High Incidence Of Relapse Research Articles

Peri-operative Therapies for Localized Retroperitoneal Soft Tissue Sarcoma

Retroperitoneal soft tissue sarcomas are rare solid tumors that usually arise in the retroperitoneum or the pelvis. They are often large at presentation and push adjacent structures, displacing them, anatomically. The most common adult histotypes are liposarcoma and leiomyosarcoma. Five-year overall survival is less than 50 % and is mainly determined by the high incidence of local relapse and to a lesser extent by their capacity to metastasize. Radical surgery is still the most effective treatment. While an aggressive surgical policy consisting of multivisceral resections ‘en bloc’ with the mass has undoubtedly decreased, the rate of local recurrence, prognosis remains poor. Retrospective analyses and early prospective data suggest a benefit from using neoadjuvant radiotherapy in order to improve local control. Chemotherapy plays an important role in advanced disease, but very little evidence supports a real advantage in delivering it prior to surgery to make the resection more likely to achieve clear margins or postoperatively to decrease the risk of systemic recurrence. Further studies are required to explore the role of these neoadjuvant/adjuvant therapies, particularly in the context of new developments in molecular therapeutic agents.

Involvement of the cerebrospinal fluid cells in children with acute lymphoblastic leukemia: prognostic implications.

In this issue of the Revista Brasileira de Hematologia e Hemoterapia, Cancela et al.(1) analyzed the incidence and the risk factors for central nervous system (CNS) relapse in children and adolescents with acute lymphoblastic leukemia (ALL) treated using the GBTLI-ALL 99 protocol and found that a leukocyte count > 50 x 109/L at diagnosis was the only significant factor associated with a high incidence of CNS relapse. Leukemic infiltration of the CNS is defined as five or more leukocytes/mm3 and blast cells in cerebrospinal fluid (CSF) or cranial nerve palsy(2). It is a well-established prognostic factor in children with ALL(2-6). The cumulative incidence of CNS relapse (combined or isolated) presently varies from 2.6 to 9.5%(7). No clinical or morphological CNS involvement is evident at diagnosis in about 60% of patients who eventually develop CNS relapse(3-6,8-10). Similar to systemic chemotherapy in the treatment of systemic ALL, there is a growing concern to identify factors associated with increased risk of leukemia infiltration of the CNS and to consequently adapt the protocol aimed at the treatment and prophylaxis of neurological involvement(11). Several risk factors have been associated with a higher incidence of initialinvolvement or relapse in CNS, such as high risk genetic abnormalities [t(9;22) and mixed lineageleukemia (MLL) rearrangements], T-lineage ALL and high peripheral leukemic-cell burden(7,12). Some studies have also demonstrated that patients with any identifiable blast cells in CSF, or CSF contamination by blastic cells during traumatic lumbar puncture, present an increased risk of CNS relapse(13-15). Others however have not found this association(16-18). Conventional cytological analysis has proved useful, but the analysis of cells in CSF, especially with low cell counts, is more difficult than is widely admitted and it is not always conclusive(19). Molecular involvement detected by more sensitive and specific techniques such as PCR and direct sequencing has been shown in around 45% of pediatric patients; the prognostic impact of this molecular involvement seems to be dependent of the intensity of treatment(20,21). It is possible that morphological involvement of the CNS would represent one of the extremes of a clinical spectrum ranging from gross to minimal residual disease involvement of the CNS and that molecular involvement could reflect biologically more aggressive disease. The explanation for these discrepancies is probably related to the efficacy of systemic and CNS-directed therapy in different treatment regimens, suggesting that the poor prognosis associated with these variables can be overcome by more effective therapy(21).

Long-term outcome of the difficult nephrotic syndrome in children

To determine the long-term outcome of nephrotic syndrome (NS) in children, we studied 48 patients with the NS aged seven months to 12 years at onset and followed for a long period (3-9 years). Consanguinity was positive in 31.2%. Patients' history of atopy was present in 25%, while family history of allergy was present in 18 (37.5%) patients. Renal impairment at initial presentation was observed in 12.5% of the patients. Among 32 biopsied patients, 11 (34.3%) had focal segmental glomerulosclerosis and eight (25%) revealed mesangial IgM nephropathy. Outcome at two years of presentation showed 41.6% patients as frequent relapsers, 39.5% as steroid dependent and 18.7% as steroid resistant. Forty-three patients were available for follow-up after ten years of presentation, 22 (51%) patients had complete remission, 15 (34.8%) were steroid dependent, two (4.6%) developed chronic renal failure and two (4.6%) died. Two patients (4.6%) developed insulin-dependent diabetes mellitus, two (4.6%) had cataract and one (2.3%) had documented peritonitis. In conclusion, the high incidence of steroid-dependent, frequent relapses and steroid resistance in children can be explained by different factors, including consanguinity, atopy and severe presentation at onset of disease. We suggest longer initial treatment at onset for this group of patients. The low incidence of infection in this group needs to be addressed in future studies.

Endogenous anticancer mechanism differentiation

It has been recently shown that within heterogeneous tumor masses a small population of less differentiated transformed cells has the ability to self-renew and regenerate the bulk of the tumor. Their similarities with normal stem cells in terms of gene expression patterns, proliferative capacity and surface markers rendered them the name of cancer stem-like cells (CSC), and these are thought to be the tumor initiating cells (TIC). Their limited susceptibility to classical anti-tumor therapy help explain the high incidence of cancer-treatment relapses observed in selected malignancies. Much effort is being directed towards the understanding of factors that maintain CSC survival and their self-renewal capacity, with the goal that these same signaling pathways can be harnessed for treatments that aim at inducing CSC differentiation. This review will discuss the CSC theory, its implications, potential signaling pathways responsible for maintaining their undifferentiated and pluripotent states, and new venues being explored to target these cells in modern cancer therapy.

Burden of Illness of FLT-3 Mutated Acute Myeloid Leukemia (AML)

Abstract 4765 Introduction:Patients with FLT3-mutated AML have poor prognoses due to shorter survival, a high incidence of relapse, and a lack of effective treatment options. Limited information is published on the burden of illness (BOI) of AML, especially for patients with FLT3-mutated disease. This study reviewed the epidemiologic, clinical, humanistic, and economic literature and estimated the burden of FLT3-mutated AML in the US. Methods:A systematic literature review was conducted in PubMed to identify clinical and economic publications on AML published in English from 2000 to 2011. Data relevant to the burden of FLT3-mutated AML were abstracted. 607 citations were identified in PubMed. 581 abstracts were screened and 35 articles were abstracted. Epidemiologic data were also sought from the Surveillance, Epidemiology and End Results (SEER) database. Areas where information was limited or not available were identified and discussed with clinicians experienced in treating AML. An Excel model was then developed to estimate the population-level BOI of AML by FLT3 status. Resource utilization estimates were obtained from the literature and expert opinion. Direct costs included procedures, hospitalizations, outpatient/office visits, other resource use (home health care, hospice, skilled nursing facility), and medications (including chemotherapy). Indirect costs included lost productivity but did not include costs associated with premature retirement or premature mortality. Results:In patients age <60 years, the literature reported FLT3 mutations in up to 30% of AML cases. Patients with FLT3-mutated AML have poorer prognoses: per the literature, median overall survival estimates of 15.2–15.5 months for FLT3-mutated AML patients <60 years of age was noted compared to 19.3–28.6 months for wild-type AML patients. Five-year survival rates for age <60 years range from 15% for high ITD-mutant levels to 31% in low ITD mutant-levels for FLT3-mutated AML patients vs. 42% for wild-type AML patients.No studies were identified containing estimates for the incidence or prevalence of FLT-3 mutated AML. The prevalence of AML in 2008 was obtained from SEER data and was estimated at 27,813 patients aged ≥20 years. Age- and gender-specific incidence and relative 5-year survival rates were obtained from SEER data. Projections for the prevalence, incidence, and mortality of FLT3-mutated AML through 2020 were calculated based on the SEER estimates, age- and gender-specific US Census population projections, and an assumption of FLT3 mutations in 23% of AML cases. In 2010, it was estimated that 725 patients aged 20–60 years were diagnosed with FLT3-mutated AML, with 572 disease-related deaths.Three studies were identified which reported information on the impact of AML on quality of life (QoL), though none described the QoL impact of FLT-3 mutated AML. One study specifically examined the <60 year old population, noting that AML patients receiving stem cell transplants had significantly worse long-term impact on QoL vs. patients receiving conventional chemotherapy. No studies quantifying the impact of AML on productivity were identified.In our analysis, the overall economic burden of FLT-3 mutated AML in the US was estimated at $244 million in 2010, including $184 million in direct costs and $60 million in indirect costs from lost productivity. Stem cell transplants accounted for 21% of direct costs, inpatient hospitalizations accounted for 44%, and medications for 4%.For AML patients <60 years, the overall cost per newly diagnosed FLT3-mutated AML patient was estimated at $114,198 vs. $105,825 for newly diagnosed FLT3-wild-type AML patients. This is likely an underestimate of the cost as the impacts of early mortality and early retirement were not included in the indirect costs. In addition, the impact of QoL was not included and this may also underestimate costs due to more frequent use of transplantation in the FLT3-mutated AML population. Conclusions:AML poses a large economic burden, both for the healthcare system and society. FLT3-mutated AML potentially represents a greater per-patient burden than FLT3 wild type AML due to shorter survival rates and use of more costly therapies such as stem cell transplants. Investigational treatments targeting the FLT3 mutation may provide an additional therapeutic option for these patients and have the potential to improve clinical outcomes. Disclosures:Sotak:Novartis: Research Funding. Marin:Novartis: Research Funding. Coombs:Novartis: Employment. Schiller:BMS: Research Funding; Celgene: Research Funding; Ambit: Research Funding; Novartis: Research Funding; Sunesis: Research Funding. Teitelbaum:Novartis: Research Funding.

Expression of CD56 in Acute Myeloid Leukemia (AML) Is Associated with Poor Outcome When Patients Treated with Stem Cell Transplant in Second Remission but Not in the First Remission

Abstract 4880 Background:The CD56 is a neural cell adhesion molecule (N-CAM) expressed in natural killer cells. CD56 expression on the surface of leukemic cells in acute myeloid leukemia (AML) has been reported to correlate with higher rate of relapse and to be associated with poor outcome when patients are treated with conventional intensive chemotherapy. The role of allogeneic hematopoietic stem cell transplantation (HSCT) in improving outcome in this subgroup of AML patients is not known. We investigated whether the outcome of CD56-positive AML patients differ from average AML patients when treated with allogeneic HSCT after intensive chemotherapy and its prognostic relevance in patients transplanted in the first (CR1) or second complete remission (CR2). Methods:Immunophenotyping data of 106 patients with AML who were treated with allogeneic HSCT was reviewed. The expression of the CD56 on the blast population as determined by flow cytometry was correlated with clinical data and outcome. The median age of patients was 24 (range: 14–57) and included 72 patients in the intermediate cytogenetic group and 30 in the adverse cytogenetic group. Of the 106 patients, 71 (67%) were treated with HSCT in their first remission (CR1) and the remaining patients were treated in CR2. Results:Twenty nine (28%) of all studied patients expressed CD56 on the surface of the blasts at diagnosis. When we consider only patients treated with HSCT in CR1, 17 (24%) were CD56 positive. The overall survival (OS) and event free survival (EFS) for patients who were positive for CD56 were not significantly different from the rest of the patients in the CR1 group. In contrast, in the group of patients who were treated with HSCT after relapsing (CR2), patients with CD56 positivity had significantly shorter OS (P=0.03) and DFS (P=0.006). In this group, 11 of the 35 (31%) were CD56+ and their median survival was 8.85 months while the median has not been reached in the CD56 negative patients. Conclusion:Our data suggests that the expression of CD56 in AML is a significant poor prognostic factor if patients are treated with HSCT after relapsing in their second remission. Although this should be confirmed in larger studies, the CD56 expression in AML should be considered as an adverse risk factor and favors treatment with allogeneic HSCT in the first remission and not after relapse in second remission. AML patients with CD56 positive blasts have higher incidence of relapse after chemotherapy and they might lose their opportunity of good outcome if HSCT is delayed and performed only in the second remission. [Display omitted] Disclosures:No relevant conflicts of interest to declare.

Bone Marrow Cellularity, but Not Dysplasia, Is An Additional Prognostic Factor for Patients with Acute Myeloid Leukemia After Allogeneic Stem Cell Transplantation

Abstract 4467 Background:Relapse incidence (RI) and non-relapse mortality (NRM) are competing risks limiting overall survival (OS) after allogeneic stem cell transplantation (SCT) in acute myeloid leukemia (AML). Disease and transplant specific factors predicting relapse like measurement of minimal residual disease (MRD) and chimerism analysis are widely used to aid prophylactic and preemptive treatment decisions. Prediction of NRM mostly relies on pretransplant features. Although most transplant centers routinely perform bone marrow (BM) cytomorphology after SCT for AML, the impact of factors beyond blast count is not well studied. Study Design:We analyzed frequencies and prognostic impact of dysplasia and cellularity upon BM cytomorphology of 112 patients (60 m/52 f, median age 53 [range 17–72] years) with AML at 1st manifestation/ relapse at day 30 (d30) and day 100 (d100) after SCT. Using peripheral blood as main graft source (n=106), donors were unrelated in 87 cases, related in 25. Conditioning was reduced (RIC, n=72) or myeloablative (MAC, n=40). All patients received G-CSF from day 5 until stable engraftment was achieved. Dysplasia was assessed following WHO criteria with different thresholds (10%, 20%, 50%) to define a hematopoietic lineage as dysplastic. We performed a correlation of dysplasia and age-adapted cellularity with outcome measures, calculating RI and NRM as competing risks. Only patients who achieved blast clearance on d30 after SCT were included in the study. Patients who developed hematological relapse between d30 and d100 were only evaluated for d30. At d30 (d100), BM aspirates from 75 (65) patients were available for morphologic evaluation. Result:Dysplasia was a frequent event both at d30 and d100, with ≥10% dysplastic features in granulopoiesis in 25.0% of cases at d30 (31% d100), in erythropoiesis in 34.6% of cases at d30 (43.6% d100) and in megakaryopoiesis in 47.7% of cases at d30 (63.5% d100). Overall, cellularity at d30 was increased in 17.3% (d 100: 6.5%), reduced in 37.3% (d100: 38.7), and normal in 45.3% (d100: 54.8%). No significant correlation with CMV reactivation or with the type of immunosuppression (cyclosporine/ methotrexate versus cyclosporine/ mycophenolic acid) was noted. Cumulative incidences of 2-year-RI and 2-year-NRM were 34% (95% CI, 24%-44%) and 17% (95% CI, 9%-25%). Dysplasia both at d30 and d100 did not correlate with OS or RI. Yet, a statistically significant correlation of normal overall cellularity at d30 with less relapses (RI 20.6%) when compared with reduced overall cellularity (RI 32.1%) or increased overall cellularity (RI 76.9%; p=0.001) was observed. Estimated 2-year-OS was 59% in pts with normal overall cellularity versus 31.4% (reduced) and 44.0% (increased), respectively (p=0.009). The same results, favoring normal cellularity, were observed for each lineage (granulopoiesis, erythropoiesis, megakaryopoiesis). Conversely, increased overall cellularity at d30 correlated with lower NRM (8.3%) when compared to normal (NRM 23.7%) and reduced overall cellularity (NRM 39.6%, p=0.031). Thus, whereas reduced overall cellularity at d30 correlated both with higher RI and higher NRM, the impact of increased cellularity on survival was less clear. The analysis of subdistributive hazards in the competing risk factor model revealed a cumulative RI of 62% (95%CI 35%-89%, HR 6.68, p=0.00014) for increased cellularity, making it the most potent hazard in this analysis. Presence of an informative sample was of prognostic value, too (2-year-OS/ NRM 54.7%/ 80.4% for “evaluable” versus 20%/ 36.9% for “not evaluable” due to low cellularity, p<0.001). Cellularity at d100 showed no significant correlation with survival outcomes. We found no correlation of either dysplasia or cellularity with the pretransplant cytogenetic risk group and CMV serostatus. In this study, patients with AML who achieved normal cellularity early in the post-transplant period had improved survival outcomes and a reduced relapsed incidence as compared to patients with abnormal cellularity in bone marrow aspirates. Conclusion:These data suggest that cellularity of BM cytomorphology at d30 after allogeneic SCT aids to assess risk of relapse and NRM in transplant recipients with AML. At this time, it can only be speculated whether underlying persistent leukemia below the microscopic level might be associated with disturbed BM cellularity. Disclosures:Haferlach:MLL Munich Leukemia Laboratory: Employment, Equity Ownership.

MicroRNAs in Intermediate Risk Cytogenetic Acute Myeloid Leukemia Add Relevant Prognostic Information to Molecular Categorization

Abstract 235The prognosis of AML patients within the intermediate cytogenetics category is mainly determined by the mutational status of some relevant genes, such as NPM1 mutations (NPMmut), or biallelic CEBPA mutations (CEBPAmut), associated with a favorable outcome, and with the presence of FLT3 internal tandem duplication (FLT3-ITD), which correlates with an adverse prognosis. Nonetheless, additional biological features such as microRNA (miRNA) expression pattern might contribute to refine prognosis and guide therapy in this setting.The aim of the present study is to investigate whether miRNA expression is associated with molecular characteristics and clinical outcome in intermediate-risk AML patients (IR-AML).We have analyzed samples from 85 IR-AML patients (median age, 52 [range, 18–71]; 52% males) who received intensive therapy from 1994 to 2009. Forty-three patients (51%) harbored NPMmut, 37 (44%) harbored FLT3-ITD (including 23 with NPMmut), and 11 (13%) harbored CEBPAmut, including 7 with biallelic mutations. The expression of 670 mature miRNAs was analyzed by multiplex Real Time PCR using TaqMan Human MicroRNA Arrays (Applied Biosystems). All PCR reactions were performed using an ABI 7900 HT sequence detection system. miRNA expression data was analyzed by the 2−DDCt method, using RNU48 as endogenous control. Statistical analysis was performed with BRB Array Tools, SPSS version 15.0.1 and R software version 2.9.0.Supervised analysis by means of t-test based on multiplex permutations (class comparisons analysis, p<0.001) revealed a distinctive miRNA signature in patients with NPMmut, with overexpression of miR-10a, miR-10a*, miR-10b and miR-196b, and downregulation of miR-126, miR126*, miR-424, miR-424* and miR-335, as well as patients with biallelic CEBPAmut, characterized by downregulation of miR-196b and upregulation of miR-181a. Response rate in this series of patients was 84%, with 5-year survival of 43±11% and relapse incidence (RI) of 55±14%. Multivariate analysis for overall survival(OS) including NPM status, FLT3-ITD status, age, WBC, and Log Rank OS significant miRNAs (miR-632, miR-23b, miR-409-3p, let-7a*, miR-565 and miR-196b) identified age, absence of NPMmut, and FLT3-ITD as unfavorable variables together with low expression of miR-409-3p (p<0.001; HR=3.3, 95% CI: 1.7–6.4), and increased level of let-7a* (p=0.026; HR=5.1, 95% CI: 1.21–21.5) and miR-196b (p=0.056; HR=7.27, CI: 0.95–55.6). Concerning risk of relapse (RR), multivariate analysis including NPM status, age, FLT3-ITD, WBC, and Log Rank RR significant miRNAs (miR-632, miR-155*, miR-135a, miR-409-3p, miR-150, miR-23a* and miR-363) the absence of NPMmut, FLT3-ITD and increasing leukocyte count were associated with a higher RI. Remarkably, decreased miR-409-3p expression (p=0.011; HR=3.3, 95% CI: 1.3–8.2) and miR-135a (p=0.02; HR=4.2, 95% CI: 1.2–14.2), together with higher levels of miR-23a* (p<0.001; HR=6.2, 95% CI: 2.61–14.7) were independently associated with a higher relapse risk. Of note, a decreased miR-409-3p level retained its adverse prognosis value in the subgroup of patients without favorable molecular markers (i.e., wild-type NPM1 and CEBPA and/or FLT3-ITD;p=0.001) together with low miR-361-3p (p=0.013, HR= 2.4, CI: 1.2–5.1). On the contrary, let-7a* levels segregated subgroups of patients in the category of favorable genotype (i.e., mutated NPM1 without FLT3-ITD p=0.027).In this series of patients of intermediate-risk cytogenetic AML, measurement of expression levels of several miRNAs such as miR-409-3p, miR-135a, let-7a* or miR-23a* showed independent prognostic value, and contribute to predict the outcome within specific molecular subgroups. Nonetheless, confirmation of the prognostic impact of these miRNAs and investigation of possible underlying mechanisms account for this effect require future studies. Disclosures:No relevant conflicts of interest to declare.

The Presence of An Internal Tandem Duplicate of FlT3 Receptor (ITD) Is An Unfavorable Prognostic Factor on the Outcome of Adult Patients with Acute Myeloid Leukemia (AML) Autografted in First Remission (CR1) Only in the Absence of An NPM1 Mutation,

Abstract 4139The prognosis of patients with AML harboring the FlT3 ITD is known to be poor in those patients treated with chemotherapy alone. However, it remains uncertain whether this abnormality has also an impact on outcome following high dose intensification and autologous stem cell transplantation (ASCT).We addressed this question using the EBMT data base: we initially reported on a total of 134 patients in 2010 (Blood 2010, 3356a). Following further queries, we have now extended our study to a total of 357 patients with AML autografted in CR1 between January 2000 to December 2009, and in whom the information on the presence or the absence of FlT3ITD was available. 258 (136 with a normal karyotype) patients were ITD negative and 99 (63 with a normal karyotype) were ITD positive. 96% of the patients received peripheral blood as a source of stem cells. The median follow up was 30 m. (range, 1–118).Patients who were ITD positive had higher white cell counts at diagnosis (54 vs. 12.5 109/L; p<0.0001) and had a higher proportion of slow remitters (needing more than one induction course to achieve CR) (22% vs. 11%; p=0.04). Interestingly, patients who were ITD positive were more frequently found to be NPM1 mutated (59% vs. 40%; p=0.03).In the univariate analysis, Leukemia-Free Survival (LFS) at 3 years was significantly lower in patients who were ITD positive (34±5% vs. 52±4%; p=0.001) and the relapse incidence was higher (58±5% vs. 42±4%; p=0.002). The Non-Relapse Mortality (NRM) rate was similar (8±3% vs. 6±1%; p= 0.7).By multivariate analysis, the only unfavorable prognostic factors for outcome were failure to achieve CR with more than one induction course (slow remitters), and the presence of an ITD, which were associated with higher relapse incidence (p= 0.006; p=0.03) and lower LFS (p=0.05; p=0.005).In this series, it was interesting to observe that the only group with a significantly lower LFS in univariate analysis, was the group of patients who were FlT3ITD positive without NPM1 mutation (23±11% vs. 56±6% for FLT3ITD negative/NPM non-mutated, 46±8% for FLT3ITD negative/NPM mutated and 48±13% for FLT3ITD positive /NPM mutated; p=0.03).We conclude that in the context of autografting for AML in CR1, the presence of a FLT3ITD is an unfavorable prognostic factor only in less than 50% of the patients corresponding to those with the absence of a NPM1 mutation. This study helps to better define the population of patients with AML that would benefit most from intensification with autologous stem cell transplantation. Disclosures:No relevant conflicts of interest to declare.

Allogeneic Hematopoietic Cell Transplantation with FLAMSA-RIC Can Overcome the Poor Prognosis of Primary Refractory or Relapsed AML

Abstract 1938▪▪This icon denotes a clinically relevant abstract Introduction:Patients with relapsed or primary refractory AML have a dismal prognosis. Even salvage therapy with allogeneic hematopoietic cell transplantation (HCT) could not improve outcome due to high incidence of relapse and high non-relapse mortality (NRM). Recently, promising results in patients with unfavorable karyotype or treatment refractory AML have been reported using a sequential treatment with aplasia inducing chemotherapy consisting of Fludarabine, Ara-C and Amsacrine (FLAMSA) followed within 3 days by reduced intensity conditioning (RIC) for allogeneic HCT (Schmid et al., Blood 2006 Aug 1;108(3):1092–9). Methods:We report a retrospective analysis of our single center experience with FLAMSA-RIC in primary refractory or relapsed AML patients. We searched our database for patients receiving FLAMSA-RIC in the past 10 years. Details on characteristics and clinical course of the patients were confirmed by retrospective chart review. Results:We retrospectively identified and analyzed 51 consecutive patients (f=22, m=29) transplanted after FLAMSA-RIC at our institution from 2006–2011. At time of HCT patients were refractory after chemotherapy (n=22) or had an untreated relapse (n=29). Data on molecular and cytogenetic markers were available in 36 and 44 patients, respectively. 34 were initially high-risk because of unfavorable karyotype (n=25) or molecular genetic alterations (n=9). Median age of patients was 56 years (range, 20–72) and diagnosis of all patients was acute myeloid leukemia (de-novo AML, n=27, secondary AML, n=24). FLAMSA (Fludarabine 30 mg/m2 day −12 to −9, AraC 2000 mg/m2 day −12 to −11 and Amsacrine 100 mg/m2 day −12 to −9) was used as salvage therapy followed by RIC (Fludarabine 30 mg/m2 day −5 to −4/Busulfan 0.8 mg/kg day −6 to −4, n=10; TBI 4Gy on day −5/Cyclophosphamide 60 mg/kg on day −4 to −3, n=28; Busulfan 0.8 mg/kg day −6 to −4/Cyclophosphamide 60 mg/kg for matched and mismatched unrelated donors (MUD/MMUD) or 40 mg/kg for matched related donors (MRD) on day −3 to −2, n=13). As GVHD prophylaxis calcineurin inhibitor combined with mycophenolate mofetil and anti-thymocyte globuline (ATG-Fresenius®, 10 mg/kg for MRD and 20 mg/kg for MUD/MMUD) was used. 10 patients were transplanted from MRD, 16 from MUD, 21 from a MMUD and 4 from a MMRD. 14 patients received DLI (2 × 106 - 1 × 108 /kg after a median of 186 days, range 72–922) in absence of GVHD in case of mixed chimerism or relapse after HCT. Current overall survival (OS) was 18/51 patients with a median follow-up of 410 days (range, 179–1557) of patients alive resulting in a Kaplan-Meier estimated 2-year OS and event-free-survival (EFS) of 34% and 29%, respectively. There was no significant difference between the different RIC regimens with 50% Fludarabine / Busulfan vs. 26% TBI 4Gy / Cyclophosphamide and 40% Fludarabine / Busulfan (p=0.37). Causes of death were relapse (n=19), infections (n=5), GVHD (n=2), multi-organ-failure (n=5), cerebral hemorrhage (n=1) and progressive multifocal leukencephalopathy (n=1). Cumulative incidence of relapse at 2 years with death due to NRM as competing risk was 40% and cumulative incidence at 2 years of NRM with death due to relapse as competing risk was 27%. 2-year OS was inferior in patients with secondary AML compared to patients with de-novo AML (28% vs. 38% p=0.79). The outcome in the elderly subgroup defined by age ≥60 years (median age 67, n=22) was similar to the group of younger patients (median age 46, n=29) with 2-year OS of 31% vs. 37% (p=0.87). Patients with a blast count < 10% in the bone marrow at time of HCT had a better outcome with 64% vs. 25% OS (p=0.09). 2-year-OS was inferior in patients being refractory after chemotherapy (25% vs 38%, p=0.78). Incidence of acute GVHD (aGVHD) ≥II and chronic GVHD (cGVHD, limited, n=11, extensive, n=3) was 22% and 27%, respectively. Presence of aGVHD did not influence survival while presence of cGVHD was associated with an improved overall survival after HCT (58% vs 24%, p=0.009). Conclusion:FLAMSA-RIC followed by allogeneic HCT enables long-term disease free survival, even in primary refractory or relapsed AML patients. The sequential approach of this regimen seems to overcome the dismal prognosis of these patients. Its moderate toxicity allows the application of this curative salvage therapy option even in an elderly patient population. Disclosures:Off Label Use: The use of some agents in the conditioning is off-label.

Terapia biológica en las vasculitis sistémicas

Several biological therapies have been evaluated in systemic vasculitis. Anti TNF-α agents may have a role in the treatment of Takayasu's arteritis and probably in giant cell arteritis. In Kawasaki's disease, infliximab is an option in subjects with intravenous immunoglobulin-resistant disease. Anti TNF-α cannot be recommended to treat ANCA-associated vasculitis. Anti-T lymphocyte globulin and alemtuzumab could have a role in the treatment of ANCA associated vasculitis, although current information about these two biological treatments comes from conventional resistant treatment cases, so the high incidence of complications and relapses observed with these treatment may be intrinsic to the severity of the disease and not related to the biological agents.

Predictive clinical outcome of the intratumoral CD66b‐positive neutrophil‐to‐CD8‐positive T‐cell ratio in patients with resectable nonsmall cell lung cancer

The role of the interaction between tumor cells and inflammatory cells in nonsmall cell lung carcinoma (NSCLC) is unclear. In this study, the authors assessed the prognostic impact of intratumoral cluster of differentiation 66b (carcinoembryonic antigen-related cell adhesion molecule 8 [CD66b])-positive neutrophils and of the intratumoral CD66b-positive neutrophil-to-cluster of differentiation 8 (cell surface antigen T8 [CD8])-positive lymphocytes (the CD66b-positive neutrophil-to-CD8-positive lymphocyte ratio [iNTR]) in patients with resectable NSCLC. Expression levels of CD66b and CD8 were evaluated by immunohistochemistry on tissue microarrays consisting of 632 NSCLC specimens from patients who underwent curative surgery. The relation between clinicopathologic variables and patient outcome was assessed. Intratumoral CD66b-positive neutrophils were elevated in 318 patients (50%). In univariate analysis, an increase in CD66b-positive cells was associated with a high cumulative incidence of relapse (CIR) (median CIR, 51 months for low CD66b-positive cell density; 36 months for high CD66b-positive cell density; P = .002) and trended toward worse overall survival (OS) (median OS, 57 months for low CD66b-positive cell density; 54 months for high CD66b-positive cell density; P = .088). The iNTR was elevated in 190 patients (30%). An increased iNTR was strongly associated with both a high CIR (median CIR: 43 months for an iNTR ≤1; 34 months for an iNTR >1; P < .0001) and poor OS (median OS: 60 months for an iNTR ≤1; 46 months for an iNTR >1; P < .0001). In multivariate analysis, independent prognostic factors for a higher CIR were high iNTR (hazard ratio [HR], 0.71; 95% confidence interval [CI], 0.56-0.90; P = .005) and tumor stage >I, (HR, 0.39; 95% CI, 0.30-0.52; P < .0001). Independent prognostic factors for worse OS were a high iNTR (HR, 0.70; 95% CI, 0.54-0.91; P = .007) and tumor stage >I (HR, 0.35; 95% CI, 0.26-0.47; P < .0001). The current results indicated that the iNTR is a novel, independent prognostic factor for a high rate of disease recurrence and poor OS in patients with resectable NSCLC.

Treatment outcomes for different subgroups of nasopharyngeal carcinoma patients treated with intensity-modulated radiation therapy

Although many studies have investigated intensity-modulated radiation therapy (IMRT) for nasopharyngeal carcinoma (NPC), sample sizes in the reported studies are usually small and different in outcomes in different T and N subgroups are seldom analyzed. Herein, we evaluated the outcomes of NPC patients treated with IMRT and further explored treatment strategy to improve such outcome. We collected clinical data of 865 NPC patients treated with IMRT alone or in combination with chemotherapy, and classified all cases into the following prognostic categories according to different TNM stages: early stage group (T1–2N0–1M0), advanced local disease group (T3–4N0–1M0), advanced nodal disease group (T1–2N2–3M0), and advanced locoregional disease group (T3–4N2–3M0). The 5-year overall survival (OS), local relapse-free survival (LRFS), and distant metastases-free survival (DMFS) were 83.0%, 90.4%, and 84.0% respectively. The early disease group had the lowest treatment failure rate, with a 5-year OS of 95.6%. The advanced local disease group and advanced nodal disease group had similar failure pattern and treatment outcomes as well as similar hazard ratios for death (4.230 and 4.625, respectively). The advanced locoregional disease group had the highest incidence of relapse and death, with a 5-year DMFS and OS of 62.3% and 62.2%, respectively, and a hazard ratio for death of 10.402. Comparing with IMRT alone, IMRT in combination with chemotherapy provided no significant benefit to locoregionally advanced NPC. Our results suggest that the decision of treatment strategy for NPC patients should consider combinations of T and N stages, and that IMRT alone for early stage NPC patients can produce satisfactory results. However, for advanced local, nodal, and locoregional disease groups, a combination of chemotherapy and radiotherapy is recommended.

Allogeneic bone marrow transplantation compared to peripheral blood stem cell transplantation for the treatment of hematologic malignancies: a meta-analysis based on time-to-event data from randomized controlled trials

Controversy remains regarding the transplant outcomes of human leukocyte antigen-identical related bone marrow transplantation (BMT) and peripheral blood stem cell transplantation (PBSCT) for the treatment of patients with hematological malignancies. To provide an estimate of the effect of BMT and PBSCT on clinical outcomes in patients with hematological malignancies, we conducted a meta-analysis based on time-to-event data from 17 randomized controlled trials. PubMed, EMBASE, and Cochrane Central Register of Controlled Trials (CENTRAL), from 1972 through July 2010, and conference proceedings through July 2009 and reference lists, without any language restriction, of randomized trials that compared the transplant outcomes after BMT and PBSCT in patients with hematological malignancies were searched for details. Two independent reviewers extracted the data. The outcomes examined were engraftment, graft-versus-host disease (GVHD), relapse, transplant-related mortality (TRM), leukemia-free-survival (LFS), and overall survival (OS). Compared to PBSCT, BMT had lower neutrophil (HR, 2.08; 95% CI, 1.80 to 2.42; p < 0.00001) and platelet (HR, 2.77; 95% CI, 1.78 to 4.30; p < 0.00001) engraftment. BMT was associated with a significant decrease in the development of grades II-IV (HR, 0.75; 95% CI, 0.63 to 0.90; p = 0.002) and III-IV (HR, 0.63; 95% CI, 0.47 to 0.84; p = 0.001) acute GVHD as well as overall (HR, 0.70; 95% CI, 0.59 to 0.83; p < 0.0001) and extensive (HR, 0.60; 95% CI, 0.39 to 0.91; p = 0.002) chronic GVHD. BMT was associated with a higher incidence of relapse (HR, 1.91; 95% CI, 1.34 to 2.74; p = 0.0004). Comparable TRM (1.08; 95% CI, 0.56 to 2.10; p = 0.81), LFS (HR, 1.04; 95% CI, 0.83 to 1.30; p = 0.73), and OS (HR, 1.06; 95% CI, 0.81 to 1.39; p = 0.65) were demonstrated for both treatments. An inverse linear relationship was observed between the acute GVHD difference (PBSCT minus BMT) and the outcome of OS (p = 0.016). Our meta-analysis suggest that BMT leads to slower hematological recovery, increasing rates of relapse, and a lower risk of GVHD, but no significant difference in LFS and OS. A lower incidence of acute GVHD is associated with a superior OS.

Serum levels of cytoplasmic melanoma-associated antigen at diagnosis may predict clinical relapse in neuroblastoma patients

The high molecular weight melanoma-associated antigen (HMW-MAA) and the cytoplasmic melanoma-associated antigen (cyt-MAA/LGALS3BP) are expressed in melanoma. Their serum levels are increased in melanoma patients and correlate with clinical outcome. We investigated whether these molecules can serve as prognostic markers for neuroblastoma (NB) patients. Expression of cyt-MAA and HMW-MAA was evaluated by flow cytometry in NB cell lines, patients' neuroblasts ((FI)-NB), and short-term cultures of these latter cells (cNB). LGALS3BP gene expression was evaluated by RT-qPCR on (FI)-NB, cNB, and primary tumor specimens. Soluble HMW-MAA and cyt-MAA were tested by ELISA. Cyt-MAA and HMW-MAA were expressed in NB cell lines, cNB, and (FI)-NB samples. LGALS3BP gene expression was higher in primary tumors and cNB than in (FI)-NB samples. Soluble cyt-MAA, but not HMW-MAA, was detected in NB cell lines and cNBs supernatants. NB patients' serum levels of both antigens were higher than those of the healthy children. High cyt-MAA serum levels at diagnosis associated with higher incidence of relapse, independently from other known risk factors. In conclusion, both HMW-MAA and cyt-MAA antigens, and LGALS3BP gene, were expressed by NB cell lines and patients' neuroblasts, and both antigens' serum levels were increased in NB patients. Elevated serum levels of cyt-MAA at diagnosis correlated with relapse, supporting that cyt-MAA may serve as early serological biomarker to individuate patients at higher risk of relapse that may require a more careful follow-up, after being validated in a larger cohort of patients at different time-points during follow-up. Given its immunogenicity, cyt-MAA may also be a potential target for NB immunotherapy.

Diffuse large B-cell lymphoma with involvement of the kidney: outcome and risk of central nervous system relapse

Renal involvement is uncommon in diffuse large B-cell lymphoma. Recent data suggest that it is an independent risk factor for central nervous system relapse. We reviewed the clinical features, risk of central nervous system involvement, and survival of patients with diffuse large B-cell lymphoma with involvement of the kidney at diagnosis. All patients with diffuse large B-cell lymphoma and renal involvement diagnosed from January 1, 1982 to December 31, 2008 at the British Columbia Cancer Agency were retrospectively identified in the Lymphoid Cancer Database. Patients were included if they were 16 years old or over, had advanced stage disease [stage III/IV, or stage I/II with B symptoms or bulky mass (>10 cm)] and were treated with curative intent. Central nervous system involvement was diagnosed by cerebrospinal fluid cytology, radiology or clinically. We identified 55/2656 (2%) patients with diffuse large B-cell lymphoma and renal involvement at diagnosis. The male to female ratio was 2:1. The patients' median age was 58 years. Bilateral renal involvement was present in 24 (44%) and stage IV disease in 50 (91%). The International Prognostic Index score was 3, 4 or 5 in 52 (95%), the glomerular filtration rate was less than 30 mL/min/m² in 9 (16%) and elevated lactate dehydrogenase was recorded in 46 (84%). Twenty-five (46%) patients received CHOP plus rituximab and 30 (54%) received CHOP-like regimens without rituximab. In total, 20 (36%) patients had central nervous system involvement: four at the time of diagnosis and 16 at relapse. The median time to central nervous system relapse was 5.6 months (range, 1.2 months-4.6 years), and was not affected by the addition of rituximab (P=0.547). The 5-year overall and progression-free survival rates for the whole cohort were 29% and 25%, respectively. In patients who received rituximab, there were trends towards improved 5-year overall survival (43% versus 18%, P=0.071) and progression-free survival (40% versus 13%, P=0.057). There is an exceptionally high incidence of central nervous system relapse in patients with diffuse large B-cell lymphoma and kidney involvement at diagnosis. The addition of rituximab may improve overall survival in this poor-risk population, likely through improved control of systemic disease.

Alemtuzumab for the prevention and treatment of graft-versus-host disease

Alemtuzumab is a humanized monoclonal antibody against the CD52 antigen, which is expressed on the surface of various hematopoietic cells such as B and T lymphocytes, and has been widely used for preventing acute graft-versus-host disease (GVHD) in allogeneic stem cell transplantation (SCT). Administration of 100 mg alemtuzumab before transplantation has resulted in a low incidence of acute GVHD in HLA-matched and mismatched transplantation from either related or unrelated donors. However, because alemtuzumab could remain in the blood at the lympholytic level 1-2 months after transplantation, immune reconstitution was substantially delayed, leading to a high incidence of viral infection and relapse. A dose reduction of alemtuzumab was attempted in a reduced-intensity conditioning setting to facilitate immune reconstitution, and this resulted in earlier immune reconstitution, but the clinical benefits were unclear. The dose of alemtuzumab and the timing of its administration should be optimized to maximize the benefit of acute GVHD suppression and minimize the risk of infection and relapse. Another strategy to facilitate immune reconstitution and augment anti-tumor effects is donor cell infusion of T and NK cells. Although there is accumulating evidence regarding the use of alemtuzumab for acute GVHD prevention, information on the salvage treatment for steroid-refractory acute and chronic GVHD is still limited.

Thermal- and Oxidative Stress Causes Enhanced Release of NKG2D Ligand-Bearing Immunosuppressive Exosomes in Leukemia/Lymphoma T and B Cells

Immune evasion from NK surveillance related to inadequate NK-cell function has been suggested as an explanation of the high incidence of relapse and fatal outcome of many blood malignancies. In this report we have used Jurkat and Raji cell lines as a model for studies of the NKG2D receptor-ligand system in T-and B cell leukemia/lymphoma. Using real-time quantitative RT-PCR and immunoflow cytometry we show that Jurkat and Raji cells constitutively express mRNA and protein for the stress-inducible NKG2D ligands MICA/B and ULBP1 and 2, and up-regulate the expression in a cell-line specific and stress-specific manner. Furthermore, we revealed by electron microscopy, immunoflow cytometry and western blot that these ligands were expressed and secreted on exosomes, nanometer-sized microvesicles of endosomal origin. Acting as a decoy, the NKG2D ligand-bearing exosomes downregulate the in vitro NKG2D receptor-mediated cytotoxicity and thus impair NK-cell function. Interestingly, thermal and oxidative stress enhanced the exosome secretion generating more soluble NKG2D ligands that aggravated the impairment of the cytotoxic response. Taken together, our results might partly explain the clinically observed NK-cell dysfunction in patients suffering from leukemia/lymphoma. The adverse effect of thermal and oxidative stress, enhancing the release of immunosuppressive exosomes, should be considered when cytostatic and hyperthermal anti-cancer therapies are designed.

Mutually exclusive expression of DLX2 and DLX5/6 is associated with the metastatic potential of the human breast cancer cell line MDA-MB-231

BackgroundThe DLX gene family encodes for homeobox transcription factors involved in the control of morphogenesis and tissue homeostasis. Their expression can be regulated by Endothelin1 (ET1), a peptide associated with breast cancer invasive phenotype. Deregulation of DLX gene expression was found in human solid tumors and hematologic malignancies. In particular, DLX4 overexpression represents a possible prognostic marker in ovarian cancer. We have investigated the role of DLX genes in human breast cancer progression.MethodsMDA-MB-231 human breast carcinoma cells were grown in vitro or injected in nude mice, either subcutaneously, to mimic primary tumor growth, or intravenously, to mimic metastatic spreading. Expression of DLX2, DLX5 and DLX6 was assessed in cultured cells, either treated or not with ET1, tumors and metastases by RT-PCR. In situ hybridization was used to confirm DLX gene expression in primary tumors and in lung and bone metastases. The expression of DLX2 and DLX5 was evaluated in 408 primary human breast cancers examining the GSE1456 and GSE3494 microarray datasets. Kaplan-Meier estimates for disease-free survival were calculated for the patients grouped on the basis of DLX2/DLX5 expression.ResultsBefore injection, or after subcutaneous growth, MDA-MB-231 cells expressed DLX2 but neither DLX5 nor DLX6. Instead, in bone and lung metastases resulting from intravenous injection we detected expression of DLX5/6 but not of DLX2, suggesting that DLX5/6 are activated during metastasis formation, and that their expression is alternative to that of DLX2. The in vitro treatment of MDA-MB-231 cells with ET1, resulted in switch from DLX2 to DLX5 expression. By data mining in microarray datasets we found that expression of DLX2 occurred in 21.6% of patients, and was significantly correlated with prolonged disease-free survival and reduced incidence of relapse. Instead, DLX5 was expressed in a small subset of cases, 2.2% of total, displaying reduced disease-free survival and high incidence of relapse which was, however, non-significantly different from the other groups due to the small size of the DLX+ cohort. In all cases, we found mutually exclusive expression of DLX2 and DLX5.ConclusionsOur studies indicate that DLX genes are involved in human breast cancer progression, and that DLX2 and DLX5 genes might serve as prognostic markers.

Biological Features and Prognostic Impact of CRLF2 Overexpression In Childhood ALL

AbstractAbstract 271 Introduction.Although in AIEOP-ALL 2000 protocol, early MRD assessment allowed to better recognize high risk (HR) cases, still about 20% of children relapse, with more than half of relapses occurring in the largest subgroup of non-HR patients. Therefore, new prognostic markers are useful to adapt treatment. Recently, high-level expression of the CRLF2 gene was recognized to characterize a novel subgroup of BCP-ALL. Over-expression of CRLF2 can be the consequence of a translocation at the IGH@ locus, and/or an interstitial deletion, juxtaposing CRLF2 with the promoter of the P2RY8 gene. CRLF2 over-expression appeared to be the driver of STAT5 activation, either alone or in combination with gain-of-function mutations in Janus Kinases (JAKs), mainly JAK2 R683. Aim. In order to estimate the incidence of this abnormality, its prognostic value and the association with patients' biological features, we analyzed CRLF2 gene expression in 515 non-Down Syndrome BCP-ALL children, treated according to the ALL-AIEOP 2000 protocol. Methods.Ig/TcR PCR-MRD and RT-PCR screening for known chromosomal translocation were routinely performed. Gene expression profiling by Affymetrix HG U133 Plus 2.0 arrays; RQ-PCR for CRLF2 expression; PCR detection of P2RY8-CRLF2 fusion, FISH for CRLF2 translocations, High Resolution Melting (HRM) and sequencing for JAK2 mutations, gene Copy Number Analysis by Affymetrix Cyto 2.7M array were performed. CRLF2 expression was reported as a fold increase to the median of all values detected in the complete series. Results.Out of 515 samples, CRLF2 expression was 10 times higher than the overall median in 46 cases (8.9%), and 20 times more in 24 (4.7%). The P2RY8-CRLF2 rearrangement was detected in 15/168 cases overall (8.9%), in 13/43 tested as CRLF2-high(>10) samples (30%) and in 11/22 considering only the CRLF2-highest(>20) expression group (50%). JAK2 mutations were tested in the first 121 cases highly expressing CRLF2 (>3 times), and were observed in 4 cases (3.3%). All JAK2 mutated cases were over-expressing CRLF2 (19, 31, 43 and 58 times), and all were P2RY8-CRLF2 positive; 2 were R683G substitutions, and 2 cases presented 6 and 12 inserted nucleotides, respectively. Comparing CRLF2-highest(>20) and low expressing patients, none of the CRLF2-highest cases had recurrent chromosomal translocations (while 1 BCR/ABL and 3 TEL/AML1 positive cases were in the >10 times, and <20, overexpressing group). CRLF2-highest patients tend to have a lower probability for high WBC count at diagnosis (>20,000/μ l: 25% vs 35%) and a higher age at diagnosis (median age 67 months vs 56). CRLF2-highest and low had a similar incidence of prednisone poor response (9.2% vs 12.5%). Interestingly, among CRLF2-highest patients only 2 were in the PCR-MRD HR group. Remarkably, all 15 cases P2RY8-CRLF2-positive were non-HR by MRD (4 were SR, one of them in the CRLF2>20 group). Patients CRLF2-highest had a statistically significant higher 5-year Cumulative Incidence of Relapse (CIR) compared to CRLF2-low patients (37.5±9.8% vs. 17.7±1.7%; relapses=9/24 vs 93/491, p=0.00296). This difference was due to a higher CIR for P2RY8-CRLF2 positive cases; in fact, among CRLF2 >20 times cases, CIR for deleted cases was 60±15.5% compared to 16.6±10.7% for non-deleted (relapses=6/10 versus 3/14). The difference in CIR between CRLF2>20 times and CRLF2-low remains statistically different within the hyperdiploid subgroup (interestingly, none of the P2RY8-CRLF2 positive was hyperdiploid). Only 2 of the 4 JAK2 mutated (and CRLF2 deleted) cases relapsed. Conclusions.High levels of CRLF2 expression (>20 times the median) define a subgroup of childhood ALL (around 5%) without known high risk features, associated with a higher incidence of relapse if treated according to the AIEOP-ALL 2000 protocol. This effect is mainly related to the presence of the P2RY8-CRLF2 rearrangement. Once prospectively confirmed in large series, the assessment of CRLF2 status may serve as a new stratification marker. Disclosures:No relevant conflicts of interest to declare.