Intensity Conditioning Allogeneic Hematopoietic Stem Research Articles

Current and emerging treatment options for mantle cell lymphoma.

Mantle cell lymphoma (MCL) is a B-cell non-Hodgkin lymphoma with typically aggressive behavior. The genetic signature is the chromosomal translocation t(11;14)(q13;q32) resulting in overexpression of cyclin D1. Asymptomatic newly diagnosed MCL patients with low tumor burden can be closely observed, deferring therapy to the time of disease progression. Although MCL classically responds to upfront chemotherapy, it remains incurable with standard approaches. For patients in need of frontline therapy, the initial decision is whether to proceed with an intensive treatment strategy or a non-intensive treatment strategy. In general, given the unfavorable risk-benefit profile, older MCL patients should be spared intensive strategies, while younger and fit patients can be considered for intensive strategies. The bendamustine and rituximab (BR) regimen is becoming an increasingly popular treatment option among the elderly population, with improved progression-free survival (PFS) and acceptable side-effect profile. Although rituximab maintenance after R-CHOP improves survival outcomes in elderly patients, no clinical trial to date has shown statistical significance to support the use of rituximab maintenance after BR induction in older patients. In young and fit patients with MCL, an intensive strategy to maximize the length of first remission has emerged as a worldwide standard of care. With current high-dose cytarabine-containing immunochemotherapy regimens followed by autologous stem cell transplantation, the median PFS has exceeded 7 years. In the relapsed or refractory (R/R) setting, reduced intensity conditioning allogeneic hematopoietic stem cell transplantation may offer the highest likelihood of long-term survival in young R/R MCL patients, at the cost of increased risk of non-relapse mortality and chronic graft versus host disease. Novel agents targeting activated pathways in MCL cells, such as bortezomib, lenalidamide, ibrutinib and temsirolimus are now available for the management of R/R disease.

Hematopoietic Stem Cell Transplant in Adolescent and Young Adults With Fanconi Anemia Is Feasible With Acceptable Toxicity, With Those Surviving 100 Days Posttransplant Having Excellent Outcomes.

Fanconi anemia is a congenital bone marrow failure syndrome that is associated with congenital anomalies and increased risk of cancer. Hematopoietic stem cell transplant is a potentially curative modality for bone marrow failure in Fanconi anemia patients. Here, we report our center's experience regarding adolescent and young adult patients with Fanconi anemia and hematopoietic stem cell transplant. We conducted a retrospective patient record analyses of patients who presented at our center from 1988 to 2014. We included patients greater than 14 years old with confirmed Fanconi anemia based on positive chromosome breakage study and who underwent hematopoietic stem cell transplant at our institution. Our study group comprised 12 patients with Fanconi anemia who underwent hematopoietic stem cell transplant at our institution. The median age was 20 years (range, 14-31 y) with a female predominance of 83%. Low-dose cyclophosphamide (20-80 mg/kg)-based conditioning regimens were used with different combinations that included fludarabine, antithymocyte globulin, or total body irradiation. All patients had HLA-matched sibling grafts. In all patients, stem cell source was the bone marrow. All patients showed engraftment. Four patients (33%) developed acute graft-versus-host disease. Three patients (25%) died early before day 100 after hematopoietic stem cell transplant due to infectious complications, with 1 patient having steroid refractory acute graft-versus-host disease. Overall survival was 75% at a median follow-up of 43 months. All patients who survived are well and remained transfusion independent without evidence of secondary malignancy. Our findings support the feasibility of reduced intensity conditioning allogeneic hematopoietic stem cell transplant in older and more heavily pretreated patients with Fanconi anemia, especially for those who are engrafted.

Reduced intensity conditioning allogeneic hematopoietic stem cell transplantation in chronic lymphocytic leukemia (CLL) patients with the aberration of p53 gene

目的探讨减低强度预处理的异基因造血干细胞移植（RIC-allo-HSCT）治疗伴p53缺失的超高危慢性淋巴细胞白血病（CLL）的疗效及安全性，并提高allo-HSCT在CLL治疗中的认识。方法回顾性分析2012年7月至2014年1月进行同胞全相合供者RIC-allo-HSCT且伴p53缺失的4例超高危CLL患者资料，移植方式采用RIC方案，观察造血重建、移植相关并发症、总体生存（OS）、无进展生存（PFS）等临床指标。结果4例CLL患者中男3例，女1例，中位年龄56（49~61）岁。输注的中位单个核细胞（MNC）数为6.54（2.85~14.70）×108/kg，中位CD34+细胞数为5.81（2.85~7.79）×106/kg。4例患者移植后均获得快速而持久的造血重建，中性粒细胞和血小板植入时间分别为11（9~12）和5.5（0~11）d。造血重建后植活细胞嵌合鉴定证实3例为供者完全植入，1例为供受者混合植入。2例发生Ⅰ度急性移植物抗宿主病（GVHD），2例出现CMV感染，1例发生带状疱疹病毒及EB病毒血症，对症支持治疗后均好转；无移植相关死亡。中位随访时间为26.5（21~39）个月，3例完全缓解期行RIC-allo-HSCT的患者均无病生存，1例部分缓解期行移植的患者于移植后5个月发生疾病进展。结论伴p53缺失的超高危CLL患者对临床常规化疗敏感性差，生存期短；RIC-allo-HSCT对此类患者不良反应小并耐受性良好，临床缓解期长，值得进一步观察、推广。

Antithymocyte Globulin (ATG) 4.5 Vs. 6.0 Mg/Kg in Reduced Intensity Conditioning (RIC) Allogeneic Hematopoietic Stem Cell Transplant (alloHSCT)

Antithymocyte Globulin (ATG) 4.5 Vs. 6.0 Mg/Kg in Reduced Intensity Conditioning (RIC) Allogeneic Hematopoietic Stem Cell Transplant (alloHSCT)

Comparison of Two Doses of Antithymocyte Globulin (ATG) in Reduced Intensity Conditioning (RIC) Allogeneic Hematopoietic Stem Cell Transplant (alloHSCT)

Introduction: The appropriate dose of antithymocyte globulin (ATG) to be used in reduced-intensity conditioning (RIC) allogeneic hematopoietic stem cell transplantation (allo-HSCT) is yet to be determined. In our previous retrospective analysis we compared two dosing schedules of ATG (7.5 mg/kg vs 6 mg/kg) in 136 patients who had undergone RIC allo-HSCT, and found no significant differences in the incidence of acute or chronic graft-versus-host disease (GVHD), non-relapse mortality (NRM), relapse, progression-free survival (PFS) or overall survival (OS). As of October 2013, our ATG dosing was lowered from 6.5 to 4.5 mg/kg. We now compare the outcomes of patients who received ATG at a dose of 4.5 mg/kg (r-ATG) to 6 mg/kg (R-ATG)Methods: We retrospectively analyzed the outcomes of patients who underwent unrelated or mismatch related RIC allo HSCT for hematologic malignancies and received r-ATG (40 patients) vs R-ATG (216 patients) at The Ohio State University Comprehensive Cancer Center between October 2007 and September 2014. Cumulative incidences of GVHD, infection, NRM, and relapse were analyzed using Gray's test, accounting for competing risks. PFS and OS were analyzed using the log-rank test.Results: Patients with hematologic malignancies included AML/MDS (53%), NHL/Hodgkin's (19%), CLL (12%), and other hematologic malignancies including ALL (16%). There was a significant association between disease group and ATG dose (p<0.001), with none of the patients diagnosed with CLL receiving r-ATG and a higher percentage of those with other malignancies receiving r-ATG vs R-ATG than expected. Secondary to the imbalance in disease groups, those receiving r-ATG were younger (median 50 vs 59 yrs, p=0.01) and more likely to have bone marrow stem cell source (18% vs 5%, p=0.008). There were no significant differences in recipient or donor sex, degree of HLA match, prior autografts, comorbidity index, donor/recipient CMV status and CD34 cell dose between the two groups. The cumulative incidences of acute GVHD grade II-IV at day 180 in the r-ATG and R-ATG groups were 63% and 44% (p=0.009), and of grade III-IV 18% and 11% (p=0.25) respectively (Figure 1A and B). When controlling for differences in underlying disease, the estimated risk of acute GVHD grade II-IV was 1.6 times higher with r-ATG (p=0.04). The respective cumulative incidences at 6 months of chronic GVHD were 14% and 16% (p=0.65), and of extensive chronic GVHD 14% and 13% (p= 0.29). With limited follow-up in patients receiving r-ATG (median 10 months), significant differences were not observed in longer-term outcomes between the two groups including relapse rate (p=0.83), NRM (p=0.91), PFS (p=0.92), and OS (p=0.996). The incidence of CMV reactivation at day 180 was lower in the r-ATG group (5% vs 26%, p=0.005), though the incidence of competing risks including GVHD, relapse and death prior to documented reactivation was higher in the r-ATG group (p<0.0001). No statistically significant differences were seen in Epstein-Barr virus reactivation (p=0.74), BK-virus associated hemorrhagic cystitis (p=0.79), bacterial infections (p=0.11), or Clostridium Difficile infections (p=0.22).ConclusionsWhile there was an increase in grade II-IV acute GVHD with r-ATG, there was no significant difference in acute GVHD grade III-IV, relapse, NRM, PFS and OS between the two cohorts. r-ATG resulted in a lower proportion of CMV reactivation, but in a higher proportion of other competing risks. Given the increasing use of RIC allo-HSCT for treating malignant hematologic conditions, the correct dose and schedule of ATG administration should be defined by prospective randomized controlled trials. [Display omitted] [Display omitted] DisclosuresNo relevant conflicts of interest to declare.

Graft Failure In Reduced Intensity Conditioning Allogeneic Hematopoietic Stem Cell Transplantation

A decade ago reduced intensity conditioning (RIC) allogeneic hematopoietic stem cell transplantation (allo-HSCT) was successfully introduced to facilitate transplantation in patients with co-morbidities. In contrast to myeloablative conditioning regimens RIC transplants are associated with less toxicity and thus preferred in the elderly population. However, there are also disadvantages with RIC such as the increased risk of graft failure caused by rejection by remnant recipient T-cells at transplant, which often results in mixed chimerism during the first months post-transplant. Here, we present risk factors for graft failure in all first RIC allo-HSCTs performed at our center from 1995 to mid-2010 (n=357). Graft failure was defined as &gt;95% recipient T-cells any time after engraftment or reinfusion of donor cells due to &gt;50% recipient cells with no clinical or laboratory signs of relapse. Thirty-six patients (10%) experienced graft failure. The median age of the patients was 51 and 57% were males. In univariate analysis, graft failure was 3-fold increased in male compared to female patients (15% versus 4%; P&lt;0.01). Furthermore, patients with non-malignant disorders (26% versus 2%; P&lt;0.01) and solid tumors (20% vs. 2%; P&lt;0.01) had an increased risk of graft failure when compared to acute leukemia. Graft versus host disease (GVHD) prophylaxis using cyclosporine A (CSA) in combination with mycophenolate mofetil (MMF) resulted in increased numbers of graft failure when compared to our standard regimen with CSA and methotrexate (18% vs. 5%; P&lt;0.01). The graft failure rate was the lowest among HLA-identical sibling donors (6%), slightly higher in 8/8 matched unrelated donors (10%), and the highest in 6/6 matched unrelated donors (18%; P&lt;0.01). Total nucleated cell (TNC) dose was also important with less graft failures when the TNC dose was &gt;10 x 108/kg, whereas CD34+ cell dose had no impact on graft failure (P=0.15). Moreover, in univariate analyses year of transplant, donor sex, cell source, CMV mismatch, ABO mismatch, or pre-planned G-CSF did not influence graft failure rates (P&gt;0.05). In multivariate analysis (Table 1), solid tumors were associated with markedly increased risk of graft failure (RR=10.95; P=0.03), whereas there was a tendency towards increased graft failure risk in non-malignant disorders (RR=8.01; P=0.05). Graft failures were also increased in male recipients (RR=3.27; P&lt;0.01), in grafts with a TNC dose less than 10 x 108/kg (RR=2.17; P=0.03), when using MMF containing GVHD prophylaxis (RR=3.61; P&lt;0.01), and in transplants with HLA match less than 8/8 (RR=4.94; P&lt;0.01). In conclusion, graft failure is augmented in male recipients, and associated with diseases which usually do not receive high-dose chemotherapy pre-transplant such as solid tumors. HLA mismatch as well as TNC dose and GVHD prophylaxis were also important risk factors for graft failure in the present study.Table 1Multivariate analysis of risk factors for graft failure in reduced intensity conditioning allo-HSCT.CharacteristicsNRR95% CIP-valueNo of patients357Recipient sexFemale1531Male2043.271.35-7.93&lt;0.01DiseaseAcute leukemiaa661CML276.810.70-66.310.10CLL225.380.55-52.630.15Lymphoma361.540.10-24.830.76MDS324.260.38-47.190.24MPD187.400.67-82.360.10Multiple myeloma2300-82.361Aplastic anemia382.540.25-26.210.43Non-malignant disorders348.010.96-66.800.05Solid tumors6110.951.34-89.170.03HLA matchHLA-identical sibling1561Unrelated donor 6/6454.941.84-13.24&lt;0.01Unrelated donor 8/81232.160.90-5.180.09Other matched300-13.241Other mismatched303.301.18-9.240.02Total nucleated cell dose (x108/kg)0-58615-10920.540.24-1.220.1410-14870.370.15-0.940.04&gt;14870.240.08-0.750.01GVHD profylaxisCSA+MTX2401CSA+Pred142.160.63-7.400.22CSA+MMF403.611.38-9.44&lt;0.01Fk 506 +Rapamune451.320.43-4.080.63Other176.242.27-17.16&lt;0.01aAML (n=60) and ALL (n=6). Disclosures: No relevant conflicts of interest to declare.

Autologous Whole Tumor Cell Vaccination Early After Allogeneic Stem Cell Transplantation Elicits Anti-Tumor T Cell Responses in Patients with Advanced Chronic Lymphocytic Leukemia (CLL)

Abstract 1892▪▪This icon denotes a clinically relevant abstractPatients with advanced hematological malignancies remain at high risk for eventual disease progression following reduced intensity conditioning (RIC) allogeneic hematopoietic stem cell transplantation (allo-HSCT). We hypothesized that vaccination with whole leukemia cells during the critical period of immune reconstitution early after transplant may enhance antitumor immunity and facilitate expansion of leukemia-reactive T cell responses. We tested this hypothesis in a prospective clinical trial, in which patients with advanced chronic lymphocytic leukemia (CLL) received up to 6 vaccine doses initiated between day 30–45 following RIC allo-HSCT. Each vaccine consisted of 1×107 irradiated autologous tumor cells admixed with 1×107 irradiated K562 bystander cells secreting GM-CSF (GM-K562). All patients received tacrolimus and mini-methotrexate as graft-versus-disease (GvHD) prophylaxis. Tacrolimus was maintained at therapeutic levels during the vaccination period without taper.Twenty-two patients were enrolled, all with advanced disease (median number of prior therapies 3; range 2–11). Many of the leukemias expressed markers associated with aggressive disease (e.g. unmutated IgVH - 68%) and displayed high-risk cytogenetic abnormalities (sole del(11q) - 41%; sole del(17p) - 23%; del(11q and 17p) - 18%). Greater than 50% (n=13) of patients had persistent marrow involvement (≥10%) at time of allo-HSCT. Eighteen of 22 subjects were vaccinated after allo-HSCT and received a median of 6 (range 1–6) vaccines. The remaining 4 patients were precluded from vaccination due to development of acute GvHD before day 45. Vaccines were generally well tolerated, but mild, transient injection site erythema was common. Only one grade 4 event (neutropenia) with a possible attribution to treatment occurred. We observed a similar incidence of grade II-IV aGvHD at 1 year in the 18 vaccinated patients (39%; 95% CI: 17–61%) and 42 control CLL patients that underwent RIC allo-HSCT at our institution from 2004–2009 (31%; 95%CI: 18–46%). At a median follow-up of 2.9 (range 1–4) years, the estimated 2-year rates of progression-free survival and overall survival of vaccinated study participants were 80% (95% CI: 54–92%) and 84% (95% CI: 58–95%).With these promising clinical results, we next focused on gaining insight into the mechanism that generated the observed clinical graft-versus-leukemia (GvL) responses. To delineate the specific contribution of vaccination to the overall GvL effect, we performed T cell assays to detect CLL-specific reactivity in serial pre- and post-HSCT samples obtained from vaccinated patients (n=9) who received median of 6 vaccines (range 3–6). In comparison, we examined T cell responses in study subjects (n=4) that developed aGvHD at a median of 44.5 days (range 26–56) after HSCT; and control CLL patients (n=4; no vaccine, no GvHD in the early post-transplant period) that were not enrolled in the study. Although early post-transplant vaccination had no impact on recovering absolute T cell numbers, reactivity of CD8+ T cells from the vaccinated patients was consistently directed against autologous tumor cells but not alloantigen bearing-recipient cells (PHA T cell blasts and fibroblasts) in IFNγ ELISpot assays. A peak response against autologous tumor cells was reached at day 60 after allo-HSCT (average 221 SFC/5×105 cells vs. 29 and 33 average SFC/5×105cells for PHA blasts and fibroblasts, respectively). CD8+ T cell clones were isolated from 4 vaccinated study subjects by limiting dilution and 17% (range 13–33%) reacted solely against CLL-associated antigens. In contrast, broad CD8+ T cell reactivity indicating an alloantigen response was observed in GvHD patients, while no increase in T cell reactivity against tumor-associated or alloantigens was seen in control patients. Tumor-reactive CD8+ T cells isolated from vaccinated patients secreted a broad profile of effector cytokines (GM-CSF, TNFα and IP10). Moreover, the amount of cytokines secreted by these CLL-specific CD8+ T cells steadily increased following early post-transplant vaccination, but not after allo-HSCT alone or in relation to GvHD.Our studies reveal that vaccination with autologous whole CLL/GM-K562 cells between days 30–100 after allo-HSCT is associated with induction of immunity against recipient CLL cells, and suggest that this is an effective strategy for promoting GvL following RIC allo-HSCT. Disclosures:Brown:Genzyme, Celgene: Research Funding; Calistoga, Celgene, Genentech, Pharmacyclics, Novartis, Avila: Consultancy. Cutler:Pfizer, inc: Research Funding; Astellas, Inc: Consultancy, Research Funding.

Concurrent Fludarabine and Cyclophosphamide As a Reduced Intensity Conditioning Regimen Prior to Allogeneic Hematopoietic Stem Cell Transplantation Ablates Host T-Cells and Results in Rapid Full Donor Chimerism

Abstract 1937▪▪This icon denotes a clinically relevant abstract Background:Reduced intensity conditioning (RIC) allogeneic hematopoietic stem cell transplantation (HSCT) is associated with decreased transplant-related mortality (TRM). However, RIC-HSCT is typically associated with higher rates of mixed chimerism and graft rejection compared to myeloablative conditioning. Host T-cell immunity has been demonstrated to be an important predictor of engraftment and establishment of full donor chimerism in clinical studies. It was previously demonstrated in murine models that concurrent fludarabine (F) and cyclophosphamide (C) ablated host T-cells to the extent of myeloablative total body irradiation with reduced myeloid cell toxicity and prevented rejection of fully MHC-disparate marrow allografts (Petrus et al, BBMT, 2000). While fludarabine and cyclophosphamide are agents commonly used in reduced intensity conditioning regimens, their concurrent use has never been reported. Here, we analyze results from 102 patients who received the reduced intensity conditioning FC regimen in the setting of matched related or unrelated allogeneic stem cell transplantation. Methods:On four consecutive protocols at the National Cancer Institute, hematologic malignancy patients received induction chemotherapy followed by the FC regimen: fludarabine 30 mg/m2/d, days −6 to −3 and cyclophosphamide 1200 mg/m2/d, days −6 to −3. Peripheral blood stem cells were infused on Day 0. GVHD prophylaxis was either a calcineurin inhibitor alone or in combination with other agents. Results:102 patients (females, 36; males, 66) were enrolled on study. Median age was 50 yrs (range, 21–71). Diagnoses included AML/MDS (n = 2), HL (n = 12), DLBCL (n = 35), CLL (n = 13), FL (n = 12), MCL (n = 10) and TCL (n = 10). Median number of prior regimens = 3 (range, 1 – 9); 25 patients had prior autologous transplant. Transplants were performed using HLA - matched sibling donors (n = 82) or 10/10 matched unrelated donors (n = 20). At the time of study entry, disease status was defined as chemosensitive (n = 53) or chemorefractory (n = 49). Patients were in CR (n = 19), PR (n = 26), SD (n = 37), or PD (n = 19); one patient was not evaluable. 101 of 102 patients (99%) proceeded to transplant. Median CD3+, CD4+, and CD8+ lymphocyte counts after induction chemotherapy (pre-FC conditioning) were: 150 cells/μl (1–1557), 80 cells/μl (0–1332), and 52 cells/μl (52–1195), respectively. Following FC conditioning, median CD3+, CD4+, and CD8+ counts were: 3 cells/μl (0–65), 3 cells/μl (0–93), and 0 cell/μl (0–22) (each p< 0.0001). All patients engrafted. Median time to neutrophil engraftment (ANC > 500) was 10 days and platelet engraftment (plt > 20 48 hours post transfusion) was 11 days. At Day +14, median CD3+ chimerism was 100% (range 30–100%), CD14+/15+ chimerism was 100% (range 6–100%), and whole blood chimerism was 100% (range 11–100%). Patients maintained full donor chimerism as evidenced by median 100% (range 50–100%) whole blood chimerism at Day +100. By Day +28 post-transplant, 41 patients (40%) achieved (n=24) or maintained (n=17) a CR and 38 patients (37%) achieved or maintained a PR for an overall response rate of 77%. Fourteen patients had SD and 4 had PD. Day +100 and one year TRM were 7% and 15% respectively. With a median follow-up of 92.4 months, 1 yr and 2 yr EFS were 52% and 41% and 1 yr and 2 yr OS were 68% and 58% respectively. Both EFS (p = 0.0003) and OS (p = 0.01) were significantly associated with response to FC. Acute GVHD grades II-IV and III-IV occurred in 56% and 23% of patients respectively. The rate of chronic GVHD was 65%. Grade IV non-hematologic toxicities as of Day +28 post-transplant included cardiac (n = 7, n = 1 Grade V), pulmonary (n=9), GI (n=9), and neurologic (n=3). While 62% of patients had at least one Grade III infection, only 2 patients had a Grade IV infection. Conclusion:The concurrent FC conditioning regimen resulted in host T-cell ablation and rapid full donor chimerism characteristic of myeloablative conditioning regimens. Furthermore, RIC-HSCT using concurrent FC achieved a high rate of complete remissions with an acceptable safety profile. Disclosures:No relevant conflicts of interest to declare.

Reduced intensity conditioning allogeneic hematopoietic stem cell transplant could be beneficial to angioimmunoblastic T-cell lymphoma patients with hemophagocytic lymphohistiocytosis

Dear Editor, T-cell non-Hodgkin’s lymphomas (NHLs) are a group of heterogeneous diseases with more aggressive behavior and dismal outcome than B-cell NHLs and account for less than 10% of the cases of aggressive NHLs in Western countries [1]. The outcome of T-cell NHL is even worse when it occurs in combination with hemophagocytic lymphohistiocytosis (HLH); this combination presents with fever, cytopenia, liver dysfunction, hepatosplenomegaly, hypertriglyceridemia, and hyperferritinemia [2, 3]. We report the case of a patient who had angioimmunoblastic T-cell lymphoma (AITL) and HLH and was successfully treated by allogeneic hematopoietic stem cell transplant (HSCT) with a reduced-intensity conditioning (RIC) regimen. The patient was a 62-year-old woman who did not have any other systemic diseases and presented with fever of up to 38.5°C of 1-week duration; she lost 20 kg in 6 months as well. Physical examination showed neck lymph node enlargement and hepatosplenomegaly. Abdominal computed tomography showed hepatosplenomegaly and retroperitoneal lymphadenopathy. Cervical lymph node biopsy was performed and the biopsy specimen showed heterogeneous infiltration of medium-sized atypical lymphocytes, with proliferation of post-capillary venules (Fig. 1a) and features of hemophagocytosis (Fig. 1b); it was immunohistochemically positive for CD3 and CD4, but negative for CD8, CD30, CD56, and CD20. AITL was diagnosed on the basis of these biopsy results. In situ hybridization detected Epstein–Barr virus-encoded RNA. Bone marrow examination showed prominent hemophagocytosis, but without evidence of lymphoma involvement. The patient had normal prothrombin time, activated partial thromboplastin time, fibrinogen levels, and liver and renal functions. However, the presence of anemia (hemoglobin 8.4 gdl, reference range 12–14), hyperferritinemia (ferritin 26,400 μg l, reference range 10– 120), elevated lactate dehydrogenase (673 Ul, reference range 120–240), hypertriglyceridemia (triglyceride 278 mg dl, reference range <200), and profound hemophagocytosis in both lymph nodes and bone marrow confirmed that she had HLH. We initiated treatment with one cycle of cyclophosphamide, adriamycin, vincristine, and prednisolone (CHOP), but the fever recurred in 2 weeks. Salvage chemotherapy with one cycle of etoposide, methylprednisolone, cytarabine, and cisplatin (ESHAP) and two cycles of mesna, ifosfamide, mitoxantrone, and etoposide (MINE) was administered. Her cervical lesions partially responded to these treatments; however, positron emission tomography and computed tomography detected a new nodular lesion in the patient’s J.-T. Yu :W.-L. Hwang : C.-L. Teng (*) Division of Hematology/Oncology, Department of Medicine, Taichung Veterans General Hospital, 160, Section 3, Chungkang Road, Taichung 407, Taiwan e-mail: drteng@vghtc.gov.tw

Features of Epstein-Barr Virus (EBV) reactivation after reduced intensity conditioning allogeneic hematopoietic stem cell transplantation

This single centre study assessed the incidence, kinetics and predictive factors of Epstein-Barr Virus (EBV) reactivation and EBV-related lymphoproliferative diseases (LPDs) in 175 consecutive patients who received a reduced-intensity conditioning (RIC) before allogeneic hematopoietic stem cell transplantation (allo-HSCT). The cumulative incidence of EBV reactivation at 6 months after allo-HSCT defined as an EBV PCR load above 1000 copies of EBV DNA/10(5) cells was 15%, and none of these patients experienced any sign or symptom of LPD. A total of 17 patients, who had EBV DNA levels exceeding 1000 copies/10(5) cells on two or more occasions, were pre-emptively treated with rituximab. With a median follow-up of 655 (range, 92-1542) days post allo-HSCT, there was no statistically significant difference in term of outcome between those patients who experienced an EBV reactivation and those who did not. In multivariate analysis, the use of antithymocyte globulin as part of the RIC regimen was the only independent risk factor associated with EBV reactivation (relative risk=4.9; 95% confidence interval, 1.1-21.0; P=0.03). We conclude that patients undergoing RIC allo-HSCT using anti-thymocyte globulin as part of the preparative regimen are at higher risk for EBV reactivation. However, this did not impact on outcome, as quantitative monitoring of EBV viral load by PCR and preemptive rituximab therapy allowed for significantly reducing the risk of EBV-related LPD.

Epstein Barr Virus (EBV) Reactivation After Reduced Intensity Conditioning (RIC) Allogeneic Hematopoietic Stem Cell Transplantation

AbstractAbstract 1259Following allogeneic hematopoietic stem cell transplantation (allo-HSCT), EBV reactivation and EBV lymphoprolipherative disease (LPD) are well recognized complications. To date, few data has been reported regarding the features of EBV LPD following RIC allo-HSCT. The aim of this study was to define the incidence and risk factors of EBV reactivation in 175 consecutive adult patients undergoing RIC allo-HSCT between January 2005 and June 2009 in our institution and to assess its impact on clinical outcome.In this series, the median age of recipients was 56 (range 18–71) years. In all, 85 patients (49%) had a myeloid malignancy, whereas 86 (49%) patients were diagnosed with lymphoid malignancies. The remaining 4 patients (2%) were treated for severe aplastic anemia. In total, 165 patients (94%) received peripheral blood stem cells (PBSC) whereas 10 patients (6%) received a bone marrow (BM) graft. 84 grafts (48%) were obtained from HLA identical sibling donors, 80 (46%) from HLA matched unrelated donors and 11 (6%) from 1 Ag HLA mismatched unrelated donors. The conditioning regimen associated fludarabine, busulfan, and ATG in 107 cases (61%), while 37 patients (21%) received fludarabine and low-dose TBI. The remaining 31 patient (18%) received different chemotherapy-based RIC regimens. EBV reactivation was defined as any EBV PCR load above 1000 copies of EBV DNA /105 cells. EBV LPD was defined as biopsy or autopsy proven post-transplantation lymphoma, or reactivation along with computerized tomography nodal or soft tissue abnormalities consistent with LPD. Patients with EBV viral load >1000 copies/105 cells on at least two consecutive occasions were treated with rituximab at a dose of 375 mg/m2 weekly until clearance of viremia.In our series, the median time to neutrophil recovery (absolute neutrophil count >0.5×109/L) was 17 (range, 6–48) days. Clinically significant grade II to IV acute GVHD occurred in 61 of cases (35%) and severe grade III to IV acute GVHD occurred in 37 of cases (21%). The cumulative incidence of EBV reactivation at 6 months after allo-HSCT was 15% (95% CI, 10–21%). EBV reactivation was observed at a median of 58 (range 0–930) days after allo-HSCT, with 27 (79%) of reactivations occurring during the first 6 months. In 141 patients (81%), the EBV load remained less than 1000 EBV copies/105 cells at all time. The remaining 34 patients (19%) experienced at least one EBV reactivation episode. Among these 34 patients, 17 patients had an EBV load superior to 1000/105 cells at a single time point after allo-HSCT. In these 17 cases, there were no concomitant clinical symptoms and the EBV load normalized spontaneously. The 17 patients who had EBV DNA levels exceeding 1000 copies/105 cells on 2 or more occasions were pre-emptively treated with a median number of 3 (range, 1–4) rituximab infusions which resulted in complete clearance of EBV viremia in all, but one patient (97%). This patient was severely immunosupressed, receiving three different immunosupressive agents and experienced both EBV and adenovirus (ADV) infection. This patient had symptoms mainly related to ADV infection, and died of multiorgan failure. Most importantly, none of the patients from this series developed EBV induced LPD. With a median follow-up of 655 (range, 92–1542) days post allo-HSCT among surviving patients, 104 patients (59%) were still alive and the overall survival (OS) was 47% at 4 years. There was no statistically significant difference in terms of OS or transplant related mortality (TRM) between patients who experienced an EBV reactivation and patients who did not (OS: log rank test, p=0.62; TRM: Gray test, p=0.99). In univariate analysis for risk factors associated with EBV reactivation only the use of ATG as part of the RIC regimen prior to allo-HSCT was significantly different between subgroups with and without EBV reactivation (Fisher's exact test, p=0.006). In the multivariate analysis, the use of ATG remained the only independent risk factor associated with EBV reactivation (Fine and Gray test; RR=4.9; 95%CI, 1.1–21.0; p=0.03).In all, we conclude that patients undergoing RIC allo-HSCT using ATG as part of the preparative regimen are at higher risk for EBV reactivation. However, this did not translate into a significant impact on outcome since monitoring of EBV viral load with quantitative PCR and early systematic pre-emptive rituximab therapy allowed for significantly reducing the risk of EBV-related LPD. Disclosures:No relevant conflicts of interest to declare.

Cytomegalovirus infection and disease after reduced intensity conditioning allogeneic stem cell transplantation: single-centre experience

The aim of this study was to analyse the incidence and risk factors for cytomegalovirus infection (CMV-I) and disease (CMV-D) after a reduced intensity conditioning allogeneic hematopoietic stem cell transplantation (alloHSCT-RIC). We included 186 consecutive alloHSCT-RIC adult patients at risk for CMV reactivation (patient and/or donor CMV seropositivity). Conditioning regimen was based on fludarabine plus an alkylating agent. For guiding pre-emptive anti-CMV therapy, Pp65 Antigenemia (pp65Ag) (n=116) or quantitative polymerase chain reaction (quantPCR) (n=70) were used. The 2-year incidence of CMV-I and/or CMV-D was 36% (11% for CMV-D). Of note, 12/14 (86%) episodes of CMV-D in the pp65Ag group had lung involvement compared with only 3/15 (20%) in the quantPCR group (P=0.01). Importantly, the number of patients who developed CMV pneumonia with prior negative screening tests was unusually high (67% overall). Multivariate analysis of risk factors for CMV-D identified two risk factors: (i) steroid therapy for moderate-to-severe graft-vs-host disease (GVHD) (hazard ratio 4.7, P=0.02); and (ii) alternative donors (non-HLA-identical siblings) [hazard ratio 2.7, P=0.002]. Our findings suggest that CMV is still a major concern in alloHSCT-RIC. Variables associated with poor anti-CMV T-cell recovery (that is, GVHD and donor type) are helpful in identifying patients at higher risk for CMV-D in the alloHSCT-RIC setting.

The relationship between circulating natural killer cells after reduced intensity conditioning hematopoietic stem cell transplantation and relapse-free survival and graft-versus-host disease

Natural killer cells are known to have anti-tumor activity in haploidentical hematopoietic stem cell transplantation. We hypothesized that reconstituted circulating natural killer cells may be associated with improved relapse-free survival after HLA-matched hematopoietic stem cell transplantation. Serial peripheral blood absolute natural killer cell counts were prospectively measured by flow cytometry of lymphocytes expressing CD56 and CD16 in 167 patients. Cluster analysis was used at engraftment and 60 days post-transplant to distinguish patients with high and low absolute natural killer cell counts. At engraftment 80 patients had high counts (> 22.2/mm3) and 43 had low counts. At 60 days post-transplant 84 patients had high counts (> 18.2/mm3) and 38 had low counts. The primary study end-points were death, relapse and acute graft-versus-host disease. The median follow-up was 373 days (range, 67-1767). Among patients given reduced intensity conditioning, a low absolute natural killer cell count at 60 days post-transplant was independently associated with relapse [adjusted hazard ratio (AHR) = 28.4, 95% confidence interval (CI) 4.3-186.4] and death (AHR = 17.5, 95% CI 4.3-71.3). Furthermore, patients given reduced intensity conditioning who had a high absolute natural killer cell count at 60 days had a significantly better 1-year survival than those with a low count by Kaplan-Meier analysis (83% vs. 11%, p<0.001). Multivariate analysis confirmed that low 60-day absolute natural killer count in patients given reduced intensity conditioning was independently associated with an increase in relapse or death (AHR = 20.22, 95% CI 4.76-85.40). In contrast, there was no significant association between 60-day absolute natural killer cell counts and clinical outcomes in patients receiving myeloablative conditioning. There was no significant association between absolute natural killer cell count and graft-versus-host disease. High natural killer cell reconstitution is associated with reduced relapse and death without an increased incidence of graft-versus-host-disease after reduced intensity conditioning allogeneic hematopoietic stem cell transplantation. Measuring reconstituted natural killer cells expressing CD56(+)/CD16(+) post-transplant may have novel prognostic and therapeutic implications.

Risk Factors for Blood Product Usage Following Sibling Allogeneic Haemopoietic Stem Cell Transplantation (allo-HCT).

Red cell and platelet transfusion requirements have been reported to be lower following reduced intensity conditioning allogeneic hematopoietic stem cell transplantation (RIC allo-HCT) when compared to myeloablative (MA) allo-HCT. However, previous studies examined RIC regimens with lower haemopoietic toxicity than many of the regimens in use today. We investigated risk factors for red cell and platelet transfusion in patients enrolled prospectively in an Australian study investigating the non-HLA immunogenetics of sibling allo-HCT. The transfusion requirements in the first year post transplant were reviewed for 122 patients transplanted between 2002 and 2006 in three Australian transplant centres. Seventy-one patients received MA and 51 RIC regimens. Using regression analysis, the outcome variables of total red cell and platelet units transfused were analysed. The factors age, transplant centre, disease, transplant type (RIC v MA), days of neutropenia, death within 12 months, disease risk (high risk (HR) v standard risk (SR)) and ABO mismatch underwent univariate analysis. Associated variables with p<0.2 were included in a multivariable analysis. Duration of neutropenia, disease risk, death within 12 months and transplant centre were significantly associated with higher red cell and platelet usage (p<0.0001). Transplant type was not associated with transfusion requirement. Each additional day of neutropenia resulted in a 9% increase in number of red cell units transfused and 11% of platelet units. HR MA patients used an estimated 17 units of red cells compared to 12 units for SR. HR RIC patients used an estimated 26 units compared to 10 for SR RIC patients. HR patients used an estimated 16.9 platelet units compared to 8.5 for low risk. These data highlight the importance of disease risk and degree of myelosuppression as key risk factors for blood product usage following allo-HSCT.

214: Cardiac complications in patients undergoing a reduced intensity conditioning allogeneic hematopoietic stem cell transplantation (HSCT): A single center experience

Background: RIC regimens can be used to extend transplantation to elderly or debilitated patients, not normally considered for stem cell transplants (SCT). Cardiac complications have been reported in patients undergoing fully myleoablative HSCT. However, in patients undergoing RIC the incidence, predisposing risk factors, and outcome in patients who develop cardiac complications is unknown. METHODS: We retrospectively reviewed the outcome of patients who suffered a cardiac complication during the time period from July 2000 until July 2006.

198: The use of recombinant human erythropoietin (rHuEpo) after reduced intensity conditioning (RIC) allogeneic hematopoietic peripheral blood stem cell transplantation (ASCT) reduces red blood cell (RBC) transfusion requirements

198: The use of recombinant human erythropoietin (rHuEpo) after reduced intensity conditioning (RIC) allogeneic hematopoietic peripheral blood stem cell transplantation (ASCT) reduces red blood cell (RBC) transfusion requirements

The Use of Recombinant Human Erythropoietin (rHuEpo) after Reduced Intensity Conditioning (RIC) Allogeneic Hematopoietic Peripheral Blood Stem Cell Transplantation (ASCT) Reduce Red Blood Cell (RBC) Transfusion Requirements.

We previously reported that hemoglobin (Hb) recovery was hastened after RIC ASCT as compared with ASCT after myeloablative conditioning (Transfusion, 44:501–8, 2004). In this setting pretransplant Hb level becomes the major predictive factor for early Hb recovery posttransplant and RBC transfusion (RBCT) requirements. We subsequently reported the efficacy of early rHuEpo administration after RIC ASCT to hasten Hb reconstitution (BMT, 36:901–6, 2005). Here we further confirm the efficacy of early posttransplant administration of rHuEpo after RIC reducing RBC requirements and maintaining high levels of posttransplant Hb in the 2 months following transplant.Forty patients surviving at least 60 days were analyzed. Patients characteristics were as follow: age: 50 (27–64); M/F: 28/12; with myeloid (4), lymphoid (29) or solid (7) malignancies. They received a RIC (Fludarabin (150 mg/m²; Busulfan (8mg/kg) and thymoglobulin (2.5 to 5 mg/kg)) followed with an ASCT (all PBSC) from a HLA identical sibling. Aranesp® (Amgen, France) was started on day 1. The 20 first patients received an infusion of 150 mcg/week while the 20 last patients were subsequently treated with 500 mcg/3 weeks. Aranesp® was administered intravenously when inpatient and subcutaneously when outpatient. Aranesp® administration was sustained until day 60 or when patients reached a Hb level of 140 g/L, whichever occurred first. Overall patients were treated for a median of 7 weeks post transplant. No serious adverse effect or thrombosis episode related to Aranesp® was reported in these patients. This cohort of 40 patients experienced a quicker Hb recovery and lower RBCT requirements than a historical and comparable control group of 27 patients (Day +30 Hb: 114 (94–141) vs. 100 (80–129), p<.0001; patients with 0 or 1 RBCT: 83% vs. 55% (p=.02)). Thirteen of the 40 patients (33%) presented with an Hb level of 120 g/L or more prior to conditioning. Over the first 60 days, these patients received 0 (0–2) RBCT as compared with 1 (0–2) RBCT for patients with a pre-RIC Hb level < 120 g/L (p=.05). On this basis, we hypothesized the interest of increasing Hb level prior to RIC by adequate rHuEpo stimulation. With this perspective, we have treated 13 patients with Aranesp® (500 mcg, SC) 3 weeks prior RIC. Nine of these 13 pts (69%) reached an Hb level of 120 g/L or more on day −7 as compared to 35% in patients not receiving Aranesp ® prior to RIC (p=.04). This indicates that Aranesp® post RIC ASCT is efficient to hasten Hb recovery and decrease RBCTs. In addition, a comprehensive strategy to minimize RBCT in this setting might include pre-transplant stimulation. We will prospectively assess this hypothesis.