AOP Orphan Pharmaceuticals AG Research Articles

Essential Thrombocythemia Versus Pre-Fibrotic/Early Primary Myelofibrosis: Discrimination By Laboratory and Clinical Data

In clinical practice there is an active interest to evaluate whether laboratory or clinical parameters would help to distinguish WHO-defined essential thrombocythemia (ET) and pre-fibrotic / early primary myelofibrosis (pre-PMF) in patients presenting with thrombocytosis given the very different outcome and treatment options.A first step in this direction was initiated by Carobbio et al. (Am J Hematol.2012;87:203-204), who used hemoglobin (Hb) level, white blood cell (WBC) count and serum lactate dehydrogenase (LDH) level in a dichotomized fashion, resulting in a step-by-step algorithm (the so-called Bergamo algorithm).The aim of the present study was to extend and improve this algorithm. In addition to the laboratory parameters, leftshift in the peripheral blood cell count (presence of single erythroblasts or myelocytes, metamyelocytes, promyelocytes or myeloblasts) and splenomegaly were also tested as presumptive parameters. The second, more important approach was to look not necessarily at each parameter in a stepwise order, but to develop a logistic regression model.Only patients diagnosed with ET or pre-PMF according to the 2008 WHO diagnostic criteria with a complete dataset (age at diagnosis, complete blood counts, left-shift, LDH-levels and presence of splenomegaly), consistent diagnosis between bone marrow (BM) morphology and clinical findings, platelet count greater than 450 x 109/L and no evidence for masked/early stages of polycythemia vera were eligible for this study. These criteria were met by 359 patients who were included in the study.Results from the first application of the Bergamo algorithm on our cohort are given in Table 1. The expanded algorithm, which includes leftshift and splenomegaly increased sensitivity with regard to pre-PMF and the number of undetermined cases could be reduced to 93 (Table 1).In an alternative approach, a logistic regression model was used, which weights the information contained in the laboratory parameters and in the dichotomous variable splenomegaly in an optimal, data-driven way and exploits the full information of the continuous laboratory parameters, instead of dichotomizing them. Leftshift was removed from the final model due to obvious negligibility for the sake of model parsimony.While step-by-step procedures deliver a prediction in the form of a patient's direct classification into either ET or pre-PMF (or undetermined), a logistic regression model transforms each set of a patient's characteristics into a predicted probability for pre-PMF. The final model's calibration plot shows a good agreement between observed and shrunk predicted pre-PMF probabilities; accordingly, the Hosmer-Lemeshow test shows a non-significant test result (p=0.255).The predicted shrunk pre-PMF probability can be used as a prediction score ranging from 0 (ET) to 1 (pre-PMF). It is calculated using the following formula:Score = 1 / [1+exp(-21.01-0.249*Hb+0.613*log2(WBC) + 2.63*log2(LDH) +1.04*Splenomegaly)]Here, log2 denotes the binary logarithm (1 is inserted for presence of splenomegaly, zero otherwise). To transform this score into a dichotomous classification rule (ET vs. pre-PMF) a cutoff equal to 0.438 is proposed which leads to approximately equal sensitivity and specificity in our data.Utilizing only dichotomized laboratory parameters we could reproduce the results of the Bergamo algorithm yielding a sensitivity and specificity of about 50% among our study cohort. Expanding these parameters by leftshift and splenomegaly, we achieved an increase of these values and provide predictions also for previously undetermined cases. Finally, we demonstrated that a risk score formula based on statistical modeling is able to exploit the information contained in the same predictor variables in a much more efficient way (Table 1). Although, according to the WHO criteria, BM biopsy examination persists as an integral part of the final diagnosis, laboratory parameters may provide clinicians with additional information to suspect pre-PMF in a patient with a presumptive clinical diagnosis of ET. However, in this context it should be underscored that our formula and the proposed cutoff for the resulting score need to be externally validated in other large cohorts of patients presenting with thrombocythemic myeloproliferative neoplasms, and most important, in prospective clinical trials. [Display omitted] DisclosuresKrauth:Celgene: Honoraria; Novartis: Honoraria; Takeda: Honoraria; Amgen: Honoraria; BMS: Honoraria; Janssen Cilag: Honoraria; AOP Orphan Pharmaceuticals AG: Honoraria. Gisslinger:AOP Orphan Pharmaceuticals AG: Consultancy, Honoraria; Novartis: Consultancy, Honoraria; PharmaEssentia: Consultancy, Honoraria; Janssen Cilag: Honoraria; Shire: Honoraria; Takeda: Honoraria.

Longitudinal Evaluation of Renal Function in Multiple Myeloma

Background: Renal impairment (RI) is frequent in patients with Multiple Myeloma (MM), yet no substantial data exist on the long-term course of renal function throughout the disease. Further, it remains unknown whether factors determinable at diagnosis might predict the course of renal function in MM.Methods: Estimated glomerular filtration rate (eGFR) values (n=22,457) were used to create renal function trajectories in 243 newly diagnosed MM patients throughout a 5-year observation period. For each 90-day interval, the eGFR mean was calculated as the area under the eGRF curve. Baseline epidemiological and laboratory factors were used for stratified analysis.Results: The cohort exhibited a mean eGFR of 61.9±24.5 ml/min/1.73m2 at diagnosis; 40.2% had an eGFR below 60 ml/min/1.73m2. An initial overall increase of 2.81±8.97 ml/min/1.73m2 within the first 90-day period was observed (Figure 1). Thereafter, a steady overall eGFR decline (mean change -0.19±6.57 ml/min/1.73m2 per period) was observed, resulting in a net mean decrease of 3.58 ml/min/1.73m2 after 5 years. Patients with an eGFR below 45 ml/min/1.73m2 at diagnosis tended to improve most throughout the observation period (+15.15 ml/min/1.73m2; Figure 2). While a lower eGFR at diagnosis was associated with higher age and lower hemoglobin, these factors as well as the percentage of bone marrow plasma cell infiltration and total serum protein were not predictive of renal function. This also applied for the specific sub-type of paraprotein.Conclusions: Renal impairment is extraordinarily frequent in MM patients both at diagnosis and throughout the disease course. In the presented cohort, kidney function followed a non-linear course; after an initial amelioration in most patients, a continuous decline of eGFR was observed. Established surrogate parameters for negative outcome did not serve as predictive markers for the course of renal function in this cohort.However, patients with the lowest initial eGFR and highest MM disease burden exhibited a strong potential for renal improvement. [Display omitted] DisclosuresGisslinger:AOP Orphan Pharmaceuticals AG: Consultancy, Honoraria; Takeda: Honoraria; Novartis: Consultancy, Honoraria; PharmaEssentia: Consultancy, Honoraria; Shire: Honoraria; Janssen Cilag: Honoraria. Krauth:Janssen Cilag: Honoraria; Novartis: Honoraria; Celgene: Honoraria; BMS: Honoraria; Takeda: Honoraria; Amgen: Honoraria; AOP Orphan Pharmaceuticals AG: Honoraria.

Multiple Myeloma and Renal Impairment: Analysis of Induction Therapy Strategies and Outcome after Autologous Stem Cell Transplantation

Introduction: Multiple Myeloma (MM) is frequently accompanied by renal impairment (RI) at diagnosis. As MM-specific therapeutic strategies have evolved drastically within the past decades, we aimed at delivering a re-evaluation of applied treatments and outcomes according to renal function at diagnosis.Methods: In this multicenter, retrospective cohort analysis, we analyzed 366 patients who were diagnosed with MM between 1997-2016 and subsequently underwent autologous stem cell transplantation (ASCT). RI at diagnosis was defined as an estimated glomerular filtration rate (eGFR) <60 ml/min/1.73m2. We carried out statistical analysis of patient groups stratified by renal function with regard to induction therapy defined as conventional chemotherapy (CT) versus immuno-chemotherapy (ICT) including either a proteasome inhibitor and/or an immunomodulator. Further, overall and progression-free survival (OS, PFS) were analyzed in the defined subgroups.Results: Of 366 patients, 287 received ICT versus 79 who had CT alone. The choice of the applied treatment strategy was highly dependent on diagnosis date, as all patients diagnosed before the year 2000 received chemotherapy alone, while all but 4 patients diagnosed after 2006 received ICT. Patients with renal impairment were just as likely to receive ICT as those without (75.9 vs. 79.5%, p=0.259). On OS analysis in the patient groups A) normal renal function/ICT (n=202), B) normal renal function/CT (n=52), C) impaired renal function/ICT (n=85), D) impaired renal function/CT (n=27), a longer survival was observed in groups A and B; however without statistical significance (p=0.080; Figure 1). On analysis of PFS, no differences were observed (p=0.784; Figure 2).Conclusions: Impaired renal function confers only a slight and statistically insignificant OS disadvantage in newly diagnosed MM patients receiving ASCT. On analysis of treatment strategy, however, it is evident that ICT attains better OS outcomes compared to CT alone. Therefore, while renal impairment remains common in patients with MM, an interdisciplinary mode of action between hemato/oncologists and nephrologists concerning the optimal induction therapy prior to ASCT is of pivotal clinical importance. The application of an adequate immuno-chemotherapy should conquer the fear of the negative impact of renal failure on outcome in patients with MM. [Display omitted] DisclosuresGisslinger:Janssen Cilag: Honoraria; Shire: Honoraria; PharmaEssentia: Consultancy, Honoraria; Novartis: Consultancy, Honoraria; AOP Orphan Pharmaceuticals AG: Consultancy, Honoraria; Takeda: Honoraria. Krauth:Takeda: Honoraria; Janssen Cilag: Honoraria; Novartis: Honoraria; Amgen: Honoraria; AOP Orphan Pharmaceuticals AG: Honoraria; Celgene: Honoraria; BMS: Honoraria.

JAK2-Inhibitor Therapy Associated Lymphomas in Myelofibrosis: Distinct Clinico-Pathological Features Recapitulated in a Mouse Model

Background: Single cases of aggressive B-cell non-Hodgkin lymphomas upon treatment with the Janus kinase 1/2 (JAK1/2) inhibitor ruxolitinib in patients with myeloproliferative disorders (MPD) have been reported (Pardanani, Mayo Clin.Proc. 2011 ; Bhatt VR et al. J Natl Compr Canc Netw . 2015;13(3):281-28; Palmason et al. BMC Hematology 2015). However, incidence and pathogenesis remain enigmatic.Methods: We investigated 626 patients with myeloproliferative neoplasms diagnosed at the Medical University of Vienna between 1997 and 2016. Of these, 69 patients with primary or secondary myelofibrosis were treated with JAK2 -inhibitors since 2009. Data on secondary malignancies were retrieved from our MPN database. Detailed clinical, pathologic and genetic data were obtained in patients developing lymphoma. These observations were recapitulated in a Stat1 knock-out mouse model (Stat1-/- mice).Results: B-cell lymphomas developed in 4 out of 69 patients (5.8%) upon ruxolitinib treatment compared to only 2 of 557 (0.36%) in the control group (16-fold increased risk, p=0.0017). The median time to lymphoma diagnosis was 25 months after ruxolitinib initiation (Table 1). Two lymphoma patients had been pre-treated with alkylating agents before ruxolitinib, one with hydroxyurea, the JAK -inhibitor fedratinib and ruxolitinib, and one received ruxolitinib only. All lymphomas were of aggressive CD19+ B-cell type (3 DLBCL, 1 HG BCL NOS) and showed distinct features with extranodal involvement and/or bone marrow infiltration (3/4), IPI of 2 or greater, and high MYC, and TP53 expression. Genetic analysis revealed abnormalities in MYC, BCL2, BCL6 or TP53 genes (Table 1). Targeted sequencing in 2 patients showed inactivating mutations in the B2M, CDKN2A, or TP53 genes. No JAK2 -mutation was found in the lymphomas. Three of four patients responded to anti-lymphoma therapy, but 3 patients eventually died from lymphoma or sAML. Of note, the clinical, and pathogenetic features closely resembled those of the published cases and 2 cases seen at a different institution (Paris, Hospital Saint-Louis).Mice deficient for the JAK kinase target STAT1 mirrored the course of the human disease: 16 of 24 Stat1-/- mice developed myeloid hyperplasia with splenomegaly and a massive expansion of myeloid blasts in bone marrow and peripheral blood. Lowering the load of myeloid blasts by ATRA or ruxolitinib led to B-cell proliferation. Transplantation of bone marrow from diseased Stat1-/- mice resulted in aggressive B-cell lymphomas displaying strikingly similar features to the human lymphomas with upregulation of c-Myc and Bcl-2 and downregulation of B2m (ß2-microglobulin) and Cdkn2a . STAT3 and STAT5 were not activated in these B-cell lymphomas indicating that the JAK/STAT pathway is dispensable for B cell transformation. B cells from diseased Stat1-/- mice gave rise to stable growth-factor independent cell lines, underlining their high grade of transformation.Conclusion. Inhibition of the JAK/STAT1 pathway in myeloproliferative diseases appears to provoke the development of a distinct type of aggressive B-cell lymphoma. In myelofibrosis treated with a JAK2 inhibitor 5 to 6% of patients are affected. Further investigations to identify potential risk factors are ongoing. [Display omitted] DisclosuresSperr:Celgene: Consultancy, Honoraria; Amgen: Consultancy, Honoraria, Research Funding; Phadia: Research Funding; Meda: Research Funding; Teva: Honoraria; Novartis: Other: Register. Staber:Janssen: Honoraria, Membership on an entity's Board of Directors or advisory committees; Gilad: Honoraria, Membership on an entity's Board of Directors or advisory committees; Morphosys: Membership on an entity's Board of Directors or advisory committees; Abbie: Honoraria, Membership on an entity's Board of Directors or advisory committees; Takeda: Honoraria; MSD: Honoraria; Amgen: Honoraria; Roche: Honoraria, Membership on an entity's Board of Directors or advisory committees. Valent:Blueprint: Research Funding; Novartis: Honoraria, Research Funding; Celgene: Honoraria, Research Funding; Incyte: Honoraria; BMS: Honoraria; Ariad: Honoraria, Research Funding; Pfizer: Honoraria; Teva: Honoraria; Deciphera: Honoraria, Research Funding. Hoermann:Gilead: Honoraria, Research Funding; Ariad: Honoraria; Amgen: Honoraria; Novartis: Honoraria. Kiladjian:Novartis: Membership on an entity's Board of Directors or advisory committees, Research Funding; AOP Orphan: Membership on an entity's Board of Directors or advisory committees, Research Funding; Celgene: Membership on an entity's Board of Directors or advisory committees. Krauth:Novartis: Honoraria; Celgene: Honoraria; AOP Orphan Pharmaceuticals AG: Honoraria; BMS: Honoraria; Takeda: Honoraria; Janssen Cilag: Honoraria; Amgen: Honoraria. Jaeger:Janssen: Consultancy, Honoraria, Membership on an entity's Board of Directors or advisory committees, Other: Travel, Accommodations, Expenses; Roche: Consultancy, Honoraria, Membership on an entity's Board of Directors or advisory committees, Other: Travel, Accommodations, Expenses; Novartis Pharmaceuticals Corporation: Honoraria, Membership on an entity's Board of Directors or advisory committees, Research Funding; Celgene: Honoraria, Membership on an entity's Board of Directors or advisory committees. Gisslinger:PharmaEssentia: Consultancy, Honoraria; AOP Orphan Pharmaceuticals AG: Consultancy, Honoraria; Novartis: Consultancy, Honoraria; Shire: Honoraria; Janssen Cilag: Honoraria; Takeda: Honoraria.

Ropeginterferon Alfa-2b Induces High Rates of Clinical, Hematological and Molecular Responses in Polycythemia Vera: Two-Year Results from the First Prospective Randomized Controlled Trial

Background: Interferon-alpha (IFNa) based therapies have been successfully used in myeloproliferative neoplasms (MPN) for over thirty years. Ropeginterferon alfa-2b (Ropeg) is a novel mono-pegylated IFNa, which is administered once every 2 weeks, or monthly during long-term maintenance. Ropeg is developed in polycythemia vera (PV), and 12-month data from the randomized controlled phase III PROUD-PV study comparing Ropeg with hydroxyurea (HU) have been presented. Here we report 2 years treatment data obtained from the follow-up phase III CONTI-PV study.Study design: 254 PV patients (WHO2008 criteria, naïve to cytoreduction or HU pretreated but not resistant) had been randomized to receive Ropeg or HU in the PROUD-PV study. After 12 months of treatment patients were rolled over to the CONTI-PV study: 95 of 106 (89.6%) patients completing the 12-month Ropeg arm, and 76 of 111 (68.5%) patients completing the 12-month HU arm continued in the second year. The latter cohort was also allowed to switch from the HU regimen to best available therapy (BAT) at the investigators discretion; a cross-over between groups was not allowed. Efficacy assessment consisted of complete hematological response (CHR) rate according to ELN criteria, and the CHR rate plus symptom improvement (PV-related symptoms and signs including clinically significant splenomegaly). Secondary endpoints included the effect of treatment on mutant JAK2 allele burden assessed as rate of molecular response (modified ELN criteria) as surrogate for disease modification.Results: 88 (Ropeg) and 73 (HU/BAT) patients completed the 24-month efficacy analysis time point, the mean treatment duration for safety analysis was 2.7 years (both after initial randomization in the PROUD study). Median drug doses in the second year remained at the same level as during the first year: 450 µg Ropeg every 2 weeks and 1000 mg HU per day. In the HU/BAT arm over 98% of patients remained treated with HU, a switch to other BAT was rare. Discontinuation rates during the second year were comparable with 8.4% in the Ropeg and 6.6% in the HU/BAT arm, respectively.At 24 months, treatment with Ropeg achieved a high CHR rate of 70.5%. This was significantly better than a CHR of 49.3% with HU/BAT, (p=0.0101, full-analysis-set). Importantly, in contrast to HU/BAT, response rates increased steadily in the Ropeg-treated group throughout the two-year treatment period. The composite endpoint CHR plus symptom improvement also favored Ropeg with 49.5% vs. 36.6% for HU/BAT (p=0.1183) at 24 months. The advantage of Ropeg was most pronounced in the effect on mutant JAK2 allele burden: at 24 months 69.6% of patients in the Ropeg arm but only 28.6% in the HU/BAT arm had achieved partial molecular response (p=0.0046).Regarding safety, a comparable number of patients (70.1% for Ropeg, 77.2% for HU) experienced treatment-related adverse events. Anemia, thrombocytopenia and leukopenia occurred more frequently with HU, whereas GGT increase was observed only with Ropeg in some patients. Events of special interest for the class of IFNa (in particular thyroid disorders and depression) were below 5% in the Ropeg arm. Disease- or treatment-related secondary malignancies occurred only in the HU cohort, including 2 cases of acute leukemia, 1 melanoma and 2 basaliomas, whereas in the Ropeg cohort 3 malignancies (glioblastoma, seminoma, adrenal neoplasm) - most likely unrelated to IFNa treatment - were reported.Conclusions: These data confirm a) the high and durable hematologic response and symptom improvement achieved with Ropeg, b) the excellent safety and tolerability profile of Ropeg, and c) the disease modification capability of Ropeg suggested by its ability to significantly reduce the mutant JAK2 allelic burden. Ropeginterferon alfa-2b will provide a valuable and safe new long-term treatment option for PV patients. DisclosuresGisslinger:AOP Orphan Pharmaceuticals AG: Consultancy, Honoraria; Novartis: Consultancy, Honoraria; PharmaEssentia: Consultancy, Honoraria; Shire: Honoraria; Takeda: Honoraria; Janssen Cilag: Honoraria. Georgiev:Alnylam: Consultancy. Mayer:Novartis: Research Funding; Eisai: Research Funding. Hasselbalch:Novartis: Membership on an entity's Board of Directors or advisory committees, Research Funding; AOR Orphan: Membership on an entity's Board of Directors or advisory committees. Kiladjian:AOP Orphan: Membership on an entity's Board of Directors or advisory committees, Research Funding; Celgene: Membership on an entity's Board of Directors or advisory committees; Novartis: Membership on an entity's Board of Directors or advisory committees, Research Funding.

Long-Term Use of Ropeginterferon Alpha-2b in Polycythemia Vera: 5-Year Results from a Randomized Controlled Study and Its Extension

Long-Term Use of Ropeginterferon Alpha-2b in Polycythemia Vera: 5-Year Results from a Randomized Controlled Study and Its Extension

Overexpression of PD-L1 Correlates with JAK2-V617F Mutational Burden and Is Associated with Chromosome 9p Uniparental Disomy in MPN

Myeloproliferative neoplasms (MPN) are characterized by clonal hematopoiesis, hyperproliferation of myeloid cells, hyperinflammation and immune deregulation. The three classical BCR-ABL1-negative MPN are essential thrombocythemia (ET), polycythemia vera (PV) and primary myelofibrosis (PMF). The disease is driven by JAK2, CALR or MPL somatic mutations in most patients. Drug resistance is a major problem in MPN. Recent data suggest that MPN cells display certain immune checkpoint molecules that may contribute to resistance, including PD-L1. Antibodies targeting the PD1/PD-L1 axis are highly promising anti-cancer drugs. Their potential use in MPN is being explored but it is unclear which MPN subtypes are most suitable for testing in clinical trials. The aim of our project was to assess PD-L1 expression in disease-initiating neoplastic stem cells (SC) and differentiated cells of MPN patients and to develop therapeutic approaches capable of blocking PD-L1 expression in MPN SC. In a first step, PD-L1 expression was assessed by RNA-sequencing of granulocytes of 106 MPN patients and 15 healthy donors (HD). The cohort included 56 PMF, 33 ET and 17 PV patients. For 102 patients data from Human Genome-wide Affymetrix 6.0 SNP arrays were available. We observed a ~5-fold higher expression of PD-L1 mRNA in patients with PV compared to other MPN (P&amp;lt;.01) or HD (P&amp;lt;.01). JAK2-V617F positive ET patients had higher expression of PD-L1 compared to CALR-mutated ET (p&amp;lt;.005) and the same was observed in PMF (p&amp;lt;.01). Other mutations (TET2, DNMT3A) detected by NGS did not affect PD-L1 expression. Since PD-L1 and JAK2 are located on chromosome 9p24, we looked into our previously published dataset of 400 MPN patients analyzed by SNP arrays and found that in all 195 patients with 9p uniparental disomy (UPD) the aberrations covered both genes. As PD-L1 is more centromeric it could represent the second target of 9pUPD which can precede the acquisition of JAK2-V617F in MPN. Granulocytes in JAK2-V617F positive patients with 9pUPD expressed significantly higher levels of PD-L1 compared to patients without 9pUPD (P&amp;lt;.0001; Figure 1A). Moreover, the JAK2-V617F mutational burden significantly correlated with PD-L1 expression (R=.52, P&amp;lt;.0001; Figure 1B). This correlation was lost when cases with 9pUPD were excluded from the analysis (R=.03, P=.9), indicating that the UPD is relevant for PD-L1 upregulation. To investigate PD-L1 surface expression on MPN SC we analyzed CD34+CD45dimCD38- cells isolated from fresh bone marrow (BM) samples of another 51 MPN patients and 7 HD by flow cytometry (FC). MPN patients showed a significantly higher surface expression of PD-L1 on CD34+CD45dimCD38- cells compared to HD (p&amp;lt;.001; Figure 1C). PD-L1 levels on the SC surface were elevated in both JAK2- and CALR-mutated MPN patients compared to HD (p&amp;lt;.001 and P&amp;lt;.005, respectively). PD-L2 was neither expressed in MPN granulocytes nor on MPN SC. CD4+ and CD8+ T-cells from BM samples of 17 MPN patients expressed the PD-L1 receptor PD-1 as assessed by FC. We cultured ex vivo primary MPN cells from 7 JAK2-V617F positive patients and showed that PD-L1 expression on MPN SC spontaneously decreases in culture, that interferon-gamma (IFN-γ) can promote expression of PD-L1 on these cells, and that ruxolitinib and the BRD4-degrader dBET6 block IFN-γ-induced PD-L1 expression in CD34+CD45dimCD38- MPN SC (P&amp;lt;.05). Together, we show that PD-L1 is overexpressed on the surface of disease-initiating MPN SC, that PD-L1 mRNA is overexpressed in granulocytes of MPN patients and that PD-L1 overexpression in granulocytes correlates with the JAK2-V617F mutational burden. In patients with JAK2-V617F positive MPN, 9pUPD leads to further PD-L1 upregulation either through increasing the mutant JAK2 gene dosage, loss of wt-JAK2,or amplification of PD-L1 allele with higher expression. Our data suggest the possibility that 9pUPD and the subsequent elevation of PD-L1 expression may provide an immune escape mechanism and may contribute to positive selection of JAK2-V617F homozygous SC. Ruxolitinib and dBET6 downregulate PD-L1 expression on MPN SC suggesting a role for the JAK2 and BRD4-MYC pathway. As recent studies revealed an immunogenic potential of JAK2 and CALR mutants, overcoming the disease-mediated immune escape may be of particular importance. Further preclinical and clinical studies are now required to examine the value of PD1/PD-L1 inhibitors in patients with MPN. Disclosures Gisslinger: Celgene: Honoraria; MyeloPro Diagnostics and Research: Honoraria; AOP Orphan Pharmaceuticals AG: Honoraria, Research Funding; Novartis: Honoraria, Research Funding; PharmaEssentia: Honoraria; Janssen-Cilag: Honoraria; Roche: Honoraria. Kralovics:AOP Orphan Pharmaceuticals AG: Honoraria; PharmaEssentia: Honoraria; Qiagen: Honoraria; Novartis: Honoraria; MyeloPro Diagnostics and Research: Current equity holder in private company. Valent:Allcyte GmbH: Research Funding; Pfizer: Honoraria; Cellgene: Honoraria, Research Funding.

The Final Analysis of Expand: A Phase 1b, Open-Label, Dose-Finding Study of Ruxolitinib (RUX) in Patients (pts) with Myelofibrosis (MF) and Low Platelet (PLT) Count (50 × 109/L to < 100 × 109/L) at Baseline

The Final Analysis of Expand: A Phase 1b, Open-Label, Dose-Finding Study of Ruxolitinib (RUX) in Patients (pts) with Myelofibrosis (MF) and Low Platelet (PLT) Count (50 × 109/L to < 100 × 109/L) at Baseline

An International Multicentric Observational Study on the Use of Ruxolitinib in Patients with Polycythemia Vera Resistant or Intolerant to Hydroxyurea: Results from Interim Analysis

Introduction Polycythemia vera (PV) is a myeloproliferative neoplasm characterized by the increased red cell mass and high thrombotic risk. The main objective of therapy is to maintain the hematocrit &amp;lt;45% with hydroxyurea (HU) being the most common drug employed in first line. Patients developing resistance/intolerance to HU are at higher risk of thrombosis due to inadequate hematocrit control. Methods This ongoing phase 4 observational study recruited 352 patients with PV resistant and/or intolerant to HU treated with ruxolitinib (RUX), with a follow-up of 24 months after treatment initiation. In the present interim analysis, 150 patients with PV receiving RUX treatment for 52 weeks were evaluated for efficacy and safety parameters. Inclusion criteria were adult patients aged ≥18 years diagnosed with PV resistant/intolerant to HU (as per European LeukemiaNet [ELN] criteria) treated with RUX according to the approved local label. RUX treatment could be initiated up to 6 months before inclusion. The informed consent was obtained from all patients. The myeloproliferative neoplasm symptom assessment form total symptom score (MPN-SAF TSS) and the pruritus symptom impact scale (PSIS) were employed for symptom evaluation. Results Of the 150 patients included, 67.3% were aged &amp;gt;60 years and 51% were males; 61% were resistant to HU and 65% were intolerant to HU. The median duration of PV was 67 months prior to the study entry. The medical history of patients included thromboembolic events (TEs) in 29.3%, infections in 18.6%, secondary neoplasms in 12.6%, and bleeding in 5.3% of patients. At baseline, TEs were present in 17.3% of patients, infections in 10.6%, secondary neoplasms in 6%, and bleeding in 2% of patients. Hematocrit was measured in 133 patients at baseline with inadequate hematocrit control being observed in 62 patients (47%): &amp;gt;45% to &amp;lt;48%, n=28; ≥48%, n=34. The proportion of patients dependent on 1 to 2 and ≥3 phlebotomies 1 year before the RUX treatment were 24% and 38%, respectively. Hematocrit levels dropped from week 8 to 12 to a sustained mean value of 40% during the observational period (Figure 1). The dependency of patients requiring 1 to 2 and ≥3 phlebotomies decreased from 24% and 38% at baseline to 10% and 4%, respectively after 1 year of RUX treatment (Figure 2). The mean MPN-SAF TSS declined rapidly from a score of 33 at baseline (n=20) to 19 (n=22) upon the treatment initiation and evolved to stabilize at week 16 (n=30) throughout the observation period (Figure 3). On mean PSIS, a rapid decline in severity of pruritus (past 7 days) from 5.20 at baseline (n=15) to 0.95 (n=20) after 4 weeks of treatment was observed. The effect of RUX treatment on patients with moderate and massive splenomegaly was observed as early as 4 weeks after the treatment initiation. The proportion of patients with moderate-to-massive splenomegaly was reduced from 34.4% at baseline to 11.9% at week 52, while the proportion with no splenomegaly increased from 45.9% to 66.7% (Figure 4). Patients received a mean daily dose of 21.1 mg RUX. The majority of patients (89%) did not have dosing interruptions, and 11% had only 1 dosing interruption. The dose increases were more prominent than the decreases (53% vs 37%, respectively), and the majority had only 1 dosing increase or decrease. Adverse events (AEs) reported during the study included infections in 43.3%, TEs in 10%, secondary neoplasms in 6%, and bleeding in 10% of patients. Grade 3 to 4 AEs reported during the study included infections in 4.6%, TEs in 2%, secondary neoplasms in 1.3%, and bleeding in 0.6% of patients. Conclusion In this phase 4 observational study, RUX treatment achieved hematocrit control in a majority of patients with PV who were resistant/intolerant to HU and was associated with a low rate of grade 3 to 4 TEs. Additional benefits included symptom improvement and reduction in splenomegaly. The safety, particularly regarding infections and secondary neoplasms, will be further explored during the final analysis of the study. Disclosures Gisslinger: AOP Orphan Pharmaceuticals AG: Honoraria, Research Funding; Novartis: Honoraria, Research Funding; PharmaEssentia: Honoraria; MyeloPro Diagnostics and Research: Honoraria; Janssen-Cilag: Honoraria; Roche: Honoraria; Celgene: Honoraria. Devos:Novartis: Consultancy, Membership on an entity's Board of Directors or advisory committees. Lippert:Novartis: Other: Personal fee, Research Funding. De Stefano:Novartis: Other: Personal fee, Research Funding; Amgen: Other: Personal fee; Bayer: Other: Non-financial support; Celgene: Other: Non-financial support, personal fee; Janssen Cilag: Other: Non-financial support. Dahm:Novartis: Other: Reimbursement of study costs and personal fee; Pfizer: Other: Personal fee, Research Funding; Bristol-Mayer Squibb: Other: Personal fee; Bayer: Other: Personal fee; MSD: Other: Personal fee. Zuurman:Novartis Pharma A.G.: Current Employment. Zaiac:Novartis: Current Employment, Current equity holder in private company. Houtsma:Novartis: Current Employment. Iqbal:Novartis: Current Employment. Di Matteo:Novartis: Current Employment.

Ropeginterferon alfa-2b versus standard therapy for polycythaemia vera (PROUD-PV and CONTINUATION-PV): a randomised, non-inferiority, phase 3 trial and its extension study

The PROUD-PV and CONTINUATION-PV trials aimed to compare the novel monopegylated interferon ropeginterferon alfa-2b with hydroxyurea, the standard therapy for patients with polycythaemia vera, over 3 years of treatment. PROUD-PV and its extension study, CONTINUATION-PV, were phase 3, randomised, controlled, open-label, trials done in 48 clinics in Europe. Patients were eligible if 18 years or older with early stage polycythaemia vera (no history of cytoreductive treatment or less than 3 years of previous hydroxyurea treatment) diagnosed by WHO's 2008 criteria. Patients were randomly assigned 1:1 to ropeginterferon alfa-2b (subcutaneously every 2 weeks, starting at 100 μg) or hydroxyurea (orally starting at 500 mg/day). After 1 year, patients could opt to enter the extension part of the trial, CONTINUATION-PV. The primary endpoint in PROUD-PV was non-inferiority of ropeginterferon alfa-2b versus hydroxyurea regarding complete haematological response with normal spleen size (longitudinal diameter of ≤12 cm for women and ≤13 cm for men) at 12 months; in CONTINUATION-PV, the coprimary endpoints were complete haematological response with normalisation of spleen size and with improved disease burden (ie, splenomegaly, microvascular disturbances, pruritus, and headache). We present the final results of PROUD-PV and an interim analysis at 36 months of the CONTINUATION-PV study (per statistical analysis plan). Analyses for safety and efficacy were per-protocol. The trials were registered on EudraCT, 2012-005259-18 (PROUD-PV) and 2014-001357-17 (CONTINUATION-PV, which is ongoing). Patients were recruited from Sept 17, 2013 to March 13, 2015 with 306 enrolled. 257 patients were randomly assigned, 127 were treated in each group (three patients withdrew consent in the hydroxyurea group), and 171 rolled over to the CONTINUATION-PV trial. Median follow-up was 182·1 weeks (IQR 166·3-201·7) in the ropeginterferon alfa-2b and 164·5 weeks (144·4-169·3) in the standard therapy group. In PROUD-PV, 26 (21%) of 122 patients in the ropeginterferon alfa-2b group and 34 (28%) of 123 patients in the standard therapy group met the composite primary endpoint of complete haematological response with normal spleen size. In CONTINUATION-PV, complete haematological response with improved disease burden was met in 50 (53%) of 95 patients in the ropeginterferon alfa-2b group versus 28 (38%) of 74 patients in the hydroxyurea group, p=0·044 at 36 months. Complete haematological response without the spleen criterion in the ropeginterferon alfa-2b group versus standard therapy group were: 53 (43%) of 123 patients versus 57 (46%) of 125 patients, p=0·63 at 12 months (PROUD-PV), and 67 (71%) of 95 patients versus 38 (51%) of 74 patients, p=0·012 at 36 months (CONTINUATION-PV). The most frequently reported grade 3 and grade 4 treatment-related adverse events were increased γ-glutamyltransferase (seven [6%] of 127 patients) and increased alanine aminotransferase (four [3%] of 127 patients) in the ropeginterferon alfa-2b group, and leucopenia (six [5%] of 127 patients) and thrombocytopenia (five [4%] of 127 patients) in the standard therapy group. Treatment-related serious adverse events occurred in three (2%) of 127 patients in the ropeginterferon alfa-2b group and five (4%) of 127 patients in the hydroxyurea group. One treatment-related death was reported in the standard therapy group (acute leukaemia). In patients with early polycythaemia vera, who predominantly presented without splenomegaly, ropeginterferon alfa-2b was effective in inducing haematological responses; non-inferiority to hydroxyurea regarding haematological response and normal spleen size was not shown at 12 months. However, response to ropeginterferon alfa-2b continued to increase over time with improved responses compared with hydroxyurea at 36 months. Considering the high and durable haematological and molecular responses and its good tolerability, ropeginterferon alfa-2b offers a valuable and safe long-term treatment option with features distinct from hydroxyurea. AOP Orphan Pharmaceuticals AG.

Neurological Outcome and Quality of Life Three Months after COVID-19: A Prospective Observational Cohort Study

BACKGROUND: Increasing evidence suggests the involvement of the central and peripheral nervous system in patients with coronavirus disease 2019 (COVID-19). Little is known about neurological outcomes and quality of life (QoL) after recovery from acute infection.METHODS: In this prospective, multicentre, observational cohort study we systematically evaluated neurological signs and diseases by detailed neurological examination and a predefined test battery assessing smelling disorders (16-item Sniffin-Sticks-test), cognitive deficits (Montreal Cognitive Assessment), QoL (36-item Short Form), and mental health (Hospital Anxiety and Depression Scale, Post-traumatic Stress Disorder Checklist-5) three months after disease onset.FINDINGS: Of 135 COVID-19 patients included, 31 (23%) required ICU-care (severe), 72 (53%) were admitted to the regular ward (moderate), and 32 (24%) underwent outpatient-care (mild) during acute disease. At three-month follow-up, 20 patients (15%) presented with one or more neurological syndromes that were not evident before COVID-19. These included poly-neuro/myopathy (n=16, 12%), mild encephalopathy (n=2, 2%), parkinsonism (n=1, 1%), orthostatic hypotension (n=1, 1%), Guillain-Barré-Syndrome (n=1, 1%) and ischemic stroke (n=1, 1%). Self-reported hyposmia/anosmia was noted in 23/135 patients (17%), which was significantly lower compared to those documented during acute COVID-19 (44%; pINTERPRETATION: Despite recovery from acute infection, neurological symptoms were prevalent at three-months follow-up. Above all, smelling disorders were persistent in a large proportion of patients. Our results urge for further studies investigating the onset and evolution of neurological diseases following COVID-19 infection to develop strategies for secondary prevention.TRIAL REGISTRATION: ClinicalTrials.gov (NCT04416100)FUNDING: Not applicable.DECLARATION OF INTERESTS: KS reports grants from FWF Austrian Science Fund, grants from Michael J. Fox Foundation, grants from International Parkinson and Movement Disorder Society, personal fees from Teva, personal fees from UCB, personal fees from Lundbeck, personal fees from AOP Orphan Pharmaceuticals AG, personal fees from Abbvie, personal fees from Roche, personal fees from Grünenthal; all outside the submitted work. PM reports grants from TWF (Tyrolean Science Fund), grants from Medtronic, personal fees from Boston Scientific, all outside the submitted work. The other authors have nothing to disclose. All other authors declare no competing interests.ETHICS APPROVAL STATEMENT: The conduct of the study was approved by the local ethics committee (Medical University of Innsbruck, EK Nr: 1103/2020). Written informed consent was obtained from all patients according to local regulations.

Disrupted Relationship between Blood Glucose Levels and Dopamine D &lt;sub&gt;2/3&lt;/sub&gt; Receptor Availability in Patients with First-Episode Schizophrenia. A Case-Control PET-Imaging Study

Introduction: An elemental function of brain dopamine is to coordinate cognitive and motor resources for successful exploitation of environmental energy sources. Dopamine transmission, goal-directed behaviour, and glucose homeostasis are altered in schizophrenia patients prior to and after initiation of pharmacological treatment. Thus, we investigated the relationship between blood glucose levels and brain dopamine signalling in drug-naive patients with first-episode psychosis. Methods: We quantified blood glucose levels and binding of the D 3 preferring dopamine D 2/3 receptor agonist radioligand (+)-[11C]-PHNO in 15 medication-naive patients and 27 healthy volunteers employing positron emission tomography. Results: Whole-brain voxel-wise linear model analysis identified two clusters of significant interaction between blood glucose levels and diagnosis on (+)-[11C]-PHNO binding-potential values. One cluster was located in the ventral striatum and pallidum, the other one in the right ventral tegmental area. We observed positive correlations between blood glucose levels and binding-potential values in healthy volunteers but negative correlations in patients with first episode psychosis. Interpretation: Extracellular dopamine levels are a major determinant of (+)-[11C]-PHNO binding in the brain. In line with the concept that increased dopamine signalling occurs when goal-directed behaviour is needed for restoring energy supply, our data indicate that in healthy volunteers, extracellular dopamine levels are low, when blood glucose levels are high and vice-versa. This relationship is reversed in patients with first-episode psychosis, possibly reflecting a pathogenic alteration underlying two seemingly unrelated aspects of the illness: dysfunctional dopamine signalling and glucose homeostasis. Trial Registration: Clinical Trial Registry:EUDRACT 2010-019586-29 Funding: Vienna Science and Technology Fund; Austrian Science Fund; Medical Scientific Fund of the Mayor of the City of Vienna Declaration of Interests: Without relevance to this work, M. Willeit declares to having received speaker honoraria and consulting fees from Janssen-Cilag Pharma GmbH, Austria. Without relevance to this work, W. Wadsak declares to having received speaker honoraria from GE Healthcare, research grants from Ipsen Pharma, Eckert-Ziegler AG, Scintomics and ITG. WW is a part time eployee ofCBmed Ltd (Center for Biomarker Research in Medicine, Graz, Austria). and is a member of advisory boards of Amgen, Chieri and Sanofi-Aventis. M. Hacker received consulting fees and/or honoraria from Bayer Healthcare BMS, Eli Lilly, EZAG, GE Healthcare, Ipsen, ITM, Janssen, Roche, Siemens Healthineers. R. Lanzenberger received travel grants and/or conference speaker honoraria within the last three years from Bruker BioSpin MR, Heel, and support from Siemens Healthcare regarding clinical research using PET/MR. He is a shareholder of the start-up company BM Health GmbH since 2019. S. Kasper received grants/research support, consulting fees and/or honoraria within the last three years from Angelini, AOP Orphan Pharmaceuticals AG, Celegne GmbH, Eli Lilly, Janssen-Cilag Pharma GmbH,KRKA-Pharma, Lundbeck A/S, Mundipharma, Neuraxpharm, Pfizer, Sanofi,Schwabe, Servier, Shire, Sumitomo Dainippon Pharma Co. Ltd. and Takeda. U. Sauerzopf, A. Weidenauer, I. Dajic, M. Bauer, L. Bartova, B. Meyer, L. Nics, C. Philippe, S. Pfaff, V. Pichler, M. Mitterhauser, L. Pezawas and N. Praschak-Rieder have no conflict of interest to declare Ethics Approval Statement: This study was approved by the Ethics-Committee of the Medical University of Vienna and Austrian federal regulatory authorities. All subjects signed an informed consent form.

Germline Genetic Factors Affecting Interferon Alpha Therapy in Polycythemia Vera

Introduction: Interferon alpha (IFNa) based therapies can induce sustained hematological and molecular responses (HR/MR) in Polycythemia Vera (PV) and other Myeloproliferative Neoplasms (MPN), however, not all patients respond sufficiently. While previous studies suggest that disease driving somatic mutations and genomic aberrations do not predict response to IFNa, the role of common germline polymorphisms remains elusive. We addressed the effect of germline genetic factors on PV therapy with Ropeginterferon alfa-2b (Ropeg), a novel monopegylated IFNa. We performed genome-wide association studies (GWAS) as an unbiased approach, and additionally evaluated a previously reported influence of polymorphisms at the IFNL4 locus in a large PV patient cohort. Methods: Genomic DNA was isolated from whole blood of PV patients (n=115) on Ropeg therapy, who provided consent within the PROUD-PV (NCT01949805) and CONTI-PV (NCT02218047) study programs. Patients were genotyped for &gt;900k tagging single nucleotide polymorphisms (SNPs) across the genome on the Affymetrix SNP 6.0 array platform. Additional IFNL4 SNPs were typed using an amplicon-based next generation sequencing approach. Association analyses were performed using the PLINK toolset. JAK2-V617F mutant allele burden was quantified using a qPCR-based assay (ipsogen MutaQuant, Qiagen). MR was measured based on changes in mutant allele burden upon therapy as defined by the European LeukemiaNet (ELN) criteria. Results: To test for potential associations between germline genetic variation and response to IFNa therapy, we performed GWAS for MR data upon 12 months (M), 18M, 24M and 30M and 36M follow-up on Ropeg treatment. Genome-wide tagging SNPs were tested both for association in a case-control setup applying chi-square statistics as well as for quantitative trait association, using peripheral blood JAK2-V617F mutational burden changes from baseline as continuous variables. After Bonferroni correction for multiple testing, none of those analyses revealed a statistically significant association, suggesting the absence of strong germline predisposition factors for MR. Germline variation at the interferon-lambda (IFNL) locus was previously reported to strongly influence viral clearance during IFNa therapy of Hepatitis C (reviewed in Wack et al., Nat Immunol, 2015). While the same variants were recently reported to also affect HR during IFNa treatment in an MPN patient cohort (Lindgren et al., EJH, 2018), their potential impact on MR as surrogate marker for the size of the malignant MPN clone has not yet been evaluated. Upon testing for MR in our PV cohort, in a case-control setup we observed a statistically significant association only upon 36M follow-up (p=0.02; OR=2.51; 95%CI=[1.14-5.62]; Figure 1a). Notably, testing for change of JAK2-V617F mutational burden under Ropeg treatment as quantitative trait, we found the association to be present at formal statistical significance at all stages during follow-up (Figure 1a). For the Hepatitis C association, it is now widely acknowledged that a diplotype of two coding variants covers most of the causality, where rs368234815_TT disrupts the open reading frame (no IFNL4) while rs117648444_G results in the impaired IFNL4-S70 in contrast to the fully functional IFNL4-P70, the latter paradoxically impacting negatively on viral clearance (Terczynska-Dyla et al., Nat Commun, 2014). Similarly, in our PV cohort genotyping and phasing of this diplotype revealed a significant influence on MR in carriers of the fully functional IFNL4-P70 (p=0.01; Figure 1b; shown are patients at 36M follow-up (n=70)). Conclusions: The absence of a strong germline predisposition factor for Ropeg treatment response in our cohort implies that any PV patient may be eligible for Ropeg therapy independently of their genetic makeup. While the IFNL4 diplotype is of potential use for patient stratification, it remains to be investigated whether increase of treatment duration and/or dose adjustments can overcome the adverse effect of functional IFNL4 on Ropeg therapy. Longitudinal monitoring of JAK2-V617F mutational burden under Ropeg treatment in conjunction with determination of the IFNL4 germline genetic status may allow for optimizing patient management. Disclosures Krejcy: AOP Orphan Pharmaceuticals AG: Employment. Klade:AOP Orphan Pharmaceuticals AG: Employment. Zoerer:AOP Orphan Pharmaceuticals AG: Employment. Gisslinger:Janssen-Cilag: Honoraria; Roche Austria GmbH: Consultancy; Novartis Pharma GmbH: Consultancy, Honoraria, Research Funding; Myelopro GmbH: Consultancy; Celgene GmbH: Honoraria; Pharma Essentia: Other: Personal fees; AOP Orphan Pharmaceuticals: Consultancy, Honoraria, Research Funding. Kralovics:Novartis: Honoraria; AOP Orphan Pharmaceuticals AG: Honoraria, Other: Advisory board; Pharma Essentia: Honoraria; Qiagen: Honoraria; MyeloPro Diagnostics and Research: Equity Ownership.

Thromboembolic Risk Reduction and High Rate of Complete Molecular Response with Long-Term Use of Ropeginterferon Alpha-2b in Polycythemia Vera: Results from a Randomized Controlled Study

Introduction: The key treatment goals for polycythemia vera (PV) are to prevent thromboembolic events and minimize the risk of progression, ultimately modifying the natural history of the disease by selectively targeting the malignant clone. In the PROUD-PV/CONTINUATION-PV study, long-term treatment with ropeginterferon alpha-2b (BESREMi®; hereafter ropeg) was compared with standard cytoreductive therapy regarding thromboembolic and other adverse events as well as hematological and molecular parameters over a four-year period. Methods: Cytoreduction-naïve or HU-pre-treated patients aged ≥18 years diagnosed with PV according to WHO 2008 criteria were eligible. A total of 257 patients were randomly allocated to ropeg or hydroxyurea at individualized doses for 12 months in the initial study phase (PROUD-PV). In the ongoing extension phase (CONTINUATION-PV), patients in the hydroxyurea arm were permitted to switch to best available treatment. Efficacy assessments included a longitudinal analysis of complete hematological response (CHR) and complete molecular response (CMR; JAK2V617F was determined using real-time PCR [ipsogen® JAK2 MutaQuant® kit; QIAGEN GmbH]), defined by modified ELN criteria. Discontinued patients were considered non-responders. A data snapshot was performed once all patients reached 48 months of treatment; all available safety data were included. Results: Ninety-five patients in the ropeg arm and 76 in the control arm entered the extension phase. At the time of analysis 139 patients remained on study: 74/95 in the ropeg arm and 65/76 in the control arm. Almost all patients in the control arm (&amp;gt;97% at the last available assessment) continued on HU. The rate of patients in CHR was significantly higher in the ropeg arm than in the control arm in the 4th year (60.6% versus 43.4%; p=0.02), as seen after 2 and 3 years of treatment. In line with this effective control of hematologic parameters by ropeg, a very low rate of major thromboembolic adverse events was observed in the ropeg arm: 0.0%, 0.0% and 1.1% of patients in the 2nd, 3rd and 4th years, respectively. In the control arm, rates of major thromboembolic adverse events in the 2nd, 3rd and 4th year were 0.9%, 1.4% and 0.0%, respectively. The median JAK2V617F allele burden declined from 37.3% at baseline to 9.8% over 4 years in the ropeg arm, whereas in the control group, the median allele burden increased from 38.1% to 43.1% in the same period (p&amp;lt;0.0001). The rate of molecular response (partial or complete) at 48 months was significantly higher among ropeg-treated patients than in the control arm (67.0% versus 25.7%; RR: 2.5 [95% CI: 1.7 to 3.7; p&amp;lt;0.0001]). No patients achieved CMR in the control arm. In the ropeg arm, 13 patients had a JAK2V617F allele burden below the threshold of 1% at month 48, 11 of whom also had a CHR at this time point. An additional 34 patients in the ropeg arm achieved an allele burden &amp;lt;10% at 48 months, suggesting that further patients may reach the &amp;lt;1% threshold with ongoing treatment. In terms of safety, no new signals were detected in the 4th year. Rates of patients with treatment-related adverse events remained similar in the ropeg and control arms in the 4th year (ropeg: 28.7% of patients; control: 22.9%). Disease or treatment-related secondary malignancies reported in the entire study period comprised 2 cases of acute leukemia, 2 cases of basal cell carcinoma and 1 case of malignant melanoma, all in the control group; 1 case of disease-related transformation to myelofibrosis occurred in each treatment arm. Conclusions: Ropeg minimizes the occurrence of thromboembolic events in patients with PV over long-term treatment, without leukemogenic risk. In addition, we show for the first time in a randomized study that, in contrast to hydroxyurea, long-term ropeg treatment is capable of inducing deep molecular responses including CMR, which underscores its disease modifying potential. These results also suggest that selected patients could achieve operational cure (with both CHR and CMR) with ropeg, opening the way for treatment discontinuation. Disclosures Kiladjian: Novartis: Honoraria, Research Funding; AOP Orphan: Honoraria, Research Funding; Celgene: Consultancy. Klade:AOP Orphan Pharmaceuticals AG: Employment. Illés:Takeda, Seattle: Research Funding; Janssen, Celgene, Novartis, Takeda, Roche, Pfizer: Honoraria, Membership on an entity's Board of Directors or advisory committees. Mayer:AOP Orphan Pharmaceuticals AG: Research Funding. Krejcy:AOP Orphan Pharmaceuticals AG: Employment. Hasselbalch:Novartis: Research Funding; AOP Orphan Pharmaceuticals: Other: Data monitoring board. Kralovics:Pharma Essentia: Honoraria; MyeloPro Diagnostics and Research: Equity Ownership; AOP Orphan Pharmaceuticals AG: Honoraria, Other: Advisory board; Qiagen: Honoraria; Novartis: Honoraria. Gisslinger:Celgene GmbH: Honoraria; Pharma Essentia: Other: Personal fees; Roche Austria GmbH: Consultancy; Janssen-Cilag: Honoraria; Novartis Pharma GmbH: Consultancy, Honoraria, Research Funding; AOP Orphan Pharmaceuticals: Consultancy, Honoraria, Research Funding; Myelopro GmbH: Consultancy.

Comparison of Different Upfront Transplant Strategies in Multiple Myeloma - a Large Registry Study from Chronic Malignancies Working Party of EBMT

Comparison of Different Upfront Transplant Strategies in Multiple Myeloma - a Large Registry Study from Chronic Malignancies Working Party of EBMT

Trends in Autologous Transplantation for Myeloma in EBMT Centres between 1993 and 2017

Trends in Autologous Transplantation for Myeloma in EBMT Centres between 1993 and 2017

Multicolor Immunophenotyping of Candidate Leukemic Stem Cell Markers in CD34+CD38- Chronic Myeloid Leukemia Stem Cells

Introduction: Detection of leukemic stem cells (LSCs) may represent a new potential prognostic parameter in chronic myeloid leukemia (CML) and a tool for minimal residual disease monitoring in combination with standard qPCR method. To date CD26 is studied as a most specific marker for CML LSC detection. Several other candidate LSC markers have been reported, such as IL1-RAP, CD25 and CD93, however a side-by-side testing of their specificity is lacking. Recently, we have identified CD69 molecule to be overexpressed in CD34+CD38-CD26+ cells, which makes this antigen another candidate marker for LSC. Aim: To compare the surface expression of LSC markers CD69, CD26, CD25, CD56, IL1-RAP, CD56, CD93 in bulk CD34+CD38- population at diagnosis using a multicolor phenotypization assay Methods: In total, 44 patients were analyzed at diagnosis of chronic phase CML before administration of any treatment. Fresh (n=38) or cryopreserved (n=6) leukocytes obtained by erythrolysis were stained with CD45, CD34, CD38, CD25, CD26, CD56, CD69, CD93, IL1-RAP antibodies and 7-AAD for selection of live cells. Analysis was performed on FACSAria Fusion (BD Biosciences). Acquisition of live mononuclear cells ranged from 2×104 to 2.5×106. Results: Expression of candidate LSC markers CD26, CD25, CD56, IL1-RAP, CD56, CD93 was analyzed in BM of 35 patients who carried at least 30 CD34+CD38- cells. Median percentage of marker positive cells was 34% for IL1-RAP, 31% for CD25, 23% for CD26, 16% for CD56 and 2% for CD93, from the parent CD34+CD38- population. Next we analyzed the overlap and combination for the three best markers - IL1-RAP, CD25 and CD26. The 3-combination (defined as IL1-RAP or CD25 or CD26 expression) identified 40% of CD34+CD38- positive cells, which was more than any of the markers alone. Expression of the three markers showed good overlap and ruled out mutually exclusive expression of the markers. This was demonstrated by median difference of 0.4% of CD34+CD38- cells (range: 0-18%) and a correlation coefficient r2=0.9914, when comparing the 3-combination and the best performing marker in each patient. In contrast, in 12/35 (34%) of patients, one of the three markers failed to identify at least half of the cells positive for another marker. In 21/35 patients, we also analyzed the expression of CD69 in the CD34+CD38- compartment. The CD69 showed similar performance as the 3-combination of CD26, CD25, and IL1-RAP, 59% vs 54% positive cells, respectively. We observed excellent overlap between CD69 and 3-combination expression in individual patients with median difference of 0% of CD34+CD38- cells (range 0-15%) and correlation coefficient r2=0.9890. Furthermore, we compared marker positivity in BM vs PB in 19 paired samples. Both, sample types showed similar frequency of CD34+CD38- cells (5×10-3 in BM, and 2×10-3 for PB), but PB carried higher percentage of LSCs identified by the 3-combination - median 76 vs 52% cells. Conclusions: We show an overlap in surface expression of three previously reported CML LSC markers - IL1-RAP, CD25 and CD26. Nevertheless, a combination of these markers can detect more positive cells than any of the markers alone. Moreover, we demonstrate that CD69 identifies the same cells within the CD34+CD38- compartment as the combination of three above mentioned markers, which makes CD69 the best candidate for routine CML LSC quantification. Disclosures Mayer: AOP Orphan Pharmaceuticals AG: Research Funding.

Progression Free Survival (PFS), and Event Free Survival (EFS) from a Global Randomized Phase 3 Study of Guadecitabine (G) Vs Treatment Choice (TC) in 815 Patients with Treatment Naïve (TN) AML Unfit for Intensive Chemotherapy (IC): ASTRAL-1 Study

Progression Free Survival (PFS), and Event Free Survival (EFS) from a Global Randomized Phase 3 Study of Guadecitabine (G) Vs Treatment Choice (TC) in 815 Patients with Treatment Naïve (TN) AML Unfit for Intensive Chemotherapy (IC): ASTRAL-1 Study

Outcomes Following Second Allogenic Haematopoietic Cell Transplantation in Patients with Myelofibrosis: A Retrospective Study on Behalf of the Chronic Malignancies Working Party of EBMT

Outcomes Following Second Allogenic Haematopoietic Cell Transplantation in Patients with Myelofibrosis: A Retrospective Study on Behalf of the Chronic Malignancies Working Party of EBMT

Nilotinib Vs Nilotinib Plus Pegylated Interferon α (Peg-IFN) Induction and Nilotinib or Peg-IFN Maintenance Therapy for Newly Diagnosed BCR-ABL1 Positive Chronic Myeloid Leukemia Patients in Chronic Phase (TIGER Study): The Addition of Peg-IFN Is Associated with Higher Rates of Deep Molecular Response

Introduction: The TIGER (CML V)-study* (NCT01657604) is a multicenter, randomized phase III trial to evaluate efficacy and tolerability of nilotinib (NIL) 2*300mg/d monotherapy vs NIL 2*300mg/d + pegylated interferon α2b (Peg-IFN) 30-50μg/week as first line therapy for chronic myeloid leukemia (CML) patients (pts) in chronic phase and discontinuation of therapy after Peg-IFN maintenance (Figure). Methods: In August 2012, recruitment started with a pilot phase, aiming to validate the recommended dose of Peg-IFN. 25 pilot phase patients were treated with the combination of NIL 2*300 mg daily and Peg-IFN (30-50μg/week according to tolerability and commenced after ≥6 weeks NIL monotherapy). During the main phase of the study, 692 newly diagnosed pts were randomized between NIL 2*300 mg/d and NIL/Peg-IFN combination according to the outcome of the pilot phase. Results: Within 5 years, a total of 717 pts (429 male; median age 51 years, range 18-85; 12.9% EUTOS high risk) were recruited from 109 sites in Germany, Switzerland, and the Czech Republic. 702 pts with typical BCR-ABL1 transcripts (97.9%) were eligible for molecular follow-up assessments according to the international scale (IS). Fifteen pts (2.1%) expressed atypical BCR-ABL1 transcripts. 692 pts were randomized after EUTOS risk stratification to receive NIL monotherapy (n=353) or NIL/PEG-IFN combination therapy (n=339). Median observation time since recruitment was 41 months. Up to now, 477 pts concluded the induction phase by achieving a confirmed major molecular response, MMR (BCR-ABL1 transcript levels ≤0.1% IS, which qualified for entering the maintenance phase of the study using NIL or Peg-IFN monotherapy. During the maintenance phase, 199 pts achieved or sustained MR4 (BCR-ABL1 ≤0.01% IS) for at least one year and then discontinued all therapy. While the rate of MMR at 12 and 18 mo - the first primary endpoint of the study - was not different between the treatment arms, adding Peg-IFN to upfront NIL significantly improved rates of MR4 and MR4.5, BCR-ABL1 ≤0.0032% IS) (Table). In competing risk analysis, median time to MMR was 5.7 vs 5.4 mo, to MR4 20.9 vs 12.5 mo, and to MR4.5 33.8 vs 23.2 mo for NIL vs NIL/Peg-IFN, respectively. After NIL discontinuation, during Peg-IFN maintenance therapy, rate of molecular recurrence (BCR-ABL1 &amp;gt;1% IS) after 18 mo was 28%. From 199 pts who discontinued all therapy, 63 experienced a molecular relapse (BCR-ABL1 &amp;gt;0.1%). Relapse free survival by 18 mo after treatment discontinuation was 61% in the total cohort. By protocol, it is too early to assign relapse rates to the randomized treatment arm. Frequencies of adverse events after 24 mo of therapy were 90 and 92% (grade 1-5) and 36 and 42% (grade 3-5) for NIL vs NIL/Peg-IFN, respectively. Adverse events of special interest (all grades) were fatigue in 34.6 vs 40.4%, thrombocytopenia in 13.3 vs 18.9% and elevation of the alanin aminotransferase (ALAT) in 11.0 vs 18.9% of pts in the NIL vs NIL/Peg-IFN arms, respectively. Fifteen pts (2.1%) progressed to accelerated phase or blast crisis; 22 pts (3.1%) received an allogeneic stem cell transplantation, 10 of them after disease progression. In total, 22 pts (3.1%) died, 16 during the induction phase, 4 in the maintenance phase and 2 in treatment free remission. Four deaths were related to CML, 3 to vascular complications. Conclusions: This per protocol interim analysis demonstrates feasibility of the first-line treatment with NIL 2*300 mg/d combined with PEG-IFN 30-50 μg/week. Peg-IFN, when added upfront to NIL further increases the rates of MR4 and MR4.5, which may translate into higher rates oftreatment free remission. *The study is being conducted on behalf of the German CML Study Group, the Swiss Group for Clinical Cancer Research (SAKK) and the East German Study Group on Hematology and Oncology (OSHO). Disclosures Hochhaus: Pfizer: Research Funding; Novartis: Research Funding; BMS: Research Funding; Incyte: Research Funding; MSD: Research Funding. Burchert:Novartis: Research Funding. Saussele:Novartis: Honoraria, Research Funding; Incyte: Honoraria, Research Funding; BMS: Honoraria, Research Funding; Pfizer: Honoraria. Baerlocher:Novartis: Research Funding. Brümmendorf:Janssen: Consultancy; Ariad: Consultancy; University Hospital of the RWTH Aachen: Employment; Pfizer: Consultancy, Research Funding; Merck: Consultancy; Novartis: Consultancy, Research Funding. La Rosée:Novartis: Research Funding; Bristol-Myers-Squibb: Consultancy, Other: Travel support, Speakers Bureau. Heim:Novartis: Research Funding. Krause:Siemens: Research Funding; Takeda: Honoraria; MSD: Honoraria; Gilead: Other: travel; Celgene Corporation: Other: Travel. le Coutre:Bristol-Myers Squibb: Honoraria, Speakers Bureau; Incyte: Honoraria, Speakers Bureau; Novartis: Honoraria, Speakers Bureau; Pfizer: Honoraria, Speakers Bureau. Niederwieser:Daichii: Speakers Bureau; Cellectis: Consultancy. Lange:Novartis: Research Funding. Fabarius:Novartis: Research Funding. Hänel:Novartis: Honoraria; Amgen: Honoraria; Takeda: Other: advisory board; Celgene: Other: advisory board; Roche: Honoraria. Stegelmann:Novartis: Consultancy, Honoraria; Incyte: Consultancy, Honoraria. Mayer:AOP Orphan Pharmaceuticals AG: Research Funding. Hasford:Novartis: Research Funding. Hehlmann:Novartis: Research Funding. Ernst:Novartis: Research Funding. OffLabel Disclosure: Combination of Nilotinib and PEG-IFN alpha is being tested is off-label and being tested in the TIGER study.