Peripheral Blood Progenitor Cell Transplantation Research Articles

Long Term Remission of Capillary Leak Syndrome Associated with Monoclonal Gammopathy with Progression to Multiple Myeloma After Autologous Stem Cell Transplantation: a Case Report and Review of the Literature.

Clarkson's disease is a very rare entity characterised by acute episodes of systemic oedema and severe hypotension associated with paraproteinaemia. Its classical treatment relies on methylxanthine combined with terbutaline. Although this prophylactic therapy reduces the mortality rate, relapses are frequent. Eighty percent of patients with Clarkson's disease present with monoclonal gammopathy of unknown significance (MGUS). The risk of progression to multiple myeloma is 1% per year. Here, we present a 49-year-old woman who suffered multiple such episodes requiring treatment in the intensive care unit. Treatment with terbutaline and theophylline was ineffective. She was diagnosed with multiple myeloma (MM) 8 years after the first of these acute episodes. Antimyeloma treatment with bortezomib and dexamethasone was started, followed by autologous haemopoietic transplantation, with no further acute episodes since then. Our case is, to our knowledge, unique because eradication of MM was followed by complete disappearance of acute episodes of capillary leakage. Our case report is also the first to support the use of bortezomib and dexamethasone in this setting. Furthermore, autologous peripheral blood progenitor cell transplantation consolidated the MM stringent complete remission achieving a very long progression-free survival (> 11 years) of both MM and Clarkson's disease.

Multicenter Phase III Trial to Evaluate CD34+ Selected Versus Unselected Autologous Peripheral Blood Progenitor Cell Transplantation in Multiple Myeloma

High-dose chemotherapy followed by autologous transplantation has been shown to improve response rates and survival in multiple myeloma and other malignancies. However, autografts frequently contain detectable tumor cells. Enrichment for stem cells using anti-CD34 antibodies has been shown to reduce autograft tumor contamination in phase I/II studies. To more definitively assess the safety and efficacy of CD34 selection, a phase III study was completed in 131 multiple myeloma patients randomized to receive an autologous transplant with either CD34-selected or unselected peripheral blood progenitor cells after myeloablative therapy. Tumor contamination in the autografts was assessed by a quantitative polymerase chain reaction detection assay using patient-specific, complementarity-determining region (CDR) Ig gene primers before and after CD34 selection. A median 3.1 log reduction in contaminating tumor cells was achieved in the CD34 selected product using the CEPRATE SC System (CellPro, Inc, Bothell, WA). Successful neutrophil engraftment was achieved in all patients by day 15 and no significant between-arm difference for time to platelet engraftment occurred in patients who received an infused dose of at least 2.0 x 10(6) CD34(+) cells/kg. In conclusion, this phase III trial demonstrates that CD34-selection of peripheral blood progenitor cells significantly reduces tumor cell contamination yet provides safe and rapid hematologic recovery for patients receiving myeloablative therapy.

Evaluation of the Role of Plerixafor in Peripheral Blood Progenitor Cell Mobilization and Collection in Autologous Donors with Multiple Myeloma and Non-Hodgkin Lymphoma

Purpose Autologous hematopoietic stem cell transplantation is commonly used as treatment for patients with Multiple Myeloma (MM) or Non-Hodgkin Lymphoma (NHL). The mobilization and collection of peripheral blood progenitor cells (PBPC) to reach the required cell dose for transplantation is problematic for some patients when standard mobilization agents such as G-CSF, alone or combined with chemotherapy, are used. These patients are considered poor mobilizers with < 20 CD34+ cells /μl on the planned day of collection and the optimal strategy to collect a sufficient number of PBPC in poor mobilizers is still not fully known. Plerixafor, a CXCR4 inhibitor, when added to the standard mobilization regimen, has been shown to improve mobilization and increase the probability of collecting a PBPC graft > 2 X106CD34 /kg in standard mobilizers. In our center, Plerixafor became available in October 2012. However, how best to use plerixafor to improve care for poor mobilizers while ensuring the most cost-effective use of health care resources for this patient population remains an important question. To begin answering this question, we evaluated the impact of plerixafor usage in our population of poor mobilizers in our institution using a historical cohort for comparison. Material and method The population of poor mobilizers in the setting of MM or NHL (defined as < 20 CD34 / μl on the planned day of collection) between January 2009 and December 2017 at Hôpital de l'Enfant Jesus (HEJ) du CHU de Québec was retrospectively studied and analyzed. To ensure that all poor mobilizers were included, we screened all flow cytometry CD34+ cell count results < 50 /μl on the planned day of collection and reviewed all the charts of patients with < 20 CD34 / μl regardless of whether they were collected or not. This chart review allowed a comprehensive description of the characteristics of our poor mobilizers, a comparison of the capacity to collect an adequate PBPC with or without plerixafor and to evaluate its impact on different variable with regard to PBPC collection and subsequent engraftment. The data were compiled in an ACCESS database using a retrospective review of digital patient charts. The data was analyzed by the Centre de Recherche du CHU de Quebec (CRCHUQ). Data were stratified by disease type and CD34 level on the planned day of PBPC collection. Results 207 patient charts were reviewed; 70 poor mobilizers with 95 mobilizations attempts, 30 of them using plerixafor, were included. The baseline characteristics of both groups were similar as well as the length of hospitalization for transplant and relapse free survival at one year. The addition of Plerixafor to our management of poor mobilizers did not significantly increase the proportion of patients proceeding to autologous PBPC transplant (80,4 vs 75% p=0,7599). During the mobilization attempts, the maximal CD34 /μl reached was similar in both groups (18,86 vs 15,4 p=0,1541). Plerixafor was associated with a superior collection efficiency (% of CD34 collected) (40,85 vs 60,91% p=0,007), but this can be explained by a greater use of central venous catheters for collection in this group (70 vs 95,1% p = 0,0275). Data stratified by initial diagnosis and CD34 level on the planned day of PBPC collection (<10 c/μl versus [10c/μl - 20c /μl [) showed the same tendency. The collection duration was not significantly reduced in the plerixafor group, but there was a trend for a shorter mean duration of 22 minutes also explained by a greater use of central venous catheters in this group. The preplanned subgroups analyses have shown the same trend when stratified by diagnosis, with a reduction of 53 minutes in the multiple myeloma subgroup with a greater total CFU-GEM / kg per collect (46,35 vs 70,55 p=0,0163). Conclusion The use of plerixafor at HEJ did not improve significantly the proportion of poor mobilizers reaching an adequate PBPC graft and did not improve transplant outcomes compared to a historical control. Better strategies are needed to improve care for true poor mobilizers. The optimal use of plerixafor needs to be further studied. Table. Disclosures Blais-Normandin: Sanofi: Other: unrestricted research grant. Laroche:Sanofi: Other: unrestricted research grant.

Label-free neuroblastoma cell separation from hematopoietic progenitor cell products using acoustophoresis - towards cell processing of complex biological samples

Processing of complex cell preparations such as blood and peripheral blood progenitor cell (PBPC) transplants using label-free technologies is challenging. Transplant-contaminating neuroblastoma cells (NBCs) can contribute to relapse, and we therefore aimed to provide proof-of-principle evidence that label-free acoustophoretic separation can be applied for diagnostic NBC enrichment and removal (“purging”) from human blood and PBPC products. Neuroblastoma cells spiked into blood and PBPC preparations served as model systems. Acoustophoresis enabled to enrich NBCs from mononuclear peripheral blood cells and PBPC samples with recovery rates of up to 60–97%. When aiming at high purity, NBC purities of up to 90% were realized, however, compromising recovery. Acoustophoretic purging of PBPC products allowed substantial tumour cell depletion of 1.5–2.3 log. PBPC loss under these conditions was considerable (>43%) but could be decreased to less than 10% while still achieving NBC depletion rates of 60–80%. Proliferation of cells was not affected by acoustic separation. These results provide first evidence that NBCs can be acoustically separated from blood and stem cell preparations with high recovery and purity, thus indicating that acoustophoresis is a promising technology for the development of future label-free, non-contact cell processing of complex cell products.

Abstract P1-17-08: High-dose chemotherapy and immunotherapy in premenopausal breast cancer patients with more than 10 axillary nodes (PBC+10N). Long-term follow-up of a phase II study

Abstract Background: PBC+10N have a high risk of relapse. Experimental studies suggest that high expression of vascular endothelial growth factor (VEGF) promotes tumor progression through neoangiogenesis and that natural killer (NK) cells mediate lytic activity against cancer cell lines. In a phase I-II study, we have shown that low-dose interleukin-2 (IL-2) and 13-cis retinoic acid (RA) increased NK cells and decreased VEGF, in patients with advanced cancer and a clinical benefit from chemotherapy (Clin Cancer Res 7: 1251, 2001). We assumed that IL-2 and RA, increasing NK and decreasing VEGF, could improve disease-free survival (DFS) and overall survival (OS) in PBC+10N. Primary endpoint was the evaluation of NK cells and VEGF; secondary endpoints were DFS, OS and toxicity. Methods: 34 patients with PBC+10N, after high-dose chemotherapy and peripheral blood progenitor cell transplantation were entered into the study. They were given hormonal therapy if needed and subcutaneous IL-2, 1.8 X 106 IU and oral RA, 0.5 mg/Kg for 5 days/week, 3 weeks/month, until progression. NK cells, VEGF, response and toxicity were assessed every 4 months. Results: After a median follow-up of 120 months (range 69-209), a total of 41 courses of high-dose chemotherapy and 60 courses of immunotherapy were delivered. A statistically significant improvement of NK cells [from a mean of 302 ± 75/mm3 to a mean of 582 ± 72/mm3 (p < 0.001)] and a decrease of VEGF [from a mean of 525 ± 68 pg/mm3 to a mean of 155 ± 13 pg/mm3, (p < 0.001)], were observed. 18-years DFS and OS were 29% and 32%, respectively. A significant improvement, with respect to NCI SEER data (*), was observed in the 5-year OS rate: 55% vs. 6% No WHO grade 3 or 4 toxicity was observed, while grade 2 cutaneous toxicity and fever occurred in 20% and 13% of patients, respectively. Conclusions: Our data show that immunotherapy with IL-2/RA, may determine, with an acceptable toxicity profile, a statistically significant improvement of NK cells, a decrease of VEGF, and better 5-year survival rates with respect to NCI SEER data. Citation Format: Recchia F, Candeloro G, Rea S. High-dose chemotherapy and immunotherapy in premenopausal breast cancer patients with more than 10 axillary nodes (PBC+10N). Long-term follow-up of a phase II study [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P1-17-08.

Feasibility and Cost Analysis of Day 4 Granulocyte Colony-Stimulating Factor Mobilized Peripheral Blood Progenitor Cell Collection from HLA-Matched Sibling Donors

Introduction: Published guidelines recommend mobilization of allogeneic peripheral blood progenitor cells (PBPC) with 4-5 days of granulocyte colony-stimulating factor (G-CSF) followed by PBPC collection on day 5. Given that some autologous transplant patients are adequately mobilized by day 4, and concern that a subset of allogeneic donors may be maximally mobilized before day 5 of G-CSF administration, we performed a feasibility study evaluating day 4 allogeneic PBPC collection.Methods: This single-center prospective study included adult patients with malignant diseases who received a first allogeneic hematopoietic stem cell transplant (HCT) at our center between 7/1/2013 - 6/30/2017. HLA-matched sibling donors received 10 μg/kg of G-CSF subcutaneously prior to PBPC collection. Donors were collected on day 4 of G-CSF if peripheral blood (PB) CD34+ counts were ≥0.04x106/ml. Donors with day 4 PB CD34+ counts <0.04x106/ml were collected on day 5, and those with inadequate collected CD34+ cells/kg recipient weight underwent repeat collection over two days. Patient and donor characteristics, PBPC product composition, transplant outcomes, and cost analysis of the PBPC collection procedure were compared to a historical cohort of donors collected on day 5 according to our prior algorithm.Results: One hundred and one patients/donors were eligible for inclusion on study, and 75 were included in the historical cohort. Of the 101 donors on study, 50 (49.5%) had adequate PBPC collection on day 4 of G-CSF, 26 (25.7%) were collected on day 5, and 25 (24.8%) required two-day collections on days 4 and 5. The median day 4 donor PB CD34+ cell count was 0.06 (range 0.03-0.13) x 106/ml among donors collecting on day 4, 0.03 (range 0.007-0.09) x 106/ml for donors collecting on day 5, and 0.019 (range 0.004-0.04) x 106/ml for donors collecting over two-days (p<0.001).The most common reported donor symptoms were bone pain, myalgia/malaise, headache, and circumoral tingling/electrolyte abnormalities. Compared to the historical cohort, donors with PBPC collection on day 4 were significantly more likely to develop bone pain, require narcotics, and take over-the-counter (OTC) medications, day 5 donors were significantly more likely to develop bone pain and take OTC medications, and two-day donors were significantly more likely to develop bone pain and circumoral tingling/electrolyte abnormalities.The median collected PBPC CD34+ cell count (7.25 x 106/kg recipient weight) and infused PBPC product CD34+ cell count (5.67 x 106/kg recipient weight) were significantly greater in products collected on day 4, compared to products collected on other days. In comparison, the infused PBPC product total nucleated cell (TNC) count (7.13 x 108/kg recipient weight), mononuclear cell (MNC) count (5.84 x 108/kg recipient weight), and CD3+ cell count (2.14 x 108/kg recipient weight) were significantly lower in products collected on day 4 compared to other collection cohorts (p<0.001, p<0.001, and p=0.002, respectively for day 5, two-day, and historical cohort).There were no significant differences in time to neutrophil or platelet engraftment, or in the incidence of acute or chronic graft-versus-host-disease, based on day of collection. There was a non-significant trend towards improved 1-year survival among patients transplanted with PBPC collected on day 4 (p=0.077). Cost analysis revealed a 6.7% savings in direct costs per collection procedure for the day 4 collection method versus historical cohort.Conclusions: Using a day 4 PB CD34+ threshold of ≥0.04x106/ml identifies donors with a high likelihood of adequate PBPC collection. While differences in PBPC product composition and donor symptoms were seen based on day of collection, we found no evidence of adverse post-HCT outcomes associated with day 4 PBPC collection. Day 4 may be the optimal day of stem cell collection for a population of healthy donors without adverse effect on transplant outcomes, and with an anticipated cost savings. Ongoing analyses include resource utilization review, matched cohort analysis of day 4 versus 5 collection and correlation with transplant outcomes, more detailed PBPC production composition analysis among the collection cohorts, and longer post-HCT follow-up and association with outcomes based on day of PBPC collection. These findings merit further analysis in larger HCT cohorts. [Display omitted] DisclosuresCook:Syros Pharmaceuticals: Consultancy. Maziarz:Incyte: Consultancy, Honoraria; Kite Therapeutics: Honoraria; Novartis Pharmaceuticals Corporation: Honoraria, Membership on an entity's Board of Directors or advisory committees, Research Funding; Athersys, Inc.: Patents & Royalties; Juno Therapeutics: Consultancy, Honoraria.

Engineering cord blood to improve engraftment after cord blood transplant.

Umbilical cord blood transplant (CBT) has traditionally been associated with slower engraftment of neutrophils, delayed immune reconstitution and consequently higher risk of infections as compared with peripheral blood progenitor cell (PBPC) or bone marrow (BM) transplants. This is primarily due to low numbers of total nucleated cells (TNCs) and the naive nature of CB immune cells. The use of double unit CB transplant (DCBT) increases the total cell dose in the graft, but it still does not produce as rapid engraftment as seen with PBPC or even BM transplants. Herein, we discuss strategies to improve engraftment after CBT. We describe methods of (I) expansion of CB graft ex vivo to increase the total cell dose; and (II) enhancement of BM homing capability of CB progenitor cells; (III) ex vivo expansion of CB derived T cells for improving T cell function against viruses, tumors and protection from graft versus host disease (GVHD). With these novel approaches, engraftment after CBT is now reaching levels comparable to that of other graft types.

Abstract P6-16-06: Maintenance immunotherapy in estrogen receptor negative (ER-) locally advanced (LA) and/or metastatic breast cancer (MBC). Long-term follow-up of a phase II study

Abstract Background: Cancer immunotherapy is revolutionizing treatment today. While MBC with estrogen receptor positive (ER+) tumors, responding or stabilizing after first line chemotherapy, may have a benefit from a maintenance endocrine therapy combined with the monoclonal antibody bevacizumab, no option exists for ER- patients. In the past, we have shown, that a combination of 13-cis retinoic acid (RA) and interleukin-2 (IL-2) was able to improve the immune function [enhancing lymphocyte and natural killer cell (NK) counts, and CD4+/CD8+ ratio] of cancer patients who had had a clinical benefit from chemotherapy (Clin Cancer Res 2001;7:1251). With the aim of improving the immune function which eventually would lead to improvement of progression free survival (PFS) and overall survival (OS), patients with ER- LA or MBC, with a clinical benefit from chemotherapy, were treated with a combination of IL-2 and RA. Methods: Eligible patients with ER-, LA or MBC, and no evidence of progression after induction chemotherapy received the following immunotherapy: IL-2, (1.8 M UI ), and oral RA (0.5 mg/kg), 5 days/week, 3 weeks/month for 1 year. Therapy was continued, with intermittent schedule until progression. Primary endpoints were the differences in lymphocyte , natural killer cell (NK) counts, and CD4+/CD8+ ratio, secondary end points were progression free survival (PFS), overall survival (OS) and toxicity. Results: From 12/1996 to 04/2009, 74 patients with ER-, LA (49%) or MBC (51%) were entered into the study. Median age was 55 years (range 31-75), 31% of patients were pre-menopausal. Each patient had received a median of 11 courses of first line and salvage chemotherapy regimens (total 850 courses). In addition, 31 patients had received high-dose chemotherapy with peripheral blood progenitor cell transplantation. Disease sites were as follows: soft tissue 54%, viscera 28%, bones 18%. After a median follow-up of 118 months (range 84-232), a total of 374 courses of immunotherapy were delivered. No WHO grade 3 or 4 toxicity was observed; grade 2 cutaneous toxicity and autoimmune reactions occurred in 19% and 16% of patients, respectively. A Statistically significant improvement with respect to baseline values was observed in the number of lymphocytes (p&amp;lt;0.001), NKs (p&amp;lt;0.001), and the CD4+/CD8+ ratio (p&amp;lt;0.01). Median PFS and OS were 44.9 months and 104.8 months, respectively. Conclusions: Maintenance immunotherapy with IL-2 and RA in ER- LA or MBC patients who do not progress after induction chemotherapy is well tolerated, improves lymphocyte, NK, CD4+/CD8+ ratios, and seems to delay disease recurrence. Citation Format: Recchia F, Candeloro G, Rea S. Maintenance immunotherapy in estrogen receptor negative (ER-) locally advanced (LA) and/or metastatic breast cancer (MBC). Long-term follow-up of a phase II study [abstract]. In: Proceedings of the 2016 San Antonio Breast Cancer Symposium; 2016 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2017;77(4 Suppl):Abstract nr P6-16-06.

Immune Reconstitution after Umbilical Cord Blood Versus Peripheral Blood Progenitor Cell Transplantation in Adults Following Myeloablative Conditioning

Immune Reconstitution After Umbilical Cord Blood Versus Peripheral Blood Progenitor Cell Transplantation In Adults Following Myeloablative ConditioningIntroduction: We report on the tempo of immune reconstitution after myeloablative umbilical cord blood transplantation (UCBT, n=61) compared with allogeneic peripheral blood progenitor cells transplantation (PBPCT, n=59).Methods: All patients 18 years or older who underwent first allogeneic transplantation after myeloablative conditioning for hematological malignancies between Jan, 2004 and Dec, 2013 and were alive at 1-year post transplant were included. Patients who received T-cell depletion or antithymocyte globulin were excluded.Results: Overall, the most common diagnosis was acute (83.6% vs 61%) or chronic (3.3% vs. 10.2%) leukemia in UCBT and PBPCT groups, respectively, p=0.07. Median age of UCBT group was 37.2 years vs. 45 years in PBPCT group, p<0.01. The majority of UCBT group (92%) received two units. Almost all patients in PBPCT group (97%) had 6/6- or 8/8-HLA matched sibling donor. More than half of recipients of either UCBT (54%) or PBPCT (51%) were cytomegalovirus (CMV) seropositive. About 97% in both groups received total body irradiation (TBI) for conditioning. Graft-versus-host disease (GVHD) prophylaxis was provided with cyclosporine plus either mycophenolate (UCBT) or methotrexate (PBPCT).The median time to neutrophil engraftment was notably faster in the PBPCT group (15 days, range 10-31) compared with the UCBT group (24 days, range 6-39), p<0.001. All subsets of cells analyzed were significantly lower in the UCBT group for at least first month post-transplant compared with PBPCT group [Figures 1-3]. Natural killer (NK) cells were the first cells to reconstitute in the UCBT group, especially the CD56bright subset, the absolute numbers of which were significantly higher in UCBT than in the PBPCT group from 2 months until at least one year. Similarly, although CD19+ B cells were lower in UCBT group for first month post- transplant, they reached comparable levels to that of PBPCT group at 2-3 months post-HCT and then surpassed the PBPCT group with UCB having significantly higher numbers at 6 and 12-months post-HCT (p<0.05). The absolute numbers of total T cells (CD3+CD56-), CD4+ and CD8+ T cells remain significantly lower in the UCBT group until 3 months, but were then comparable to that of PBPCT group at 6 and 12 months. "NKT" cells (CD3+CD56+) and the naïve T cells (CD4+CD45RO-CD27+) remain significantly lower in UCBT group at all time points tested. The numbers of effector memory (CD4+CD45RO+CD27-) and central memory T cells (CD4+CD45RO+CD27+) were lower for the first three months after transplant, but were then comparable to the PBPCT group thereafter. Regulatory T cells (Tregs; CD4+CD25brightCD127-) were lower in UCBT group for the first 6 months and then comparable to PBPCT group at 12 months.Clinical correlates: Infection density at 1 year (number of infection events/1000 patient days at risk) of bacterial (6.3 vs. 3.7, p<0.01) and viral (5.4 vs 2.2, p<0.01), but not fungal infections (0.27 vs. 0.34, p=0.69) was significantly higher in the UCBT group than in the PBPCT group, respectively. UCBT group had a significantly higher incidence of acute grade II-IV GVHD (75%, 95% confidence interval (CI) 61- 90%, versus 51%, 95% CI 37-65%, p<0.01) and grade III-IV GVHD (33%, 95% CI 21-45%, versus 17%, 95% 7-26%, p=0.03) than PBPCT group respectively. Incidence of chronic GVHD at 2 years was similar in two groups. In univariate analysis, risk of relapse at 3-years was significantly lower in UCBT (19%, 95% CI 9-28%) than PBPCT group (35%, 95% CI 22-48%), p=0.05. There was no difference in overall survival at 3 years (72% vs 66%, respectively, p=0.34).Conclusion: After myeloablative conditioning, UCBT group has significantly delayed neutrophil engraftment and reconstitution of all T cell subsets and NKT cells, compared to that of PBPCT group, which along with a higher incidence of acute GVHD explains higher infection density in the UCBT group. Conversely, rapid recovery of NK and B cells may partly explain lower risk of relapse in the UCBT group. Despite significantly lower numbers of Tregs in UCBT group, risk of chronic GVHD was similar to that of PBPCT group. Ongoing multivariate analysis of the impact of CMV serostatus and other cell subsets on clinical outcomes will provide further answers. [Display omitted] [Display omitted] [Display omitted] DisclosuresMiller:Oxis Biotech Scientific Advisory Board: Membership on an entity's Board of Directors or advisory committees.

Microbial Contamination of Haematopoietic Stem Cell Products: A Single Centre Experience

Bacterial contamination of haematopoietic stem cell products (HSCP) during collection and processing is a potential risk and has been described as cause of serious morbidity and mortality. The rate of contamination is reported in the range of 0 to 4.5% in peripheral blood progenitor cell (PBPC) apheresis to as high as 26% in bone marrow (BM) harvests. Systematic microbiological testing is an important component of the HSCP quality assessment and identification of the bacteria involved helps in the management of early infective complications. Here we report the rate of contaminated HSCP collected in a single transplant centre, our policy of the management of this complication and the relevant clinical outcomes.This is a retrospective study of prospectively collected results of microbiological analyses of 246 collections performed from January 2015 till December 2015. Stem cells were collected by BM harvesting under general anaesthesia (N=47) and by PBPC apheresis (N=199) using Optia separator system. BM harvest rather then PBPC was performed on donor request or with donor consent where BM was clinically preferable over PBPC transplant. (eg. red cell disorders). Samples of HSCP for bacterial cultures were taken pre processing, post processing, including post filtration and at defined intervals during complex procedures. Cryoprotectant is also tested to check that no contamination has occurred during manufacture of the freeze mix. Samples were cultured in BACTEC™ Lytic/10 Anaerobic/F culture vials (pre-reduced enriched Soybean-Casein Digest broth with CO2) and in anaerobic blood cultures; BACTEC Peds Plus™/F culture vials (enriched Soybean-Casein Digest broth with CO2) under aerobic conditions, both for 14 days. Organisms were specifically identified in all positive HSCP.Sixteen bacterial contaminations of HSCP were recorded (6.09% of total collections). The most frequent product contaminated was BM (N=15, 31.9%); only one PBPC apheresis product was positive (0.5%). The following bacteria were isolated: propionibacterium (N=7), coagulase negative staphylococcus (N=4), micrococcus (N=2), staphylococcus capitis (N=1), Staphylococcus epidermidis (N=2). Seven HSCP were not infused: one patient died before undergoing to transplant, two products have been collected as stem cell rescue in case of graft failure from allogeneic donors, four collections were stored for future use. Nine patients received contaminated HSCPs. After being contemporaneously alerted to the contamination, the clinical team performed daily blood cultures (BC). From these 9 patients only two minor clinical events were recorded; One, a non-neutropaenic fever on day +2 (S. Capitis cultured from HSCP, BC negative) and the other a positive BC (micrococcus cultured from both HSCP and BC) in a patient without fever or signs of infection. Both were treated with IV vancomycin on microbiology advice.These data showed a rate of bacterial contamination of HSCP comparable with reports from other groups. Moreover, at our centre no major clinical events were recorded after the infusion of contaminated HSCP. In this small study, the most frequent source of contaminated HSCP was BM and the most frequently isolated pathogens were skin commensals. No consensus exists on the requirement for antibiotics after the infusion of contaminated HSCP. Our experience supports a strategy of symptomatic management based on fevers or positive blood cultures with targeted antibiotics based on in vitro sensitivities rather than pre-emptive empirical treatment of all patients. DisclosuresApperley:Bristol Myers Squibb: Honoraria, Speakers Bureau; Ariad: Honoraria, Speakers Bureau; Pfizer: Honoraria, Speakers Bureau; Incyte: Speakers Bureau; Novartis: Honoraria, Speakers Bureau.

Rapid identification of a Leptotrichia trevisanii catheter-related bloodstream infection using matrix-assisted laser desorption/ionization time-of-flight mass spectrometry

Introduction: Leptotrichia trevisanii is a large, fusiform, non-sporulating, motile, Gram-negative rod, and is a member of the family Fusobacteriaceae in the phylum Fusobacteria. Although L. trevisanii bacteraemia is extremely rare, severe infections have been reported in immunocompromised patients. Case presentation: We present a case of a 69-year-old woman diagnosed with diffuse large B-cell lymphoma, who suffered a catheter-related bloodstream infection due to L. trevisanii during the post-autologous peripheral blood progenitor-cell transplantation aplasia phase. In this case, rapid identification of the opportunistic pathogen was achieved using matrix-assisted laser desorption/ionization time-of-flight mass spectrometry directly from a blood culture, with correct identification of the micro-organism within 2 h after the blood culture became positive. Conclusion: Rapid identification of this opportunistic pathogen allowed initiation of appropriate antimicrobial therapy, which contributed to a successful clinical outcome for the patient.

General and Virus-Specific Immune Cell Reconstitution after Double Cord Blood Transplantation

Cord blood transplantation (CBT) is curative for many patients with hematologic malignancies but is associated with delayed immune recovery and an increased risk of viral infections compared with HLA-matched bone marrow or peripheral blood progenitor cell transplantation. In this study we evaluated the significance of lymphocyte recovery in 125 consecutive patients with hematologic malignancies who underwent double-unit CBT (DUCBT) with an antithymocyte globulin–containing regimen at our institution. A subset of 65 patients was prospectively evaluated for recovery of T, natural killer (NK), and B cells, and in 46 patients we also examined viral-specific T cell recovery against adenovirus, Epstein-Barr virus, cytomegalovirus, BK virus, respiratory syncytial virus, and influenza antigen. Our results indicate that in recipients of DUCBT, the day 30 absolute lymphocyte count is highly predictive of nonrelapse mortality and overall survival. Immune recovery post-DUCBT was characterized by prolonged CD8+ and CD4+ T lymphopenia associated with preferential expansion of B and NK cells. We also observed profound delays in quantitative and functional recovery of viral-specific CD4+ and CD8+ T cell responses for the first year post-CBT. Taken together, our data support efforts aimed at optimizing viral-specific T cell recovery to improve outcomes post-CBT.

Transplantation Of Peripheral Blood Progenitor Cells (PBPC) As Compared To Bone Marrow (BM) From Unrelated Related Donors For Hematologic Cancers Using Fludarabine-Alkylating Agent Based Reduced Intensity Conditioning Regimens

We explored whether there are differences in graft-versus-host disease (GVHD) or mortality risks after transplantation of PBPC and BM from unrelated donors in the setting of reduced intensity conditioning. Included are 219 BM and 887 PBPC recipients with acute myeloid leukemia (AML), myelodysplastic syndrome (MDS) or non-Hodgkin lymphoma (NHL). Patients received an alkylating agent and fludarabine as their conditioning regimen and for GVHD prophylaxis, calcineurin inhibitor (CNI) with methotrexate (MTX) or mycophenolate (MMF). Recipients of low dose total body irradiation regimen were excluded, as PBPC was the sole graft used with this regimen. Transplantations occurred in the U.S. between 2000 and 2008. The median ages of BM and PBPC recipients were 57 years. The characteristics of the treatment groups were similar except that BM recipients were more likely to have NHL, receive melphalan + fludarabine, in vivo T-cell depletion and, tacrolimus + MTX GVHD prophylaxis. The median follow-up of BM and PBPC recipients were 6 and 5 years, respectively. Preliminary analysis suggested an interaction between graft type and GVHD prophylaxis. Therefore, the effect of graft type was tested as follows: PBPC, CNI + MTX, PBPC, CNI + MMF, BM, CNI + MTX and BM, CNI + MMF. Results are shown in Tables 1 and 2. After adjusting for age, performance score, disease / disease status and HLA-match, mortality risks were higher after transplantation of PBPC or BM when GVHD prophylaxis included MMF compared to MTX (Table 1). There were no significant differences in mortality risks after transplantation of PBPC relative to BM with CNI + MTX GVHD prophylaxis (Table 2). But mortality risks were higher after transplantation of BM compared to PBPC with CNI + MMF (Table 2). Risks of grade 2-4 acute and chronic GVHD were higher after transplantation of PBPC or BM when GVHD prophylaxis included MMF compared to MTX (Table 1). Relapse risks were higher after transplantation of BM compared to PBPC with CNI + MMF (HR 1.55, p=0.02) but not with CNI + MTX GVHD prophylaxis (HR 1.13, p=0.38). Independent of graft type and GVHD prophylaxis regimens, in vivo T cell depletion was associated with lower risks of acute (HR 0.69, p<0.001) and chronic (HR 0.52, p<0.0001) GVHD but relapse risks were higher (HR 1.24, p=0.02). The data support BM and PBPC are suitable for unrelated donor transplantation when using fludarabine-alkylating agent based reduced intensity conditioning regimens and CNI + MTX GVHD prophylaxis. The data support avoiding CNI + MMF GVHD prophylaxis in this setting.Table 1Overall MortalityNon-relapse MortalityAcute GVHDChronic GVHDBMHazard ratioHazard ratioHazard ratioHazard ratioCNI+MMF vs. CNI+MTX*2.06 p<0.00012.85 p<0.00013.30 p<0.00011.75 p=0.02PBPCCNI+MMF vs. CNI+MTX*1.27 p=0.0041.56 p=0.0012.04, p<0.00011.29, p=0.007 Disclosures:No relevant conflicts of interest to declare.

Low CD34 Cell Dose Is Associated With Higher Non-Relapse and Overall Mortality After Reduced Intensity Conditioning Hematopoietic Cell Transplantation For Acute Myeloid Leukemia and Myelodysplastic Syndrome

In allogeneic hematopoetic cell transplantation (HCT) using myeloablative conditioning, the nucleated and CD34 cell doses were found to be of importance for several outcome parameters including survival, relapse and graft- versus- host disease (GVHD). Reduced intensity conditioning (RIC) HCT is increasingly used for older patients and for younger patients with co-morbidities. Peripheral blood progenitor cells (PBPC) is the predominant graft for RIC HCT. There is no large study of the effect of CD34 cell dose in the setting of RIC transplantation. Therefore, we studied the effect of CD34 dose on 1057 patients aged 45 – 75 years with acute myeloid leukemia (AML) or myelodysplasic syndrome (MDS) who received RIC regimen HCT between 2000 and 2011. Patients received grafts from HLA-matched siblings (n = 370) or from volunteer adult unrelated donors matched at the allele-level at HLA-A, -B, -C and –DRB1 (8/8; n = 522) or mismatched at 1 HLA-locus (7/8; n = 178). All patients received peripheral blood progenitor cells (PBPC), low dose TBI regimens (200 cGy) or alkylating agent plus fludarabine containing regimens. Separate analyses were conducted for HLA-matched and unrelated donor transplants. For HLA-matched sibling transplants (AML n=301; MDS n=69), exploratory analysis identified differences in survival for CD34 dose less than 4 x 106/kg. Multivariate modeling, adjusting for performance score, disease status, cytogenetic risk and transplant period, showed transplantation of PBPC with CD34 dose < 4 x 106/kg was associated with higher risks of overall mortality (HR 1.48, p=0.008) and non-relapse mortality (HR 2.03, p=0.004) compared to transplantation of PBPC with CD34 dose ≥ 4 x 106/kg. The effect of CD34 dose was independent of the other factors associated with mortality. The likelihood of neutrophil (HR 0.76, p=0.03) and platelet recovery (HR 0.76, p=0.03) was also lower with CD34 dose < 4 x 106/kg containing PBPC grafts. CD34 dose was not associated with acute or chronic GVHD or disease recurrence. In contrast, after unrelated donor transplantation (AML n=557; MDS n=130), the effect of CD34 cell dose on mortality was marginal. Exploratory analysis identified differences in survival for CD34 dose less than 6 x 106/kg. After adjusting for age, performance score, disease status, interval from diagnosis to HCT, and HLA-match, transplantation of PBPC with CD34 dose < 6 x 106/kg was associated with marginally higher risks for overall mortality (HR 1.20, p=0.05) and non-relapse mortality (HR 1.38, p=0.02) compared to transplantation of PBPC with CD34 dose ≥ 6 x 106/kg. There were no significant differences in hematopoietic recovery, acute or chronic GVHD and disease recurrence by CD34 dose. Further, we did not identify a CD34 dose for either donor source above which acute or chronic GVHD risks were higher. In conclusion, in the setting of RIC transplants for AML and MDS, the data support optimizing PBPC collections such that the CD34 dose delivered is in excess of 4 x 106/kg for HLA-matched sibling and CD34 dose in excess of 6 x 106/kg for unrelated donor transplants. Disclosures:No relevant conflicts of interest to declare.

Immunotherapy following relapse of acute leukaemia after T‐cell‐replete allogeneic peripheral blood progenitor cell transplantation: importance of new onset chronic graft‐versus‐host disease

To further define the relative impact of immunotherapy and subsequent development of graft-versus-host disease (GVHD) on survival in patients with relapsed acute leukaemia postallogeneic hematopoietic stem cell transplant (SCT), we performed a single-centre retrospective analysis of 32 actively treated patients between 2003 and 2011. A total of 13 patients were identified who were treated actively with cessation of immunosuppression ± Fludarabine, Cytarabine, G-CSF (FLAG) induction, but no donor leucocyte infusion (DLI) (non-DLI group) and 19 patients received the same step-wise therapy plus G-CSF mobilized DLI (G-DLI group). Groups were not statistically different with regards to baseline characteristics; however, the G-DLI group contained more sibling donors as opposed to unrelated donors than the non-DLI group. With a median follow-up of 47months, the median overall survival (OS) of the non-DLI and G-DLI groups was not statistically different (8months vs. 9months, respectively, P=0.5). Survival at 3years was <10% in both groups. Univariate analysis identified response to FLAG, and new onset chronic GVHD as the only factors associated with improved OS. Second donor stem cell infusions are unwarranted in the treatment of relapse after allogeneic SCT and therapeutic strategies should focus on cytoreduction followed by immune modulation with the aim of invoking chronic GVHD.

Unrelated umbilical cord blood transplant for adult acute lymphoblastic leukemia in first and second complete remission: a comparison with allografts from adult unrelated donors

Allogeneic hematopoietic cell transplantation has an established role in the treatment of adults with acute lymphoblastic leukemia whose survival when recipients of grafts from adult unrelated donors approaches that of recipients of grafts from sibling donors. Our aim was to determine the role of mismatched unrelated cord blood grafts in transplantation for 802 adults with acute lymphoblastic leukemia in first or second complete remission. Using Cox regression we compared outcomes after 116 mismatched single or double cord blood transplants, 546 peripheral blood progenitor cell transplants and 140 bone marrow transplants. The characteristics of the recipients and their diseases were similar except cord blood recipients were younger, more likely to be non-Caucasians and more likely to have a low white blood cell count at diagnosis. There were differences in donor-recipient human leukocyte antigen-match depending on the source of the graft. Most adult donor transplants were matched at the allele-level considering human leukocyte antigens-A, -B, -C and -DRB1. In contrast, most cord blood transplants were mismatched and considered antigen-level matching; 57% were mismatched at two loci and 29% at one locus whereas only 29% of adult donor transplants were mismatched at one locus and none at two loci. There were no differences in the 3-year probabilities of survival between recipients of cord blood (44%), matched adult donor (44%) and mismatched adult donor (43%) transplants. Cord blood transplants engrafted slower and were associated with less grade 2-4 acute but similar chronic graft-versus-host disease, relapse, and transplant-related mortality. The survival of cord blood graft recipients was similar to that of recipients of matched or mismatched unrelated adult donor grafts and so cord blood should be considered a valid alternative source of stem cells for adults with acute lymphoblastic leukemia in the absence of a matched unrelated adult donor.

Rapid donor T‐cell engraftment increases the risk of chronic graft‐versus‐host disease following salvage allogeneic peripheral blood hematopoietic cell transplantation for bone marrow failure syndromes

The risk of graft-rejection after allogeneic hematopoietic cell transplantation using conventional cyclophosphamide-based conditioning is increased in patients with bone marrow failure syndromes (BMFS) who are heavily transfused and often HLA-alloimmunized. Fifty-six patients with BMFS underwent fludarabine-based reduced-intensity conditioning and allogeneic peripheral blood progenitor cell (PBPC) transplantation at a single institution. The conditioning regimen consisted of intravenous cyclophosphamide, fludarabine, and equine antithymocyte globulin. Graft-versus-host disease (GVHD) prophylaxis included cyclosporine A alone or in combination with either mycophenolate mofetil or methotrexate. To reduce the risk of graft-rejection/failure, unmanipulated G-CSF mobilized PBPCs obtained from an HLA-identical or single HLA-antigen mismatched relative were transplanted rather than donor bone marrow. Despite a high prevalence of pretransplant HLA-alloimmunization (41%) and a heavy prior transfusion burden, graft-failure did not occur with all patients having sustained donor lympho-hematopoietic engraftment. The cumulative incidence of grade II-IV acute-GVHD and chronic-GVHD was 51.8% and 72%, respectively; with 87.1% surviving at a median follow-up of 4.5 years. A multivariate analysis showed pretransplant alloimmunization and rapid donor T-cell engraftment (≥95% donor by day 30) were both significantly (P < 0.05) associated with the development of chronic-GVHD (adjusted HR 2.13 and 2.99, respectively). These data show fludarabine-based PBPC transplantation overcomes the risk of graft-failure in patients with BMFS, although rapid donor T-cell engraftment associated with this approach appears to increase the risk of chronic-GVHD. (Clinicaltrials.gov identifier: NCT00003838).

Defining “poor mobilizer” in pediatric patients who need an autologous peripheral blood progenitor cell transplantation

The definition of poor mobilizers is not clear in pediatric patients undergoing autologous peripheral blood hematopoietic progenitor cell (HPC) mobilization. Most studies conducted in children define those variables related to the collection of HPC after leukapheresis, but the information regarding exclusively the mobilization process is scarce. In our experience, most children (92.2%) reach the target CD34(+) cell dose for autologous peripheral blood progenitor cell transplantation ifCD34(+) cell count was higher than 10/μL. No differences were observed between those with >20 CD34(+) cells/μL and 11-20 CD34(+) cells/μL. In this study, we analyzed the variables that influence CD34(+) cell count; we found that prior use of radiotherapy was the main variable related to poor mobilization. Patients diagnosed with Ewing sarcoma, treated with radiotherapy and mobilized with standard doses of granulocyte colony-stimulating factor (G-CSF) were also at a high risk of mobilization failure. In these patients, we should consider mobilization with high dose G-CSF and be prepared with new mobilization agents to avoid delay on their course of chemotherapy.

Unfavorable Outcome of Single-Unit Umbilical Cord Blood Transplantation for Elderly Patients with Myelodysplastic Syndromes.

AbstractAbstract 3118▪▪This icon denotes a clinically relevant abstract Introduction:Elderly patients with myelodysplastic syndromes (MDS) are often lack of suitable human leukocyte antigen (HLA)-matched related donors. Unfortunately, the data on the efficacy of allogeneic transplantation using alternative donor sources are limited. We retrospectively compared the outcomes of HLA 6/6 antigen-matched related bone marrow or peripheral blood progenitor cells (rBM/PBPC) transplantation (6/6rBM/PBPCT), HLA 8/8 allele-matched unrelated bone marrow (uBM) transplantation (8/8uBMT), HLA 7/8 allele-matched uBM transplantation (7/8uBMT), and HLA at least 4/6 antigen-matched single-unit umbilical cord blood (CB) transplantation (sCBT) for elderly patients with MDS. Method:The data were obtained from the Transplant Registry Unified Management Program, which includes data from the Japan Society for Hematopoietic Cell Transplantation, the Japan Marrow Donor Program, and the Japan Cord Blood Bank Network.Patients aged 50–70 years old at transplantation with MDS according to French-American-British (FAB) classification who received first allogeneic transplantation between January 1, 2001 and December 31, 2010 were included. Among 336 rBM/PBPC, 291 uBM, and 215 CB transplantation recipients with complete HLA data, 268 6/6rBM/PBPCT, 147 8/8uBMT, 90 7/8uBMT, and 211 sCBT recipients were included.Cox proportional-hazards regression model was used for adjusted comparisons of the donor sources on overall survival (OS). Fine and Gray proportional-hazards model was used for adjusted comparisons of the donor sources on non-relapse mortality (NRM), relapse, grade 2–4 acute graft-versus-host disease (aGVHD2–4), and neutrophil engraftment. Recipient age at transplantation (>=60 or 50–59), recipient sex (male or female), performance status (PS) at transplantation (2–4 or 0–1), FAB classification at transplantation (refractory anemia with excess blasts (RAEB) and RAEB in transformation (RAEBt), or refractory anemia (RA) and RA with ringed sideroblasts), latest cytogenetics classification according to International Prognostic Scoring System (good, intermediate, poor, or unevaluable), transplant conditioning regimen (reduced-intensity conditioning or myeloablative conditioning), and the year at transplantation (2001–2005 or 2006–2010) were included in the multivariate models. Result:Median follow-up was 2.9 years. The unadjusted 3-year OS rates for recipients of 6/6rBM/PBPCT, 8/8uBMT, 7/8uBMT, and sCBT were 50.7%, 58.2%, 46.2%, and 28.4%, respectively. Multivariate analysis revealed that the OS for sCBT recipients was significantly inferior to those for 6/6rBM/PBPCT (relative risk (RR) [95% confidential interval], 1.9 [1.5–2.5]; P<0.001), 8/8uBMT (RR, 2.3 [1.7–3.2]; P<0.001), and 7/8uBMT (RR, 1.4 [1.0–2.0]; P=0.047) recipients. The OS for 8/8uBMT and 7/8uBMT recipients were comparable with that for 6/6rBM/PBPCT. Other variables associated with significant inferior OS were recipient age >= 60, male sex, PS > 1, FAB classification at transplantation as RAEB/RAEBt, and poor cytogenetics.The risk of relapse for sCBT recipients was comparable with that for 6/6rBM/PBPCT but significantly higher than those for 8/8uBMT (RR, 2.4 [1.5–3.8]; P<0.001) and 7/8uBMT (RR, 2.3 [1.3–4.2]; P=0.005) recipients. The risk of NRM for sCBT recipients was significantly higher than that for 6/6rBM/PBPCT recipients (RR, 1.7 [1.1–2.4]; P=0.009) but comparable with those for 8/8uBMT and 7/8uBMT recipients. The risk for NRM for 7/8uBMT recipients was significantly higher than that for 6/6rBM/PBPCT (RR, 2.1 [1.4–3.1], P<0.001) and 8/8uBMT (RR, 1.6 [1.1–2.5]; P=0.024) recipients. The risk of aGVHD2–4 for 7/8uBMT recipients was significantly higher than those for 6/6rBM/PBPCT (RR, 1.6 [1.1–2.4]; P=0.008), 8/8uBMT (RR, 1.7 [1.2–2.6], P=0.008), and sCBT (RR, 1.6 [1.0–2.3]; P=0.032) recipients. Neutrophil engraftment for sCBT recipients was significantly slower than those for 6/6rBM/PBPCT (RR, 0.26 [0.21–0.33]; P<0.001), 8/8uBMT (RR, 0.35 [0.29–0.43]; P<0.001), and 7/8uBMT (RR, 0.40 [0.31–0.51]; P<0.001) recipients. Conclusion:For elderly patients with MDS, the outcome of sCBT recipient was inferior to those of 6/6rBM/PBPCT, 8/8uBMT, and 7/8uBMT recipients. Decreasing the risk of NRM, which would be brought by improving the neutrophil engraftment, and decreasing the risks of relapse are required to improve the outcome of sCBT. Disclosures:No relevant conflicts of interest to declare.

Peripheral Blood or Marrow: Is One Better Than the Other?

A study by Bertz et al. [1] in this issue of Biology of Blood andMarrow Transplantation shows that the results of unrelated donor hematopoietic stem cell transplant for adults with acute myelogenous leukemia or myelodysplastic syndrome are better with transplantation of peripheral blood progenitor cells (PBPCs) compared to bone marrow (BM). Overall mortality risks were lower after transplantation of PBPC compared to BM. With a median follow-up of 10 years, event-free survival rate after PBPC transplants was 55% and significantly higher compared to 28% after BM transplants. This is in contrast to the findings of a randomized multicenter trial of unrelated donor PBPC vs BM for hematologic malignancies in North America [2]. That trial randomized 273 patients to receive PBPC and 278 patients to receive BM. With a median follow-up of 3 years, event-free survival rates were not significantly different after PBPC and BM transplants, 47% and 44%, respectively [2]. However, the incidence of chronic graft-versus-host disease (cGVHD) was more after transplantation of PBPC compared to BM grafts (53% vs 40%; P 5 .02) and without significant differences in non-relapse mortality rates between the 2 treatment groups [2]. Bertz et al. [1] also report more cGVHD after PBPC compared to BM transplants, but the observed difference was not statistically significant (52% vs 33%; P 5 .11). The probability estimates reported by Bertz et al. [1] and Anasetti et al. [2] are similar. Relatively few events in the small patient population in the report by Bertz et al. [1] are the most likely explanation for their inability to detect statistically significant differences in cGVHD rates between the 2 graft sources. The reported higher event-free survival rate in the PBPC group with a median follow-up of 10 years is intriguing. Several groups have reported on the