bluuebunny/crossref_metadata_2025 huggingface dataset:
Differentiation syndrome associated with enasidenib, a selective inhibitor of mutant isocitrate dehydrogenase 2 (mIDH2).
Authors: Fathi Amir Tahmasb , Dinardo Courtney Denton , Kline Irina , Kenvin Laurie , Gupta Ira , Attar Eyal C. , Stein Eytan M. , de Botton Stéphane ,   On Behalf of the AG-221-C-001 Study Investigators
Published: September 2018

7015

Background: Enasidenib (AG-221), an oral mIDH2 inhibitor, promotes myeloid differentiation of leukemic blasts. Enasidenib treatment (Tx) can result in IDH-inhibitor-associated differentiation syndrome (IDH-DS), with manifestations akin to retinoic acid syndrome seen during acute promyelocytic leukemia Tx. Methods: A phase 1 dose-escalation/expansion study (N = 239) (NCT01915498) included 109 pts with relapsed/refractory AML who received enasidenib 100 mg /day. An independent Differentiation Syndrome Review Committee (DSRC) was formed to review potential IDH-DS cases. The DSRC identified and agreed on signs and symptoms possibly characteristic of IDH-DS, including fever, lung infiltrates, pleural or pericardial effusions, rapid weight gain, edema, and azotemia. Of the 109 pts, the DSRC identified and retrospectively reviewed 27 cases (8 investigator reported IDH-DS cases and 19 cases suggestive of IDH-DS) to determine consistency with IDH-DS. Results: The DSRC found 13 of the 27 cases to be consistent with IDH-DS (11.9% of 109 pts). Median time to onset was 30 days (range 7-116). Manifestations of IDH-DS in > 2 pts were dyspnea (n = 10), pyrexia (9), lung infiltrates (8), pleural effusion (5), and kidney injury (3). IDH-DS was effectively managed with systemic corticosteroids in 12/13 cases. Leukocytosis accompanied 4 cases and hydroxyurea was used for cytoreduction. Enasidenib was interrupted for 9 pts (median 7 days) but dose reductions or discontinuation were not required. Six of 13 pts had clinical responses (2 complete remission [CR], 2 CR with incomplete hematologic recovery, 1 partial remission, 1 morphologic leukemia-free state), 6 had stable disease and 1 had progressive disease. Conclusions: Systemic corticosteroids, close hemodynamic management, and hydroxyurea (in the presence of leukocytosis) are effective management strategies, should be administered promptly when IDH-DS is suspected, and continued until improvement. Enasidenib interruption can be considered if initial intervention is unsuccessful. IDH-DS represents a novel clinical finding in m IDH2 AML treated with enasidenib, and is likely due to its suggested mechanism of action, differentiation. Clinical trial information: NCT01915498.
Effect of cytarabine/anthracycline/crenolanib induction on minimal residual disease (MRD) in newly diagnosed FLT3 mutant AML.
Authors: Stone Richard M. , Collins Robert , Tallman Martin S. , Walter Roland B. , Karanes Chatchada , Patel Prapti Arvind , Vusirikala Madhuri , Coombs Catherine Callaghan , Olson Gretchen , Jain Vinay Kumar , Wang Eunice S.
Published: September 2018

7016

Background: Baseline characteristics such as age >60, WBC>100,000/µL and FLT3/NPM1/DNMT3A+ve are known to be associated with a poor prognosis in AML. Ivey et al. (NEJM 2016) reported that FLT3-ITD+ve patients (pts) who were MRD+ve after 2 cycles of induction chemotherapy were more likely to relapse as compared to those who became MRD-ve (92% vs 35%). Eradication of FLT3+veclones may lead to reduced relapse rates. Crenolanib is a type I FLT3 TKI, which inhibits both FLT3-ITD and TKD mutations. We here report that a single induction cycle of cytarabine/anthracycline/crenolanib leads to MRD negativity by multiparameter flow cytometry (MPF), and low rate of early relapse in pts with newly diagnosed FLT3+veAML. Methods: This abstract includes 29 consecutively treated, newly diagnosed, FLT3+ve AML pts, who achieved CR1 after one course of cytarabine/anthracycline/crenolanib. Pts received 7+3 induction with cytarabine 100 mg/m2/d for 7d and either daunorubicin (<60 y: 90 mg/m2; ≥60 y: 60 mg/m2) or idarubicin 12 mg/m2 for 3d. Crenolanib (100 mg TID) was started on day 9 until 72 h prior to next chemotherapy. Results: 29 pts (15M, 14F), median age 55y (10pts ≥60y) are included. MRD at time of count recovery was assessed by MPF in 25/29 pts. 20/25 (80%) became MRD–ve. With a median follow up of 7mth, 4/25 pts have relapsed (2/5 MRD+ve, 2/20 MRD-ve).Age ≥60 was a risk factor for MRD+ve and relapse. All 4 pts with WBC>100K as well as 5 pts with FLT3/NPM1/DNMT3A+ve AML became MRD-ve after one induction cycle and none have relapsed. Conclusions: These data suggest, in the context of an ongoing trial (NCT02283177), crenolanib in combination with standard induction is associated with a high rate of achieving an MRD negative state by MPF and a low rate of relapse in previously untreated adults with mutant FLT3. Longer follow-up and comparison of MRD data with similar pts treated with standard chemo alone will be necessary to reach more definitive conclusions. Clinical trial information: NCT02283177. [Table: see text]
Outcomes with lower intensity therapy in TP53-mutated AML.
Authors: Kadia Tapan M. , Boddu Prajwal C. , Ravandi Farhad , Garcia-Manero Guillermo , Borthakur Gautam , Andreeff Michael , Jabbour Elias , Dinardo Courtney Denton , Konopleva Marina , Daver Naval Guastad , Takahashi Koichi , Patel Keyur , Kanagal-Shamanna Rashmi , Cortes Jorge E. , Kantarjian Hagop M.
Published: September 2018

7017

Background: TP53 mutations confer an adverse prognosis in patients (pts) with AML treated with standard chemotherapy. A recent study reported high response rates using a 10-day regimen of decitabine (DAC10) in pts with TP53-mutated ( TP53-MUT) AML. The question remains whether this benefit is unique to DAC10 or whether the same benefit among TP53-MUT AML applies to other low intensity therapy (Rx). Methods: We reviewed our own experience of pts treated with low intensity Rx from 2012 - 2016. Mutation testing was performed using a whole-exome sequencing panel. We reviewed the clinico-pathologic characteristics of these pts, and compared their outcomes based on the presence/absence of a TP53mutation and by the type of Rx they received. Results: There were 131 pts in our cohort of which 33 (25%) had TP53-MUT. Pt characteristics are outlined in Table 1A. All pts were treated with low intensity Rx and were divided into the following groups: DAC10 [n=34, 26%]; 5-day decitabine, or 7-day azacytidine (DAC5) [n=39, 30%]; or cladribine+low dose araC (CLAD/LDAC) [n=58, 44%]. Response rates and OS by Rx and TP53-MUT status are summarized in Table 1B. While there was no significant difference in response rates or OS by TP53-MUT status within any of the treatment approaches, there was a trend for inferior response rates and OS among pts with TP53-MUT who received either DAC-5 or CLAD/LDAC ; this was not seen in pts receiving DAC10. Conclusions: The presence of a TP53-MUT was associated with a nonsignificant trend towards inferior outcomes among pts receiving DAC5 or CLAD/LDAC, but not among those receiving DAC10. Comparing across groups, the CLAD/LDAC combination was associated with the longest OS, and DAC10 was associated with superior outcomes compared to DAC5, in TP53-MUT cohort. [Table: see text]
Sorafenib plus 5-azacytidine (AZA) in older untreated FLT3-ITD mutated AML.
Authors: Ohanian Maro , Garcia-Manero Guillermo , Levis Mark J. , Jabbour Elias , Daver Naval Guastad , Borthakur Gautam , Kadia Tapan M. , Brandt Mark , Pierce Sherry , Burger Jan Andreas , Richie Mary Ann , Patel Keyur , Cortes Jorge E. , Kantarjian Hagop M. , Ravandi Farhad
Published: September 2018

7029

Background: Sorafenib plus 5-azacytidine (AZA) is observed to be safe and effective in relapsed / refractory FLT3-ITD mutated acute myeloid leukemia (AML) patients (pts). Hypothesis: Combining sorafenib with AZA is safe and effective in older untreated FLT3-ITD mutated AML pts. Methods: Eligibility included: untreated FLT3-ITD mutated AML (≥10% mutation burden), age ≥60 yrs, adequate organ function, and ECOG performance status ≤ 2. The regimen was: AZA 75 mg/m2daily x 7 days and sorafenib 400 mg twice daily for 28 days. Results: 26 pts with untreated AML [median age 73 (61-86)] were enrolled: 16 (62%) pts had normal karyotype, 2 (8%) complex karyotype, 4 (15%) other miscellaneous abnormalities, and 4 (15%) with insufficient metaphases. Prior to the initiation of treatment, FLT3-ITD was detected in all pts with a median allelic ratio of 0.3735 (0.009-0.885). The overall response rate (ORR) in 25 evaluable pts was (76%) [7 (28%) with CR, 10 (40%) CRi/CRp, and 2 (8%) PR]. Pts underwent a median of 3 (1-35) treatment cycles. The median number of cycles to response was 2 (1-4), and the median time to achieve response, 1.77 months (mos) (0.689-4.271 mos). The median duration of CR/CRp/CRi is 14.5 mos (1.18—28.74). Three (18%) responding pts (CR, CRp, CRi) have proceeded to allogeneic stem cell transplant. With a median follow-up of 6.8 mos (0.2-18.8), 6 pts are alive, 3 in remission (CR/CRP/CRi). The median overall survival (OS) for the entire group is 8.3 mos; 9.2 mos in 17 responders. Evaluable pts treated with AZA + sorafenib (n = 25) were compared to a matched cohort of historical FLT3-ITD mutated pts > 60 yrs, but treated with hypomethylator-based (HMA) therapy without sorafenib (n = 20); the respective ORR (CR, CRp, CRi, PR) (76% vs. 70%, p = 0.653) and median OS (8.3 and 9.4 mos, p = 0.69) were similar. The remission duration for the responding pts treated with AZA+sorafenib was significantly longer (14.5 mos) than those on other HMA regimens without sorafenib (3.8 mos) (p = 0.01). Adverse events possibly attributable to the regimen included: grade (Gr) 1/2 nausea (n = 3), Gr 1/2 diarrhea (n = 2), Gr 1 dyspnea (n = 1), and Gr 1 breast pain (n = 1). Conclusions: The combination of AZA and Sorafenib is both well tolerated and effective in older untreated FLT3-ITD mutated AML. Clinical trial information: NCT02196857;NCT01254890.
Clinical observations of AML expressing mutant RUNX1 and pre-clinical studies of RUNX1-targeted novel therapy of AML.
Authors: Dinardo Courtney Denton , Mill Christopher P , Fiskus Warren , Saenz Dyana T , Nowak Agnieszka J , Sun Baohua , Patel Keyur , Kadia Tapan M. , Benton Christopher Brent , Takahashi Koichi , Kantarjian Hagop M. , Bhalla Kapil N.
Published: September 2018

7030

Background: Runt-related transcription factor 1 ( RUNX1) is critically involved in normal and malignant hematopoiesis. Somatic mutations in RUNX1 occur in ~10% of AML, especially in older patients with history of radiation or antecedent hematologic disorder. Presence of mRUNX1 is reported to confer relative resistance to therapy and poorer prognosis in AML, and there are no mRUNX1-targeted or specific therapies available. Methods: We retrospectively analyzed outcomes of 94 mRUNX1 and 444 wild-type RUNX1 AML patients treated at our institution from 9/2013 to 12/2016. We also determined the pre-clinical efficacy of a targeted therapy against cultured and primary AML cells expressing mRUNX1. Results: 67% of mRUNX1 patients were > 65 years of age. Co-occurring mutations with mRUNX1 were ASXL1 (33%), N/KRAS (20%), FLT3 (20%), IDH2 (18%), IDH1 (13%) and TET2 (10%). In patients > 65 years treated with hypomethylating agent-based therapy, the presence or absence of mRUNX1 did not impact response rate (42% vs 46% CR/CRp, p = 0.67), median event-free survival (3.4 vs 4.7 mo, p = 0.82) or overall survival (11.5 vs 9.3 mo, p = 0.97). In mRUNX1 expressing AML OCI-AML5 and MonoMac1 cells, knockdown of RUNX1 by shRNA repressed its targets, e.g., MYC and PU.1, inhibited growth and induced apoptosis. Ex vivo knockdown of RUNX1 abrogated in vivo leukemia initiation by OCI-AML5 cells. After engraftment, inducible shRNA-mediated in vivo knockdown of RUNX1 restored survival of immune-depleted NSG mice engrafted with OCI-AML5 cells. RUNX1 transcription is driven by a super enhancer occupied by the bromodomain extraterminal protein (BETP), BRD4. Accordingly, BRD4 knockdown by shRNA or treatment with the BRD4-inhibitor OTX015 depleted RUNX1 and its targets, and induced apoptosis of AML cells. Treatment of OCI-AML5 cell-engrafted NSG mice with OTX015 (50 mg/Kg/day X 5, for 3 wks) reduced AML burden and improved survival (p < 0.01). Co-treatment with the BETi and BCL2 inhibitor venetoclax or CDK4/6 antagonist palbociclib or decitabine synergistically induced apoptosis of OCI-AML5 and primary AML blasts. Conclusions: These findings highlight a novel, promising, BETP antagonist-based therapy of AML expressing mtRUNX1.
Exposure-adjusted adverse events (AEs) comparing blinatumomab to standard of care (SOC) chemotherapy in patients (pts) with relapsed/refractory B-precursor acute lymphoblastic leukemia (r/r ALL) from a randomized phase III study.
Authors: Stein Anthony Selwyn , Larson Richard A. , Schuh Andre C. , Stevenson William , Lech-Maranda Ewa , Nie Kun , Zimmerman Zachary Franklin , Kormany William , Topp Max S.
Published: September 2018

7032

Background: Blinatumomab (blin), a bispecific T-cell engaging antibody construct, has shown improved overall survival vs SOC in pts with r/r ALL in a randomized phase 3 study ( Haematologica 2016;101:S129). To better evaluate safety, we compared AEs of blin vs SOC after adjusting for varying treatment exposure times. Methods: Adults ≥ 18 yrs with r/r ALL (refractory, 1st relapse < 1 yr, ≥ 2 relapses or relapse after transplant) were randomized to receive blin or SOC (1 of 4 predefined regimens). Blin was dosed by continuous infusion (4 wks on/2 wks off) for up to 5 cycles (9 µg/d on d1−7 in cycle 1, then 28 µg/d); up to 4 maintenance cycles (4 wks on/8 wks off) were allowed for ≤ 12 mo. Exposure-adjusted (exp-adj) event rates were calculated as no. of events*100/total exposure time (Table). Results: Median (range) no. of cycles were 1 (1−4) for SOC and 2 (1−9) for blin. The highest exp-adj rates (per 100 pt-yrs) were for pyrexia (507 SOC vs 376 blin), anemia (987 vs 229), thrombocytopenia (750 vs 126) and neutropenia (351 vs 121), all lower in blin. Febrile neutropenia (365 vs 93) and infections (1216 vs 436) were also both lower in blin (p < 0.0001). Exp-adj rates for neurologic events were 743 SOC vs 472 blin, with median time (range) to onset of 7 (1−43) d and 7 (1−190) d, respectively, and gr ≥ 3 cytokine release syndrome (CRS) rates were 0 SOC vs 10 blin. The most frequent AEs in both cycles 1 and 2 were pyrexia, nausea and anemia in both arms; CRS events decreased in the blin arm between cycles 1 and 2 (14% vs 2%). Most fatal AEs were related to infection in both arms. Conclusions: Here blin showed an AE profile consistent with that previously reported for r/r ALL, including similar rates of manageable CRS and neurologic events. Exp-adj AE rates were generally higher in SOC vs blin, including for cytopenias and infections. Clinical trial information: NCT02013167. [Table: see text]
Response and survival rates with frontline hypomethylating agent (HMAs) in favorable risk AML.
Authors: Grunwald Michael Richard , Peters Daniel T. , Robinson Myra M. , Zimmerman Michael Keith Allister , Ai Jing , Knight Thomas Gregory , Lalli Peter N. , Block Jared G. , Smith Elton Travis , Lipford Edward H. , Copelan Edward Alan , Symanowski James Thomas , Gerber Jonathan Michael
Published: September 2018

7039

Background: HMAs are an accepted frontline therapy for AML patients (pts) who are unfit for intensive induction therapy (IIT), particularly pts with unfavorable cytogenetics and/or p53 mutations. However, little is known about the response of favorable risk AML to HMAs. We previously reported that NPM1 mutated and/or CD34- AML status were predictors of response to HMAs. Here, we evaluated responses to frontline HMAs in AML. Methods: A total of 117 patients with de novo AML diagnosed between 7/2013 and 9/2016 were evaluated based on pt and disease related variables, overall response rate (ORR = CR + CR with incomplete count recovery + hematologic remission (ANC > 1000/µL, Hgb > 10g/dL, Plts > 100,000/µL, & no circulating blasts)), and overall survival (OS). Categorical variables were compared using Fisher’s exact test. Kaplan Meier methods estimated survival outcomes, and log rank tests compared survival between groups. Multivariable analyses were performed using Cox proportional hazards models. Results: 51 pts, considered unfit for IIT, received frontline HMAs. ORR and OS were highest in the ELN favorable risk AML pts (n = 13; ORR = 92%, p = .009; median OS = 17.5 months, p = .022). Among 41 NPM1 mutated pts, 15 received HMAs; and 26 received intensive induction. ORRs were 73% and 84%, respectively (p = .434). No difference was found in OS distributions between the HMA and IIT groups in univariate and multivariate (adjusted for age and FLT3 status) models (p = .329 and .241, respectively). Interestingly, ORR was 100% among 9 HMA-treated pts with NPM1 mutated, CD34-, FLT3/ITD-, cytogenetically normal AML. Conclusions: HMA therapy is highly effective frontline treatment in favorable risk AML pts considered unfit for IIT. Survival results with HMAs in NPM1 mutated AML are comparable to those of fitter pts treated with IIT. In selected favorable risk pts considered unfit for standard induction, HMAs can be a successful bridge to potentially curative therapy, including more intensive therapy or transplant. Cytogenetically normal AML with an isolated NPM1 mutation and CD34- status appears to be exceptionally responsive to frontline treatment with HMAs. Prospective validation of these findings is necessary.
Emotion and Symptom-focused Engagement (EASE): A randomized pilot trial of an integrated psychosocial and palliative care intervention for individuals with acute leukemia (AL).
Authors: Rodin Gary , Malfitano Carmine , Rydall Anne , Lo Christopher , Schimmer Aaron David , Marmar Charles , Zimmermann Camilla
Published: September 2018

7041

Background: Individuals diagnosed with AL may experience severe physical and psychological distress due to the illness and its treatment, the threat of relapse and treatment failure, and a high risk of mortality. To alleviate psychological and physical distress in this population, we developed a novel, 8-week, manualized intervention called EASE. This includes: 1) EASE-psy- a tailored psychotherapeutic component to reduce psychological distress; and 2) EASE-phys-symptom screening, with moderate to severe physical symptoms triggering early palliative care. Methods: To assess the feasibility and preliminary efficacy of EASE, patients were recruited within 2 weeks of admission to a comprehensive cancer center and randomized to receive either EASE or usual care (UC). Physical and psychological symptoms were assessed at baseline, 4, 8 (primary endpoint), and 12 weeks. Intervention patients received 6-10 psychotherapy sessions over 8 weeks, weekly assessment of physical symptoms, and consultation and follow-up by palliative care, when needed. One-way ANOVA was performed to assess mean change scores over time between groups. Results: Forty-two patients were randomized to EASE (n = 22) or UC (n = 20). Predefined feasibility outcomes were all met: > 86% (19/22) of EASE participants (goal > 64%) completed > 50% of proposed EASE-psy sessions; 64% (14/22) completed symptom screenings (goal > 50%); and 100% of those with moderate to severe symptoms had > 1 meeting with the EASE-phys team (goal 100%). There were statistically significant findings favoring EASE vs. UC for satisfaction with care at 8 and 12 weeks (Δ: -3.12 vs 7.39, p < 0.04; -6.1910 vs 0.0125 p < 0.03). There were trends favoring EASE vs. UC for traumatic stress symptoms, depressive symptoms, quality of life, attachment security, and number, severity, and distress related to physical symptoms at 4, 8, and 12 weeks. Conclusions: Although not powered for statistical significance, this randomized pilot trial of EASE for AL showed promising reductions in psychological and physical distress and supports the feasibility and need for a larger randomized controlled trial. Clinical trial information: NCT02353559.
Unsupervised hierarchical clustering of surface antigen expression to identify normal karyotype AML patients with distinct disease characteristics and poor outcome.
Authors: Jentzsch Madlen , Bill Marius , Schuhmann Luba , Grimm Juliane , Schulz Julia , Schubert Karoline , Knyrim Maria , Schmalbrock Laura , Beinicke Stefanie , Häntschel Janine , Pönisch Wolfram , Vucinic Vladan , Franke Georg-Nikolaus , Behre Gerhard , Niederwieser Dietger , Schwind Sebastian
Published: September 2018

7042

Background: Surface antigen expression evaluation is part of the standard work-up at acute myeloid leukemia (AML) diagnosis. The biological & prognostic implications of surface antigen expression patterns in normal karyotype (NK) AML patients (pts) remain unknown. Methods: The diagnostic antigen expression patterns of mononuclear cells in bone marrow (BM) of 111 NK-AML pts were assessed using a standard flow cytometric panel. At diagnosis common AML gene mutations (mut) & expression levels were analyzed. Pts received stem cell transplantation (SCT, 98% allogeneic, 2% autologous; median age 63 years [y, range 26-74y]) after induction therapy at our institution. Median follow up was 3.3y. With R’s gplot package unsupervised hierarchical clustering of surface antigens was performed & revealed 4 distinct clusters. Results: Pts in cluster 1 (n = 36) had higher expression of immature, in cluster 2 (n = 31) of thrombocytic/T-cell/erythroid, in cluster 3 (n = 24) of monocytic & in cluster 4 (n = 20) of myeloid surface antigens. All 4 clusters associated with distinct clinical & molecular features. At diagnosis, compared to all others, pts in cluster 1 had a higher CD34+/CD38- cell burden ( P< .001), higher blood blasts ( P< .03) & BM blasts ( P< .06) by trend. They had less NPM1 mut ( P< .001) & DNMT3A mut ( P= .02), were more likely to be EVI1 positive ( P= .03) & had higher EZH2 ( P= .02), RUNX1 ( P= .009), BAALC ( P< .001), ERG ( P= .02) & MN1 ( P< .001) expression. Compared to all others, pts in cluster 1 had a higher cumulative incidence of relapse (CIR, P= .002, at 1y 41% vs 15%) & shorter event-free survival (EFS, P= .02, at 1y 50% vs 69%). In multivariate analysis, cluster 1 pts had a significantly higher CIR (Hazard Ratio [HR] 5.4, P= .01) after adjustment for FLT3-ITD & shorter EFS (HR 2.1, P= .02) after adjustment for FLT3-ITD, age & disease status at SCT. Conclusions: Pts in cluster 1 had high expression of immature surface antigens (eg CD34, CD117, CD13), genes involved in stem cell renewal & worse outcome. Our data indicate a relationship between easily accessible surface antigen expression patterns at diagnosis, molecular disease features & aggressiveness of the NK-AML phenotype.
The effect of donor source on outcomes after second allogeneic hematopoietic cell transplantation for relapsed leukemia.
Authors: Huselton Eric , Slade Michael , Abboud Camille N. , Cashen Amanda F. , DiPersio John F. , Ghobadi Armin , Pusic Iskra , Romee Rizwan , Uy Geoffrey L. , Vij Ravi , Westervelt Peter , Schroeder Mark A.
Published: September 2018

7044

Background: There is no standard treatment for patients with leukemia who relapse after allogeneic stem cell transplant (HCT). A second HCT (HCT2) may be the only possibly curable option; however, this is performed in few patients. We hypothesized that patient and transplant characteristics, such as donor source will affect outcomes. Methods: We retrospectively evaluated adult patients who received a HCT2 for relapsed leukemia or MDS at a single institution between 2000-2016. 85 patients underwent a HCT2 with an unmanipulated graft from a matched related (MRD, n = 21), matched unrelated (MUD, n = 40), or haploidentical (haplo, n = 24) donor, preceded by either a reduced intensity (RIC) or myeloablative conditioning (MAC) regimen. Results: The median age at HCT2 was 50 yrs and the median time between transplants was 448 days. Patients had relapsed AML (n = 62), ALL (n = 12), and MDS (n = 10). The median length of follow up for survivors was 22.3 months (range 3.9-131) with 20 patients alive in June 2016. 65 patients died; 32 from relapse, 21 from infection, 7 from GvHD, and 5 from organ failure. 1-year OS from HCT2 was 38.6%. For patients with MRD, MUD, haplo donors, 1 year OS was 52.3%, 33.3%, and 34.6% (p = 0.72). 1-year DFS in the entire cohort, MRD, MUD, and haplo groups was 26.4%, 14.3%, 34.8%, and 25.3% (p = 0.45). 1-year TRM was 36.2% and not different across these groups (p = 0.80). Univariate analyses of OS, DFS, and TRM based on patient, disease, and transplant characteristics showed an association with RIC and worse OS and DFS (HR 2.0, 95% CI 1.2-3.3; and HR 1.9, 1.2-3.1). Having > 1 year between transplants was associated with lower TRM (HR 0.38, 0.19-0.77). Traditional risk factors like age, presence of active disease at HCT2, shorter time between transplants, and using the same donor from the first HCT were not otherwise significantly associated with OS, DFS, or TRM. Conclusions: Outcomes after HCT2 did not differ based on donor source. MAC is associated with better OS relative to RIC (1yr OS 51% vs 23%, p < 0.01), DFS (1yr DFS 37% vs 12%, p < 0.01), with similar TRM (1yr TRM 30% vs 47%, p = 0.12). Based on these data, serious consideration is necessary before using RIC regimens for HCT2 in patients with relapsed leukemia.
Impact of dose reductions on 5-year efficacy in newly diagnosed patients with chronic myeloid leukemia in chronic phase (CML-CP) from DASISION.
Authors: Cortes Jorge E. , Hochhaus Andreas , Kantarjian Hagop M. , Guilhot François , Kota Vamsi K. , Hughes Timothy P. , Shelat Suresh , Li Li , Jabbour Elias
Published: September 2018

7051

Background: Dasatinib (DAS) dose modifications generally mitigate adverse events (AEs) without affecting efficacy for responding patients (pts). A 2-year retrospective analysis of DASISION showed that rates of cytogenetic and molecular responses remained higher for pts given DAS vs imatinib (IM), even when daily doses were modified (Jabbour ASH 2011). Efficacy was not compromised due to dose reductions to manage DAS-related AEs. Here, we report results from a 5-year analysis evaluating the impact of dose reductions on efficacy in pts from DASISION. Methods: In DASISION (NCT00481247), pts with treatment-naïve CML-CP were randomized to receive either DAS (100 mg once/day; N = 259) or IM (400 mg once/day; N = 260). Up to 2 dose reductions were permitted for AEs (DAS: 80 mg, then 50 mg; IM: 300 mg, then 200 mg). Efficacy in all pts was evaluated retrospectively by 5 years. Results: Molecular response rates remained higher for DAS than IM, independent of dose reductions, and were comparable in pts with and without dose modifications in each arm (table). Overall, 95 (37%) DAS- and 44 (17%) IM-treated pts had dose reductions at any time due to AEs. Median average daily dose was 83 mg DAS and 328 mg IM for pts with reductions for any cause and 82 mg DAS for pts with reductions due to pleural effusion. The most common AEs resulting in dose reduction were hematological toxicity for IM (9%) and pleural effusion for DAS (12%). Conclusions: A 5-year retrospective analysis of DASISION showed molecular responses remained higher for DAS vs IM when daily doses were modified due to AEs. Dose reductions for any cause, including pleural effusion, did not affect efficacy (MMR rates were not reduced). In this analysis, for pts who experienced AEs, DAS dose reductions to 80 mg or 50 mg were safe and effective treatment options. Clinical trial information: NCT00481247. [Table: see text]
Hypomethylating agent (HMA) therapy use and survival in older patients with higher risk myelodysplastic syndromes (HR-MDS) in the United States (USA): A large population-based study.
Authors: Zeidan Amer M , Hu Xin , Long Jessica B. , Wang Rong , Huntington Scott F. , Podoltsev Nikolai Alexandrovich , Giri Smith , Stahl Maximilian , Gore Steven , Ma Xiaomei , Davidoff Amy J.
Published: September 2018

7057

Background: The HMA azacitidine improved overall survival (OS) compared to conventional care in patients with HR-MDS in the landmark randomized clinical trial AZA-001 by a median of 9.5 months compared to conventional care regimens. However recent registry data from USA (Zeidan et al, 2016) and Spain (Bernal et al, 2015) did not show substantial population-level gains in OS. We used HMA market entry in the US (2004-06) as a natural experiment to assess the effect of HMA on OS. Methods: We conducted a retrospective cohort study using Surveillance, Epidemiology, and End Results-Medicare data.Individuals were included if they were 66 years or older in age, had refractory anemia with excess blasts (RAEB, considered to have HR-MDS), and were diagnosed in 2001-11.We performed 2-stage residual inclusion instrumental variable (IV) analysis, using diagnosis year as the IV. Residuals from the first stage model were added to the second stage regression to control for effects of unobserved factors between HMA treatment and OS. We also adjusted for demographic characteristics, comorbidity, disability status and transfusion receipt. Results: Among 2,581 patients with RAEB, the median OS from diagnosis was 9 months, and 35.8% received HMAs. In the first stage model, diagnosis year was a strong predictor of HMA (2001-06 vs. 2011, Odds Ratio = 0.004-0.56, P-value < .01). In IV analysis, patients who received HMAs showed no gain in OS (Hazard Ratio (HR) = 0.93, 95% Confidence Interval (CI) = 0.76-1.14), while there was a strongly protective effect of unobservable characteristics on OS (HR = 0.58, 95% CI = 0.47-0.73). Conclusions: In our US population-based analysis,HMA use was not associated with survival prolongation in older adults with HR-MDS. It is unclear if this is related to suboptimal use of HMAs (alternate schedules, doses, number of cycles), use of decitabine (which did not show survival benefit in randomized studies), or the unselected nature (compared to strict eligibility in clinical trials) of patients receiving HMAs at the community level. Better understanding of these issues is vital for optimal HMA patient selection and administration.
Ruxolitinib (RUX) in combination with azacytidine (AZA) in patients (pts) with myelodysplastic/myeloproliferative neoplasms (MDS/MPNs).
Authors: Assi Rita , Cortes Jorge E. , Pemmaraju Naveen , Jabbour Elias , Bose Prithviraj , Kadia Tapan M. , Dinardo Courtney Denton , Zhou Lingsha , Pierce Sherry , Van Derbur Stephanie , Tuttle Carla , Borthakur Gautam , Estrov Zeev , Garcia-Manero Guillermo , Kantarjian Hagop M. , Verstovsek Srdan , Daver Naval Guastad
Published: September 2018

7064

Background: Clinical trials exclusively focusing on pts with MDS/MPNs are lacking. Combining RUX and AZA may target distinct manifestations of MDS/MPNs. Methods: Pts were treated with single-agent RUX 15 mg or 25 mg (based on platelets count) orally twice daily continuously in 28-day cycles for the first 3 cycles. AZA 25 mg/m2 (day 1-5) was added on each cycle starting cycle 4 and could be increased to 75 mg/m2 (maximum) or started earlier than cycle 4 and/or at higher dose in pts with proliferative features or high blasts. Results: 35 pts with med age 70 years (range, 43-79) were enrolled (MDS/MPN-U, n = 14; CMML, n = 17; atypical CM (aCML), n = 4), 28 (80%) were Int-2/High per MF DIPSS, 14 (41%) had splenomegaly > 5 cm, and 12 (34%) had EUMNET MF-2/MF-3 fibrosis. Common mutations on a 28-gene sequencing panel included JAK2 (29%), RAS (27%), ASXL1 (21%), TET2 (18%), and DNMT3A (12%). All 35 pts were evaluable for response per MDS/MPN IWG criteria and 17 (49%) responded. 6/17 (35%) IWG responses occurred after the addition of AZA (med time after AZA = 1.8 months). JAK2 mutated pts had a trend to higher responses vs those with non-mutated pts (8/10 vs 9/25, P = 0.19). Ten pts had > 5% pretreatment BM blasts and 7 achieved a reduction in blasts to < 5% (70%). A > 50% reduction in palpable spleen length reduction at 24 weeks was seen in 9/12 (75%) pts. New grade 3/4 anemia and thrombocytopenia occurred in 18 pts (51%) and 19 (54%) pts but were manageable with dose modifications. Only one pt discontinued therapy due to cytopenias. At a med follow-up of 17.4 mo (range, 1.2-36.8+), 14 (40%) pts died: pneumonia (n = 4), sepsis (n = 4), progression to AML (n = 4), and cardiac arrest (n = 1). The med survival for all pts was 16.6 mo (1.0 - 36.8). Compared to CMML and aCML, MDS/MPN-U pts had significantly better med survival (26.4+ vs 15.0+ vs 1.5+ mo, respectively; p = 0.01). Conclusions: The combination of RUX and AZA showed an IWG-response rate of 49% in pts with MDS/MPNs, and was well-tolerated. The benefit appears more profound in pts with MDS/MPN-U. This study is ongoing. (ClinicalTrials.gov Identifier: NCT01787487).
Results of a phase II multicenter study of obinutuzumab plus bendamustine in pts with previously untreated chronic lymphocytic leukemia (CLL).
Authors: Sharman Jeff Porter , Yimer Habte Aragaw , Boxer Michael , DiBella Nicholas , Babu Sunil , Li Jia , Mun Yong Jun , Skettino Sandra L. , Danilov Alexey Valeryevich
Published: September 2018

7523

Background: Bendamustine (B) + rituximab (R; BR) is a commonly used 1L treatment for CLL. The CLL10 study reported an ORR of 96% and CR of 31% with BR. Obinutuzumab (GA101; G) is a glycoengineered, type II anti-CD20 monoclonal antibody. A randomized Phase III trial in 1L CLL pts showed that G significantly improved PFS and CR rate compared with R, when used in combination with chlorambucil (Goede 2014). B + G (BG) was evaluated in a subgroup of CLL pts in the GREEN study (Stilgenbauer 2015). We present results of a Phase II study (NCT02320487) evaluating the efficacy and safety of BG as 1L treatment for CLL pts. Methods: 102 pts with previously untreated CLL received BG, consisting of 6 cycles of G (cycle [C] 1: 100mg day (D) 1, 900mg D2, 1000mg D8 and D15; C2–6: 1000mg D1) and B (90mg/m2: C1, D2 and D3; C2–6, D1 and D2). Each cycle was 28 days. Primary endpoint was CR assessed using iwCLL criteria. Secondary endpoints included ORR, PFS, OS, and MRD. Median follow-up at the time of analysis was 11.0 months. Results: Median pt age was 61 yrs (range 35–90); 68.6% were male; 44.1% had Rai stage 3–4. For evaluated pts, IgVH status was 32.9% mutated and 67.1% unmutated. The incidences of trisomy 12, normal cytogenetics, and deletions of 13q, 11q, and 17p were 23.4%, 37.5%, 17.2%, 15.6%, and 6.3%, respectively. Investigator-assessed CR rate was 49.0% (95% CI 39.0–59.1) and ORR was 89.2% (95% CI 81.5–94.5) after 6 cycles. MRD negativity (MRD-) in blood, as measured by 4-color flow cytometry, was achieved in 42.7% of pts at the end of induction response assessment and in 75.5% of pts at any time following treatment. MRD- in bone marrow (BM) was 60.8% in pts with BM samples. The most common AEs (all grades [Gr]) were infusion reactions (72.5%), nausea (52.0%), pyrexia (36.3%), neutropenia (34.3%), fatigue (34.3%), constipation (26.5%), and rash (26.5%). The most common Gr 3–4 AE was neutropenia (26.5%). Incidence of Gr 3–4 infections was 11.8%. Incidence of TLS was 4.9% (all Gr 3). Three pts died; none were deemed related to study treatment or CLL by investigators. Conclusions: BG is an effective regimen for 1L treatment of CLL pts, inducing a high CR rate after 6 cycles of therapy. No unexpected safety signals were observed. Clinical trial information: NCT02320487.
Single institution experience of allogeneic stem cell transplantation for Hodgkin lymphoma.
Authors: Pineda-Roman Mauricio , Afshar Solmaz F. , Galitzeck Zachary , Steinberg Amir
Published: September 2018

7529

Background: Hodgkin lymphoma (HL) is curable in the majority of cases without stem cell transplantation (SCT). However, patients(pts) who relapse after chemotherapy require autologousSCT, and about half of those pts relapse. For over 3 decades, allogeneic SCT has been implemented in more refractory HL pts. We present the long term follow up of a group of pts from a our institution who underwent alloSCT for HL. Methods: 21 pts with HL transplanted from 2008 to 2015 and disease characteristics (HL type, status at SCT, chemosensitivity), treatment( graft source, donor type, auto and allo SCTdates, GVHD prophylaxis ) and outcomes (maximum grade of acute and chronic GVHD, survival (OS) and causes of death) were analyzed. Results: 13 males and 8 females received an alloSCT from 2008 to 2015, 11 pts had Nodular sclerosis HL, 6 NOS, 2 mixed cellularity, 1 lymphocyte predominant and 1 lymphocyte depleted. Performance status was 60 to 100, median of 90. 16 grafts were unrelated and 5 HLA identical. 18 pts received PBSC, 2 bone marrow and one double cord transplant. Most pts, 19, had a prior autoSCT, one had 2 prior autoSCT and for one , the allo was the first SCT. One patient was transplanted in unconfirmed first CR, 2 in confirmed CR, 4 in PR without prior CR, 3 in 1strelapse, 5 in 2nd relapse, 5 in 3rd relapse, and one in primary induction failure. All patients had a reduce intensity conditioning: 14 Flu/Mel, 4 Flu/Mel ATG, and one each Flu/TBI/ATG, Flu/TBI, Flu/Cy. Acute GVHD happened in 11 pts: max grade I in 1 , II in 7, III in 1 and IV in 2. 6 pts had extensive chronic GVHD. 12 pts (57.1%) have died (survival range 0.65-43.45 months, mean 13.1, median 6.12). Causes of death were primary disease in 4, infection in 3 pts, GVHD and infection in 2, ARDS, organ failure, pulmonary toxicity in 1 each. 9 pts (42.8%) are alive (survival range 1.63-8.44 years, mean 4.97, median 4.47) Conclusions: AlloSCT for pts with relapsed HL is a feasible treatment modality that can lead to long term OS in a significant proportion of pts. Our data is comparable with other published studies for HL alloSCT. The utility of alloSCT should not be dismissed even in the age of Brentuximab and checkpoint inhibitors.
Double-blind, randomized phase 3 study to compare efficacy and safety of the biosimilar CT-P10 to rituximab combined with CVP therapy in patients with previously untreated advanced-stage follicular lymphoma.
Authors: Kim Won Seog , Jurczak Wojciech , Sancho Juan-Manuel , Javrid Edvard , Kim Jin Seok , Hernandez Rivas Jose Angel , Prokharau Aliaksandr , Vasilica Mariana , Nagarkar Rajnish , Osmanov Dzhelil , Buske Christian , Kwak Larry , Ogura Michinori , Lee Sang Joon , Lee Sung Young , Bae Yunju , Coiffier Bertrand
Published: September 2018

7532

Background: CT-P10 is a biosimilar candidate to the innovator rituximab (RTX). In patients with rheumatoid arthritis, CT-P10 has demonstrated equivalence in pharmacokinetics (PK) and efficacy (Yoo, ACR 2016). This study aimed to demonstrate non-inferiority of efficacy and PK equivalence between CT-P10 and RTX in patients with newly diagnosed advanced follicular lymphoma (AFL) (NCT02162771). PK equivalence was confirmed (Coiffier, ASH 2016). Methods: A total of 140 patients were randomized in a 1:1 ratio to receive CT-P10 or RTX (375 mg/m2 i.v) plus CVP (cyclophosphamide, vincristine, and prednisone) every 3 weeks over 8 cycles. Overall response rate (ORR) according to the 1999 IWG criteria over 24 weeks was assessed by the independent review committee. Results: Noninferiority of CT-P10 to RTX was shown for the primary efficacy endpoint of ORR. The ORR difference was 4.3% (Table) and the lower bound of the 95% confidence interval was -4.25%. B-cell depleted after the 1st infusion and remained as depleted over 8 cycles in both groups. Overall safety profile of CT-P10 was consistent with that of RTX and the proportion of patients with positive anti-drug antibody was similar in both groups (4.3% and 2.9%) for 24 weeks. Neither progressive multifocal leukoencephalopathy nor Hepatitis B virus reactivation was reported in each group. Conclusions: This study demonstrates noninferiority of efficacy of CT-P10 to RTX combined with CVP in previously untreated AFL. CT-P10 was well-tolerated and the safety profile including immunogenicity of CT-P10 was comparable to that of RTX over 8 cycles of induction period. Clinical trial information: NCT02162771. [Table: see text]
Copanlisib in patients with relapsed or refractory follicular lymphoma.
Authors: Dreyling Martin H. , Santoro Armando , Leppa Sirpa , Demeter Judit , Follows George , Lenz Georg , Kim Won Seog , Mollica Luigina , Nagler Arnon , Diong Colin Phipps , Provencio Mariano , Stevens Don A. , Trevarthen David , Magagnoli Massimo , Cupit Lisa , Yin Shuxin , Hiemeyer Florian , Garcia-Vargas Jose E. , Childs Barrett H. , Zinzani Pier Luigi
Published: September 2018

7535

Background: Follicular lymphoma (FL) is the most common indolent non-Hodgkin lymphoma (iNHL) subtype, yet treatment options in the relapsed/refractory (r/r) setting are limited. Copanlisib is a pan-Class I phosphatidylinositol 3-kinase (PI3K) inhibitor with predominant PI3K-α and PI3K-δ activity. We report results from the FL subset of a large phase II study (n=141) in iNHL patients (pts) (NCT01660451, part B). Methods: A total of 104 pts with indolent FL (grade 1-3a) relapsed/refractory to ≥2 prior lines of treatment were treated with copanlisib (60 mg IV infusion) administered on days 1, 8 and 15 of a 28-day cycle. The primary endpoint was objective tumor response rate (ORR) per independent radiologic review (Cheson et al., JCO 20:579, 2007). Results: Of the 104 pts treated, 62% were refractory; median prior lines 3 (range 2-8), median time from progression 8 wks (range 1-73 wks). 52% were male, 83% white, median age 62 yrs, and 62% ECOG 0. At the time of primary analysis the ORR was 58.7%, comprising 15 pts (14.4%) with complete response (CR) and 46 (44.2%) with partial response. Stable disease was observed in 35 (33.7%) pts and progression of disease as best response in 2 pts. The median duration of response was 370 days (range 0-687), with 43 responders censored at data cut-off. Median duration of treatment was 22 wks (range 1-105); 33 (32%) pts remained on treatment. For all pts, the most common treatment-emergent AEs occurring in >25% of pts included (all grade/grade 3+): diarrhea (34%/5%), reduced neutrophil count (30%/24%), fatigue (30%/2%), and fever (25%/4%). Hyperglycemia (50%/41%) and hypertension (30%/24%) were transient. The incidence of pneumonitis (8%/1.4%), hepatic enzymopathy (AST 28%/1.4%; ALT 23%/1.4%), opportunistic infection (1.4%) and colitis (0.7%) were low. Six deaths were observed, 3 of which were attributed to copanlisib: one lung infection, one respiratory failure, and one thromboembolic event. Conclusions: Copanlisib was highly active as a single agent in heavily pretreated r/r FL pts and resulted in durable responses in the majority of pts. Toxicities were manageable, with a low incidence of severe AEs associated with other PI3K inhibitors, especially hepatic enzymopathy, opportunistic infections, and colitis. Clinical trial information: NCT01660451.
Intratumoral G100 to induce systemic immune responses and abscopal tumor regression in patients with follicular lymphoma.
Authors: Flowers Christopher , Isufi Iris , Herrera Alex Francisco , Okada Craig , Cull Elizabeth H. , Kis Bela , Chaves Jorge , Bartlett Nancy L. , Bryan Locke Johnson , Houot Roch , Ai Weiyun Z. , Chau Ian , Linton Kim , Briones Javier , de la Cruz Merino Luis , Panizo Carlos , Von Keudell Gottfried Raffael , Lu Hailing , Hsu Frank J. , Halwani Ahmad Sami
Published: September 2018

7537

Background: Follicular lymphoma (FL) is an incurable malignancy with patients (pts) ultimately relapsing following standard therapies. Active immunotherapy has the potential to induce life-long host anti-tumor immunity and disease control. G100 consists of glucopyranosyl lipid-A (GLA), a TLR-4 agonist in a specific formulation. Preclinically, G100 activates dendritic cells, T cells and NK cells, and triggers systemic anti-tumor immunity. In Merkel Cell carcinoma pts, G100 administered intratumorally (IT) induced tumor inflammation and responses including a CR after G100 alone. This is the first study of G100 IT in pts with NHL. Methods: Previously treated or naïve pts with FL with an injectable tumor site and distal sites of disease were eligible. In Part 1, G100 cohorts of 5 or 10µg were enrolled in a 3+3 design, followed by a large tumor ( > 4cm) cohort at 20µg. Pts received 6-9 doses of G100 IT ~qwk after radiation (RT, 2 Gy x2 doses) to the lesion. A 2nd course of G100 could be given without RT to an additional site. Results: As of 31Dec16, all 9 pts in Part 1 dose escalation (3 pts each at 5, 10, or 20 µg/dose) were evaluable for safety and efficacy. An additional 13 pts at 10µg/dose were included in the safety analysis only. No G100-related DLTs or SAEs were observed at any dose level. Of 22 safety pts, all G100 related AEs were grade 1/2 and none occurred in > 2 pts. Tumor biopsies following G100 demonstrated diffuse infiltration of CD8+ T cells in 5/5 pts and T cell repertoire analyses indicated an increased frequency of clonal tumor infiltrating lymphocytes (TILs). Best responses include: 4 PRs (45%), 3 SDs (33%) and 2 pending (22%). Of the 4 PR pts, tumor regression ranged 58-89% including up to 56% shrinkage of abscopal (distal) sites. Conclusions: G100 IT was safe, well-tolerated, induced CD8+ T cell infiltration and expansion of TIL clones. G100/RT treated and abscopal lesion regressions were observed signifying the induction or boosting of systemic anti-tumor immunity. The induction of immune responses, favorable safety profile and clinical activity indicate that G100 IT is an active agent that warrants further investigation. Part 2 enrollment continues with randomization to G100/RT ± pembrolizumab. Clinical trial information: NCT02501473.
Central line-associated complications during treatment with DA-R-EPOCH therapy for NHL.
Authors: David Rachel Julie , Baran Andrea , Kelly Jennifer , Reagan Patrick Michael , Casulo Carla , Barr Paul M. , Friedberg Jonathan W.
Published: September 2018

7543

Background: Certain non-Hodgkin lymphomas (NHL) such as primary mediastinal B-cell, Burkitt’s, and high-grade B-cell lymphoma with MYC and BCL2 rearrangements are often treated with infusional dose-adjusted rituximab, etoposide, prednisone, vincristine, cyclophosphamide and doxorubicin (DA-R-EPOCH), which requires a central line. We have observed meaningful line-associated complications (LAC) in patients (pts) treated with DA-R-EPOCH. With the ongoing use of this regimen, we sought to identify the rates and correlates of LAC in this population. Methods: We retrospectively identified all pts treated with DA-R-EPOCH at the Wilmot Cancer Institute between 3/2011 and 10/2015. Our primary endpoint was the rate of LAC, including venous thromboembolism (VTE), extravasation, and line-associated infection (LAI) diagnosed during DA-R-EPOCH therapy. Our secondary endpoint was the rate of VTE during therapy. Rates and 95% confidence intervals (95% CI) were calculated for all endpoints. Univariate logistic regression was used to calculate odds ratios to evaluate potential predictors. Results: 43 pts received DA-R-EPOCH during the study period. 70% of pts were male; median age was 52 years. 17 pts (39.5%, 95% CI 0.25 - 0.56) experienced at least 1 LAC: 15 pts (35%, 95% CI 0.21 - 0.51) had VTE; 3 pts had LAI; and 2 pts experienced extravasations. Grade 3 toxicity was seen in 41% (7/17): 4 pts with VTE, and 3 pts with LAI. Both extravasation events were grade 2, and both occurred with mediports. In univariate analysis, BMI ≥ 35 kg/m² and receiving therapy via peripherally inserted central catheter (PICC) line were significantly associated with an increased risk of VTE (p=0.04 and p=0.02, respectively). Conclusions: 40% of pts receiving DA-R-EPOCH therapy for treatment of NHL developed LAC, almost half of whom experienced grade 3 toxicities. Clinicians need to balance these risks when selecting therapy, particularly with the lack of randomized data to support the DA-R-EPOCH approach in many circumstances. Given observed extravasations, we avoid mediports in favor of PICC lines, however this approach carries a significant risk of VTE. Future studies are needed to evaluate the role of prophylactic anticoagulation in this population.