bluuebunny/crossref_metadata_2025 huggingface dataset:
The Net Clinical Benefit of Thrombolysis in the Management of Submassive Pulmonary Embolism: Systematic Review and Meta-Analysis
Authors: Alcedo Pedro , Rojas Hernandez Cristhiam Mauricio , Garcia Perdomo Herney Andres
Published: November 2019

Background: Benefit of thrombolytic therapy in patients with massive pulmonary embolism (PE) has been proven. Evidence supporting benefit in clinical outcomes of this approach in the subgroup of patients with submassive PE is lacking.

Objective: The primary objective was to determine the impact of thrombolysis on overall survival in patients with submassive PE. Secondary outcomes included bleeding, thrombotic complications, improvement on parameters of right ventricular strain and all cause-mortality.

Methods: A search strategy was conducted in MEDLINE (OVID), EMBASE, LILACS and the Cochrane Central Register of Controlled Trials (CENTRAL) from inception to nowadays. Search was also conducted in other databases and unpublished literature. Clinical trials were included without language restrictions. The risk of bias was evaluated with the Cochrane Collaboration's tool. We performed a meta-analysis with a fixed effect model according to the heterogeneity. PROSPERO registration number is CRD42019128229.

Results: Twelve studies were included in the qualitative and quantitative analysis. 2,564 patients were found among the twelve studies. Risk of bias was assessed mostly as low or unclear risk among the study items. The risk ratio (RR) for all-cause mortality was 1.00 95% CI (0.77 to1.30). The RR of total bleeding and major bleeding were 2.72 95% CI (1.58 to4.69) and 2.17 95% CI (1.03 to4.55), respectively, finding higher risk in thrombolytic therapy. For stroke the RR was 2.22 95% CI (0.17 to28.73), and for recurrent PE the RR was 0.56 95% CI (0.23 to1.37), finding no differences regarding these outcomes. Unfortunately, there were no results reported about overall survival in any of the studies.

Conclusion: In patients with submassive PE, the risk of bleeding is higher when thrombolysis is used. There is no significant difference between thrombolysis and anticoagulation in recurrence of PE, stroke, and all-cause mortality

Figure

Disclosures

No relevant conflicts of interest to declare.
Dose Adjusted R-EPOCH Does Not Improve Outcomes in High Grade B Cell Lymphoma with Double Expressor Status or Gain of MYC/BCL2
Authors: Hardefeldt Prue , Moore John , Milliken Sam , Fay Keith , Orly Lavee , Mayson Eleni , Withers Barbara , Hamad Nada
Published: November 2019

Introduction:

Diffuse large B cell lymphoma is a heterogenous disease with prognosis known to vary based on histological changes including immunohistochemistry and gene rearrangements by florescence in situ hybridisation (FISH). Both immunohistochemical overexpression as well as gene rearrangements in MYC, BCL2 and BCL6 are thought to contribute to poor prognosis. The benefit of high dose chemotherapy is unclear for those with high grade B cell lymphoma with double hit status (DHL) by FISH , double expressor status (DEL) or gain of MYC/BCL2. The purpose of this study was to retrospectively analyse the effect of escalated chemotherapy in this population over a 5 year period.

Methods:

All patients with DLBCL treated between 2012-2017 were screened retrospectively for inclusion in the study based on immunohistochemistry and FISH at time of initial diagnosis. Immunohistochemistry was assessed on formalin fixed, paraffin embedded specimens with BCL2 and MYC considered positive at over 40% and 50% respectively. FISH was assessed using dual colour break apart probe.

Results:

135 patients were diagnosed with DLBCL of which 53 patients had immunohistochemistry and FISH at diagnosis confirming either, DEL or gain of MYC/BCL2 status. The mean age was 65 years and median follow up 21 months. The overall response rate in DH treated with DA-R-EPOCH was 57%. There were insufficient cases treated with R-CHOP for comparison. Overall response rates in DEL were 94% for DA-R-EPOCH and 93% for R-CHOP. Overall survival (OS) and disease free survival (DFS) in DHL was 6 months and 2 months respectively when treated with DA-R-EPOCH. There was no significant difference in OS or DFS in DEL treated with DA-R-EPOCH compared with R-CHOP (OS: 42 months vs 38 months respectively (p=0.962), DFS 36 months vs 30 months (p=0.931)). Gain of MYC/BCL2 did not affect OS (p= 0.539) or DFS (p=0.439) when comparing treatment regimen.

Conclusion: DA-R-EPOCH did not improve treatment response rates OS or DFS in patients with double expresser lymphoma or gain of MYC/BCL2. This study also confirms the previously reported poor outcomes associated with DHL

Disclosures

No relevant conflicts of interest to declare.
Safety of Doacs in Patients with CNS Malignancies
Authors: Swartz Andrew , Drappatz Jan
Published: November 2019

Background: Neuro-oncology patients, like all cancer patients, are at a high risk for thromboembolic complications and frequently require treatment with anticoagulation. DOACs have emerged as a less burdensome treatment for cancer associated thrombosis with comparable safety and efficacy to LMWH. Unfortunately, there is a paucity of data to support the use of DOACs in patients with primary and metastatic brain tumors and there is concern in the medical community for increased risk of intracranial hemorrhage. Objectives: The purpose of this study is to better understand the safety profile of anticoagulants in brain tumor patients, with a particular interest in the safety and efficacy of DOACs. Our hypothesis is that DOACs are as safe and effective as LWMH in this patient population. Methods: This study was conducted through retrospective chart review of patients with primary and metastatic brain tumors on anticoagulation. Our outcomes of interest were major bleeding (as defined by ISTH guidelines), with particular interest in Intracranial hemorrhage as well as minor bleeding and recurrent thrombosis. Radiographic images of all patients were reviewed for evidence of ICH and CTCAE v5 criteria were used to grade severity of ICH cases with range from 1 (asymptomatic imaging finding) to 5 (death). Results and Conclusions: A total of 130 patients with brain tumors were evaluated (69% primary brain tumor, 15% CNS lymphoma, 16% metastatic disease). Out of this population, 62 were on LMWH and 52 were on DOACs. The incidence of major bleeding was 20.9% in the LMWH group vs. 9.6% in the DOAC group (P =0.1, 95% CI -2.45 - 24.1). The incidence of ICH was 14.5% in the LMWH group and 5.8% in the DOAC group (P =0.13 95% CI -3.23 - 20.2). The severity of ICH in both groups was low with median CTCAE v5 scores of 2 in LMWH group and 3 in the DOAC group. The incidence of minor bleeding was 16.1% in LMWH group and 21.1% in the DOAC group (P = 0.49 CI -9.2 - 19.7). Recurrent thrombosis in both groups occurred in <5% of cases. Our conclusion is that in patients with primary and metastatic brain tumors, DOACs are not associated with an increased incidence of major bleeding or ICH compared to LMWH and are a safe and effective option in this patient population.

Disclosures

No relevant conflicts of interest to declare.
Next Generation CRISPR Gene-Edited and Off-the-Shelf Virus-Specific T-Cells for the Immunocompromised Patient
Authors: Basar Rafet , Daher May , Uprety Nadima , Gokdemir Elif , Alsuliman Abdullah Saleh , Mendt Mayela Carolina , Kerbauy Lucila , Shanley Mayra , Ozcan Gonca , Ensley Emily , Cortes Ana Karen Nunez , Li Li , Lu Junjun , Kaplan Mecit , Nandivada Vandana , Bdaiwi Mustafa , Li Ye , Garcia Luciana Melo , Liu Enli , Ang Sonny , Banerjee Pinaki P , Champlin Richard E. , Shpall Elizabeth J. , Rezvani Katayoun
Published: November 2019

Introduction: A number of Clinical trials have demonstrated the feasibility, safety and efficacy of cell and gene therapy for cancer, autoimmune disorders and infectious disease. Strategies that enhance the function and survival of immune cells are critical for the success of immunotherapy. We have developed a strategy for the ex vivo expansion of off-the-shelf viral-specific T cells (VSRs) from healthy donor buffy coat which have been extremely effective in eradicating refractory cytomegalovirus (CMV), polyomavirus and adenovirus infections in immunocompromised patients. Glucocorticoids commonly used to treat graft-versus-host disease (GVHD) after allogeneic hematopoietic stem cell transplantation (HSCT) are a common cause of iatrogenically-induced immunosuppression and contribute the risk of life-threatening viral-infections. To render VSTs resistant to the lymphocytotoxic effect of glucocorticoids, we have developed a novel strategy to silence the expression of the glucocorticoid receptor using RNA-guided endonucleases CRISPR (clustered regularly interspaced short palindromic repeats) and CRISPR-associated (Cas) 9 gene editing..

Methods: The technique involves the expansion from donor blood of CMV, BKV or adenoviral-specific T cells using peptide libraries from the immunodominant viral proteins followed by CRISPR knockout of exon 2 of the GR gene on chromosome 5 of the human NR3C1 gene. Cells are electroporated with the RNP (Cas9 plus guide RNA) complex (IDT pre-designed alt-R crispr Cas9 platform) using Neon electroporation and the Amaxa 4-D nucleofector system.

Results: GR knockout efficiency in ex vivo expanded virus-specific T cells was consistently > 90%. In vitro experiments confirmed the resistance of VSTs to corticosteroid treatment as assessed by annexin V assay. GR KO VSTs maintained potent antiviral activity as assessed by their ability to proliferate and release effector cytokines in response to viral antigens.

Conclusions: CRISPR gene-editing to knock-out the glucocorticoid receptor gene in viral-specific T cells can preserve the activity of VSTs in the presence of corticosteroid-induced immunosuppression. Engineering runs using GMP-compliant Cas9 protein and gRNA are underway in anticipation of a clinical trial.

Disclosures

Champlin: Sanofi-Genzyme: Research Funding; Actinium: Consultancy; Johnson and Johnson: Consultancy.
Comparison of Two Different ELISA Methods for Heparin-Induced Thrombocytopenia (HIT) Screening on an Automated ELISA Platform
Authors: Mardovina Tatsiana , Chromczak John G , Riley Paul W
Published: November 2019

BACKGROUND:

Heparin-induced thrombocytopenia (HIT) is an adverse complication of unfractionated and low molecular weight heparin caused by antibodies recognizing platelet factor 4-heparin (PF4/hep) complexes leading to platelet activation. The diagnosis of HIT is based on the combination of the clinical picture, using the 4T score along with screening and confirmatory methods to detect platelet activating anti‐PF4/H antibodies.

OBJECTIVES:

Performance was evaluated for two enzyme linked immunosorbent assays (ELISAs), 1) Asserachrom HPIA , Diagnostica Stago Inc., Parsippany, NJ, USA and 2) LIFECODES PF4 Enhanced, Immucor, Inc., Norcross, GA, USA for screening-based detection of PF4/hep antibodies.

METHODS:

ELISA assays were run per manufacturer recommendations and adapted for automation on a Dynex DS2 automated ELISA platform. Performance characteristics of the two immunoassays were assessed, including sensitivity, specificity, concordance with serotonin release assay (SRA), positive predictive value (PPV) and negative predictive value (NPV). 21 samples were used in the study.

Results:

Both assays, Asserachrom HPIA and LIFECODES PF4 Enhanced demonstrated 100% sensitivity and NPV, confirming both assays' reliability to detect and rule out HIT (see table). The diagnostic specificity was significantly higher for Asserachrom HPIA vs. LIFECODES PF4 Enhanced (77.8% vs 31.6%). Asserachrom HPIA showed fewer false positive results, with PPV of 42.9% for Asserachrom HPIA vs. 13.3% for LIFECODES PF4 Enhanced. No false negative results were found for either assay. Asserachrom HPIA demonstrated 81.0% concordance with SRA, vs. 38.1% for LIFECODES PF4 Enhanced.

CONCLUSIONS:

HIT is a life-threatening disorder, with diagnosis depending on clinical findings using the 4T score along with laboratory evaluation. Combining the 4T score with PF4/hep antibody screening increases the accuracy of excluding HIT. Our observations indicate Asserachrom HPIA provides results with high sensitivity and specificity, minimizing false positivess, allowing use of alternative anticoagulants more selectively in at risk patients, to potentially improve patient management while minimizing costs.

Disclosures

Mardovina: Diagnostica Stago, Inc.: Employment. Chromczak:Diagnostica Stago, Inc.: Employment. Riley:Diagnostica Stago, Inc.: Employment.
The Clinical Impact of Modified Barthel Index in Elderly Patients over 60 Years with Diffuse Large B-Cell Lymphoma
Authors: Ogura Shinji , Akimoto Masahiro , Sakurai Aki , Ito Chisako , Fujita Yuriko , Aisa Yoshinobu , Nakazato Tomonori
Published: November 2019

[Introduction]Modified Barthel Index (MBI) is widely used to measure performance in activities in daily living (ADL), especially in elderly patients. MBI consists of 10 items: feeding, personal hygiene (grooming), bathing, dressing, toilet transfer, bladder control, bowel control, chair/bed transfers, stair climbing, and ambulation. A total score ranges from 0 to 20. MBI has been studied in several types of cancer which is correlated with prognosis. However, the prognostic role of MBI in diffuse large B-cell lymphoma is still unknown. The study aims to investigate the predictive role of MBI in elderly patients over 60 years with DLBCL.

[Methods]This retrospective study included elderly DLBCL patients over 60 years treated at our institution between 2009 and 2018. MBI score of each patient was evaluated at diagnosis. Receiver operator characteristic (ROC) curve was used to generate a cut off value for MBI. Kaplan-Meier method and univariate, multivariate analysis by Cox proportional hazards model were performed to assess the prognostic influence of the factors including Stage, Revised International Prognostic Index score (R-IPI), Performance status (PS), Extra-nodal Site Involvement (ESI), Lactate Dehydrogenase (LDH), Soluble Interleukine-2Receptor (sIL-2R), Albumin, B symptoms and MBI. The study protocol was approved by the Institutional Review Board of Yokohama Municipal Citizen's Hospital, and it was carried out in accordance with the Declaration of Helsinki.

[Results]A total of 187 patients were included in the analysis. There were 102 males and 85 females, with a median age of 77 (range: 61-93). The median follow-up time was 39 months. The optimal MBI cutoff value for predicting 3-year survival was determined by ROC analysis to be 14.Patients with low MBI scores (< 14) had significantly shorter overall survival (OS) than those with high MBI scores (≥ 14) (3-year OS, 14.2 % vs. 65.2 %, p < 0.001). Among 163 patients receiving chemotherapy, patients with low MBI scores had shorter OS than those with high MBI scores (3-year OS, 21.2 % vs. 66.4 %, p < 0.001). In multivariate analysis, parameters having independent adverse significance for OS were: Low MBI (< 14) (p < 0.001, HR 2.49), PS ( ≥ 2) (p=0.04, HR 1.84).

[Conclusion]In the present study we demonstrated that Low MBI was deeply associated with poor outcome in elderly patients with DLBCL. In particular, our data proved that a low MBI is an independent prognostic factor for survival in elderly patients with DLBCL. These results suggest that Low MBI may have an important role in DLBCL and may be also a useful prognostic marker. Since our results are based on a small-sized analysis, further large prospective studies are warranted to verify this conclusion.

Disclosures

No relevant conflicts of interest to declare.
Mutation Status and Burden Can Improve Prognostic Prediction of Patients with Lower-Risk Myelodysplastic Syndromes
Authors: Jiang Lingxu , Luo Yingwan , Jin Jie , Tong Hongyan
Published: November 2019

Patients with lower-risk myelodysplastic syndromes (LR-MDS) as defined by the International Prognostic Scoring System (IPSS) have more favorable prognosis in general, but significant inter-individual heterogeneity exists. In this study, we examined the molecular profile of 15 MDS-relevant genes in 159 patients with LR-MDS using next-generation sequencing. In univariate COX regression, shorter overall survival (OS) was associated with mutation status of ASXL1 (P=0.001), RUNX1 (P=0.031), EZH2 (P=0.049), TP53 (P=0.016), SRSF2 (P=0.046), JAK2 (P=0.040), and IDH2 (P=0.035). We also found significantly shorter OS in patients with a TET2 variant allele frequency (VAF) ≥18% versus those with either a TET2 VAF <18% or without TET2 mutations (median: 20.4 vs. 47.8 months; P=0.020; HR=2.183, 95%CI: 1.129-4.224). After adjustment for the IPSS, shorter OS was associated with mutation status of ASXL1 (P<0.001; HR=4.306, 95%CI: 2.144-8.650), TP53 (P=0.004; HR=4.863, 95%CI: 1.662-14.230) and JAK2 (P=0.002; HR=5.466, 95%CI: 1.848-16.169), as well as a TET2 VAF ≥18% (P=0.008; HR=2.492, 95%CI: 1.273-4.876). Also, OS was increasingly shorter as the number of mutational factors increased (P<0.001). A novel prognostic scoring system based on the IPSS and the presence/absence of the 4 independent mutational factors further stratified LR-MDS patients into three prognostically different groups (P<0.001).The newly developed scoring system re-defined 10.1% (16/159) of patients as higher-risk group, who could not be predicted by the currently prognostic models. In conclusion, integration of IPSS with mutation status/burden of certain MDS-relevant genes may improve the prognostication of patients with LR-MDSand could help identify those with worse-than-expected prognosis for more aggressive treatment.

Figure

Disclosures

No relevant conflicts of interest to declare.
Fyn Specifically Regulates the Activity of Red Cell Glucose-6-Phosphate-Dehydrogenase
Authors: Mattè Alessandro , Lupo Francesca , Tibaldi Elena , Di Paolo Maria Luisa , Andrea Carpentieri , Pucci Pietro , Brunati Anna Maria , Cesaro Luca , Turrini Francesco , Manzo Saúl Gómez , Choi Soo Young , Quino Jaime Marcial , Kim Dae Won , Pantaleo Antonella , An Xiuli , Federti Enrica , Iatcenko Iana , Cappellini Maria Domenica , Forni Gian Luca , De Franceschi Lucia
Published: November 2019

Fyn is a tyrosine kinase belonging to the Src family (Src-Family-Kinase, SFK), ubiquitously expressed. Previously, we reported that Fyn is important in stress erythropoiesis. Here, we show that in red cells Fyn specifically stimulates G6PD activity, resulting in a 3-fold increase of the enzyme catalytic activity (kcat) by phosphorylating tyrosine (Tyr)-401. We found Tyr-401 on G6PD as functional target of Fyn in normal human red blood cells (RBC), being undetectable in G6PD deficient RBCs (G6PD-Mediterranean and G6PD-Genova). Indeed, Tyr-401 is located to a region of the G6PD molecule critical for the formation of the enzymatically active dimer. Amino acid replacements in this region are mostly associated with a chronic hemolysis phenotype. Using mutagenesis approach, we demonstrated that the phosphorylation status of Tyr401 modulates the interaction of G6PD with G6P and stabilizes G6PD in a catalytically more efficient conformation. RBCs from Fyn-/-mice are defective in G6PD activity, resulting in increased susceptibility to primaquine-induced intravascular hemolysis. This negatively affected the recycling of reduced Prx2 in response to oxidative stress, indicating that defective G6PD phosphorylation impairs defense against oxidation. In human RBCs, we confirm the involvement of the thioredoxin/Prx2 system in the increase vulnerability of G6PD deficient RBCs to oxidation. In conclusion, our data suggest that Fyn is an oxidative radical sensor, and that Fyn-mediated Tyr-401 phosphorylation, by increasing G6PD activity, plays an important role in the physiology of RBCs. Failure of G6PD activation by this mechanism may be a major limiting factor in the ability of G6PD deficient RBCs to withstand oxidative stress.

Disclosures

Cappellini: Genzyme/Sanofi: Honoraria, Membership on an entity's Board of Directors or advisory committees; Vifor Pharmaceutical: Membership on an entity's Board of Directors or advisory committees; Novartis: Membership on an entity's Board of Directors or advisory committees; Celgene Corporation: Honoraria; CRISPR Therapeutics: Membership on an entity's Board of Directors or advisory committees. Forni:Novartis, Iron chelation: Research Funding; Celgene, Erithropoiesis Stimulation: Research Funding; Roche, Erithropoiesis Stimulation: Research Funding; BlueBirdBio: Consultancy.
Eltrombopag Treatment for Patients with Thrombocytopenia Post-Transplantation Showed a Good Chance of Platelet Recovery
Authors: Gao Fei , Zhao Yanmin , Huang He
Published: November 2019

Allogeneic hematopoietic stem cell transplantation (Allo-HSCT) dramatically improves the outcomes of patients with hematologic disorders. However, thrombocytopenia post-transplantation is a common and severe complication, which not only diminishes the quality of life but also leads to fatal bleeding events. Blood transfusion could not be a permanent solution and it seldom achieves satisfactory results. Eltrombopag (EPAG), a novel oral thrombopoietin receptor agonist (TPO-RA), has been shown promising effects in thrombocytopenia caused by immune thrombocytopenic purpura (ITP) and severe aplastic anemia (SAA). Yet, the effectiveness of EPAG for patients with thrombocytopenia post-transplantation still needs to be discovered. From September 2017 to April 2019, twenty-two patients were diagnosed as thrombocytopenia post-transplantation in our center, including 10 patients with poor graft function (PGF) and 12 patients with secondary failure of platelet recovery (SFPR). Since insensitive to traditional treatment such as thrombopoietin and intravenous immunoglobin, all these patients received the EPAG treatment. So far, 16 (72.7%) patients achieved hematopoietic overall recovery (OR) and 11(50.0%) patients were complete recovery (CR). 12(75.0%) of the responded patients discontinued or tapered the drug and 9 patients (56.3%) successfully maintained their best response. Among 16 responded patients, the median time to achieve PR status was 33 (range, 7-105) days and the median time of CR was 67 (range, 40-175) days. Interestingly, 11 (91.7%) patients from SFPR subgroup achieved OR, while only 5 (50%) patients from PGF subgroup achieved OR. Besides, patients with normal spleen size (n=16) experience a higher CR rate than splenomegaly patients (n=8) (10 vs 1, 71.4% vs 12.5%). On univariate and multivariate analysis, PGF was identified as the independent risk factor of OR (P=0.050) and splenomegaly was identified as the independent risk factor of CR (P=0.019). Interestingly, 3 patients with enlarged spleen received ruxolitinib to minimize the spleen size during the EPAG treatment. Accompanied by the reduction in spleen size, the platelet counts increased gradually and all these 3 patients achieved OR. In contrast, only 2 of the other 5 splenomegaly patients who without ruxolitinib achieved OR. In conclusion, EPAG treatment for patients with thrombocytopenia post-transplantation showed a good chance of platelet recovery.

Disclosures

No relevant conflicts of interest to declare.
Allogeneic Hematopoietic Stem Cell Transplantation for Therapy-Related Myelodysplastic Syndromes and Acute Myeloid Leukemia
Authors: Metheny Leland , Saber Wael , Weisdorf Daniel J. , de Lima Marcos , Callander Natalie Scott , Litzow Mark , Kebriaei Partow , Hall Aric C. , Sandmaier Brenda M , Zhang Mei-Jie , Wang Hai-Lin , Bo-Subait Khalid
Published: November 2019

Patients who develop therapy-related myelodysplastic syndromes (t-MDSs) or acute myeloid leukemia (t-AML) following prior chemotherapy or an autologous hematopoietic cell transplant (HCT), have a poor prognosis. An earlier analysis of allogeneic HCT (n=868, 1990-2004) showed 5-year overall survival (OS) and disease free survival (DFS) were 22% and 21% (reference). Furthermore, older age, graft source other than a HLA-matched sibling or HLA well matched unrelated donor (URD), t-AML not in remission or advanced t-MDS, and poor risk cytogenetics were associated with worse outcomes.

Modern supportive care and conditioning regimens including reduced intensity (RIC) regimens may have improved outcomes. Therefore we analyzed 1531 HCT for t-AML (n = 772) or t-MDS (n = 759) performed from 2000 to 2014.

The median age at transplant was 52 (18-77) for t-AML and 59 (18-74) for t-MDS. Eleven percent of patient with t-AML and 24% of patient with t-MDS had a prior autologous transplant. A myeloablative regimen was used for conditioning in 61% of patients with t-AML and 49% of patients with t-MDS (Table 1).

For t-AML, the 5-year non-relapse mortality (NRM) and relapse rates (RR) were 33% (95% confidence interval [CI], 30-36) and 43% (40-47), respectively. For t-MDS, the 5 year TRM and RR were 32% (29-36) and 46% (43-50), respectively. Five year DFS and OS were 24% (21-27) and 25% (22-28), respectively, for patients with t-AML. Five year DFS and OS were 21% (18-24) and 27% (23-31), respectively, for patients with t-MDS.

In multivariate analysis, t-AML OS and DFS was worse for: previous autologous transplant, relapsed disease at HCT, intermediate or adverse cytogenetics, partially matched and cord blood grafts, and RIC. For t-MDS: age greater than 60, previous autologous transplant, very high IPSS score, and use of HLA-partially matched unrelated grafts.

A significant minority of patients with t-AML and t-MDS can achieve long-term remission with allogeneic HCT, yet risks of both NRM and relapse are still excessive. Relapse is the major cause of treatment failure.

Disclosures

Metheny: Takeda: Speakers Bureau; Incyte: Speakers Bureau. Weisdorf:Incyte: Research Funding; Fate Therapeutics: Consultancy; Pharmacyclics: Consultancy. Kebriaei:Jazz: Consultancy; Amgen: Research Funding; Pfizer: Honoraria; Kite: Honoraria.
Association of Nucleophosmin-1 (NPM1) Expression with Leucocyte Count, Blast Count, and Gingiva Hypertrophy in Acute Myeloid Leukemia De Novo Patients in General Hospital of Dr M Djamil Padang Indonesia
Authors: Wahid Irza , Atmakusuma Tubagus Djumhana
Published: November 2019

Acute myeloid leukemia (AML) is a malignant disease derived from hematopoietic system characterized by neoplastic transformation of myeloid progenitor cell, present as excessive proliferation and differentiation alteration leading to inhibition of myeloid maturation. From various studies, incident and prevalence of AML these days is increasing in morbidity and mortality. This make AML known with poor prognosis. Nucleophosmin-1 (NPM-1) was established by WHO revision 2016 as prognostic gene marker in AML. Nucleophosmin-1 gene is mutated in 35-60% of AML cases. Recently, molecular biologic development suggests that prognostic gene examination is needed to reduce morbidity and mortality of AML patients. If myeloid progenitor cell encounters carcinogenic/leukemogenic stresses, mutation of several genes could happen. NPM1 gene is a likely mutated gene and predominantly located in nucleolus. Overexpression of NPM1 will promote activities of tumor suppressors like P53, ARF and MDM2. Interactions of those tumor suppressors promote proliferation, differentiation, cell survival, apoptosis and DNA repair, which give a better prognosis in AML patients.

To study about association of NPM1 expression with leucocyte count, blast count, and gingiva hypertrophy in AML de novo patients in general hospital of Dr M Djamil Padang, Indonesia.

Analytic observational study with cross-sectional approach to 25 adult AML patients from Policlinic and Inpatient Installation of Dr M Djamil Hospital from March to August 2018 who met inclusion and exclusion criteria. Expression of NPM1 was measured with qRT-PCR.

We found significant increase of NPM1 expression in AML in the amount of 22.62x107 copies/ml. There was a significant very strong correlation between NPM1 expression and leucocyte count (p<0.05 & r=0.870) and blast count (p<0.05 & r=0.828). There was also significant differences of NPM1 expression in AML patients with gingival hypertrophy and without gingival hypertrophy (31.3 x 107 copies/ml dan 9.6 x 107 copies/ml).

There was a significant very strong correlation between NPM1 expression with leucocyte count and blast count. There was significant increases of NPM1 expression in AML patients with gingival hypertrophy.

Keywords: acute myeloid leukemia, Nucleophosmin-1, leucocyte, blast, gingival hypertrophy

Disclosures

No relevant conflicts of interest to declare.
ABL Kinase Domain Mutation in Chronic Myeloid Leukemia - Compliance to Imatinib Matters
Authors: PK Jayachandran , Ganesan Trivadi S , Mehra Nikita , Kannan Krishnarathinam , Dhanushkodi Manikandan , Radhakrishnan Venkatraman , Rajan Arun Kumar , Girishchandra Joshi Archit , Selvarajan Gangothri , Karunakaran Parathan , Sagar Tenali Gnana
Published: November 2019

Background: Imatinib resistance mutation analysis (IRMA) or abl kinase domain mutation analysis is performed in patients with Chronic myeloid leukemia (CML) whenever the response to treatment is inadequate. We have analyzed the reports of IRMA at our centre.

Methods: The clinical details of 71 patients with CML on Imatinib, who underwent IRMA testing during the period of January 2017 to March 2019 were collected from the patient records and analyzed. IRMA was performed for failure or warning or progression, anytime during the course of treatment. IRMA was done by either Sanger sequencing (n=45) or next generation sequencing (n=26, Illumina, NGS). The associations between variables were tested using Chi - Square test.

Results: Median age at diagnosis of 71 patients was 44 years (Range 18 - 71 years). Males constituted 70% (n=50). At diagnosis, 92% (n=65) of patients were in chronic phase and the remainder were in accelerated phase (n=4) or blast crisis (n=2). Mutations in the abl kinase domain were detected in 26 patients (37%). Next Generation Sequencing (NGS) could identify more mutations (13/26 - 50%) compared to conventional Sanger Sequencing (13/45 - 29%), but the difference was not significant (p=0.07). NGS could identify three or more mutations in 5 patients in contrast to Sanger. All the mutations detected were those previously described except for an insertion of 35bp near the C-Terminal which was identified in 3 patients. E459K translocation was identified in 6 patients. E355G translocation was identified in 4 patients. F359V, M351T, Y253H, G250E, H396R, T315I translocations were identified in 3 patients each. Patients who were not compliant to therapy had increased frequency of mutations (14/26 - 54%) compared to those who were compliant (12/45 - 27%), which was significantly different (p=0.02). Patients who had loss of complete hematological response (CHR) had significantly higher frequency of mutations (14/21- 67%) compared to other reasons for performing the test (p=0.001). Patients who had failure to achieve targets at various time points had a significantly lower frequency of mutations (4/23 - 17%, p=0.02) compared to other reasons for performing the test.

Conclusion: Patients who were not compliant for treatment were more likely to have mutations. Loss of CHR showed an increased frequency compared to other reasons. NGS could identify mutations in more number of patients. NGS identified numerically higher mutations in patients. Larger prospective data are needed to confirm these observations.

Table

Disclosures

No relevant conflicts of interest to declare.
Implementation of the Peripherally Inserted Central Venous Catheter for Patients with Hematological Malignancies in a Peruvian Cancer Center
Authors: Roque Katia , Enriquez Daniel J , Elizabeth Elera , Ortega Emperatriz , Haro Juan C , Poma Nathaly , Ponce Ricardo , Tirado-Hurtado Indira , Neciosup Silvia , Gomez Henry
Published: November 2019

Background: A central venous access is essential during active treatment for most patients with hematological malignancies, and historically, the central inserted venous catheter (CVC) has been the preferred option in clinical practice. In the last years, the peripheral inserted central catheter (PICC) has increasingly been used as an alternative to CVC with less incidence of catheter related infections (CRI). Our aim was to compare the incidence of documented catheter related infections and mortality for patients with PICC versus CVC.

Methods: We prospectively enrolled patients who were candidates for PICC implantation from March 2018 to February 2019, and matched them with a CVC candidate patient. PICC patients were followed at our PICC line program and CVC patients with their primary oncologist team as per institutional protocol. All patients received intensive treatment at a public tertiary cancer center in Lima-Peru (Instituto Nacional de Enfermedades Neoplasicas).

Results: We included 94 cases during the study period (44 PICC and 50 CVC cases), median age was 39 years and M:F ratio was 2:1. In the PICC group, main diagnoses were acute leukemias (46%), Lymphomas (22%) and Multiple Myeloma (16%), on the other hand, in the CVC group, acute leukemias (72%), lymphoma (16%) and multiple myeloma (8%). Mean length of catheterization was 40 and 24 days for PICC and CVC, respectively. The incidence of documented CRI was lower in PICC group (12.6 versus 3.1 per 1000 days for CVC and PICC, respectively), showing a risk reduction of 75% of bacteremia (RR: 0.25, 95%CI 0.1-0.6, p<0.01). Mortality rate was 20% and 14% in CVC and PICC groups, respectively (p=0.4).

Conclusion: PICC represents a safe and effective alternative to CVC for patients with hematological malignancies in a limited source setting. An alarming high incidence of catheter related infections was noted in this study.

Disclosures

No relevant conflicts of interest to declare.
Expansion of Th/Tc17 T Cells and Loss of CX3CR1+ Macrophages Play a Critical Role in the Pathogenesis of Steroid-Refractory Acute Intestinal Gvhd
Authors: Song Qingxiao , Wang Xiaoning , Martin Paul J , Chen Yuanzhong , Zeng Defu
Published: November 2019

Acute gut graft-versus-host disease (GVHD) is the major contributor to mortality and morbidity of allogeneic hematopoietic stem cell transplantation recipients. Steroids are the first-line therapy for acute GVHD, but approximately 30% of patients develop steroid refractory GVHD (SR-GVHD). The pathophysiology of SR-GVHD is poorly understood.

In the current studies, we explored the mechanisms of SR-GVHD, using a murine model of MHC-mismatched HCT with C57BL/6 donors and BALB/c recipients. Acute GVHD can be mediated by either Th/Tc1 or Th/Tc17 T cells. We evaluated the impact of dexamethasone (DEX) treatment on acute GVHD induced by spleen and BM cells from WT, IFN-γ-/- or RORγt-/- C57BL/6 donors. WT donor T cells give rise predominantly to Th/Tc1 cells early after HCT, but Th/Tc17 cells can expand as time goes on. IFN-γ-/- donor T cells give rise to Th/Tc17 cells but not to IFN-γ-producing Th/Tc1 cells, while RORγt-/- donor T cells give rise to Th/Tc1 cells but not to Th/Tc17 cells. BALB/c recipients were treated with single dose dexamethasone (DEX) at 5 mg/Kg on day 3 after HCT. DEX treatment effectively prevented acute GVHD in recipients given WT or RORγt-/- grafts for up to 20 days after HCT. GVHD then recurred in recipients grafted with WT cells but not in recipients grafted with RORγt-/- cells. In contrast, DEX treatment had no effect on acute GVHD in recipients grafted with IFN-γ-/- cells. Recurrence of GVHD in DEX-treated recipients grafted with WT cells and the lack of DEX effect in recipients grafted with IFN-γ-/- cells was associated with expansion of Th/Tc17 cells that produced both IL-17 and IL-22. In recipients grafted with IFN-γ-/- cells, we also observed marked reduction of donor-type CX3CR1+ intestinal macrophages that play a critical role in controlling bacterial translocation from the intestinal lumen to the liver and blood. In addition, the DEX-treated recipients showed augmentation of Th/Tc17 differentiation and exacerbation of acute GVHD, When CX3CR1GFP/GFP mice that are deficient in generating CX3CR1+ intestinal macrophages were used as donors.

These results indicate that DEX-treatment can cause expansion of Th/Tc17 and loss of protective donor-type CX3CR1+ intestinal macrophages, leading to SR-GVHD.

Disclosures

Martin: Abgenomics: Research Funding; Enlivex Therapeutics: Consultancy; Genentech: Consultancy, Other: One-time advisory board; Neovii: Other: One-time advisory board; Pfizer: Other: Data and Safety Monitoring Committee; Pharmacyclics LLC: Other: One-time advisory board; Procter and Gamble: Equity Ownership; Xenikos: Research Funding.
Tissue-Resident PSGL1loCD4+ T Cells Interact with B Cells Via PD-1 and PD-L2 in Gvhd Target Tissues to Augment Autoimmune-like Chronic Gvhd
Authors: Kong Xiaohui , Zeng Deye , Wu Xiwei , Yang Shijie , Wang Bixin , Song Qingxiao , Zhu Yongping , Salas Martha , Qin Hanjun , Nasri Ubaydah , Nakamura Ryotaro , Martin Paul J , Huang Aimin , Zeng Defu
Published: November 2019

Chronic graft versus host disease (cGVHD) is a systemic autoimmune-like syndrome, and donor-type CD4+ T interaction with B cells plays an important role in its pathogenesis. Our recent publication has demonstrated that cGVHD pathogenesis does not require germinal center formation and is associated with expansion of extrafollicular CD44hiCD62LloPSGL1loCD4+ (PSGL1loCD4+) T cells in the spleen and GVHD target tissues. The causal role of PSGL1loCD4+ T cells in cGVHD pathogenesis remains unclear. With murine and humanized murine models, we show that both murine and human PSGL1loCD4+ T cells reside in tissues and do not circulate in the blood, and their high expression of PD-1 and ICOS and production of IL-21 suggest that they provide B cell help. In murine models, PSGL1loCD4+ T cells augment plasma cell expansion and autoantibody production via their PD-1 interaction with PD-L2 on B. In humanized mouse models, human PSGL1loCD4+ T cells from GVHD target tissues augment memory B cell differentiation into plasma cells and antibody production via their production of IL-21.These results indicate that tissue-resident PSGL1loCD4+ T cells augment autoantibody production and cGVHD pathogenesis. Targeting tissue-resident T cells may represent a novel approach for treating cGVHD.

Disclosures

Nakamura: Alexion: Other: support to a lecture at a Japan Society of Transfusion/Cellular Therapy meeting ; Kirin Kyowa: Other: support for an academic seminar in a university in Japan; Celgene: Other: support for an academic seminar in a university in Japan; Merck: Membership on an entity's Board of Directors or advisory committees. Martin:Abgenomics: Research Funding; Enlivex Therapeutics: Consultancy; Genentech: Consultancy, Other: One-time advisory board; Neovii: Other: One-time advisory board; Pfizer: Other: Data and Safety Monitoring Committee; Pharmacyclics LLC: Other: One-time advisory board; Procter and Gamble: Equity Ownership; Xenikos: Research Funding.
Novel Conditioning Regimen for Haploidentical Hematopoietic Cell Transplant for Severe Aplastic Anemia in Children
Authors: Hashem Hasan , Rihani Rawad , Khattab Eman , Abu Shanap Mayada , Tbakhi Abdelghani , Sultan Iyad
Published: November 2019

New hematopoietic cell transplant (HCT) approaches are urgently needed for patients with severe aplastic anemia (SAA) who lack an HLA-identical donor. Haploidentical HCT with post transplant cyclophosphamide (PTCy) represent a potential universal available option for almost all children with SAA.

We present a novel conditioning regimen for haploidentical HCT in children with SAA in a center where horse ATG is not available. Conditioning regimen consists of rabbit ATG 2.5 mg/kg/day from day -9 to -7, Fludarabine 30 mg/kg/day from day -6 to -2, Cyclophosphamide 14.5 mg/kg/day from day -6 to -5, Thiotepa 5 mg/kg/day from day -4 to -3, and 4 Gy TBI on day -1 in in two fractions. GvHD prophylaxis consist of PTCy 50 mg/kg/day on days +3 and +4 along with Cyclosporine A and Mycophenolate mofetil (MMF) starting on day +5.

Four consecutive children with SAA referred to our center for haploidentical HCT starting in 2018. Median age at HCT was 9 years (5-16) with 3 males and 1 female. All patients were heavily transfused with both blood and platelets prior to referral for HCT. Two patients had strong and one had weak positive anti-HLA antibodies (DSAs) and received desensitization with IVIG, Rituximab and plasmapheresis. One patient received buffy coat infusion on day -1 due to persistent strong DSAs despite desensitization. Median CD34+ dose received was 12 x 10e6, and median CD3+ dose was 29 x 10e6. Donors were all same blood group to patients.

All patients successfully engrafted neutrophils at median of 13 days (12-14). Platelets engraftment in 3/4 patients at median of 7 days (5-10). All patients received peripheral blood as stem cell source. Three of four patients survived and doing well at last follow up. One patient had toxic death on day +38 due to chemotherapy related toxicity causing multi-organ failure. Chimerism analysis was full donor in all four patients at median follow up time of 11 months (2-12). Patients were sent home at median of 24 days post HCT. None developed grade 2-4 acute GvHD nor chronic GvHD. Acute GvHD of skin grade 1 stage 1 developed in 2 patient and managed with topical steroids. Viral reactivations consisted of CMV viremia and BK hemorrhagic cystitis in all patients, and have all resolved. No post transplant autoimmune complications.

Haploidentical HCT with PTCy represents a quick and first line approach in heavily transfused children with SAA. Although yet limited number of patients, this regimen is feasible and appears to be safe. A great advantage of this regimen is the rapid engraftment of both neutrophils and platelets. Moreover, although using peripheral blood as a stem cell source, there was no severe acute or chronic GvHD.

Disclosures

No relevant conflicts of interest to declare.
Loss of Zyx Impairs Neutrophil Production in Zebrafish Embryos
Authors: Konno Katsuhiro , Kulkeaw Kasem , Nii Takenobu , Kaneyuki Ayako , Sugiyama Daisuke
Published: November 2019

Zebrafish is a useful model to study vertebrate hematopoiesis, but lack of antibodies to zebrafish proteins has limited purification of hematopoietic cells. Here, we purified neutrophils from larval and adult zebrafish using the lectin Phaseolus vulgaris erythroagglutinin (PHA-E) and DRAQ5, a DNA-staining fluorescent dye. In adult kidney marrow, we purified neutrophil-like PHA-E4low DRAQ5low cells, which neutrophil-type granules. Specifically, at 96-hr post fertilization, we sorted large-sized cells from larvae using forward scatter and found that they consisted of PHA-Elow DRAQ5low populations. These cells had myeloperoxidase activity, were Sudan Black B-positive and expressed high levels of neutrophil-specific (csf3r and mpx) mRNAs, all neutrophil characteristics. Using this method, we conducted functional analysis suggesting that zyxin (zyx) plays a role in neutrophil generation in zebrafish larvae. Overall, PHA-E and DRAQ5-based flow cytometry may serve as a tool to purify zebrafish neutrophils.

Disclosures

No relevant conflicts of interest to declare.
Trasposon Mediated Horizontal Gene Transfer (T-HGT) of Circulating Tumor DNA Reshapes MM Clonal Architecture
Authors: Cinar Munevver , Flygare Steven , Mosunjac Marina , Nagaraju Ganji , Park Dongkyoo , Faith Sheff , Saxe Debra , Bernal-Mizrachi Leon
Published: November 2019

Spatial genetic heterogeneity is a characteristic phenomenon that influences multiple myeloma's (MM) phenotype and drug sensitivity (Rasche L. et al and Bolli N et al.). Hence, the branch model of tumor evolution is not sufficient to explain the disorganized architecture observed in MM. In this study, we investigated whether MM ctDNA horizontal gene transfer (HGT) affect tumor genetic architecture and drug sensitivity, resembling what is seen in prokaryotes, and elucidated the mechanisms involved in the mobilization of genetic material from one cell to another. We identified that plasma from patients with MM transmits drug sensitivity or resistance to cells in culture. This transmission of drug sensitivity is mediated by ctDNA transfer of oncogenes to a host cell. Importantly, in vitro and in vivo demonstrated that ctDNA mainly targets cells resembling the cell of origin (tropism). Karyotype spreads and whole genome sequencing demonstrated that once patients ctDNA encounters host cells, it migrates into the nucleus where it ultimately integrates into the cell's genome. Integration to the genome was confirmed to be targeted to myeloma cells. Further sequencing analysis of multiple MM samples identified ctDNA tropism and integration is dependent on the 5' and 3' end presence of transposable elements (TE), particularly of the MIR and ALUsq family. These results were further validated by TE mediated delivery of GFP into MM cells in vitro and HSVTK in tumors of mouse xenografts. In conclusion, this data indicates for the first time that TE mediates MM ctDNA HGT into homologous tumor cells shaping the hierarchical architecture of tumor clones and affecting tumor response to treatment. Therapeutically, this unique quality of ctDNA can be exploited for targeted gene therapeutic approaches in MM and potentially other cancers.

Disclosures

Bernal-Mizrachi: Kodikas Therapeutic Solutions, Inc: Equity Ownership; TAKEDA: Research Funding; Winship Cancer Institute: Employment, Patents & Royalties.
The Efficacy and Safety of Cidofovir in Salvage Therapy for CMV Infection in the Patients with Haploid Hematopoietic Stem Cell Transplantation
Authors: Yu Guo-Pan , Yin Zhao , Fan Zhiping , Huang Fen , Xu Na , Jiang Ling , Wang Zhixiang , Xuan Li , Liu Qifa , Feng Ru , Sun Jing
Published: November 2019

Cidofovir (CDV) is a nucleotide analogue with broad antiviral activity and has been approved for the treatment of cytomegalovirus (CMV) retinitis in patients with acquired immunodeficiency syndrome. Data on the use of CDV for anti-CMV treatment in the patients with allogeneic hematopoietic stem cell transplantation (allo-HSCT) are limited. To evaluate the efficacy and safety of CDV in salvage treatment of CMV infection after allo-HSCT, we prospectively enrolled 18 patients with CMV infection after allo-HSCT in this study, of whom failed or intolerant to preemptive antiviral therapy. Dose of CDV as 5 mg/kg per week was used until CMV-DNA negative twice with quantification polymerase chain reaction (qPCR) detection or disease progression. All these 18 patients received haploid HSCT and suffered from a median of II (I~IV) ° acute graft versus host disease (aGVHD) before or at the same time of CMV infection. The patients showed as CMV DNAemia (n=7), CMV syndrome (n=5) and CMV disease (n=6) at a median time of 37 (range, 26 to 49) days post transplantation. Before CDV, all the patients received ganciclovir (n=9) or/and foscarnet (n=10) as pre-empty treatment for CMV infection, and 15 cases failed while 3 untolerated to the side effect. After a median of 2 (1-4) course of CDV therapy, 14 (77.8%) patients acquired clinical cure, 1 improved, and 3 (16.7%) failed, presenting a median response time of 2 courses. 11 (61.1%) patients had a 1-log decrease in CMV-DNA copy number after 1 cycle of CDV treatment, and 10 (55.6%) patients obtained virus clearance after 1 to 2 courses of treatment. With a median follow-up of 5 (1 to 12) months, 14 patients remained continuously CMV-DNA negative. During CDV treatment, 4 (22.2%) patients developed mild reversible renal damage and 5 (27.8%) experienced I~II° gastrointestinal reactions. Taking together, it could be effective and safe to use cidofovir in salvage treatment for CMV infection in the patients with allo-HSCT, including haplo-HSCT.

Disclosures

No relevant conflicts of interest to declare.