Gy TBI Research Articles

Case Report: Haploidentical Stem Cell Transplantation In a 78 Year-Old Patient

An older chronologic age has been a consistent predictor of poor outcomes in hematopoietic stem cell transplantation (HSCT), mainly due to non-relapse mortality (NRM). Therefore, non-curative treatment strategies are commonly adopted for these patients. However, mortality and treatment toxicity has decreased as a result of improved supportive measures, such as reduced intensity conditioning regimens and optimized infection management. T-cell replete haploidentical HSCT emerged as a feasible alternative for leukemia patients without substantial differences in outcomes when compared to fully matched related donor. We report an old adult woman treated with haploidentical HSCT.A 78 year-old female patient presented with anemia, leukocytosis, thrombocytopenia and blasts in the peripheral blood. Diagnosis of acute myelogenous leukemia was established. Conventional cytogenetic demonstrated chromosome eight trisomy, and FISH was negative for other common MDS/AML cytogenetic abnormalities. FLT3-ITD and NPM1 mutations were negative. Her medical history was negative except for heavy smoking. Considering the patients advanced age, the first attending physician chose not to administer intensive treatment and started on decitabine 20 mg/m2 for 5 days. She was refractory to the first-line treatment with persistent cytopenias and blasts in the peripheral blood four weeks after treatment was started. Comprehensive geriatric assessment was performed. She was considered independent for Basic Activities of Daily Living (ADL score 6) and Instrumental Activities of Daily Living (IADL score 27), without cognitive impairment in mini-mental state examination (MMSE score 30), at risk of malnutrition in mini nutritional assessment (MNA 9). As she was considered fit, we decided to perform high-dose chemotherapy with idarubicin and cytarabine, but, once more, the disease was refractory. A rescue regimen was attempted with high-dose cytarabine and mitoxantrone, again, with no response. After discussing pros and cons with the patient and the family, we decided to start Another regimen consisting of topotecan and high dose cytarabine immediately followed by allogeneic hematopoietic stem cell transplantation (HSCT). At day 14, she had 3% blasts in the BM aspirate a T-cell replete haploidentical HSCT using her 52 year-old son as donor and mobilized peripheral blood as stem cell source was performed. Conditioning regimen consisted of fludarabine, cyclophosphamide, TBI 2Gy and post-transplant cyclophosphamide. Graft versus host disease (GVHD) prophylaxis consisted of mycophenolate mofetil and cyclosporine. She had neutrophil engraftment with complete donor chimerism at day+15 and platelet engraftment at day+17. At day+48, she had mild (stage II) skin acute GVHD resolved with topical steroids. Cyclosporine was withdrawn at day+ 93. Due to high relapse risk, the patient was started on monthly post-transplant azacitidine 36 mg/m2. At day+100 the patient remained in complete remission, complete donor chimerism in peripheral blood and bone marrow. Functionality was preserved (ADL score 6 and IADL score 24), presented discrete cognitive impairment (MMSE 28) and malnoutrition (MNA 5). She is now at day+182, doing well and performing again all usual daily activities.To the best of our knowledge, this is the oldest patient treated with haploidentical HSCT. Post transplant cyclophosphamide as T cell depletion strategy in haploidentical HSCT is well tolerated and widely available, being therefore an excellent alternative for patients without conventional donors who require immediate transplant. Older adults with hematologic malignancies are a heterogeneous group and decisions based on chronological age alone are clearly inappropriate. Recently, geriatric assessment proved to be an important prognostic tool in acute leukemia and may be useful in HSCT. In experienced centers, haploidentical HSCT in older adults may be a safe procedure and more accurate pre-transplantation risk stratification tools should be developed. [Display omitted] Disclosures:No relevant conflicts of interest to declare.

Cardiac Toxicity Of High Dose Cyclophosphamide Post T Cell Replete HLA Haploidentical Hematopoietic Stem Cell Transplantation

BackgroundT cell replete (TCR) HLA haploidentical hematopoietic stem cell transplantation (SCT) using high dose cyclophosphamide post-transplant (HDCy) to prevent graft versus host disease (GvHD) and graft's rejection is a promising approach which extends the possibility of grafting patients who lack a conventional donor. Notably, non relapse mortality (NRM) is greatly decreased compared to T-cell depleted haploidentical SCT, giving a low rate of lethal infections or severe GvHD and allowing the possibility to reduce doses of conditioning regiment without impairing the engrafting of the TCR bone marrow. Nevertheless, HDCy post transplant might increase the risk of cardiac toxicity. MethodsFrom March 2012 to July 2013, 11 consecutive adult patients received a TCR haplo-SCT for high risk hematological malignancies: de novo or secondary acute myeloid leukemia (AML) with unfavorable cytogenetics in CR1 (n=5), refractory AML (n=2), chronic myeloid leukemia (n=2), and refractory Hodgkin disease (n=2). Patients with myeloid disease received a myeloablative conditioning (MAC) (Cy 30mg/Kg/d at day -4 and -3 + TBI 12Gy or Busulfan 3.2mg/Kg/d for 4 days + Cy 14.5mg/Kg at day-3 and day-2 + Fludarabine 90mg/m2) or a reduced intensity conditioning (RIC) with Melphalan 140 mg/m2 + Thiotepa 10mg/m2 + Fludarabine 160mg/m2. Two patients with Hodgkin disease and 1 patient who rejected a previous MAC-double cord blood received a RIC with Cy 14.5mg/Kg at day-6 + TBI 2gy + Fludarabine 150mg/m2. Ten patients received HDCy 50 mg/kg/day on days +3 and +4, plus tacrolimus and mycophenolate mophetil for GvHD prophylaxis. In one patient, HDCy was reduced to 50mg/Kg at day+3. All patients but one received a bone marrow graft. Median age was 39.1 (range 22-62). Donors were related for 10, and unrelated for 1 patient with a median of 5.4/10 allele matches (range 5-8). Cardiac evaluation pre-SCT was performed for all patients. Cardiac ultrasound was normal for all (median left ventricular ejection fraction was 62%; range 53-67%). None of the patients had cardiovascular risk factors such as hypertension, diabetes, obesity or history of valvular or ischemic cardiopathy. Median Sorror score was 0.63 (range 0-2). The rate of early deaths (within the 1st month post transplant) related to cardiac toxicity was compared to that of the whole cohort of 875 patients who received an allogeneic HSCT in our center from May 1984 to July 2013 without HDCy post transplantation. ResultsAmong the 11 patients who received HDCy post SCT, 3 patients developed a compressive pericardial effusion at day 4, day 14 and day 41. An extensive microbiological research found no infectious etiology of this cardiac complication and toxicity of HDCy post transplant was the most probable. One patient had received a MAC (TBI 12Gy –Cy) and the 2 other patients had received the RIC Mel-Thio-Flu regimen. Evolution was reversible for 2 patients after the administration of angiotensin-converting enzyme inhibitors and/or pericardial drainage. One patient died at day+16 of a refractory cardiogenic shock.In the control cohort, early death correlated to cardiac toxicity was reported in 6 patients out of 875 (0.69%), as compared to 1/11 (9%) in the haploidentical cohort. In the control cohort, median age of patients who died from cardiac toxicity was 40.1 (range 30-51). All but 1 received a MAC including HDCy pre-transplantation. No HDCy was administered after SCT. The death occurred at a median time of 14.6 days post-transplant. No early death correlated to cardiac toxicity was reported after 1 month post SCT. ConclusionAlthough limited by the small number of patients, the rate of cardiac toxicity seems to be increased after HDCy post TCR haplo-SCT. This toxicity is probably multi-factorial and HLA mismatches syndrom may contribute to the severity of symptoms. Nevertheless, such severe and early cardiac complication is an unusal observation in patients without any particular cardiovascular risk factor or other co-morbidities at the time of transplant. Caution should be taken during the days following the administration of HDCy in collaboration with intensive care specialists. Disclosures:Leblond:Roche : Consultancy, Honoraria, Membership on an entity's Board of Directors or advisory committees, Speakers Bureau; Janssen: Honoraria, Membership on an entity's Board of Directors or advisory committees; Mundipharma: Honoraria, Membership on an entity's Board of Directors or advisory committees, Speakers Bureau.

Allogeneic Stem Cell Transplantation In Adults With High Risk Acute Lymphoblastic Leukemia (ALL) In 1. Remission (CR1): Promising, But Strongly Influenced By ALL Subtypes

Stem cell transplantation (SCT) has contributed to improved overall survival particularly in high risk adult ALL patients and the indication for SCT is a matter of ongoing discussion. We report the results obtained over a period of 18 years in a large center. Patients received first line treatment according to three consecutive trials of the German Multicenter Study group for Adult ALL (GMALL) and risk stratification was performed accordingly. In the most recent trial patients with high risk and very high risk factors are candidates for allogeneic stem cell transplantation (SCT) in CR1 from matched sibling or unrelated donors. The risk factors are: very high risk (VHR): Philadelphia chromosome positive ALL (Ph+ALL); high risk group (HR) of B-lineage ALL (HR-B): leukocytes > 30/nl at diagnosis and/or delayed CR > 3 weeks (other B) or pro B-ALL and of T-lineage ALL (HR-T): early-T-All and mature T-ALL. In addition standard risk patients were candidates for SCT in case of molecular failure or molecular relapse (SR-Mol). 106 high risk ALL patients in CR1 underwent allogeneic SCT between 1995 and 2012 at our center. Median age was 38 years (17 – 67). 40/106 patients had Ph+ALL (VHR), 57/106 patients were HR patients (HR-B n = 32: pro-B-ALL n = 15, other B n = 17; HR-T n = 25: early T n = 17, mature T n = 4, thymic n = 4). 9/106 patients belonged to the SR-Mol group. Stem cell donors were matched related donors (MRD) in 42 patients and compatible unrelated donors in 64 patients. The conditioning regimen was 12 Gy TBI ± Cyclophosphamide or VP16 in 86 patients, other n = 1, and in patients > 55 years 8 Gy TBI + Fludarabine (n = 5) or Fludarabine + Busulfan (n = 14). ATG as GvHD and rejection prophylaxis was given since 5/2005 in all patients with unrelated SCT and in reduced intensity conditioning regimens (RIC). Results60/106 (57 %) patients with high risk ALL transplanted in CR1 are alive, 46/106 (43 %) patients are dead. The median follow-up of the surviving patients is 64 months (5 – 172). Causes of death were leukemia in 16/106 patients (15%) and transplant-related mortality (TRM) in 30/106 patients (28%), mainly infections ± GvHD (n = 24), secondary malignancies (n = 2) and other (n = 4). In Ph+ALL 19/40 patients (47 %) are alive in CR (CCR), 12/40 are dead due to TRM and 9/40 due to leukemia. In HR-B ALL 23/32 patients (71 %) are in CCR, 8/32 are dead due to TRM and 1/32 due to leukemia. In HR-T ALL 11/25 patients (44 %) are in CCR, 10/25 died due to TRM and 4/25 due to leukemia. In SR-Mol patients 7/9 patients (77 %) are in CCR, 2/9 died due to leukemia. Probability of survival (OS) for all patients at 96 months is 0.48, probability of disease free survival (DFS) at 96 months is 0.47, probability of TRM at 96 months is 0.34. OS was 0.50 for patients with myeloablative conditioning (MAC) (n = 86) and 0.38 for patients with RIC (n = 19), n.s. OS was different for the 4 risk groups: VHR 0.42, HR-B 0.67, HR-T 0.27, SR-Mol 0.74, but not significant (0.095). DFS: VHR 0.42, HR-B 0.68, HR-T 0.24, SR-Mol 0.76 (0.041) and TRM: VHR 0.34, HR-B 0.26, HR-T 0.58, SR-Mol 0. (0.026). In HR-B OS was better for pro-B-ALL than other B-lineage (0.73.vs. 0.66, resp.). OS was lower in early-T-ALL (0.24). In mature T-ALL 3/4 patients are dead, in thymic ALL 1/4 patients. In ConclusionLong term survival and probably cure can be reached in high risk ALL patients after allogeneic stem cell transplantation in CR1. OS in pro-B-ALL and B-lineage-HR-ALL patients is better than in Ph+ALL or in HR-T-ALL due to lower relapse rate and lower TRM. Whether the quality of remission before allogeneic SCT could be improved in Ph+ALL and HR-T-ALL, has to be studied. Allogeneic SCT in SR with molecular failure or relapse show promising data, though in a small patient cohort. For all patients the TRM-rate due to GvHD and infection has to be improved due to better supportive care. Disclosures:No relevant conflicts of interest to declare.

Intensification Of Treosulfan and Fludarabine-Based Conditioning With 4 Gy TBI For Allogeneic Stem Cell Transplantation In Patients With Hematological Malignancies

BackgroundHematopoietic stem cell transplantation (HSCT) is so far the only potentially curative option for patients with aggressive hematological malignancies. Since many patients cannot find a suitable HLA-identical (related or unrelated) donor, it is essential to analyze the safety of alternative graft sources, such as haploidentical donors. The use of reduced-intensity conditioning regimens in patients with an advanced disease did not improve the outcome because of a higher incidence of relapse. Here we present an interim analysis of this phase II prospective clinical trial that investigates a new conditioning regimen for allogeneic HSCT based on a well established one (Fludarabine and Treosulfan) intensified adding 4 Gy TBI with the aim of maintaining an acceptable toxicity profile while reducing the incidence of relapse in high-risk patients (TrRaMM4Gy study, Eudract 2011-001534-42). Patients and MethodsNinety-six patients underwent allogeneic HSCT for AML (n=46), ALL (n=13), acute biphenotypic leukaemia (n=2), HD (n=8), NHL (n=7), MDS (n=6), Myelofibrosis (n=5), MM (n=4), CML (n=2), CMML (n=2) or CLL (n=1). The median age was 45 years (range 17-67). At the time of the transplantation most patients (n=76) were in advanced disease phase, while the remaining 20 patients were in early phase. Twenty-eight patients were enrolled for relapse after a previous allogeneic HSCT. Median time from diagnosis to transplantation was 443 days (range 56-5249). Median comorbodity index score (according to Sorror criteria) was 2 (range: 0-8). Sixty-two patients received the graft from haploidentical donors, 17 from MUD, 14 from HLA-identical sibling and 3 patients from a single cord blood unit. Median number of CD34+ and CD3+ cells/kg were 6.46 millions and 241 millions respectively. The conditioning regimen included Treosulfan (14 g/m2 for 3 days), Fludarabine (30 mg/m2 for 5 days) and 4 Gy TBI split in 2 fractions. Patients receiving HSCT from haploidentical donor (arm A) were also treated with ATG-Fresenius (10 mg/kg for 3 days) and Rituximab (200 mg/m2 in single dose), patients receiving HSCT from HLA-identical sibling, MUD or single cord blood unit and in early disease status (arm B) were also treated with ATG-Fresenius (5 mg/kg for 3 days) and Rituximab (200 mg/m2 in single dose), while patients receiving HSCT from HLA-identical sibling, MUD or single cord blood unit and in advanced disease status (arm C) did not receive any ATG or Rituximab. GvHD prophylaxis consisted of Sirolimus (target concentration 8-15 ng/ml, till day +60) and Mycophenolate Mofetil (10 mg/kg tid till day +30). ResultsNeutrophils engraftment was reported at a median time of 17 days (range: 9-46) in all 91 evaluable patients; five patients died of transplant-related causes (n=4) or disease progression (n=1) before day +15. Platelets engraftment occurred after a median time of 17 days (range: 4-153) in 75 patients (82%). At the first marrow evaluation on day +30 all the evaluable patients showed full donor chimerism, 77 patients (90%) were in complete remission and 9 were in stable disease or progression. After a median follow-up of 425 days, cumulative incidence of grade 2-4 and 3-4 aGvHD were 40% and 26% respectively. Cumulative incidence of moderate or severe cGvHD (according to NIH criteria) was 57%. Cumulative incidence of NRM at day +100 and +365 were 23% and 36% respectively; cumulative incidence of relapse at day +365 was 33%. Overall survival and progression-free survival 1 year after HSCT were 51% and 43% respectively. EBV reactivation occurred in 7 patients, but no PTLD was observed. ConclusionsThe new conditioning regimen we investigated proved to be feasible in this high-risk population. We did not observe any major difference in terms of NRM and aGvHD compared to the data from our previous trial (TrRaMM, Eudract 2007-5477-54) with similar inclusion criteria and patient characteristics, but a reduced-intensity conditioning regimen based on Treosulfan and Fludarabine. Interestingly, we observed a trend of lower relapse incidence, resulting in a better OS and PFS. The low toxicity profile of Treosulfan and Fludarabine should be considered as a myeloablative platform for further intensification; more studies are warranted in order to find the association for a conditioning regimen endowed with a low toxicity profile but still a strong anti-tumor activity. Disclosures:Bonini:MolMed SpA: Consultancy.

Post-Transplant Cyclophosphamide Following a Myeloablative Conditioning For Hematologic Malignancies Receiving An Unmanipulated Haploidentical Bone Marrow Transplant

BackgroundUnmanipulated family haploidentical transplants are becoming increasingly used in patients lacking an HLA identical family donor, or a well matched unrelated donor. Aim of the studyThis is an updated analysis of our program of haploidentical bone marrow transplant (hBMT) , followed by post-transplant high dose cyclophosphamide (PT-CY) in 95 patients with hematoloigic malignancies receiving a myeloablative conditioning. MethodsThe conditioning regimen consisted of thiotepa, busulfan, fludarabine (TBF) (n=47) , thiotepa melphalan fludarabine (n=5) , or 9.9-12 Gy TBI + fludarabine (n=43). The patients' median age was 49 years (17-74); the disease status at the time of transplant, was first complete remission (CR1, n=29) , CR2 (n=23), or active disease (n=38,40%). The diagnosis was AML (35%), ALL (24%), MDS (12%) myeloproliferative disorders (12%), other malignancies (17%). The total nucleated cell dose infused was 3.37 (1.4-9.17). The median follow up for surviving patients is 440 days (90-930). Graft versus host disease (GvHD) prophylaxis consisted in PT-CY on day+3 and +5 , cyclosporine (from day 0) , and mycophenolate (from day +1).▪ ResultsThe cumulative incidence of neutrophil (PMN) engraftment was (90%) and all surviving patients on day +30 had full donor chimerism. The median day for neutrophil engraftment was day +17 (11-32). The cumulative incidence (CI) of grade II-III acute GvHD was 14%, and of moderate chronic GvHD 8%, severe cGvHD 9%. The CI of transplant related mortality (TRM) is respectively 7%, 17%, 26% for patients in CR1, CR2, or with active disease. The CI of relapse is respectively 17%, 30%, 37% for patients in CR1, CR2, or with active disease. The overall actuarial survival is respectively 75%, 44%, 32% for patients in CR1, CR2, or with active disease (p=0.002) (Fig.1). The most frequent cause of death was leukemia (26%) followed by infections (9%). ConclusionsThese data confirm our first report on 50 patients and support the use of myeloablative conditioning regimens, followed by h-BMT with PT-CY. The risk of acute and chronic GvHD seems relatively low , as well as the overall transplant related mortality. We have not seen the excess relapse rate reported when patients are given a non myeloablative regimen, and disease control has been satisfactorily both for patients in remission, as well as for patients with active disease at the time of transplants. Disclosures:No relevant conflicts of interest to declare.

Host Tissue PD-1 Pathway Contribute To Murine Chronic Graft-Versus-Host Disease Via Th1+Th17+ Cells

Chronic graft-versus-host disease (cGVHD) remains a major cause of late-phase mortality and morbidity after allogeneic hematopoietic stem cell transplantation. Programmed death-1 (PD-1) and its ligands B7H1 and B7DC, which deliver inhibitory signals and regulate T cell activation, tolerance, and immunopathology, are involved in autoimmune disease. Although several studies have shown that blocking the PD-1 pathway enhances acute GVHD, its relationship to cGVHD remains unclear. We investigated the role of the PD-1 pathway in cGVHD, using a well-defined mouse cGVHD model. Recipients received 6 Gy TBI and were transplanted with purified splenic T cells and BM from either syngeneic BALB/c or allogeneic B10.D2 donors. On days 14, 21, 28, and 56 post-transplant, CD4 and CD8 cells from the spleens and peripheral lymph nodes (pLN) in the allogeneic recipients expressed significantly more PD-1 than those in the syngeneic recipients (p<0.005). Allogeneic recipients had elevated B7H1 mRNA levels from day 14-28 post-transplant (p<0.05) and immunohistochemical analysis of skins from allogeneic recipients showed more B7-H1 expression than from syngeneic recipients on days 14-28 post-transplant, while this declined to the same level as in the syngeneic group after day 42. These findings suggest that donor cells express more PD-1, while target tissues of recipients transiently up-regulate B7H1 expression only in the early phase and soon down-regulate it to syngeneic levels.Upon transfer of PD-1-/- donor T cells with the B10.D2 background into allogeneic BMT models, weight loss was severe and 100% of the recipients died by day 23 post-transplant. To avoid early death, we administered antibodies blocking the PD-1 pathway to recipients of WT donors beginning on day 14 post-transplant, just before they developed clinical signs of cGVHD. Mice treated with anti-PD-1 Ab showed 70% mortality by day 35 and 10% mortality was seen in those given anti-B7H1 Ab or anti-B7DC Ab. All groups treated with anti-PD-1, anti-B7H1, or anti-B7DC Ab had significantly higher cGVHD scores than controls (p<0.05). We next used B7H1-/- mice with the BALB/c background as recipients to evaluate how host B7H1 expression contributes to cGVHD. Allogeneic B7H1-/- recipients showed significantly more severe skin cGVHD and histopathological damage than WT controls (5.86 ± 0.85 vs. 8.38 ± 0.38, p<0.05). We previously elucidated the contribution of Th1+Th17+T cells to cGVHD and Am80, a potent synthetic retinoid, regulated both Th1 and Th17 responses, resulting in an attenuation of cGVHD (Nishimori et al. Blood 2012). Recipients of B7H1-/- showed fewer Foxp3+ regulatory T cells in the early phase (day 14, 13.5±4.2% vs. 6.4±4.4%, p<0.05), whereas there was no difference in the frequency of Foxp3+ regulatory T cells in the late transplantation period (day 28), as compared to WT recipients. Th1+Th17+T cells were detected significantly more frequently in recipients of B7H1-/- donors than those of WT recipients (day 28 2.7±0.35% vs. 1.4±0.2%, p<0.05). Administration of Am80 reduced Th1+Th17+T cells and cGVHD damage in recipients of B7H1-/- donors.To explore the contribution of B7H1 expression on hematopoietic cells or non-hematopoietic cells to cGVHD, (B7H1-/-→WT), (WT→B7H1-/-), and (WT→WT) chimeric mice (BALB/c background) were created by reconstituting sublethally irradiated WT or B7H1-/- Balb/c mice with BM cells from WT or B7H1-/- BALB/c mice. There were no differences in the clinical and pathological cGVHD scores between (B7H1-/-→WT) and (WT→WT) chimeric mice. CD4+CD25+ Foxp3+ Treg cells from (B7H1-/-→WT) recipients were detected less frequently on day 14 than in (WT→WT) recipients (p<0.05), but at similar levels on days 21 and 28. These findings suggest that B7H1 expression on hematopoietic cells plays a role in the development of Tregs only during the early transplantation period, but does not affect cGVHD severity. Unlike (B7H1-/-→WT) recipients, (WT→B7H1-/-) chimeras had significantly worse clinical cGVHD scores (p<0.05), histopathological damage (p<0.05), and Th1+Th17+T cell expansion (p<0.05), but no Treg cell changes. Collectively, these findings indicated that B7H1 expression on host tissues was dedicated to the expansion of IFN-g/IL-17 double-positive cells leading to cGVHD and that modulation of the tissue expression of B7-H1 might represent a new strategy for preventing or treating cGVHD. Disclosures:No relevant conflicts of interest to declare.

Tacrolimus Extended Release Formulation Given As An Alternative To Ciclosporine A In Case Of Renal Impairment After Allogeneic HSCT: Results From a Prospective Pilot Study

Introduction Tacrolimus is a widely used calcineurin inhibitor in allogeneic HCST for prophylaxis and treatment of GvHD. This molecule is now available in both standard-release (Prograf, twice-daily tacrolimus, Astellas Pharma) and extended-release (Advagraf, once-daily tacrolimus, Astellas Pharma) formulations. Compared with the standard-release formulation, the extended-release (ER) tacrolimus has been shown in previous pharmacological studies to provide bioequivalent drug exposure, efficacy and safety. Moreover, this formulation of tacrolimus was followed by a clinically significant improvement in kidney graft function for kidney recipients. Based on these observations, we have conducted a prospective study in wich ciclosporine A (CsA) (Neoral) is switched for tacrolimus ER (Advagraf) in case of renal impairment after alloHSCT. Method We enrolled 16 consecutive patients with renal impairment (serum creatinine &gt;110 µMol/L) from May 2012 to May 2013 during the follow-up at outpatient clinic, the conversion dose was established on an mg:mg basis 1:100 from CsA total oral daily dose to a single dose of oral tacrolimus ER formulation. The dose was readjusted to obtain a tacrolimus blood trough level between 5 and 15 µg/L. Tacrolimus ER was given at noon in a single dose one hour before lunch. We evaluated the tacrolimus blood trough level changes after switch, serum creatinine, glycemia, potassium, acute and chronic GvHD. A satisfaction survey for tacrolimus ER treatment was performed 3 months after the switch, the questionnaire included administration compliance questions. Results All patients in this cohort had hematological malignancies, the median age was 52 years (range, 28-66). Eight patients (50%) had a matched related donor, 7 patients (43.75%) had a HLA-10/10 matched unrelated donor and 1 patient underwent alloHSCT with two cord blood units. Seven patients (43.75%) received a myeloablative regimen with 12 Gy TBI and 9 patients (56.25%) a reduced intensity regimen. The stem cell source was bone marrow for 7 patients (43.75%), PBSC for 8 patients (50%) and cord blood for one patient. The status at transplantation was CR1 for 6 patients (37.5%), CR2 or more for 6 patients (37.5%) and partial response for 4 patients (25%). The median follow-up of the cohort was 7 months (range,2-14). Non-parametric tests such as exact Wilcoxon Mann-Whitney test or Kruskal Wallis were performed for the analysis of the physiological parameters. The median of serum creatinine was 112 µmol/L (range, 51-262) with CsA and 87 µmol/L (range, 50-125) with tacrolimus ER (p&lt;.0001) (Figure). The median of potassium level was 4.2 (range, 3.5-5.2) with CsA and 4.0 (3.4-4.5) with tacrolimus ER (p =.001) (Figure). The median time of switch was 45 days (10-162) and the median of serum creatinine in which the switch was realized was 138 µmol/L (range,110-262). Nor patient had diabetes mellitus neither elevation of potassium &gt; 4.5 mmol/L after the switch for tacrolimus ER. The median blood trough level was 300 µg/L (range,100-438) for CsA 14 days after starting and 7.2 (range,3-15) for tacrolimus ER 20 days after starting (Figure). The cumulative incidence of aGvHD grade &gt;1 at 3 months was 25% (95%CI,14-36). After the switch for tacrolimus ER, no patient developped aGvHD. Eight patients (50%) developed aGvHD grade &gt;1 during the prophylaxis with CsA. For 6 patients (37.5%), aGvHD was resolutive after the switch for tacrolimus ER with an association of tacrolimus ER and prednisone or tacrolimus ER alone. For 2 patients (12.5%), aGvHD was resolutive with CsA and prednisone before the switch for tacrolimus ER. Two patients in this study developed severe chronic GvHD after the discontinuation of prophylaxis (5 months and 10 months). One patient received tacrolimus ER with a complete resolution of cGvHD and the second patient is now on therapy with everolimus. All patients in this cohort are alive and all patients except two are still in complete response. Moreover, the satisfaction survey demonstrated that the patients were satisfied with the switch and the one daily formulation of tacrolimus. Conclusion The conversion from oral CsA to oral tacrolimus ER formulation was followed by a clinically significant improvement in kidney function with stable tacrolimus blood trough levels. The patients were satisfied with this formulation of tacrolimus. We have now extended this study to several centers in the aim to confirm these observations. Disclosures: No relevant conflicts of interest to declare.

Allogeneic Stem Cell Transplantation For Cytogenetically Normal Acute Myeloid Leukemia: Impact Of FLT3 and NPM1 Mutational Status

▪ PurposeCytogenetic abnormalities as detected by conventional karyotyping are among the strongest predictors for the long-term outcome of patients (pts) with acute myeloid leukemia (AML). However, up to 50% of pts are cytogenetically normal (CN) and the screening for mutations of the FLT3 and the NPM1 genes allowed to further dissect this heterogeneous group. Allogeneic stem cell transplantation (alloSCT) has become an integral part of the post-remission therapy for pts with intermediate or high-risk AML in case an HLA-compatible donor is available. Here, we analyzed the impact FLT3 and NPM1 mutations on the outcome of pts with CN-AML who underwent alloSCT at our center between 2006 and 2013. Pts and MethodsFollow-up data of all pts were prospectively collected in a computer database and retrospectively analyzed as of June 30th, 2013. 101 pts (46 female, 55 male) with a median age of 54 (range: 18-75) years with CN-AML were included. 71 pts had de novo AML, whereas 30 pts had secondary or therapy-related AML. All pts were treated in a German multicenter AML trial and received at least two courses of induction therapy. The FLT3 and NPM1 mutational status was as follows: 14 pts were FLT3-mutated/NPM1 wild-type, 15 pts were NPM1 mutated/FLT3 wild-type, 22 pts were FLT3-mutated/NPM1 mutated, and 50 pts were wild-type for both FLT3 and NPM1. At alloSCT, 62 pts were in first complete remission (CR1), 16 pts were in CR2, and 23 pts had refractory disease. In 96 pts alloSCT was performed using peripheral blood stem cells (PBSCs), 5 pts received a bone marrow (BM) graft. Conditioning consisted of standard myeloablative conditioning (MAC) (6x2 Gy TBI and 2x60 mg/m2 cyclophosphamide) in 24 pts. 77 pts received reduced intensity conditioning (RIC) (2x4 mg/kg oral busulfan, 6x30 mg/m2 fludarabine and 4x10 mg/kg ATG). A matched related donor was available for 27 pts, whereas 55 pts or 19 pts were transplanted from a matched-unrelated or mismatched unrelated donor. ResultsAfter a median follow-up of 11 (range: 1-83) months for the surviving pts, 64 pts are alive and in CR. Causes of death were relapse or NRM in 26 pts or 12 pts, respectively. At 1, 3 and 5 years projected overall survival (OS) or disease-free survival (DFS) of the entire cohort was 67% (57-77%), 58% (46-69%), and 54% (42-67%) or 60% (51-71%), 57% (47-68%), or 50% (37-54%). At the same time points the cumulative incidence of relapse (CIR) or non-relapse mortality (CINRM) was 27% (19-38%), 30% (22-43%), and 37% (36-52%) or 12% (6-21%) remaining stable thereafter. Subgroup analysis showed that the presence of a NPM1 mutation in the absence of mutated FLT3 is associated with a significantly lower CIR, i.e. 8%, at 3 years. In the other subgroups the CIR ranges between 32% for pts lacking FLT3 and NPM1 mutations and 37% for pts carrying both mutations (p=0.002). In univariate analysis, pts with refractory disease had a significantly lower DFS (p=0.0002) and a higher relapse incidence (p=0.0001) as compared to pts transplanted in CR. All other factors examined, i.e. AML subtype, stem cell source, type of conditioning, donor/HLA-match were not associated with OS, DFS, or relapse incidence. Notably, there was no correlation between FLT3 or NPM1 mutational status and remission status at the time of alloSCT. OS did not differ significantly between the four subgroups due to an increased NRM in patients with NPM1-mutated CN-AML. Finally, in multivariate analysis only remission status was identified as an independent prognosticator for DFS and relapse incidence, whereas alloSCT from a mismatched unrelated donor predicted a higher NRM. ConclusionsTaken together, our results indicate that pts with high-risk AML, as defined by the presence of a FLT3-mutation, may achieve durable long-term remissions following either MAC and RIC-alloSCT from related an unrelated donors. In turn, the presence of a mutation of the FLT3 gene may not per se predict a poor outcome in this setting. In contrast, remission status is among the strongest predictors for long-term outcome in patients with CN-AML undergoing alloSCT. Disclosures:No relevant conflicts of interest to declare.

Double umbilical cord blood transplantation in patients with hematologic malignancies using a reduced-intensity preparative regimen without antithymocyte globulin

Reduced-intensity conditioning (RIC) regimens in cord blood transplant (CBT) are increasingly utilized for older patients and those with comorbidities. However, the optimal conditioning regimen has not yet been established and remains a significant challenge of this therapeutic approach. Antithymocyte globulin (ATG) has been incorporated into conditioning regimens in order to decrease the risk of graft failure; however, use of ATG is often associated with infusion reactions and risk of post-transplant complications. We report the results of a non-ATG-containing RIC regimen, where patients received 2 Gy TBI unless they were considered to be at higher risk of graft failure, in which case they received 3 Gy of TBI. Thirty patients underwent CBT using this protocol for high-risk hematological malignancies. There was only one case of secondary and no cases of primary graft failure. At 1 year, estimates of non-relapse mortality, OS and PFS were 29%, 53% and 45%, respectively. The cumulative incidences of grade III-IV acute and chronic GVHD were 14% and 18%, respectively. In summary, the results of this study demonstrate that this non-ATG-containing conditioning regimen provides a low incidence of graft failure without increasing regimen-related toxicity.

G-CSF Stem Cell Mobilization Is Protective Against Acute Graft-Versus-Host Disease (aGvHD) by Increasing Myeloid-Derived Suppressor Cell (MDSC) Frequencies

AbstractAbstract 1898 Background:In mice, graft-versus-host disease (GvHD) can be abrogated by ex vivo expanded, bone marrow derived myeloid-derived suppressor cells (MDSCs) generated in the presence of GM-CSF, G-CSF and IL-13 (Highfill et al). Whether MDSCs play a role in human allogeneic hematopoietic stem cell transplantation (allo-HSCT) is still unclear. We hypothesized that G-CSF stem cell mobilization may be protective from acute GvHD (aGvHD) by increasing MDSC frequencies. Methods:G-CSF-mobilized peripheral blood (PB) samples were collected from 40 healthy unrelated donors (median age 34, range 20–43, male/female 31/9) who received G-CSF (Filgrastim) at 10 μg/kg/day for 5 days. Donor selection had been performed according to standard criteria, including molecular typing for HLA-A,-B,-C, DRB1, and DQB1. Donors were 10/10 HLA-matched (MUD) in 20 cases, 9/10 in 13 cases and 8/10 in the remaining 7 cases (MMUD). Patients (median age 46, range 18–67) received reduced intensity conditioning based or low-dose total body irradiation (TBI 2Gy) (8), Fludarabine-Rabbit Antithymocyte Globulin (ATG) (9) or Thiotepa-ATG (23). Diagnosis were lymphomas (29), myelomas (8), acute myeloid leukemia (3). GvHD prophylaxis was cyclosporine plus either methotrexate (36) or mycophenolate mofetil (4). As controls, PB samples were collected from 10 healthy adults. Informed consent was obtained from all subjects. Cells were characterized using flow cytometry with Abs against CD3;CD14;CD16;CD19;CD20;CD56;CD11b;HLADR;CD33. The frequencies of MDSCs and T regulatory cells (Tregs, CD4+CD25+CD127-FoxP3+) in the grafts were correlated with the clinical characteristics and outcome of the 40 patients. To verify that G-CSF treatment increases the number of MDSCs that are transferred with the graft and prevent GvHD, a major histocompatibility complex (MHC) mismatched HSCT mouse model was also used. After lethal irradiation, recipient BALB/c mice received spleen and bone marrow (BM) cells from C57BL/6 (B6) donors (GvHD cohort, n=5) or BM cells only (negative control, n=3). To generate MDSC enriched allografts, donor mice were treated with G-CSF (5 μg/d for 5 days) and thereafter BM cells and spleen cells were transferred in recipient mice (MDSC cohort, n=5). Results:Expansion of MDSCs (Lin-/LoHLADR−CD33+CD11b+) in the PB of G-CSF-treated unrelated donors was found with respect to steady state control individuals (p< 0.03, Mann Whitney-U). Acute GvHD occurred in 16 of 40 patients (40%). There was no significant correlation between the incidence of aGvHD and the degree of HLA incompatibility or the presence of donor-recipient sex mismatches. Neither the conditioning regimens nor the GvHD prophylaxis had effect on risk of aGvHD. There was no correlation between the number of Tregs infused and the occurrence of GvHD.Conversely, aGvHD patients received grafts containing significantly lower number of MDSCs when compared to non- aGvHD patients (p < 0.006, Mann Whitney-U). The ability of MDSC levels in the graft to predict the occurrence of aGvHD was determined by the receiver operating characteristic (ROC) curve: sensitivity was 100%, specificity 60%, AUC=0.768. The immunosuppressive activity of the MDSCs on activated T lymphocytes was confirmed in vitro. To confirm these results, we set up a MHC mismatched HSCT mouse model. G-CSF treatment induced a significant increase in MDSCs (up to four fold, p<0.05) whereas the frequencies of CD34+ and CD3+ cells were not affected. The MDSC-enriched BM cells transferred into lethally irradiated recipient mice together with spleen cells, resulted in a less severe aGvHD as confirmed by monitoring the clinical signs of GvHD (weight loss, generalized erythema of the skin, poor fur quality and overall survival) compared to the GvHD cohort not receiving G-CSF. Conclusions:G-CSF mobilization significantly increases circulating MDSC both in Matched Unrelated Donors and in mice. In humans, a significant correlation between the frequencies of MDSC present in the graft and the incidence of aGvHD was found. This result was further confirmed using a MHC mismatched HSCT mouse model. Mice treated with G-CSF received grafts containing higher numbers of MDSCs and developed less severe aGvHD than the untreated mice. Taken together, these findings strongly suggest that G-CSF stem cell mobilization is protective against aGvHD through MDSCs augmentation and might be relevant to modify GvHD prophylaxis. Disclosures:No relevant conflicts of interest to declare.

Impact of Tandem Autologous/Non Myeloablative Allogeneic Hematopoietic Stem Cell Transplantation in Patients with Multiple Myeloma Relapsing After a First High Dose Therapy in the Era of Novels Anti-Myeloma Agents

AbstractAbstract 2035 Background:We previously reported 23 MM patients, treated in first relapse by a sequential autologous-allogeneic tandem transplantation (aATT) approach. Data from this series compared favorably with a non allografted control population (Karlin, 2011). However, most of the patients were treated before the availability of novel anti-myeloma agents. We now report a larger series of 50 patients and conducted an overall survival (OS) comparison with a matched cohort. Patients and methods:From 2002 to 2011, fifty patients with MM were treated by a sequential autologous-allogeneic tandem approach in our institution. All were included in the study. A series of 64 non-allografted MM patients treated during the same period was used as a control group. An individual matching procedure was completed using the following factors: response to first line therapy, delay from first treatment to relapse, patient's age, year of relapse, ISS, serum Beta 2 microglobulin and albumin. OS comparisons were performed by using proportional hazards models stratified on each individual matched pair, or adjusted on strata to allow interaction test between cohort and stratum. Results:Median age of the allografted patients was 50.8 years (range 28.5 to 59.5 years). Forty-three (86%) were in first relapse, 7 (14%) in second relapse. First line treatment included a first high dose therapy with an autologous blood stem cell transplantation (aSCT) for all patients; 31 (62%) pts relapsed less than 2 years after this aSCT. At relapse, all patients received novel agents (IMID’s and/or bortezomib). Overall response rate before aATT was 96%, including 8% complete response (CR), 42% of very good partial response (VGPR), and 46% of partial response (PR). First transplant of aATT was performed after high dose melphalan alone (n=28, 56%) or combined with bortezomib (n=22, 44%). For allotransplant, all patients received a reduced intensity conditioning regimen based on 2 Gy TBI with (n=14) or without (n=22) fludarabine). Acute GvHD prophylaxis used cyclosporine plus MMF. Donors were HLA-identical siblings in 29 patients (58%) while 21 (42%) had an unrelated-donor including 2 with one mismatch. The source of stem cells was peripheral blood in all patients. After allotransplant, complete donor chimerism was detected in all cases at day 100. The cumulative incidence function (CIf) of acute graft-versus-host disease (GvHD) grade II to IV was 27% at day 100 (95%CI 14 – 40) and 27 patients developed a chronic GvHD.After a median follow-up of 24.3 months (IQR: 11.3–44.2), 23 patients died, including 12 free of relapse (Infections, n=7; GvHD, n=5) leading to a 1 year-CIf of TRM of 16.4% (5.8–27.0). Twenty four patients relapsed. Sixteen patients received a revlimid-based salvage therapy. Donor lymphocyte infusions were performed for 3 patients. The disease free survival (DFS) at 2-year was 61.2% (95%CI 47.0–75.4). The OS at 2 and 5 years was 72.3% and 46.1% respectively (Figure 1A). No factor allowed to predict neither TRM, relapse, DFS nor OS.In the non-allograft group, within a median post relapse follow up of 1.8 years, post relapse 2 year OS was 47.8%. We identified 19 pairs of allograft and non-allograft pts eligible for a matched-pair comparison. All experienced their first relapse less than 2 year after initial high dose therapy with aSCT performed frontline. There was no significant difference between survival of allografted pts as compared to the control group (p = 0.35, HR = 0.68 [95% IC 0.3 – 1.55]) (Figure 1B). Conclusion:In this single center study of 50 young MM patients treated in relapse by tandem autologous-allogeneic transplantation, we observed a relatively low TRM of 16.8%. In contrast to our first series, a matched-pair analysis suggested similar OS between allografted and non-allografted patients. These results questioned the role of non myeloablative allogeneic hematopoietic stem cell transplantation in the management of multiple myeloma in the era of novel anti-myeloma agents, but they should be confirmed. Incidence of relapse post aATT may justify a systematic post allo maintenance therapy. [Display omitted] Disclosures:No relevant conflicts of interest to declare.

Impact of Early Blast Clearance Following Induction Chemotherapy On the Outcome of Patients with Acute Myelod Leukemia Undergoing Allogeneic Stem Cell Transplantation in First Complete Remission

AbstractAbstract 1998▪▪This icon denotes a clinically relevant abstract Purpose:In patients with newly diagnosed acute myeloid leukemia (AML) rapid achievement of remission by induction chemotherapy is an important predictor for long-term disease control. In turn, patients who fail to attain early blast clearance after the first chemotherapy course have an inferior outcome. Here, we investigated the impact of early blast clearance on the overall outcome of patients with AML undergoing allogeneic stem cell transplantation (alloSCT) in first complete remission (CR1) as consolidation therapy. Patients and Methods:169 (90 female, 79 male) patients with AML who underwent alloSCT in CR1 at our center between 1994 and 2011 were included. Data were prospectively recorded in our transplant data base and retrospectively analyzed as of December 31st, 2011. In detail, 107 patients (64%) had de novo AML, 31 patients (18%) had AML evolving from myelodysplastic syndrome (MDS), and 31 patients (18%) had therapy-related AML. According to the criteria of the SWOG/ECOG, cytogenetic risk was either favorable (6 patients, 4%), intermediate (104 patients, 62%), or poor (47 patients, 27%). Prior to alloSCT all patients were treated in a German multicenter AML trial and received at least two courses of induction chemotherapy, i.e. either standard “7+3” (daunorubicin 60 mg/m2, day 3–5 and Ara-C 100 mg/m2, day 1–7) or a “high-dose Ara-C” containing regimen (Ara-C 1–3 g/m2). In 98 patients (58%) induction chemotherapy resulted in blast clearance after the first course, whereas 71 patients (42%) failed to achieve early remission, but entered remission after 1 or 2 subsequent courses. Median age at transplantation was 47 years (range: 17–69 years). In 146 patients (86%) alloSCT was performed using peripheral blood stem cells (PBSCs), whereas 23 patients (14%) received a bone marrow (BM) graft. Conditioning consisted of standard myeloablative conditioning (MAC: 6 × 2 Gy TBI and 2 × 60 mg/m2 cyclophosphamide) in 81 patients (48%), whereas 86 patients (52%) received reduced intensity conditioning (RIC: busulfan 2 × 4 mg/kg, fludarabine 6 × 30 mg/m2 and ATG 4 × 10 mg/kg). A matched related donor was available in 82 patients (49%), whereas 68 patients (40%) or 19 patients (11%) were transplanted from a matched-unrelated or mismatched unrelated donor. Results:After a median follow-up of 45 months (range: 3–196 months) for the surviving patients, 91 patients (54%) are alive and in continuous remission. Causes of death were relapse in 38 patients (22%) or NRM in 33 patients (19%). At 1, 3 or 5 years projected overall survival (OS) was 72±6%, 58±6%, or 54±8% for all patients. Probability of relapse or non-relapse mortality (NRM) at 1, 3, and 5 years was 20±10% (20±11%), 31±12% (20±11%), and 34±12% (20±11%). Although there was no statistically significant difference in OS at 3 and 5 years between patients who achieved early blast clearance as compared to patients who failed to do so (p=0.09), disease-free survival (DFS) and probability of relapse differed significantly between the two groups at 3 years (77±8% vs 55±14%) or 5 years (75%±9% vs 52%±14%) following alloSCT (p=0.02). There was no significant difference in NRM between the two subgroups. Likewise, there was no statistically significant difference between patients conditioned with either MAC or RIC. In multivariate analysis cytogenetic risk group and remission status were identified as independent prognostic factors for DFS and probability of relapse. Conclusions:These results suggest that in patients with AML undergoing alloSCT in CR1 early blast clearance, i.e. following the first course of induction chemotherapy, predicts a very favorable outcome. Disclosures:No relevant conflicts of interest to declare.

Flamsa-RIC Sequential Regimen in High Risk CR1 AML Patients: Preliminary Results From a Pilot Study

AbstractAbstract 4549 IntroductionPatients with high risk AML have poor outcomes. However, the only approach with curative potential remains allogeneic HSCT. With the aim to improve the effect of allogeneic HSCT by sequential use of chemotherapy, RIC regimen and pDLI, we are currently conducting a prospective pilot study for high risk AML. High risk AML was defined by unfavorable cytogenetics, adverse molecular abnormality, secondary AML, and AML requiring 2 induction courses to obtain CR1.After identification of a HLA 10/10 donor, patients are received the sequential regimen consisted of fludarabine (30mg/m2/d), Ara-c (2g/m2/d) and amsacrine (100mg/m2/d) (FLAMSA) chemotherapy for 4 days. After 3 days of rest, RIC regimen consisted of 4 Gy TBI, cyclophosphamide for 2 days (40 mg/kg in case of matched related donors, and 60 mg/kg for unrelated or mismatched donors), and ATG (5mg/kg total dose) (German regimen) or Busulfan 3.2mg/kg/d during 4 days followed by ATG (5mg/kg total dose) (French regimen). The modified regimen has been established after our results in refractory AML patients (ASH 2011, poster 1957). Prophylactic donor lymphocyte transfusion was given from day +120 in patients who were not receiving immunosuppression and were free of GvHD.Our objective is to include 20 patients and to compare with a control cohort of patients with the same high risk AML treated according to the conventional strategy during the same period. ResultsBetween August 2010 and November 2011, we have included 12 consecutive patients in first complete response who underwent an allogeneic HSCT after sequential FLAMSA-RIC regimen with a median follow-up of 12 months (range [7–22]). Nine patients were < 55 years old (median age: 54 [28–64]), 7 patients had an unrelated donor and 5 patients had a related donor. The stem cell source was PBSC for 11 patients and two cord blood unit for 1 patient. Before FLAMSA-RIC regimen, 3 patients had received two induction courses to obtain CR1. All patients had adverse cytogenetics or molecular abnormalities and 1 patient had a secondary AML.At the last follow-up, 6 patients (50%) are alive in CR. (Figure 1.) Four patients (33.3%) died in remission. The cause of death was infection for 2 patients, aGvHD for 1 patient and graft failure for 1 patient. Only one patient died from relapse 6 months after transplantation.Five patients (41.6%) experienced aGvHD and 2 patients (16.6%) had an extensive cGvHD including the patient who has been transplanted with 2 cord blood unit. Six patients (75%) in a group of 8 patients aged > 45 years experienced complications (infection (n=3) and GvHD (n=3)). One patient (25%) from a group of 4 patients aged < 45 years had infectious complication after transplantation. Prophylactic donor lymphocyte transfusion was given in 6 patients, the causes of no administration were GvHD for 2 patients, cord blood unit as stem cell source for 1 patient and 3 patients were dead before 120 days after transplantation. From the 6 patients who had received pDLI, 5 patients are alive in CR and 1 patient died from GvHD. ConclusionThe FLAMSA-RIC regimen before allogeneic HSCT is a new approach for high risk AML. Between 2012 January and 2012 July, 8 additionnal patients have been included and the results for the whole study will be communicated later. Our primary results are promising especially for young patients (< 45 years) who seem to better profit from this sequential FLAMSA-RIC regimen. [Display omitted] Disclosures:Nicolini:Novartis, Bristol Myers-Squibb, Pfizer, ARIAD, and Teva: Consultancy, Honoraria, Membership on an entity's Board of Directors or advisory committees, Research Funding.

Prospective Phase II Multicenter Study of Conditioning with Treosulfan, Fludarabine and Low-Dose (2 Gy) Total Body Irradiation Followed by Hematopoietic Cell Transplantation From Related or Unrelated Donors for Acute Myeloid Leukemia and High-Risk Myelodysplastic Syndrome

AbstractAbstract ▪963▪This icon denotes a clinically relevant abstract Background:We showed previously that a transplant conditioning regimen of treosulfan combined with fludarabine was associated with low non-relapse mortality (NRM) and a high probability of survival in patients with acute myeloid leukemia (AML) or myelodysplastic syndrome (MDS) with low or intermediate risk cytogenetics (Nemecek et al, BBMT 2011). Relapse rates were high, however, in patients with high-risk cytogenetics, which resulted in a 2-year relapse-free survival of 39% in this group. Objective:The objective of the present study was to reduce the relapse incidence and improve overall survival (OS) in patients with high-risk AML or MDS by adding low-dose TBI (2 Gy) to the treosulfan plus fludarabine regimen. Patients and methods:Ninety-six patients with AML (n=60) or MDS (n=36) were enrolled. Patients were 60 years of age or younger (median age: 50 years) and had high-risk MDS, unfavorable or intermediate-risk AML in first complete remission (CR) or any AML beyond first CR. Cytogenetic risk in AML was stratified using the Southwest Oncology Group criteria, while the World Health Organization-based Prognostic Scoring System was used in patients with MDS. Patients received intravenous (IV) treosulfan, 14 g/m2/day on days -6 to -4, IV fludarabine 30 mg/m2/day on days -6 to -2, and 2 Gy TBI on day 0, followed by infusion of marrow (n=11) or peripheral blood stem cells (n=85) from related (n=27) or unrelated (n=69) donors. Donors were single HLA allele-level mismatched in 9 patients and HLA-matched at the allele level in 87 patients. Graft-versus-host disease (GVHD) prophylaxis consisted of methotrexate (10 mg/m2 on days +1, +3, +6 and +11 post-HCT) and tacrolimus (days –1 to +180). Results:All evaluable patients engrafted. With a median follow-up of 12.8 (range, 0.2 – 34.7) months in surviving patients, the estimated 2-year progression-free survival and OS were 59% and 68%, respectively. The cumulative incidences of relapse or progression and NRM at 2 years were 30% and 11%, respectively (Figure 1). The incidences of grade II (grades III-IV) acute and extensive chronic GVHD at 2 years were 48% (11%) and 40%, respectively.Relapse occurred in 39% of patients with AML and 18% of patients with MDS (Figure 2A). OS was 61% among patients with AML and 79% in patients with MDS (Figure 2B). In univariate analyses, cytogenetic risk status did not impact relapse for the entire cohort nor for patients with AML or MDS analyzed separately (Figures 3A and 3B). As a result, 2-year OS rates were similar in patients with favorable/intermediate and unfavorable cytogenetic risk AML (64% and 57%, respectively) or in good/intermediate and poor risk MDS (88% and 71%, respectively). Patients with AML with minimal residual disease (MRD; n=10) or in refractory relapse (n=4) at the time of HCT, had higher relapse rates (87% vs. 25%) and lower OS (25% vs. 81%) at 2 years than patients in remission without MRD at the time of HCT. Conclusions:In summary, treosulfan, in combination with fludarabine and low-dose TBI was an effective conditioning regimen for allogeneic HCT in patients with AML (in CR at the time of HCT) or MDS. Relapse and OS rates in patients with high-risk cytogenetics did not differ significantly from those in patients with low or intermediate risk karyotypes. The relapse rate was particularly low in patients with MDS, including those with high risk cytogenetics, and further trials with treosulfan-based regimens are warranted. For patients with AML who have residual disease at HCT novel regimens need to be developed. The data suggest that in patients with AML high risk as defined by cytogenetics had a different impact on outcome than high risk as defined by other parameters, such as tumor burden. [Display omitted] [Display omitted] [Display omitted] Disclosures:Gyurkocza:medac GmbH, Hamburg, Germany: Research Funding. Off Label Use: Off-label usage of treosulfan, fludarabine, methotrexate and tacrolimus will be discussed. Sickle:medac GmbH, Hamburg, Germany: Research Funding. Baumgart:medac GmbH, Hamburg, Germany: Employment. Deeg:medac GmbH, Hamburg, Germany: Research Funding.

Second Allogeneic Hematopoietic Cell Transplantation in Patients with Hematologic Malignancies for Relapse After First Allografts

AbstractAbstract ▪4207▪This icon denotes a clinically relevant abstractWe retrospectively analyzed outcomes of 90 consecutive patients with hematologic malignancies (median age: 34, range: 3–68 years) who relapsed after first allogeneic hematopoietic cell transplantation (HCT) and underwent second or subsequent allografts. Diagnoses included acute myeloid leukemia (AML, n=45), acute lymphocytic leukemia (n=22), myelodysplastic syndrome (MDS, n=11), chronic myeloid leukemia (n=4), non-Hodgkin lymphoma (n=3), chronic lymphocytic leukemia (n=2), Hodgkin’s lymphoma (n=2) and myelofibrosis (n=1). Eighty-seven patients had recurrence of their original hematologic malignancy, while in three patients, AML (n=2) or MDS (n=1) arose from the donor cells.Donors for first allogeneic HCT were HLA-matched related (n=45), HLA-matched unrelated (n=26) or HLA-mismatched (n=19, including 5 HLA-haploidentical and 6 double cord blood unit) donors. Conditioning regimens for first HCT included myeloablative regimens with or without ATG (cyclophosphamide-total body irradiation, TBI, n=49; busulfan-cyclophosphamide, n=24); low-dose TBI (2 Gy) with or without fludarabine (n=10) and other regimens (n=7).The median interval between first and second allogeneic HCT was 24 (range: 2–137) months. Donors for second allogeneic HCT were HLA-matched related (n=24), HLA-matched unrelated (n=42) or HLA-mismatched (n=24; including 5 HLA-haploidentical and 8 double cord blood unit) donors. In 15 cases the original donors were used for second HCT, while in 75 cases different donors were identified. Conditioning for second HCT included low-dose TBI (2–4 Gy) with or without fludarabine, with or without cyclophosphamide (n=49), treosulfan and fludarabine containing regimens with or without low-dose (2 Gy) TBI (n=17), high-dose TBI (n=16), or busulfan (n=8) based regimens.With a median follow-up of 38 (range, 7 to 154) months among surviving patients, the 2-year Kaplan-Meier overall survival (OS), relapse rate and non-relapse mortality (NRM) estimates were 36%, 44% and 27%, respectively (Figure 1). When the analysis was restricted to patients with AML, OS, relapse rate and NRM were 29%, 45% and 30%, respectively. For the whole cohort, cumulative incidences of grades 2–4 acute, grades 3–4 acute and extensive chronic graft-versus-host disease (GVHD) at 2 years were 67%, 13% and 31%, respectively. Relapse was the leading cause of treatment failure. Patients with early relapse after their first allogeneic HCT (within 6 months vs. 6–12 months vs. more than 12 months) had significantly higher 2-year relapse rates after second transplants (64%, 44%, 31%, respectively; p=0.01; Figure 2A). This translated into overall survival differences with borderline statistical significance (21%, 24% and 51%, respectively, p=0.08; Figure 2B).Patient age, donor type (related, unrelated, HLA-mismatched), same vs. different donors for second HCT, conditioning intensity and HCT comorbidity scores did not appear to affect outcomes in univariate analyses in this group of patients.Based on this retrospective analysis, we conclude that post-transplant relapse can be treated with second allogeneic HCT. Limitations of this study include the retrospective nature of the analysis and heterogeneity of conditioning regimens; nonetheless, rates of acute and chronic GVHD, relapse and NRM appear similar to those reported after 1st allogeneic HCT. Therefore, second allogeneic HCT should be considered for post-transplant relapse, especially in patients who relapse more than 12 months after their first allografts. [Display omitted] [Display omitted] Disclosures:No relevant conflicts of interest to declare.

Lenalidomide Is Effective Therapy for Relapse After Allogeneic Stem Cell Transplant for Multiple Myeloma.

AbstractAbstract 3064Allogeneic stem cell transplantation (Allo-SCT) can result in long-term remissions in patients with multiple myeloma although it’s overall role in disease management remains controversial. Patients who relapse after AlloSCT have limited treatment options. We evaluated the response and tolerance of lenalidomide monotherapy administered to patients with multiple myeloma who progressed or relapsed by EBMT criteria after Allo-SCT. Patients were required to have an ECOG PS of ≤2, ANC ≥1.5 × 109/l, Plts ≥50 × 109/l, creatinine ≤2, bilirubin ≤1.5, SGOT and SGPT ≤2 times ULN. Patients were allowed to take prednisone for acute GVHD but were excluded for GVHD ≥ grade 3. The initial starting dose of lenalidomide was 25 mg orally for 21 of 28 days. Dose reductions after cycle 1 were allowed for neutropenia, thrombocytopenia or other dose related toxicities. Eighteen patients, 5 female, and median age of 48 years (range 28–61) enrolled a median of 12 months (range 3–104) following transplant. Patients were transplanted from 11 matched related donors, 6 matched unrelated donors and 1 mismatched unrelated donor. Conditioning regimens were, fludarabine, 2Gy TBI for 16 and busulfan, melphalan for 1. One patient had 2 allografts from the same donor; the first with cyclophosphamide, fludarabine, the second after intermediate dose melphalan. Treatment duration of lenalidomide was a median of 8 months (range 1–51). Common grade 1–2 adverse events included diarrhea (17%) or constipation (11%), fatigue (17%), myalgias (17%), nausea (11%) and neuropathy (11%). Ten patients required dose reductions to 5–20 mg at a median of 3 cycles (range 1–12); 8 for neutropenia; 1 for thrombocytopenia, and 1 for myalgias and weakness. Serious adverse events N=5, included H1N1 influenza (2), bacterial pneumonia (2), and fever, myalgia and hypoxia. In addition, 2 patients died at 3 and 5 months of GVHD that occurred within 1 month of dosing. One death was gastrointestinal GVHD, the second from liver GVHD in a patient who was enrolled but later deemed ineligible due to elevated SGOT and SGPT by the time of study entry. These were the only 2 patients who discontinued lenalidomide due to GVHD. Three patients were on prednisone 0.5–1 mg/kg for 2, 2, and 11 months for GVHD, but only 1 patient was started on prednisone after initiation of lenalidomide. These results are in contrast to a reported 47% rate of discontinuation of lenalidomide used for maintenance after allografting due to GVHD (Kneppers, et al. Blood 118:2413, 2011) The differences between the two trials may result from the later start of lenalidomide administration in our trial (12 months v. 3 months). Best responses included CR (7), VGPR (1), PR (3), MR (1) and SD (2) for an overall response rate (≥PR) of 61%. Nine patients discontinued therapy due to PD at 1–15 months. Five patients have died from PD. Seven patients remain on therapy at a median of 33 months (range 8–51), 5 in CR. Lenalidomide for relapse of multiple myeloma after allografting can result in extended disease control in 38% of patients. Disclosures:Bensinger:Celgene: Consultancy, Honoraria, Research Funding.

Analysis of Infection-Related Mortality in Allogeneic Hematopoietic Stem Cell Transplantation Recipients with Refractory/Relapse Acute Leukemia

Abstract 4513 BackgroundInfection-related mortality (IRM) is a major cause of transplant-related mortality (TRM) in recipients of allogeneic hematopoietic stem cell transplant (allo-HSCT). However, the data about IRM in refractory/relapse acute leukemia patients undergoing allo-HSCT was scarce. We conducted a retrospective study to describe the incidence, causes and risk factors for IRM in recipients with refractory/relapse acute leukemia at a single center. MethodsClinic datas of 127 cases received transplant for refractory/relapse acute leukemia between January 1997 and August 2011 were reviewed. There were 67 cases died at the end of follow-up. In this 67 cases, 27 patients were female and 40 were male; the media age was 31 years (range, 11–61).Uderlying disease was acute myeloid leukemia (AML) in 37 cases, acute lymphoblastic leukemia (ALL) in 21 and acute leukemia of ambiguous lineage in 9. Status of underlying diseases was CR in 19 cases, PR in 15 and NR in 33. There were 25 cases with residual infection diseases before HSCT, including 21 in stable state and 4 in active state with effective control. A total of 59 cases received the conditioning regimen which is 4.5Gy TBI for 2 days and CTX 60mg·kg−1·d−1 for 2 days and 8 patients received busulfan 3.2 mg·kg−1·d−1 for 4 days and CTX 60mg·kg−1·d−1 for 2 days. Patients with PR and NR status of underlying diseases also received fludarabine 50mg·d−1 for 5 days and cytarabine 2 g·d−1 for 5 days as the conditioning regimen. Forty-two cases received related-donor transplant and 25 received unrelated-donor transplant; 30 cases had HLA typing (HLA-A, B and DR) matched-family donor, 12 cases has mismatched-family donors and 25 cases had unrelated-donors. The most common source of stem cells for HSCT was the peripheral blood (n=49), followed by bone marrow plus peripheral blood (n=10) and bone marrow (n=8). Cyclosporine A (CsA) with methotrexate (MTX) (on days +1, +3 and +6) was administered for GVHD prophylaxis in patients undergoing HLA-matched sibling donor transplantation. CsA only or CsA with MTX (on days +1 and +3) was administered for GVHD prophylaxis in patients not received CR before transplant. Patients receiving an unrelated donor or HLA-mismatched sibling donor transplant received CsA + MTX and human antithymocyte globulin (ATG 6–7.5 mg/kg) as GVHD prophylaxis. Logistic regression was used for the identification of risk factors of IRM. ResultsWithin a median 23 months follow-up for patients alive, 67 cases died including 36 died of leukemia relapse and 31 died of TRM. The incidence of 5-years overall survival was 35.2% whereas disease-free survival was 30.8%. Of the 127 cases, 36 cases occurred IRM and the 2-year cumulative incidence of IRM was 36.6%. Fungal infections were responsible for a major proportion of the cases of IRM followed by virus and bacteria infections. Multivariate analyses showed II∼IV°aGVHD (OR=3.017, 95%CI 1.007–9.041, P=0.049) and IFI (OR=3.223, 95%CI 1.103–9.421, P=0.032) were the risk factors of IRM. ConclusionsAs a common cause of transplant-related mortality, IRM occurred more frequently in refractory/relapse acute leukemia than in the standard-risk patients. Reduction of IRM will require effective prophylaxis and treatment of severe GVHD. Disclosures:No relevant conflicts of interest to declare.

Older Recipients Require a Less Potent Induction Treatment to Achieve Bone Marrow Based Chimerism

Background: Tolerance induction through mixed chimerism holds promise for clinical translation but has only been investigated in young recipients so far. Frequencies of memory T cells (Tmem) increase with age and are in general considered a substantial barrier to tolerance induction. As the average recipient age has increased substantially in clinical organ transplantation, we investigated the consequences of recipient age on the outcome of mixed chimerism and tolerance induction. Methods: Young (2mth; 20 g) and old (12mth; 25 g) recipients (C57BL/6) were treated with either 3 or 1Gytotal body irradiation (TBI) and received un-separated Balb/c BM cells adjusted to body weight (1×103/kg, i.e. young 20x106/mouse; old 25×106/mouse); recipients received an induction treatment of anti-CD154 mAb and CTLA4Ig. Lymphocyte subsets and cytokine production were compared between young and old naïve mice and multi-lineage chimerism was assessed by flow cytometry. Results: Senescence modifies alloimmune responses: Old naïve mice contained significantly higher frequencies of CD4 (p< 0.001) and CD8 (p< 0.001) memory T cells (CD44highCD62Llow), early activated CD4 T cells (CD4+CD69+; p< 0.001)and comparable amounts of CD4, CD8 and regulatory T cells (Tregs; CD4+CD25+, p=n.s. vs. young animals). Moreover, older CD4 T cells released significantly more IFN-γ (p< 0.05) and IL-6 (p< 0.05) after polyclonal stimulation. In contrast, the alloreactive IFN-y production upon allogeneic stimulation was comparable between young and old T cells. Older recipients become chimeric: Old and young recipients become chimeric and tolerant when induced with 3 Gy TBI and co-stimulatory blockade (26/29 vs 20/30 old and young recipients, resp. became chimeric by week 1 and 7/8 vs 11/11 maintained chimerism over 13 weeks). Mixed chimerism in both, young and old mice induced peripheral and central clonal T cells tolerance. Of note, frequency of Tregs were significantly higher (p< 0.05) in older compared to younger chimeras. Age facilitates chimerism: Old recipients became even chimeric with a reduction of the TBI to 1 Gy and co-stimulatory blockade. In sharp contrast, none of the young recipients became chimeric under those conditions (4/8 vs 0/8 chimeras in young recipient, p< 0.05, week 3). Conclusion: BM engraftment and chimerism can be successfully induced in older recipients. Chimerism in older recipients seemed to be linked to higher frequencies of Tregs and required a less potent induction treatment.

Normal tissues toxicities triggered by combined anti-angiogenic and radiation therapies: hurdles might be ahead

Background:Combined-modality therapy is a promising approach to improve the therapeutic index of radiotherapy. However, these improvements could come at the cost of increased toxicities. Clinical trials evaluating anti-tumour efficacy of bevacizumab combined with radiotherapy have encountered unexpected side effects. This study is the first systematic evaluation of normal tissue toxicity triggered by anti-angiogenic agents combined with radiation therapy in mice.Methods:Effect of a mouse anti-VEGF antibody was monitored on acute toxicity studying radiation-induced intestinal ulceration (12 Gy TBI); on subacute toxicity using a model of oral mucositis (16.5 Gy); on late radiation injuries by monitoring lung fibrosis (bleomycin and 19 Gy).Results:Combination of irradiation with anti-VEGF antibody enhanced intestinal damages with severe epithelial ulcerations, had no adverse impact on oral mucositis and dramatically worsened the fibrotic picture induced by bleomycin and irradiation to the lung.Interpretation:These reports bring to light the important questions about safety and underscore the need for appropriate preclinical modelling of the impact on normal tissues of novel drug–radiation regimens. Our findings also highlight the complexity of anti-VEGF action, which could in defined conditions exert tissue-specific protection. The findings indicate that the combination of targeted drugs with radiotherapy should be approached with caution.

A reduced intensity conditioning regimen of fludarabine, cyclophosphamide, antithymocyte globulin, plus 2 Gy TBI facilitates successful hematopoietic cell engraftment in an adult with dyskeratosis congenita

Dyskeratosis congenita (DKC), also known as Zinsser–Engman–Cole syndrome, is a relatively rare, inherited form of progressive BM failure (BMF) syndrome characterized by the triad of reticulated skin pigmentation abnormalities, nail dystrophy and oral leukoplakia.1 Patients with DKC and associated BMF, generally, do not respond to immunosuppressive therapy(ies) and are at higher risks of increased morbidity and mortality associated with allogeneic hematopoietic cell transplantation (allo-HCT), due to underlying organ impairment, particularly when using myeloablative doses of chemotherapy or chemoradiotherapy.2, 3 Published literature with regard to effective conditioning regimen(s) for allo-HCT for patients with DKC is limited to single case reports or small case series.4, 5, 6, 7 Accordingly, the optimal allo-HCT preparative regimen to be offered to patients with DKC remains unknown.