Median ANC Research Articles

Levels of Nrf2 and Keap1 Are Associated with Poor Prognostic Features In Myelodysplastic Syndromes (MDS)

AbstractAbstract 1874 Background:Cellular metabolism and oxidative stress are important in the biology and pathophysiology of hematologic malignancies. Limited studies are available regarding metabolic pathways, including production of reactive oxygen species (ROS), and biology and pathogenesis of MDS. Elevated levels of ROS have been described in other leukemias, linked to increased levels of antioxidant molecules and activation of pathways that protect cells from the oxidative stress. The Nuclear erythroid 2 related factor 2 (Nrf2), Kelch-like ECH-associated protein 1 (Keap1) - Antioxidant Response Element (ARE) complex is the main signaling pathway involved in oxidative stress. Nrf2 is a transcription factor that induces expression of antioxidant responsive genes like heme oxygenase-1, catalase, glutathione dismutates and superoxide dismutase. With low oxidative stress, Nrf2 is associated with Keap1 in the cytoplasm and is continuously degraded by the E3 ubiquitin ligase complex. Keap1 contains multiple cysteine residues that are modified by oxidation to accelerate Keap1 dissociation from Nrf2, allowing Nrf2 to enter the nucleus and bind to ARE. In MDS, high levels of ROS have been described related to iron overload. We studied expression of Nrf2 and Keap1 in newly diagnosed, untreated patients with MDS to correlate with clinical features, pathogenesis, and clinical outcomes. Methods:24 newly diagnosed pts with MDS and 4 normal donors were evaluated for Nrf2 and Keap1. CD34+ cells were sorted from pts and normal donor bone marrow. RNA was isolated using standard protocols and cDNA was obtained by reverse transcriptase using the Invitrogen SuperScript® One-Cycle cDNA Kit. Nrf2 and Keap1 expression were analyzed by qRT-PCR using Applied Biosystems Real-Time PCR 7900 and SYBR® GreenER™ Reagent System from Invitrogen. Patient clinical and clinical-laboratory characteristics, including IPSS, blood counts, bone marrow features, serum ferritin were used for analysis. Patients were followed for time-to-event endpoints, including time to transformation to AML and survival, dated from initial sample collection. Results:The median pt age was 70 years (range 37–82); 62.5% were male. The median % bone marrow (BM) blast count was 4.5% (range 1–25). Low-risk cytogenetics by metaphase karyotype was noted in 13%, intermediate-risk in 67%, and high-risk in 21%. According to the IPSS scoring system, 25% had high-risk, 17% Int1, 37% Int2, and 21% had low-risk MDS. Bone marrow was hypercellular in 18/24 (75%) pts; 87% for males and 56% for females. The median ANC was 1579/mL (range, 90–17061); hemoglobin was 9.4 gm/dL (range, 6.4–13); and platelet was 63.5/mL (range, 9–1040). The median ferritin level was 859 ng/mL (range, 24–14564); 15/21 (71.4%) had ferritin levels higher than the normal range. The mean relative Nrf2 transcript level was 0.167 (range, .001-.69) vs. 0.004 for normal donors P= 0.147 and the mean relative Keap1 transcript level was 0.014 (range, .003-.05) vs. 0.008 for normal donors P= 0.54. Increased bone marrow (BM) blast was associated with higher Nrf2 transcript level: 7/10 (70%) pts with BM blasts >10% presented higher Nrf2 levels. Increased ferritin level was associated with presence of int-poor cytogenetic features(10/24). The median follow-up time is 11 months (range, 1–43); transformation to AML occurred in 5 pts and overall 18 patients have died. The median survival time is 11 months. There was a trend for shorter survival or Time To Transformation (TTT) associated with higher Nrf2 (median 6 months vs 14 months p=0.328) and higher Keap1 transcript levels (median 6 months vs 14 months p=0.45), although not statistically significant. Conclusions:CD34+ cells from bone marrow of patients with MDS have higher transcript levels of Nrf2 and Keap1 than normal donor CD34+ cells consistently with data reported in the current licterature for other hematological malignancies, such as CLL and AML. One of the reasons could be the activation and the integrity of Nrf2 signaling in MDS in response to high ROS levels. Among patients with MDS, there was a trend for shorter survival associated with higher Nrf2 and Keap1 transcript levels. These findings suggest that Nrf2/Keap1 signaling may play an important role in the pathophysiology of MDS and merit further investigation and must be confirmed in larger numbers of patients with MDS and normal donors. Disclosures:No relevant conflicts of interest to declare.

Association Between Elevated Hemolysis at Diagnosis and Early Mortality and Risk of Thrombosis In Paroxysmal Nocturnal Hemoglobinuria (PNH) Patients with Cytopenia

AbstractAbstract 4241 Introduction:PNH is a rare, progressive and life threatening disease driven by chronic hemolysis leading to thrombosis, renal impairment, pain, severe fatigue, poor quality of life and premature death. Thrombosis is the leading cause of death (accounting for 40–67% of PNH-related deaths) and was recently identified as a significant risk factor for mortality in Asian PNH patients. Abdominal pain is a common and distressing symptom in PNH and has also been found to be risk factor for thrombosis and mortality in PNH patients. In PNH patients with concomitant aplasia/cytopenias (PNH-cytopenia), the symptoms associated with hemolytic PNH (i.e., severe fatigue and anemia) may be attributed to a hypocellular marrow, potentially masking the life threatening risk of hemolysis-mediated thrombosis and abdominal pain. Here we evaluate the correlation of clinical risk factors with hemolytic symptoms in cytopenic PNH patients. Methods:We retrospectively analyzed medical charts of 286 PNH patients from the National Data Registry in South Korea to identify aplastic PNH patients with evidence of hemolytic symptoms at the time of diagnosis. We defined PNH-cytopenia patients with evidence of at least 2 of the following hematological values at diagnosis: Hgb <10 g/dL; ANC <1.5×109/L; thrombocytopenia <100×109/L. Hemolysis was defined as LDH °Ã1.5 fold above the upper limit of normal (ULN). Results:The median patient age was 37 years (range: 8 to 88 years) and median PNH duration was 7.8 years. At diagnosis, median PNH granulocyte clone was 49% and LDH was 3.9-fold above ULN. Median platelet count was 99×109/L and median ANC was 1.2×109/L, 21% with ANC <1.0×109/L. PNH-cytopenia was identified at diagnosis in 42% of PNH patients. PNH-cytopenic patients experienced a similar prevalence of hemolytic symptoms and mortality compared to PNH patients with no evidence of cytopenia (PNH) (see table below). Thrombosis was equally prevalent in PNH-cytopenia compared to PNH (12% vs18%; P=0.175). Abdominal pain was equally prevalent in PNH-cytopenia and PNH (52% vs 42%; P=0.112) and there was similar mortality between the 2 groups (13% vs 11%; P=0.631). There was a significantly higher prevalence of mortality (14% vs 4%; p=0.048), thrombosis (22% vs 4%; p=0.003) and abdominal pain (53% vs 32%; p=0.007) in patients with elevated hemolysis (°Ã LDH 1.5 above ULN) compared to patients without hemolysis. We found that 69% of PNH-cytopenia patients demonstrated elevated hemolysis at diagnosis. Thrombosis was identified in 17% of PNH-cytopenia patients with elevated hemolysis compared to 3% with no evidence of elevated LDH (p=0.051); abdominal pain (59% vs 32%; p= 0.012) and death (16% vs 3%; p=0.070) were higher in PNH-cytopenia patients with hemolysis compared to PNH-cytopenia patients without hemolysis.CONCULSION: These data demonstrate that the presence of hemolysis at diagnosis is associated with of life-threatening thrombosis, poor quality of life, and mortality in PNH patients. Despite the evidence of hypoplasia, PNH-cytopenia patients with hemolysis demonstrate a higher risk of life-threatening thrombosis, pain, and mortality. These data indicate that hemolysis is a potential risk factor for life- threatening complications independent of the presence of cytopenia in patients with PNH. Treatment for PNH patients with cytopenias should focus on both controlling hemolysis as well as improving hypoplasia. Disclosures:No relevant conflicts of interest to declare.

P80 Antiviral therapy in HCV cirrhotic patients: early on-treatment haematological parameters and genotype predict response

IntroductionPegylated interferon-a (Peg-IFN)+ribavirin (Riba) is standard of care for treatment of chronic hepatitis C (CH-C). Antiviral therapy is recommended in those with compensated disease and lower rates of treatment responses...

Concomitant pemetrexed/carboplatin chemotherapy with 3-D conformal radiotherapy followed by pemetrexed/carboplatin consolidation chemotherapy in locally advanced non-small cell lung cancer in a Chinese population

e18502 Background: Pemetrexed in combination with carboplatin has been shown to have promising activity, as well as superior toxicity profile in advanced non-small cell lung cancer(NSCLC). Radiotherapy(RT) has been shown to improve survival of patients with locally advanced NSCLC when combined with other platin doublets. This phase II study of concomitant pemetrexed/carboplatin chemotherapy(CT) with 3-D conformal RT followed by pemetrexed/carboplatin consolidation CT in locally advanced NSCLC was designed to evaluate the efficacy and safety of this novel regimen. This report presents preliminary information of 10 patients who have completed treatment. Methods: 10 chemoradiation (CRT)-naive and stage IIIA or IIIB (not effusion) with KPS≥80 patients were included in this study between February 2008 and October 2008. Patients received pemetrexed 500 mg/m2, carboplatin AUC 5 CT repeated q3 weeks for 2 cycles concomitant with RT and 3 cycles of consolidation pemetrexed (500 mg/m2) and carboplatin (AUC=5) q3 weeks. Median total dose of RT, without elective nodal irradiation, was 62 Gy (range: 60-66 Gy) with 2 Gy daily fractions. Results: 1 (10%) and 8 patients (80%) had a complete or partial response respectively, while 1 patient(10%) had progression of the disease(brain metastases). The overall response rate (90%,95% confidence interval (CI): 68%-97%) exceeded the goal per study design. After concomitant CRT, the main toxicity was neutropenia, with a median ANC nadir of 1.6, three patients had Grade 3 neutropenia, One patient had Grade 4 neutropenia. Grade 3 thrombocytopenia was seen in one patient, grade 3 esophagitis in one patient and grade 3 radiation pneumonitis in one patient. Consolidation CT was not administered to 3 patients- one due to the development of brain metastases during the first month after chemoradiation, one due to patient refusal and one due to grade 3 radiation pneumonitis. Conclusions: This preliminary data suggests that concomitant treatment was well tolerated, with promising activity and a significant improvement of QoL in a Chinese population with locally advanced NSCLC. No significant financial relationships to disclose.

Optimal Thalassemia Free Survival and Minimal Regimen Related Toxicity in 50 Consecutive Transplants of High Risk Beta Thalassemia Pediatric Patients Using Myelablative Therapy with Intravenous Busulphan.

In the developed world, the survival and quality of life of patients with beta thalassemia (Bthal) has dramatically improved with optimization of blood transfusions and iron chelation. By contrast, in countries with limited resources most affected children die before the age of 20 because of the unavailability of safe blood products, expensive iron chelating drugs and inadequate management of co-morbidities. For these patients allogeneic stem cell transplantation (SCT) from matched donors offers a cure with low morbidity and mortality. Between June 2005 and May 2008, 47 consecutive Bthal patients underwent SCT from an HLA identical sibling in our center, among these, 3 patients underwent 2 SCTs. Median age was 8 years (2–15), country of origin: Lebanon (9), Iraq (19), Palestine (3), Syria (16). One pt was classified as Lucarelli class I, 24 as class II and 22 as class III. Most patients had severe iron overload evidenced by irregular iron chelation (83%), median ferritin 2973 (956–14280), median liver iron concentration 22 mg Fe/g (6.9–95.7). Most patients had liver toxicity due to iron overload and hepatitis evidenced by median ALT 71 (12–545), AST 59 (18–371), liver fibrosis Ishak 3 (0–5), HepC pos 16/47 (34%). Patients had inadequate transfusional management evidence by a median pre-transfusion Hb of 8 g/dL and anti HLA antibodies in 81% pts. Class I-II patients were conditioned with a regimen based on iv busulphan (iv Bu, Busilvex®, dosage according to weight, adjusted from the 5th dose to a target AUC 1200 umol/min) and cyclophosphamide (Cy) 200mg/kg (n19) with the addition of thiotepa (TT 10mg/kg) if <4 years (n6). Class III pts received a preconditioning based on hydroxiurea and azathioprine followed by fludarabine (Flu) 100mg/m2, iv Bu and Cy 160mg/kg (n6) or, from April 2007, Flu 150mg/m2, iv Bu, Cy 160 mg/kg and Atg (Thymoglobuline®) 7,5mg/kg (n16); patients receiving a 2nd SCT following graft rejection (n3) received preconditioning followed by Flu 150mg/m2, iv Bu, Cy 200 mg/kg, TT 10 mg/kg and Atg Sangstat 7,5mg/kg. Anti seizure prophylaxis consisted of clonazepam; due to liver disease all patients received anti VOD/SOS prophylaxis with oral defibrotide 40 mg/kg. GVHD prophylaxis consisted of cyclosporine A (CyA) and short course methotrexate, in addition methylprednisolone for 30 days was given to pts not receiving ATG. Thirtythree patients (66%) achieved Bu AUC in the expected range of 900–1500 umol/min following the 1st dose. Seventeen patients (34%) required dose adjusted because either above (n9) or below (n8) the expected range. The source of stem cells was unmanipulated bone marrow from an HLA identical sibling; median CD34 cells were 8x10^6/kg (3.3–19), CD3+ cells 73x10^6/kg (36–117). Fourtyseven patients engrafted with donor cells with median ANC take on day 19 (12–39) and median PLT take on day 17 (13–54). Three class III patients had primary graft failure, among these 2 reconstituted with autologous cells and 1 died in aplasia. Post transplant toxicity was mild and characterized by: hemorrhagic cystitis (n4), reversible CyA related posterior encephalopaty (n3), VOD/SOS (n1), grade II-IV stomatitis (n7), reversible lung infiltrates of unknown origin (n4), CMV reactivation requiring preemptive treatment (n23), FUO in aplasia (n33), MOF and death (n1). The incidence of acute GvHD II-IV was 5/47 evaluable patients (4 grade II, 1 grade III). Limited chronic GvHD was observed in 3/47. At a median follow-up of 528 days (112–936), 46/47 patients (98 %) are alive with a 100% Lansky score. Current thalassemia free survival is 94% of which 100% in class I-II pts and 86% in class III. In conclusion, in this population of high risk thalassemic it is recommended to perform Bu pharmacokinetic studies to avoid excessive toxicity or ineffective myeloablation. With appropriate dose adjustment, a myeloablative conditioning based on iv Bu resulted in limited regimen related toxicity and excellent thalassemia free survival in patients affected by Bthal coming from countries with limited resources.

Spontaneous Recovery and Normalization of Blood Neutrophil Counts in Young Children with Severe Chronic Neutropenia

Severe chronic neutropenia is a general term used to organize and study the inherited and acquired diseases causing blood neutrophils to be less than 0.5 × 109/L for months, years or a lifetime. The inherited or congenital disorders include severe congenital neutropenia (SCN) (the autosomal recessive form often called Kostmann syndrome), cyclic neutropenia, Shwachman-Diamond syndrome, Barth syndrome, myelokathexis or WHIM syndrome, and several other rare conditions. The genetic bases for many of these conditions are now known and the molecular, cellular and pathophysiological mechanisms are rapidly being discovered. The acquired disorders are less well characterized and include the immune, autoimmune and idiopathic neutropenias of childhood and adults. These disorders are often confused with the inherited disorders, particularly early in life. In 1994, the Severe Chronic Neutropenia International Registry (SCNIR) was established to study the causes, consequences, and treatment of severe chronic neutropenia with offices in Seattle WA, USA and Hannover, Germany. The total enrollment in the SCNIR-Seattle is currently 1100; 289 children (age less than 33 months at enrollment) and 811 patients (age greater than 33 months at enrollment). Of the 289 children, 119 were diagnosed with either idiopathic or autoimmune neutropenia. This analysis describes twenty children (8 male, 12 female, current age 3.6 to 16.6 years) with clinical diagnoses of idiopathic (11), autoimmune (5), cyclic (3), and congenital (1). These patients were enrolled in the SCNIR, followed with or without treatment of granulocyte colony stimulating factor (G-CSF), and spontaneously normalized their blood neutrophil counts. The median ANC for this population prior to G-CSF treatment was 0.263 × 109/L (range 0.061 to 0.926). All 20 patients had a pre G-CSF bone marrow examination read by a referring hematologist or pathologist and normal cytogenetics. In 15 patients there was normal maturation of the myeloid line. Five patients had “maturation arrest” at the myelocyte (1), metamyelocyte (1), or band (3) stage of neutrophil development. None were described as having early stage “maturation arrest” as is characteristically observed in SCN patients.Neutrophil recovery was defined by an increase in blood neutrophils to 2.0 × 109/L. Two patients had only mild symptoms and did not receive G-CSF before recovery occurred. The other 18 patients were treated with G-CSF, (median dose 1.375 mcg/kg/day, range 0.192 to 4.839 mcg/kg/day; duration median months 24.18, range 0.07 to 102.27 months). Before recovery, these 18 patients responded to G-CSF with an increase in the median ANC to 3.151 × 109/L, (range 0.120 to 14.553 × 109/L, all counts on G-CSF). All were reported to have diminution of recurrent fevers, mouth ulcers, and infections with G-CSF therapy. The daily dose during the first year of G-CSF treatment was positively correlated to the length of treatment: A low initial daily dose corresponded to less time to resolution (r=0.529; p=0.024). A similar relationship existed between a narrower dose range and the length of time a patient was neutropenic. Variability of dosing for this population ranged from 0.045 to 3.354 mcg/kg/day. Low variability between the highest and lowest doses was correlated to less time to resolution (r=0.66; p=0.0029). After recovery, the median ANC for 12 of the 18 patients was 3.337 × 109/L (range 2.181 to 9.282 × 109/L); the referring physicians reported normalization of blood cell counts in the other 6 cases, but did not submit documentation of these counts. No relapses and no evolution to myelodysplasia or leukemia (MDS/AML) have been reported with up to 8 years of follow-up for patients in this report. Similarly, the other 103 young children in the SCNIR with a diagnosis of idiopathic or autoimmune neutropenia have not transformed to MDS/AML. A retrospective review suggests that the patients in this report who were identified as having a diagnosis of cyclic or congenital neutropenia were probably misdiagnosed.These data confirm previous reports that spontaneous remissions may occur in children with idiopathic and autoimmune neutropenia. The data suggest that a normal marrow, normal cytogenetic analysis and response to a low dose of G-CSF are predictors of future recovery. In this patient group, treatment with G-CSF should be individualized and reserved for patients with a history of recurrent fevers and infections.

Mobilization, Harvesting and Transplantation of Peripheral Blood Stem Cells in Patients with Severe Refractory Systemic Lupus Erythematosus - A Single Center Experience.

The prognosis for patients with severe refractory systemic lupus erythematosus (SLE) is poor; High dose chemotherapy with hematopoietic stem cell support is a salvage treatment under investigation for these patients. In our center, 17 patients with severe refractory SLE received autologous peripheral blood stem cells transplantation (PBSCT); Peripheral blood stem cells were mobilized with cyclophosphamide 4g/m2 and granulocyte colony-stimulating factor (G-CSF) 5 μg/kg/day. Enough PBSC were collected in all patients. There's no mobilization-related mortality, while 3 patients developed active lupus after mobilization which was controlled by slightly increasing the dosage of steroids. Following conditioning with cyclophosphamide 6g/m2 plus anti-thymocyte globulin (ATG, 20mg/kg/d, 5 days), cryopreserved PBSC (mean MNC 4.28×108/kg and CD34(+) cell 2.48×106/kg) were infused. Median ANC and platelet engraftment time were days +11 and +12 after transplantation, respectively. Treatment related complications include mucositis (14/17), infection (12/17), liver malfuction (10/17), edema or/and heart failure (3/17), renal failure (2/17), bleeding (5/17); One patient died from cerebral hemorrhage. Median follow-up is 22 months (9–28 months); All the patients improved with the SLEDAI score reduced from 25.2±6.6 before to 9.7±1.2 3 months after transplantation; Steroids were stopped or maintained at very low dose (equal to 5 to 7.5 mg/d predinisone). One patient had overt lupus relapse 8 months following transplant Conclusions Mobilization, harvesting and transplantation of peripheral blood stem cells in patients with severe refractory systemic lupus erythematosus is safe; The short-term result of the approach is effective in this group of patients; More patients needed to enroll a control study to validate the role of high-dose chemotherapy/PBSCT as the salvage treatment for severe SLE.

Y-90 Ibritumomab Tiuxetan as Consolidation Following Three Cycles of Fludarabine-Cyclophosphamide-Rituximab Chemoimmunotherapy in Patients with Relapsed Follicular, Indolent or Mantle-Cell Lymphoma: A Prospective “Dose”-Finding Study.

BACKGROUND: Tumed sequential treatment with fludarabine/cyclophosphamide/rituximab (FC-R) followed by Y-90 ibritumomab tiuxetan (IT) radioimmunotherapy may improve progression-free survival in patients (pts) with CD20+ NHL. However, even unpretreated pts submitted to four to six cycles of a fludarabine-containing combination and then IT at an Y-90 activity of 15 MBq/kg will experience severe prolonged, transfusion-dependent and only partially reversible pancytopenia, thus limiting its use in a non-curative setting (Jurczak et al., ASH 2005).AIM: We report on a trial including anthracycline-pretreated pts with relapsing CD20+ lymphoma > age 50 and unsuitable for myeloablative treatment. These received 3 cycles of FC-R. If at least stable disease was achieved and neutrophil as well as platelet counts had normalized (2.5 vz. 150/nl) within 8 weeks, this was immediately followed by IT at 11 or 15 MBq/kg Y-90 activity. Primary endpoint was the rate of dose-limiting toxic events (DLT) induced by consolidation IT as a function of Y activity employed. DLT was defined as NIH-CTC grade 4 neutropenia or thrombocytopenia for > 14 days or non-hematological toxicity of > grade 2 for > 7 days. Per level of activity, a maximum of 1 DLT episode occurring in two cohorts of 3 pts was considered acceptable.RESULTS: We recruited 21 patients into the trial (10 follicular, 9 mantle cell, 2 other). Median age was 70 years, all were stage III/IV and median no. of pretreatments was 1 (range 1 to 3). 9 had marrow involvement (< 25%), and 7 elevated LDH. 8 pts went off treatment before IT, mostly because of persistent cytopenia or progression. 13 received IT. Pt characteristics in this subcohort were comparable to the baseline cohort. Hematologic nadirs occurred at median 6 weeks post-IT. Median ANC nadir was 0.45/nl, with 1 pt in the 11 MBq and 2 in the 15 MBq activity level sustaining grade 4 neutropenia of > 2 weeks duration. Median PLT nadir was 26/nl. Grade 4 thrombocytopenia was found in only 1 pt at the 15 MBq level (duration 10 days) who did not require transfusion. Median ANC and PLT counts normalized by week 12, one showing persistent otherwise unexplained thrombocytopenia. Non-hematological toxicitiy including fever or infections was rare and < grade 3. No correlation was found with extent/type of pretreatment, baseline cell counts or presence of marrow involvement. With median 8 months follow-up, 1 has so far improved remission status to CR, and 1 pt in stable disease and 1 in PR before IT have progressed.CONCLUSIONS: In order to avoid neutropenia grade 4 of > 2 weeks duration, IT following 3 cycles of FC-R should be performed at an Y activity level of 11 MBq/kg. Nevertheless, the possibly higher incidence of prolonged severe neutropenia following IT at 15 MBq does not translate into a higher rate of infections or persistence of neutropenia and may therefore be regarded safe.

MDS with Isolated Neutropenia or Thrombocytopenia. Incidence and Characteristics in the Groupe Francophone des Myélodysplasies (GFM) Registry.

Background: MDS classification is regularly refined over time. WHO classification (2001) puts emphasis on cases with anemia and isolated dyserythropoiesis, as opposed to multilineage dysplasia, while the next modifications to WHO classification will probably consider cases with isolated or predominant granulocytic or thrombopoietic involvement.Methods: In this context, we analyzed cases of IN and IT included in the GFM registry of MDS.Results: From Jul 2003 to Jul 2007, 1009 newly diagnosed MDS patients (including 145 therapy MDS, and excluding CMML,) from 11 centers were included in the GFM registry. 22 of them (2%) presented with neutropenia (ANC <1.5×109/l) (IN) and 24 (2.4%) with thrombocytopenia (plts<100×109/l) (IT) as only cytopenia, respectively. IN included 13 F and 9 M and IT 17 F and 7 M. Median age was 70 years (range 54-89) in IN, and 72 years (range 50-84) in IT. Median ANC was 0.89×109 (range 0.14-1.48×109) in IN, and median platelet count 62×109 (range 7-99×109) in IT. According to WHO (2001), IN included 5 RA (diagnosis based in 4 pts and 1 pt on prominent unilineage dyserythropoiesis and unilineage dysmegacaryopoiesis respectively, and elimination of other causes of anemia, as karyotype was normal in all 5 pts), 1 RCMD, 8 RAEB-I, 2 RAEB-II, 1 patient with 5q- syndrome (with Hb=12.5g/dl), 1 unclassified MDS with marrow hypocellularity (of 39 U -MDS in the registry,) and 4 therapy-related MDS. IT included 13 RCMD, 7 RAEB-I, 4 RAEB-II. Cytogenetic findings were: for IN: good risk: 15 (normal: 13, del 5q, -Y), intermediate: 2 (+8), poor: 1, cytogenetic failure: 4 ; for IT: good risk: 13 (normal: 12, del 20q:1), intermediate: 5 (del 2, del3p,+8, del 9+t(9;14), del11+del13p), poor: 2, cytogenetic failure: 4. IPSS was: For IN: low (5), Int-1 (7), Int-2 (5), High (1) patients (4 ND); For IT: low (7), Int-1 (9), Int-2 (4) and High (0) (4 ND). Median follow-up of IN and IT was 23 months (range 2-48 mos). 5 IN pts progressed to AML and 4 of them died, 1 IT pt progressed to AML and 2 died.Conclusion: IN and IT are rare in MDS, predominate in females, contrary to overall MDS, and are widely distributed in the current WHO classification. IT was always associated with multilineage dysplasia, and/or excess of marrow blasts contrary to some IN, which were therefore more difficult to diagnose, especially as karyotype was usually normal. Follow-up in the GFM registry is still limited to evaluate the prognosis of IN and IT. These findings are to be considered if new specific MDS categories are to be individualized.

Gemtuzumab Ozagamicin Is Well Tolerated as Post-Consolidation Therapy in Childhood AML.

The NOPHO-AML 2004 protocol includes a post-consolidation randomization to Gemtuzumab ozagamicin, (GO, Mylotarg) or no further therapy. Randomization is offered to all standard-risk patients and to high-risk patients without a donor for SCT. GO is administered as a 2-hour infusion of 5 mg/m2 at least four weeks after the last consolidation including high-dose cytarabine and etoposide (HA2E). GO is repeated following a scheduled interval of three weeks. By August 2007 a total of 45 patients have been randomized (39 with standard-risk and 6 with high-risk AML). An additional nine patients were eligible but not randomized due to clinical decision (n=2), parental refusal (n=6), or administrative error (n=1). Twenty-three were randomized to receive GO. Detailed toxicity data were available from 21 of these patients. The median age was 3 years (six patients less than 2 years of age) at the time of GO. The median interval from HA2E to first GO was 32 days (range 27 – 43). The median interval from first to second GO was 22 days (range 20 – 28). All randomized patients received the second GO except one who relapsed shortly after the first infusion. No major events were reported in relation to the infusion. ALAT showed a slight elevation from a median baseline of 64 U/L to a median peak of 82 U/L and bilirubin increased from a median baseline of 5 μmol/L to a median peak of 8 μmol/L; highest value 25 μmol/L. No patients showed signs of VOD. No significant decrease in hemoglobin was observed whereas all patients became severely leukopenic (median nadir WBC 0.6) and neutropenic (median nadir ANC 0.1). Recovery to ANC > 0.5 lasted a median of 14 days (range 0 – 21). Fever needing antibiotic treatment occurred following 8 of 40 GO courses. None of the infectious episodes were life-threatening. Only a modest decline in platelet count was noted, median nadir 77 (range 10 – 239). Platelet transfusion was given following 5 of 40 GO courses. In conclusion GO infusion was well tolerated without clinical liver toxicity. Severe neutropenia was common but antibiotics were necessary following only 20% of the courses. Thrombocytopenia was modest.

Pegfilgrastim in Congenital Neutropenia: An Observational Survey from the French SCN Registry.

PegFilgrastim is registered in France since 2002. Its pharmacokinetic characteristic allows the possibility to limit the number of injections in patients with congenital neutropenia receiving long term G-CSF therapy. To date, no report has been issued about the outcome of patients with congenital neutropenia receiving this drug. At the cut-off date of July 31th, 2007, 339 patients with congenital neutropenia had been included in the French Severe chronic neutropenia (Severe congenital neutropenia n=142, WHIM n=16, Cyclic n=75; GSDIb n=16 SDS n=90). Eight patients (SCN n=4, Cyclic n=3 and GSDIb n=1) had been identified to receive PegFilgrastim. Median age at PegFilgrastim onset was 18.2 years (min 6.1-max 37.6). In 7 cases, PegFilgrastim was given in the continuation of Filgrastim (n=3) or Lenograstim(4), with a median delay of 13 years after G-CSF onset and in one case, PegFilgrastim was the initial prescription of cytokine. Dose of PegFilgrastim was usually a vial per injection, except in one child (1/2vials) resulting in a dose per injection between 90 and 286 μg/kg per injection. The rhythm of PegFilgrastim injection varied from 1 injection every 7 days until 1 injection every 14 days, with discontinuation period. The median duration (between onset of PegFilgrastim and the last dose) was 0.7 year (min 0.3–2.7). The efficiency measured by ANC criteria appears to better than G-CSF (fig 1: baseline Median ANC 156/mm3, Under G-CSF 501/mm3, Under PegFilgrastim 1901/mm3/ Kruskall Wallis test p=0.02). Severe infection was never reported under PegFilgrastim, but neither in the previous G-CSF therapeutic periods for the 7 patients. More frequent ENT infection was observed in one patient who consider the PegFilgrastim as less efficient than G-CSF. The side effects appeared to be more frequent compare to the G-CSF therapy. Bone pains were reported in 7 patients, anemia and thrombocytopenia (WHO gr II) in one, urticarian chronic skin rash in 3. Finally, at the last update, 7 patients had withdrawn PegFilgrastim, and had resumed G-CSF therapy. Only one patient is still receiving PegFilgrastim. In conclusion, PegFilgrastim appeared efficient in Congenital neutropenia, but more frequent short term side effects were observed compare to standard G-CSF therapy, resulting in a limited quality of life improvement, leading to drug withdrawn in most of the patients. [Display omitted]

Preliminary Results from a Phase I Study of Revlimid® (Lenalidomide) in Combination with Vidaza® (Azacitidine) in Patients with Advanced Myelodysplastic Syndromes (MDS).

Background: Early MDS becomes more advanced as immature myeloid cells proliferate, angiogenesis increases, genetic lesions accumulate, and tumor suppressor genes become inactivated through hypermethylation. Progression to acute myeloid leukemia (AML) may be prevented by targeting these defects through combination therapy, using an immunomodulatory, anti-angiogenic agent, lenalidomide (LEN), and a hypomethylating drug, azacitidine (AZA).Methods: We conducted a multicenter, Phase I trial in patients (pts) with advanced MDS (IPSS score ≥1.5, or FAB or WHO classification with ≥5% myeloblasts) starting in 6/06, with results reported through 7/07. Pts were enrolled using a “3+3” design (See Table), and could not receive LEN or AZA previously. Cycles lasted 28 days, to a maximum of 7 cycles of therapy. The primary endpoint was to determine the maximum tolerated dose (MTD) and dose-limiting toxicities (DLTs, defined as Grade 3/4 non-hematologic toxicity or >50% neutrophil (ANC) or platelet (plt) drop without recovery by Day 56) of the combination. A secondary endpoint was response as defined by the Modified International Working Group.Dose LevelAZA ScheduleLEN Schedule175 mg/m2 SC days 1–55 mg PO days 1–14275 mg/m2 SC days 1–55 mg PO days 1–21375 mg/m2 SC days 1–510 mg PO days 1–21450 mg/m2 SC days 1–5, 8–125 mg PO days 1–14550 mg/m2 SC days 1–5, 8–125 mg PO days 1–21650 mg/m2 SC days 1–5, 8–1210 mg PO days 1–21Results: Seven patients have been enrolled, 6 are evaluable for toxicity data. Median age was 64 years (range 52–70), 1 pt was female, and median follow-up is 5.5 months (range 1.5–13). All pts had RAEB-2; IPSS scores were 1.5 (4), 2.0 (2), and 3.0 (1), with IPSS cytogenetic risk categories of poor (1), intermediate (1), and good (5). No pt had a del (5q) lesion. Median time from MDS diagnosis was 3.5 wks (range 2–106). No DLTs occurred in Dose Levels 1 or 2, and MTD has not yet been reached. Grade 1/2 non-hematologic toxicities (n=6) included fatigue (4), injection site reaction (6), rash (3), pruritis (3), constipation or diarrhea (6), dizziness (1), and mucositis (1). Grade 3/4 non-hematologic toxicities included febrile neutropenia (1). Median ANC drop was 16.4% and plt drop was 10.4%. Although one patient was delayed 1 week in starting cycle 2 for neutropenia, there were no dose-reductions for toxicities. Four pts are evaluable for response: 2 had a complete response, 1 an erythroid response, and 1 progressive disease.Conclusions: The combination of LEN and AZA is well-tolerated and early results suggest efficacy in advanced MDS. Responses and toxicity data from higher Dose Levels will be presented.

A phase I trial of bexarotene, a retinoid X receptor agonist, in non-M3 acute myeloid leukemia

7061 Background: In vitro, bexarotene inhibits the proliferation of non-M3 AML cell lines and induces differentiation of leukemic blasts. This phase I study was designed to evaluate the safety of escalating doses of bexarotene in patients with non-M3 AML and has completed enrollment. Methods: Bexarotene was administered daily until disease progression occurred. Dose escalation occurred in cohorts of 3–6 patients through 6 dose levels ranging from 100–400mg/m2. Results: 27 patients were enrolled: 19M/8F, median age 69 (range 51–82), 13 prior MDS, 12 primary refractory, median number of induction attempts 2, no prior chemotherapy 3, prior autologous stem cell transplant 5, 26 blood transfusion dependent, 18 platelet transfusion dependent, and 20 neutropenic. Despite prophylactic use of antihyperlipidemic agents, 4 patients developed grade ≥3 hypertriglyceridemia. Two patients developed a syndrome reminiscent of retinoic acid syndrome, consisting of dyspnea, pleural/pericardial effusions, and edema in the setting of a rising neutrophil count. This syndrome resolved with stopping bexarotene and initiating steroids. Evidence of activity was noted with bone marrow blasts decreasing to ≤5% in 4 patients. Seven patients showed evidence of neutrophil response (pretreatment median ANC 364/μL, range 28–1,242/μL, treatment ANC 3,540/μL, range 1,200–26,207/μL). Flow sorted peripheral blood neutrophils were collected from 3 of these patients and examined by FISH. Between 92–100% of neutrophils contained the patient's leukemic cytogenetic abnormality suggesting differentiation of the leukemic blasts. Eleven patients with platelet counts &lt;100,000/μL had increases in their platelet counts &gt;20,000/μL (peak range 40- 292x103/μL). Five of these patients with platelet counts &lt;20,000/μL had improvement to 40–91,000/μL and became transfusion independent. Conclusions: Bexarotene is well tolerated at the dose levels studied. Evidence for clinical activity has been seen as exemplified by improvement in platelet counts, increased neutrophil counts and decreased bone marrow blasts. We postulate that bexarotene may induce leukemic blast differentiation in non-M3 AML and represent a novel non-cytotoxic treatment. No significant financial relationships to disclose.

A Novel and Efficient Induction Approach for Accelerated Differentiation and Rapid Hematopoietic Recovery in Acute Promyelocytic Leukemia (APL) Patients by Combining All-Trans Retinoic Acid (ATRA) with Granulocyte-Colony Stimulating Factor (G-CSF).

Background: Despite successful treatment with ATRA and chemotherapy (CT), nearly 10% of APL patients die during early part of treatment because of life threatening complications like bleeding, thrombosis, Retinoic Acid Syndrome (RAS) or infection. This number increases to >20% in most developing countries and presents significant challenge for clinicians. The goal is to develop therapy that rapidly corrects coagulopathy and also normalizes counts. Recent in-vitro data had suggested that G-CSF markedly and selectively stimulates the differentiating effect of ATRA in APL cells without increasing apoptosis. The objective of this pilot study was to evaluate the effect of G-CSF given along with ATRA during induction therapy in patients with APL.Patients and Methods: From 2003, 25 patients (ages 1 yr to 43 yrs; median 24 yrs) with APL ineligible for standard CT were treated on a pilot study with Oral CT: Prednisolone 40 mg/m2/d, Etoposide 50 mg/m2/d & 6TG 40 mg/m2/d (PET) for 21 days as induction therapy along with ATRA (45 mg/m2/d for 90 days) (Blood 2005; 106:900). On completion of oral CT, G-CSF (5 mg/kg/d) was added after day 25 to ATRA in 12 patients in view of persistent cytopenia (low ANC &/or platelets).Results: Patients received a median of 4 doses of G-CSF (range 2–12). The median ANC before starting G-CSF was 0.493 × 109/L (range 0.014–4.21) which increased to a median of 1.78 × 109/L (range 0.525–13.0) post G-CSF (> 1.0 × 109/L in 10/12 patients). Interestingly, platelet count which was < 50.0 × 109/L in 8/12 patients (median 44.15 × 109; range 12–178) prior to G-CSF, increased to > 100.0 × 109/L in all except one patient (median 177 × 109; range 64–357). Comparison of pre and post G-CSF cytogenetic status by FISH showed significant decrease in t (15; 17) positivity post ATRA-G-CSF exposure (78-0; 80-11; 54-10). In rest nine patients the bone marrow cytogenetic studies were done post G-CSF only. Complete morphological, cytogenetic and molecular remission was achieved in 9 patients (75%) at a median of 40 days. None of the patients developed RAS, bleeding or thrombotic complications. Presently all 12 patients continue to be in molecular remission at a median follow-up of 17 months (range 9–35 months).Conclusions: There is still a valuable role of single institutional trials in exploring innovative therapies in APL. Chemotherapy, ATRA and arsenic trioxide, all induce apoptosis which causes over expression of Annexin II, which in turn increases plasmin generation and thrombin generation. However, when G-CSF is used in combination with ATRA, neither proliferation arrest nor induction of apoptosis precedes the differentiation. Thus, use of G-CSF along with ATRA very early in therapy of APL may help to decrease or avoid the early life-threatening coagulation abnormalities. Also, rapid improvement in ANC and platelet count could decrease the other induction complications of infection & bleeding, further improving survival.

Shwachman-Diamond-Bodian Syndrome (SBDS): Long-Term Follow-Up of 31 Patients.

Shwachman-Bodian-Diamond syndrome (SBDS) is an autosomal recessive multisystem disorder primarily affecting the bone marrow, exocrine pancreas, and skeleton. As with other constitutional bone marrow failure syndromes, there is a predisposition to malignant myeloid transformation. The risk can only be estimated and varies considerably in the literature. Significant hematologic abnormalities can be present from early childhood with requirement of growth factor treatment (granulocyte-colony stimulating factor, erythropoietin). Since the first description of mutations in the SBDS gene, most clinically diagnosed patients have been genetically analyzed meanwhile, which now allows for genotype-phenotype correlations. Here, we report long-term clinical data of 31 SBDS patients (10 female, 21 male; 27 patients alive, 3 expired, 1 lost to follow up) with regard to different genotypes collected by the European Branch of the Severe Chronic Neutropenia International Registry since 1994: Severe Neutropenia (ANC <500/μl) is present in 11 patients, of whom 9 receive G-CSF treatment. In 16 of the remaining 22 untreated patients, the median ANC is below 1500/μl. G-CSF doses range from 0.4 to 7.7 μg/kg/day (mean G-CSF dose: 3.15 μg/kg/d). One patient is treated with granulocyte-macrophage colony stimulating factor (GM-CSF). Two of the G-CSF-treated patients have received a combination of G-CSF plus erythropoietin prior to stem cell transplantation. In 4 patients, G-CSF therapy was started within the first year of life, in 1 patient at the age of 20 months, and in 2 patients at the age of 8 and 13 years, respectively. MDS-like leukemic transformation occurred in 2 (1 male/1 female) out of 31 patients (6.5 %) at an age of 5.3 and 7.0 years. Both patients had additional cytogenetic abnormalities (monosomy 7 and complex aberrant karyotype). One patient had received G-CSF for 22 months at a dose of 3.8 μg/kg/d prior to SCT. In the other patient, pancytopenia including severe neutropenia started at the time cytogenetic aberrations were detectable. Both patients received stem cell transplantation (SCT) from unrelated donors (1 MUD, 1 haploident.). 14 months after MUD-SCT the girl is in a good clinical condition with full hematologic reconstitution, whereas the boy died within the first month after haploident. SCT from septicemia. SCT was also performed in 4 non-leukemic patients due to pancytopenia and prior to lung transplantation (2 HLA ident SCT: alive, 2 MUD SCT: 1 alive, 1 expired). SBDS gene analysis has been carried out in 14 of 19 German patients. Ten of 14 patients (71%) were compound heterozygous for 183–184TA>CT/258+2T>C. The rare genotypes 199A>G/258+2T>C, 297–300delAAGA/258+2T>C, and TGC>TGG/258+2T>C were observed in single patients. In another individual, a complex aberration with 7 mutations (Rosendahl et al, 2006) was found. Interestingly, two of the latter four patients presented with severe hematological anomalies early in life. One of them died from SCT after leukemic transformation. The third patient has developed severe osteoporosis and diabetes mellitus type 1. The fourth is on continuous G-CSF treatment. Our data demonstrate the importance of hematologic follow-up and regular cytogenetic evaluation of the bone marrow in SBDS patients. Patients with rare SBDS gene mutations seem to develop a more severe phenotype, but it requires a larger patient cohort for statistical proof.

Low Doses of Thalidomide (Thal) in Low Risk MDS with Transfusion-Dependant Anemia: The GFM THAL-SMD-200 Trial.

Background: Thal has shown some efficacy in low risk MDS, but with dose-limiting toxicity requiring discontinuation in > 50% pts (Bouscary D, BJH , 2005, 131, 609 and other groups). Thus we assessed Thal at lower dose in such MDS.Methods: From Jan 2003 to Oct 2005, we performed a prospective study of low dose Thal in 87 MDS pts with transfusion-dependant anemia (THAL-SMD-200 trial). The first 59 pts received Thal at 200 mg/d, whereas the last 28 pts received 50 mg/d. Responses (IWG) were evaluated at week 12.Results: 48 M and 39 F pts were included. Median age 73.6 years. IPSS Low 34 pts, INT-1 44 pts, INT-2 9 pts. Mean number of RBC units transfused within 2 months of inclusion 6 (2–16). Median ANC, plts, Hb were 1960/μl (0–24160), 164 000/μL (1 000–789 000) and 8,2 (5,1–14,7) resp. 14 (16%) patients had del 5q. Thirty two (37%) pts stopped Thal before week 12, 19 (32%) and 13 (46%) patients in the 200mg/d and the 50mg/d groups resp. Reasons for interruption were: important toxicity in 23 (72%) (mainly dizziness, fatigue, sleepiness), patient's decision in 6 (19%), progression to AML in 3 (9%) and death in 1 (3%). 3 pts developed deep venous thrombosis in the 200mg/d group (none in the 50mg/d group). 55 patients completed 12 weeks of treatment, 22 of them (40%, ie 25% of pts included) had an erythroid response, including 12 major responses (HI-EM) and 10 minor responses (HI-Em). We observed 17 (43.5% of pts who completed 12 weeks, 28% of all pts) and 5 (29.4% of pts who completed 12 weeks, 18% of all pts) erythroid responses in the 200mg/d and the 50mg/d group respectively, not statistically different (p = 0,27). Erythroid response was seen in 15 (44%) patients with IPSS low, versus 6 (14%) in INT-1 and 1 (11%) in INT-2 resp (p = 0.005), whereas no other prognostic factor of response was found. No neutrophil or platelet response was seen.Conclusion: Thal at 200mg/d improved erythropoiesis in 40% of the pts who reached week 12 (28% of included pts). Side effects leading to treatment interruption < week 12 occurred in 32% of pts, ie a similar efficacy and somewhat better tolerance than in our experience with higher doses. Most erythroid responses occurred in IPSS Low pts. On the other hand, Thal at 50mg/d gave a similar incidence of side effects as 200mg/d, with slightly lower but not statistically different erythroid response rate, and thus brought no obvious benefit over 200mg/d. Longer follow up of pts who continued Thal will be presented.

Pediatric Hematopoietic Progenitor Cell Collection and Transplant: Does Pegfilgrastim Represent Progress?.

The particular technical challenges of apheresis in children require the highest quality of stem cell mobilisation. To date, G-CSF remains the reference. The arrival of pegfilgrastim (pegf) theoretically allows the maintenance of an elevated and constant serum level of G-CSF after only one injection.DESIGN: eleven children (2–16 yrs) undergoing chemotherapy for malignancy were consecutively included in a prospective pilot study. Mobilization consisted of one sc injection of 300 μg/kg pegf in haematological steady state. Apheresis was begun once the value of 20 CD34+/μl cells was reached in the blood, or at day 4 after pegf administration.RESULTS: at first apheresis the mean CD34+ cell, mononuclear cell and polynuclear blood counts were respectively 98/μl (12–353), 7.26×109/l (1.0–9.5) and 39.3×109/l (4.6–57.3). The CD34+cell peak level was obtained on day 3 after injection (3–5). The first standard apheresis (less than 3 patient blood volumes) allowed the harvest of more than 5×106 CD34+ cells in 9/11 pts, the median CD34+ cell harvest being 13.5×106/kg (range 1.6–36). On day six after injection, the median ANC was 13.6×109/l. These results were compared to 3 historical prospective cohorts of children who received non-conjugated G-CSF at 10, 20 or 2×12 μg/kg/j, respectively. The four cohorts were not different for age, weight, diagnosis and rounds of chemotherapy. Mobilisation with pegf was more efficient than with G-CSF at 10 μg/kg/d (p<0.001); there were no significant differences between the other regimens. [Display omitted] Tolerance: 8 pts had an elevation of LDH, 3 a hyperuricemia respectively up to 2 times and 1.5 times the upper limit. After reinfusion, polynuclear recovery (ANC>500/μl) was obtained after (median) 11.5 days (11–13); platelet recovery (>20 G/l) was reached on median day 17 (12–20).CONCLUSION: the combination of predictable mobilisation kinetics similar to those of non-pegylated G-CSF, a better acceptance profile together with an efficiency which appears to be at least as good, seems to represent progress in stem cell mobilisation in children. However, sustained blood WBC levels indicating that hematopoiesis has not returned to steady state necessitates a slight delay (at least 7 days) in resuming the chemotherapy program.

A Phase I Trial of Bexarotene, a Retinoid X Receptor Agonist, in non-M3 Acute Myeloid Leukemia: Evidence of Myeloid Differentiation and Clinical Activity.

In vitro, bexarotene has been shown to inhibit the proliferation of non-M3 AML cell lines and induce differentiation of leukemic blasts. This phase I study was designed to evaluate the safety of escalating doses of bexarotene in patients with non-M3 AML. Bexarotene was administered orally daily until disease progression occurred. Prophylactic antihyperlipidemic agents were used in all patients. Six dose levels ranging from 100 to 400mg/m2 are planned. Dose escalation occurred in cohorts of 3–6 patients based on dose-limiting toxicity. Twenty patients have been enrolled in 5 dose cohorts (100–300mg/m2) with enrollment demographics: 13M/7F, median age 69 (range 51–82), 11 prior MDS, 8 primary refractory, median number of induction attempts 2, no prior induction chemotherapy 2, prior autologous stem cell transplant 4, 19 blood transfusion dependent, 13 platelet transfusion dependent, and 16 neutropenic. Consistent with reported toxicity, 2 patients developed hypothyroidism, 7 patients developed grade 2–4 hypertriglyceridemia and 1 patient developed grade 2 pancreatitis. Two patients developed a syndrome reminiscent of retinoic acid syndrome, consisting of dyspnea/hypoxia, pleural/pericardial effusions, weight gain/edema and dry cough in the setting of a rapidly rising neutrophil count. This syndrome resolved within 48 hours of stopping bexarotene and initiating steroids. No CR's were noted, however significant evidence of drug activity were seen. Six patients showed evidence of neutrophil response (pretreatment median ANC 286/μL, range 28–1,037/μL, posttreatment ANC 3,150/μL, range 1,100–27,207/μL). Flow sorted peripheral blood neutrophils were collected from three of these patients and examined by FISH. Between 92–100% of purified neutrophils contained the patient's leukemic cytogenetic abnormality suggesting differentiation of the leukemic blasts. Bone marrow blasts decreased to <6% in 3 patients. Nine patients with platelet counts <100,000/μL had increases in their platelet counts >30,000/μL (peak range 40–292x103/μL). Four of these patients with platelet counts <20,000/μL had improvement in their counts to 40–91,000/μL and became transfusion independent. One patient, with sustained clinical response, had 2 independent leukemic clones (7- and 7q- respectively) and no normal metaphases on bone marrow cytogenetic analysis prior to treatment. After 2 months of treatment, cytogenetic analysis showed 93% normal metaphases and no evidence of the original clones. However, 7% of metaphases consisted of 2 new leukemic clones with multiple cytogenetic abnormalities derived from his original clones. This is suggestive of partial eradication of the original leukemic clones and reestablishment of normal hematopoesis but with clonal evolution of the leukemic clones. Daily oral bexarotene is well tolerated at the dose levels studied to date. Early evidence for clinical activity has been seen as exemplified by improvement in platelet counts, increased neutrophil counts, cytogenetic effects, and decreased bone marrow blast counts. We postulate that bexarotene may work by inducing leukemic blast differentiation in non-M3 AML and may represent a novel non-cytotoxic treatment modality. Patient enrollment is ongoing.

Cytopenias in Patients (pts) with Chronic Myelogenous Leukemia (CML) in Chronic Phase (CP) Treated with Dasatinib (SPRYCEL®): Clinical Features and Management, Including Outcome after Hematopoietic Growth Factor Therapy.

Dasatinib (SPRYCEL®, formerly BMS-354825) is a potent inhibitor of BCR/ABL, SRC, and other kinases with activity in pts with CML in all phases after imatinib failure. Although well-tolerated, dasatinib is associated with cytopenias in some pts, which may be a reflection of rapid elimination of the BCR/ABL(+) clone. We analyzed 122 pts with CML in CP treated with dasatinib at our institution. Thirty-eight (31%) pts developed at least 1 episode of grade 2–4 neutropenia (NP) and/or thrombocytopenia (TP) while on dasatinib; in 35 (29%) this was grade 3–4. Median age of these 38 pts was 55 yrs (range, 19 to 81) and median time from CML diagnosis to dasatinib start was 57 mo (range, 0.5 to 207). Pts had received imatinib for a median of 41 mo (range, 1 to 68); other prior therapies included interferon-α in 23 (61%), homoharringtonine in 6 (16%), farnesyl transferase inhibitors in 4 (11%), and nilotinib and allogeneic stem cell transplantation in 2 (5%) each. Initial dasatinib dose was 70 mg twice daily in 18 (47%), 140 mg once daily in 1 (3%), 50 mg twice daily in 6 (16%), 100 mg once daily in 4 (10%), >140 mg daily in 3 (8%) and < 100 mg daily in 6 (16%). Dasatinib was administered for a median of 57 wks (range, 7 to 140). NP occurred in 29 (24%) pts: grade 2 in 6 (5%), grade 3 in 14 (11%), and grade 4 in 9 (7%). TP occurred in 33 (27%) pts: grade 2 in 8 (7%), grade 3 in 15 (12%), and grade 4 in 10 (8%). Concomitant grade 2–4 NP and TP was observed in 24 (20%) pts (grade 3–4 in 13, 11%). The median time to NP was 59 days (range, 2 to 149) and to TP 28 days (range, 11 to 368). Grade 2–4 NP or TP was recurrent in all but 3 (92%) pts. Grade 2–4 hematologic toxicity occurred within the first 3 mo of therapy in 8 (21%) pts, after 3 mo in 7 (18%), and both before and after 3 mo in 23 (61%). Dasatinib was interrupted at some point due to grade ≥3 NP or TP in 34 (28%) pts. Anemia was observed in 29 (76%) of the 38 pts with grade 2–4 NP or TP; it was grade ≥3 in 5 (13%). Seven pts received G-CSF 300 mcg daily 2–7 days/wk after a median of 59 days (range, 11 to 268) from dasatinib start. G-CSF dose was adjusted to keep an ANC >1.0x109/L. The median ANC at G-CSF start was 0.75x109/L (range, 0.3 to 0.9x109/L). All pts reached ANC >2.0x109/L after a median of 10 days. From dasatinib start to G-CSF start, pts had been off dasatinib a median of 40% of the total treatment time, compared to 24% after G-CSF start (p=0.07). The combination of dasatinib and G-CSF was well tolerated. Of the 7 pts who received G-CSF, 5 were subsequently evaluable for response, and 2 achieved a major cytogenetic response (<35% Ph-positive cells). Three pts with grade ≥3 TP received support with interleukin-11 (IL-11) 10 mcg/kg 3 times per week (in 2 pts while on dasatinib). None of these pts had required platelet transfusion. Two pts reached a platelet count >100x109/L 94 and 125 days after the start of IL-11, respectively, and 1 pt had persistent TP that led to permanent dasatinib discontinuation. Fifteen (39%) pts received EPO and 9 (60%) of them had increments of their Hb levels ≥2 g/dL. In conclusion, cytopenias occur in a significant proportion of pts with CML in CP treated with dasatinib. This complication can be readily managed and can be frequently overcome by using growth factor support, which may allow for a more continuous dasatinib administration.

Lack of necessity of granuloctye-colony stimulating factor (GF) in Hodgkin’s disease (HD) treated with ABVD

7515 Background: DI is important in the therapy of HD, and GF has been used to maintain DI. Recent data suggest that toxicity (bleomycin pulmonary toxicity [BPT]) is higher in patients (pts) who receive GF (JCO 2005;23:7614). We reviewed all HD pts treated since Jan 1996 with attention to GF use, DI, blood counts, BPT and survival. Methods: We analyzed biopsy-confirmed HD pts who received all of their therapy at NU from Jan 1996 to Oct 2005. BPT was defined as: pulmonary symptoms, bilateral infiltrates on scans and no infection. Results: We identified 95 pts, of whom 77 (81%) received ABVD, 7 (7.4%) Stanford V, and 11 (11.6%) other. Of the 77 ABVD pts, 51 completed all cycles with no GF, 23 received GF and 3 are unknown. In the “no GF” group, median age was 31 yrs, 31% had stage III/IV disease (33% Hasenclever Index &gt; 3); 18% had bulky disease, 37% B symptoms and 53% received radiation (RT). In the GF group (n = 23), median age was 33, 42% had stage III/IV disease (21% Hasenclever index &gt; 3); 17% had bulky disease, 42% B symptoms and 50% had RT. Among the 51 “no GF” ABVD pts (287 cycles), median treatment-day ANC were 0.9, while % monocytes were consistently elevated (see Table). There were no dose adjustments or treatment delays for ANC on day of treatment. Normalized DI was &gt; 99% for all treatment days and median cycle duration was 28.6 days (planned = 28 days). 1/51 of these pts had BPT and 2 episodes of uncomplicated neutropenic fever were seen (2/287 cycles = 0.6% incidence). If Stanford V pts are included (n = 7, 2 without and 5 with GF), BPT occurred in 1/53 with “no GF” and 2/28 with GF (see Table). CR rate (100%), PFS and OS were similar in all groups (see Table). Conclusion: 1) GF is not necessary in order to administer ABVD at &gt; 99% DI, and its absence is associated with low toxicity. 2) ABVD should be given at 100% dose with no delay despite ANC on day of treatment. 3) GF should not be used routinely in HD pts treated with ABVD. [Table: see text] No significant financial relationships to disclose.