bluuebunny/crossref_metadata_2025 huggingface dataset:
Imatinib Mesylate Discontinuation in Patients with Chronic Myelogenous Leukaemia in Complete Molecular Remission for More Than Two Years.
Authors: Rousselot Philippe , Huguet Françoise , Cayuela Jean Michel , Maarek Odile , Marit Gérald , Gluckman Eliane , Reiffers Josy , Mahon François X.
Published: April 2020

Background. Imatinib mesylate (IM, Gleevec®) induces cytogenetic remission (CCR) defined as the disappearance of Philadelphia (Ph) chromosome-positive metaphases in more than 85% of patients with chronic myelogenous leukaemia (CML). However, less than 10% achieve a complete molecular response which may be defined by a minimum residual disease undetectable using polymerase chain reaction (PCR). Virtually all patients in CCR will relapse after IM interruption because of detectable residual disease. In the present study, we have discontinuated IM in patients with undetectable residual disease for more than 2 years.

Patients and method. We prospectively collected the results from 8 CML patients (median age 62 years; 41 years to 82 years) treated with IM (400 mg/day). Residual disease was quantified by RTQ-PCR and expressed as the BCR-ABL/BCR ratio. PCR negativity was controlled independently by two molecular laboratories every 4 months and patients were included in the study if they have been PCR negative during at least 2 years under IM therapy. After IM discontinuation, RTQ-PCR was monitored every month.

Results. According to Sokal’s classification, 4 patients were considered low risk, 3 intermediate risk and one high risk. All patients except one received interferon (treatment duration 3 to 72 months). One of them received an autologous stem cell transplantation for interferon failure. Median duration of IM therapy was 37 months (34 months to 40 months) and median time from CML diagnosis to IM discontinuation was 104 months (43 months to 152 months). RTQ-PCR negativity was observed during 30 months in median (24 months to 46 months) as required for the inclusion in the study. Four patients presented a molecular relapse with a detectable BCR-ABL transcript rising from 0,001% to 0,01% confirmed at least two times after 2 months (2 patients), 3 months and 4 months of IM discontinuation without detectable BCR-ABL kinase domain mutation. IM was then restarted and lead to a novel molecular remission in 2 patients and to a major molecular response in the 2 others. Four other patients are still negative with a follow up of 8, 9, 12 and 13 months after IM discontinuation. Of note, all these patients received interferon before IM therapy and one patient still have detectable serum antinuclear antibodies.

Conclusion. As we have previously reported with interferon, it is possible to stop IM in patients with CML who achieve a molecular remission as we have strictly defined. Early molecular relapses are sensitive to IM re-challenge. Interestingly, we did not observed late relapses at this point. As our patients in persistent molecular remission were previously exposed to interferon, it is possible that IM therapy combined with immune response modifiers could be responsible for a putative cure of the disease.
Phase I Study of Flavopiridol in Combination with Imatinib Mesylate (STI571, Gleevec) in Bcr/Abl+ Hematological Malignancies.
Authors: Grant Steven , Karp Judith E. , Koc Omer N. , Cooper Brenda , Luger Selina , Figg William D. , Egorin Merrill , Druker Brian J. , Jacobberger James W. , Ramakrishnan Viswanathan , Perkins Edward B. , Colevas A. Dimitrios , Roberts John D.
Published: April 2020

Imatinib (Im), a rationally designed inhibitor of the Bcr/Abl kinase as well as other kinases, represents the standard treatment for Bcr/Abl+ malignancies. Im as a single agent, however, is not curative. Flavopiridol (Fl), an investigational cyclin dependent kinase inhibitor, is broadly active in vitro against human leukemia cells (Blood91:2482,1998). Previously we have shown that simultaneous disruption of a survival signaling pathway and a cell cycle regulatory pathway results in a pronounced increase in leukemic cell death (Cancer Res.61:5106,2001) and in more recent preclinical studies demonstrated synergistic interactions between Im and Fl in Bcr/Abl+ leukemia cells, including some that were resistant to Im (Clin Cancer Res8;2976,2002). Based on these considerations, we have initiated a phase I trial to identify appropriate doses of Im+Fl for further investigation. Eligible patients (pts) have CML with a suboptimal response to prior Im, CML in blast crisis, or Bcr/Abl+ acute lymphocytic leukemia (ALL). CML-BC and ALL patients may be Im-naïve. Pts receive Im by continuous daily oral dosing and Fl by 1 hour intravenous infusion weekly x 3 repeated every 4 weeks. Targeted dose levels are (Fl/Im; mg/m2): 30/400, 30/600, 45/600, 60/600, 60/800, 60/1000. Patients are divided into 2 strata based upon blast percentage in peripheral blood or bone marrow: stratum 1, <15%; and stratum 2, ≥15%. For stratum 1 dose limiting toxicity (DLT) is defined as NCI CTCAE grade 4 ANC/platelet for > 1 week or grade ≥ 3 non-heme toxicity; for stratum 2, DLT is profound marrow hypoplasia in the absence of persistent leukemia. In stratum 1, 16 pts have been treated at 4 dose levels; in stratum 2, 5 pts in the 1st and 3rd dose level. In stratum 1, 1 DLT has occurred at dose level 4 (cholecystitis requiring cholecystectomy); in stratum 2, 1 DLT has occurred at dose level 3 (sepsis/multi-organ failure which was not clearly related to treatment). The only frequent toxicities have been hematological. 4 pts have experienced objective responses including complete hematological remissions in 2 pts in stratum 1 treated with Im/Fl 30/600 who had been previously treated with Im 800 and complete hematological remissions in 2 pts in stratum 2 (who had not received prior Im). Preliminary studies indicate no Fl impact upon Im pharmacokinetics, and variable post-treatment effects on signaling pathways in CML cells. These findings indicate that a regimen consisting of Fl and Im is tolerable and active in at least some patients with Bcr/Abl+ hematologic malignancies, including some with Im-resistant disease. Pending identification of the MTD and the recommended Phase II dose (RPTD), Phase II trials will be necessary to assess the activity of this strategy more definitively.
Triphasic Exponential Decline of BCR-ABL Transcripts during Imatinib Therapy for Chronic Myelogenous Leukemia.
Authors: Miyamura Koichi , Ohnishi Kazunori , Naoe Tomoki , Takeuchi Hitoshi , Yoshiki Nishimura , Yagasaki Fumiharu , Fujisawa Shin , Kimura Yukihiko , Motoji Toshiko , Imai Kiyotoshi , Yamane Takahisa , Yoshida Shinichiro , Miyawaki Shuichi , Saburi Yoshio , Kitamura Kunio , Ohno Ryuzo
Published: April 2020

In Japan Adult Leukemia Study Group (JALSG) clinical trial, imatinib was used as initial therapy for 171 patients with chronic myelogenous leukemia. We measured levels of BCR-ABL transcripts in the blood of all patients in this trial before and 1, 2, 3, 6 and 12 months after the treatment. Levels of BCR-ABL transcripts were measured by a quantitative real-time polymerase-chain-reaction assay. Results were expressed copy number of BCR-ABL per 1 microgram of RNA. Median number of BCR-ABL transcript was 106,478 at diagnosis and 61328, 24213, 4981, 331 and 98 at 0, 1, 2, 3, 6, 12 months after the treatment, respectively. Three log reductions were obtained 0%, 35.5% and 50.9% of patients at 3, 6 and 12 months of the treatment. Half reduction time between 0 and 1 month (0M–1M) is 1.3 M. In the next month (1M–2M), it is 0.75M and those between 2–3 and 3–4.5 months are 0.44 and 0.51. Thereafter, reduction speed is down because half reduction time is 1.5 between 4.5 and 6 months. After 6 months half time is 4.1months. This reduction curve shows the. Exponential decline value per day are 1.8%, 3.1% and 5.2% during first, second and third month, respectively. Thereafter exponential decline value is decreasing as 4.4% (3M–4.5M), 1.5% (4.5M–6M) and 0.6% (6–12M). In the previous study reported that, successful therapy leads to a biphasic exponential decline of leukemic cells (Nature435:1267–1270, 2005). The first slope is determined by calculating the exponential decline between 0 and 3 months; mean value of 0.05 per day was observed. While the second slope showed 0.008 per day. Our observation suggests that imatinib leads to a triphasic exponential decline of leukemic cells; between 0 and 2 months, much slower declining curve in comparison with between 2–6 months.
Higher Rate of Thrombotic Thrombocytopenic Pupura (TTP) Associated with Graft Versus Host Disease (GVHD) and Unrelated Donor Bone Marrow Transplantation (BMT).
Authors: Oran B. , Aleman A. , Shpall E. J. , Hosing C. , Korbling M. , Anderlini P. , Champlin R. , Donato M.
Published: April 2020

TTP is one of the complications of allogeneic hematopoietic stem cell transplantation (HSCT). In contrast to idiopathic cases, post-transplantation TTP may not be associated with severe von Willebrand factor-cleaving protease deficiency but rather a diffuse endothelial injury. Our aim was to define incidence, risk factors and mortality of TTP following allogeneic HSCT. 1312 patients with lymphoid malignancies (n=605), myeloid malignancies (n=688) or aplastic anemia (AA, n=18) who were treated with ablative preparative regimens (n=614) or reduced intensity regimens (n=697) followed by HSCT from an HLA matched related (MRD, n=694) or unrelated donor (MUD; n=461) and 1–3 antigen mismatched related (MMR, n=99) or unrelated donor (MMUD, n=57) between December 1997 and December 2004 were studied. Patients with prior allogeneic HSCT or graft failure were excluded. GVHD prophylaxis was tacrolimus-based in 1276 (97.3%) and cyclosporine based in 15 (1.1%) patients. Twenty patients did not receive GVHD prophylaxis per protocol. Anti-thymocyte-globulin (ATG) was added in 350 patients. Stem cell sources were bone marrow (n=626), peripheral blood (n=635) or cord blood (n=50).

The following variables were evaluated: age, gender, primary diagnosis, disease status before HSCT, intensity of preparative regimen, stem cell source and acute GVHD(aGVHD) grade ≥2 (time dependent variable).

Of the 1312 patients with a median follow-up from transplantation of 11.4 months (range, 5 days-7.2 years), 77 developed TTP (6%). The actuarial risk of developing TTP was 6.5% at 1 year. The median time of the onset of TTP was 67 days post HSCT (range, 11–1812) with 27 cases (35%) presenting after day 100. Female gender, lymphoid malignancies, unrelated or antigen mismatched related donor and aGVHD grade ≥2 were found to be independent risk factors. (Table1). Among the patients who had aGVHD grade≥2, the median time of interval between the onsets of two events was 25 days (range, 2–335 days). All patients were treated with therapeutic plasma exchange (PE). Of the 77 patients only 1 died of TTP (intracranial hemorrhage). The overall one-year survival after TTP was 29% and the most common cause of death were acute or chronic GVHD (n=35, 55%) and primary disease progression (n=10, 16%).

Stem cell donors other than MRD, lymphoid malignancies and aGVHD≥2 have been established as risk factors associated with development of TTP and therapeutic PE has been shown to decrease TTP related mortality.

Risk factors for TTP after allogeneic HSCT Variables sample size events HR 95% CI p Male 793 33 1.0 Female 518 44 2.2 1.3–3.6 0.002 Myleoid malignancy 688 33 1.0 Lymphoid malignancy 605 42 1.9 1.1–3.3 0.03 AA 18 2 1.3 0.2–8.0 0.75 MRD 694 28 1.0 MUD 461 40 2.9 1.6–5.1 <0.001 MMR 99 7 2.4 0.9–6.0 0.06 MMUD 57 2 1.7 0.4–7.6 0.5 aGVHD ≥2 370 39 3.3 2.0–5.5 <0.001
Frequent Genomic Alterations in Epithelium Measured by Microsatellite Instability Following Allogeneic Hematopoietic Cell Transplantation in Humans.
Authors: Spyridonidis Alexandros , Faber Philipp , Fisch Paul , Waterhouse Miguel , Schmitt-Graeff Annette , Bertz Hartmut , Finke Juergen
Published: April 2020

While typically found in cancers, frameshift mutations in microsatellites have also been detected in chronically inflamed tissues. Allogeneic hematopoietic cell transplantation (HCT) may potentially produce chronic tissue stress through graft-versus-host reactions. Therefore, we examined non-neoplastic epithelial tissues (colon, buccal) obtained 1 to 5061 days after human allogeneic HCT for the presence of genomic alterations at three tetranucleotide (SEE33, THO-1, D14S120) and three mononucleotide (ZP3, BAT26, SRY) microsatellite loci. All except two colon biopsies examined had histological signs of GvHD. No signs of mucositis or oral GvHD were present at the time of buccal sampling. Novel bands indicative of microsatellite instability (MSI) were detected in laser-capture microdissected (LCM) colonic crypts in 12 out of 16 patients (75%) and in buccal smears in 10 out of 24 (42%) allografted patients. In contrast to the allografted patients, no MSI was found in the LCM crypts obtained from 4 patients after intensive chemotherapy or from 7 control subjects with no history of either colon malignancy or chemotherapy, and in the buccal smears obtained from 8 patients after autologous HCT or from 9 healthy controls. MSI was found only at tetranucleotide markers but not at mononucleotides. There was no statistical correlation between the presence of MSI in colon and the underlying disease, the previous history of multiple (>=3) intensive chemotherapies before transplantation, the type of preparative regimen for HCT, the overall GVHD grade any time before sampling or the GvHD stage in colon at sampling. The MSI found in colon, which was often affected by graft-versus-host disease, was not due to loss of expression or nitrosylation of DNA repair proteins (MLH1, MSH2, MSH3, APE-1, XPA). There was no significant association between MSI in the buccal mucosa and patient age, gender, disease, type of conditioning, history of oral GvHD or overall GvHD occured at any point before buccal sampling. Interestingly, we found a significant association between the time of buccal sampling after transplantation and the presence of MSI (p=0.008). MSI was also found in three post-transplant squamous cell cancers examined. The frameshift alterations found in post-transplant tumors often differed from those in the associated non-malignant tissues. Our data show that genomic alterations in epithelium regularly occur after allogeneic HCT. This previously unacknowledged genomic instability after allogeneic HCT may be implicated in the evolution of post-transplant diseases, including secondary cancer.
Autografting Followed Closely by Nonmyeloablative Allografting as Consolidation Immunotherapy Reduces Disease Progression Compared to Tandem Autografting in Multiple Myeloma.
Authors: Carella A.M. , Spriano M. , Corsetti M. T. , Scalzulli P. , Beltrami G. , Lerma E. , Cascavilla N. , Carella M. , Nati S. , Congiu A. , Musto P.
Published: April 2020

Autografting (AutoSCT) has been limited by high-relapse rates and conventional allografting (AlloSCT) by excessive TRM and toxicity in the treatment of Multiple Myeloma (MM). Reduced intensity conditioning for transplant (RICT), a less toxic procedure for AlloSCT that aims to exploit graft versus tumor effect, has been shown to achieve remissions in MM. High-dose therapy/AutoSCT followed shortly thereafter by RICT might improve outcomes in MM as compared to AutoSCT or conventional AlloSCT used alone. We compared two retrospective cohort of patients who underwent either tandem AutoSCT (HDT consisted of Melphalan 200 mg/m2) or AutoSCT followed closely by related RICT (patients with HLA-matched siblings). The two groups were matched for pre-transplant therapy, disease status at transplant, time from diagnosis to transplant. GVHD prophylaxis for RICT patients consisted of CyA/MTX. The major results are summarized in the Table. In the AutoSCT/RICT group the complete remission rate was higher (p=0.004) and the risk of disease progression after transplant was significantly reduced (p=0.005). All patients who reached CR responded after full chimerism and GVHD developed. This finding confirms the existence of a graft-versus-myeloma effect. Since the first clinical signs of response in remitters patients were noted between 70 and 120 days and maximum response between 160 and 200 days after RICT (after DLI in one patient), these responses should be considered immunological responses. These data suggest than an allograft following an AutoSCT significantly reduces the incidence of disease progression.

Tandem ASCT (N=35) ASCT + RICT (n=20) Age, median 56 (range, 38–66) 51 (range, 34–63) Median prior cycles of Chemoth. 4 (range, 3–6) 4 (range, 3–6) Time from Dx to 1st AutoSCT (median mo.) 6 (range, 5–60) 9 (range, 7–42) Conditioning Regimen for AutoSCT Melphalan (200 mg/m2) Melphalan (200 mg/m2) Conditioning Regimen for RICT --- TBI/Fludarabine Complete Remission 14% 50% p=0.004) Disease-Free Survival at 3 yrs 11% 45% (p=0.005) Overall Survival at 3 yrs 66% 70% (p=NS) Median Follow-Up (mo.) 30 (range, 6–104) 38 (range, 5–59) Transplant-Related Mortality 0% 0% Median days from AutoSCT to RICT --- 80
Reduced-Intensity Conditioning Followed by Allogeneic Stem Cell Transplantation (allo-SCT) Is an Effective Salvage Treatment for Peripheral T-Cell Non-Hodgkin’s Lymphoma (PTCL).
Authors: Corradini Paolo , Dodero Anna , Bregni Marco , Zallio Francesco , Farina Lucia , Rambaldi Alessandro , Patriarca Francesca , Olivieri Attilio , Bonifazi Francesca , Gianni Alessandro Massimo , Tarella Corrado
Published: April 2020

Patients with relapsed PTCL have a poor prognosis. We had previously shown the existence of a graft-versus-lymphoma effect against PTCL (J Clin Oncol, 2004). In the present report, we extended our previous observations to 26 patients (pts) receving allo-SCT. All patients received several courses of debulkying chemotherapy (usually 3 DHAP and/or high-dose chemotherapy) followed by the same RIC regimen containing thiotepa (10 mg/kg), fludarabine (60 mg/ms) and cyclophosphamide (60 mg/kg). GVHD prophylaxis consisted of cyclosporine A and short-course methotrexate. Patients’ median age was 45 years (range, 15–64). Histologic PTCL subtypes included: PTCL not otherwise specified (n=12), ALCL (n=7), angioimmunoblastic (n=3), others subtypes (n=4). Twenty-two pts (84%) received transplant from HLA-identical sibling, 3 from haploidentical sibling and one from unrelated donor. The median time from diagnosis to transplantation was 17 months. Thirteen patients (50%) had failed a previous auto and the majority received at least 2 lines of chemotherapy before allo-SCT. Seven (27%) and 13 pts (50%) were in CR and PR at the time of allo-SCT, respectively. At median follow-up of 27 months (range, 8–73), 17 (65%) were alive (n=14 in CR) and 9 died (n=6 disease, n=3 toxicity). The estimated 3-year TRM was 13%. The estimated 5 year OS and PFS projections were 61% (95% CI, 41–81%) and 51% (95% CI, 30–72%), respectively. Relapses occurred in the first 6 months after allo-SCT and we did not observe differences in PFS between specified and unspecified variants. De-novo acute GVHD (II/IV) and chronic GVHD incidence were 28% and 24%, respectively. Eight patients received DLI, 6 for relapse, 1 pre-emptive, 1 for infection: 3 responded (n=1 CR, n=2 PR). Following DLIs, 4 patients developed GVHD with associated a clinical response. In conclusion, our data indicate: 1) long-term disease control was achieved in patients with an aggressive subtype of NHL; 2) although optimal therapeutic strategies for relapsed PTCL are yet to be defined, further prospective evaluation of allo-SCT is required.
Reduced-Intensity Conditioning (RIC) Followed by Allogeneic Stem Cell Transplantation (SCT) for Relapsed Lymphomas: Impact of Pre-Transplantation Factors on Long-Term Outcome.
Authors: Corradini Paolo , Dodero Anna , Bregni Marco , Ciceri Fabio , Olivieri Attilio , Farina Lucia , Valagussa Pinuccia , Scime’ Rosanna , Locasciulli Anna , Patriarca Francesca , Gianni Alessandro Massimo , Tarella Corrado
Published: April 2020

Allogeneic stem cell transplantation (SCT) represents a potentially curative treatment for recurrent lymphoid malignancies. In fact, potential advantages include the use of a tumor free graft and immune-mediated graft-versus-lymphoma effect. Here, we analyzed the impact of pre-transplantation factors on outcome in 141 lymphoma patients (pts) receiving RIC and allogeneic SCT from HLA-identical sibling donors. Histologic types included in the study were: low-grade non-Hodgkin lymphoma (LG-NHL; n=58), high-grade NHL (HG-NHL, n=55), Hodgkin disease (HD; n= 28). Median age was 50 years (range: 20–69). The three groups (HD vs LG-NHL vs HG-NHL) had similar characteristics in terms of: chemosensitive disease (57% vs 69% vs 67%, p=ns) and complete remission (CR) at transplant (18% vs 27% vs 34%, p=ns). Pts with HD had received more lines of chemotherapy (>2 vs ≤2) as compared to LG-NHL and HG-NHL (82% vs 52% vs 42%). Furthermore, the proportion of pts receving previous autologous SCT was significantly higher in HD and HG-NHL versus LG-NHL (75% vs 54% vs 27%). In addition, patients with HG-NHL and HD underwent frequently allo-SCT less than 2 years after diagnosis as compared to LG-NHL (58% vs 39% vs 24%). All patients received debulkying chemotherapy followed by the same RIC containing thiotepa (10 mg/kg), fludarabine (60 mg/ms) and cyclophosphamide (60 mg/kg). GVHD prophylaxis consisted of cyclosporine A and short-course methotrexate. At a median follow-up of 30 months (8–70), the overall survival (OS) and progression-free survival (PFS) were 65% (95%CI, 56–74%) and 57% (95%CI, 47%–67%), respectively. Univariate analysis showed that age (< or > 55 years), donor sex, interval between diagnosis and SCT, number of previous treatments did not influence outcome whereas diagnosis of HD was associated with a significant inferior PFS and OS. Chemosensitive disease (CR+PR) influenced PFS in HG-NHL (p<0.0003) and HD (p<0.0036) but not in LG-NHL (p=0.69). Complete remission at transplant was associated to a significant better PFS in HD (p<0.01) but not in HG-NHL (p= 0.14) and LG-NHL (p=0.7). Previous autologous SCT was associated to inferior PFS (64% vs 50%, p<0.04) but did not affected OS and TRM. By multivariate analysis, diagnosis of HD and refractory disease were associated to an inferior PFS (p<0.0001, p<0.001) whereas diagnosis of HD and no-CR at transplant remained of prognostic value on OS (p<0.006 and p<0.007). We conclude: 1) age and previous treatments, including autologous SCT, are no longer limitations for allogeneic SCT; 2) debulking therapy before RIC allogeneic SCT is required for HD and HG-NHL; 3) new strategies for an early indentification of chemorefractory pts are necessary.
Allogeneic Stem Cell Transplantation (allo-SCT) from a HLA Identical Sibling for CR1 AML Patients Aged above 55 Years Old after a Reduced Intensity Conditioning: A Survey from the Société Française de Greffe de Moelle et de Thérapie Cellulaire (SFGM-TC).
Authors: Blaise Didier , Chir Zina , Attal Michel , Bourhis Jean-Henri , Sotto Jean-Jacques , Boiron Jean-Michel , Milpied Noel , Cahn Jean-Yves , Rio Bernard , Lioure Bruno , Guilhot Francois , Berthou C. , Buzyn Agnes , Michallet Mauricette
Published: April 2020

Background: AML incidence increases with age. Allogeneic stem cell transplantation (Allo-SCT) offers the best leukemic control but is associated with high non-relapse mortality (NRM). Recent advances using non-myeloablative strategies have established the feasibility of allo-SCT in elderly patients. However in the context of AML, an important reduction of the intensity of the preparative regimen may be also associated with a loss of leukemic control, offsetting the impact of toxicity reduction in elderly.

Methods: We retrospectively analyzed AML patients in first complete remission (CR1) reported to the SFGM-TC, aged above 55 and transplanted from a HLA identical sibling donor prior to 01/01/05.

Results: 62 patients prepared with a non-myeloablative conditioning (NMAC) (fludarabine (75mg/m2) + TBI (2Gy)) (N=14) or a reduced intensity conditioning (RIC) (busulfan (4 to 8 mg/m2) + fludarabine (150 to 180 mg/m2) + thymoglobulin (2.5 to 12.5 mg/m2)) (N=48). GVHD prophylaxis used CSA+MMF for NMAC, CSA +/− MMF for RIC. With few exceptions, all patients in a given centre were treated identically. Major characteristics were: age 58 (55–67), M/F= 27/35. Time between diagnosis and allo-SCT: 171 days (101–467). BMT/PBSCT: 7/55. Pts have been considered for allo-SCT because of poor prognosis factors: no favorable cytogenetics (100%), secondary AML (15%), 2 chemotherapy course to achieve CR1 (24%) or M0, M6 or M7 FAB (20%). All pts engrafted. Acute GVHD occurred in 16 pts (grade 1: 6; grade 2: 6; grade 3–4: 4) and chronic GVHD in 18 pts (limited: 8; extensive: 10) with no difference in the 2 groups. The cumulative incidences of grade 2–4 aGVHD and cGVHD were 16% (95%CI: 7–25) and 29% (95%CI: 18–40) respectively. 15 pts relapsed and 8 died from NRM. Relapse and NRM cumulative incidences were 24% (95%CI: 13–35) and 13% (95%CI: 5–21) respectively. 49 pts were evaluable for cGVHD: of the 18 expressing cGVHD none have relapsed as compared to 12 of the 31 who did not present cGVHD (39%, 95%CI: 22–56) (p=.007). The 2 year KM survival and DFS probabilities are 63% (47–76) and 56% (42–69). In a landmark analysis investigating patients alive on day 100, 2 year DFS are 94% and 38% respectively with or without cGVHD (p=0.001) and 2 year KM OS are respectively 94% and 45% (p=0.01).

Conclusions: We conclude that such a strategy in elderly can afford a high relapse control with low NRM conducting to high survival probability at 2 years. Results are achieved through the allogeneic effect as expressed by cGVHD inviting to a careful immunomodulation in the early post transplant period to further improve results.
Arkansas Autotransplant (AT) Experience with > 2500 Myeloma (MM) Patients: Follow-Up Extending to >15 Years.
Authors: van Rhee Frits , Tricot Guido , Anaissie Elias , Reiner Maureen , Zangari Maurizio , Burns Michael , Epstein Joshua , Shaughnessy John , Rasmussen Erik , Crowley John
Published: April 2020

Background: AT’s have become the standard of care for MM. Long-term follow-up studies from large centers are critical to understand who benefits most and who should be considered for alternative treatment approaches.

Patients and Methods: 2,605 MM patients receiving at least one AT at the University of Arkansas were considered for this study. Kaplan-Meier analysis was used to estimate median event-free (EFS) and overall survival (OS). Cox regression was used to evaluate independent prognostic factors of EFS and OS from AT.

Results: Of the 2,605 patients, 891 were enrolled into front line Total Therapy (TT) protocols TT1/2/3 (TT); 1,012 were treated on protocols for previously treated patients (non-TT); and 702 were treated off protocol due to significant co-morbidities or patient/MD preference (non-P). Median EFS and OS for all patients are 29 mo and 51 mo; 10-yr EFS and OS are 18% and 23%; 12% survived >15yr. Features independently predicting superior survival included TT (HR 0.51, p<.001), absence of cytogenetic abnormalities (no CA) (HR 0.47, p<.001), timely application of 2nd transplant (< 6 months of 1st transplant) (HR 0.71, p<.001) as well as B2M < 3mg/L, CRP < 6mg/dL, albumin >=3g/dL, platelet count >=100.000/microL (all p<.001) and age <65yr (p=.008). The figure depicts survival (landmarked at 6 months after 1st transplant) according to the number of favorable features present of the 5 strongest predictors (TT, 2 transplants within 6 months, no CA, low B2M, low CRP).

Conclusion: This large single institution experience demonstrates that > 10yr survival can be accomplished in over one-half of the patients presenting without CA (14%), with low levels of B2M and CRP and receiving TT and timely 2nd autotransplant. The worst constellation affected 5% of all patients presenting with at most 1 good-risk feature whose 5-yr survival was only 8%. Collectively, these data should serve as a standard for MM investigators and patients alike, against which long-term outcome of newer treatments should be measured.

Figure Figure
The Time Required To Achieve Complete Remission (CR) during Intensive Therapy on Total Therapy 2 Does Not Influence Event Free Survival (EFS), While Improvement in Quality of Response with Ongoing Treatment Clearly Does.
Authors: Tricot Guido , Reiner Maureen , Zangari Maurizio , van Rhee Frits , Anaissie Elias , Milner Teresa , Barlogie Bart
Published: April 2020

In acute leukemia and intermediate/high grade lymphoma it is important to achieve a CR as early as possible. The aim of the study was to evaluate if the same is true in myeloma treated with intensive therapy including tandem transplants (Tx-1; Tx-2). A total of 668 patients were enrolled on our Total Therapy 2 protocol, which randomized patients upfront to intensive therapy with or without thalidomide. The protocol consisted of 4 induction cycles followed by tandem transplants, 1 year of consolidation chemotherapy and maintenance therapy with dexamethasone pulsing every 3 months for 1 year and interferon-α, if tolerated. This study is limited to the 570 patients who received at least one transplant. CR was defined as absence of serum and urine M-protein with negative immunofixation electrophoresis and < 5% bone marrow plasma cells. EFS analyses were performed using Kaplan-Meier plots and log rank statistics to compare different groups. A 1 year landmark after Tx-1 was employed to compensate for guaranteed time of CR patients. Prior to Tx-1 89 patients (16%) were in CR, 111 in near CR (nCR), 110 in partial remission (PR) and 260 in < PR. After Tx-1, 170 (30%) achieved CR, 159 nCR, 116 PR and 125 < PR. The ultimate best response was CR in 319 patients (56%), nCR in 134, PR in 68 and < PR in 49. EFS of patients ultimately achieving CR was similar for those who were either in CR, nCR, PR or < PR prior to Tx-1 (p=0.47; Fig 1a). Patients in PR prior to Tx-1, but ultimately achieving CR or nCR faired considerably better than those who remained in PR (p=0.003 Fig 1b). Similarly, EFS of patients ultimately achieving CR was comparable for those who were either in CR, nCR, PR or < PR prior to Tx-2 (p=0.53). The same observations were made for both patients randomized to thalidomide or no thalidomide, or with and without baseline metaphase cytogenetics. With a median follow-up of 3 year after Tx-1 no difference in EFS was seen relative to the timing of achievement of CR. However, improvement of quality of response with further therapy resulted in a significant increase in EFS, strongly suggesting additional benefit from the second transplant and consolidation chemotherapy.

1a Event-Free Survival Comparing best Response Before TX1 To Best Response Overall (Landmark 12 months posts TX1) 1a. Event-Free Survival Comparing best Response Before TX1 To Best Response Overall (Landmark 12 months posts TX1) 1b Event-Free Survival Comparing best Response Before TX1 To Best Overall Landmark 12 months posts TX1 1b. Event-Free Survival Comparing best Response Before TX1 To Best Overall Landmark 12 months posts TX1
Flow Cytometric Detection of Circulating Myeloma Cells Pretransplant in Patients with Multiple Myeloma: A Simple Risk Stratification System.
Authors: Dingli David , Nowakowski Grzegorz S. , Dispenzieri Angela , Lacy Martha Q. , Hayman Suzanne R. , Rajkumar Vincent S. , Greipp Philip R. , Litzow Mark R. , Gastineau Dennis A. , Witzig Thomas E. , Gertz Morie A.
Published: April 2020

Background: The presence of circulating myeloma cells (CMC) detected by flow cytometry at the time of diagnosis of multiple myeloma is associated with a shortened response to therapy and reduced overall survival (OS). We hypothesized that the presence of CMC at the time of stem cell collection prior to high dose therapy (HDT) and autologous stem cell transplantation (ASCT) would identifies a cohort of patients with a high risk of rapid progression.

Methods: The Mayo Clinic myeloma transplant database was queried for patients who were mobilized using cyclophosphamide and hematopoietic growth factors. CMC was determined using flow cytometry by gating on a population of CD38 bright and CD45 negative cells. The impact of CMC on OS and time to progression (TTP) and its role in the context of established prognostic parameters was evaluated.

Results: Of 246 patients with MM undergoing ASCT, 95 had CMC. Patients with CMC had significantly higher plasma cell labeling index, adverse cytogenetics, B2-M and resistant disease. Complete response (CR) rates post transplant were 32% and 36% for patients with and without CMC (p=0.5034). OS was 33.2 and 58.6 months (p=0.0052) while TTP was 14.1 and 22 months respectively (p=0.0005).

Figure Figure

On multivariate analysis, CMC remained an independent prognostic factor in a model that included cytogenetics and disease status at time of transplant (p=0.0314). A prognostic system based on the presence or absence of CMC and karyotype abnormalities was developed. Patients with neither, one or both parameters had a median, OS of 55, 48 and 21.5 months respectively (p<0.0001) while TTP was 22, 15.4 and 6.5 months for the same groups (p<0.0001).

Conclusion: The presence of CMC at the time of HDT and ASCT is an independent prognostic factor. The combination of CMC and cytogenetics provides a simple yet powerful scoring system that stratifies patients and guides their management.
The Role of Stem Cell Mobilization Regimen on Lymphocyte Collection Yield and Survival after Autologous Hematopoietic Stem Cell Transplantation in Multiple Myeloma.
Authors: Porrata Luis F. , Hayman Suzanne R. , Gertz Morie A. , Lacy Martha Q. , Dispenzieri Angela , Kumar Shaji K. , Litzow Mark R. , Inwards David J. , Ansell Stephen M. , Micallef Ivnna N. , Johnston Patrick B. , Gastineau Dennis A. , Tefferi Ayalew , Elliot Michelle , Hogan William J. , Markovic Svetomir N.
Published: April 2020

We previously have reported that autograft absolute lymphocyte count (A-ALC) is a possible prognostic factor for survival after autologous peripheral blood stem cell transplant (ASCT) for myeloma (MM). Factors affecting A-ALC in MM are unknown. We hypothesize that method of stem cell mobilization, hematopoietic growth factor (HGF) vs. HGF+Cytoxan chemotherapy (C+HGF), directly affects A-ALC collection. 191 consecutive MM patients between 1994 and 2004 were analyzed retrospectively. Patients generally were mobilized with C+HGF prior to 2003. Thereafter, C+HGF was reserved largely for those with ≥4% circulating peripheral blood plasma cells (PC), a negative prognostic indicator. No patients were transplanted in disease relapse or refractory disease. Patients also were matched for age, sex, β2-microglobulin, conventional cytogenetics, LDH, c-reactive protein, number of prior therapies, plasma cell labeling index (PCLI), pre-mobilization ALC, and % bone marrow (BM) PC. The groups HGF (n=80) and C+HGF (n=111) differed with respect to the conditioning regimen (p < 0.0001), and presence of (≥4%) circulating peripheral blood PC (p<0.005). The primary end-point of the study was to assess the correlation between HGF vs C+HGF, and A-ALC. The secondary endpoint was to determine if HGF vs C+HGF affected survival post-ASCT. Patients mobilized with HGF had a higher A-ALC compared to those mobilized with C+HGF [0.764 x 109 lymphocytes/kg (range: 0.146–1.803) vs. 0.212 (range: 0.016–1.26), p<0.0001]. No association was identified between A-ALC and conditioning regimens (p = 0.19) and PC (p = 0.31). Median overall survival (OS) and progression-free survival (PFS) were longer in those mobilized with HGF vs. C+HGF (not reached vs. 48 months, p<0.0150; not reached vs. 21 months, p<0.007, respectively). Multivariate analysis demonstrated that age ≥50 vs age ≤50 (p<0.05) and A-ALC ≥0.5 vs <0.5x109 lymphocytes/kg (p<0.0397) were independent predictors of OS. Factors influencing PFS in the multivariate analysis included circulating PC ≥4% vs <4% (p<0.0157), PCLI ≥ 1% vs PCLI ≤ 1% (p<0.0107), and A-ALC ≥0.5 vs <0.5x109 lymphocytes/kg (p<0.0042). On multivariate analysis, the method of stem cell mobilization and the conditioning regimen did not have a statistically significant effect on either OS or PFS. We hypothesize that the differences in PFS and OS seen between the HGF vs C+HGF mobilization groups are mediated through the A-ALC. These data suggest that mobilization regimens should not only collect CD34+ stem cells, but also be optimized to collect an A-ALC target which may impact on PFS and OS post-ASCT.
Transplant Outcomes after Topotecan-Melphalan-Cyclophosphamide (TMC) Conditioning for Autologous Stem Cell Transplantation for Multiple Myeloma. Comparison to Melphalan 200 mg/M2 (MEL200).
Authors: Donato Michele , Aleman Ana , Weber Donna , Wang Michael , Qazilbasch Muzaffer , Davis Marilyn , Roden Linda , Mendoza Floralyn , Champlin Richard , Giralt Sergio
Published: April 2020

Background: Topotecan at modest doses has activity in multiple myeloma (MM). The combination of high-dose topotecan, melphalan, and cyclophosphamide (TMC) has been used as a conditioning regimen for autologous SCT in patients with MM. We report the results of a phase II trial with this combination and perform a retrospective analysis comparing TMC to a standard preparative regimen of melphalan 200 mg/m2 (MEL200).

Patients and Methods: Between 10/99 and 3/04, 55 patients with newly diagnosed MM were treated on a Phase II trial of topotecan 3.5 mg/m2 daily for 5 days in combination with cyclophoshamide 1 gm/m2 daily for 3 days, and melphalan 70 mg/m2 daily for 2 days followed by autologous SCT. Patient characteristics are summarized in table 1. In brief, median age was 55 (range, 37–67), median time to transplant was 6 months (range, 2-59); median B2M @diagnosis 3.3 (range, 1.4–17.2); 76% of patients had chemosensitive disease prior to transplant.

Results: No treatment related deaths were observed, the regimen was well tolerated with grade 2 Bearman mucositis and diarrhea the most common toxicities, and no grade 3 or 4 toxicities observed. When compared to a group of patients who received MEL 200 the overall response rate was lower 75% vs 82% and a lower CR rate 11% vs 36%, but a similar median time to disease progression (14 m vs 13 m), with a trend towards a better 3 yr overall survival (87% vs 77%; p=.05) (Table 2 and Figure 1).

Conclusion: TMC is a well tolerated conditioning regimen for myeloma, our results suggests that although no more effective than MEL200 as a single preparative regimen for MM, it warrants exploring as part of a tandem transplant program.

Patient Characteristics TMC MEL200 N 55 157 Median Age (range) 55(37-67) 56(29-75) Median B2M @Dx 3.3 (1.4 - 17.2) 4 (0.5 - 49.8) % Abn Cytogenetics 15% 22% CR/PR @ SCT 4%/73% 10%/89% % 1ry Refractory 24% 27% Transplant Outcomes TMC MEL200 p ORR/CR conversion 75%/11% 82%/36% Non Relapse Mortality 0 2 Median OS NR 52 months .05

Figure Figure
Evidence for Alternative Lengthening of Telomeres in Chronic Lymphocytic Leukemia Patients.
Authors: Damle Rajendra N. , Banapour Taraneh , Sison Cristina , Allen Steven L. , Rai Kanti R. , Chiorazzi Nicholas
Published: April 2020

Telomere shortening is a consequence of repetitive clonal replication and leads to clonal deletion unless DNA extension and repair occur. All tumors must circumvent this problem by up-regulating mechanisms that lead to chromosomal lengthening. Two mechanisms have been identified that maintain chromosome ends- telomerase that does so by reverse transcription and alternative lengthening of telomeres (ALT) that occurs by homologous recombination. The latter function is characterized by the presence of promyelocytic leukemia protein-associated nuclear bodies (PML-NBs) and the presence of PML-NB is used to mark cells that use this process.

B cell Chronic lymphocytic leukemia (B-CLL) cells with unmutated Ig V genes have shorter mean telomere lengths compared with those exhibiting mutated Ig V genes. In addition, cells with unmutated Ig V genes demonstrate more telomerase activity than their mutated counterparts. The mutated cases show long and heterogeneously elongated telomeres in spite of the absence, in most cases, of detectable telomerase activity. Therefore we determined whether the ALT pathway plays a role in telomere maintenance in B-CLL, using a monoclonal anti-PML antibody and a flow-cytometric assay for assessment of PML protein. Telomerase-expressing Jurkat T cells and murine fibroblasts-L cells served as negative controls for PML staining, whereas the ALT positive Osteosarcoma cell line U2-OS served as a positive control. In a cohort of 20 B-CLL cases, PML protein was detected in all cases regardless of Ig V mutation status. In addition, a similar percentage of cells within the clones contained PML (10 - 90% of the members of unmutated clones and 11–96% of mutated clones), whereas peripheral blood B cells from 6/6 elderly normal donors did not show any PML staining. PML expression was compared with telomere length and telomerase activity in the same cases. The percentage of cells showing PML expression inversely correlated with telomerase activity (r= −0.58; p=0.029). Although in most published reports telomere maintenance by ALT occurs in the absence of telomerase activity, we found ALT (as suggested by PML positive cells) in cells with telomerase activity (detected by the standard TRAP assay). Thus, B-CLL cases can express PML bodies and some B-CLL cells can contain both PML-NB and express telomerase activity. These findings suggest that B-CLL cells can use two distinct mechanisms to assure telomere maintenance and perpetuate clonal survival and expansion.
Expression of Angiogenin in Normal B Lymphocytes and B-CLL Cells.
Authors: Paul Santanu , Allen Steven L. , Rai Kanti R. , Chiorazzi Nicholas
Published: April 2020

Angiogenesis is critical for the clinical progression of hematopoietic malignancies and depends on a series of angiogenic factors. Angiogenin is a potent angiogenic factor produced by the host microenvironment and certain neoplastic cells. The association between angiogenin, cancer progression and poor outcome in solid tumors has been documented, but its significance in B-CLL has not been defined. A previous study suggests that B-CLL patients in Rai stage O with higher angiogenin levels have a better clinical outcome. This is surprising in light of the association of angiogenin levels with progression in solid tumors. Therefore we analyzed angiogenin mRNA and protein expression by the leukemic cells of B-CLL patients in order to correlate the production of this molecule with disease progression in B-CLL.

Angiogenin was expressed in B-CLL cells as well as in B cells of normal donors, although the expression in the former was much higher than in the latter. Q PCR revealed a 7-fold induction in angiogenin-specific mRNA transcription in B-CLL cells (n=10) in comparison to normal B cells (n=13). In addition, angiogenin protein was identified by confocal microscopy both within and on the cell surface of B-CLL cells. All B-CLL cases, regardless of IgV gene mutation status, express angiogenin as defined by FACS. Approximately 85% of the cells that comprise B-CLL clones (n=28) display angiogenin on their surface membranes (range: 55-98%). Furthermore approximately 13% of polyclonal B cells from normal subjects (n=12) also produce angiogenin (range: 1–33%). Using enzyme immunoassay, we also measured serum angiogenin levels and detected significant differences in 66 B-CLL patients (median: 381 ng/mL; range: 185–875) versus 24 age- and sex-matched healthy controls (median: 301 ng/mL; range: 192–536) (P = 0.0056). Surprisingly, there was no correlation between surface and serum angiogenin levels and the different V gene-defined B-CLL subgroups.

Our results show for the first time that a small fraction of normal B cells and all cases of B-CLL express angiogenin transcripts as well as intracellular and surface membrane protein. Angiogenin levels do not correlate with IgV gene mutations status or expression of surface membrane CD38. The role of angiogenin in the pathogenesis and progression of B-CLL needs further study.
Expression Levels of CD38 in Tumor Cells and T-Cells Are of Prognostic Value in B-CLL.
Authors: Tinhofer Inge , Rubenzer Gabriele , Egle Alexander , Greil Richard
Published: April 2020

Purpose: CD38 expression level of tumor cells was identified as predictor for progression, overall survival and response to therapy in B-chronic lymphocytic leukemia. Though CD38 is involved in effector functions of T-cells, the prognostic value of CD38 expression in these cells has not been addressed in B-CLL before.

Patients and Methods: CD38 expression levels in B-CLL cells and T-cells from 170 patients were analyzed by flow cytometry and correlated with clinical and molecular risk parameters.

Results: CD38 expression levels significantly differed not only in the neoplastic clone but also in T-cells from B-CLL patients with low vs advanced stage and stable vs progressive disease. Combined analysis of CD38 in T-cells and B-CLL cells identified 4 subgroups of patients with distinct clinical course. Multivariate analysis including clinical (Rai stage, anemia) and molecular risk parameters (Zap-70 expression levels, IgVH mutational status) identified CD38 expression levels in B-CLL (RR 6.9; 95% CI: 2.4 to 20.2; p=.0004) and T-cells (RR 2.4; 95% CI 1.2 to 4.8; p=.0106) as independent prognostic factors. Furthermore, CD38 expression in T-cells as a risk factor for increased peripheral tumor load and progressive disease was significantly associated with male gender.

Conclusion: Combined analysis of CD38 in tumor cells and T-cells is superior in predicting outcome in B-CLL than either parameter alone. Our data on the prognostic value of CD38+ T-cells in B-CLL in general, and their identification as male risk factor in particular strongly encourage further studies on their role on survival and proliferation of B-CLL cells and the underlying mechanisms.