summarize the case fatality rate of recurrent VTE during and following anticoagulation therapy.

Data Source: A systematic literature search strategy was conducted using MEDLINE, EMBASE, the Cochrane Register of Controlled Trials and all EBM Reviews. Study Outcome: We selected 62 studies that reported the rates of fatal PE in patients with recurrent VTE. Fatal PE was defined as

confirmed autopsy report; death preceding with confirmed deep vein thrombosis (DVT) or non-fatal PE; sudden death not explained by a condition other than PE.

Measurements: Pooled case fatality rates were generated. Ninety-five percent CI were calculated for each case fatality rate using averaged, inverse variance-weighted estimates from each study.

Data Synthesis: 30,885 VTE patients were included (17,650 DVT, 8801 PE and 4434 DVT or PE

Limitations: Unable to determine the case fatality rate by etiology of VTE (i.e. provoked, unprovoked).

Conclusion: Case fatality rates for recurrent VTE are elevated during and following anticoagulation treatment for VTE but appear lower than the case-fatality rate for major bleeding with oral anticoagulants. This information must be considered by clinicians when counseling patients on whether to continue or discontinue anticoagulant therapy following VTE. Not only must absolute recurrent VTE and major bleeding rates be compared between groups that continue and discontinue anticoagulants but the relative consequences (i.e. case fatality rates) must be also considered with more weight placed on major bleeding episodes.

Initial event During anticoagulation Treatment (%, 95% CI) Following anticoagulation Treatment (%, 95% CI) DVT 10.6 (8.3–13.0) 7.3 (5.0–9.7) PE 12.3 (5.9–18.7) 12.5 (6.4–28.7) Any event 10.2 (7.9–12.5) 9.0 (7.3–10.8)
Validation of Pharmacokinetic {PK} Simulation for Fondaparinux (FPX) Dosing by FPX-Specific Anti-Factor Xa Assay in Elderly Cancer Patients with Severe Renal Dysfunction
Authors: Liu Chin Y , Andersen Judith C.
Published: April 2020

Background: Fondaparinux (FPX) is a synthetic pentasaccharide inhibitor of factor Xa indicated for prophylaxis and treatment of venous thromboembolism (VTE). It has an 18 hr half-life (T 1/2), thus is suitable for once-daily dosing, but is cleared by the kidney and not recommended for patients with SRD (creatinine clearance (CrCl) <30 mL/min) in whom drug accumulation could increase bleeding risk. No published clinical trials have evaluated the use of FPX in this population. However, in a pharmacokinetic simulation, serum FPX concentrations in such patients receiving FPX for VTE prophylaxis every other day were predicted to be similar to those in patients with mild renal impairment on daily dosing. Validation of this dosing regimen with an automated assay that determines anti-factor Xa activity levels using FPX calibrators could make this versatile drug accessible to many hypercoagulable patients with severe renal dysfunction

Methods: A retrospective analysis of institutional pharmacokinetic protocol outcomes was conducted in a small population of elderly cancer patients with chronic or acute-on- chronic SRD (CrCl < 30ml/min for >72 hrs) who received subcutaneous FPX 2.5 mg every 48 hrs for VTE prophylaxis. Peak and trough levels were determined at 3 hours post-dose and 1hr pre-dose respectively, for at least 3 doses. FPX levels were assayed with FPX-specific calibrators.

Descriptive data appear in Table 1.

Pt Age Sex Race D Height (cm) Weight (kg) Creatinine (mg/dL) CrCl (ml/min) Peak (mcg/mL) Trough (mcg/mL) 1 71 F W Bladder CA 167.6 71.9 2.7 18 0.52 0.15 2 86 M B Lung CA 166.4 76.2 1.7 28 0.47 0.14 3 67 M W Giloma 180.3 75.0 3.2 24 0.27 0.12 4 83 M W Bladder CA 175.3 90.0 1.9 29 0.33 0.08 5 75 M W Prostate CA 167 74.5 5.4 11 0.6 0.11 6 62 M W Lymphoma 172 61.5 3.1 22 0.28 0.03 7 59 F B Uterine CA 160 115.0 4.8 10 0.37 0.1 8 53 M B Multiple myeloma 177.8 57.0 6.0 10 0.27 0.2

Results: Eight patients were included in this study with mean age of 69.5 ± 11.5 years and creatinine clearance of 19 ± 7.9 mL/min. The mean peak FPX concentration was 0.39 ± 0.13 mcg/mL, in the lower target range for prophylaxis efficacy (0.39–0.50 mcg/mL) and mean trough concentration, thought to be an indicator of drug accumulation, 0.12 ± 0.05 mcg/mL (target range: 0.14–0.19 mcg/mL). No major bleeding or VTE events were noted during FPX administration.

Conclusion: A pharmacokinetic simulation permitting extrapolation of FPX dosing for VTE prophylaxis in patients with severe renal dysfunction from data in patients with mild dysfunction has been shown to be valid in a small population of sick elderly cancer patients by PK monitoring using a FPX -specific anti-Factor Xa assay, showing no drug accumulation over at least three doses (144 hrs) [cyl1] and the drug clinically safe as dosed.
Novel Antimicrobial Peptide-Based Blood Safety Strategies for Bacterial Reduction
Authors: Mohan Ketha V. K. , Rao Shilpakala Sainath , Atreya Chintamani D
Published: April 2020

Bacterial contamination of blood and blood components is a major safety concern in transfusion medicine. In order to facilitate safer transfusion products to the end users, there is a critical need for novel proof-of-concept ideas for pathogen reduction, which are different from the current ones that outweigh the associated toxicity and/or contamination risk. Present study involves use of nine novel synthetic antimicrobial peptides (four originated from thrombin-induced human platelet derived antimicrobial proteins named PP1-PP4 and five having 1–5 repeats of arginine and tryptophan residues, named DP1-DP5. These peptides were tested on plasma samples spiked with 10-fold dilutions of 5 different bacteria (Staphylococcus aureus, Escherichia coli, Pseudomonas aeruginosa, Klebsiella pneumoniae, and Bacillus cereus) that are important to the field of transfusion medicine and analyzed whether these spiked plasma samples could be cured of the pathogens. Each spiked sample was incubated with a peptide (PP1-PP4 and DP1-DP5) for 2 hours at 37°C. Following incubation, a fixed volume of the inoculum was plated on nutrient agar plates and incubated overnight at 37°C for colony count. Spiked sample without any peptide was included as control. Results revealed that out of nine peptides tested, while DP3 and DP4 were active against all 5 organisms tested resulting in 50–100 % of inhibition of specific organisms, peptide PP4 was only active against E. coli, P. aeruginosa and Bacillus cereus resulting in a 30–100% reduction in the CFU/ml compared to the controls.

Table 1

Organism Colony count expressed in % Control PP1 PP2 PP3 PP4 DP1 DP2 DP3 DP4 DP5 S. aureus 100 90 100 26 100 100 20 10 56 100 E. coli 100 95 100 100 71 100 93 4 18 85 P. aeruginosa 100 100 100 100 0 100 0 0 13 100 K. pneumoniae 100 100 100 100 100 74 3 0 0 25 B. cereus 100 100 100 100 50 100 100 25 77 100

Based on these results, it appears that peptides used in this study provide a new antibacterial strategy against a range of bacteria and with further studies and refinement, these peptides could prove useful towards bacterial reduction in blood and blood products.

The findings and conclusions in this abstract have not been formally disseminated by the Food and Drug Administration and should not be construed to represent any Agency determination or policy.
The Addition of Rituximab to First-Line Chemotherapy (R-CHOP) Results in Superior Response Rates, Time to Treatment Failure and Response Duration in Patients with Advanced Stage Mantle Cell Lymphoma: Long Term Results of a Randomized GLSG Trial
Authors: Hoster Eva , Unterhalt Michael , Wörmann Bernhard , Dührsen Ulrich , Metzner Bernd , Eimermacher Hartmut , Neubauer Andreas , Wandt Hannes , Steinhauer Hjalmar , Martin Sonja , Heidemann Else , Aldaoud Ali , Hiddemann Wolfgang , Dreyling Martin
Published: April 2020

Background: The addition of rituximab to chemotherapy (R-CHOP) has been shown to improve response rates in mantle cell lymphoma (MCL), but prolongation of response duration or overall survival was not observed (Lenz et al., JCO 2005). In a similar randomized comparison of 90 patients, again the addition of rituximab to MCP showed a tendency towards higher CR rates, but no improvement of overall response rate, progression free, or overall survival (Herold et al., ICML-10, 2008).

Methods: We present an update of a previously published trial randomly comparing efficacy and safety of R-CHOP to CHOP induction in previously untreated patients with advanced stage MCL.

Results: Of the 123 evaluable patients, 63 patients were randomized to R-CHOP. Median age was 62 years, and risk profiles of the two treatment arms were comparable. Overall response rates were 92% vs. 75% for R-CHOP vs. CHOP (p = 0.0139) and complete remission rates 33% vs. 8% (p = 0.0008). After a median follow-up of 65 months, median time to treatment failure was prolonged from 14 months for CHOP to 28 months for R-CHOP (p = 0.0003). Similarly, median response duration was prolonged from 18 (CHOP) to 29 months (R-CHOP, p = 0.0052). So far, no significant improvement of overall survival has been observed with median not reached vs. 59 months and 5-years OS rates of 59% and 46% (p = 0.27) after R-CHOP and CHOP, respectively. Toxicity was not significantly higher for R-CHOP treated patients.

Conclusions: After longer follow-up, superior remission rates, time to treatment failure, and response duration of combined immuno-chemotherapy were confirmed. However, in contrast to other lymphoma entities, improvement of overall survival has not yet been proven in MCL patients. Therefore new therapeutic options are urgently warranted to further improve the long term outcome in this otherwise dismal disease.
Inhibition of Pulmonary Coagulopathy by Nebulized Natural Anticoagulants during Streptococcus Pneumoniae Pneumonia in Rats
Authors: Hofstra J. J. , van den Boogaard F. E. , Cornet A. D. , Vlaar A. P.J. , van der Poll T. , Levi M. , Schultz M. J.
Published: April 2020

RATIONALE: Alveolar fibrin deposition is intrinsic to pneumonia and acute lung injury. Activation of coagulation during pulmonary inflammation is primarily mediated by the tissue factor–factor VIIa pathway. Tissue factor levels in the lungs increase during pulmonary inflammation due to disruption of endothelial–epithelial barrier and expression of tissue factor on alveolar macrophages. Intravenous infusion of the natural anticoagulants activated protein C (APC) or antithrombin (AT) has been shown to have lung–protective effects in critically ill patients, but increases the risk of severe bleeding. Local administration may allow for higher treatment dosages and increased local efficacy while at the same time reducing the risk of bleeding. We evaluated the effect of nebulized tissue factor pathway inhibitor (TFPI), APC or AT on pulmonary coagulopathy and inflammation in a rat model of Streptococcus pneumoniae pneumonia.

DESIGN: Randomized controlled in vivo study in a rat model of S. pneumoniae pneumonia. Twenty–eight male Sprague–Dawley rats were challenged intratracheally with S. pneumoniae (serotype 3, 106 colony forming units), inducing pneumonia. Rats were randomized to nebulization with TFPI, APC, AT or normal saline.

RESULTS: Rats infected with S. pneumoniae had increased pulmonary and systemic levels of thrombin–antithrombin complexes (TATc) and fibrin degradation products (FDP), indicating increased coagulation. Simultaneously, pulmonary plasminogen activator inhibitor 1 (PAI–1) activity was increased and plasminogen activator activity (PAA) was reduced, indicating inhibition of endogenous fibrinolysis. Treatment with any nebulized natural anticoagulant significantly attenuated the rise in bronchoalveolar TATc (3.5 ± 0.9 ng/mL (TFPI), 3.6 ± 0.6 ng/mL (APC) and 4.6 ± 0.6 ng/mL (AT) versus 9.1 ± 0.75 ng/mL in saline treated rats, P<.01) and FDP (290 ± 92 ng/mL (TFPI), 310 ± 90 ng/mL (APC) and 158 ± 44 ng/mL (AT) versus 559 ± 116 ng/mL in saline treated rats, P<.01). TFPI and APC also significantly reduced systemic TATc levels while AT did not have any effect on systemic coagulopathy (17 ng/mL ± 3.4 (TFPI) and 13.8 ± 2.3 ng/mL (APC) versus 19.7 ± 1.6 ng/mL in saline treated rats, P<.05 and P<.01 respectively). While TFPI and APC did not affect host defense to S. pneumoniae, treatment with AT resulted in a reduction of bacterial outgrowth from the lungs, a reduction of neutrophil influx into the pulmonary compartment and less histopathologic lung injury.

CONCLUSIONS: Nebulization of natural anticoagulants attenuates pulmonary coagulopathy during S. pneumoniae pneumonia. While APC and TFPI leaves local inflammation and host defense unaltered, AT exerts significant lung–protective effects in pneumococcal pneumonia in rats.
Inhibition of γ′ Fibrinogen Production in Liver Cells by D-Dimers
Authors: Rein Chantelle M , Chu May-Lynn , Farrell David H.
Published: April 2020

γ′ fibrinogen contains a variant γ chain that arises from an alternative splicing event within the γ gene mRNA. While the more abundant γA chain contains the platelet-binding AGDV sequence at its carboxyl terminus, the γ′ chain carboxyl terminus has an extended VRPEHPAETEYDSLYPEDDL amino acid sequence that is highly negatively charged and contains two sulfated tyrosine residues. The γ′ chain contains binding sites for factor XIII zymogen and thrombin. This extended γ chain variant confers several unique properties on clots formed with γ′ fibrinogen, including resistance to fibrinolysis. γ′ fibrinogen is also a newly-emerging cardiovascular disease biomarker that shows an inverse association with deep venous thrombosis and thrombotic microangiopathy, and a significant positive association with coronary artery disease, myocardial infarction, and stroke. However, the underlying factors that regulate its production remain unknown. A recent study investigating the role of γ′ fibrinogen in stroke showed that the ratio of γ′ fibrinogen to total fibrinogen was higher in patients during the acute phase of a stroke and lower in the convalescent phase following a stroke. We therefore hypothesized that the end products of fibrinolysis may feed back to regulate γ′ fibrinogen expression. Fibrin(ogen) degradation products, including fibrinopeptides A and B, E-domains, and D-dimers, were therefore assayed for their effects on the production of γ′ fibrinogen in HepG2 human liver cells. The results showed that fibrinopeptide A, fibrinopeptide B, and E-domains had no effect on γ′ fibrinogen production by HepG2 cells, as measured by ELISA. However, the production of γ′ fibrinogen decreased in a dose-dependent manner when incubated with purified cross-linked D-dimers. RT-PCR demonstrated an 85.1 ± 4.6% inhibition in γ′ mRNA levels by 31 nM D-dimers after 24 hours of exposure. For comparison, the lower limit of the pathophysiologic cutoff of D-dimer concentration in disseminated intravascular coagulation is in the range of 41 nM. To further investigate the interactions of the D-dimers with the cells, D-dimers were labeled with fluorescein, incubated with HepG2 cells, and examined by fluorescence microscopy. Fluorescein-labeled D-dimers entered the cells within 20 minutes of incubation and displayed a diffuse cytoplasmic distribution. The D-dimers showed an increasing peri-nuclear localization with increasing time. By 60 minutes, the D-dimers had largely been cleared from within the cells. D-dimer uptake displayed a very different staining pattern than the non-receptor-mediated uptake of fluorescein-labeled albumin, which showed only a weak, diffuse cytoplasmic staining. These results suggest that D-dimers regulate γ′ fibrinogen production in liver cells in a process that involves binding to a cell-surface receptor, internalization, and degradation.