Impaired Bone Marrow Function Research Articles

Acute Myeloid Leukemia Transformed from Aplastic Anemia following Anti-thymocyte Globulin Therapy: A Case Report with Clinicopathologic and Molecular Findings

Abstract: Aplastic Anemia (AA) incidence is threefold higher in Asia compared to the western world. It is associated with pancytopenia that is induced by impaired bone marrow function. Cytopenias of at least two lineages are required for the diagnosis. Symptoms include pallor, weakness, fever, frequent infections, bruises, petechiae, and mucosal bleeding. Bone Marrow Transplant (BMT) and immunosuppressive therapy are the treatment options. Patients with Severe Aplastic Anemia (SAA) are susceptible to developing malignancies like acute myeloid leukemia (AML) or Myelodysplastic Syndrome (MDS). In this report, we present a case of SAA who transformed to AML/MDS. 5 years of post- Anti-Thymocyte Globulin (ATG), she acquired monosomy 7, RUNX1 & SETBP1 gene mutations. RUNX1 and SETBP1 mutations are correlated with poor overall survival and are predicted to have a lack of response from hypo-methylating agents. As the aspect of somatic mutation is complex and still not fully understood, it should be cautiously analyzed along with morphologic and cytogenetic results.

Changes in hemoglobin and clinical outcomes drive improvements in fatigue, quality of life, and physical function in patients with paroxysmal nocturnal hemoglobinuria: post hoc analyses from the phase III PEGASUS study

Paroxysmal nocturnal hemoglobinuria (PNH) is a rare, chronic, acquired, hematologic, life-threatening disease characterized by thrombosis, impaired bone marrow function, and complement-mediated hemolysis. The PEGASUS phase III clinical trial demonstrated superiority of pegcetacoplan over eculizumab regarding improvements in hemoglobin levels in patients with suboptimal response to prior eculizumab treatment. The objective of this post hoc analysis was to compare the patient-reported outcome (PRO) response rates observed among PEGASUS participants and the relationships between their PRO scores with clinical and hematological parameters. Data from the 16-week randomized, controlled (1:1 to pegcetacoplan or eculizumab) period of the PEGASUS trial included comparisons of weekly PRO measurements taken using the Functional Assessment of Chronic Illness Therapy-Fatigue (FACIT-F) scale and the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire Core-30 (EORTC QLQ-C30) scales. A clinically meaningful FACIT-F response was defined as an increase from baseline of ≥5 points. Convergent validity was assessed using conventional threshold correlations between FACIT-F, EORTC QLQ-C30, and laboratory parameters. A clinically meaningful improvement in FACIT-F score was seen in 72.2% of pegcetacoplan-treated patients compared to 22.9% of eculizumab-treated patients. At week 16, the FACIT-F total score correlated with hemoglobin levels (r=0.47, p< 0.0001), absolute reticulocyte count (r=−0.37, p<0.01), and indirect bilirubin levels (r=−0.25, p<0.05). Clinically meaningful improvements in pegcetacoplan-treated patients were also observed for multiple EORTC scales. Fatigue and other self-reported outcomes were correlated with clinically meaningful improvements in clinical and hematological parameters. Clinical trial registration: NCT03500549

Hematologic toxicity profile and efficacy of [225Ac]Ac-PSMA-617 α-radioligand therapy of patients with extensive skeletal metastases of castration-resistant prostate cancer.

Actinium-225-labeled prostate-specific membrane antigen ([225Ac]Ac-PSMA-617) is safe and effective in the treatment of metastatic castration-resistant prostate cancer (mCRPC). No study has specifically assessed its safety in patients with extensive skeletal metastases of mCRPC. We aimed to investigate the hematologic toxicity and efficacy of [225Ac]Ac-PSMA-617 therapy in patients with extensive skeletal metastases of mCRPC. We retrospectively reviewed the medical record of patients treated with [225Ac]Ac-PSMA-617 for mCRPC. We included patients with a superscan pattern of skeletal metastases and those with 20 or more multifocal sites of skeletal metastases on baseline [68Ga]Ga-PSMA-11 PET/CT. We reviewed the levels of hemoglobin, white blood cell (WBC), and platelet prior to each cycle of treatment and determined the presence of impaired bone marrow function at baseline and the grade of toxicity in the hematologic parameters induced by treatment. We evaluated the predictors of hematologic toxicity using binary logistic regression analysis. We also determined the presence of renal dysfunction before or during treatment. We assessed response to treatment using prostate-specific antigen response and the progression-free survival (PFS) and overall survival (OS). A total of 106 patients were included. Skeletal metastasis was in the superscan pattern in 34 patients (32.1%) and multifocal in 72 patients (67.9%). The median treatment cycle was 4 (range = 1-9). Ninety-eight patients (92.5%) had abnormal baseline hematologic parameters. One patient had grade 4 thrombocytopenia. Grade 3 anemia, leukopenia, and thrombocytopenia were seen in 1 (0.9%), 3 (2.8%), and 2 (1.9%) patients, respectively. Age, the number of treatment cycles, and the presence of renal dysfunction were significant predictors of hematologic toxicity. Eighty-five patients (80.2%) achieved PSA response. The median PFS and OS of the study population were 14:00 (95%CI: 8.15-19.86) months and 15.0 (95%CI: 12.8-17.2) months, respectively. [225Ac]Ac-PSMA-617 induces a good anti-tumor effect in about 80% of patients with extensive skeletal metastases of mCRPC with a rare incidence of severe hematologic toxicity. Age, number of treatment cycles, and the presence of renal dysfunction were significant risk factors for hematologic toxicity of [225Ac]Ac-PSMA-617 therapy.

12-Month Analysis of a Phase 2 Study of Iptacopan (LNP023) Monotherapy for Paroxysmal Nocturnal Hemoglobinuria

Background: Paroxysmal nocturnal hemoglobinuria (PNH) is a rare, acquired hematological disorder caused by somatic mutations in the phosphatidylinositol glycan A (PIGA) gene in hematopoietic stem cells, resulting in complement alternative pathway (AP)-mediated severe hemolysis, life-threatening thrombosis, and impaired bone marrow function. The current standard-of-care for PNH consists of anti-C5 blockade with either eculizumab or ravulizumab. While both monoclonal antibodies effectively control intravascular hemolysis (IVH), reduce thrombosis and improve long-term survival, a significant proportion of patients remains anemic and continues to require transfusions, largely due to persistent extravascular hemolysis (EVH). Conversely, pegcetacoplan, a recently FDA-approved anti-C3 inhibitor, prevents both IVH and EVH and showed superiority to eculizumab in improving hemoglobin (Hb) levels in PNH. Nevertheless, the need for effective oral treatment options in PNH remains unmet. Iptacopan (LNP023) is a new, oral, selective and potent first-in-class inhibitor of factor B, a key component of the AP. Recent phase 2 data showed that iptacopan effectively controls both IVH and EVH and leads to rapid, transfusion-free improvements in Hb levels in the majority of PNH patients.Methods: CLNP023X2204 (NCT03896152) is a multicenter, randomized, open-label phase 2 study in adult PNH patients with active hemolysis and no complement inhibitor treatment within 3 months prior to study entry. Patients are randomized to receive twice daily (BID) iptacopan in one of two dose-sequences, either 25 mg for 4 weeks followed by 100 mg for up to 2 years (Cohort 1) or 50 mg followed by 200 mg (Cohort 2). The key objectives are to assess the effect of iptacopan on markers of IVH/EVH (incl. lactate dehydrogenase (LDH)) and on Hb levels, as well as safety. 12-month interim results are summarized below.Results: The study has completed enrolment. A total of 13 patients (mean age 38.2 years, 7 female) were randomized to either Cohort 1 (n=7) or 2 (n=6). Mean (SD) lab values at baseline were LDH 2097.8 (911.2) U/L, reticulocytes 203.3 (82.9) x10E9/L, bilirubin 32.4 (10.1) µmol/L, and Hb 85.8 (13.2) g/L, and most patients required red blood cell transfusions in the prior 12 months (median 3.0, range 0-19). At the time of the interim analysis, 11 patients had been treated with iptacopan for at least 52 weeks, with a maximum treatment duration of 81 weeks; 2 patients discontinued treatment early, one after 2 days due to a non-serious adverse event of headache (hence not evaluable for the primary endpoint), the other after 13 weeks due to physician decision. Amongst the 12 evaluable patients, all of whom were anti-C5 naive, all reached the primary endpoint of lowering LDH by at least 60% within the first 12 weeks. The LDH response was rapid and durable, with all patients treated with ≥50 mg BID reaching this threshold after only one week of treatment and all ongoing patients except one maintaining the threshold up until the data cutoff, i.e., for at least 52 weeks. Equivalent improvements were also observed for other markers of IVH and EVH. Similarly, Hb levels improved significantly and durably in most patients, and all except one of the ongoing patients have remained transfusion-free since the start of iptacopan treatment. Moreover, no thromboembolic events occurred during the study, and the FACIT fatigue score improved significantly in most patients. Iptacopan monotherapy was safe, with no severe or serious adverse reported up to the data cutoff.Conclusion: Iptacopan is a new, well tolerated oral complement AP inhibitor that blocks both IVH and EVH in adult PNH patients with hemolytic PNH. 12-month results from this non-pivotal study demonstrate that iptacopan monotherapy leads to rapid and durable improvements in various hemolytic markers and meaningful and sustained clinical benefit as seen in improvements in Hb levels, transfusion requirement and FACIT fatigue score. These results suggest that proximal inhibition of the complement cascade parallels and further improves the hematological benefit seen with anti-C5 therapies, paving the way for the phase 3 evaluation of iptacopan as potentially new oral first-line therapy for patients with PNH. [Display omitted] DisclosuresWong: Astellas Pharma, INc.: Research Funding. Li: Novartis: Current Employment, Current equity holder in publicly-traded company. Rozenberg: Novartis: Current Employment, Current equity holder in publicly-traded company. Nidamarthy: Novartis: Current Employment, Current equity holder in publicly-traded company. Chawla: Novartis: Current Employment, Current equity holder in publicly-traded company. Junge: Novartis: Current Employment, Current equity holder in publicly-traded company. OffLabel Disclosure:Iptacopan (LNP023) is a new, oral, selective and potent first-in-class inhibitor of factor B, a key component of the complement alternative pathway. It is currently being investigated in paroxysmal nocturnal hemoglobinuria (PNH) as well as in several renal indications.

Use of an Antifibrinolytic Agent and Vitamin K As Alternative to Platelet Transfusions in Autologous Hematopoietic Cell Transplantation

BackgroundManaging thrombocytopenia with a prophylactic strategy was previously recommended for patients with impaired bone marrow function, hematological malignancies, and recipients of HCT when platelet counts declined to under 10,000/uL. However, the updated 2018 ASCO guidelines now suggest a place for a therapeutic i.e., after a bleeding event rather than a prophylactic platelet transfusion strategy for patients with hematologic malignancies undergoing autologous HCT. Studies show a lack of significant difference between trial groups in hemostatic outcomes, such as the number of WHO grade 2-4 bleeds, and number of days with bleeding events. Platelet transfusions increase risks of infectious and non-infectious complications as well as inducing a platelet refractory state. Our Transfusion Free Medicine Program has now performed over 200 autologous hematopoietic stem cell transplants (HCT) in Jehovah's Witnesses who due to religious convictions, do not accept red cell or platelet transfusions.Vitamin K is a fat-soluble vitamin that is required for normal blood clotting. Autologous HCT patients are at risk for vitamin K deficiency from multiple reasons including malnutrition, frequent use of antibiotics, chemotherapy induced gastrointestinal toxicity leading to malabsorption and colitis. The prothrombin test lacks the sensitivity and specificity to detect mild deficiency. A mild vitamin K deficiency may be underdiagnosed in our transplant patients adding to bleeding risk. With the effective use of antifibrinolytic agents and Vitamin K as an alternative to platelet transfusions we believe this may enhance hemostasis and prove a valuable adjunct to a therapeutic approach.MethodsPatients in our study were those who were of the Jehovah's Witness faith undergoing autologous HCT for Multiple Myeloma and Lymphoma. Patients received aminocaproic acid as an alternative to platelet transfusion to enhance hemostasis at a dose of 1 g every 4 hours or prophylactically for platelet counts less than 30,000 /uL. Titration to 4 g every 4 hours intravenously was required for platelet counts less than 10,000/ul or clinical bleeding. Vitamin K 10 mg orally or subcutaneous was also started at this time.ResultsTable 1 illustrates the low number of bleeding events especially grade 3 or 4 that occurred. There were no Grade 3 or 4 bleeding events in patients with platelet counts above 5000/uL. No patient had residual long term effects nor was there an increase in thromboembolic events.ConclusionsThese data add to the body of literature supporting a therapeutic platelet transfusion strategy in an experienced center for autologous HCT patients and challenges the prophylactic platelet count of 10,000 /uL suggesting instead 5000/uL. The safety and efficacy of antifibrinolytic agents and Vitamin K as an alternative to platelet transfusions to enhance hemostasis in autologous stem cell transplant patients may prove beneficial not only in JW patients but also in those transplant centers wishing to offer a therapeutic platelet transfusion approach and as a strategy to manage platelet refractoriness. [Display omitted] DisclosuresNo relevant conflicts of interest to declare. OffLabel Disclosure:Aminocaproic Acid is an antifibrinolytic agent approved for treatment of bleeding in surgical patients and hematological bleeding disorders. Vitamin K is approved for use in reversal of anticoagulation from Warfarin, vitamin K deficiency without liver disease and in the newborn.

Categorized Hematologic Response to Pegcetacoplan Versus Eculizumab in Patients with Paroxysmal Nocturnal Hemoglobinuria: Post Hoc Analysis of Data from a Phase 3 Randomized Trial (PEGASUS)

Categorized Hematologic Response to Pegcetacoplan Versus Eculizumab in Patients with Paroxysmal Nocturnal Hemoglobinuria: Post Hoc Analysis of Data from a Phase 3 Randomized Trial (PEGASUS)

Bone marrow failure

Bone marrow failure Abstract. Bone marrow failure involves a heterogeneous spectrum of rare benign hematological disorders caused by an impaired bone marrow function. Bone marrow failure can be acquired (acquired aplastic anemia) or congenital (inherited bone marrow failures). The disease is clinically characterized by cytopenias of one or more blood cell line (anemia, neutropenia and / or thrombocytopenia), possibly combined with signs of hemolysis and thrombophilia in paroxysmal nocturnal hemoglobinuria or morphological abnormalities in inherited forms. Due to significant advances in molecular genetic diagnostics, a comprehensive differentiation of an acquired or congenital form is central, since the cause of disease significantly affects the choice of therapy. Standard therapy has changed little in past decades (immunosuppression and / or allogeneic stem cell transplantation), however thrombopoietin receptor agonists just recently showed an improvement of all three blood cell lines in acquired aplastic anemia and are likely to be included in the future treatment algorithms. This article gives an overview of the disease, diagnosis and therapy of this heterogeneous disease group.

Longitudinal Tracking of MDS Patients Using Next Generation Sequencing Provides a Predictive Measure for Azacitidine Response and AML Progression

▪Introduction:Myelodysplastic syndromes (MDS) are clonal hematopoietic disorders characterized by dysplastic changes in one or more cellular lineages causing impaired bone marrow function. One third of patients diagnosed with MDS progress to secondary acute myeloid leukemia (sAML). These patients have significantly worse prognoses than de novo AML patients. Azacitidine (AZA), a hypomethylating agent is commonly used to treat MDS patients as a frontline therapy. Although its survival benefits over supportive care in a randomized trial has been demonstrated, the underlying genetics and clonal dynamics upon AZA response/AML progression have not been well examined. Using next generation sequencing (NGS) technology, we attempted to assess the clinical relevance of somatic mutations and their dynamics as they relate to AZA treatment in MDS patients using longitudinal samples.Patients and Methods:Ninety-five MDS patients (56 lower risk and 39 higher risk MDS based on the revised IPSS scoring system) were enrolled in this study. The median age of the 95 patients is 67 years (range of 31 Ð 84) and median follow-up duration was 747 days (range of 137-3328 days). We performed targeted deep sequencing (entire exon region of a panel of 84 myeloid genes, Agilent custom probe set) on 285 bone-marrow samples including the longitudinal samples taken at diagnosis (n=95) and post-AZA treatment, (median 4 cycles) as well as T-cell fraction (CD3+). We multiplexed and sequenced the samples using an Illumina Hiseq 2000. After read mapping and variant calling, hierarchical clustering, pathway and survival analyses were performed in R.Results:Targeted sequencing on the myeloid gene panel revealed 176 mutations in 68 patients (68/95, 71.6%) with a median of 2 mutations per patient (ranges 2-6). The average on-target coverage for 285 sequenced samples was 1205x. Twenty-five of 44 mutated genes were recurrently mutated. ASXL1 was the most frequently mutated in the cohort (21%), followed by TET2 (15%), DNMT3A (11%), and SRSF2 (11%). Mutated genes were then grouped into 8 biological pathways, defined in The Cancer Genome Atlas (TCGA) AML study. The most frequent biological pathway with mutated genes at diagnosis was DNA methylation (28.4%), followed by spliceosome (25.2%), chromatin modifiers (22.1%), myeloid transcription factors (TFs) (11.6%), activated signaling (11.6%), tumor suppressors (12.6%), and cohesin complex (6.3%).When assessing the differences in patterns of variant allele frequency (VAF), we found significant VAF reduction in responders compared to non-responders (p = 0.007, repeated measures using general linear model, Figure A). Multivariate analyses revealed that mutation burden in different genes and biological pathways have distinct impact on AZA response, AML transformation, and overall survival. Higher bone marrow blast percentage (5%) was associated with all three measures (Figure B). Most significantly, mutations in activated signaling pathway genes are associated with AML progression (p=0.002). In addition, we could not detect decreased VAFs in activated signalling pathway genes even in responders (Figure C-D). Patients with SRSF2 mutations tend to respond to AZA (OR 14.084, p=0.003). Mutations in tumor suppressors (HR 4.825, p<0.001) and myeloid TFs (HR 3.070, p=0.020) were adverse prognostic factors in overall survival. Of interest, mutations in DNA methylation pathway were not independent prognostic factor for AZA response, AML transformation, or overall survival.Conclusion:These data and analyses show that reduction in mutation burden is correlated with AZA response. Mutations in different genes and biological pathways are associated with distinct clinical measures that tumor suppressors and myeloid TFs were identified as poor prognostic factors in terms of OS. Persistent mutation burden in activated signaling pathways is a strong predictor for AML transformation. In summary, longitudinal tracking of MDS patients using NGS may improve criteria for AZA response and early detection of AML progression. [Display omitted] DisclosuresJang:Alexion Pharmaceuticals, Inc: Consultancy, Honoraria, Research Funding.

Dose-intensified bendamustine followed by autologous peripheral blood stem cell support in relapsed and refractory multiple myeloma with impaired bone marrow function.

Therapeutic options in heavily pretreated relapsed/refractory multiple myeloma patients are often very limited because of impaired bone marrow function. Bendamustine is effective in multiple myeloma and has a favourable toxicity profile. We hypothesized that dose-intensified bendamustine (180 mg/m2 , day 1 and 2) followed by autologous blood stem cell support (ASCS) would improve bone marrow function with low post-transplant toxicity in patients with severely impaired haematopoiesis. We analyzed 28 consecutive myeloma patients, with a median of three prior lines of therapy (range 2-7), who had relapsed from the last treatment with very limited bone marrow function and were therefore ineligible for conventional chemotherapy, novel agents or trial enrolment. Dose-intensified bendamustine with ASCS improved haematopoiesis as reflected by increased platelet counts (median 40/nl vs 94/nl, p = 0.0004) and white blood cell counts (3.0/nl vs 4.8/nl, p = 0.02) at day +100. The median time until engraftment of platelets (>50/nl) was 11 days (0-24 days) and of white cell counts (>1.0/nl) 0 days (0-24 days). At least, a minimal response was achieved in 36% of patients. The disease stabilization rate was 50% while the median progression-free survival rate was limited to 2.14 months. Most importantly, patients were once again eligible for alternative treatments including enrolment into clinical trials. We conclude that dose-intensified bendamustine followed by ASCS is safe and feasible for multiple myeloma patients with very limited bone marrow reserve. Copyright © 2015 John Wiley & Sons, Ltd.

A phase II pilot efficacy trial of the combination regimen peg asparaginase/peg liposomal doxorubicin/dexamethasone (ODD) in patients with refractory lymphoid malignancies (NCT00837200).

e19502 Background: Asparaginase is a mainstay of the treatment for ALL depriving the malignant cells of asparagine leading to cell death. There are reports of asparaginase activity in non-ALL malignancies including CLL, NHL, and multiple myeloma. We developed a combination regimen with full dose PEG-Asparagase (O) together with low dose liposomal doxorubin (D) and dexamethasone (D) (ODD regimen) as a non-myelotoxic regimen for pts with advanced lymphoid malignancies and impaired bone marrow function, hoping this novel approach of inducing asparaginine deficiency would translate into benefit. Methods: A phase II trial of ODD with the O given D1 and D15 at 2500 IU/m2, D given D1 and D15 as 20 mg/m2 and the Dex given as 20 mg D1, D8, D15 and D22 of a 28 day cycle was initiated. Pts with any non-ALL lymphoid malignancy were eligible if they had failed at least one prior standard regimen. The study had a Simon 2-stage design with Response Rate as the primary endpoint. Secondary endpoints were safety and correlation of asparginase levels with response/toxicity. Results: 13 pts enrolled of 16 screened of whom 12 were evaluable for response. These included 7 MM pts and 6 with diffuse large B-cell lymphoma. The pts were heavily pre-treated with 3 (range 1 to 8) median prior regimens. 6 of the13 pts were over 70 yrs. One pt progressed before one complete cycle was given so was not evaluable for response. 2 pts (both MM) had a response which was defined as Stable Disease &gt; 2 months; the other 10 had Progressive Disease. One responding pt was later taken off for O-related toxicities (DVT/PE, elevated enzyme levels). Effective Asparaginase levels were obtained in the serum of most tested pts. In general, the regimen was well tolerated considering the advanced nature of these cases, but typical O related toxicities were observed. Conclusions: We conclude that the ODD regimen, although well tolerated, had little appreciable activity in this heavily pre-treated group of pts with refractory DLBCL and MM. Whether it would have meaningful activity in less advanced states of these diseases or other lymphoid neoplasms remains an open question. Clinical trial information: NCT00837200.

A Longitudinal Prospective Study Evaluating the Effects of Eltrombopag Treatment On Bone Marrow in Patients with Chronic Immune Thrombocytopenia: Interim Analysis At 1 Year.

AbstractAbstract 2195 Introduction:Eltrombopag (epag), a thrombopoietin receptor agonist (TPO-RA), increases platelet counts in patients with chronic immune thrombocytopenia (cITP). TPO-RAs have been associated with varying degrees of increases in bone marrow reticulin (Brynes 2011; Ghanima 2011). Due to lack of pretreatment evaluations, the incidence and clinical significance of these findings have not been established. Inconsistencies in specimen preparation, staining, and analysis across institutions further confound conclusions. The purpose of this 2-year (y) study (NCT01098487) is to assess for bone marrow fibrosis (reticulin and/or collagen) in patients treated with epag for cITP. Baseline and 1y findings are presented. Methods:Bone marrow biopsies are being collected at baseline (before treatment with epag) and at 1 and 2y of treatment. Specimens are centrally processed and stained for reticulin (silver) and collagen (trichrome) and undergo central independent pathology review of cellularity; megakaryocyte, erythroid, and myeloid quantity and appearance; trabecular bone quality; reticulin grade; and presence of collagen (European Consensus scale-MF; Thiele 2005). Results:Baseline and 1y (10–14 months) data are available for 101 patients. Median age is 42y (18–78); 70 patients are female; 50% are Caucasian/European, 22% are East Asian, and 29% are Central South Asian. Median time since ITP diagnosis is 4.2y (0.2–45.7). All patients had received prior ITP therapy, and 8 patients had received prior TPO-RA treatment (epag [7], romiplostim [1]), the last dose ≥6 months before enrollment.At baseline, 91 patients had reticulin grade 0 (MF-0), 10 MF-1, and 0 MF≥2. At 1y, 59 patients had MF-0, 38 MF-1, 3 MF-2, and 1 MF-3 (Figure). Compared with baseline, there was no change at 1y in MF grade in 61 patients, a decrease by 1 grade in 3, an increase by 1 grade in 35, and an increase in 2 or 3 grades in 1 patient each (Table). Three patients had collagen at 1y (1 patient each with MF-1, MF-2, and MF-3). None of the 4 patients with MF≥2 had adverse events or hematologic abnormalities considered related to impaired bone marrow function, and none withdrew due to bone marrow findings. Among the 8 patients with prior TPO-RA treatment, all had baseline reticulin of MF-0 and none had collagen; at 1y, 6 remained MF-0, 1 was MF-1, and 1 MF-3 (collagen demonstrated).Cellularity was normal in 83% and 80% of patients at baseline and 1y, respectively. Other than normalization of erythroid lineage numbers, no changes occurred in marrow cellular composition. In 3 of 4 patients with MF≥2, cellularity was increased at 1y.Trabecular bone thinning was found at baseline in 28 patients (the majority with prior steroid use) and 51 patients at 1y. Discussion:10% of patients had MF-1 at baseline. After 1y of treatment, no increase or a mild increase in reticulin was observed in 63% and 35% of patients. No patient with MF≥2 (n=4) had clinical signs or symptoms indicative of bone marrow dysfunction and none withdrew from the study. Results were similar to those reported for EXTEND, an eltrombopag extension study (median treatment duration >2 years; Brynes 2011). Conclusion:These data suggest that treatment with epag is generally not associated with clinically relevant increases in bone marrow reticulin or collagen. The potential association of TPO-RAs and increased bone marrow reticulin needs further study. [Display omitted] [Display omitted] Disclosures:Brynes:GlaxoSmithKline: Research Funding. Orazi:GlaxoSmithKline: Research Funding. Wong:Roche: Research Funding; MSD: Research Funding; Johnson & Johnson: Research Funding; Bayer: Consultancy, Research Funding; Novartis: Consultancy, Membership on an entity’s Board of Directors or advisory committees, Research Funding, Speakers Bureau; Biogen-Idec: Consultancy, Membership on an entity’s Board of Directors or advisory committees, Research Funding; Pfizer: Research Funding; GlaxoSmithKline: Research Funding; Bristol-Myers Squibb: Research Funding. Bakshi:GlaxoSmithKline: Employment, Equity Ownership. Bailey:GlaxoSmithKline: Employment, Equity Ownership. Brainsky:GlaxoSmithKline: Employment, Equity Ownership, Patents & Royalties.

Evaluation of Bone Marrow Reticulin in Patients with Chronic Immune Thrombocytopenic Purpura (ITP) Treated with Eltrombopag – Data From the EXTEND Study

Abstract 528▪▪This icon denotes a clinically relevant abstract Introduction:Eltrombopag is a thrombopoietin receptor agonist (TPO-RA) that increases platelet counts in patients with chronic ITP. The potential association of TPO-RA and increased bone marrow reticulin fibrosis is currently under investigation. The EXTEND study, an open-label extension study of eltrombopag, enrolled patients with heavily pre-treated chronic ITP who had received eltrombopag or placebo in a previous eltrombopag study. In EXTEND, patients underwent bone marrow biopsies at 12 months (+/− 2 months) after the first dose of eltrombopag, and thereafter annually (+/− 2 months) while on study. Methods: In order to reduce pre-analytic variables and standardize the analysis, a central laboratory processed specimens, except when only pre-stained slides were available. Morphology review was carried out by two hematopathologists, blinded to clinical information, who assessed specimens for cellularity, megakaryocyte, erythroid, and myeloid quantity and appearance, trabecular bone changes, and scored for reticulin and collagen deposition (European Consensus Classification). Results: In the EXTEND study, 301 patients with chronic ITP have been treated with eltrombopag for up to 4.5 years. 185 specimens from 110 patients, collected up to February 2011, were reviewed (Table). 156 of 185 could be reviewed for all parameters (154 for trabecular bone). Cellularity was within the normal range (40-60%) in 142 specimens (91.0%). 146 specimens (93.6%) demonstrated megakaryocytic hyperplasia. Megakaryocyte morphology was normal in 148 (94.9%) specimens. Six specimens had megakaryocytes reminiscent of those seen with polycythemia vera or essential thrombocythemia, and 2 of 6 were associated with increased reticulin fibers. Erythroid hyperplasia was observed in 35 (22.4%) and granulocytic maturation was hyperplastic in 9 (5.8%) specimens. Trabecular bone thinning was found in 62/154 (40.3%) of specimens, the majority collected from patients with prior exposure to steroids. Reticulin fibers were increased (MF ≥2) in 4/156 (2.6%) of specimens. Three of 4 specimens with MF ≥2 were positive for collagen. All 4 specimens with increased reticulin fibers were judged as hypercellular, and 2 of 4 contained megakaryocytes with myeloproliferative neoplasm-like features as described above. These 4 specimens were collected from 3 patients: 2 patients had reticulin documented after 763 and 970 days of treatment, and were preemptively withdrawn from the study. One of these two patients had an MF-0 and negative collagen 7-months following withdrawal. The third patient had MF-2 at Day 415 and MF-3 at Day 772, with presence of collagen, and is still on treatment almost one year after the last biopsy. None of these 3 patients experienced any adverse events or abnormality in hematologic parameters potentially related to impaired bone marrow function. Discussion: Reticulin fibrosis has been described as a rare adverse event in chronic ITP patients receiving TPO-RA. In this evaluation of EXTEND study specimens, reticulin was within the normal range in 152/156 (97.4%) of specimens collected from 102 patients, after a median of 25 months of treatment. None of the patients with reticulin or collagen findings showed clinical signs or symptoms indicative of bone marrow dysfunction. No pattern of increasing reticulin deposition with longer treatment periods is apparent based on bone marrow biopsy data available to date. These data suggest that for most patients treatment with eltrombopag is not associated with the development of bone reticulin or collagen fibrosis; however, the potential association of TPO-RA and increased bone marrow fibrosis still needs to be better understood.CellularityMegakaryocyte QuantityMyeloid QuantityErythroid QuantityTrabecular Bone*Reticulin ≥MF-2CollagenNormal142 (91.0%)10 (6.4%)144 (92.3%)121 (77.6%)90 (58.4%)152 (97.4%)153 (98.1%)Increased13 (8.3%)146 (93.6%)9 (5.8%)35 (22.4%)0 (0%)4 (2.6%)**3 (1.9%)Decreased1 (0.6%)0 (0%)3 (1.9%)0 (0%)62 (40.3%)NANAOsteoclastic————1 (0.6%)——Osteoblastic————1 (0.6%)——NA=not applicable*154 cases evaluated**1 of the 4 specimens was graded MF-3 Disclosures:Brynes:GlaxoSmithKline: Consultancy, Research Funding. Brainsky:GlaxoSmithKline: Employment, Equity Ownership. Bailey:GlaxoSmithKline: Employment, Equity Ownership. Bakshi:GlaxoSmithKline: Employment.

Novel Immunosuppressive Strategies for Bone Marrow Failure Syndromes: A Focus on Alemtuzumab

Acquired bone marrow failure syndromes (BMFS) are a heterogeneous group of hematological disorders characterized by impaired bone marrow function and subsequent cytopenia of one or more blood cell lineages [1,2]. The well-accepted pathogenic mechanism of the typical bone marrow failure - aplastic anemia (AA)- is a T cell mediated immune attack targeting the hematopoietic tissue [3]. This pathogenic mechanism is at least partially shared by other bone marrow failure syndromes, such as lineage-restricted aplasias and some myelodysplastic syndromes. Thus, for these disorders immunosuppression (IS) is the pivotal etiologic treatment. While the standard IS regimen include the heterologous anti-thymocyte globulin [4], here we review the recent data on the anti-CD52 monoclonal antibody alemtuzumab as a novel IS agent for marrow failures. Alemtuzumab led to objective responses in aplastic anemia patients in 3 recent prospective studies, with overall response rates ranging between 37% and 72%. Adverse events were irrelevant, ruling out even the concerns about the risk of infectious complications. Alemtuzumab was effective even for the treatment of lineage-restricted marrow failure, with very acceptable toxicity and excellent response rates (as high as 80%). More recently, even patients suffering from myelodysplastic syndromes showed a remarkable hematological response to alemtuzumab-based IS treatment. Thus, alemtuzumab is a novel IS agent representing an excellent alternative to ATG for all immune-mediated marrow failure syndromes. Even if the dose and the schedule may still require further refining, the available data support the need of large prospective trials comparing alemtuzumab to current standard IS regimens.

Hope for very elderly patients with diffuse large B-cell lymphoma

Advanced age has a strong negative effect on the prognosis of patients with cancer. Elderly and very elderly patients present with variable degrees of functional impairment, comorbidity, chronic undernutrition, decline in cognitive functions, and socioeconomic problems. These features, together with impaired bone-marrow function and altered metabolism of drugs, explain the decreased ability of elderly patients to tolerate treatment. The increasing incidence of many cancers—such as diffuse large B-cell lymphoma—with age, and the increase in life expectancy of the general population in developed countries makes treatment of cancer in the elderly a substantial challenge for oncologists and haematologists.

Hematologic effects of subcutaneous administration of recombinant human granulocyte colony-stimulating factor (filgrastim) in healthy alpacas

To determine the effects of SC administration of filgrastim on cell counts in venous blood and bone marrow of healthy adult alpacas. 10 healthy alpacas. Alpacas were randomly assigned to receive treatment with filgrastim (5 microg/kg, SC; n=5) or an equivalent volume of physiologic saline (0.9% NaCl) solution (5) once a day for 3 days. Blood samples were obtained via jugular venipuncture 1 day prior to treatment and once a day for 5 days commencing 24 hours after the first dose was administered. Complete blood counts were performed for each blood sample. Bone marrow aspirates were obtained from the sternum of each alpaca 48 hours before the first treatment was administered and 72 hours after the third treatment was administered. Myeloid-to-erythroid cell (M:E) ratio was determined via cytologic evaluation of bone marrow aspirates. In filgrastim-treated alpacas, substantial increases in counts of WBCs and neutrophils were detected within 24 hours after the first dose was administered. Band cell count and percentage significantly increased 24 hours after the second dose. Counts of WBCs, neutrophils, and band cells remained high 48 hours after the third dose. Red blood cell counts and PCV were unaffected. The M:E ratio also increased significantly after treatment with filgrastim. Filgrastim induced rapid and substantial increases in numbers of circulating neutrophils and M:E ratios of bone marrow in healthy alpacas. Therefore, filgrastim may be useful in the treatment of camelids with impaired bone marrow function.

Erythropoiesis in Multiply Injured Patients

Posttraumatic anemia in multiply injured patients is caused by hemorrhage, reduced red blood cell survival, and impaired erythropoiesis. Trauma-induced hyperinflammation causes impaired bone-marrow function by means of blunted erythropoietin (EPO) response, reduced iron availability, suppression and egress of erythroid progenitor cells. To treat posttraumatic anemia in severely injured patients, symptomatic therapy by blood transfusion is not sufficient. Furthermore, EPO, iron, and the use of red cell substitutes should be considered. The posttraumatic systemic inflammatory response syndrome (SIRS) induces posttraumatic anemia. Thus, a worsening of SIRS by a "second-hit" through blood transfusion ought to be avoided.

Dendritic Cell Deficiencies in Pediatric Acute Lymphoblastic Leukemia Patients.

Acute lymphoblastic leukemia (ALL) cells are particularly poor at generating anti-leukemia immunity, despite residing in lymphoid organs. The mechanisms accounting for this phenomenon of immunoevasion are poorly understood. To assess a potential role of dendritic cells (DC) in poor anti-leukemia immunity, we analyzed peripheral blood DC in 55 pediatric ALL patients at the time of initial diagnosis and 44 age-matched healthy controls. DC were identified by their expression of HLA-DR, lack of B-, T-, NK-, and monocyte-markers, and expression of CD11c (myeloid DC) or BDCA-2 (plasmacytoid DC) using flow cytometry. T-lineage ALL patients showed normal plasmacytoid DC and significantly elevated myeloid DC (p=0.003) levels with normal expression of HLA-DR and co-stimulatory molecules. Preliminary data suggest that these DC may be less capable of stimulating allogeneic T cell responses than DC from healthy volunteers. In contrast, we found that in children with B-lineage ALL, numbers of both myeloid and plasmacytoid DC were significantly reduced (p=0.0001) as compared to healthy controls. A decrease in DC could not be explained by impaired bone marrow function, since we could not demonstrate a correlation of DC numbers with granulocyte or monocyte counts, hemoglobin levels, or platelet counts in patients with B-lineage ALL. Interestingly, in univariate analysis there was a significant correlation of lack of myeloid DC with aberrant expression of myeloid surface marker CD13 on B-lineage ALL blasts. This unexpected finding raises the hypothesis that in some cases of B-lineage ALL the physiological differentiation of a common myeloid progenitor cell might be blocked and differentiation might be skewed towards leukemia-development. No correlation of DC numbers with subtype of ALL (proB, common, preB ALL) could be demonstrated. Furthermore, in a subgroup of B-lineage ALL patients, a complete lack of plasmacytoid DCs correlated with prednisone poor response, a surrogate marker of poor prognosis. It remains currently unclear, whether lack of myeloid or plasmacytoid DC directly correlates with long-term survival. Thus, depletion of DC in B-lineage ALL patients may contribute to poor anti-leukemia immune responses in pediatric patients with ALL. Further investigations will prove whether these deficiencies may impact on patient survival and may support the concept of immunosurveillance in lymphatic malignancies.

Teniposide (VM-26) as a single drug treatment for patients with extensive small cell lung carcinoma

Teniposide (VM-26) was reported to have activity in small cell lung carcinoma (SCLC). The authors performed a Phase II study of teniposide as a treatment for patients with previously untreated extensive SCLC. The study was open to patients with a histologic or cytologic diagnosis of extensive SCLC who had not received prior radiation or chemotherapy. Patients with hematologic values below normal were considered eligible if the impaired bone marrow function was directly attributable to disease involvement. Treatment consisted of teniposide 60 mg/m2 given intravenously (i.v.) on Days 1-5 every 3 weeks. This study opened on September 15, 1988, closed permanently on November 15, 1990, and accrued 45 patients identified at 19 academic, military, and Community Clinical Oncology Program institutions affiliated with the Southwest Oncology Group. Of the 45 registered patients, 41 were eligible. Twenty eight (68%) were males and 13 (32%) were females; the median age was 64 years (minimum, 46 years; maximum, 83 years). Twenty-four patients (59%) had a performance status (PS) on the Zubrod scale of 0-1 and 17 cases (41%) had a PS of 2. Of the 41 eligible patients, 10 had confirmed partial responses (24%) (95% confidence interval, 12-40%). The median survival was 7 months. The significant toxicities noted were Grade 4 leukopenia and/or granulocytopenia, experienced by 15 patients; 1 of these patients also had Grade 4 hyponatremia. One patient died of a respiratory infection. When administered according to the dosage and schedule selected for this study (60 mg/m2 i.v. on Days 1-5 every 3 weeks), teniposide as a single agent had modest activity in extensive small cell lung carcinoma. The toxicities observed in this study were acceptable.

African swine fever virus infection of bone marrow: lesions and pathogenesis.

The effects of African swine fever (ASF) virus infection on bone marrow hematopoiesis and microenvironment were determined by studying the sequential development of ultrastructural lesions of bone marrow and blood cell changes. Eight pigs (two pigs/infected group) were inoculated by intramuscular route with 10(5) 50% hemadsorbing doses (HAD50) of the Malawi'83 ASF virus isolate. Two uninfected pigs were used as controls. Ultrastructural changes developed by day 3 postinoculation (PI), persisted through day 7 PI, and were characterized by activation of macrophages. From day 5 PI, viral replication was observed in monocytes/macrophages, reticular cells, immature neutrophils, and promonocytes. Also viral replication was detected in megakaryocytes, endothelial cells, and pericytes at day 7 PI. Vascular alterations consisted of activation of sinusoidal endothelial cells, intravascular coagulation, and fibrin strands interspersed among microenvironment and hematopoietic cells. No significant changes were observed in total white blood cells counts, percentage of monocytes, and platelet counts; however, severe lymphopenia and neutrophilia were detected from day 3 PI. Results of this experiment indicate that there is increased hematopoiesis in bone marrow during acute ASF, coinciding with macrophage activation. Neither vascular changes nor viral replication in different bone marrow cell populations gave rise to impaired bone marrow function. Increased hematopoiesis would exert a positive influence by preventing the early onset of thrombocytopenia and would exert a negative influence by stimulating the spread of the virus via neutrophils. Increased hematopoiesis would be unable to compensate for the lymphopenia.

Prognostic factors in COPP-treated patients with Hodgkin's disease.

In a recently published review of the literature [40] we came to the conclusion that the Ann-Arbor staging classification is of limited prognostic value for chemotherapy of Hodgkin's disease (Table 2). Four risk factors accounted for impaired complete remission rates: stage IVB, lymphocyte depletion or not classifiable histologic type, previous chemotherapy, and older age. Fifty-eight evaluable patients were treated with COPP; 23 reached a complete remission (40%). Disease-free survival was 31%, overall survival 49% after five years [33]. Besides the known risk factors, impaired bone marrow function (leucocyte counts less than 4 X 10(9)/l, platelet counts less than 100 X 10(9)/l) at the start of therapy was associated with poor treatment results: none of six patients achieved a complete remission [41]. Eleven of 16 patients with no and 11 of 23 patients with one risk factor achieved a complete remission, as did only one patient with more than one risk factor. Survival rates after 30 months were: 87% with no, 66% with one, 36% with two, and 13% with more than two risk factors. We can conclude from our results that the prognosis of patients undergoing chemotherapy for Hodgkin's disease depends on the number of risk factors.