Morphologic Evidence Of Disease Research Articles

High Dose Cyclophosphamide and Pre-Treatment Disease Burden Dictate Response and Survival in a Multicenter Clinical Trial Using CD19-Specific CAR T Cells for Relapsed/Refractory B-ALL

Background: CD19-specific chimeric antigen receptor (CAR) T cells have demonstrated significant clinical impact in patients with relapsed or refractory (R/R) B-cell acute lymphoblastic leukemia (B-ALL). Several factors have been implicated in successful application including conditioning chemotherapy, CD4/8 ratio, CAR T cell expansion, and persistence. We undertook a multi-center clinical trial to test the feasibility of exporting this technology to other centers, determine the toxicity following infusion, and establish requisite factors for optimal response.Methods: Pediatric and young adult patients with R/R B-ALL were treated with CD19-specific CAR (19-28z) T cells. Patients received cyclophosphamide based conditioning chemotherapy prior to infusion of CAR T cells.Results: A total of 25 pediatric/young adult patients were treated with 19-28z CAR T cells. Based on conditioning chemotherapy 17 patients received high dose (3000mg/m2) cyclophosphamide (HD-Cy) and 8 patients received low dose (1500mg/m2) cyclophosphamide (LD-Cy) prior to CAR T cell infusion. Among evaluable patients (n = 24) complete response (CR) was demonstrated in 94% and 38% for HD-Cy vs LD-Cy cohorts respectively (p=0.01). Overall survival was significantly longer in the HD-Cy cohort as compared to the LD-Cy cohort (median survival = 585 days vs. 138 days; p=0.004) - Figure 1. Based on disease status at time of CAR T cell infusion 14 patients had minimal residual disease (MRD; <5% blasts in bone marrow) and 10 patients had morphologic evidence of disease (≥5% blasts in bone marrow). Complete response was 93% (13/14) and 50% (5/10) in the MRD and morphologic cohort respectively (p=0.05). Overall survival was significantly longer in the MRD cohort as compared to the Morphologic cohort (median survival = 585 days vs. 129 days; p=0.01) - Figure 2. Minimal residual disease as assessment by multi-parameter flow cytometry was assessed for all responders and was achieved by 89% of responding patients (16/18). MRD-negative status in the cohort subsets included 93% (14/15) in HD-Cy cohort, 66% (2/3) in LD-Cy cohort, 92% (12/13) in MRD cohort, and 80% (4/5) in Morphologic cohort. The rate of CR did not differ significantly when analyzed by target dose, fludarabine as part of conditioning chemotherapy, or ex-vivo fold growth of CAR T cells during production. Expectedly, CAR T cell peak and persistence correlates with response as measured by q-PCR and/or flow cytometry in the peripheral blood or bone marrow. The most common treatment-related adverse events were cytokine release syndrome (CRS) and neurotoxicity consistent with finding previously reported. Overall, CRS of any grade occurred in 80% patients (20/25) with severe CRS (grade III/IV) occurring in 20% (5/25) of patients treated. Neurologic symptoms of any grade occurred in 72% (18/25) with severe neurotoxicity (grade III/IV) occurring in 24% (6/25) of patients treated. All toxicity was reversible and was managed with supportive care and/or immunomodulation (IL-6R blockade or corticosteroids).Conclusions: The use of HD-Cy or treatment with low disease burden positively correlated with complete response and overall survival for pediatric/young adult patients with R/R B-ALL treated with CD19-specific CAR T cells. [Display omitted] DisclosuresCurran:Juno Therapeutics: Research Funding; Novartis: Consultancy. Kernan:Gentium: Other: Received grants from Gentium during the conduct of the study and research was supported by The National Cancer Institute of the National Institutes of Health under award number P30 CA 008748, Research Funding. Park:Amgen: Consultancy. Smith:Juno Therapeutics: Membership on an entity's Board of Directors or advisory committees, Patents & Royalties: BCMA targeted CAR T cells, Research Funding. O'Reilly:Atara: Patents & Royalties, Research Funding. Brentjens:Juno Therapeutics: Consultancy, Membership on an entity's Board of Directors or advisory committees, Patents & Royalties, Research Funding.

9. Next generation sequencing for myeloid neoplasms: a diagnostic management team approach

The hematopathology Diagnostic Management Team (DMT) utilizes decision-support algorithms to guide test ordering for bone marrow biopsies. Although next-generation sequencing (NGS) testing is commonly available for myeloid malignancies, there is little guidance on optimal utilization in the diagnosis and management of these diseases. We have incorporated marrow morphology into DMT algorithms for NGS testing, recommending testing only if there is morphologic evidence of disease at diagnosis or first presentation, transformation, or relapse. To evaluate the effectiveness of this approach, testing outcomes were evaluated to determine the percentage of positive tests and the number and type of mutations in marrows that were morphologically positive or negative for disease.

A Single Arm, Phase II Study of Eltrombopag to Enhance Platelet Count Recovery in Older Patients with Acute Myeloid Leukemia Undergoing Remission Induction Therapy

IntroductionIn AML patients (pts) undergoing 7+3 induction chemotherapy (IC), incomplete platelet (plt) recovery can lead to increased risks of bleeding, prolonged dependence on plt transfusions, plt alloimmunization, and can hinder post-remission therapy. Eltrombopag is a thrombopoietin receptor agonist that stimulates megakaryopoiesis and has anti-leukemic effects (Erickson-Miller 2008; Will 2009; Roth 2012). We present results of an interim, prespecified analysis of an ongoing trial [ClinicalTrials.gov Identifier: NCT02071901] evaluating the efficacy of eltrombopag in accelerating plt count recovery in older AML pts (>60 years) receiving IC.MethodsAll newly diagnosed AML pts >60 years (yrs) with ECOG scores of 0-2, no active second malignancy, and no evidence of marrow fibrosis at the time of AML diagnosis were included. Acute promyelocytic leukemia, acute megakaryocytic leukemia, and AML out of myeloproliferative neoplasms were excluded. IC consisted of an anthracycline (daunorubicin at 45_mg/m2 or idarubicin at 12 mg/m2 x 3 days) and infusional cytarabine (100 mg/m2 x 7 days). Eltrombopag was administered starting day 15 (range, day 15-18) of IC in pts who had no morphological evidence of disease (marrow blasts <5%) on day 14 (range, day 14-17). The primary endpoint was the proportion of pts achieving plt>50000/µL by day 24 of IC. Eltrombopag was administered at a dose of 200 mg (100 mg for East Asian [EA] pts) daily with a one-time maximal dose escalation to 300 mg daily (150 mg in EA pts) if plt remained<50,000/µL after 2 weeks on treatment. Eltrombopag was discontinued once plt exceeded 100,000/µL. A two-stage accrual design with a maximum accrual goal of 31 eligible pts was employed with early stopping if>5 of 12 initial eligible pts (42%) failed to achieve plt>50,000/ µL by day 24. Informed consent was obtained prior to start of IC.ResultsBetween 9-2014 and 6-2016, 34 pts were consented of whom 13 met the eligibility criteria. Reasons for failing eligibility (21/34 pts, 62%) included >5% blasts on day 14 marrow (n=15); acute clinical worsening (n=3); marrow fibrosis at AML diagnosis (n=1); active second malignancy (n=1); and elevated transaminases (n=1). Characteristics of the study cohort were: 54% females, 1 pt of EA heritage, median age of 64 yrs (range, 60-71), and 75% with good ECOG status (ECOG 0 or 1). Most pts (62%) had de novo AML, 38% had secondary AML (therapy-related or prior MDS). By CALGB criteria, 82% had intermediate cytogenetics, 9% had adverse karyotype and in 9% cytogenetic analysis was unsuccessful. The median eltrombopag treatment duration was 10 d (range, 8-14 d), and no dose escalations were required. Pts received a median of 4 units of plt (range, 3-11), which equated to 1 unit every 3.6 d, during induction, while during the eltrombopag treatment period, the median requirement decreased to 2 units (range, 0-6) or 1 unit every 4.8 d (p=.04). Pts were transfused with a median of 7 units of red blood cell (RBC) (range, 3-17; 1 unit every 2d) during induction, while on eltrombopag, the median RBC unit transfusion requirement decreased to 4 (range,1-7; 1 unit every 3.6 d) (p=.02). 92% of pts achieved CR at a median time of 32.5 d from IC (range, 29-42). One pt had incomplete CR due to poor ANC recovery. Median times from the start date of IC to plt>20,000/µL,>50,000/µL, and>100,000/µL were 19 d (range, 15-24), 24 d (range, 21-33), and 25 d (range, 23-33), respectively. By day 24 of IC, 8 of 13 pts (62%) had plt>50,000/µL. Trends in the levels of hemoglobin, absolute neutrophil count (ANC), and plt count over time along with median eltrombopag start and stop times are shown in Figure 1. The median peak plt count reached on eltrombopag was 719,000/µL (range, 280-1,935,000/µL). The median time to reach peak plt count from start date of eltrombopag was 19 d (13-28 d). The reported toxicities were all grade 1/2 and included nausea (n=2), decreased vision (n=1), elevated transaminases (n=1 each), and one each with hypokalemia and hypomagnesaemia.ConclusionsOur interim analysis suggests that eltrombopag can hasten plt recovery, potentially reduce plt transfusions and increase CR rates in older AML pts undergoing IC without any limiting toxicities.The initial cohort does not show evidence for acceleration of the leukemic process and progression stopping milestones were not reached. The study met its interim objectives and is currently accruing pts. [Display omitted] [Display omitted] [Display omitted] DisclosuresMukherjee:Celgene: Consultancy, Honoraria, Research Funding; Ariad: Consultancy, Honoraria, Research Funding; Novartis: Consultancy, Honoraria, Research Funding.

B acute lymphoblastic leukemia with t(14;19)(q32;p13.1) involving IGH/EPOR: a clinically aggressive subset of disease

B acute lymphoblastic leukemia (B-ALL) with t(14;19)(q32;p13.1), in which IGH and EPOR are juxtaposed, has been reported rarely. We describe the clinicopathological features of six patients, three men and three women, with a median age of 39 years. Initial and follow-up bone marrow samples were examined from each patient. The clinical, morphologic, and immunophenotypic results were compared with data obtained from conventional cytogenetic analysis and by using home-brew fluorescence in situ hybridization (FISH) probes for IGH at 14q32 and EPOR at 19p13.1. The bone marrow specimens were hypercellular (median 90%; range 80–100%), with a median blast count of 90% (range 60–93%). Immunophenotypic analysis performed by flow cytometry demonstrated a stable, precursor B-cell immunophenotype. The t(14;19)(q32;p13.1) was present in all cases with morphologic evidence of disease. The translocation was stable and appeared morphologically subtle on conventional karyotypic analysis. Detection was facilitated using FISH, which confirmed IGH/EPOR rearrangement in all cases. All patients received aggressive multiagent chemotherapy as part of a variety of regimens. Four of six patients achieved an initial complete remission, but all relapsed. At last follow-up, five of six patients had died of disease (median survival, 12 months after diagnosis). We conclude that B-ALL associated with t(14;19)(q32;p13.1) is a distinctive form of disease that is associated with younger patient age and an aggressive clinical course.

Liposome-encapsulated doxorubicin citrate (Myocet) for treatment of recurrent epithelial ovarian cancer

The aim of this study was to assess the clinical activity and toxicity of liposome-encapsulated doxorubicin citrate (Myocet) in a retrospective multicenter cohort of epithelial ovarian, primary peritoneal, and tubal cancer patients. Records of patients with recurrent epithelial ovarian, primary peritoneal, and tubal cancer treated with liposome-encapsulated doxorubicin citrate (60 mg/m on day 1 of a 21-day cycle) after failure of more than one previous regimen were reviewed. Fifty-three patients were evaluated for efficacy and toxicity. The median age of the patients was 59 (range 39-73). The median follow-up was 6 months (range 1-17). One patient (1.9%) showed a complete response and 13 patients (24.5%) showed a partial response, yielding an overall response rate of 26.4% (14/53 patients). Clinical benefit was achieved in 36 patients (67.9%). The median progression-free survival (PFS) for the entire study population was 4.0 months (range 1.0-14.8). The median PFS for platinum-sensitive and platinum-resistant patients was 4.0 months (ranges 1.0-14.8 and 1.0-9.4, respectively; P=0.652). The median overall survival from the start of liposome-encapsulated doxorubicin citrate was 10.0 months. Multivariate survival analysis showed no association between the liposome-encapsulated doxorubicin citrate line of treatment or platinum sensitivity to PFS in age and BRCA status-adjusted models. Only 11.3% of patients experienced grade 3-4 hematologic toxicities, 80% grade-2 alopecia, and 50% grade-1-2 fatigue. No other grade-4 toxicities, no significant cardiac events, or hand and foot syndromes were reported. Liposome-encapsulated doxorubicin citrate was well tolerated, with a good response and high clinical benefit rate. Further evaluation in a larger prospective cohort is warranted.

Flow Cytometric Evaluation Of Minimal Residual Disease In Adult Acute Lymphoblastic Leukemia Using a Simplified, Single-Tube Approach

▪Flow cytometry for detection of minimal residual disease (MRD) in acute lymphoblastic leukemia (ALL) has been widely used in pediatric patients to quantify therapeutic response and to assess the risk of relapse. Flow cytometry for MRD provides roughly the same level of sensitivity (0.01%) as molecular methods but at lower cost and with faster turnaround time. MRD assessment in ALL currently requires an evaluation of 20 or more parameters divided among multiple tubes.In part due to the assessment complexity, the use of flow cytometry for MRD detection in adult ALL patients has been relatively limited. We developed a 6-color, single-tube, flow cytometry assay to detect MRD in bone marrow (BM) aspirate specimens from adult ALL patients. The 73 patients included 52 patients with B-ALL (71%), 19 patients with T-ALL (26%) and 2 patients with T/myeloid leukemia (3%) and were treated with one of several standard chemotherapeutic regimens or targeted therapies. Patients were tested for MRD by flow cytometry after induction or re-induction therapy and serially thereafter. The 6-marker MRD panel was customized for each patient based on the 18-20-marker diagnostic immunophenotype.Sixty-three percent of B-ALL patients (n=33) had lymphoblasts with an aberrant immunophenotype; expression of a myeloid marker (e.g., CD13, CD15 or CD33) was the most common aberrancy. The remaining 37% of B-ALL patients (n=19) had disease with a hematogone immunophenotype, which comprised surface expression of CD10, CD19, CD20, CD34, CD38 and CD45; in the majority of these cases, leukemic cells were distinguishable from normal hematogones based on the intensity of surface marker expression. Forty-seven percent of T-ALL patients (n=9) had an aberrant immunophenotype, most often characterized by CD33 expression.One-hundred forty-six consecutive specimens analyzed for MRD by flow cytometry were classified as positive (23%), negative (72%) or uncertain (5%). Of the 34 samples classified as positive, 14 (41%) showed morphologic (i.e., BM aspirate or biopsy) evidence of disease; nineteen (65%) samples did not show morphologic evidence of disease and 1 sample did not have a concurrent morphologic assessment. Of the 105 samples classified as negative by flow cytometry, 103 (98%) were also negative by morphology and 1 sample did not have a concurrent morphologic assessment. One sample that was negative by flow cytometry had morphologic evidence of disease in the biopsy (10-20% blasts) but not the aspirate, suggesting that aspirate sampling artifact was responsible for the discrepancy. None of the 7 samples classified as uncertain by flow cytometry had morphologic evidence of disease; five out of 7 uncertain classifications were in B-ALL patients with hematogone immunophenotypes. Overall, MRD flow cytometry showed 86% concordance with the results of morphologic assessment.We evaluated outcomes in all patients with negative morphologic results and any positive MRD flow cytometry result(s). Of the 73 patients in this study, 61 had morphology-negative results that were either MRD-negative (n=45) or MRD-positive (n=16). Patients in this group were at various points of treatment post-induction or re-induction. Four out of 45 patients (9%) with MRD-negative results relapsed during a median follow-up period of 22 months, and 8 out of 16 patients (50%) with an MRD-positive result relapsed during a median follow-up period of 15 months (odds ratio for relapse 10.3, 95% confidence interval 2.5-42.4, P=0.001). In addition, relapse-related and overall mortality (Figure 1) were higher in patients with MRD-positive results (P=0.0023 and P=0.0016, respectively, by the log-rank test).In summary, we present a simplified, single-tube, flow cytometry assay that can be used to detect MRD in adult ALL at relatively low cost with rapid turnaround time; our approach was applicable to cases with either hematogone or aberrant immunophenotype, yielding a definitive result in 95% of cases. Notably, the presence of MRD was associated with relapse and mortality, suggesting that our method of MRD assessment could be used to guide treatment of adult ALL. Further analysis of the correlations between MRD results, clinical management and patient outcomes is ongoing.▪ Disclosures:No relevant conflicts of interest to declare.

A 2 Step Approach To Myeloablative Haploidentical Hematopoietic Stem Cell Transplantation (HSCT): Low Non-Relapse Related Mortality (NRM) and High Overall Survival (OS) Rates Confirmed In Second Generation Trial

Over 7 years ago, we developed a 2 step myeloablative approach to haploidentical HSCT in which patients, after conditioning with 12 Gy of total body irradiation (TBI days -9 to -6), receive a fixed dose of 2 x 108/kg of donor T cells (DLI-step 1 of HSCT) immediately after the last fraction of TBI. This large dose of haploidentical lymphocytes results in high fever, and in some cases, diarrhea and rash, developing on days-5 and -4. Cyclophosphamide (CY) 60 mg/kg, given on days -3 and -2 for T cell tolerization, results in complete resolution of this “alloreaction.” Tacrolimus and MMF are begun on day-1, followed by a CD 34 selected donor product infused on day 0 (Step 2 of HSCT). The separation of the lymphoid and myeloid portions of the graft (1) avoids the exposure of allogeneic stem cells to CY, (2) avoids the polarization of T cells to a TH2 phenotype because the donor T cells are collected prior to the initiation of G-CSF, (3) allows the administration of a fixed dose of T cells establishing a consistent platform from which to compare outcomes, and (4) provides a method to deliver higher doses of T cells. Recent data suggests that T cell doses > 1.1 x108/kg are associated with superior GVT effects as compared to lower T cell doses (Guo et al. JCO, 2012;30:4084 and Colvin et al. BBMT, 2009;15:421). To date, over 180 patients have undergone 2 step haploidentical myeloablative and reduced intensity HSCT at our institution. In the initial myeloablative haploidentical trial (2006-2009), twenty-seven patients underwent treatment using this approach. Immune reconstitution was brisk with median CD3/4 and CD3/8 counts at day +28 of 33.6 and 28.7 cells/ul respectively Cumulative incidences of grades III-IV graft versus host disease (GVHD), NRM, and relapse-related mortality were 7.4%, 22.2%, and 29.8% respectively. OS for the 12 patients without disease at HSCT was 75% and 48% for the whole cohort with 51-79 (median 63) months of follow-up.A 2nd generation myeloablative 2 step trial specific to patients without morphologic evidence of disease at the time of their haploidentical HSCT completed accrual in 2013. Twenty-eight patients with AML (15), ph+ ALL (4), B cell ALL (4), T cell ALL (2), MDS (1), mantle cell NHL (1), and hepatosplenic NHL (1), were treated and are 3-32 (median 14) months post HSCT. All patients engrafted and no patients died of GVHD or infection. Median CD3/4 and CD3/8 counts at 28 days were 74 and 47 cells/ul respectively. The only death related to treatment occurred in a patient who suffered a subdural hematoma after an LP performed for fever. Four patients have relapsed (14%), 3 of whom have died of their disease. The probability of OS of the patients treated on the current trial is 85% at 15 months. The combination of the most recently treated 28 patients with the 12 patients treated on the initial trial who were in morphologic CR at the time of HSCT, has resulted in a probable OS rate of 78% with 3 to 79 (median 18 months of follow-up).For patients without morphologic evidence of their disease at the time of HSCT, the 2 step myeloablative approach to haploidentical HSCT has been associated with robust immune reconstitution resulting in low rates of infectious death. There have been no deaths from GVHD, and very low rates of treatment-related mortality. OS rates of the good risk patients treated on this approach are very high due to this low degree of NRM. The results of this 2nd generation trial have confirmed that the 2 step myeloablative approach to haploidentical HSCT is safe and efficacious and produces outcomes that are comparable to those reported by CIBMTR (2000-2010) for recipients of matched related or other alternative donor grafts. This approach has become our alternative HSCT strategy of choice allowing virtually every patient to be treated with HSCT rapidly at our institution. Disclosures:Kasner: Roche: Research Funding.

Incidence and Kinetics Of Full Donor Chimerism and The Impact Of Minimal Residual Disease Status Following Outpatient Non-Myeloablative Allogeneic Stem Cell Transplantation For Myeloma

BackgroundChimerism analysis is routinely performed following allogeneic haemopoietic stem cell transplantation (allo HSCT) as a means of monitoring donor engraftment and relapse risk, although its role in the management of allografted myeloma patients is controversial. Multiparameter flow cytometry (MFC) assessment of minimal residual disease has been demonstrated to predict outcome following myeloblative autologous stem cell transplantation (ASCT) in multiple myeloma (MM). Relapse and disease progression is the principle cause of allograft failure and the detection of minimal residual disease (MRD) following tandem autologous/non-myeloablative(NMA) allo HSCT may potentially identify patients at risk of early relapse and provide a platform for early post-allograft therapy designed to further cytoreduce or enhance alloreactive T cell function and graft versus myeloma effect. AimTo evaluate the impact of MRD assessment performed at 3 months post-allo HSCT on PFS and OS and document the incidence and kinetics of full donor chimerism (FDC) in a cohort of myeloma patients undergoing tandem ASCT/outpatient non-myeloablative (NMA) allogeneic HSCT for MM. MethodsRetrospective analysis of 33 MM patients referred to our centre for tandem ASCT/outpatient NMA HSCT between May 2008 and December 2012. Patients were transplanted as part of their front line management (upfront) (n=18) if they had one or more high risk disease features (poor prognosis cytogenetics/FISH abnormalities, elevated LDH, stage III disease or less than a PR following a novel agent-containing induction regimen) or as a ‘deferred' procedure (n=15), if relapsing/progressing after an initial ASCT and maintenance/consolidation. Allo HSCT was undertaken as an ambulatory procedure and conditioned with oral fludarabine 48mg/m2 on days -4 to -2 and 2Gy TBI on day 0 followed by donor stem cell infusion, with a target CD34 dose of 2 x 106/kg and T cell dose of 3 x 108/kg. Sequential peripheral blood monitoring of CD3+ and CD33+ donor-specific chimerism was performed on days 30, 60, 90, 180 and 365 following allo HSCT. Bone marrow samples were collected for MRD analysis using MFC incorporating a CD56/CD19/CD45 panel following CD38/CD138 gating on plasma cells. MRD assessment was performed every 3 months during the first 12 months, 6 monthly during the second year and annually thereafter. ResultsThe median age for the entire cohort (M 19, F 14) was 52 years (range 39-65) and the analysis performed after a median follow up of 719 days (50-1733). All patients were transplanted using matched sibling (20/33) or unrelated donors (13/33). Non-relapse mortality was 0% at 1 year and 6% overall. At the time of analysis, 26 (79%) patients were alive including 15 (45%) in CR. The median PFS for all patients was 2.8 years and although the median OS for the entire cohort has not been reached, the estimated probability of overall survival at 4 years is 67% (95% CI: 38-85%). 29/33 (88%) patients had MRD assessments performed at least once post-allo HSCT and 4 patients progressed within 3 months prior to MRD evaluation. At the first 3 month assessment, 11/29 (38%) were MRD +, 12/29 (41%) were MRD – , results were unavailable in 3/29 (10.5%) and 3 (10.5%) patients had morphological evidence of disease. Patients achieving MRD negativity at 3 months had superior PFS in comparison to those who remained MRD positive (median 2.81 years v 1.02 years; p=0.01) but this has yet to translate into an OS advantage. The MRD + patients transplanted as a deferred procedure (n=6) had a median PFS of less than 6 months (0.47 years), suggesting this subset of patients have a particularly poor outcome, although overall numbers are insufficient to directly compare outcome according to MRD status and transplant timing. 30 (91%) patients achieved FDC (16 and 14 in the upfront and deferred groups respectively) with 2 patients not assessed. The median time to FDC for the entire cohort was 180 days (range 30-730) and there was no significant difference according to transplant timing or relationship between FDC and MRD status, GVHD, PFS or PS. ConclusionThe majority of patients undergoing outpatient-based tandem ASCT/NMA allo HSCT for myeloma achieve FDC. MRD status as assessed by MFC at 3 months post-allo HSCT appears to predict PFS and may be a useful early trigger for additional post-allograft therapy, particularly in patients with high risk disease or those transplanted later in their disease course. Disclosures:Spencer:Celgene: Honoraria, Membership on an entity's Board of Directors or advisory committees.

Superior Graft-versus-Leukemia Effect Associated with Transplantation of Haploidentical Compared with HLA-Identical Sibling Donor Grafts for High-Risk Acute Leukemia: An Historic Comparison

The outcomes of an historic comparison of 117 consecutive, high-risk, acute leukemia patients undergoing hematopoietic stem cell transplantation (HSCT) from HLA-mismatched/haploidentical donors (HID, n = 81) or HLA-identical sibling donors (ISD, n = 36) without the use of in vitro T cell depletion (TCD), between the period of January 2005 and April 2009 were compared. Full engraftment was achieved in 98% of patients in the HID group and 97% in the ISD group. The cumulative incidences of grades II-IV acute graft-versus-host disease (aGVHD) in the HID and ISD cohorts were 49% and 24%, respectively (P = .014) with a relative risk (RR) of 2.99 (1.25-7.21) (P = .014). The incidence of chronic GVHD (cGVHD) did not differ significantly between the 2 cohorts. The 2-year cumulative incidence of relapse was significantly lower in HID (26%) than in ISD patients (49%) (P = .008). The 2-year cumulative incidence of nonrelapse mortality (NRM) was comparable in recipients of HID (34%) and ISD grafts (38%) (P = .85). The 3-year probability of overall survival (OS) was higher in HID patients (42%) than in ISD (20%) (P = .048) patients. Our comparisons suggest that HID transplants can achieve a stronger graft-versus-leukemia (GVL) effect than ISD for high-risk acute leukemia patients.

Clinical response and miR-29b predictive significance in older AML patients treated with a 10-day schedule of decitabine

A phase II clinical trial with single-agent decitabine was conducted in older patients (>or=60 years) with previously untreated acute myeloid leukemia (AML) who were not candidates for or who refused intensive chemotherapy. Subjects received low-dose decitabine at 20 mg/m(2) i.v. over 1 h on days 1 to 10. Fifty-three subjects enrolled with a median age of 74 years (range, 60-85). Nineteen (36%) had antecedent hematologic disorder or therapy-related AML; 16 had complex karyotypes (>or=3 abnormalities). The complete remission rate was 47% (n = 25), achieved after a median of three cycles of therapy. Nine additional subjects had no morphologic evidence of disease with incomplete count recovery, for an overall response rate of 64% (n = 34). Complete remission was achieved in 52% of subjects presenting with normal karyotype and in 50% of those with complex karyotypes. Median overall and disease-free survival durations were 55 and 46 weeks, respectively. Death within 30 days of initiation of treatment occurred in one subject (2%), death within 8 weeks in 15% of subjects. Given the DNA hypomethylating effect of decitabine, we examined the relationship of clinical response and pretreatment level of miR-29b, previously shown to target DNA methyltransferases. Higher levels of miR-29b were associated with clinical response (P = 0.02). In conclusion, this schedule of decitabine was highly active and well tolerated in this poor-risk cohort of older AML patients. Levels of miR-29b should be validated as a predictive factor for stratification of older AML patients to decitabine treatment.

Systolic Heart Failure in a Patient With Hypertrophic Obstructive Cardiomyopathy

Systolic Heart Failure in a Patient With Hypertrophic Obstructive Cardiomyopathy

Early Onset of Lysosomal Storage Disease in a Murine Model of Mucopolysaccharidosis Type VII: Undegraded Substrate Accumulates in Many Tissues in the Fetus and Very Young MPS VII Mouse

Lysosomal storage diseases (LSDs), due to deficiency of a lysosomal enzyme, are inherited, progressive disorders that are often fatal during childhood. The mucopolysaccharidoses (MPS) are LSDs caused by deficiency of a lysosomal enzyme needed for the stepwise degradation of glycosaminoglycans. A murine model of MPS VII shares many clinical, biochemical, and pathologic features with human MPS and has proved valuable for the study of the pathophysiology of MPS and for evaluation of therapies for LSDs. Early therapy of MPS VII mice, initiated in the first weeks of life, is much more effective in decreasing clinical and morphologic evidence of disease than treatment begun in mature animals. Whether such early therapy decreases existing storage or prevents its accumulation is incompletely investigated. We performed an analysis of storage in very young MPS VII mice to define the extent of disease at and before the time of initiation of early treatments. MPS VII pups from 12 days postcoitus (dpc) to 31 days postnatal (dpn) were studied. Storage accumulated in fixed tissue macrophages in the liver and cartilage as soon as 12 dpc and was present in central nervous system glia, leptomeninges, and perivascular cells by 15 dpc. Osteoblast and primitive neocortical cell storage was apparent at 18 to 19 dpc. At 2 dpn, lysosomal distention appeared in circulating leukocytes. Abundant lysosomal storage was present in many sites by 14 dpn. Secondary accumulation of beta-hexosaminidase paralleled increasing glycosaminoglycan storage. These results confirm the presence of widespread storage even in utero and in the very young MPS VII mouse and highlight the importance of early treatment to prevent storage accumulation.

Enhanced coronary vasoconstrictive response to serotonin subsides after removal of dietary cholesterol in atherosclerotic monkeys.

Constriction in response to serotonin is enhanced in the coronary arteries of atherosclerotic monkeys. The main objective of the present study was to determine whether abnormal responses to serotonin in atherosclerosis are reversed following removal of dietary cholesterol. In addition, we examined the effect of an atherogenic diet and reduction in dietary cholesterol on vascular responses to activation of ATP-sensitive K+ channels with aprikalim. Diameters of small coronary arteries were measured on the epicardial surface of the left ventricle in vivo by using stroboscopic illumination synchronized to the heart cycle to visually freeze the motion of the heart. Diameters were measured with a microscope-video system during topical application of two vasoconstrictor agonists, serotonin and the thromboxane mimetic U46619, and the vasodilator agonists aprikalim and nitroprusside. Responses were compared in normal (n = 9), atherosclerotic (n = 14; high-cholesterol diet), and regression (n = 8; high-cholesterol diet followed by normal diet) monkeys. Constriction of coronary arteries in response to serotonin was enhanced in monkeys on an atherogenic diet and was normal in regression monkeys. Vasoconstriction in response to U46619 and vasodilation in response to nitroprusside and aprikalim were not altered by atherosclerosis. Thus, abnormal vascular responses to serotonin in small coronary arteries of atherosclerotic monkeys without morphological evidence of disease can be reversed to normal by reducing dietary cholesterol.