Cumulative Incidence Of Acute GVHD Research Articles

Maximally Tolerated Busulfan Area Under the Concentration-Time Curve (AUC) In Combination with Fludarabine as Conditioning Prior to Allogeneic Hematopoietic Cell Transplantation.

AbstractAbstract 3499Intravenous busulfan (IV Bu) dosing in hematopoietic cell transplantation (HCT) conditioning regimens has been based largely on bioequivalence studies done with the oral dosage form. As systemic exposure to Bu has been correlated to both efficacy and toxicity, we used area under the concentration-time curve (AUC) to prospectively determine the maximally tolerated systemic exposure to IV Bu when given daily in combination with fludarabine as HCT conditioning. Three AUC levels were planned: 6000, 7500, and 9000 micromole*min/L, in cohorts of 20 patients (pts) each, with an additional 10 pts to be enrolled at the maximally tolerated AUC. To be included, pts had be 16–65 years old and have a hematologic malignancy, an HLA A, B, C, DRB1 8/8 or 7/8 matched related or unrelated donor, Karnofsky performance status 70–100%, and adequate organ function. The initial dose of IV Bu for the first AUC level was 170mg/m2/day on day -6 and day -5 then, on day -4 and day -3 doses were adjusted based on pharmacokinetic modeling after the first dose to achieve an average daily AUC of 6000. First doses for the subsequent cohorts were based on the linear correlation between AUC and dose in the previous cohort: 180mg/m2/day for AUC 7500 and 220mg/m2/day for AUC 9000, with dose adjustment on days -4 and -3 as described. Pharmacokinetic analysis was done after the day -3 dose to verify the accuracy of the dose adjustments. The first 20 pts in the AUC 6000 cohort (DL1) were coenrolled onto a randomized trial of GVHD prophylaxis (tacrolimus and methotrexate vs tacrolimus and mycophenolate mofetil) and were analyzed separately from a second cohort of 20 pts receiving an AUC 6000 (DL1A) and GVHD prophylaxis with tacrolimus and methotrexate. 20 pts were then enrolled onto AUC 7500 (DL2), followed by 3 pts on AUC 9000 (DL3). All DL3 pts had dose limiting toxicity so accrual to that level was stopped. An additional 9 pts have been treated to date on DL2 (5 of these are <100 days posttransplant and are not evaluable for toxicity or GVHD). The median (and range) average daily AUC for each of the cohorts were: DL1 5955 (5375-6557); DL1A 6145 (4846-7018); DL2 7555 (5920-8682); DL3 8899 (8784-8955). There were no primary engraftment failures and median times to neutrophil engraftment were: DL1 15 days, DL1A 16 days, DL2 14 days, and DL3 12 days (p=0.01). The dose-limiting toxicity seen at DL3 was hepatic venoocclusive disease (VOD) which developed in all 3 pts; two of these pts died. There were no seizures attributable to IV Bu seen at any dose level. NCI CTCAE toxicities (observed in the first 100 days unrelated to infection or GVHD) that were significantly different between the dose level groups were dermatitis and VOD with more severe toxicity seen in DL2 and DL3. Diarrhea and the use of total parenteral nutrition appeared to be more common on DL2 and DL3 but not significantly so. The cumulative incidence of acute GVHD was similar across the cohorts (p=0.11). There was no difference between the dose levels in cumulative incidence of relapse (p=0.54) or event-free survival (p=0.4). Nonrelapse mortality at 6 months was significantly different: DL1 20%, DL1A 0%, DL2 17.5% and DL3 67% (p=0.008) as was overall survival at 6 months: DL1 75%, DL1A 90%, DL2 80%, DL3 33% (p=0.04). We conclude that in the pts studied, 7500 micromole*min/L is the maximally tolerated AUC based on protocol-defined criteria but exceeding an AUC of 6000 may not provide any survival benefit. Disclosures:Perkins:PDL BioPharma: Research Funding. Off Label Use: IV busulfan was used in combination with fludarabine as conditioning prior to allogeneic hematopoietic cell transplantation in patients with a variety of hematologic malignancies. Field:PDL BioPharma: Research Funding.

Fludarabine and Treosulfan Conditioning for Allogeneic Stem-Cell Transplantation; a Dose- Intense Regimen with Limited Toxicity.

AbstractAbstract 3473Allogeneic stem cell transplantation (SCT) is a potentially curative approach for patients (pts) with various hematological malignancies. However, standard myeloablative conditioning (MAC) is limited to younger, medically fit pts. Reduced-intensity conditioning (RIC) is feasible in pts not eligible for MAC, allowing engraftment and limiting organ toxicity, however, relapse rates are increased, especially in pts not in remission at the time of SCT. Novel approaches are in need to deliver dose intense conditioning, yet with RIC type toxicity, to these pts. Treosulfan is a bifunctional alkylating agent with cytotoxic and immunosuppressive effects. Prior studies demonstrated the feasibility of a fludarabine-treosulfan (FT) conditioning regimen, suggesting it is effective with limited toxicity. To better define the role of FT, we analyzed outcomes of a relatively large cohort of pts, treated in a single institution. Pts were eligible for FT only if considered not eligible for MAC, due to advanced age, comorbidities or extensive prior therapy (including a prior SCT). FT included fludarabine 30 mg/m2, on days -6 to -2, and treosulfan 10–12 gr/m2 on days -6 to -4. Pts with an unrelated donor or no prior chemotherapy were also given ATG (Fresenius, total dose 15 mg/kg). The study included 105 pts, median age 57 years (range, 20–76). Diagnoses included AML (n=56), MDS (n=33), CML (n=3), lymphoid malignancies (n=12) and myelofibrosis (n=1). The donor was an HLA-matched sibling (n=50) or matched unrelated [MUD, n=55; 10/10 match (n=43), 9/10 (n=7), 8/10 (n=5)]. Disease status was defined as early (n=17), intermediate (n=24) or advanced (n=64) by standard criteria. This was a relatively high-risk pt group as only 24 pts (23%) were in CR (first or later), 30 pts had a comorbidity score ≥3 and 22 pts had a Karnofsky score ≤80 at the time of SCT. Twenty-seven pts had a prior SCT; 13 autologous and 14 allogeneic (12 from a different donor). Ninety-five pts engrafted; 7 died prior to engraftment, 3 had early primary or secondary graft failure (MUD-1, mismatched MUD- 2 pts). The median time to neutrophil and platelet engraftment was 12 (range, 9–23) and 16 (range, 10–66) days, respectively. With a median follow-up of 16 months (range, 1–73), 57 pts are alive and 48 have died. The cumulative incidence of acute GVHD and grade III-IV acute GVHD was 26% and 11%, respectively. The cumulative incidence of chronic GVHD was 53%. In all, 8 pts died of complications of GVHD and 16 from other non-relapse causes, including multi-organ failure (n=4), CNS bleeding (n=2), infections (n=7), graft failure (n=2) and suicide (n=1). The cumulative incidence of non-relapse mortality 3-years after SCT was 25% (95%CI, 18–35). Twenty-four pts died of disease recurrence, cumulative incidence 30% (95%CI, 21–44) at 3 years. Considering that only 26% of the pts were in CR at the time of SCT, this rate seems promising. The median 3-year overall (OS) and progression-free survival were 45% (95%CI, 33–57) and 37% (95%CI, 26–49), respectively. The 2 most important factors predicting for OS in multivariate analysis were advanced disease and a low Karnofsky score at the time of SCT. Hazard ratios were 3.7 (p=0.03) and 4.2 (p=0.001), respectively. The 3-year OS was 71% (95%CI, 45–96), 33% (95%CI, 6–69) and 26% (95%CI, 6–46) for low, intermediate and advanced stage, respectively (p=0.03). Best results were obtained in pts with previously untreated MDS (n=33, including 28 pts with > 10% marrow blasts at SCT) and pts with high-risk AML in first CR (n=14), with 3-year OS rates of 61% (95%CI, 42–80) and 65% (95%CI, 38–93), respectively. Interestingly, a second SCT was not associated with a worse outcome. OS was 43% (42/78 alive), 46% (8/13 alive) and 40% (7/14 alive) in first SCT, a second SCT after a prior autologous SCT or a prior allogeneic SCT, respectively. In conclusion, treosulfan-based conditioning is a promising approach in pts with advanced hematological malignancies, not eligible for standard MAC. Favorable results were observed not only in pts with early stage disease, but also in previously untreated advanced MDS. Second SCT was also feasible with FT with a relatively favorable outcome. The low relapse risk suggests that this regimen can be considered a dose-intensive regimen, with a toxicity profile that resembles RIC regimens. The role of FT should be further defined in larger prospective studies. Disclosures:No relevant conflicts of interest to declare.

Reduced-Intensity Unrelated Cord Blood Transplantation (RICBT) for Elderly Patients with Hematological Malignancies

AbstractAbstract 2349 Introduction:Incidence of hematological malignancies is higher in elderly population. However, standard chemotherapy has not been established and the potential role of RICBT has remained unclear. This study reports the results of RICBT for elderly patients with hematological malignancies, retrospectively. Objective:To investigate the feasibility of RICBT. Primary endpoints were engraftment and overall survival (OS). secondary endpoint was transplant-related mortality (TRM). Patients and Methods:Between Feb.2009 and Jun.2010, 29 patients (median age 70 years, range 58–76) received RICBT for hematological malignancies. Primary diseases were divided into 2 groups; advanced (intermediate and high risk; n=21) or standard (n=8). All cases in 70's were included in the high risk. Median follow up time was 238 days (range 8–464).Conditioning regimen and GVHD prophylaxis consisted of fludarabine, busulfan or cyclophosphamide, and TBI 2Gy with tacrolimus± MTX for <70 years(n=18), fludarabine, busulfan or cyclophospamide, and ATG 7.5mg/kg with cyclosporine ± MTX for >70 years (n=11) and <70 years with comorbidities. Median total transplanted nucleated cells: 3.2 × 10|jE7 cells (2.0–4.8); Median CD34+: 0.4× 10|jE5 cells (0.3–2.9); HLA match: 5/6 (n=1), 4/6 (n=28). Time to event curves were plotted by using the actuarial method of Kaplan-Meier, and differences between curves were analyzed by log-rank tests. Results:Neutrophile (>500/μL) and platelet engraftment (>20,000/μL) were observed in 89.6% (95% CI; 79–100) at day 60 (median; 18.0 days, range; 13–28), and 62.1% at day 100 (median; 36.5 days, range; 17–60), respectively. Neutrophile engraftment was 100% in TBI regimen (median; 18 days, range; 13–28), 75% in ATG regimen (95% CI; 51–100, median; 19 days, range; 16–27)(p=0.04). Platelet engraftment was 77% in TBI regimen, 42% in ATG regimen, respectively (p=0.06). Primary graft failure occurred in 3% of all cases. Cumulative incidence of acute GVHD (II-IV) was 58% (95% CI; 39–78) at day 100 (median; 27.5 days, range; 13–82), 81% (95% CI; 62–100, median; 28 days, range; 17–82) in TBI regimen and 12.5% (95% CI; 0–35, median; 13 days, range; 13) in ATG regimen, respectively (p=0.01). The 1-year estimated OS was 51% (95% CI: 25–77) in all cases, 51% (95% CI: 13–90) in TBI, and 48% (95% CI: 18–77) in ATG, respectively (p=0.08). According to the age, OS was 80% (95% CI: 45–80) in 50's, 53% (95% CI: 20–86) in 60's, and 38% (95% CI: 0–77) in 70's (P=0.0765). Causes of TRM included infections (n=5 including 3 cases in 70's), TMA (n=2). Incidence of TRM at day 100 was 20% (95% CI; 4–35, median; 47 days, range; 8–79), 7% in TBI regimen (95% CI; 0–21, median; 79days), 41% in ATG regimen (95% CI; 9–72, median; 30 days, range; 9–72). Incidence of TRM, according to the age, was 40%,0%, and 52% in 50's,60's, 70's, respectively. Discussion and Conclusion:Because of the high incidence of high risk disease and TRM, despite low incidence of GVHD, RICBT is associated with a low OS in patients over 70 years compared with those who are under 70 years. Eligibility of RICBT needs to be investigated, especially in 70's patients, and further studies are warranted to clarify the safety in elderly patients. Disclosures:No relevant conflicts of interest to declare.

Unrelated Cord Blood Transplantation: Comparison After Single Unit Cord Blood Intrabone Injection and Double Unit Cord Blood Transplantation In Patients with Hematological Malignant Disorders. A Eurocord-EBMT Analysis

AbstractAbstract 223The use of single cord blood unit for transplantation in adult patients is limited due to the high risk of graft failure and delayed neutrophil and platelet recoveries. The limited hematopoietic progenitors in UCB grafts and their homing after IV injection, have prompted investigators to study the design of delivering CB grafts directly into the bone marrow (BM) space (IBCBT) or to use double cord blood transplantation (dUCBT) to improve engraftment. To evaluate the impact of IBCBT, we made a retrospective based registry comparison with dUCBT performed in the same time period (2006-2010) and reported to Eurocord-EBMT. We included 87 and 149 patients who received either IBCBT or dUCBT, respectively, after a myeloablative conditioning regimen for malignant disorders. IBCBT was performed in 8 EBMT centers whereas dUCBT was performed in 56 EBMT centers. Majority of patients in both groups had acute leukemia. IBCBT patients were older (p<0.001), more frequently received an autologous graft (p<0.001) and had positive CMV serology (p<0.001), and importantly had more advanced disease at transplantation (p=0.04). Median number of infused (after thawing) nucleated cells injected intrabone was 2.5×107/kg and it was 3.9×107/kg in dUCBT (p<0.001). In 72% of both groups, CB grafts were HLA 4/6 (the highest HLA disparity was taken into consideration in dUCBT). Other differences were regarding GVHD prophylaxis that was based on CSA+MMF in 100% of IBCBT and in 62% of dUCBT cases; ATG was used in all IBCBT and 40% of dUCBT. Median follow-up time was 18 months in IBCBT and 17 months in dUCBT. At day 30, cumulative incidence (CI) of neutrophil recovery (ANC >500) was 83% after IBCBT and 63% after dUCBT, and at day 60, it was 90% in both groups; the median time to reach ANC>500 was 23 and 28 days after IBCBT and after dUCBT (p=0.001) respectively. At Day-180 CI of platelets recovery was 81% after IBCBT and 65% after dUCBT (p<0.001) with a median time of 36 days and 49 respectively (p=0.002). At day 100, CI of acute GVHD (II-IV) was 19% and 47% (p<0.001) and chronic GVHD 34% and 37% respectively (p=NS) respectively. Unadjusted 2 years-CI of NRM and RI were 31% and 23% after IBCBT and 35% and 28% after dUCBT, respectively (p=NS). Unadjusted 2 y-DFS estimation was 47% after IBCBT and 37% after dUCBT (p=NS). In multivariate analysis adjusting for statistical differences between 2 groups (such as status of the disease at transplant, age, CMV, previous transplants, GVHD prophylaxis), recipients of IBCBT had improved DFS (HR: 1.64, p=0.035), faster platelet recovery (HR:2.13, p<0.001) and decreased acute GVHD (HR:0.31; p<0.001) compared to dUCBT recipients. We did not find a cut-off value of number of nucleated cells after IBCBT or dUCBT that could be associated with outcomes after both approaches. In conclusion, both strategies have extended the use of CB transplants to adults in need of cord blood transplantation. Therefore, IBCBT is an option to transplant adult patients with single CB units after myeloablative conditioning regimen and may impact the total costs of cord blood transplantation. Based on these results, intra-bone technique may disclose new transplant potentialities also with other HSC sources. Disclosures:No relevant conflicts of interest to declare.

Allogeneic Stem Cell Transplantation for Acquired Aplastic Anemia: Better Outcome with Bone Marrow as Compared to Peripheral Blood in HLA-Matched Sibling Donor Transplantation and Improved Outcome Over Time After Matched Unrelated Donor Transplantation. A Retrospective Analysis of Transplants Reported to the German Registry for Stem Cell Transplantation (DRST).

Abstract 876 Background:Transplantation of bone marrow (BM) from a HLA-matched sibling donor is an effective treatment for severe aplastic anemia (AA) with long-term survival in excess of 80%. In the recent years there were two trends in allogeneic stem cell transplantation (SCT) for AA: (1) increasing proportion of transplants performed from matched unrelated donors (MUD) and (2) increasing proportion of transplants using peripheral blood progenitor cells (PBSC) as stem cell source instead of BM. A similar switch to PBSC over BM grafts is reported in leukemia transplants. PBSC grafts for leukemia are associated with higher rates of chronic graft-versus-host disease (cGVHD). This adverse consequence may be offset by lower rates of leukemia relapse in some settings. In contrast, there is no perceived benefit of cGVHD for AA. A recent retrospective analysis of EBMT/CIBMTR reported worse outcome after PBSCT compared to BMT in young patients after HLA-matched sibling (sib) transplantation. The impact of stem cell source on outcome after MUD transplants has not been studied in detail so far.Some reports on favourable results after MUD SCT prompted the discussion whether MUD SCT should be performed earlier in the treatment algorithm in AA instead of considering it as salvage treatment after failure of immunosuppressive treatment. Therefore we performed a retrospective study on the dataset of the German Registry of Stem Cell Transplantations (DRST) to (1) analyze outcome after MUD compared to sib SCT and (2) to study impact of stem cell source (PBSC vs BM) on both sibling and MUD SCT and (3) to analyze impact of transplant period (1998-2002 vs. 2003-2008). Results:We analyzed 182 sib SCT and 114 MUD SCT (first transplants only). The interval between diagnosis and transplant was significantly longer for MUD SCT as compared to sib SCT (median 98.5 days vs. 511.5 days; p<0.001 ) suggesting that the majority of sib SCT were performed upfront whereas MUD SCT in the majority of cases was performed after failure of other treatments. Median age was 28.5 years (sib SCT) and 30 years (MUD) years (p=0.41). PBSC were used as stem cell source in 50.5% of sib SCT and 61.4% of MUD (p=0.097). 5-year probability of survival was 84.6% (95%-CI: 79.3-90.3%) after sib SCT and 70.1% (95%-CI. 61.8-79.6%) after MUD (p<0.003). In univariate comparison age at transplant has significant impact on survival: After sib SCT 5-year probability of survival in patients ≤ 30 years vs. > 30 years was 94.5% (95%-CI: 90.0-99.3%) vs. 73.5% (95%-CI: 64.3-84.1%)(p<0.001) . 5-year probability of survival after MUD SCT in patients ≤ 30 years vs. > 30 years was 77.7% (95%-CI: 67.3-89.7%) and 60.6 (95%-CI: 48.2-76.2%) (p=0.044). In the most recent period (2003-2008) 2-year probability of survival was 81.6% (95%-CI: 72.9-91.3%) after sib SCT (n=80) and 75.6 (66.1 – 86.5%) after MUD SCT (n=73) (p=0.34). After sib SCT survival was significantly better with BM as compared to PBSCT (5-yr. prob. 95.3%; 95%-CI: 90.9-99.9%; n=89 vs. 74.1%, 95%-CI: 65.1-84.2%; n=92; p<0.001) and cumulative incidence of chronic GvHD was significantly higher with PBSCT as compared to BM (47.0% vs. 18.4%; p<0.01). Cumulative incidence of acute GvHD II-IV did not differ significantly between BM and PBSC. In contrast, stem cells source did neither significantly affect overall survival nor cumulative incidence of acute or chronic GvHD after MUD. In multivariate analysis of the sib SCT older age (>30 years) and use of PBSC were significant risk factors for mortality (Hazard Ratio (HR) 3.4 (1.2-9.3) and HR 4.0 (1.3-12.2). Other variables in the model (conditioning regimen; GvHD prophylaxis; sex match; time diagnosis to transplant and transplant period) were not significant. For MUD SCT none of these variables were significant in a multivariate model. Conclusion:These results indicate that BM grafts should be preferred to PBSC in patients undergoing HLA-identical sib SCT for AA. In contrast, no negative impact of stem cell source on outcome after MUD SCT could be demonstrated. Results of MUD SCT substantially improved over time. In the most recent period from 2003- 2008 the probability of survival after MUD and HLA-identical sib SCT was no longer different. So far majority of MUD transplants were performed late after diagnosis, mostly after failure of immunosuppression. Re-assessment of both the indication of MUD SCT for AA and the timing of MUD SCT is warranted.Supported by the Deutsche José Carreras Leukämie-Stiftung. Disclosures:No relevant conflicts of interest to declare.

Genetic Variations in Heparanase Gene (HPSE) Are Associated with Increased Risk of Graft Vs. Host Disease Following Allogeneic Hematopoietic Stem Cell Transplantation: Effect of Discrepancy Between Recipient and Donor.

Abstract 3556Poster Board III-493 IntroductionGraft-versus-host disease (GVHD) is the most common cause of overall mortality and morbidity after HSCT. Heparanase, endo-â-glucuronidase that specifically cleaves the saccharide chains of heparan sulfate proteoglycans, is involved in the process of inflammation and release of heparan sulfate-bound chemokines, cytokines and bioactive angiogenic factors that are main players in the development of GVHD. Therefore, we investigated the possible association of HPSE gene SNPs with the risk of post HSCT GVHD and transplantation outcome. Patients and methodsFour hundred and fourteen patients with hematological malignancies and their HLA matched donors were included in the study. Genotyping of two HPSE gene SNPs rs4693608 and rs4364254 was carried out using PCR-RFLP-based analysis and allele-specific amplification. ResultsAssessment of heparanase gene SNPs among healthy individuals demonstrated a significant correlation between HPSE gene SNPs and the expression level of heparanase, SNP rs4693608 being the most prominent (p=0.00043). This approach allowed distribution of all possible HPSE genotype combinations into three groups (LR, MR and HR) correlating with low, intermediate and high heparanase mRNA and protein expression levels. In the group of HSCT patients we found a highly significant correlation between HPSE gene SNPs rs4693608 and rs4364254, their combinations and risk of acute GVHD. The cumulative incidence of acute GVHD, grade II-IV, was 54.4% (95% CI 44.7-66.2) in the recipient group HR, while in recipient groups MR and LR, the cumulative incidences were 40.5% (95% CI 33.2-49.4) and 24.9% (95%CI 17.7-34.9), respectively (P=0.0001). Moreover, discrepancy between recipient and donor in these SNPs combinations significantly affected the risk of acute GVHD. Genotype combination LR in patients exerted a protective effect against GVHD regardless of the donor genotype combinations. Acute GVHD rates were highest when recipients possessed genotype combinations HR. correlating with high heparanase mRNA levels, while their donors possessed the MR or LR genotype combinations correlating with a lower heparanase mRNA level, (HR-MR and HR-LR pairs). The other combinations were associated with an intermediate risk. Therefore, we divided all recipient-donor pairs to three groups according to potential risk for acute GVHD development. The first group, LAGR, included three pairs with low risk of acute GVHD development (LR-LR, LR-MR, and LR-HR pairs). The second cohort, HAGR, contained pairs with high risk of acute GVHD development (HR-MR and HR-LR pairs). The third group, MAGR, consisted of pairs with moderate risk of acute GVHD development (MR-MR, MR-HR, MR-LR and HR-HR pairs). Cumulative rate of acute GVHD incidence was 71.2% (95% CI 58.2-87.0) in the HAGR group, 41.5% (95% CI 34.4-50.1) in the MAGR group, and 24.9% (CI 95% 17.7-34.9) in the LAGR group (÷2=29.3, P< 0.00001 for grade II-IV and ÷2=34.1, P< 0.00001 for grade III-IV). In addition, HPSE gene SNPs disclosed a correlation with extensive chronic GVHD, non-relapse mortality and overall survival. Multivariate analysis confirmed the independent effect of both host genotype and host-donor genotype risk groups. ConclusionsThe study demonstrated significant correlation between HPSE gene SNPs and heparanase expression levels and the risk of acute and extensive chronic GVHD. Our findings may imply the involvement of heparanase in the pathogenesis of GVHD. We speculate that secreted levels of cytokines and chemokines affected by heparanase are higher in patients possessing HR genotype in comparison to possessors of the MR and LR genotypes. Higher cytokine and chemokine signals originating from the patient activate donor T-cells and increase the risk of GVHD. When donor T-cells originated from a donor environment with lower heparanase levels as dictated by donor genotype LR/MR, the infusion into a high heparanase level environment may cause hyperactivation and an even higher risk of GVHD. This aggressive phenotype of donor T lymphocytes results in infiltration and destruction of patient tissues and GVHD development. Disclosures:No relevant conflicts of interest to declare.

Feasibility of Cyclosporine and Short-Term Methotrexate for Graft-Vs.-Host disease Prophylaxis in T-Cell-Replete, Reduced-Intensity Allogeneic Bone Marrow Transplantation From Unrelated Donors.

Abstract 4347Optimal graft-vs.-host disease (GVHD) prophylaxis in T-cell-replete, reduced-intensity allogeneic stem cell transplantation from an unrelated donor (u-RIST) has not been established yet. Tacrolimus-based acute GVHD prophylaxis has been widely used in allogeneic stem cell transplantation from unrelated donors. In addition, T-cell-depletion conditioning regimen containing anti-thymocyte globulin (ATG), or alemtuzumab with/without 2-4 Gy total body irradiation (TBI) has been reportedly applied in u-RIST. However, in-vivo T cell depletion using ATG or alemtuzumab may cause increased risk of infection or relapse after transplantation. TBI may also possibly cause increased incidence of GVHD via tissue damage. Here we report the feasibility of using cyclosporine and short-term methotrexate for GVHD prophylaxis in u-RIST. The conditioning regimen consisted of fludarabine and busulfan (Flu+Bu) without T-cell depletion, such as ATG or alemtuzumab, and without TBI for u-RIST in patients who received prior chemotherapy.In this study, we retrospectively analyzed 30 consecutive patients with hematologic malignancies (median age: 53; range: 22 to 69 years; AML: 11; ALL: 9; MDS: 2; NHL: 5; ATL/L: 3) who received unrelated-donor bone marrow transplantation from HLA 6/6 (A, B, DRB1), either allele-matched (n = 24 patients), one DRB1 allele-mismatched (n = 5 patients), or one A allele-mismatched (n=1) donor at our institution between September 2002 and June 2009. All patients received at least one cycle of prior chemotherapy (median cycle: 6; range: 1 to 19). Of these, 15 patients (50%) were at high risk of relapse. For all, acute GVHD prophylaxis consisted of cyclosporine and short-term methotrexate (day 1: 10mg/m2; day 3 and 5: 7 mg/m2). The reduced intensity conditioning consisted of fludarabine 180mg/m2 and oral busulfan 8 mg/kg for 12 patients; the other 18 patients' conditioning consisted of fludarabine 180 mg/m2 and intravenous busulfan 8mg/kg.Neutrophil and platelet engraftments were achieved in 100% (30/30) and 93% (28/30) of patients, respectively. The median times for neutrophil and platelet engraftments were 16 days (range: 12 to 26 days) and 24.5 days (range: 18 to 291 days), respectively. In patients receiving oral and intravenous busulfan for conditioning, the achievement rates of complete T-cell chimerism by day 100 were 75% (9/12) and 100% (18/18), respectively (p = 0.03). The median period of follow-up was 280 days (range: 34∼1987). During the follow-up our observational periods, 19 patients were alive and 11 patients died of relapse (n = 8) or transplant-related mortality (n = 3). The cumulative incidences of acute GVHD of grade II to IV and III to IV at day 100 were 40% and 17%, respectively. Extensive type of chronic GVHD was 30% in 23 evaluable patients. The 2-year overall survival (OS) and event-free survival rates were 58% (low/standard risk group: 78%; high risk group: 43%; p = 0.04) and 52% (low/standard risk group: 72%; high risk group: 33%; p = 0.01), respectively. In multivariate analysis, grade III to IV acute GVHD and disease status at high relapse were significantly associated with worse OS (p = 0.03 and 0.008, respectively). Day 100 and 2-year TRM were 3% and 10%, respectively. Cyclosporine and short-term methotrexate for GVHD prophylaxis without T-cell deplete-conditioning allowed acceptable incidence of GVHD even in u-RIST. Additionally, only Flu+Bu conditioning for uRIST ensured high rate of complete T-cell chimerism especially in patients receiving intravenous busulfan. Our results suggested that we might be required to determine optimal conditioning and GVHD prophylaxis regimens based on patient characteristics, including a history of prior chemotherapy. Disclosures:Hino:Kyowa Hakko Kirin Co., Ltd. : Research Funding.

Cyclophosphamide-Busulfan Instead of Busulfan-Cyclophosphamide for Conditioning in Allogeneic Hematopoietic Stem Cell Transplantation.

Abstract 2268Poster Board II-245Busulfan-cyclophosphamide (BU-CY) is the established non total body irradiation based myeloablative conditioning regimen for allogeneic hematopoietic stem cell transplantation (HSCT). The introduction of intravenous busulfan has facilitated its application and reduced toxicity. Theoretical considerations and pharmacological data indicate that previous application of busulfan may trigger liver toxicity of subsequent cyclophosphamide. A reverse order of cyclophosphamide-busulfan (CY-BU) would be preferable. Recent animal data confirmed this hypothesis, showing less liver toxicity and better outcomes in mice treated with CY-BU. While CY-BU was not feasible in patients with oral busulfan, it has become a possibility with the introduction of i.v. busulfan. We were therefore interested in exploring this concept and changed the order of drug application to CY-BU in 2003 in those patients not on a multicentre standardized BU-CY protocol. We now retrospectively analyzed in this single centre cohort study liver toxicity and transplantation outcome in patients receiving BU and CY as conditioning regimen for allogeneic HSCT. We analyzed 93 consecutive patients between 1993 and 2008, 52 male (55.9%), median age 46 years (range 16 to 70) with hematological malignancies (AML 41 [44.1%], ALL 11 [11.8%], CML 12 [12.9%], myelodysplastic syndrome and myeloproliferative neoplasia 22 [23.7%], lymphoproliferative disorders 4 [4.3%]) or other diseases (3 [3.2%]), receiving an allogeneic HSCT from an HLA- identical sibling (52 [55.9%]), other family member (3 [3.2%]) or a matched unrelated donor (38 [40.9%]) after conditioning regimen with BU-CY (34 patients; 18 patients with oral, 16 patients since 2003 with i.v. busulfan) or CY-BU (59 patients). Outcomes were analyzed using a Cox regression model, adjusting for disease, stage, donor type, stem cell source, previous total body irradiation (TBI) and busulfan administration (oral vs. intravenous). Pretransplant patient characteristics were comparable in the two cohorts for age, gender, underlying disease, stem cell source, donor type and EBMT risk score, but differed in stage (advanced disease BU-CY 28 [84,8%] vs. CY-BU 40 [66.7%]) and previous TBI (BU-CY 16 [48.5%] vs. CY-BU 9 [15.0%]). Liver function as measured by levels of bilirubin and liver enzymes (aspartate amino transferase [AST], alanine amino transferase [ALT], gamma glutamyl transpeptidase [GGT] and alkaline phosphatase [AP]) was not different between the groups before starting conditioning regimen. In contrast liver function differed significantly at day 20, with higher levels of ALT (median 51.0 vs 27.0 IU/l; p=0.012) and a higher incidence of veno-occlusive disease (VOD) (5/34 vs. 1/59, p=0.036) in the BU-CY group (Figure 1A). The cumulative incidence of transplant-related mortality (TRM) at 2 years was significantly higher in patients receiving BU-CY (BU-CY 0.48, CY-BU 0.24, p=0.024; hazard ratio 4.594 for BU-CY, 95% CI 1.382-15.268, p=0.013) (Figure 1B). The cumulative incidence of TRM with BU i.v.-CY was lower (0.44) than with BU oral-CY (0.56) but still higher than CY-BU. This did translate into a higher overall survival in patients after conditioning regimen with CY-BU (hazard ratio for mortality 0.426 for CY-BU, 95% CI 0.184-0.987, p=0.047). Time to engraftment (BU-CY median 13 days vs. CY-BU median 14 days), cumulative incidence of acute GVHD and relapse were similar between patients receiving BU-CY or CY-BU. These data support the concepts derived from Sadeghi et al in their mouse model in favor of CY-BU compared to the traditional BU-CY. They form the basis for prospective controlled studies. [Display omitted] Disclosures:No relevant conflicts of interest to declare.

The Outcome of Unrelated Hematopoietic Stem Cell Transplants with Total Body Irradiation (800 cGy) and Cyclophosphamide (120 mg/kg) in Adult Patients with Severe Aplastic Anemia.

Abstract 3397Poster Board III-285 Backgrounds:We had reported the results of a pilot prospective study demonstrating the superiority of 800 cGy of total body irradiation (TBI) in combination with a 120 mg/kg of cyclophosphamide (CY) [TBI-800/CY-120] compared to the higher doses of TBI (1000 and 1200 cGy) as a conditioning regimen for unrelated stem cell transplantation (SCT) in adult patients with severe aplastic anemia (SAA) [Biology of Blood and Marrow Transplant 2007;13:836-870]. Patients and methods:To analyze the long-term results of unrelated SCT with TBI-800/CY-120 for adult SAA who failed to respond to immunosuppressive treatment, we prospectively enrolled 50 adult patients with SAA [median age, 28 years (range, 15-53)], including 26 patients of a previous pilot study. All patients received fractionated TBI (400 cGy/day) for 2 days followed by CY (60mg/kg/day, 2 days). Nine patients (18%) were very SAA. Enrolled patients had received multiple transfusions (median 64 units, range, 10-363) and long disease duration (median 48 months, range 2-323). High resolution DNA typing was done at HLA-A, -B, -C, -DR level. Seventeen patients (34%) received HLA-mismatched SCT at allele level. Thirty-eight patients (76%) received bone marrow and 12 (24%) peripheral blood stem cells (PBSC). All patients received tacrolimus and short-course of methotrexate as GVHD prophylaxis. Results:All patients achieved engraftment and the median day of neutrophil and platelet recovery was 13 days (range, 8-30) and 20 days (range, 9-200), respectively. There was one case of delayed platelet recovery, but platelet count rose slowly to the normal level thereafter. At a median follow-up of 38 months (range, 1-84), the estimated 3-year overall survival was 87.8%. The cumulative incidence of acute GVHD (aGVHD) over grade II (6/23, grade III and IV) and chronic GVHD (cGVHD) were 46.0% and 50.3% [limited (39%) vs. extensive (61%)], respectively. Among 7 patients who died, 4 patients and 1 patient died of severe aGVHD (grade III and IV) and cGVHD, respectively, 1 patient multi-organ failure, and 2 patient sepsis. Univariate analysis revealed the following risk factors: very SAA (P=0.018), HLA-mismatched donor at allele level (P=0.012), and older donor age (P=0.080) for aGVHD and previous aGVHD (P=0.030) and PBSC (P=0.024) for cGVHD. Multivariate analysis showed that only a HLA-mismatched donor at allele level (hazard ratio: 2.7, 95% CI: 1.2-6.2, P=0.018) was a significant factor associated with higher cumulative incidence of aGVHD over grade II. Conclusions:TBI-800/CY-120 conditioning resulted in excellent outcome of unrelated transplants in adult patients with SAA who had received multiple transfusions and long disease duration, which was comparable to those of matched sibling transplants. Additional strategies to prevent severe GVHD, for example, adding anti-thymocyte globulin, particularly for HLA-mismatched transplant and in case of PBSC as a stem cell source, will be helpful to improve the outcome in the future. Disclosures:No relevant conflicts of interest to declare.

Relationship between tacrolimus blood concentrations and clinical outcome during the first 4 weeks after SCT in children

The relationship between tacrolimus concentration and acute GVHD is not well known, with few published data available for lower target levels. We hypothesized that lower levels of tacrolimus would correlate with higher incidence of acute GVHD and poorer prognosis. Receiver operator characteristic curves (ROC) were used to quantify tacrolimus blood levels as predictors of grade II-IV acute GVHD. A total of 97 pediatric patients with hematological malignancies met the study criteria. On the ROC, a cutoff of 7 ng/ml provided the best balance between sensitivity and specificity (62.8 vs 68.2%, respectively). Cumulative incidence of acute GVHD was 65.9% (range 58.5-73.3%) in patients with mean tacrolimus concentration of < or =7 ng/ml and 34.8% (range 27.8-41.8%) in patients with mean tacrolimus concentration of >7 ng/ml (P=0.002). Incidence of non-relapse mortality (NRM) was higher in patients with tacrolimus of < or =7 ng/ml (42.9%; range 35.6-50.2%) than in patients with tacrolimus of >7 ng/ml (28.3%; range 17.4-39.2%; P=0.008). This translated into better EFS in patients with tacrolimus of >7 ng/ml (48.9%; range 39.8-58.0%) than in patients with tacrolimus of < or =7 ng/ml (31.8%; range 25.0-38.6%; P=0.031). Multivariate analysis showed that tacrolimus concentration was significantly associated with clinical outcomes. Mean whole-blood level of tacrolimus as continuous infusion should be maintained at > or =7 ng/ml for pediatric patients.

Reduced Intensity Conditioning (RIC) Regimen Followed By Allogeneic Hematopoietic Stem Cell Transplantation (HSCT) In Adult Patients (PTS) With Acute Lymphoblastic Leukemia (ALL)

Background: RIC regimens are less myelosuppressive, but still allow for successful engraftment with acceptable treatment-related mortality (TRM) in frail pts who otherwise would not be suitable candidates for HSCT. This is particularly relevant in ALL, since pts often sustain toxicity from dose-intense regimens, or may be diagnosed in advanced age. The antitumor effect of this approach is not well-established in ALL. Methods: We evaluated 30 ALL pts (19 M/11 F) treated from 1996 to 2008 with fludarabine 120 mg/m2, melphalan 140 mg/m2 and unmanipulated stem cells. GVHD prophylaxis consisted of tacrolimus and mini-methotrexate. Anti-thymocyte-globulin was added to matched unrelated pts. Results: Median age was 44 years (range 23–64). ECOG status at time of HSCT was 0 (n = 16), 1 (n = 10) or 2 (n = 4) with median co-morbidity score of 3 (range 0–7) by Charlson Comorbidity Index. 24 pts had B-lineage and 6 had T-lineage disease. Cytogenetic data were available for 26 pts; 19 had high-risk cytogenetics, including 9 with Ph+ disease. Disease stage at time of study entry was CR1 (n = 5), ≥CR1 (n = 12), or primary or refractory relapse (n = 13), with median 2 prior chemotherapy regimens (range 1–4); five pts had a prior allogeneic HSCT. Donor type was matched related (n = 13) or matched unrelated (n = 17) and stem cell source was bone marrow (n = 14) or peripheral blood (n = 16). The median total nucleated cell dose and CD34+ cell dose were 3.80 × 108 cells (range 0.68 – 17.16) and 4.15 × 106 cells (range 1.78 – 12.03), respectively. Median time to ANC 0.5 × 109/L was 13 days (range 10–24). Median time to platelet count 20 × 109/L was 18 days (range 10–57). Eight pts were alive at a median follow up of 12 months from HSCT (range 3–59). OS and DFS were 32% and 29%, respectively, at 1 year. Of note, only 1 among 5 pts in CR1 had disease progression, compared to 8 among 13 with refractory disease at time of HSCT. The cumulative incidence of acute GVHD, grades II-IV and III-IV were 40% and 13%, respectively, and chronic GVHD was 22% (7% for extensive). The cumulative incidence of TRM at 100 days and 1 year were 17% and 33%, respectively. There were 22 deaths: recurrence 14, infection 4, GVHD 4. Conclusion: RIC HSCT can provide disease control in patients with ALL, and merits further evaluation. Alternative treatment strategies need to be explored in pts with advanced disease. The observed TRM rate is comparable to previously reported rates in in heavily pre-treated leukemia patients.

Cyclosporin, methotrexate and prednisolone for graft-versus-host disease prophylaxis in allogeneic peripheral blood progenitor cell transplants

The utility of GVHD prophylaxis with cyclosporin, MTX and prednisolone (CSA/MTX/Pred) in allogeneic PBPC transplants is not well described although there are published data using this combination after bone marrow transplants. The effectiveness of this regimen on the prevention of GVHD was assessed in 107 consecutive sibling and less-than-ideal donor transplant recipients over a 5-year period and compared to that observed in 65 patients receiving standard CSA and short-course MTX without prednisolone. Oral prednisolone was commenced on day +14 at 0.5 mg/kg per day, increased to 1 mg/kg per day on day +21 to day +34 then gradually tapered and ceased by day +100. The cumulative incidence of acute GVHD (grades II-IV) to day 100 in those receiving prednisolone prophylaxis was lower (52 versus 76%, P<0.01). The onset of symptomatic GVHD requiring systemic treatment was delayed from a median of 41 days post transplant to 92 days. When assessment of the cumulative incidence of symptomatic GVHD continued to day +180 incidence became similar (74 versus 78%), there was no difference between the two groups in rates of relapse, transplant-related mortality, infections or chronic GVHD. We conclude that the addition of prednisolone to CSA/MTX delays the onset of early acute GVHD in PBPC recipients but has no impact on the overall incidence of GVHD.

Superior Long Term Progression Free Survival of Myeloablative Allogeneic Hematopoietic Stem Cell Transplantation for Multiple Myeloma Compared to Autologous Hematopoietic Stem Cell Transplantation after Identical Conditioning Regimen.

Allogeneic hematopoietic stem cell transplantation (HSCT) is a treatment option with curative potential that exploits graft versus myeloma effect (GVM). However, myeloablative allogeneic HSCT has been associated with high transplant-related mortality and its impact on risk of relapse has been questioned. The differences in conditioning regimens, GVHD prophylaxis and short follow up have limited our ability to assess the impact of GVM when comparing allogeneic and autologous HSCT.Method: We evaluated the long term outcomes of 74 consecutive patients under the age of 60 who underwent autologous (n=46) or related allogeneic HSCT (n=28) between 3/1994 and 12/2000 following a single myeloablative conditioning regimen of TBI (3 Gy daily on days -10 to -8), oral Busulfan 2.4 mg/kg per day (day -7 to -4) and Cyclophosphamide 60 mg/kg IV daily (day-3 and -2). GVHD prophylaxis was tacrolimus or cyclosporine with or without methotrexate.Results: There were no significant differences observed between groups in regard to gender, immunoglobulin subtype, stage, and time to HSCT and disease status at HSCT. However, there were younger patients with advanced disease in the allogeneic group (Table 1). With median follow up of 10 years as of 12/2006, the allogeneic group had superior progression free survival than autologous group (37% v 9%; P = 0.04). After HSCT, 12 of 22 and 9 of 39 evaluable patients improved to complete remission in the allogeneic and autologous group, respectively (55% v 23%; P=0.02). Overall survival favored the allogeneic group but was not statistically significant (46% v 23%; P=0.56). The cumulative incidence of relapse was 18% in the allogeneic group and 74% in the autologous group (P=0.0001). The cumulative incidence of non-relapse mortality (NRM) was 32% in allogeneic group and 11% in autologous group (P=0.001). The cumulative incidence of acute GVHD (grade II-IV) was 46% and the cumulative incidence of chronic GVHD was 73%.Conclusion: The superior long term progression free survival and lower relapse rate in the allogeneic group suggests strongly GVM effect. However, the NRM in the allogeneic group partially offset the overall survival benefit. The higher than expected OS rate for both allogeneic and autologous group may be related to a beneficial effect of myeloablative conditioning. Future strategies with reduced toxicity myeloablative conditioning regimens and improved GVHD prophylaxis may reduce NRM while harnessing GVM effect.Selected CharacteristicsCharacteristicsAutologousAllogeneicPMedian age at HSCT; y (range)53 (38–59)47 (30–56)0.01Disease status at HSCT, n0.12CR11 (24%)2 (7%)PR32 (70%)22 (79%)Stable or progressive3 (6%)4 (14%)Disease Status after HSCT, n0.79CR20 (44%)14 (50%)PR13 (28%)8 (29%)Stable or progressive6 (13%)0 (0%)Non-evaluable7 (15%)6 (21%)HSCT; hematopoietic stem cell transplantation, CR; complete remission, PR; Partial remission [Display omitted]

Allogeneic Stem Cell Transplantation (AlloSCT) for the Treatment of Therapy-Related Myelodysplastic Syndrome (tMDS) and Acute Myeloid Leukemia (tAML): Results from the Center for International Blood and Marrow Transplant Research (CIBMTR).

Cytotoxic chemoradiotherapy may lead to the development of tMDS and tAML. These disorders are associated with a poor prognosis with non-transplant therapy. We report outcomes of alloSCT for tMDS and tAML in 868 subjects transplanted between 1990 and 2004 at 211 centers in 33 countries. Subjects were excluded (n=322) if they had a prior disease predisposing to MDS or AML, if they had a diagnosis of tALL or had received a twin or cord blood transplant. 21% were ≤19 years old (yo); 55% were female and 63% had tAML (including 30% with prior tMDS). Prior diagnoses included Hodgkin lymphoma (23%) and non-Hodgkin lymphoma (21%), breast cancer (16%), ALL (12%), sarcoma (8%), germ cell tumor (6%), and autoimmune disorders (5%). There were rare cases (≤3%) of CLL, plasma cell disorders, neuroblastoma, Wilms and CNS tumors or other cancers. Prior treatment was chemotherapy in 43%, chemotherapy and radiation therapy in 51% and radiation therapy alone in 4%. Cytogenetic data (cd) at the time of transplant were known in 84%: good prognosis 4%, intermediate 61% and poor 34%. The IPSS score at diagnosis for subjects with tMDS was intermediate-2 or high in 54%. At transplant, 51% of subjects with tAML were in first complete remission (CR1), 7% ≥CR2, 15% in relapse and 27% were primary induction failures. For the tMDS pts, 37% had been treated with other modalities before receiving an alloSCT. Pre-transplant conditioning regimen was myeloablative (M) 77% and reduced intensity (RI or non-M) in the remainder. Donors were related 38% and unrelated 62%; 66% of the grafts were bone marrow and 34% peripheral blood stem cells. Cumulative incidence of acute GVHD (grade II-IV) @100 days was 39% (95% confidence interval [CI]), 35–42). Outcomes, with a median follow-up of 61 (range, 3–187) months were:Outcome:5 year probability (95% CI)Chronic GVHD30 (27–33)Treatment-related mortality (TRM)48 (44–51)Relapse31 (28–34)Disease-free survival (DFS)21 (18–24)Overall survival (OS)22 (19–26)In multivariate analysis (MVA), TRM was significantly higher in subjects >35 yo, in those with a poor (<90%) performance score (PS), with untreated MDS or if a mismatched related or unrelated donor was used. Relapse risk was higher for subjects >35 yo, with preceding ALL or poor prognosis cytogenetics or tAML not in CR. DFS and OS were lower in subjects >35 yo, with poor prognosis cd, AML not in CR or untreated MDS, or with a mismatched related or unrelated donor. Of 649 pts who died, the cause of death was tMDS or tAML in 33% and TRM in the others. The use of a RI or non-M conditioning regimen did not improve outcomes in the MVA. Approximately 20% of pts with tMDS and tAML achieve long term survival following alloSCT. Survival was significantly better in pts <35 yo, with good or intermediate risk cd, disease control at the time of transplant and having a matched related or complete or partially matched-unrelated donor. The 5 year survival was 50% (95% CI, 39–61) with all 4 good risk factors (grf); 25% (95% CI, 20–31) with any 3 grf, 19% (95% CI, 14–24) with any 2 grf, 12% (95%CI, 8–18) with only 1 grf, and only 4% (95%CI, 0–15) without any of these factors. In conclusion, these data may be helpful in guiding clinical decision-making on the role of alloSCT in the management of t-AML and t-MDS.

Use of Intravenous Busulphan for Reduced Intensity Conditioning (RIC) Haematopoietic Stem Cell Transplantation (HSCT) Is Associated with Delayed T-Cell Full Donor Chimerism and Lower Incidence of Acute Graft Versus Host Disease.

The use of IV busulphan (Bu) has reported improved bioavailability with lower variability of busulphan plasma levels, and may reduce the effects of transplant related toxicity particularly in the context of myeloablative regimens. In contrast, there is limited data avaliable on the use of IV Bu in the setting of reduced conditioning (RIC) regimens. We retrospectively analysed data from 163 consecutive patients treated at our centre for myeloid malignancies (AML n=78, MDS/MPD n=73, CML n= 12) using RIC HSCT, and evaluated the engraftment and chimerism kinetics as well as the early transplant outcomes between patients receiving either IV or oral Bu. Patients received fludarabine (30mg/m2 × 5 days), alemtuzumab (20mg × 5 days) and either oral Bu (4mg/kg × 2 days) or IV Bu (3.2mg/kg × 2 days). 84 consecutive patients received oral Bu up to Jan 2004. Thereafter, 79 consecutive patients received IV Bu. The median age of the cohort was 53 years(range: 19–72). 50 patients received stem cells from HLA-matched sibling donor, and 113 from a volunteer unrelated donor. 128 patients received PBSC and 35 received BM stem cells. 64 patients had early disease vs 99 advanced disease (advance disease defined as AML > CR1, CML > CP1, MDS with RAEB or AML with multilineage dysplasia). Median follow-up was 1531 days (range: 853–1987) for the oral Bu group and 551 days (range: 228–1072) for the IV Bu group. There was no difference between groups in terms of recipient age, stem cell dose/source, donor type, prior therapies or disease type. However, patients receiving IV Bu had more advanced disease compared with oral Bu (70% vs 52%, p=0.03). There was no significant difference in the median time to neutrophil and platelet regeneration between groups. In contrast lymphoid(CD3) engraftment was significantly delayed in the IV Bu group, with 35% vs 53%(p=0.04) recipients achieving full donor chimerism(FDC) at day 30, and 32% vs 51%(p=0.03) at day 100. The cumulative incidence of acute GvHD was lower in the IV Bu group 18% vs 29%(p=0.04), with no difference in the cummulative incidence of chronic GvHD between groups. Early(1-year) transplant-related mortality (TRM) was higher in the oral Bu group(TRM:: 25%vs13%, p=0.07) with a significantly lower overall survival(60%vs79%, p=0.02) primarily as a result of death from GvHD and related infection complications. There was no significant difference in relapse incidence at 1 year between cohorts(IV Bu 27% vs oral Bu 23%, p=0.84). On multivariate analysis, the type of conditioning regimen had no effect on the overall transplant outcomes. Attainment of CD3 FDC at day 30(HR: 2.14, 95%CI: 1.26–3.63, p<0.01) and advanced disease stage(HR:2.62, 95%CI: 1.41–4.89, p<0.01) were the only significant variables associated with a poorer OS. In contrast, the presence of CD3 mixed donor chimerism at day 30(HR:2.70, 95%CI: 1.24–5.90, p=0.01) was the only independent variable associated with improved TRM. Advanced disease stage was the only independent predictor of disease relapse(HR:2.34, 95%CI: 1.17–4.66, p=0.02). In summary, RIC HSCT with IV busulphan is a safe and well tolerated regimen. When compared with oral Bu, use of IV Bu as part of an FBC regimen is associated with delayed attainment of CD3 FDC, and is associated with a corresponding lower incidence of acute GvHD and early complications.

High Dose Chemotherapy Using Beam without Autologous Rescue Followed by Reduced Intensity Conditioning Allogeneic Stem Cell Transplantation for Refractory or Relapsing Lymphomas - A Comparison of Delayed Versus Immediate Transplantation.

Patients with refractory/relapsing lymphoma are rarely cured by chemotherapy, so that allogeneic Hematopoietic Stem Cell Transplantation (HSCT) is often considered as an alternative despite being associated with substantial mortality. Reduced intensity conditioning (RIC) HSCT can induce a graft-vs-lymphoma (GvL) effect but relapse rate is high in advanced disease. High dose chemotherapy (HDC) for tumor debulking given before RIC HSCT has been advocated as a concept. We prospectively compared in a single center two sequential strategies in patients with refractory or relapsing lymphoma: a first cohort (group A) received BEAM chemotherapy without autologous stem cell support followed by delayed RIC HSCT at day 28. The second cohort (group B) received BEAM followed immediately by RIC HSCT. RIC HSCT was based on fludarabine 3×25 mg/m2 followed by 200 cGy TBI. Pretransplant characteristics were comparable in the two groups: group A included 10 patients, 7m/3f, median age 51 years (range 25–63) with 2 CLL, 3 follicular lymphomas (FL), 1 DLBCL, 2 Hodgkin lymphomas and 2 other B-cell lymphomas. Group B included 11 patients, 5m/6f, median age 48 years (range 31–59) with 4 CLL, 3 FL, 2 DLBCL, and 2 other lymphomas. Donors were HLA identical siblings (8 and 9 in group A and B) or unrelated donors (2 in each group).Three patients died before day 100 in group A (all from acute GvHD), whereas none died in group B. Non-hematological toxicity of the regimen before engraftment was comparable, only gut toxicity was higher in group B. As expected, days in aplasia (36 vs 12 days; A vs B; p< 0.001), days on antibiotics (61 vs 26 days; p =0.016) and length of hospital stay (36 vs 63 days; p =0.017) were significantly different. Cumulative incidence of acute GvHD ≥ grade II (90% vs 36% p= 0.01) and incidence of cGVHD (7/7 vs 6/11, p= 0.03) was higher in group A; hence we failed to show an advantage of separating RIC HSCT from the cytokine storm induced by BEAM. At last follow up, 7/10 patients in group A (median follow up 51 months) were alive, 6 of them in CR, 1 relapsed 9 months after RIC HSCT. In group B (median follow up 20 months), 9/11 patients were alive, 7 of them in CR, 1 in PR and 1 with no change. The two deaths in group B were related to cGvHD. No significant difference in 3 year overall survival (70% ±14% vs. 76%±14%, p= 0.53) was seen. These data challenge the initial concept of debulking first and delaying allogeneic RIC HSCT. They demonstrate encouraging tumor response and acceptable toxicity in patients with relapsing or refractory lymphoma. We confirm that allogeneic HSCT is a valid alternative for patients with resistant/relapsed lymphoma. These patients should be considered candidates for allogeneic HSCT earlier in the course of their disease and direct standard full conditioning with BEAM should be considered.

Randomized Comparison of 4-Times-Daily Versus Once-Daily Intravenous Busulfan in a Conditioning Therapy for Hematopoietic Cell Transplantation (HCT).

Several single-arm studies have shown that once-daily or twice-daily intravenous busulfan (iBU) may be equally safe and effective compared to traditional 4-times-daily iBU. We performed a prospective randomized trial of 4-times-daily vs. once-daily dosing of iBU in a conditioning therapy for HCT, and compared pharmacokinetic (PK) characteristics of iBU and clinical outcomes in terms of engraftment, post-HCT toxicities, non-relapse mortality (NRM), and overall survival. All of 60 patients, who received iBU on the first day of conditioning therapy for HCT, were randomized to receive iBU either as 0.8 mg/kg over 2 hr 4 times a day (BU4 arm) or 3.2 mg/kg over 3 hr once a day (BU1 arm) between May 2004 and August 2005. Limited sampling strategy was used for PK studies, which were done for the first busulfan dosing. Baseline patient and donor characteristics were well balanced between 2 arms regarding sex, age, diagnosis of underlying disease, time from diagnosis to HCT, disease status at HCT, GVHD prophylaxis regimen, conditioning therapy regimen, ABO mismatch between donor and recipient, donor-recipient sex pair, donor age, type of graft, donor type, and cell doses of graft. The complete PK data were obtained from all 60 patients and those were comparable between 2 arms: elimination half-life (mean ± SD) was 2.75 ± 0.22 vs. 2.83 ± 0.21 hr in BU4 arm vs. BU1 arm, respectively (P=0.304), estimated AUC was 7933.43 ± 2177.71 vs. 8556.86 ± 2452.07 μM × min per day (P=0.367), and clearance was 2.05 ± 0.36 vs. 1.91 ± 0.31 ml/min/kg (P=0.133). Median times to engraftment of neutrophils (BU4 arm vs. BU1 arm, 14 vs. 14 days, P=872) and platelets (26.5 vs. 25.5 days, P=0.946) after HCT were similar between 2 arms. There were no significant differences in cumulative incidence of acute GVHD (BU4 arm vs. BU1 arm, 31.0% vs. 13.8%, P=0.145) and occurrence of CMV infection (40.0% vs. 23.3%, P=0.165) or hepatic veno-occlusive disease (10.0% vs. 16.7%, P=0.448). Other toxicities within 100 days after HCT were not significantly different between two arms. Cumulative incidence of NRM was 25.5% vs. 17.3% (P=0.488) and overall survival probability at 1 year was 69.0% vs. 70.0% (P=0.758). In conclusion, our randomized study demonstrates that once-daily iBU has similar PK profiles and results in at least not inferior clinical outcomes compared to traditional 4-times-daily iBU.

Reduced-Intensity Unrelated Cord Blood Transplantation (RICBT) for Myelofibrosis (MF).

Introduction: Although allogeneic hematopoietic stem cell transpslantation is the only curative treatment for patients with MF, the potential role of cord blood transplantation remains still unclear. We report the results of RICBT for hematological diseases with primary and secondary MF.Patients and Methods: We reviewed medical records of 179 patients with advanced hematological diseases who received RICBT between March 2002 and June 2005 at our institution. Of 179 patients, pre-transplant bone marrow specimens were available for 82 patients. We evaluated bone marrow specimens by aspiration and trephine biopsy. Aspiration may be not enough to evaluate marrow fibrosis, but could reflect fibrotic change in bone marrow (Am J Clin Pathol 1971; 56: 25). One patient had primary MF and 47 had secondary. Underlying diseases for secondary MF included AML/MDS (35), ALL (6), CML (1), severe aplastic anemia (2), malignant lymphoma (2), essential thrombocythemia (1). For staging of MF, we used pathological criteria by Michiels (Int J Hematol 2000; 76: 133). MF0: no reticulin fibrosis (n=35), MF1: slight reticulin fibrosis (n=38), MF2: marked increase in reticulin and slight to moderate collagen fibrosis (n=8), MF3: advanced collagen fibrosis-osteosclerosis (endophytic bone formation) (n=1). Median age of the patients was 55 years (17–71). Most of the conditioning regimens were fludarabine 125 mg/m2, melphalan 80 mg/m2 and TBI 4 Gy. GVHD prophylaxis was cyclosporine (n=35) or tacrolimus (n=47). The median number of infused nucleated cells: 2.66 x 10e7 cells (1.67_5.24 x 10e7); CD34 positive cells: 0.69 x 10e5 cells (0.11_3.90 x 10e5); HLA disparity: 6/6 (n=4), 5/6 (n=14), 4/6 (n=60), 3/6 (n=4).Results: Neutrophil engraftment at day 50 was observed in 70.8 % with MF (median 22 days) and 73.7 % without MF (median 22 days). Platelet engraftment at day 100 was observed in 40.0 % with MF (median 42 days) and 60.0 % without MF (median 40 days). There was no statistical significance in neutrophil and platelet engraftment between patients with MF and without MF. Of 48 patients, 6 showed biopsy-proven MF greater than stage 1. Their neutophil and platelet engraftment was observed in 100 % (median 22 days) and 66.7 % (median 48 days), respectively. Cumulative incidence of acute GVHD (II–IV) was 17 % with MF and 28 % without MF. There was no statistical significance. The estimated OS was 25 % with MF and 52 % without MF (p=0.03) (Figure 1). Most cause of death with MF was relapse.Conclusion: Despite of marrow fibrosis, neutophil and platelet engraftment was not influenced. These results have suggested that RICBT is feasible for MF. However, the existence of MF could be poor prognostic factor of RICBT for hematological diseases due to relapse. [Display omitted]

Comparison among Related Peripheral Blood Stem Cell Transplantation (R-PBSCT), Unrelated Bone Marrow Transplantation (U-BMT), and Unrelated Cord Blood Transplantation (U-CBT) with Reduced Intensity Regimens for Acute Myeloid Leukemia (AML) and Myelodysplastic Syndrome (MDS).

<Background> Previous reports about comparison between unrelated donor and cord blood for acute leukemia with myeloablative regimens showed that at least relapse rate (RR) and overall survival (OS) were not significantly different in the two groups. However we have not yet understood comparison among R-PBSCT, U-BMT, and U-CBT with reduced intensity regimens for elderly AML/MDS patients.<Objective> The 1st purpose of this report was to investigate OS and causes of death and the 2nd was to investigate engraftment, incidence of acute/chronic GVHD, and RR for AML/MDS patients received R-PBSCT, U-BMT, and U-CBT with reduced intensity regimens.<Patients/Methods> We reviewed medical records of 62 AML/MDS patients who had received RIST between June 2001 and March 2005 at Toranomon Hospital, Tokyo, Japan. 20 patients received R-PBSCT, 19 patients U-BMT, and 23 patients U-CBT. Median age was 56 years (17–70). Primary diseases were de novo AML (n=34) and MDS overt leukemia (n=11), and MDS (n=17) including advanced (n=47) or standard (n=15). Median follow-up was 7.2 months (1.5–37). Conditioning regimen consisted of Fludarabine (Flu) + Busulfan (BU) with cyclosporine (CyA) + MTX in R-PBSCT, Flu + BU + TBI 4Gy with CyA or tacrolimus +MTX in U-BMT, and Flu + Melphalane (Mel) + TBI 4Gy with tacrolimus only in U-CBT, respectively. G-CSF was used after RIST until neutrophile engraftment.<Results> HLA disparities were 6/6 match (n=18) and 5/6 (n=2) in R-PBSCT, 6/6 (n=18) and 5/6 (n=1) in U-BMT, and 5/6 (n=2) and 4/6 (n=21) in U-CBT, respectively (P<0.001) and infused CD34 cell counts were 3.6, 1.53, and 0.081 ×10E6/kg, respectively (P<0.001). Neutrophile (>500/μL)/platelet recovery (>20,000/μL) were observed 100% (median 16.5 days) and 90% (13.5) in R-PBSCT, 90% (20) and 79% (26) in U-BMT, and 91% (21.5) and 70% (41.5) in U-CBT, respectively (P<0.05). In R-PBSCT, U-BMT, and U-CBT cumulative incidence of acute GVHD (II-IV) was 50%, 59% and 30%, and chronic GVHD was 30%, 29%, and 25%, respectively (NS). Causes of death included infections (n=5), GVHD (n=8), TRM (n=1) and progressive disease (n=16) in total cases after RIST and there was no difference among three groups. OS was 43% (95% CI: 26–59) in all cases, 69% (95% CI: 26–59) in standard, and 39% (95% CI: 24–54) in advanced, respectively (p<0.05). According to stem cell sources, OS and RR was 64%, 34% in R-PBSCT, 68%, 35% in U-BMT, and 59%, 45% in U-CBT, respectively (NS).<Discussion/Conclusion > In this report, the differences were followings; HLA disparities, infused CD34 cell dose, conditioning regimen with GVHD prophylaxis, neutorphile and platelet engraftment. The incidence of acute/chronic GVHD, OS, RR, and causes of death were same among three groups. This Flu+Mel+TBI 4Gy + tacrolimus with U-CBT would be feasible and acceptable for elderly patients with AML/MDS. [Display omitted]

Reduced-Intensity Unrelated Cord Blood Transplantation (RICBT) for Adults with Hematological Diseases.

<Introduction>The potential role of RICBT in adults remains unclear. This study reports the results of RICBT for adults with hematological diseases.<Objective>The 1st purpose of this report was to investigate the risk factors of non-relapse mortality (NRM) within day 100 of RICBT and the 2nd was to identify its prognostic factors.<Patients and Methods>We reviewed medical records of 107 patients with advanced hematological diseases who had received RICBT between March 2002 and June 2004 at Toranomon Hospital, Tokyo, Japan. Median age of the patients was 55 years (17–79). Primary diseases were advanced (n=88) or standard (n=19). Median follow-up was 14 months (0.5–27). Conditioning regimen was fludarabine 125 mg/m2, melphalan 80 mg/m2 and TBI 4 Gy. GVHD prophylaxis was cyclosporine (n=87) or tacrolimus (n=26). Median total nucleated cells (TNC): 3.2 x 10^7 cells (1.7–4.3); Median CD34+: 1.4 x 10^5 cells (0.21–3.28); HLA match: 6/6 (n=4), 5/6 (n=3), 4/6 (n=95), 3/6 (n−1). Time to event curves were plotted by using the actuarial method of Kaplan-Meier, and differences between curves were analyzed by log-rank tests. The following factors were considered potential predictors of outcomes about 1st and 2nd purpose: age, weight, sex, risk, HLA disparities, TNC, CD34+, GVHD, pre-engraftment reactions (PER) that we have reported (Clin Cancer Res.10:3586-92, 2004), and use of steroids for PER. All factors were tested for the proportional hazards assumption.<Results>Neutrophile (>500/μL) and platelet recovery (>20,000/μL) were observed in 77.9% at day 60 (median; 19.5 day), 48.7% at day 100 (45.5 day), respectively. Primary graft failure was occurred in 8% of all cases. Cumulative incidence of acute GVHD (II-IV) and chronic GVHD were 39.8% and 21.1%, respectively. Causes of NRM included infections (n=30), regimen related mortality (RRM) (n=19), and GVHD (n=6). Incidence of NRM at day 100 was 51.6% (95% CI: 42–61), 33 patients with use of steroids for PER had NRM at day 100 of 75% (95% CI: 67–94), as compared to 39% (95% CI: 25–48) in 77 patients without use of steroids (p<0.05). The estimated OS was 29.9% (95% CI: 17.8–40.2) in all cases, 54.5% (95% CI: 29.8–78.4) in standard, and 21.2% (95% CI: 6.7–35.7) in advanced (p<0.05), respectively. In multivariate analysis, the most important risk factor of NRM was use of steroids for PER (p<0.05), while other factors did not influence. As for OS, disease status and use of steroids for PER were significant predictors of OS (p<0.05).<Discussion and Conclusion> RICBT is associated with a high NRM. This study has demonstrated status of underlying diseases and use of corticosteroid for PER as a significant prognostic factor. Eligibility of RICBT needs to be investigated, and further studies are warranted to clarify the pathogenesis of PIR and its optimal management. [Display omitted]