Autologous Transplant For Myeloma Research Articles

The Impact of Lymphocyte Composition in the Stem Cell Harvest on Blood Lymphocytes 1-2 Weeks Post-Autologous Stem Cell Transplant for Newly Diagnosed Myeloma

Background It is known that cellular composition of the stem cell harvest in autologous stem cell transplantation for multiple myeloma is important for engraftment and blood reconstitution, with CD34 count commonly used as a marker for harvest adequacy; however, there is a relative lack of data on the importance of lymphocyte marker-expressing cells in the harvest and their implications for immune reconstitution and outcome. Here, we demonstrate that the amount and proportion of lymphocyte marker-expressing cells in the stem cell harvest directly correlate with the cellular composition of the peripheral blood 1-2 weeks post-transplant. Objective To investigate whether the immunological cellular composition of the stem cell harvest prior to autologous stem cell transplantation in multiple myeloma correlates with the cellular composition of peripheral blood 1-2 weeks post-transplant. Methods We analysed stem cell harvest (SCH) and post-autologous stem cell transplant (PASCT) cellular composition data for 185 patients from the Myeloma XI trial. Utilising flow cytometry, SCH data was obtained from a 0.5ml aliquot of the total harvest and PASCT data was obtained from a peripheral blood sample collected 1-2 weeks post-transplant. Spearman's rank tests were performed across a variety of cell markers to assess for correlations between the cell count per µl and for correlations between the cell percentage (defined as the proportion of total CD45+ cells in each sample that expressed the given combination of cell markers) between the SCH and PASCT samples. Analysed cell marker phenotypes included CD45+, total CD3+, CD3/4+, CD3/8+, CD19+, and CD16/56+. Results We demonstrated statistically significant correlations for multiple cell markers between the composition of the SCH and peripheral blood 1-2 weeks post-transplant. Regarding cell count per µl, significant correlations were found in CD45+ (r=0.2168; p=0.0030), CD3+ (r=0.2254, p=0.0020), CD3/4+ (r=0.2050, p=0.0051), CD3/8+ (r=0.2733, p=0.0002), CD19+ (r=0.2787, p=0.0001), and CD16/56+ (r=0.3085, p<0.0001). Regarding cell percentages, significant correlations were found in CD3+ (r=0.3013, p<0.0001), CD3/4+ (r=0.3551, p<0.0001), CD3/8+ (r=0.4640, p <0.0001), CD19+ (r=0.2080, p=0.0048), and CD16/56+ (r=0.3221, p<0.0001). Further data assessing for correlations between harvest composition and progression-free and overall survival is also being analysed. Conclusions These data demonstrate clear correlations between higher lymphocyte counts in the stem cell harvest and higher lymphocyte counts 1-2 weeks post-autologous stem cell transplantation. Additionally, correlations between cell percentages indicate that harvest composition is directly correlated to the cellular composition of the blood following transplant. The correlations were statistically significant for a variety of phenotypes, including T cells, B cells, and NK cells, and indicate that the total dosage of lymphocytes re-introduced during transplantation may have wide ramifications for immune reconstitution as early as 1-2 weeks post-transplant. Our findings demonstrate that cellular composition of the harvest is a potentially important consideration that could influence immune reconstitution following autologous transplantation for myeloma. This research suggests that the lymphocyte constitution of the stem cell harvest, currently an overlooked metric during harvest collection, is correlated with immune recovery and further investigations may reveal implications for transplant outcome.

Hematopoietic Stem Cell Transplantation in Bangladesh : Activity and Outcome Update

Background : Hematopoietic stem cell transplantation(HSCT) is a potentially life saving curative modality of treatment procedure for many hematological malignancies, bone marrow failure syndromes and thalassemia. Bangladesh started first bone marrow transplant program with autologous transplant for myeloma in 2014 with the international collaboration between Massachusetts general hospital ( MGH) and Dhaka Medical College Hospital (DMCH). Since then it is growing in both public and private sector hospitals. Method : This is a multicenter retrospective study describing the demographics, activities and outcome of HSCT in Bangladesh. HSCT related Data were collected from three eminent HSCT centres of Bangladesh ( DMCH, Evercare hospitals and Combined Military Hospital Dhaka) and were analyzed. Result : As of June 2022, total 163 HSCT have been done in Bangladesh in major three centres as DMCH(52), Evercare hospital (62)and CMH Dhaka(49). Mean age of all patients is 39.4 years( range 15-69 Y) and sex distribution is M:F 3:1. Total autologous transplants were 125(77%) for myeloma(52), Hodgkins lymphoma(27) ,non-Hodgkins lymphoma(39) and others(7). Total allogeneic transplants were 38(23%) for AML(23), ALL(6), other hematological malignancy(03), Severe aplastic anemia (04) and thalassemia (02). Donor type wise majority were from matched sibling transplant (30/78%) from mostly male donor. Eight (08) haplo transplant were also successfully done. Each center follows specific infection control protocols, conditioning chemo protocols and growth factor protocols for the best patient care. Conditioning chemo protocols that usually used are high dose melphalan for MM, BEAM( Carmustine, Etoposide, Ara-C and Melphalan) for lymphoma and Bu-Cy( Busulphan-Cyclophosphamide) based for acute leukemia. Some leukemia patients received total body irradiation( TBI), thiotepa and Fludarabine based conditioning chemotherapy. All centres use irradiated blood components as transfusion products to avoid transfusion associated GVHD. As all centre used almost similar conditioning for particular disease, mean engraftment time in all centres were almost similar. Average time for neutrophil and platelet engraftment was 10-12 and 12-16 days post transplant respectively. Major early complications following transplant were neutropenic fever (>80%) and bacteraemia (25-30%) commonly with coagulase negative Staphylococcus, Pseudomonas sp, E. Coli and Klebsiella sp. Severe sepsis, pneumonia, typhlitis, hemorrhagic cystitis and CMV reactivation were observed in few cases. Acute GVHD ( G I to GII) was observed in almost all allogeneic transplanted patients. Mucositis, vomiting and diarrhoea were mild to moderate in most patients. Almost all patients required at least 1-3 red cell and platelet transfusion during the time waiting for engraftment. Progression free survival for all patients was variable in different centres (62% to 83%) since 2014 . Relapse of primary disease is more observed in autologous than allogeneic. Transplant related mortality( TRM) was 2% for autologous transplants and 5% for allogeneic transplant. Three early deaths were due to sepsis with COVID-19 infection in autologous transplant in pandemic period. Overall cost of transplantation is much lower in Bangladesh than that of developed countries. Approximate cost of autologous stem cell transplant is about $7000 and that for allogeneic transplant is $12000 to $15,000. Conclusion : Considering total population and burden of hematological malignancy in Bangladesh, the number of transplant is very low and it needs to be grown more rapidly to provide maximum benefit to save the lives as HSCT offers a curative approach to many hematological malignancies. Financial constrain, lack of health insurance and shortage of trained human resource are the main challenges for doing transplant in Bangladesh. National transplant registry and national donor registry both are yet to be developed. Comparing the cost difference with developed countries the overall outcome of stem cell transplantation is not inferior in Bangladesh.

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

306 - Assessing the Severity and Impact of Oral Mucositis after Autologous Transplantation for Myeloma: A Prospective Pilot Study Comparing the Patient-Reported Quality of Life and Objective Evaluation by a Healthcare Professional

306 - Assessing the Severity and Impact of Oral Mucositis after Autologous Transplantation for Myeloma: A Prospective Pilot Study Comparing the Patient-Reported Quality of Life and Objective Evaluation by a Healthcare Professional

Supersaturated Calcium Phosphate Rinse in Prevention and Treatment of Mucositis in Patients Undergoing Hematopoietic Stem Cell Transplant.

Mucositis is a common morbidity in patients undergoing bone marrow transplant. Various agents have been used to prevent and treat it with variable success. Here, we assessed the efficacy of supersaturated calcium phosphate rinses in prevention and treatment of oral mucositis in patients undergoing hematopoietic stem cell transplant. In this retrospective study, we evaluated the records of 80 patients who underwent hematopoietic stem cell transplant and received supersaturated calcium phosphate rinses for preVention of mucositis from April 2012 to January 2016. The World Health Organization scale was used to grade mucositis. Various parameters assessed included grade of mucositis, duration of mucositis, peak mucositis day, duration of pain, peak pain day, duration of total parenteral nutrition, neutrophil engraftment (defined as absolute neutrophil count ≥ 500/μL), mean dose of fentanyl used, incidences of infections, and type of transplant. Supersaturated calcium phosphate rinses at 4 times/day were started for prevention of mucositis as soon as a patient was admitted. All patients also received betadine mouth gargles for oral hygiene. Our study group included 42 autologous and 38 allogeneic hematopoietic stem cell transplant patients. Grade 1, 2, 3, and 4 mucositis levels were seen in 1, 19, 26, and 31 patients. We found no differences between our study group and historical control regarding parameters studied. Grade of mucositis was statistically significant (P < .01) when autologous transplant for myeloma was compared with autologous transplant for other diagnoses. Supersaturated calcium phosphate rinses were ineffective in the management of mucositis associated with autologous and allogeneic bone marrow transplant.

A Retrospective Single Center Comparison of Cyclophosphamide Plus G-CSF Versus G-CSF Alone for Peripheral Blood Stem Cell (PBSC) Mobilisation Following First Line Therapy in Patients with Multiple Myeloma

▪IntroductionAutologous transplantation is considered standard therapy for young and fit myeloma patients after initial therapy. Cyclophosphamide+ G-CSF is considered standard therapy for collection even though there is evidence for minimal anti-myeloma effect of cyclophosphamide, some increased short term toxicity and potential concerns regarding long term toxicity. There have been a few retrospective comparisons and one randomized study comparing cyclophosphamide based and G-CSF alone based PBSC collection. To our best knowledge they have not reported any impact in progression free survival (PFS) or overall survival (OS). We have compared here our myeloma patient cohort to explore these important endpoints.Patients and methods89 patients (55 male and 34 female) who underwent first autologous transplant for myeloma between 2003 and 2010 were analysed in our study. Mobilization was with G-CSF alone in 45 patients (median age 58 yrs, range 38-70 yrs.) and cyclophosphamide and G-CSF in 44 (median age 58 yrs, range 41-74 yrs.). Cyclophosphamide was used at 3g/m2 and in both cases G-CSF used was lenogastrim at 10mcg/kg. There were 7 patients with ISS stage 3 in the G-CSF only group as compared to 10 in the Cyclophosphamide group. Prior chemotherapy was cyclophosphamide, thalidomide and dexamethasone in majority of cases (n=55) with no difference across both groups. Data regarding high risk genetics and pre-transplant response was unavailable. We collected data progression free survival, overall survival, harvest dose and engraftment kinetics. Data was analyzed using SPSS and log rank test.ResultsThe median dose of stem cells collected with G-CSF alone was 3.59×106 CD34 cells/kg (range 1.84-8.09) where as with cyclophosphamide and G-CSF it was 3.8×106 CD34 cells/kg (range 1.6-13). There was no difference in engraftment between the two groups with median neutrophil engraftment (Absolute neutrophil count>0.20×109/L) at day 14 and platelet engraftment (>50×109/L) at day 15 and 16 respectively. Progression free survival was significantly better in G-CSF alone cohort (46 months vs. 38 months, P=0.016) (fig. a) Overall survival was better in the GCSF only group as well (113 months vs. 75 months, P=0.029) (fig b). In the 17 high risk patients PFS was much better in the G-CSF group (60months vs. 22 months, P=0.02) (Fig c). There were 4 (9%) admissions in the cyclophosphamide group due to neutropenic sepsis as compared to none in the G-CSF group.DiscussionCyclophosphamide and G-CSF may be associated with slightly higher stem cell yields but this margin is becoming smaller and not significant in the era of liberal plerixafor usage. In addition some patients are hospitalized due to neutropenic sepsis with this regimen. Our data shows anti-myeloma effects of cyclophosphamide +G-CSF is not demonstrated. There are ongoing studies from the Finland group which show no difference in the number of CD34+ cells collected after initial therapy with lenalidomide. The only difference is the number of days required for apheresis. In addition to above our single center experience shows both PFS and OS benefit for G-CSF only PBSC mobilization. . This may partially be explained by the slight difference in ISS risk stages in our patients but on censoring for ISS stage 3 these results were more pronounced. This is the first time we have seen any report point out towards a PFS and OS difference between two widely used mobilization regimens. This needs testing in a large randomized multi-center study to see if there is a difference and if so is this due to a change in milieu of lymphocytes. We have previously reported that absolute lymphocyte count on day 15 post autograft was reflective of a higher lymphocyte count in the apheresis bag in case of G-CSF only mobilizations as compared to cyclophosphamide +G-CSF. The absolute lymphocyte count on day 30 was a predictor for better OS. [Display omitted] [Display omitted] [Display omitted] DisclosuresSutton:bayer: Honoraria. Paneesha:Janssen: Consultancy. Nikolousis:Alexion: Honoraria. Kishore:Jazz pharma: Honoraria; Celgene: Honoraria.

Immune Reconstitution and Quality of Life Analyses After Autologous Transplant for Multiple Myeloma

Abstract 4460 Introduction:Multiple myeloma patients after autologous hematopoietic stem cell transplant (HSCT) achieve a minimal residual disease state, providing an opportunity for immunomodulatory therapy – but the details of immune recovery after transplant are not clear. Early lymphocyte recovery is associated with improved overall survival (Porrata et al, 2003) which is thought to be related to NK cell recovery. Myeloma patients with long term disease control have recovered circulating B-cells, bone marrow dendritic cells and tissue macrophages similar to healthy adults, but have few circulating regulatory T-cells (Pessoa et al, Haematologica, 2012). Methods:This trial assessed immune function as measured by response to the conjugate vaccine to Streptococcus pneumoniae (Prevnar, PCV7), detailed peripheral blood lymphocyte subset analysis (including NK cell subsets and Tregs), as well as quality of life measures (Hospital Anxiety and Depression Scale, Brief Fatigue Inventory [BFI], Brief Pain Inventory [BPI], and the FACT-G) after autologous transplant for myeloma. Myeloma patients after either 140 or 200 mg/m2 melphalan HSCT were enrolled if they had ANC ≥1000/μL, platelet count ≥ 75,000/μL, and adequate hepatic function by the time Prevnar [serotypes 4, 9V, 14, 18C, 19F, 23F, and 6B] was administered on weeks 9 [month 2], 17 [month 4], and 25 [month 6] after autologous HSCT. Maintenance therapy was an exclusion criteria. Results:Thirty patients were enrolled – twelve with ISS stage 1 at diagnosis, six with ISS 2, five patients with ISS 3, and nine were unknown. Disease status pre-transplant revealed 34% CR and 78% ≥PR, at +60 days 44% CR and 94% ≥PR, but by +180 days the ≥PR was down to 76% due primarily to relapses from CR. With a median follow-up of 35 months since diagnosis and 28 months since transplant, median time to progression has not been reached.We used ELISA to assess antibody concentration against immunogenic antigens (14 & 18c) and the less immunogenic antigen 23F. Two months after each PCV7 injection [weeks 13, 25, and 33], an adequate response (>35 mcg/mL) was demonstrated for antigen 14 in 7% (2/29) at week 13, 16% (4/25) at week 25, and 19% (5/27) at week 33. For antigen 18C, 6.7% (2/30) at week 13, 8.3% (2/24) at week 25, and Z% (4/26) at week 33. At one year responses faded with only 10% (2/20) for antigen 14, 0% (0/24) for antigen 18C, and 0% (0/7) for antigen 23F.Quality of life analyses including BFI, FACT-G, BPI, and HADS showed no significant changes from weeks 9, 17, 25, and off study except for worsening anxiety and depression at one year post-transplant compared to study entry.Peripheral blood flow cytometry using Cox univariate analysis showed an association with overall survival with late activated T-cells (CD3+HLA-DR+, p<0.05 at 30 days and p<0.01 at 100 days) and degranulated T-cells (CD3+CD63+,p<0.09 at 30 days, p<0.06 at 100 days. An association with the achievement of CR at day +30 post-transplant was seen for NK cells (CD3-CD16+CD56+, p<0.024), KIR- NK cells (CD3-CD16+CD56+CD158b-, p<0.07), and CD314+ NK-cells (CD3-CD16+CD56+CD314+, p<0.04. Calculating Spearman correlation coefficients between lymphocyte subsets and Prevnar antibody response found no lymphocyte subset associated with response in more than one antigen. Conclusions:In this pilot trial of 30 myeloma patients we have shown that the adaptive immune system is profoundly suppressed with a minority of patients reacting to the conjugate vaccine Prevnar. Depression and anxiety both worsen in the first year post transplant. Multivariate and grouped covariate analyses of peripheral blood lymphocyte subsets with both Prevnar response and time to progression will be presented at the meeting. Disclosures:No relevant conflicts of interest to declare.

A Phase I/II Trial Combining High-Dose Melphalan and Autologous Transplant with Bortezomib for Multiple Myeloma: A Dose- and Schedule-Finding Study

We did a randomized phase I/II trial designed to evaluate the safety and efficacy of combining the proteasome inhibitor bortezomib with high-dose melphalan as the conditioning for high-dose therapy and autologous transplant for myeloma. Enrolled patients were limited to those who did not achieve a very good partial remission (VGPR) following one or more induction regimens, and were randomized to receive a single escalating dose of bortezomib (1.0, 1.3, or 1.6 mg/m(2)) either 24 hours before or 24 hours after high-dose melphalan. Dose escalation was based on the escalation with overdose control (EWOC), a Bayesian statistical model. Bone marrow aspirates were collected before initiation of therapy and at the time of transplant to evaluate which sequence resulted in maximal plasma cell apoptosis, and response to transplant was assessed by the International Myeloma Working Group criteria. Among 39 randomized patients, 20 received bortezomib after melphalan and 19 received bortezomib before melphalan. Toxicities and posttransplant hematopoietic recovery rates were similar between arms. The overall response rate for all patients was 87%, with 51% achieving a VGPR or better. Pharmacodynamic studies showed greater plasma cell apoptosis among patients who received bortezomib following melphalan. The use of bortezomib in conjunction with high-dose melphalan is safe, with data suggesting improved efficacy. A single dose of bortezomib administered after high-dose melphalan is the recommended dose and schedule for future clinical investigation.

Abstract 2270: Design, synthesis, and functional characterization of new cycle-peptides inhibitors for C-X-C chemokine receptor-4 (CXCR4)

Abstract Modulation of the axis CXCR4/CXCL12 affected primary tumor growth and secondary lesions development. Moreover, CXCR4 inhibition increases hematopoietic stem cell mobility in patients undergoing autologous transplantation for myeloma and non-Hodgkin lymphoma. Although several CXCR4 inhibitors were described neither one reached satisfactory efficacy, bioavailability and acceptable toxicity. To develop new CXCR4 inhibitors through a rationale design approach, comparative studies were undertaken evaluating the N-terminal structure of the ligand CXCL12 and v-MIP II, an inhibitory chemokine like produced by the herpes virus 8-Kaposi associated. A common amino acidic motif (RFF) was identified in both structures although in inverted orientation. Having as a core this small domain, a new library (20 units) of cycle-peptide molecules was generated. 20 units of cycle-peptide molecules were synthesized that consists of 5 and 7 amino-acid residues cycled by a S-S bridge designed to interact with the receptor CXCR4. The peptides were characterized for functionally CXCR4 interaction through: 1. inhibition of CXCR4 binding; 2. inhibition of migration CXCL12-induced; 3. inhibition of calcium release CXCL12-induced; 4. Inhibition of P-Erk CXCL12-induced. Four peptides were identified as CXCR4 inhibitors. These four CXCR4 inhibitory peptides were further evaluated for the in vivo efficacy through inhibition of metastasis formation. B16 mouse melanoma cells transfected with CXCR4 were injected in the vein tail in C57 Bl mice and peptide treatment followed for 10 days. Dramatic reduction in number and size of lung metastases were registered in mice peptides-treated. Moreover, xenograft of human renal cancer cells SN12C-EGFP were subcutaneously injected and systemic peptides treatment followed for 10 days. Statistically significant decrease in tumor growth was showed in peptides treated mice. Taken together the data define four new CXCR4 inhibitory peptides, designed through innovative strategy, effective in “in vivo” systems deserving further development. Note: This abstract was not presented at the AACR 101st Annual Meeting 2010 because the presenter was unable to attend. Citation Format: {Authors}. {Abstract title} [abstract]. In: Proceedings of the 101st Annual Meeting of the American Association for Cancer Research; 2010 Apr 17-21; Washington, DC. Philadelphia (PA): AACR; Cancer Res 2010;70(8 Suppl):Abstract nr 2270.

Abstract B50: Design, synthesis, and functional characterization of new cycle-peptides inhibitors for C-X-C chemokine receptor-4

Abstract Inhibition of the axis CXCR4/CXCL12 can affect tumor growth and metastases. Moreover, CXCR4 inhibition increases hematopoietic stem cell mobility in patients undergoing autologous transplantation for myeloma and non-Hodgkin lymphoma. Although several inhibitors were described neither one reached satisfactory efficacy, bioavailability and acceptable toxicity. To develop new CXCR4 inhibitors through a rationale design approach, comparative studies were undertaken evaluating the N-terminal structure of the ligand CXCL12 and v-MIP II, an inhibitory chemokine like produced by the herpes virus 8-Kaposi associated. A common amino acidic motif (RFF) was identified in both structures although in inverted orientation. Having as a core this small domain, a new library (20 units) of cycle-peptide molecules was generated. 20 units of cycle-peptide molecules were synthesized that consists of 5 and 7 amino-acid residues cycled by a S-S bridge designed to interact with the receptor CXCR4. The peptides were characterized for functionally CXCR4 interaction through: 1. inhibition of CXCR4 binding; 2. inhibition of migration CXCL12-induced; 3. inhibition of calcium CXCL12-induced; 4. Inhibition of P-Erk CXCL12-induced. Four peptides were identified as possible CXCR4 inhibitors. These four CXCR4 inhibitory peptides were further evaluated for the in vivo efficacy through inhibition of metastasis formation. B16 mouse melanoma cells transfected with CXCR4 were injected in the vein tail in C57 Bl mice and peptide treatment followed for 10 days. Dramatic reduction in number and size of lung metastases were registered in mice peptides-treated. Moreover, xenograft of human renal cancer cells SN12C-EGFP were subcutaneously injected and systemic peptides treatment followed for 10 days. Statistically significant decrease in tumor growth was showed in peptides treated mice. Taken together the data define three new CXCR4 inhibitory peptides, designed through innovative strategy, effective in “in vivo” deserving further development. Citation Information: Clin Cancer Res 2010;16(7 Suppl):B50

Effect of KGF (Palifermin) On Immune Reconstitution After Autologous Transplantation for Multiple Myeloma.

Abstract 1152Poster Board I-174 IntroductionHuman-keratinocyte growth factor 1(KGF) is currently being evaluated in clinical trials for its safety and efficacy in preventing mucosal damage from irradiation and after bone marrow transplantation (BMT). It has been suggested that, besides having preventive effects on oral mucositis, it may also have immunomodulating effects by uniquely protecting thymic epithelial cells. A potential clinical application of KGF is the amelioration of prolonged post BMT-immune deficiency in BMT recipients. In animal models of autologous and allogeneic BMT, KGF administration during BMT resulted in enhanced thymopoiesis and increased peripheral T-cell numbers. Therefore, a potential clinical application of KGF is the improvement of prolonged post BMT-immune deficiency in BMT recipients. Thymopoiesis can be assessed by analysis of T-cell receptor excision circles (TREC). This marker for recent thymic emigrants might be a novel prognostic factor for outcome after transplantation in multiple myeloma patients. We investigated the potential influence of KGF on immune reconstitution after autologous transplantation for myeloma using this marker. Materials and MethodsTwenty-four myeloma patients from a single institution were treated homogeneously with the induction combination bortezomib (Velcade®) plus dexamethasone (DXM), followed by high dose melphalan (140-200 mg/m2) and an autologous transplantation with peripheral blood stem cells. Patients were randomized for KGF treatment in 2 groups, 11 having received three doses of palifermin (Kepivance®) (60 μg/kg once daily i.v.) pre- and post-conditioning regimen (total six doses). Blood samples were drawn at diagnosis, before BMT, and at 1, 3, 6, 9, 12 and 18 months post BMT. We analysed signal joint (sj) TREC in peripheral blood lymphocytes using quantitative RT-PCR. The percentage and absolute numbers of lymphocyte populations were monitored by flow cytometry. Values were expressed as means ± SEM. Patient groups were compared by the Mann-Whitney test. ResultsBoth CD4+ and CD8+ naïve T cells (CD45RA+ CCR7+) were strongly decreased by pretransplantation bortezomib plus DXM treatment. SjTREC decreased sharply after transplantation and returned to baseline after 1 year without differences between the two groups of patients. Natural regulatory T lymphocytes (phenotypically assessed as CD4+ CD25 high, CD127 low) were not modified by KGF treatment either. Notably, the CD3+ cell population was significantly higher during the first 3 months post BMT in KGF treated patients (1518 ± 380 vs 821 ± 105 CD3+/blood mL, p = 0.032 at 1 month post BMT). This was related to a higher CD8+ cell counts, specifically in the CD8 effector memory cells (assessed as CD45 RA- CCR7-) (790 ± 320 vs 292 ± 55, p< 0.05 at 1 month post BMT). No correlation was found with documented infectious complications, relapse or survival. ConclusionsThese data suggest that, unexpectedly, the main effect of KGF on immunity in that autologous BMT setting, is not to be accounted by changes in thymic function but rather by the peripheral expansion of CD8+ effector memory cells which could be favoured by the treatment prior BMT and/or by the post-BMT lymphopenia. DisclosuresNo relevant conflicts of interest to declare.

Continued M Protein Responses Beyond Day 100 After Autologous Transplantation for Myeloma: Implications for Post Transplant Strategies

Background: Patients undergoing autologous stem cell transplantation (SCT) for myeloma usually undergo disease evaluation approximately 100 days after the SCT. Decisions regarding post transplant consolidation strategies such as tandem transplantation and maintenance therapies are usually taken at the time of this evaluation. It is not clear how often patients continue to have a drop in their M protein after day 100 in the absence of additional therapy.

Assessment of the role of timing of second transplantation in multiple myeloma by multistate modeling

Stem cell transplantation has a place in the management of many patients with hematological disorders, but is no longer the final and definitive treatment for most of these individuals. The relapsing patient may be offered further therapy, and evaluating the contribution of the treatments available has become statistically challenging. This study was designed to evaluate further the benefit and timing of double autologous transplantation in the management of patients with myeloma. We investigated the potential benefit of a second autologous transplantation for myeloma before relapse or progression ("elective" transplantation) and the importance of the timing of the procedure using a multistate approach. We used data from 7452 patients with myeloma who received autologous transplantation and who were reported to the registry of the European Group for Blood and Marrow Transplantation. With use of statistical and visual models, the multistate approach shows the benefit of being able to undergo a second transplantation within 12 months of the first transplantation. Our study focuses on the importance of appropriate statistical analysis and illustrates how use of the Cox model within a multistate framework may be applied to the assessment of the role of an intermediate event in the disease process. The study illustrates both mathematically and visually the improved survival resulting from undertaking an elective second transplantation in patients with myeloma as soon as medically prudent-usually within 3 to 6 months of the first transplantation.

A randomized phase I trial of melphalan + bortezomib as conditioning for autologous transplant for myeloma

17550 High dose chemotherapy and autologous transplant (HDT) clearly benefits most patients with myeloma, but the addition of chemotherapy or TBI to melphalan (M) does not improve outcomes. Bortezomib (B) is a proteasome inhibitor which synergizes with chemotherapy due to its effects on DNA repair enzymes. Recent data has shown that B upregulates the anti-apoptotic protein MCL-1, which would suggest that B followed by M is inferior to M followed by B. We designed a randomized phase I trial combining B and Melphalan 200 mg/m2 (Mel200) in order to determine the toxicity, optimal dose and sequence of administration. Patients were randomized to receive either B 24 hours before Mel 200 or B 24 hours after Mel 200. Standard transplant criteria were used with the addition of requiring measurable numbers of plasma cells at the time of transplant. Enrolled patients underwent BM aspirate on day -4 (before B) and day 0 (before PBSC infusion). Bone marrows were tested for apoptosis, and myeloma cells were sorted for protein analysis. Age range was 48–74 years. Prior therapy has included Velcade (n = 2, both responsive) thalidomide (n = 2) and prior melphalan in 2 (1 HDT). Time to WBC and Plt engraftment were not different from historical cohorts receiving MEL 200 alone. Four patients have been randomized to date with 3 in the B “before“ arm, and 1 in the B “after” arm. Of the 3 patients who received B before M, day 0 bone marrow revealed minimal changes in marrow myeloma cell apoptosis in two patients, and in one patient a &gt;20 fold increase in myeloma cell apoptosis on the day 0 marrow sample when compared to the day - 4 marrow. In the patient enrolled in the B after M arm, there was a 10 fold increase in the day 0 marrow myeloma cell apoptosis. Western blot analysis for DNA repair enzymes and MCL-1 on sorted tumor cells are planned, as is ELISA for secreted cytokines before and after therapy. Toxicity and response data with an update of the molecular correlates will be presented. The combination of B and M as conditioning for HDT is feasible. The optimal dose and sequence of administration remains unknown. Accrual continues. [Table: see text]