Limited cGVHD Research Articles

Alloimmune Effect May Improve Survival of De Novo Myelodysplastic Syndrome After allogeneic hematopoietic cell transplantaion: A Single Center Analysis of 115 Patients

Abstract 2033 Background:As patients with myelodysplastic syndrome (MDS) tend to be older and to have more comorbidities, reduced-intensity conditioning (RIC) has been more frequently used in allogeneic hematopietic cell transplantation (HCT) for patients with MDS. Although alloimmune effect by donor T-cells is important to control disease especially after HCT using RIC, significance of this effect has not been fully evaluated in patients with MDS.Patients and Methods: We retrospectively reviewed medical records of 115 patients with de novo MDS or acute myeloid leukemia with multilineage dysplasia (AML-MLD) who underwent first allogeneic HCT at our center between 2000 and 2009.Patients with therapy-related MDS and cord blood transplant recipients were excluded. Karyotypic risk group was stratified according to the International Prognostic Scoring System (IPSS). Results:The median age of the patients was 55 yrs (range, 19–68). The median follow-up of surviving patients was 40 months (8–130). FAB classification at diagnosis included RA/RARS (n=45), RAEB (40), CMMoL (4), RAEB-T (12), and AML-MLD (14). Karyotype at diagnosis was good-risk in 45 patients, intermediate-risk in 30, and poor-risk in 40. The IPSS risk at diagnosis was Low in 4 patients, Int-1 in 33, Int-2 in 44, and High in 20. Among the 115 patients with MDS or AML-MLD, 68 (59%) received chemotherapy before HCT. Blast count at HCT was less than 5% in 60 patients, 5–19% in 38 patients, 20% or more in 10 patients, and not evaluable in 7 patients. Fifty-five patients received grafts from a related donor (BM 3, PBSC 52), and 60 patients received BM grafts from an unrelated donor. Conditioning regimens included myeloablative (MAC, n=34) and RIC (n=81). Among the 81 RIC recipients, 23 received low-dose TBI and 26 received ATG. The patients who received RIC were significantly older (median, 57 yrs vs. 46 yrs, p<0.001) and included more patients with poor karyotypic risk (41% vs. 21%, p=0.03) than those who received MAC. The incidence of grade II-IV acute GVHD was 42% and that of grade III-IV acute GVHD was 14%. Among the 107 patients who survived more than 100 days after HCT, 10 developed limited cGVHD (9%) and 48 (45%) developed extensive cGVHD. The OS (47% vs 42% at 4 yrs from HCT, p=0.84), the cumulative incidence of NRM (29% vs 33%, p=0.89), and that of relapse (26% vs. 25%, p=0.97) were not significantly different between the MAC and RIC groups, respectively. A multivariate analysis for OS showed that older patient age (≥50 yrs, HR 2.20, 95%CI 1.11–4.33, p= 0.02), high BM blast at HCT (>20%, HR 3.74, 95%CI 1.73–8.08, p<0.01/ 5%- 20%, HR 1.859, 95%CI 1.04–3.30 0.035), and karyotype (poor-risk, HR 1.88, 95%CI 1.08–3.27, p= 0.02) were associated with a significantly worse OS. The presence of cGVHD seemed to be associated with a better OS (HR 0.54, 95%CI 0.29–1.01, p= 0.054). In a landmark analysis, the OS of the patients with cGVHD was significantly higher than that of those without cGVHD (59% vs. 33%, p=0.02). The OS of 26 patients who received ATG was significantly lower than that of those who did not (21% vs. 51% at 4 yrs, p=0.02). In subgroup analyses according to karyotypic risks, the OS of patients with cGVHD was significantly higher than that of those without cGVHD (54% vs. 12% at 4 yrs, p<0.001) in patients with poor karyotypic risk, whereas the OS was not significantly different between the two groups (62% vs. 47% at 4 yrs, p=0.37) in patients with good/intermediate karyotypic risk (Figure). The OS of the patients with cGVHD was significantly higher than that of those without cGVHD (50% vs. 11% at 4 yrs, p=0.002) in patients with more than 5% BM blast at HCT. The OS of the patients with cGVHD was significantly higher than that of those without cGVHD (54% vs. 17% at 4 yrs, p<0.001) in patients who received RIC, whereas the OS was not significantly different between the two groups in patients who received MAC. Conclusions:Our single center analysis of patients with MDS showed that the outcomes after HCT with RIC were similar to those after HCT with MAC. Our data also showed an improvement of OS and especially in patients with more advanced MDS. In the setting of RIC, alloimmune effect by donor T-cells may be more important for prevention of relapse in patients with MDS. [Display omitted] Disclosures:No relevant conflicts of interest to declare.

Effect of acute and chronic GVHD on relapse and survival after reduced-intensity conditioning allogeneic transplantation for myeloma

We evaluated the effect of acute and chronic graft-versus-host disease (GVHD) on relapse and survival after allogeneic haematopoietic stem cell transplantation (HSCT) for multiple myeloma (MM) using non-myeloablative conditioning (NMA) and reduced-intensity conditioning (RIC). The outcomes of 177 HLA-identical sibling HSCT recipients between 1997 and 2005 following NMA (n=98) or RIC (n=79) were analyzed. In 105 patients, autografting was followed by planned NMA/RIC allogeneic transplantation. The impact of GVHD was assessed as a time-dependent covariate using Cox models. The incidence of acute GVHD (grades I–IV) was 42% (95% confidence interval (CI) 35 – 49%) and of chronic GVHD at five years was 59% (95% CI 49 – 69%), with 70% developing extensive chronic GVHD. In multivariate analysis, acute GVHD (≥ grade I) was associated with an increased risk of TRM (relative risk (RR)=2.42; p=0.016), whereas limited chronic GVHD significantly decreased the risk of myeloma relapse (RR=0.35, p=0.035) and was associated with superior event-free survival (RR=0.40, p=0.027). Acute GVHD had a detrimental effect on survival, especially in those receiving autologous followed by allogeneic HSCT (RR=3.52; p=0.001). The reduction in relapse risk associated with chronic GVHD is consistent with a beneficial graft-versus-myeloma effect, but this did not translate into a survival advantage.

Phase 2 Study of Allogeneic Stem Cell Transplantation (ASCT) From Matched Related Donor (MRD) In Patients Older Than 55 Years After Reduced Intensity Conditioning (RIC) Associating Fludarabine, Intravenous Busulfan and Rabbit Thymoglobulin

AbstractAbstract 1320ASCT is a powerful treatment for many hematological malignancies but the frequency of these diseases increases with age notably after 55 years. Indeed, this age cut-off has been a long time edge for performing ASBMT because of the increased non relapse mortality (NRM) probability making this therapy not available for this population. RIC development has recently modified this border. However because of the population characteristics non myeloablative regimen are more often considered than RIC because of the anticipated NRM with higher myeloablation. This might be questionable if we consider the antitumoral activity of conditioning.We designed a phase 2 study (ITAC protocol: EudraCT NB: 2005–005051-17) aiming to assess in patients older than 55 years the one year NRM after ASCT prepared with a RIC delivering intermediate myeloablation by associating: Fludarabine (Fludara®)(30mg/m2/d from D–5 to D-1), IV Busulfan (Busilvex®) (0.8 mg/kg × 4/d on D-4 and D-3) and rabbit anti-T cell globulins (Thymoglobuline®) (2.5 mg/kg/D on day –2 and -1) (F5BX2A2 regimen). Patients older than 55 years with poor prognosis hematologic malignancies were eligible for this program if they have a matched related donor. All grafts were peripheral blood stem cell (PBSC) mobilized with Neupogen®. IV cyclosporine A (CSA) (2 mg/kg/d) was started on day -2. It was calculated that 82 patients were looked-for to identify a one year NRM under 25% with adequate power (P<= .01; β=.9). Eight centers actively participated including these 82 patients between March 2007 and May 2010. Median age was 60 (55-70); Diagnoses: Acute leukemia (45%), myelodysplasic syndrome (19%); multiple myeloma (15%), diverse lymphoid malignancies (19%) and others (2%). Disease status: Complete remission (66%); Partial remission (26%); Progression or Stable disease (8%).Median follow-up of alive patients is 400 days (141-1086) and 63 (77%) patients have a minimal follow-up of one year. All patients engrafted. The cumulative incidence of grade 2–4 AGVHD, limited and extensive CGVHD were respectively of 17% (7-27), 35% (23-47) and 17% (7-27). Median time for grade 2–4 AGVHD and CGVHD were 40 (34-91) and 146 (90-316) days respectively. A single patient died prior day 100 on day 60 from sepsis. The cumulative incidence of NRM at 1 year was 18% (8-28). The cumulative incidences of relapse at 1 year and overall were respectively of 27 % (16-38) and 32% (20-44) with a median of 171 (22-775) days for relapse (patients in CR vs. more advanced at transplant: 28% vs. 42%; p=.26). The probabilities of overall survival at one and two years were 75% and 61% (45-75) respectively. The probabilities of disease free survival at one and two year 53% and 42% respectively.In conclusion these results are quite promising for older patients with hematological malignancies. This study prospectively shows that F5BX2A2 RIC is well adapted to a population older than 55 years inducing a limited NRM. This is in line with the low AGVHD probability, probably related to the use of ATG. Disease control is probably preserved by the use of 2 days of IV BU and the existence of a high rate of CGVHD (52%). However, it looks like that the use of 2 days of ATG allows limited CGVHD while limiting the rate of extensive GVHD, stem of mortality and poor quality of life (QOL). On the grounds of the limited NRM, we are presently studying various tuning of this RIC to improve disease control. Prospectively assessed details including economic and QOL evaluations, quite important for this population, will be presented. Disclosures:Blaise:PIERRE FABRE: Honoraria, Research Funding; GENZYME: Honoraria, Research Funding. Michallet:Bristol-Myers Squibb: Honoraria.

Safety and Efficacy of the mTOR Inhibitor Everolimus as Early Interventional Replacement for Calcineurin Inhibitors In Graft-Versus-Host Disease (GvHD) Prophylaxis After Allogeneic Stem Cell Transplantation

AbstractAbstract 2325 Background:The medical backbone of GvHD prophylaxis has been considered the use of a calcineurin inhibitor (CNI) like cyclosporine or tacrolimus in combination with methotrexate (MTX) or mycophenolate mofetil (MMF). The mammalian target of rapamycin (mTOR) inhibitor everolimus (RAD001, Certican®) is a novel immunosuppressive drug and beside sirolimus approved in solid organ transplantation. Recently, it was reported that mTOR-inhibitors in combination with CNI showed promising clinical effectiveness in innovative prevention strategies of acute GvHD after allogeneic stem cell transplantation (SCT). In this single centre retrospective analysis, we report the outcome on patients (pts), treated interventional with everolimus due to severe toxicity induced by CNI-based GvHD prophylaxis. Patients and Methods:Ten pts (3 acute myeloid leukaemias, 1 myelodysplastic syndrome, 1 acute lymphoblastic leukaemia, 4 Non-Hodgkin-lymphomas) underwent allogeneic blood SCT between 7/2007 and 3/2010. The median age was 51 years [range: 24–64] with 6 pts in advanced stages of their disease. Myeloablative conditioning was used in 3 pts (12 G TBI/120mg/kg cyclophosphamide (cyclo)] and reduced-intensity conditioning in 7 pts [5× treosulfan/fludarabine (flu), 1× busulfan/flu and 1× amsacrine/cytarabine/flu followed by 4 G TBI/cyclo]. HLA-matched family donors in 4 pts and unrelated donors in 6 pts donated on day 0 a median of 4.73 × 106 kg per bodyweight CD-34 positive stem cells. GvHD-prophylaxis consisted of standard CNI+MTX in 3 pts, CNI+MMF in 6 pts and CNI+MMF+MTX in 1 patient. Antithymocyte globulin as in vivo T-cell depletion was given in 7 pts as part of the reduced intensity conditioning regime. Results:Everolimus (0.75 mg Certican ® twice a day orally) was individual started after a median of 14 days [range: 6–16] after SCT. Primary reasons for stopping CNI (median day +10 [range 1–15]) were nephrotoxicity (CTC ≥ grade 3) in 7 pts and neurotoxicity (CTC ≥ grade 3) in 3 pts. Two pts received steroids in addition to everolimus temporally, 5 pts MMF and 3 pts steroids+MMF. The intended plasma therapeutic level of everolimus was 3–8 mg/l. All patients showed neutrophil engraftment on median day +18 [range: 8–20] and platelet engraftment on day +21 [range: 10–88]. Acute GvHD ≥ grade II (Glucksberg/Consensus NHI) occurred in 3pts (30%) (2× grade II, 1× grade III) or IBMTR-Index-Score ≥ B (2×B, 1×C). Chronic GvHD limited disease score grade I (Consensus NIH) was observed in 3 pts (n=1 overlap syndrome and n=2 de-novo cGvHD). Two out of 7 high risk pts for CMV reactivation developed viral activation. Until day +100 3 pts stopped interventional GvHD prophylaxis due to oral bleeding on day +46 (n=1) and assumed TMA on day +57/+64 (n=2). The period of everolimus administration was 140 days on average [range: 19–509]. As per August 2010 6 pts are alive resulting in a median cumulative overall survival of 58%. ALL-relapse had to be observed on day +312 in one patient. Fatal casualties occurred on day +19 by multiorgan failure (MOD), on day +103 by pneumonia, on day +211 by questionable pulmonary embolism and on day+ 411 by MOD and limited cGvHD. Conclusions:A delayed CNI-free GvHD-prevention strategy with the m-TOR inhibitor everolimus is feasible and efficacious in a series of patients after allogeneic SCT. The manageable toxicity profile in our cohort with pre-existing organ dysfunction at treatment onset mandates further evaluation of everolimus after SCT. A prospective multicentre phase II trial of everolimus as intended early replacement for CNI after SCT with a focus on tolerability is scheduled to start soon. Disclosures:Sayer: Novartis Pharma: Honoraria, Research Funding. Off Label Use: Everolimus -Certican (R)- is only approved as a immunosuppressive drug in solid organ transplantation. Hochhaus: Novartis: Consultancy, Research Funding.

Impact of Donor Source and Match on Outcome of Allogeneic Hematopoietic Cell Transplantation with Reduced Intensity Conditioning

AbstractAbstract 3539The introduction of reduced intensity conditioning (RIC) regimens in allogeneic hematopoietic cell transplantation (HCT) allows the use of this treatment option even in older, comorbid or heavily pretreated patients. The impact of donor source and match on outcome of HCT after RIC remains to be evaluated. We retrospectively analyzed 254 consecutive adult patients (f=104, m=150) who received allogeneic HCT using RIC treated at our institution between 2000–2010. Median age of patients was 58 years (range, 18–76). Diagnoses were acute leukemia (AML, n=127, ALL, n=9), Non-Hodgkin lymphoma (n=30), multiple myeloma (n=29), myelodysplastic syndrome (n=27), osteomyelofibrosis (n=19), chronic myeloid leukemia (n=5), chronic lymphatic leukemia (n=5) and Hodgkin lymphoma (n=3). 91 patients were transplanted in complete remission (CR), 163 in partial remission (PR). 49 patients were transplanted from a matched related donor (MRD), 93 from a matched unrelated donor (MUD), 68 from a mismatched unrelated donor (MMUD, up to 2 allel/antigen mismatches), 3 from a mismatched related donor and 41 from a haploidentical donor (haplo). Remission status at time of HCT in patients transplanted from haplo donors (21 CR, 20 PR) was balanced, whereas patients transplanted from MRD (10 CR, 39 PR), MUD (36 CR, 57 PR) or MMUD (24 CR, 47 PR) were predominantly in PR. 82 of the patients were high-risk because of preceding autologous or allogeneic HCT (MRD=19, MUD=27, MMUD=11, haplo=25). Kaplan-Meier estimated 3-year overall survival (OS) for all patients was 45%, 47% with MRD, 46% with MUD, 53% with MMUD and 29% with haplo (p=0.07). Kaplan Meier estimated 3-year-OS and statistical analysis by univariate log-rank test in different subgroups are described in table 1.Table 13-year OS (in %)MRDpMUDpMMUDpHaplopRemission CR394962290.30PR494549280.19NRM223428390.24aGVHD3II1000.49130.001530.91250.91no aGVHD3II40515023cGVHD no480.97400.07560.93160.03limited75395050extensive35665753Donor source and match had no significant impact on OS in the different subgroups. Non-relapse mortality was 31% without a difference between different donors. 3-year OS in the biggest diagnostic group AML was 47% with MUD, 51% with MMUD, 30% with MRD and 31% with haplo, respectively (p=0.38). Incidence of acute GVHD (aGVHD) ≥II was 14% (4% with MRD, 15% with MUD, 15% with MMUD and 17% with haplo) with a lower incidence of acute GVHD with MRD compared to haplo (p=0.02). Incidence of chronic GVHD (cGVHD) was 37% (33% with MRD, 45% with MUD, 33% with MMUD and 34% with haplo). Presence of aGVHD ≥II was associated with an inferior outcome (3-year OS 30 vs. 45%, p=0.02) while presence of limited or extensive cGVHD was associated with an improved OS (52% and 50% vs. 39% without cGVHD, p= 0.25). cGVHD had a positive impact on OS especially after HCT with MUD (p=0.07) or haplo (p=0.03) Thus, RIC for allogeneic HCT in elderly or heavily pretreated patients shows promising results irrespective of donor source. The lack of a MRD should not preclude MUD or MMUD allogeneic HCT using RIC in elderly patients. Disclosures:No relevant conflicts of interest to declare.

The Outcome of the Combination of Tacrolimus, Sirolimus, and ATG for GvHD Prophylaxis on Allogeneic Stem Cell Transplantation From Matched Unrelated Donors

AbstractAbstract 2345 Background:Graft-vs-Host Disease (GvHD) remains a significant complication of allogeneic stem cell transplantation from matched unrelated donors (MUD). Compared to MTX-based regimen, Tacrolimus/Sirolimus was found to decrease the incidence of acute GvHD (Keil et al, Biol Blood Marrow Transplant. 2009;16(2):S319, and Cutler et al, Blood. 2007;109:3108–14), whereas, the incorporation of Antithymocyte globulin (ATG) into MTX-based regimen decreases the incidence of chronic GvHD (Bacigalupo et al, Biol Blood Marrow Transplant. 2002;8(12):656–61). There are no reports of the outcome of the combination of Tacrolimus/Sirolimus and ATG. We compared the results of MUD using tacrolimus and sirolimus (day-3 to day +180) combined with ATG (2.5 mg/kg day −3,−2, and −1) (TSA) prophylaxis in consecutive patients treated at our institution from September 2006 to March 2009, with those using MTX-based prophylaxis without ATG in consecutive patients treated from January 2000 to August 2006. The primary endpoints were incidence of acute and chronic GvHD, lethal infectious complications, relapse, and survival. Result:Between 1/2000 and 3/2009, 71 MUD stem cell transplants were performed. 27 patients received TSA regimen as GvHD prophylaxis and 44 patients received traditional MTX-based prophylaxis without ATG. More patients in the TSA group received PBSC compared to the MTX group (63% vs. 36%; P=0.029), otherwise both groups were matched for age, sex, underline malignancies, disease risk per ASBMT criteria, degree of HLA-match, CMV serology, and conditioning regimens. The cumulative incidence of Grade II-IV classic acute GvHD at day +100 was significantly lower in the TSA group compared to control group (11.7% vs. 41.6%; Gray's test P =0.008). However, the cumulative incidence of aGvHD at day +365 was not statistically significant between both groups (33.1% vs. 44.4%; Gray's test P=0.154); this was due to an increase rate of delayed-onset aGvHD in TSA group (18.5%) compared to MTX group (2.3%). The rate of limited cGvHD was 7.1% vs. 30% in the TSA group and MTX group, respectively (Fisher's P= 0.12). 23% of patients surviving beyond day +100 in MTX group developed extensive/overlap cGvHD, whereas, there were no cases in the TSA group. The rate of CMV infection in patients not receiving corticosteroid treatment for GVHD was higher in the TSA group, although not statistically significant (36.8% vs. 16%, P=0.27). The rate of invasive fungal infections was similar (10.7% vs. 11.8%). The cumulative incidence of relapse at 2 years was 38.5% vs. 22.8% in the TSA and MTX groups, respectively (Gray's test P=0.18). Non-relapse mortality at 2 years was similar in both groups (42% vs. 48%; Grays's test P=0.8). Day +100 mortality was 14.4% and 27.3% in TSA and MTX group respectively. The median survivals were 251 days (95% CI, 170–332) vs. 349 days (95% CI, 236–462) for TSA and MTX groups, respectively. The 1- and 2-year overall survival were 42.3% and 31.7% for TSA group vs. 47.7% and 34.1% for MTX group, respectively (P=0.704). While the mortality rate from bacterial sepsis were equivalent, more patients in the TSA group who were not receiving corticosteroid treatment for aGvHD died from viral and fungal infection (14.3% vs. 0% at 12 months, Fisher's P=0.014). Summary:This is the first report of the combination of TSA for GvHD prophylaxis in MUD transplants. This regimen resulted in a significant decrease in classic aGvHD as previously reported for combination of Tacrolimus/Sirolimus, and decrease in incidence of cGvHD as reported previously in the studies incorporated ATG in MTX-based regimens. Hence, this did not translate into benefit in overall survival due to an increased rate of relapse and lethal viral and fungal infections with TSA regimen. Our study does not demonstrate an appreciable benefit for the addition of ATG, at the dose used, to sirolimus and tacrolimus for GvHD prophylaxis. Further studies directed at optimizing the dose of ATG to lower the rate of lethal infections may result in an overall benefit. Disclosures:No relevant conflicts of interest to declare.

Outcome of Patients Aged ≥60 After Allogeneic Hematopoietec Cell Transplantation: Age Has No Impact on Survival

AbstractAbstract 3540Historically, allogeneic hematopoietic cell transplantation (HCT) has been offered only to patients with good performance status and below the age of 60. However, the peak incidence of most hematologic malignancies is above 60 years of age. The introduction of reduced intensity conditioning (RIC) regimens enabled successful allogeneic HCT in patients with considerable comorbidities and older than 60 years. The impact of age on outcome of allogeneic HCT in patients ≥60 years has not been evaluated extensively. We retrospectively analyzed 109 consecutive patients (f=43, m=66) aged≥60 who received allogeneic HCT 2000–2010 at our institution. Median age of the patients was 65 years (range, 60–76). Patients were grouped in two cohorts depending on age: group 1 aged 60–65 years (n=60, median age=63) and group 2 aged 66–76 years (n=49, median age=68). Diagnoses were acute leukemia (AML n=65, ALL n=1), myelodysplastic syndrome (n=14), osteomyelofibrosis (n=7), non-Hodgkin lymphoma (n=9), multiple myeloma (n=8), aplastic anemia (n=1), chronic myeloid leukemia (n=2) and chronic lymphatic leukemia (n=2). At time of HCT, 41 of the patients were in complete remission (CR), 68 in partial remission (PR) (group 1: CR 21, PR 39; group 2: CR 20, PR 29) and 18 patients had a preceding HCT, 14 in group 1. Conditioning regimens were grouped in high (TBI/Bu+Cy, n=5, all group 1), intermediate (FLAMSA, Flu/Mel/BCNU, n=28, group 1=11, group 2=17), low (FLU+alkylans, n=48, group 1=32, group 2=16) and minimal (2GyTBI/Flu, n=28, group 1=12, group 2=16) intensity. Intermediate intensity conditioning was particularly used for high risk patients in PR (25/28). 22 patients were transplanted from matched related (MRD), 46 from matched unrelated (MUD) and 41 from mismatched unrelated donors (MMUD). Kaplan-Meier-estimated 3-year overall survival (OS) was 45% for all patients, 32% for group 1 and 62%, for group 2, respectively (p=0.02), with more patients with high risk constellation in group 1. 3-year OS for patients transplanted with MUD was 57%, with MMUD 46% vs. with MRD 0% (p=0.01). Non-relapse-mortality was 28% for all patients, 40% in group 1 and 12% in group 2, probably due to the higher intensity in conditioning in group 1. The outcomes with intermediate, low and minimal intensity conditioning were comparable, while all patients after high intensity conditioning died. Table 1 describes Kaplan-Meier estimated 3-year-OS and statistical univariate analysis by log-rank test in the different subgroups.Table 13-year OS (in%)AllGroup 1 Age 60–65Group 2 Age 66–76Remission CR52p=0.2531p=0.7677p=0.15PR403250Conditioning high0p=0.50p=0.08–p=0.38intermediate525053low484357minimal451767Donor MRD0p=0.010p=0.0673p=0.45MUD575365MMUD464033GVHD acute no18p=0.00313p=0.00833p=0.27≥II435358chronic no39p=0.2536p=0.7052p=0.08limited5230100extensive503067In group 1 the outcome of minimal conditioning was inferior compared to intermediate and low conditioning while patients in group 2 had a better outcome with minimal vs. low and intermediate conditioning. Incidences of acute GVHD ≥II, limited and extensive chronic GVHD (cGVHD) were 10%, 28% and 13%, respectively. In group 1, acute GVHD ≥II occurred in 13% and cGVHD in 35%, in group 2 in 5% and 41% of the patients, respectively. Acute GVHD ≥II was associated with inferior outcome (3-year OS of 18% vs. 43%, p=0.003) while cGVHD had a positive impact on OS. In group 2 patients with limited cGVHD showed better 3-year OS than patients without cGVHD (67% vs. 52%, p=0.12). Age alone had no major impact on outcome of allogeneic HCT. Patients aged ≥60 seemed to benefit from the use of MUD rather than an older MRD. Chronic GVHD had a positive influence on survival. Our data indicate that the regimen used should be tailored to disease risk and patient performance status. Disclosures:No relevant conflicts of interest to declare.

Allogeneic Hematopoietic Cell Transplantation in AML: Comparable Results After Matched or Mismatched Unrelated Versus Matched Related Transplantation.

Abstract 1199Poster Board I-221Currently, most treatment algorithms reserve the use of allogeneic hematopoietic stem cell transplantation (HCT) in patients with acute myeloid leukemia (AML) in first complete remission (CR) to patients with a matched related donor (MRD) and intermediate/high-risk disease. However, the role of HCT from a matched or mismatched unrelated donor (MUD/MMUD) in patients with AML remains to be defined. We retrospectively analyzed a cohort of 219 consecutive adult patients (98 female, 121 male) with AML who received HCT from 2000-2009 at our institution. The patients were transplanted after either myeloablative (MAC, n=139) or dose-reduced-conditioning regimens (RIC, n=80). Median age of patients was 50 years (range, 18-76). 77 patients were transplanted from MRD, 80 patients from MUD and 62 patients from MMUD (one antigen mismatch (MM)=31; two antigen MM=2; one allel MM=24; two allel MM=3, one antigen/one allel MM= 2). In all but six patients receiving MMUD grafts, ATG was included in the conditioning. Age, risk profile and pretreatment were evenly distributed among the three cohorts of patients. At time of HCT 22 (MRD), 18 (MUD) and 28 (MMUD) patients were not in CR. Current overall survival is 40 of 77 (52%) in patients transplanted from MRD, 48 of 80 (60%) from MUD and 34 of 62 (55%) from MMUD with a median follow-up of 1309 (range, 98-3173), 796 (range, 87-3075) and 648 (range, 111-1973) days of alive patients, respectively. Kaplan-Meier-estimated 3-year overall survival (OS) was similar with 54% after MRD-, 56% after MUD- and 46% after MMUD-HCT (p=0.4554). In patients transplanted in CR, 3-year estimated OS was also comparable (64% MRD vs. 58% MUD vs. 55% MMUD, p=0.6614). However, in patients transplanted in partial remission (PR) we observed a trend for a better survival in patients receiving a MUD graft (30% MRD vs. 46% MUD vs. 39% MMUD, p=0.1707). In the patients receiving MAC we observed a better OS compared to RIC with an estimated 3-year OS of 58% vs. 38% (p=0.1047) mainly due to a lower incidence of relapse. In the subgroup of patients receiving MRD-HCT this survival benefit was significant (61% vs. 21%, p= 0.0327) while there was only a trend for MUD- or MMUD-HCT (60% vs 45%, p=0.5702 and 49% vs. 43%, p= 0.7566, respectively). There was no significant difference in the incidence of acute GvHD >II with 25% (MRD), 35% (MUD) and 34% (MMUD) or chronic GvHD with 43% (MRD), 46% (MUD) and 34% (MMUD), respectively. A significant better survival of patients with limited cGvHD vs. extensive or without cGvHD (estimated 3-year OS 73% vs. 34% vs. 47%, p=0.0001) was observed. This advantage was present in all subgroups with a significant better survival in the group with MRD (86% vs. 38% p= 0.0034), a trend in MUD (67% vs. 55% p= 0.0564) and MMUD (59% vs. 55%, p= 0.3111). No significant influence on survival or GVHD of the degree and loci of HLA-mismatch could be detected. In conclusion in our cohort of patients, HCT from MUD or MMUD in AML resulted in a similar outcome compared to MRD. In patients with PR at time of HCT, the use of MUD and occurrence of limited cGVHD may lead to improved survival due to an enhanced graft-versus-leukemia-effect. Disclosures:Off Label Use: some chemotherapeutical agents in the conditioning are off-label-use.

Validation of the Lung Function Score as a Valuable Parameter for the Assessment of Chronic Graft-Versus-Host Disease and Clinical Outcome After Allogeneic Haematopoietic Cell Transplantation.

Abstract 2259Poster Board II-236The modified lung function score (LFS), which combines changes in forced expiratory volume in the first second (FEV1) and the capacity of the lung for carbon monoxide adjusted for haemoglobin level (cDLCO), has been proposed by the NIH consensus project on criteria for clinical trials in chronic graft versus host disease (cGVHD) in 2006, but since then it has not been validated. We evaluated the outcome of 205 patients who underwent allogeneic haematopoietic cell transplantation (allo-HCT) between 1998 and 2006 with regard to their LFS (grade I to IV) before HCT as well as to their LFS at 90 days and at 1 year after HCT, and compared the impact of LFS with standard grading systems for changes in FEV1, cDLCO, total lung capacity (TLC) and forced vital capacity (FVC). Mean follow-up was 973.3 (22 – 3091) days.Before allo-HCT, 35.2% of patients had a LFS I, 58.4% a LFS II, 6.4% a LFS III and none a LFS IV, respectively. We found no correlation of overall survival (OS) with pre-transplantation-FEV1, -TLC or -FVC, whereas a significant association was seen with the cDLCO (5-year OS: cDLCO > 80%: 50.7% vs. cDLCO 70-80%: 34.1% vs. cDLCO 60-70%: 56.3% vs. cDLCO 50-60%: 41.3% vs. cDLCO < 50%: 20.0%, p = 0.045). A higher pre-transplantation-LFS did show a trend towards increased mortality but did not reach statistical significance (5-year OS LFS I: 51.4% vs. LSF II: 44.1% vs. LFS III: 30.8% vs. LFS IV: NA; LFS I vs. LFS III: p = 0.057).A reduction in lung function parameters after allo-HCT is often associated with the development of pulmonary graft versus host disease. According to the current ATS/ERS guidelines, FEV1 can be used as universal parameter for grading the severity of obstructive as well as restrictive pulmonary function changes. Prior studies demonstrated, that FEV1 decreases frequently after allo-HCT, and that cDLCO is often reduced before allo-HCT and shortly after with subsequent increase or recovery. Respective changes where also seen in our patient cohort. A reduction in FEV1 at 3 months and at 1 year after allo-HCT did strongly correlate with increased overall mortality (5-year OS (FEV1 on day 90): FEV1 > 80%: 72.1% vs. FEV1 70-80%: 50.0% vs. FEV1 60-70%: 0% vs. FEV1 50-60%: 25.0% vs. FEV1 <50%: NA, p < 0.001; 5-year OS (FEV1 on day 360): FEV1 > 80%: 82.7% vs. FEV1 70-80%: 69.3% vs. FEV1 60-70%: 83.3% vs. FEV1 50-60%: NA vs. FEV1 < 50%: 33.3% p = 0.012), whereas changes of the cDLCO only at day 360 (5-year OS: cDLCO > 80%: 82.8% vs. cDLCO 70-80%: 80.9% vs. cDLCO 60-70%: 80.1% vs. cDLCO 50-60%: 84.6% vs. cDLCO < 50%: 60.0%, p = 0.02) but not at day 90 (cDLCO > 80%: 53.5% vs. cDLCO 70-80%: 80.6% vs. cDLCO 60-70%: 73.1% vs. cDLCO 50-60%: 56.1% vs. cDLCO < 50%: 60.0%, p = 0.11) could be associated with differences in survival. A LFS of I/II/III/IV was found in 22.5/64.0/12.6/0.9% at day 90 and in 24.5/63.3/11.2/1.0% at day 360, respectively, and a clear correlation was seen between the development of cGvHD and elevated LFS levels at day 360 (no cGvHD: 20.0% LFS I, 76.7% LFS II, none LFS III, 3.3% LFS IV vs. limited cGvHD: 27.6% LFS I, 65.5% LFS II, 6.9% LFS III, none LFS IV vs. extensive cGvHD: 25.8% LFS I, 48.4% LFS II, 25.8% LFS III, none LFS IV, p = 0.004). As for FEV1, both at day 90 and 360 after allo-HCT there was a clear correlation between the level of LFS and overall mortality (5-year OS: LFS I: 69.5%, LFS II: 70.4%, LFS III: 45.1%, LFS IV: 0% at day 90 and LFS I: 90.2%, LFS II: 81.6%, LFS III: 64.9%, LFS IV: 0% at day 360, p < 0.001).In summary, the LFS presents a valid approach to assess and clinically interpret changes in lung function in patients undergoing allo-HCT. Our data show, that pre-HCT LFS scores potentially provide information on allo-HCT outcome, allowing a better risk assessment of transplantation-related mortality. More importantly, post-HCT LFS levels strongly correlate with cGvHD and overall survival, making the LFS a valuable tool for adequate and tailored patient follow-up and adaption of immunosuppression. LFS assessment should therefore be routinely incorporated in the pre- and postransplantation care of allo-HCT patients. Disclosures:Holler:Fresenius Hemocare: Consultancy; Research Support Gentium: Research Funding.

Proteomic Screening Applied to the Diagnosis of Chronic Graft-Versus-Host-Disease.

Abstract 1164Poster Board I-186Allogeneic hematopoietic stem cell transplantation (allo-HSCT) is a curative treatment for many hematologic malignancies or hematopoietic dysfunction syndromes, but the application is still limited due to major complications, such as severe graft versus host disease (GvHD) and infectious complications. Diagnosis chronic GvHD is based on clinical features and biopsies, a non invasive, unbiased laboratory test does not exist.We used the urine collected from 20 patients (10 with limited cGvHD, 10 with extensive cGvHD) to establish a proteomic pattern that allowed the diagnosis of cGvHD development and tested the resulting set of polypeptide markers (27 differentially excreted peptides) on more than 200 patients prospectively and blinded for the correct classification of cGvHD samples. The majority of the patients included were transplanted for hematological malignancies (n=209), 6 for hematopoietic failure syndromes. Conditioning regimens included dose reduced conditioning regimens (FLAMSA and ClaraC for the majority of the patients of MHH), as well as standard conditioning regimens (TBI+Cy or Busulfan+Cy) for about 35% of the patients, with GvHD-prophylaxis including cyclosporine A and mycophenolate (MMF) or metothrexate (MTX) as appropriate. Eighty percent of the patients received ATG (antithymocyte globulin) prior to HSCT.A peptide pattern of 27 peptides, differentiating chronic from acute GvHD was developed. Controls were patients at least 100 days post HSCT, with no GvHD in the history, no infections and without relapse at the time of sampling. Prospective and blinded evaluation of the patients revealed the correct classification of patients developing cGvHD with a sensitivity of 85% and specificity of 95%.Further evaluation of the cGvHD patterns specific for particular organ manifestations of cGvHD are currently ongoing. Interestingly, the cGvHD pattern seems to be predictive for GvHD developing post DLI, while the aGvHD-specific proteomic pattern only predicts GvHD of the intestine, which may be more similar to “late acute GvHD”. DisclosuresKrons:mosaiques-diagnostics GmbH: Employment. Metzger:mosaiques-diagnostics GmbH: Employment.

Appropriate Patient Selection Before Allogenic Stem Cell Transplantation (allo-SCT) and Chronic GvHD After Allo-SCT Would Be Necessary for Better Outcome of Chemorefractory Non-Hodgkin's Lymphomas-A Single Institute Retrospective Study-.

Abstract 4302 IntroductionsAllogenic stem cell transplantaion (allo-SCT) for non-Hodgkin's lymphomas (NHLs) may be curative for chemorefractory patients, but few studies are available to guide transplant decision making in this setting. It would be very important to assess the eligibilities of allo-SCT for NHLs. To clarify the possibilities and eligibilities of allo-SCT for aggressive NHLs and come out the better prognostic factors, we analyzed 18 NHL patients who underwent allo-SCT in our institute retrospectively. Design and methodsThere were 55 NHL patients who had been undergone allo-SCT in our institute from August 2001 to March 2009. Thirty-seven patients out of 55 were adult T-cell leukemia/lymphoma (ATLL) patients, and we excluded these 37 ATLL patients in this study so that eliminate selection bias. We analyzed about rest of 18 patents. We analyzed 3 years overall survival (OS), disease free survival (DFS), related factors such as gender, age, diagnosis, disease status, IPI, HCT-CI score, transplantation methods, acute GVHD, chronic GVHD, and causes of death. ResultsMedian age was 37.5 years old (19-63). Thirteen patients were male and 5 female. Diagnosis included FL (n=4), PTCL-u (n=3), MNKL (n=3), BL (n=2), DLBCL (n=2), ALCL (n=1), T-LBL (n=1), hepatosplenic lymphoma (n=1), and MF (n=1). Median overall survival time and disease free survival time after SCT were 215.5 days (6-2436) and 73 days (2-2436). Overall survival rate after SCT was 38.9%. IPI was Low in 2 patients, 8 L-I, 5 H-I, and 3 High. Low/L-I group showed significantly superior OS, DFS compare to H-I/High group (54% vs 0% p=0.0014, 56.3% vs 0% p=0.0112). HCT-CI scoring 0 in 12 patients, five 1, and only one patient scored over 2. HCT-CI score significantly related to OS after SCT in our cases (p=0.024). There were 13 sibling donors (included 5 HLA haplo-identical donors) and 5 unrelated donors (URD) (included 2 cord blood donors) in our cases. Ten patients received myeloablative conditioning and 8 reduced intensity conditioning (RIC). Disease status at SCT was CR in 5 patients, 7 PR, and 6 PD. Eleven patients died after SCT (3 a-GVHD, 2 disease progression, 2 sepsis, 1 TMA, 1 pneumonia, 1 invasive aspergillosis, and 1 liver failure). Five patients died within 100 days after SCT (three patients died within day 30). Six patients have been alive over 3 years (3 yrs OS, DFS: 33.3%, 27.8%). Seven patients were complicated grade 0-1 a-GVHD and 9 grade 2-4. Grade 0-1 group patients showed significantly superior DFS compare to grade 2-4 (p=0.0314). Five patients complained limited c-GVHD and 3 extensive. The patients group complained with c-GVHD showed better OS and DFS than asymptomatic group (53.6% vs 12.0% p=0.0062, 58.3% vs 12.5% p=0.0267). Four patients suffered relapse or progressive disease after SCT. Two out of these 4 patients showed GVL effect only with reducing immunosuppressive therapies. Discussion and conclusionInterestingly, about a-GVHD, grade 2-4 group obtained poor prognostic result compared to grade 0-1 group. On the other hand, the group which showed c-GVHD obtained better survival results. Our study was based on relatively small numbers of cases, but it might be showed that c-GVHD is important and GVL effect would be possibly existed. 3 years OS and DFS of allo-SCT for chemorefractory NHL in our institute were 33.3%, 27.8%, and NRM was 50%. Although it was not acceptable results, in some groups such as IPI Low/L-I, low scored HCT-CI groups, allo-SCT would be acceptable. Further studies including large patients numbers will be required. Disclosures:No relevant conflicts of interest to declare.

5–azacitidine Treatment of Imminent Relapse Defined by Decreasing Donor CD34+ Progenitor Subset Chimerism in Patients with CD34+ High-Risk Myelodysplastic Syndromes (MDS) or Acute Myeloid Leukemia (AML) after Allogeneic Stem Cell Transplantation.

Besides graft versus host disease (GVHD), disease relapse is one of the major challenges in the care of patients with acute myeloid leukemia (AML) or myelodysplastic syndrome (MDS) undergoing allogeneic peripheral blood stem cell transplantation (PBSCT). However, we and others have shown that relapse can be predicted in case of CD34-expression on the malignant clone by a sensitive chimerism analysis in sorted CD34+ peripheral blood cells. If the percentage of donor cells in this compartment drops below 80%, leukemia relapse is inevitable within 4–8 weeks in the absence of clinical interventions like immediate cessation of immunosuppressive drugs or the administration of donor lymphocyte infusions. However, both approaches often result in clinically significant GVHD. Therefore, new strategies are warranted in order to treat imminent relapse in MDS or AML patients. We report results of an ongoing phase II clinical trial evaluating the efficacy of 5-azacitidine (5-aza) to prevent hematological relapse in patients with CD34+ AML or MDS and a decreasing CD34-donor chimerism after allogeneic PBSCT. Therefore, a total of 23 patients with CD34+ MDS (n=3) or AML (n=20) were prospectively screened on day 56, 84, 112, 140, 184, 365 and at later time points after PBSCT for a decreasing chimerism of donor CD34+ cells in the peripheral blood. In case of imminent relapse, defined as a drop of donor CD34+ cells below 80%, 5-aza was given at a dose of 75mg/m2/d s.c. day 1–7. A total of 4 cycles every 28 days were allowed in the absence of hematological relapse or toxicity. A median of 226 days after PBSCT, 9 out of 23 patients screened entered the treatment phase of the study with a median of 31% (range 0–53%) CD34+ donors cells in the peripheral blood (PB). However, a complete overall PB donor chimerism and less than 5% marrow blasts were documented in all patients before 5-aza treatment. Reversible neutropenia and thrombocytopenia grade 3/4 occurred in 50% of the patients. Only three patients still had immunosuppression prior 5-aza, which in two of them was slowly tapered during the period of 5-aza administration. With a median follow-up of 186 days after starting 5-aza all nine patients are eligible for response evaluation. Of these, CD34-chimerism was reverted to complete donor type (>90%) in 6 (66%) patients. Two patients showed a further decrease of donor CD34+ cells and relapsed shortly after having completed the 1st or the 4th cycle of 5-aza, respectively. One patient showed an increase of CD34-chimerism after two cycles, however, died from non-relapse mortality. No hematological relapse occurred in the responders and in the screening cohort without decreasing CD34+ chimerism. Two patients (one without immunosuppression) developed limited cGVHD during 5-aza treatment. Preemptive treatment of minimal residual disease defined by decreasing donor CD34+ subset chimerism with 5-aza seems to be a potent strategy to prevent hematological relapse of CD34+ myeloid malignancies after allogeneic PBSCT.

Possible Involvement of γδ-T Cells in the Development of Chronic Graft-Versus-Host Disease after Allogeneic Hematopoietic Stem Cell Transplantation.

Background: Chronic graft-versus-host disease (cGVHD) remains the major cause of late morbidity and non relapse mortality after allogeneic hematopoietic stem cell transplantation (allo-HSCT). However, the pathogenesis of cGVHD is poorly understood. This study was designed to explore the immunological mechanism of cGVHD with comprehensive analysis of peripheral T cell subsets (CD4, CD8, Th1, Th2, γδ-T and NKT), dendritic cell (DC) subsets and serum 17 different cytokines.Methods: 20 patients (pts) with complete donor cell engraftment over 100 days after allo-HSCT were enrolled, including 6 pts without cGVHD (control) and 14 pts with cGVHD (5 limited/ 9 extensive). All of the pts with extensive cGVHD were under systemic immunosuppressive therapy, and the pts with limited cGVHD or without cGVHD were free from immunosuppressant. T cell subsets including CD4 (CD3+CD4+CD8−), CD8 (CD3+CD4−CD8+), Th1 (CD4+CXCR3+CCR4−), Th2 (CD4+CXCR3−CCR4+), γδ-T (CD3+TCRVδ2+), and NKT (CD3+CD161+) and DC subsets (CD11c+DC and CD123+DC) were determined with a flow cytometer. Serum cytokines, including IL–1β, IL-2, IL-4, IL-5, IL-6, IL-7, IL-8, IL-10, IL-12, IL-13, IL-17, TNF-α, IFN-γ, G-CSF, GM-CSF, MIP-1β, and MCP-1) were analyzed by Bio-Plex Cytokine Assay. Differences among extensive cGVHD, limited cGVHD and control were evaluated by one-way ANOVA followed by Bonferroni method as a post hoc test.Results: A significant difference was found only in γδ-T cells, but not in any of the other cells, including CD4, CD8, Th1, Th2, NKT, and DC subsets among extensive cGVHD, limited cGVHD and control. There was a significant decrease in the mean absolute number of γδ-T cells in extensive cGVHD (4.0 /μl, n=9, p<0.001) and limited cGVHD (16.0 /μl, n=5, p=0.01), compared to that in control (56.7 /μl, n=5). This marked reduction of γδ-T cells in cGVHD was found also in the mean percentage of γδ-T cells in CD3 T cells (%-γδ-T) as follows: extensive cGVHD (0.53%, n=9, p<0.0001), limited cGVHD (1.00%, n=5, p<0.001) in contrast with control (4.74%, n=5). On the other hand, dramatical increase in IL-6 was observed in extensive cGVHD (18.4pg/ml, n=5), in contrast with limited cGVHD (2.5pg/ml, n=3, p=0.02) or control (0.8pg/ml, n=5, p=0.004), demonstrating IL-6 involvement in the severity of cGVHD. Moreover, IL-10 as a kind of Th2 cytokines was likely to increase in extensive cGVHD (3.8pg/ml, n=5, p=0.02), compared to that in control (0.2pg/ml, n=5), suggesting Th2 involvement in extensive cGVHD. The other cytokines including IL-4, TNF-α, IFN-γ did not show any significant changes between cGVHD and control. Interestingly, a positive correlation was observed between IL-6 and the reciprocal of the percentage of γδ-T cells in CD3 T cells (1/%-γδ-T) (n=12, r=0.79, p=0.002) with all samples put together, suggesting γδ-T cells as a negative regulator of IL-6.Discussion: γδ-T cells have been reported to control the innate immune system and participate in anti-tumor or anti-infection immunity in a major histocompatibility complex-unrestricted manner. Our data suggest the possible involvement of the reduction of γδ-T cells in the pathogenesis of cGVHD, and the usefulness of monitoring γδ-T cells in predicting the development of cGVHD after allo-HSCT.

Avoidance of Post-Thaw Wash Prior to Transplantation of Plasma Depleted Cord Blood (PD CB) Is Associated with Improved Engraftment & Decreased Severity of Chronic GvHD (cGvHD) without Increased Relapse.

Post-thaw washing of frozen CB prior to transplantation is widely practiced to remove DMSO, red cell debris and free hemoglobin, however, washing a red cell containing product may result in cell loss. We analyzed outcomes of engraftment, survival, relapse and GvHD in 299 patients transplanted with plasma depleted but not red cell reduced (PD) CB where 154 were washed (W) and 145 were directly infused - (non-washed or NW). 207 (69%) of 299 patients had malignant diagnosis. The two groups were comparable for patient, disease and graft characteristics except for a higher % of Asian patients in the NW group in contrast to a higher % of Caucasian/Hispanic patients, higher % of US transplant centers (TC) and higher number of malignant diagnoses for the W group. Nucleated cell recovery after thawing, as reported by TC, was higher for NW (median 85% vs. 79%, p=0.003). The NW group had higher cumulative incidences of and faster neutrophil (ANC500) and platelet engraftment (Plt 20K and 50K) than the W group. No difference was seen for acute GvHD (aGvHD); however, the NW group had significantly lower rates of extensive (Ext) cGvHD and higher rates of limited (Ltd) cGvHD (p=0.0005 and <0.0001). Relapse rates were similar between W and NW. Multivariate analysis and matched pair analysis between W versus NW confirm these observations. In univariate analysis, overall survival (OS) and disease-free survival (DFS) were significantly higher for the NW group. This retrospective analysis represents the largest series comparing different thaw methods for PD CB and is the first to demonstrate a potential association of no post-thaw wash with significant decrease in extensive cGvHD rate without concomitant increase in relapse rate. These improvements may contribute to the apparently better survival for the NW group. Prospective trials which may include infusion of wash supernatants into patients are necessary to confirm and better understand these observations.ANC 500 & Plt 20K100 Day TRM1 & 3 Yr OS1 & 3 Yr DFS1 Yr RelapseII-IV/III-IV aGvHDLtd/Ext cGvHDOverall88±4/69±417±261±3 56±351±3 39±523±335/1420/11W87±5/64±517±354±4 48±443±5 30±627±536/159/17NW91±6/76±616±369±4 67±460±5 57±520±436/1436/1P value0.002/0.0010.050.020.050.290.93/0.80<0.0001/0.0005ANC 500 & Plt 20KTRMOSDFSRelapseII-IV/III-IV aGvHDLtd/Ext cGvHDMV adjusted Cox RR & P value1.51 0.002/1.70 0.0010.67 0.110.71 0.090.74 0.110.76 0.34N/A3.88/<0.001Matched Pairs P value0.008/0.00020.530.320.220.190.98/0.440.02/0.001All results in % except for p-values & where indicated. Engraftment presented as cumulative incidence, GvHD as proportions; all others estimated by Kaplan-Meier.

Photopheresis in pediatric graft‐versus‐host disease after allogeneic marrow transplantation: clinical practice guidelines based on field experience and review of the literature

Extracorporeal photochemotherapy (ECP) gives positive results in the management of graft-versus-host disease (GVHD), but in children, specific difficulties can outweigh this benefit. These difficulties must be taken into consideration when establishing a standardized reproducible procedure for implementation under a quality management plan. Twenty-seven children underwent ECP for severe acute GVHD (aGVHD) or chronic GVHD (cGVHD) after allogeneic marrow transplantation. Data were collected prospectively, with particular emphasis placed on technical, biologic, immunologic, clinical, and long-term follow-up issues. The 27 children underwent a total of 750 sessions. Mononuclear cells were collected on a commercially available apheresis system (COBE Spectra, Gambro BCT). Overall survival was 73 percent, and ECP led to significant improvement in 21 of the 27 patients (11 with complete response and 10 with partial response, i.e., >50% of organ involvement). Tolerance was good overall, the main limiting factors being vascular access and the psychological impact of repeated apheresis procedures. Children weighing less than 25 kg were not more susceptible to side effects. A specifically pediatric-dedicated and -experienced team faces only limited difficulties when treating children with GVHD by ECP. Overall, ECP is efficient and well tolerated. Our experience was therefore pooled together with available pediatric data to establish clinical practice guidelines. These guidelines consider ECP as a first-line therapy in Grade IV aGVHD (in association with conventional pharmacologic approaches) and limited cGVHD and as a second-line therapy in steroid-resistant Grades II to III aGVHD and extensive cGVHD.

Allogeneic immunotherapy by hematopoietic stem cell transplantation (ASCT) after reduced intensity conditioning (RIC) following high-dose chemotherapy for patients with acute myeloblastic leukemia (AML) in first complete remission (CR1): Reduced toxicity

7098 Background: RIC-based ASCT can be used after intensive chemotherapy in pts with CR1AML(Blaise, Cancer, 2005). Initial disease control was high and was not related to selection bias (Mohty, Leukemia, 2005).Here, we investigated if this control was maintained after a long follow-up. Methods: 37 pts (age: 51 (26–60)) with high risk clinical characteristics (70%) (Age = 50 (N=22, 59%); severe comorbidity (30%)) and/or poor risk leukemic features (65%) (Cytogenetics (35%); 2 induction courses (27%); secondary leukemia (11%), High white blood cell counts(14%) or partial remission (3%)) were treated. After CR1, pts received at least either 1 course of high dose cytarabine (24 g/m2) and anthracycline (HIDAC: N=21) or HIDAC + 1 course of. melphalan (140 mg/m2) (HDMEL) with auto-SCT Pts (HIDAC +HDM N=16). All pts were then scheduled to receive ASCT prepared with RIC (fludarabine (180 mg/m2), busulfan (8 mg/kg), Thymoglobulin (2.5 to 10 mg/kg)) followed with BMT (28%) or PBSC (72%). Results: With a Median follow-up of 3 years (16–70 mths). 15 pts experienced aGVHD (grade 2–4 aGVHD cumulative incidence (CI):22% (9–35). 10 and 14 pts presented a limited and extensive cGVHD respectively (CI cGVHD:65 % (50–80). 3 deaths were attributed to non-relapse causes (NRD) (AGVHD: 1; CGVHD: 2° (NRD CI: 8% (0–17). In all, 9 pts relapsed at 5 mths (2–19) (24% (9–35). Relapse was associated with the absence of cGVHD (cGVHD: 8 (0–19), no cGVHD 44% (12–76), p=.05). 25 pts are still alive in CR1 for overall survival and leukemia-free survival (LFS) probability estimates at 4 years of 65 % (48–79%) and 66% (49–80%) respectively. When restricting the analysis to the 33 pts evaluable for cGVHD, cGVHD remained the only independent risk factor positively influencing LFS (cGVHD: 81% (59–92); no cGVHD (56% (27–81), p=.05) Conclusions: We conclude that RIC Allo-SCT preceded by adequate prior intensive chemotherapy might offers a relatively low NRD while exerting a sustained leukemia control even in high risk pts deserving prospective evaluation against standard strategy of conventional Allo SCT. No significant financial relationships to disclose.

BAFF/Blys Levels Correlate with Disease Activity and Alter Peripheral B Cell Subsets in Patients with Chronic GVHD.

Patients with chronic graft versus host disease (cGVHD) after allogeneic hematopoietic stem cell transplantation (HSCT) have been found to have high titers of allo-reactive antibodies, but a role for B cells in the pathology of this disease remains undefined. B Cell Activating Factor, BAFF/Blys (BAFF), promotes differentiation and expansion of antigen-activated B cells and contributes to loss of B cell tolerance in animal models. We hypothesized that the BAFF/BAFF receptor (BAFF-R) pathway may perpetuate potentially allo- or auto-reactive antigen-experienced CD27+ B cells in patients with cGVHD after HSCT. Soluble BAFF was measured in plasma from 104 patients after HSCT. Median BAFF levels were statistically different when groups were compared using a two-sided Wilcoxon-Rank-Sum test (see Table below). Logistic regression analysis revealed that higher BAFF levels were associated with active cGVHD after adjusting for other GVHD prognostic factors (p=0.0007). Patients with ≥10ng/ml BAFF levels had ten-fold increased odds of having cGVHD compared to patients with BAFF levels of <10ng/ml (OR of 10.8, p=<0.0001). High dose prednisone reduced median plasma BAFF levels (3.8ng/ml in patients receiving ≥30mg daily prednisone versus 14ng/ml for those receiving <30mg or no prednisone). Serial BAFF measurements revealed peak BAFF levels at 6 months post-HSCT in patients who later developed limited cGVHD. 81% of patients with BAFF levels >10ng/ml at 6 months subsequently developed cGVHD (median BAFF was 20ng/ml) compared to 39% of patients with BAFF levels <10ng/ml at 6 months (p=0.002). We also found that BAFF-R expression on B cells was down-regulated in vitro in the presence of BAFF. Consistent with this finding flow cytometry revealed very low BAFF-R expression on B cells in patients with active cGVHD. BAFF-R expression on peripheral B cells correlated with BAFF levels (p=0.0001), suggesting that BAFF signals via BAFF-R in cGVHD. We used 5-color FACS to characterize peripheral B cell subsets in 68 post-HSCT patients. Compared to patients without cGVHD, the proportion of antigen-experienced CD27+ B cells was increased in patients with limited cGVHD (n=20, p=0.04). The extensive cGVHD patient group was smaller (n=11) with greater variability in CD27+ B cell frequency resulting in no statistical difference (p=0.27). The proportion of CD27+ post-germinal center B cells was also increased in patients with active cGVHD (p=0.04 and p=0.03 extensive and limited cGVHD, respectively). High BAFF levels correlated with increased total numbers of CD27+ B cells (p=0.05), but not with total or naïve B cell numbers, suggesting that BAFF plays a role in perpetuation of circulating antigen-experienced and memory B cells in cGVHD patients. Our results suggest that high levels of BAFF after HSCT help break peripheral B cell tolerance and contribute to cGVHD pathobiology.Comparison of BAFF Levels Between Extensive/Limited versus Inactive/No cGVHD GroupscGVHD TypeNMedian BAFF (ng/ml)p-value vs. inactivep-value vs. noExtensive1511.50.140.02Limited339.00.020.0004Inactive275.7-0.02No294.40.16-Normal261.90.00020.004

Infliximab for the Treatment of Chronic Graft Versus Host Disease.

Chronic graft-versus-host disease (cGVHD) remains the major cause of late morbidity and non relapse mortality after allogeneic stem cell transplantation. Tumor necrosis factor alpha (TNF-α) is a cytokine involved in the pathogenesis of GVHD. Infliximab is a murine-human chimeric monoclonal antibody that binds TNF-α, preventing interaction with its receptor and its ability to mediate the development of GVHD. Infliximab is active in the treatment of steroid refractory acute GVHD, particularly for patients with GI GVHD (Couriel et al Blood. 2004 Aug 1;104(3):649–54).We performed a retrospective analysis to evaluate the activity of infliximab in 22 patients with AML/MDS (n=5), lymphoma (n=8), ALL (n=3), and others (n=6) with steroid refractory chronic extensive GVHD. Response was measured according to standard response criteria (Pavletic et al. Biology of Blood and Marrow Transplantation 2006 Mar;12(3):252–66). The median age of the patients was 50 years (range 20 – 64). Fourteen (64%) patients had matched sibling donors, 8 (36%) had matched unrelated donors, 9 (41%) underwent nonmyeloablative conditioning, one patient had a bone marrow transplant and the other 21 patients had peripheral blood stem cell transplants. All patients were given standard doses of tacrolimus or cyclosporine for GVHD prophylaxis with either short course methotrexate or mycophenolate mofetil. All patients were treated with systemic steroids at the onset of GVHD. Fifty percent of the patients initially presented with acute GVHD that progressed to chronic extensive GVHD. The other half presented with late onset or de novo chronic extensive GVHD. Nineteen had skin involvement (86%), 15 (68%) had gastrointestinal involvement, and 10 (45%) had liver involvement at the time of treatment with infliximab. All patients were considered refractory to tacrolimus/cyclosporine and systemic steroids, had intolerable side effects from steroids or could not be successfully tapered off steroids prior to infliximab administration. Median time from transplant to infliximab administration was 337days (range 122 to 932 days). The patients received a median of 4 weekly courses (range 1–20 courses) of infliximab at 10mg/kg. The overall response rate was 64% (n=14); 11 (50%) experienced a complete response (CR); 3 (14%) experienced a partial response (PR); 8 (36%) had progressive GVHD. The response rate for skin GVHD was 68%, GI was 60% and liver was 50%. One patient suffered an acute infusion reaction after the first infliximab dose and had no further drug administered. Median survival of all patients following initiation of infliximab was 223 days. Median survival of all responders was 625 days after infliximab, while median survival of the non-responders was 70 days after infliximab. Six patients remain alive at a median follow-up of 55 months (27%). Three of six survivors are on minimal immunosuppression with limited cGVHD and three are off all immunosuppression with no evidence of cGVHD. Of the patients who died, 7 (32%) died from infectious complications, 5 (23%) died from complications of progressive cGVHD, 4 (18%) died from hemorrhagic or embolic strokes, 2 died from complications of post-transplant lymphoproliferative disorder (PTLD), and one patient from relapse. In conclusion, infliximab has activity for cGVHD. Prospective trials investigating the activity of infliximab, the infectious risks, predictive measures responding patients and optimal timing of administration are needed.

Risk Factors and Outcome of Chronic GVHD: Analysis of 5,660 Patients Undergoing Unrelated Bone Marrow Transplantation through the Japan Marrow Donor Program.

Background: Chronic GVHD (cGVHD) remains the major cause of late morbidity and mortality after allogeneic stem cell transplantation. However, there are limited data available on cGVHD after unrelated BMT (UR-BMT). We retrospectively analyzed the data of 5,660 patients who underwent UR-BMT through the Japan Marrow Donor Program (JMDP) between January 1993 and June 2004.Methods: Data were collected by the JMDP using a standard report form. Follow-up reports were submitted at 100 days, 1 year, and then annually after transplantation. Overall survival (OS) was estimated by the Kaplan-Meier method and patients surviving beyond day 100 after transplant were analyzed for the development of cGVHD. The log-rank test was used for univariate analysis and time-dependent Cox proportional hazards modeling was used for multivariate analysis. The cumulative incidence of cGVHD and of relapse was calculated using the Gray method considering death without cGVHD and death without relapse as respective competing risks.Results: The median age of all patients was 28 years and the median follow-up was 433.5 days after transplant. Estimated 5-year OS of all patients and those with hematological malignancies was 47.4% and 45.5%, respectively. A total of 3,974 patients survived beyond day 100 after transplant and their cumulative incidence of cGVHD was 43.2% at day 500 and 44.9% at day 2,000 post-transplant. The cumulative incidence of extensive cGVHD was 28.8% at day 2,000 post-transplant. In multivariate analysis, variables predicting cGVHD were recipient age (p=0.000), donor age (p=0.002), diagnosis of hematological malignancy (HR=1.99, p=0.000), HLA class I mismatch by either serology or DNA typing (HR=1.24, p=0.020), acute GVHD (I: HR=1.50, p=0.000; II: HR=2.07, p=0.000; III and IV: HR=2.25, p=0.000) and no platelet recovery over 50,000/mm3 before day 100 (HR=1.36, P=0.002). There was a significant difference between patients <20 and ≥20 years old (HR=1.27, p=0.000). However, there were no significant differences between any adults grouped by age decade (p=0.894). OS at 5 years in patients surviving >100 days post-transplant was 62.4% without cGVHD, 68.0% with limited cGVHD, and 55.4% with extensive cGVHD (p=0.000). In the patients with hematological malignancies, OS at 5 years was 58.8%, 67.3% and 55.8%, respectively (p=0.000). Cumulative incidence of relapse of hematological malignancies at day 2,000 in patients surviving >100 days post-transplant was 17.6% with limited cGVHD, 18.4% with extensive cGVHD and 27.1% without cGVHD (P=0.000).Conclusions: This study provides strong evidence of risk factors for developing cGVHD after UR-BMT and suggests that limited cGVHD provides a survival benefit to patients with hematological malignancies by reducing the risk of relapse without increasing the risk of death from cGVHD. There was a significant difference in occurrence of cGVHD between patients <20 and ≥20 years old but no differences comparing any age ≥20 years.

Relationship of Harvest CD34+ and CD3+ Counts To Chronic Graft-Versus-Host Disease (cGVHD), Relapse and Survival Following Sibling Allogeneic Stem Cell Transplant.

G-CSF mobilized peripheral blood stem cells are increasingly used as a source of cells for sibling allogeneic transplantation. In comparison with bone marrow transplants (BMT), peripheral blood stem cell transplants (PBSCT) have been associated with increased chronic graft-versus-host disease (cGVHD). In order to examine the relationship between CD34+ and CD3+ counts and the development of cGVHD, we analyzed the outcome of patients from an international database of nine randomized trials comparing PBSCT and BMT. There were a total of 1111 patients: 305 patients developed extensive cGVHD, 261 limited cGVHD, 368 had no cGVHD and 177 did not have adequate information concerning cGVHD for analysis. We excluded patients with limited cGVHD because this can be a difficult diagnosis to make with certainty. We also excluded those without adequate data and thus the analysis is based on 673 patients (305 with extensive cGVHD and 368 with no cGVHD). There was no common baseline hazard for the development of extensive cGVHD among studies and thus the analysis was stratified by study. The primary outcomes were time to development of extensive cGVHD and time to the composite endpoint of death or relapse. Harvest CD34+ and CD3+ counts were analyzed as dichotomous variables based on the median cell counts. In the PBSCT group, the median CD34+ and CD3+ counts were 6.05 and 288.01×106/kg and in the BMT group, the median CD34+ and CD3+ counts were 2.89 and 32.79×106/kg respectively. As previously reported, there was an increased risk of developing extensive cGVHD with PBSCT compared to BMT (hazard ratio 1.77, 95% CI 1.39–2.23). The time to develop extensive cGVHD was not affected by the CD34+ or CD3+ count within either the PBSCT or BMT group. In addition, the composite endpoint of death or relapse was also not affected by either the CD34+ or CD3+ count in the PBSCT group. However, in the BMT group, a higher median CD3+ count was associated with an increased risk of death or relapse (p=0.04). Furthermore, a higher median CD34+ count was associated with a trend to a decreased risk of death or relapse (p=0.09). In summary, we confirm the higher risk of developing extensive cGVHD with PBSCT compared to BMT. In this analysis, we did not find a relationship between CD34+ and CD3+ counts and the risk of extensive cGVHD within either the PBSCT or BMT groups. However, our analysis suggests an association between higher median CD3+ counts and an increased risk of death or relapse in the BMT group. If this observation is confirmed, further studies are required to determine whether the higher CD3+ cell content of the marrow graft exerts a direct effect on the risk of relapse or death, or whether it is a surrogate for a less effective marrow harvest.