bluuebunny/crossref_metadata_2025 huggingface dataset:
Estimation Of GFR With Different EGFR Equations In Multiple Myeloma Patients Receiving Lenalidomide Treatment
Authors: Kleber Martina , Koch Bernd , Waesch Ralph , Engelhardt Monika
Published: October 2019

Introduction

Renal impairment (RI) in patients with MM is detrimental organ damage. The estimation of glomerular filtration (eGFR) rates is based on using different equations such as CKD-EPI, MDRD or Cockcroft-Gault (CG). Methods: We enrolled 132 consecutive MM patients treated with lenalidomide for the approved indication in our department between 2006 and 2012. The GFR for quantifying RI was estimated by the CKD-EPI, MDRD- and CG-equations at baseline and after 3 months under lenalidomide therapy. We assessed hematological response by the EBMT criteria, and renal response according to recently proposed criteria (Dimopolous et al. Leukemia 2013) and by comparing the CKD-EPI, MDRD- and CG equations.

Results

Median patient age was 64 years (range 41-90; males 62%) with predominantly advanced stage II/III Durie & Salmon and International Staging System disease (96% vs. 65%, respectively). Fifty-four MM patients had received ≥2 therapy lines and 50% prior stem cell transplantation. The median lenalidomide dose was 25mg (D1-21/28 day cycle) given with dexamethasone (Rd) as published. The median serum creatinine was normal at 1.0mg/dl, whereas the median eGFR showed CKD stage 2, with substantially different median CKD-EPI, MDRD and CG equations of 77, 81 and 74ml/min/1.73m2, respectively (Figure 1A). For each equation, the number of patients with CKD stage 3–5 via CKD-EPI, MDRD and CG equation was 32%, 23% and 30%, respectively (Table 1). In total, 26 (20%) MM patients with eGFR values by the MDRD equation were reclassified to higher CKD-stages according to CKD-EPI equation and 3 (2%) to lower CKD stages (Figure 1B). This demonstrates that the MDRD may substantially overestimate the GFR, especially in elderly patients with normal or less impaired renal function (GFR >60ml/min/1.73m2). Best overall response (ORR=CR+PR) and clinical benefit rate (CR, PR, SD) in this advanced, substantially pretreated cohort was 48% and 93%, respectively. After 3 months, renal response (CR, PR, MR) according to CKD-EPI, MDRD and CG were 17%, 11% and 15%, respectively, and renal response defined as any eGFR improvement was 52%, 51% and 51%, respectively. For each eGFR equation, the number of patients with renal improvement according to CKD stage 1-2 was more pronounced with the CKD-EPI (68% → 76%), less with the MDRD (77% → 83%) and least with the CG equation (70% → 75%; Table 1).

Conclusions

To the best of our knowledge, we are the first to demonstrate that measuring renal function by the CKD-EPI equation in Rd-treated MM patients is highly valuable. In these substantially pretreated MM patients, renal response under lenalidomide was seen via CKD-EPI in 17% and any eGFR improvements in 52%, indicating that Rd in these patients is effective and RI best defined via CKD-EPI. Our results enlarge the arsenal of available eGFR equations by the CKD-EPI formula.

Disclosures:

Kleber: Celgene: Educational grant Other. Engelhardt:Celgene: Educational grant Other.
The Senescence-Associated Secretory Phenotype In Multiple Myeloma
Authors: Wildes Tanya M , Paasch Jacob , Fiala Mark A. , Chen Ling , Vij Ravi , Stockerl-Goldstein Keith E. , Stewart Sheila , Colditz Graham A. , Tomasson Michael
Published: October 2019

Introduction

The incidence of multiple myeloma (MM) increases with age, yet some cytogenetic changes are actually more common in younger patients with MM (Avet-Loiseau J Clin Oncol 2013).  This suggests that a mechanism other than chromosomal changes underlies the increased incidence with age.  Senescent cells secrete a number of proinflammatory cytokines, chemokines, growth factors and proteases resulting in the senescence-associated secretory phenotype (SASP), which can promote tumor growth.  Preclinical data suggests that myeloma bone marrow stromal cells express the SASP (Andre PLOS ONE 2013). We hypothesized that SASP factors correlate with age in patients with MM.

Methods

Peripheral blood serum and matched bone marrow aspirate plasma from patients with multiple myeloma were evaluated for selected factors associated with the SASP using quantitative multiplex immunoassay (Rules Based Medicine, Austin TX USA).  SASP factors with a known role in MM [interleukin-6 (IL-6), interleukin-8 (IL-8), interleukin-15 (IL-15), granulocyte-macrophage colony-stimulating factor (GMCSF), intercellular adhesion molecule 1(ICAM1), osteoprotegerin (OPG), hepatocyte growth factor (HGF), insulin-like growth factor-binding protein(IGFBP-1), interleukin-1 beta (IL1b), monocyte chemotactic protein 1(MCP-1), macrophage inflammatory protein-1 alpha(MIP-1a), angiogenin, leptin,  vascular endothelial growth factor receptor 1(VEGFR1) and stem cell factor(SCF)] were selected. The relationship between age and SASP factors were analyzed using Kendall tau rank correlation coefficient.

Results

Samples from 25 patients (each with peripheral blood serum and matched bone marrow aspirate plasma) were analyzed.  The median age was 62 (range 47 - 74). Disease states were as follows: 36% newly diagnosed/untreated, 24% pretransplant and 40% relapsed.  ISS stage included 40% stage I, 28% stage II and 32% stage III.  Three of the selected SASP factors in the peripheral blood correlated   with age:  IL-8 (Kendall Tau 0.334, p=0.027), OPG (Kendall Tau 0.289, p=0.046) and MCP-1 (Kendall Tau 0.332, p=0.022).  No SASP factors tested in the bone marrow plasma were significantly correlated with age.

Conclusions

We demonstrated age-associated differences in the SASP factors IL-8, OPG and MCP-1 in the peripheral blood of myeloma patients.  Future research will examine differences between patients with myeloma and age-matched controls without cancer.

Disclosures:

Vij: Celgene : Honoraria, Research Funding, Speakers Bureau; Millennium: Honoraria, Speakers Bureau; Onyx: Honoraria, Research Funding, Speakers Bureau. Stockerl-Goldstein:Celgene : Speakers Bureau; Celgene : Speakers Bureau; Millennium: Speakers Bureau; Millennium: Speakers Bureau.
Observational Study Of VMP (Bortezomib, melphalan, prednisolone) Regimen For Newly Diagnosed Korean Myeloma Patients Who Are Not Eligible For Transplantation
Authors: Kim Kihyun , Lee Mark , Kim Hyo Jung , Kim Yang Soo , Park Keon Woo , Bae Sung Hwa , Shin Ho Jin , Lee Won Sik , Lee Jung-Hee , Lee Jeong Ok , Yoon Sung-Soo , Kim Ki Hwan , Nam Sung-Hyun , Min Chang-Ki , Bae Sang Byung , Park Joon Seong , Hyun Myung Soo , Mun Yeung-Chul , Kwak Jae-Yong , Lee Je-Jung
Published: October 2019

Background

VMP regimen for newly diagnosed myeloma patients is well-documented treatment. However patients in real practice generally have worse performance status and less attention than those in clinical trials. Thus we conducted observational study to evaluate the efficacy and toxicity of VMP treatment in newly diagnosed Korean myeloma patients.

Patients and Methods

Data were prospectively collected from 39 hospitals. One hundred seventy three patients who started VMP as first line from 2011 May to 2012 April were included for analysis.

Results

Median age was 71 and 22.5% were more than 75 years old. Fifty-seven per cent were male sex. IgG type was most common (61.9%) and IgA 24.9%. ISS stage I was 13.8% and III was 51.5%. Patients with high risk FISH (Del17p, t(4;14), and t(4;16)) were 4.1%, 4.1%, and 2.3% respectively. Dose and schedule was followed original VISTA trial except for use of prednisolone instead of prednisone. Median 5cycles (range 1-9) were given and 105 patients stopped in the course of treatment. Most common cause were adverse event (28.8%) followed by disease progression or no response (19.6%). Twenty-five mortality cases were reported and 22 were in the course of treatment. The most common cause of mortality was infection (61%) followed by disease progression (13%). Overall response rate was 72.3% and response more than VGPR was 37.6%. Median progression free survival is 455 days and median OS was 504 days. One year PFS was 80.9 % and one year OS was 83.4%. Most common toxicity was cytopenia, peripheral neuropathy, and gastrointestinal toxicities such as nausea and diarrhea. Peripheral neuropathy of all grade and grade 3 or more was 58.6% and 6.36%, respectively

Discussions

Even though patients with higher proportion of ISS stage, efficacy of VMP regimen was considerable in Korean patients. With relatively high mortality due to infection in the course of treatment prophylactic measures for infection need to be developed. To reduce the incidence of peripheral neuropathy, close observation and intervention are needed to prevent aggravation of neuropathy.

Disclosures:

Off Label Use: lenalidomide in newly diagnosed myeloma. Kwak:celgene: Research Funding.
CMV Infection Alone Does Not Affect The Survival In Patients After Umbilical Cord Blood Transplantation: Can We Put Off The Time Of Preemptive Therapy?
Authors: Tong Juan , Sun Zimin , Liu Huilan , Ding Kaiyang , Geng Liangquan , Zheng Changcheng , Tang Baolin , Liu Xin
Published: October 2019

Objective

Analysis and discuss the time of cytomegalovirus (CMV) preemptive therapy after umbilical cord blood transplantation (UCBT). Analysis the risk factors of CMV infection and the effect on survival of CMV infection after UCBT.

Method

From April 2000 to March 2013, 176 cases of patients undergo UCBT who were detected plasma CMV-DNA twice a week routinely. Preemptive antiviral therapy was initiated with ganciclovir or foscarnet for positive PCR of 103 DNA copies or more per ml.

Results

125 of 176 patients developed CMV infection (71%) at a median of 32d (range 19 to 98) post-transplant and only 4 patients developed CMV disease (2.3%). The 5-year overall (OS) was 59.4% in the patients with CMV infection and 64.9% in patients without CMV infection (P=0.193). The study identified that younger age, high-risk disease, infused little CD34 positive cells, developed III-IV degree acute graft-versus-host disease (GVHD), high-dose methylprednisolone, and treated with basiliximab and other strong immunosuppressive agent as significant risk factors for developing CMV infection. It had nothing to do with the gender of patients, transplantation of UCB units, the conditioning regime, the day of neutrophil recovery and chronic GVHD. Preemptive therapy when the CMV-DNA copies are greater than 103 does not increase the incidence of CMV disease, and the survival has not been impacted.

Conclusion

Preemptive therapy can be initiated when CMV-DNA copies are greater than 103 which can achieve the same effects in UCBT.

Disclosures:

No relevant conflicts of interest to declare.
Low Incidence Of Severe Cgvhd and Late NRM In a Phase II Trial Of Thymoglobulin®, Tacrolimus and Sirolimus For Gvhd Prevention
Authors: Al-Kadhimi Zaid , Eghtedar Alireza , Gul Zartash , Chen Wei , Smith Daryn , Deol Abhinav , Abidi Muneer H. , Lum Lawrence G , Bhutani Divaya , Ayash Lois , Ratanatharathorn Voravit , Uberti Joseph P.
Published: October 2019

Introduction

Chronic graft-versus-host disease (cGVHD) is a major factor determining long term outcome and quality of life following allogeneic hematopoietic cell transplantation (AHSCT). In fact, cGVHD is the leading cause of late non-relapse mortality (NRM) and morbidity after AHSCT. The rates of severe cGVHD using NIH consensus criteria reported in the literature are 15-38%. Effective regimens are needed to reduce the severity of cGVHD and improve NRM. We analyzed and updated the long term outcomes of our phase 2 trial evaluating the efficacy of intermediate dose rabbit anti-thymocyte globulin (Thymo) in combination with tacrolimus and sirolimus for the prevention of acute and chronic GVHD after unrelated donor transplantation.

Methods

In a Phase II trial, 47 adult patients (pts) underwent AHSCT from unrelated donors using Thymo, tacrolimus, and sirolimus for GVHD prophylaxis. Thymo was given as follows: 0.5 mg/kg day -3, 1.5mg/kg day -2, and 2.5mg/kg day -1. Chronic GVHD was measured using NIH consensus criteria.

Results

Twenty-two pts received 8/8 and 25 received 7/8 HLA matched unrelated grafts. Thirteen pts received a reduced intensity preparative regimen, while 34 pts received a full intensity regimen. The median follow-up duration was 45.2 months (95% CI 37.7-48.8), with minimum follow up of 30 months. At 4 years of follow up, the cumulative incidence of NIH severe cGVHD a, was 6.4 % (95% CI 1.6-15.9), and overall cumulative incidence of cGVHD was 48.9% (95% CI 33.6-62.6). Of 20 pts who are alive and disease free, only 4 pts continue to need systemic immune suppression at the last follow up. At 4 years of follow-up, the cumulative incidence of NRM and disease relapse were 27.7% (95% CI 15.7- 41.0) and 30.0% (95% CI 17.5- 43.6), respectively. There has been one non relapse death beyond 12 months and none after 18 months of follow up. Only one pt died from cGVHD and bronchiolitis obliterans, while two other pts had minimal symptoms from bronchiolitis obliterans. Progression free survival (PFS) and overall survival (OS) at 2 years were 50% (95% CI 35-64) and 56% (95% CI 42-70). Median OS is 33.9 months [95% CI (9.8 -*) *the upper limit of the CI was not calculated due to the pattern of censoring] All patients were censored after 40 months, so PFS and OS could not be calculated at 48 months. The median karnofsky performance status at 2 years was 90%.

Conclusion

At long term follow up, the combination of Thymoglobulin, Tacrolimus, and Sirolimus was associated with low incidence of severe cGVHD, low incidence of late NRM, and good performance status. Further validation of these results in randomized phase III trials is needed.

Disclosures:

Al-Kadhimi: Genzyme: Research Funding. Off Label Use: The use of Thymoglobulin® for GVHD prevention.
Extracorporeal Photophoresis (ECP) For Chronic Graft Versus Host Disease (cGVHD): A Systemic Review and Meta-Analysis
Authors: Hashmi Shahrukh K , Malik Mohsin , Murad Hassan , Prokop Larry , Hogan William , Patnaik Mrinal M , Winters Jeffrey L. , Litzow Mark R.
Published: October 2019

Introduction

Steroid refractory chronic graft-versus-host-disease (SR-cGVHD) is the leading cause of late morbidity and mortality in allogeneic transplant patients. Safety of extracorporeal photophoresis (ECP) has led to multiple studies evaluating its role in SR-cGVHD. Overall and organ specific response rates (RR) of SR-cGVHD have varied significantly between studies. We conducted a systemic review and meta-analysis to assess the efficacy of ECP in SR-cGVHD.

Methods

A comprehensive search of several databases (Ovid Medline In-Process & Other Non-Indexed Citations, MEDLINE, EMBASE, Cochrane Central register of Controlled Trials,, Scopus) for articles published in any language between 1984-2012 was conducted. Unpublished studies using electronic databases from the annual meetings abstracts of hematology/transplant societies were searched. Experts in the field were also contacted for selection of studies and missing data from selected trials. End points included complete response rate (CR), overall RR (ORR), and organ-specific RR's.

Results

Initial search generated 312 studies, out of which 18 studies (4 prospective) met selection criteria (N=595). Random effects model was used for pooled rates. Pooled CR rate (11 studies) was 29% (CI 19%-42%). Pooled ORR (16 studies) was 64% (CI 65-82%). 1 year overall survival was 49% (CI 29-70%). There was significant heterogeneity between studies (I²=72) likely due to differences in ECP schedules utilized, and a variety of scales used to measure outcomes.  Pooled RR's for SR-cGVHD of skin was 74% (CI 60-85%), liver was 68% (CI 57-77%), ocular was 60% (CI 40-78%), oral was 72% (CI 51-86%), lung was 48% (CI 33-63%), gastrointestinal (GI) was 53% (CI 21-83%), and musculoskeletal (MSK) was 64% (CI 18-94%). No significant differences in responses to ECP for pediatric and adult populations were found. Sensitivity analysis could not be done due to limited number of prospective studies.

Conclusions

ECP is an effective therapy for oral, skin & liver SR-cGVHD, with modest activity in lung and GI SR-cGVHD. Further studies must report standardized outcomes with a uniform schedule of ECP.

Disclosures:

No relevant conflicts of interest to declare.
A Lower Dose Of Melphalan (140 mg/m2) As Preparative Regimen For Multiple Myeloma In Patients >65 Or With Renal Dysfunction
Authors: Saunders Ila Maewal , Gulbis Alison M , Champlin Richard E , Qazilbash Muzaffar H.
Published: October 2019

Background

Melphalan at a dose of 200 mg/m2 IV (MEL 200) is considered the standard preparative regimen for autologous hematopoietic stem cell transplantation (auto-HCT) for multiple myeloma. However, reduced doses of melphalan such as140 mg/m2 (MEL 140) are often used in older patients or patients with renal dysfunction.

Methods

The purpose of this retrospective analysis was to determine if there was a difference in toxicity, treatment-related mortality (TRM), response rate, progression- free survival (PFS) or overall survival (OS) in patients that received 140 mg/m2 of melphalan (MEL 140) compared to those receiving MEL 200 for auto-HCT. From June 1, 1996 through December 31, 2012, 63 patients received MEL 140. We compared their outcomes with 252 patients that received MEL 200.

Results

Patient characteristics and outcomes are shown in the attached Table. Patients in the MEL 140 group were older, had a higher β2 microglobulin (β2M) level both at diagnosis and auto-HCT, and had a higher serum creatinine (Cr) at auto-HCT (Table). A higher proportion of patients in MEL 140 were older than 65 with serum Cr > 2 mg/dL. There was no significant difference in disease status or high-risk cytogenetics between the 2 groups (Table). NCI CTCv3 > III non-hematologic toxicity was not significantly different between MEL 140 and MEL 200. Transplant-related mortality (TRM) at 100 days and at 1 year was 0% and 0.4% in MEL 140 and 200 (p=1.0), respectively. Complete remission (CR) rates in MEL 140 and MEL 200 were 16% and 29%, respectively (p=0.03). There was no significant difference in (CR) + very good partial remission (VGPR), or overall response (CR + VGPR + PR) between MEL 140 and MEL 200. Median follow up in surviving patients in MEL 140 and 200 was 7.6 and 25 months, respectively. Fifteen (24%) and 64 (25%) patients died in MEL 140 and MEL 200 groups, respectively, with >90% of deaths due to recurrent disease. Median PFS was 26.4 and 30.6 months in MEL 140 and MEL 200 groups, respectively (p=0.46). Median OS was 38.4 and 93.0 months in MEL 140 and MEL 200 groups, respectively (p=0.02). However, there was no significant difference in PFS or OS in patients older than 65 or with serum Cr > 2 mg/d between MEL 140 and MEL 200.

Conclusion

The dose of melphalan can be safely reduced to 140 mg/m2 in patients >65 or with renal insufficiency without adversely impacting the overall response rate or PFS.

Disclosures:

Qazilbash: Otsuka Pharmaceuticals: Research Funding; Onyx Pharmaceuticals: Honoraria, Membership on an entity’s Board of Directors or advisory committees; Millennium Pharmaceuticals: Honoraria, Membership on an entity’s Board of Directors or advisory committees; Celgene Corporation: Honoraria, Membership on an entity’s Board of Directors or advisory committees.
Association Between S6K1 Phosphorylation and Cytotoxic Efficacy Of S6K1 Inhibitors
Authors: Liu Hongqi , Gallo Catherine A. , Plas David R.
Published: October 2019

S6K1 (ribosomal protein S6 Kinase 1) is emerging as a potential target for counteracting the glucose-dependent survival programs induced by oncogenes.  In PTEN-deficient cells, previous analysis revealed that inactivating S6K1 was sufficient to reduce glycolysis and induce programmed cell death.  In BCR-ABL+ cells, we found that S6K1 inactivation was cytotoxic when combined with a fatty acid oxidation inhibitor.

To begin to translate these findings, we have investigated the cytotoxic efficacy of a panel of S6K1 inhibitors.  Although all compounds were efficient inhibitors of S6K1 phosphorylation of downstream substrates, there was one class of inhibitors that strongly induced the phosphorylation of S6K1 itself.  These inhibitors were not cytotoxic for PTEN-deficient cells.  In contrast, inhibitors that avoided strong phosphorylation of S6K1 overcame the pro-survival program in PTEN-deficient cells.  These results suggest that S6K1 inhibition may be beneficial as a chemotherapeutic approach, but that inhibitors should be selected to avoid the phosphorylation of S6K1 itself while also inhibiting kinase activity.

Disclosures:

No relevant conflicts of interest to declare.
Indications For Hospital Admissions and Outcomes Of Hospitalization Among Multiple Myeloma Patients In The U.S: Data From National Inpatient Sample
Authors: Nooka Ajay K. , Kaufman Jonathan L. , Shah Nishi N , Langston Amelia , Collins Hannah , Boise Lawrence H. , Lonial Sagar
Published: October 2019

Introduction

A recent Spanish study suggested an impact of the type of hospital (teaching versus non-teaching) on survival of multiple myeloma (MM) patients. Such data, as well as other hospitalization parameters such as indications, length of stay (LOS), in-hospital mortality (IHM)  in MM patients admitted to hospitals in the U.S are lacking. We have explored the National Inpatient sample (NIS) data to address the indications for hospitalization in MM patients and their survival outcomes of the hospitalization.

Methods

We obtained the National Inpatient Sample (NIS) data for the years 01/2001 until 12/2010 from Healthcare Cost and Utilization Project database (HCUP) database. The 2010 NIS contains all discharge data located in 45 States, approximating a 20% stratified sample of the U.S hospitals. Teaching hospital was defined as a hospital supported by AMA-approved residency program, is a member of the council of teaching hospitals or has a ratio of full-time equivalent interns and residents to beds of ≥0.25.

Results

A total of 178354 admissions reported to NIS were analyzed. Majority of admissions were to teaching hospitals (61.7% admissions: 45.8% for non-SCT and 15.9% for SCT indications) (Table 1). Among the patients that were admitted for non-SCT indications, significantly younger patients were admitted to teaching hospitals. Complicated procedures such as cancer chemotherapy were admitted to teaching hospitals (teaching vs. non-teaching: 8.3% vs. 3.4%; p=<0.0001) and simple procedures such as blood transfusions were admitted to non-teaching hospitals (teaching vs. non-teaching: 13% vs. 19.2%; p=<0.0001). The IHM is significantly increased in non-teaching hospitals (teaching vs. non-teaching: IHM: 9.8 vs. 12.5%; p=<0.0001). Among the patients that were admitted for SCT as the primary procedure, IHM for autologous SCT is 1.64% and for allogeneic SCT is 5.94%.

Conclusions

This analysis suggests inferior survival outcomes in MM patients admitted to non-teaching hospitals. Despite the difference in severity of admissions, IHM is significantly increased in non-teaching hospitals. This effect is at least partially attributable to older patient admissions. IHM in SCT admissions is similar to published literature, validating our findings.

Disclosures:

Kaufman: Onyx: Consultancy; Celgene: Consultancy, Research Funding; Novartis: Consultancy, Research Funding; Janssen: Consultancy; Millenium: Consultancy; Merck: Research Funding. Boise:Onyx Pharmaceuticals: Consultancy. Lonial:Millennium: Consultancy; Celgene: Consultancy; Novartis: Consultancy; BMS: Consultancy; Sanofi: Consultancy; Onyx: Consultancy.
A Selective TNFR2 Agonist Expands Host Treg Cells in Vivo to Protect from Acute Graft-Versus-Host Disease
Authors: Beilhack Andreas , Chopra Martin , Biehl Marlene , Vaeth Martin , Brandl Andreas , Amich Jorge , Findeis Janina , Jordán Garrote Ana-Laura , Brede Christian , Bäuerlein Carina A , Schwinn Stefanie , Einsele Hermann , Berberich-Siebelt Friederike , Wajant Harald
Published: October 2019

Donor CD4+Foxp3+ regulatory T cells (Tregs) suppress graft-versus-host disease (GVHD) after allogeneic hematopoietic stem cell transplantation (allo-HCT) while maintaining the anti-tumoral effect of transplanted conventional T cells in preclinical mouse models. Current clinical study protocols with donor Tregs for treatment or prophylaxis of GVHD rely on their ex vivo expansion and infusion in high numbers. Here we present a fundamentally novel strategy for inhibiting GVHD that is based on the in vivo expansion of recipient Tregs prior to allo-HCT, exploiting the crucial role of tumor necrosis factor receptor 2 (TNFR2) in Treg biology.

To this end we constructed a recombinant nonameric TNFR2-specific agonist, mimicking the activity of murine membrane-bound TNF on TNFR2 without TNFR1 stimulation, thereby avoiding the inflammatory side effects observed with conventional TNF. In vitro, this TNFR2-agonist expanded natural Tregs from wild type but not from TNFR2 KO mice. Accordingly, a human variant of this TNFR2-specific agonist expanded human Tregsin vitro. In vivo treatment of healthy mice with the murine TNFR2-agonist significantly increased Treg numbers in secondary lymphoid organs and peripheral tissues, particularly in the gastrointestinal tract, a prime target of acute GVHD.

Next, we pre-treated recipient mice with this novel TNFR2-agonist to expand host-type radiation resistant Tregs prior to of allo-HCT in two models across MHC barriers (C57BL/6, H-2b->Balb/c, H-2d and FVB/N, H-2q->C57BL/6, H-2b). TNFR2-agonist pre-treatment resulted in significantly prolonged survival and reduced GVHD severity when compared to TNFR2-deficient recipients or untreated allo-HCT recipients. This was accompanied by reduced donor T cell proliferation and infiltration into GVHD target organs as assessed by in vivo and ex vivo bioluminescence imaging, flow cytometry and immunofluorescence microscopy. While in vivo TNFR2-agonist pre-treatment protected allo-HCT recipients from GVHD, anti-tumor effects of transplanted T cells remained unaffected in two different murine B cell leukemia models. In vivo depletion of host derived Tregs completely abrogated the protective effect of TNFR2-agonist pre-treatment.

Our study shows that the expansion of host Tregs by selective in vivo TNFR2-activation significantly improves the outcome after allo-HCT and results in prolonged tumor-free survival.

Disclosures

No relevant conflicts of interest to declare.
Elevated End-Tidal Carbon Monoxide Concentration in Children with Sickle Cell Anemia
Authors: Lal Ashutosh , Yen Kristen , Patterson Lasandra , Goldrich Alisa , Marsh Anne M , Bhatnagar Anish
Published: October 2019

Background: Carbon monoxide (CO) produced during oxygen-dependent cleavage of porphyrin ring of heme is excreted in exhaled breath. The catabolism of heme is increased when red blood cells are destroyed at an accelerated rate. Thus, quantifying CO in exhaled breath could serve as an indicator of hemolysis. However, the requirement for forced breath sample has limited the measurement of exhaled CO in young children.

Objective: To assess end-tidal CO concentration (ETCOc) in children with sickle cell anemia (SCA).

Design/Methods: ETCOc was measured using the CoSense ETCO Monitor (Capnia Inc. Palo Alto, CA). Children between 5-14 years with SCA (Hb SS) who were not on chronic transfusions were eligible. Healthy children served as age-matched controls. Children with exposure to second-hand smoke, acute respiratory infection or symptomatic asthma were excluded. End-tidal breath samples were collected by placing the tip of a nasal cannula 5 mm into the nares. Up to 3 measurements were taken for each subject and the highest ETCOc value was used for analysis. (ClinicalTrials.gov: NCT01848691)

Results: The mean (range) age of 16 children with SCA and 16 controls was 9.7 years (5-14 years) and 9.9 years (5-14 years), respectively. The mean (± s.d.) ETCOc for SCA was 4.85 ± 2.24 ppm versus 0.96 ± 0.54 ppm for control group (p<0.001). The ETCOc in the control group ranged from 0.2 to 2.3 ppm, but was ≤1.2 ppm in 14/16, which is suggested as the upper limit of normal for healthy children. In the SCA group, the ETCOc range was 1.8 to 9.7 ppm, with values ≥2.4 ppm in 15/16 subjects. A threshold ETCOc value of >2.1 ppm provided both sensitivity and specificity equal to 93.8% (69.8-99.8%) for distinguishing SCA from healthy children. Children with SCA who had higher absolute reticulocyte count also demonstrated higher ETCOc (r=0.62, p=0.011). Patients with severe anemia (hemoglobin <8 g/dL) had a higher mean ETCOc (5.43 ppm) than the rest (4.40 ppm) but the difference was not significant. ETCOc level tended to increase with age in SCA (r=0.45, p=0.08).

Conclusions: Carbon monoxide in exhaled breath can be measured in young children in the clinic using a portable monitor. ETCOc may be a valuable tool for non-invasive monitoring of the severity of hemolysis in SCA. The mean ETCOc was 5-fold higher in SCA compared with controls, with little overlap seen between the groups. This suggests a potential use for ETCOc as a point-of-care screening test for SCA in children.

Figure 1 Figure 1.

Figure 2 Figure 2.

Disclosures

Lal: Capnia, Inc: Research Funding. Yen:Capnia, Inc. : Employment. Bhatnagar:Capnia, Inc: Employment.
Dasatinib Is Effective in the Treatment of Mice Models with Immune Thrombocytopenia
Authors: Shimoyama Tadashi , Okano Yoshiaki , Fujishima Yukiteru , Oyake Tatsuo , Kowata Shugo , Murai Kazunori , Ito Shigeki , Ishida Yoji
Published: October 2019

Background: Immune thrombocytopenia (ITP) is an autoimmune disease in which anti-platelet antibody (APA) is produced. APA-coated platelets are captured and phagocytized by macrophages in the spleen. Recent study revealed that spleen tyrosine kinase (Syk) inhibitor is effective in the treatment of ITP, because Syk phosphorylation is the key step of the phagocytosis by macrophages. Activated Fc receptor signal transduction is initiated by phosphorylation of immunoreceptor tyrosine-based activation motifs (ITAMs) tyrosine residues by SRC family kinases. Recruitment of Syk to dually phosphorylated ITAMs triggers the activation of Syk. To prove the hypothesis that the inhibition of SRC family kinase induces the decreased phosphorylation of Syk, resulting in decreased phagocytosis by macrophages, a SRC family kinase inhibitor, dasatinib, was used in the experiments.

Methods, Results and Discussion:

In vitro study; Murine macrophage cell line, RAW, was incubated with APA coated murine platelets for 30 minutes. Phagocytosis by RAW was significantly decreased with dasatinib (100nM, p<0.01), indicating SRC family kinase activity is required for efficient phagocytosis. Phosphorylated Syk was decreased in RAW, incubated with anti-Fc receptor antibody (rat IgG) and anti-rat IgG antibody with dasatinib (100nM), shown in the Western blot analysis (Figure 1). These results suggest that Syk phosphorylation is the key step in phagocytosis.

In vivo study; (1) Three hours before APA intra-peritoneal injection, dasatinib (2.5mg/kg) was oral-administrated. Six hours after APA injection, platelet counts were measured. The platelet counts were 366 ± 164 x109/L with dasatinib (n=4, mean ± SD) and 114 ± 51 x109/L without dasatinib (n=4)(P=0.026)(Figure 2). (2) Osmotic pump, filled with APA, were inserted in murine intra-peritoneal cavity and dasatinib (2.5mg/kg) was oral-administered once daily for 7 days. The platelet counts were 499 ± 98 x109/L with dasatinib (n=4, mean ± SD) and 82 ± 131 x109/L without dasatinib (n=4) at day 7 (p<0.0022) (Figure 3). These results strongly suggest that dasatinib inhibit the phagocytosis in vivo.

Conclusion: Dasatinib inhibits phosphorylation of Syk, inducing decreased phagocytosis of APA-coated platelets via decreased SRC family kinase activity. These findings reveal that SRC family kinase controls the efficiency of phagocytosis in part through the regulation of Syk function. Dasatinib might be effective in the treatment of ITP.

Disclosures

No relevant conflicts of interest to declare.
Immune Response to FIX Is Dependent on Mouse Background Strain and Modulated By TLR4
Authors: Markusic David M
Published: October 2019

Introduction

Many investigators rely on mouse models to study immune responses against factor IX protein (FIX) products. While it is recognized that there are distinct differences in immune responses towards FIX in different mouse strains, there is an absence of studies conducted on mice with a F9 gene deletion. Our laboratory has developed protocols to prevent or reverse ongoing anti-hFIX IgG inhibitors in hemophilia B mice with a F9 gene deletion (F9-/Y) on both a BALB/c and C3H/HeJ background. Interestingly C3H/HeJ F9-/Y mice develop high titer anti-FIX IgG1 inhibitors and anaphylaxis, while BALB/c F9-/Y mice have mild anti-hFIX IgG1 inhibitors without anaphylaxis. The C3H/HeJ mouse strain is deficient for the innate immune sensor toll like receptor 4 (TLR4) while a congenic C3H/OuJ strain has functional TLR4. Several recent studies have indicated an important link between coagulation and innate immunity and TLR4 has been linked to sensitivity in food allergy models. Together these studies suggest that TLR4 may have a role in modulating FIX immunity. Here we report results from a study exploring B and T cell responses against FIX protein therapy on two different mouse strains BALB/c and C3H/HeJ with the same F9 gene deletion and the role of TLR4 in modulating FIX immunity.

Methods

BALB/c and C3H/HeJ F9-/Y mice were challenged weekly with recombinant FIX protein. Humoral immune responses were determined by IgG1 and IgG2a anti-hFIX ELISA, Bethesda assay for inhibitors and B cell ELISpot on bone marrow and spleen cells to measure FIX specific antibody secreting B cells. T cell studies measured the TH1 (IFN-γ) and TH2 (IL-4) cytokine responses in splenocytes at the mRNA and protein level in response to FIX protein. Antibody responses were also measured in C3H/HeJ/OuJ F9-/Y mice with restored TLR4 function following FIX challenge.

Results

BALB/c F9-/Y mice have a TH2 skewed response and a reduction in anti-hFIX secreting plasma cells in the bone marrow. Independent antigen challenge revealed both strains generated equivalent IgG1 antibody titers to an intravenously delivered antigen suggesting the reduced anti-FIX response in BALB/c mice is antigen specific. C3H/HeJ F9-/Y mice have a mixed TH1 and TH2 response (mainly TH2). Importantly TLR4 signaling has an important modulatory role in the C3H background on the levels of anti-hFIX IgG1 and incidence of anaphylaxis.

Conclusions

The background strain has an important impact on FIX immune responses, which in permissive strains can be modulated by mutations in innate immune sensors.

Disclosures

No relevant conflicts of interest to declare.
Validation of the rAHF-PFM PK Guided Dose Calculator Medical Device Using an Unrelated Clinical Dataset
Authors: Steinitz Katharina Nora , Spotts Gerald , Loew-Baselli Alexandra , Oh Myungshin , Penny Mark , Gringeri Alessandro , Reininger Armin J
Published: October 2019

Introduction: Prevention of bleeding represents the standard of care for patients with hemophilia without inhibitors. However, standard prophylactic dosing regimens with FVIII are currently based on body weight alone and do not take into account considerable inter-individual variability in FVIII PK profiles. In order to facilitate personalization of prophylaxis to individual needs and individual PK response we have developed a device that allows PK guided dosing in routine clinical care. In fact, the major barrier of PK-guided dosing in clinical practice is the necessity of multiple blood samples (6 to 11 over 48 hours) associated with a single infusion and the lack of easy-to-use statistical software to generate classical PK profiles. Leveraging the vast rAHF-PFM clinical database with more than 150 classical PK assessments, a Population PK model for children and adults was combined with a Bayesian algorithm to create a user friendly medical device. This methodology allows the use of only a few samples after different infusions to estimate individual PK parameters and help to calculate dosing regimens.

Methods: In order to carry on an external validation of the Bayesian population PK model of the device, individual 10 point PK assessment data from an unrelated source, i.e. not included in the base population PK model, (rAHF-PFM prophylaxis study, Valentino et al 2012) was utilized to validate the accuracy of the calculation. First, we compared predicted post infusion FVIII levels with observed FVIII levels using all the available post infusion samples. In a second step we compared individually estimated PK parameters as obtained by using 10 post infusion samples with a progressively reduced number of post infusion samples.

Results: The external validation study indicated a good agreement between the observed and predicted FVIII levels (Figure) and PK parameters. Furthermore it showed that the rAHF-PFM medical device had a good predictive performance even when using only 2 sampling time-points.

Figure 1 Figure 1.

Conclusion: An easy-to-use medical device that can estimate PK parameters and thus assists in designing prophylactic dosing regimens based on individual- PK characteristics represents a groundbreaking innovation. This literally shifts the treatment paradigm from one-size-fits-all prophylaxis towards a more personalized therapy in hemophilia A and allows further optimization of dosing in patients in order to improve outcome in a sustainable fashion.

Disclosures

Steinitz: Baxter: Employment. Spotts:Baxter Healthcare Corporation: Employment. Loew-Baselli:Baxter Innovations GmbH: Employment, Equity Ownership. Oh:Baxter Healthcare Corporation: Employment. Penny:Baxter Healthcare Limited: Employment, Equity Ownership. Gringeri:Baxter Innovations GmbH: Employment. Reininger:Baxter Innovations GmBH: Employment, Equity Ownership.
Absolute Lymphocyte Count As an Independent Prognostic Factor of IPI and NCCN-IPI in DLBCL Patients
Authors: Okada Kazuya , Ochi Shinichi , Nagayama Takashi , Nabe Shogo , Sakai Kazuya , Muranushi Hiroyuki , Okamoto Yusuke , Sugiura Hiroyuki , Sato Aki , Sato Takayuki , Maeda Takeshi , Onishi Tatsuhito , Ueda Yasunori
Published: October 2019

Background: Previous studies have shown that the absolute lymphocyte count (ALC) in peripheral blood at diagnosis may be an independent prognostic factor of IPI for patients with diffuse large B-cell lymphoma (DLBCL). In the rituximab era, the U.S. National Comprehensive Cancer Network International Prognostic Index (NCCN-IPI) was developed to improve the risk stratification of DLBCL in comparison to the existing IPI. Therefore, the aim of this study was to clarify the impact of ALC at diagnosis on event free survival (EFS) and overall survival (OS) on analysis performed with factors included in NCCN-IPI.

Patients and methods: We retrospectively reviewed the ALC of 413 patients with newly diagnosed DLBCL treated with R-CHOP at our hospital between January 2005 and March 2013. Primary central nervous system lymphoma patients were excluded from this study. ALC was determined in all patients from complete blood count with differential white blood count at the time of diagnosis, and prior to therapy administration. EFS and OS were estimated according to the Kaplan-Meier method. Multivariate analysis was performed with the proportional hazard Cox model.

Results: The median ALC was 1.2x10E9/L (range, 0.06-9.0). We set an ALC cut-point at 1.0x10E9/L based on previous studies. The median follow-up duration was 40 months. Baseline characteristics according to ALC (<1.0x10E9/L[n=145] and >1.0x10E9/L[n=268]) are summarized in Table1. Patients with ALC<1.0x10E9/L had a significantly poorer EFS and OS than patients with ALC>1.0x10E9/L (5-year EFS, 37.0% versus 68.9%, p<0.001; 5-year OS, 46.3% versus 80.0%, p<0.001). On multivariate analysis performed with factors included in IPI and NCCN-IPI, ALC remained an independent predictor of EFS (IPI: hazard ratio [HR] 1.95; 95% confidence interval [CI] 1.43-2.68; p<0.001, NCCN-IPI: HR 1.94; 95%CI 1.42-2.65; p<0.001) and OS (IPI: HR 2.35; 95%CI 1.61-3.42; p<0.001, NCCN-IPI: HR 2.29; 95%CI 1.57-3.33; p<0.001) (Table2). Importantly, within the poor R-IPI group, ALC distinguished patients with different 5-year EFS (24.4% versus 50.4%, p<0.001) and OS (35.7% versus 65.7%, p<0.001). For the high NCCN-IPI group also, ALC distinguished patients with different 5-year EFS (14.8% versus 39.8%, p<0.01) and OS (17.5% versus 54.5%, p<0.001) (Figure1).

Conclusions: According to our results, ALC<1.0x10E9/L is an adverse prognostic factor and independent of IPI and NCCN-IPI. ALC might be more successful in identifying high-risk patients in which IPI and NCCN-IPI analysis was unrevealing. Our results suggest that other therapeutic strategies may be more effective in high-risk patients with DLBCL.

Disclosures

No relevant conflicts of interest to declare.
Azacitidine Treatment in High Risk Myelodysplastic Patients in Complete Haematological Remission Reverts Mesenchymal Stem Cells to a Normal Phenotype
Authors: Poloni Antonella , Maurizi Giulia , Mattiucci Domenico , Costantini Benedetta , Mariani Marianna , Mancini Stefania , Fanelli Mirco , Olivieri Attilio , Leoni Pietro
Published: October 2019

Introduction. Myelodysplastic syndromes (MDSs) are a heterogeneous group of clonal hematopoietic stem cell (HSC) malignancies that are characterized by ineffective bone marrow hematopoiesis, peripheral blood cytopenias, and a substantial risk for progression to acute myeloid leukemia. Mesenchymal stem cells (MSCs) isolated from bone marrow of patients affected by myelodysplastic syndromes (MDS) play a critical role in myelodysplastic microenvironment showing altered structural epigenetic and functional features.

Methods. In this work we evaluated the effect of azacitidine treatment on MSC-MDS. In particular, we analyzed MSC-MDS from 24 high-risk patients at diagnosis and after azacitidine treatment, studying their morphology, proliferative potential, cell cycle activity and their capacity to support haematopoiesis.

Results. MDS-MSCs at diagnosis appeared larger and flattened, achieved confluence at a significantly lower rate than donors and displayed reduced proliferative capacity. In particular 40% of samples were unable to expand.

This reduced proliferative capacity of MSC-MDS at diagnosis suggested changes in the cell cycle activity. Therefore we studied the gene expression profiles of 37 regulatory genes, observing CDKN2B up-regulation in MDS-MSCs (8 times higher than donors).

Notably, after azacitidine treatment MDS-MSCs of patients who reached complete haematological remission (MDS-MSCs-CR) reverted to the typical BM-MSC morphology and recovered a proliferative potential similar to normal BM-MSC achieving confluence at a significantly higher rate.

Molecular analysis on MDS-MSC-CR revealed a significant reduction in the expression level of CDKN2B showing correlation between cell cycle progression and expression level of this gene.

Moreover, to study the long-term hematopoietic maintaining ability, MDS-MSCs at diagnosis were cultured with CD133+ cells, and they showed a decreased ability to support the growth of myeloid and erythroid progenitors. Conversely, MSC-MDS-CR showed an increased capacity to support haematopoiesis similar to healthy donors.

Conclusion. We showed that MDS-MSCs at diagnosis were structurally and functionally altered while MSC-MDS-CR after azacitidine revert to a normal phenotype. It has been supposed that healthy MSCs adopt MDS-MSCs like molecular features when exposed to haematopoietic MDS cells.

Our results may confirm these data suggesting that myelodysplastic cells can alter bone marrow microenvironment interacting with MSC and affecting their normal role and functionality.

Disclosures

No relevant conflicts of interest to declare.
Circulating Multiple Myeloma Cells (CMMCs): A Novel Method for Detection and Molecular Characterization of Peripheral Blood Plasma Cells in Multiple Myeloma Precursor States
Authors: Weiss Brendan , Sasser Kate , Rao Chandra , Foulk Brad , Gross Steven , Mallon Gayle , Erb Colleen , Berkowitz Anne , Mangan Patricia A. , Shelly Brenda K. , Cohen Adam D. , Vogl Dan T. , Garfall Alfred L. , Stadtmauer Edward A.
Published: October 2019

Background Circulating plasma cells (PCs) have been identified as a prognostic factor in patients with myeloma precursor states (MGUS and SMM) and active multiple myeloma (MM). Enumeration of circulating PCs by available methods is not suitable for widespread use and does not provide molecular characterization. We developed and evaluated a novel method for enumeration and molecular characterization of circulating PCs (circulating multiple myeloma cells, “CMMC”), based on the CELLSEARCH® System (Janssen Diagnostics LLC, Raritan, NJ), an automated technology for the capture, enumeration and characterization of rare cells in the peripheral blood.

Methods We are performing a prospective study of patients with MGUS and SMM to evaluate CMMCs as biomarker for progression to active MM. Utilizing the CELLSEARCH® System CMMCs were captured by CD138 ferrofluid magnetic particles and identification was defined as CD38+ and CD19-, CD45-. Nonviable cells were excluded by DAPI. Isolated CMMCs were stored and FISH for t(4:14), t(14;16) and del17 was performed.

Results We have enrolled 16 patients, MGUS = 3, SMM = 11, and newly diagnosed MM = 2. The Mayo Risk stratification for MGUS patients was: low risk = 2, low-intermediate = 1. All SMM patients were low risk by Mayo Model incorporating serum free light chains. The median number of bone marrow plasma cells for MGUS patients was 7 (range 7-9) and for SMM patients was 15 (range 10-40). The median CMMCs for MGUS = 6 (range 2-55), median CMMCs for SMM = 31 (5-1918). The two patients with NDMM had 5870 and 5 CMMCs, respectively. A single patient with SMM progressed with a symptomatic solitary lumbar plasmacytoma and had CMMCs of 5 and 3 at baseline and progression, respectively. Abnormalities by FISH were detected in both bone marrow and CMMCs. Accrual is ongoing and additional data will be presented at the meeting.

Conclusions The CELLSEARCH® CMMC assay can detect, quantify and provide molecular characterization of circulating PCs in MGUS/SMM/MM; longer prospective follow-up is needed to test the prognostic value of CMMCs.

Disclosures

Weiss: Janssen: Consultancy, Research Funding. Sasser:Janssen: Employment. Rao:Janssen: Employment, Equity Ownership. Foulk:Janssen: Employment. Gross:Johnson & Johnson: Employment, Equity Ownership. Cohen:Janssen: Membership on an entity's Board of Directors or advisory committees. Vogl:Celgene Corporation: Consultancy; Amgen: Consultancy; Millennium/Takeda: Research Funding; GSK: Research Funding; Acetylon: Research Funding. Stadtmauer:Janssen: Consultancy.