Red Cell Transfusion Dependence Research Articles

Therapeutics of managing reduced red cell mass associated with chronic kidney disease – Is there a case for earlier intervention?

Reduced red cell mass is a poor prognostic indicator in chronic kidney disease (CKD) patients. Whilst overt anaemia impacts on the quality of life of patients with CKD, lowered red cell mass may also compromise oxygen delivery to proximal tubular cells and contribute to progressive kidney injury. Epidemiological data from cats with CKD support this hypothesis although controlled interventional studies involving drugs that raise red cell mass in trials designed to test this hypothesis are lacking in both human and veterinary medicine. Recombinant analogues of erythropoietin (EPO) are currently standard of care for human CKD patients where low red cell mass impacts on their quality of life. Resistance to EPO is encountered in 20% to 40% of patients treated, probably due to functional iron deficiency, reflecting the difficulties of managing iron deficiency associated with the chronic inflammation of CKD. Similar issues are likely faced in managing anaemia in feline CKD although published data on the use of human EPO analogues are limited as such treatment in cats risks antibody formation resulting in red cell aplasia and transfusion dependency and so is reserved for late stage cases only. This article reviews the recent alternative therapeutic approach to increase red cell mass using HIF-prolyl hydroxylase inhibitors and explains their mode of action and theoretical advantages over EPO analogues in the context of iron metabolism. The results of human clinical trials and the potential benefit of adopting this approach in feline CKD patients are discussed.

Real World Use of Narsoplimab in a Case of Severe HSCT-TMA

Introduction: Hematopoietic stem cell transplantation (HSCT) offers a curative approach for hematologic malignancies. However, endothelial injury from HSCT activates the lectin pathway of complement, resulting in complications such as thrombotic microangiopathy (TMA). HSCT-TMA causes significant mortality. Incidence is reported up to 39%, although lack of consensus on diagnostic criteria results in under-recognition. Risk factors for HSCT-TMA include calcineurin inhibitors (CNI), conditioning, and infection. There is currently no approved treatment for HSCT-TMA.Narsoplimab is a monoclonal antibody that inhibits MASP-2, the effector enzyme of the lectin pathway. We report a patient with late-onset HSCT-TMA who was successfully treated with narsoplimab via a compassionate use program.Methods and Results: A 60-year-old woman with de novo acute myeloid leukemia t (9;11) (p22; q23) who achieved first complete remission (CR1) with minimal residual disease positivity confirmed by flow cytometry (0.04%) underwent matched related allogeneic HSCT from her sister. Patient was cytomegalovirus (CMV) seropositive and blood group O, whereas donor was CMV seronegative and blood group B. Patient received induction with 7+3 and HiDAC consolidation, achieving CR1. Conditioning regimen was Bu4Flu with graft versus host disease (GVHD) prophylaxis of mini methotrexate and tacrolimus.Letermovir was used for CMV reactivation prophylaxis until Day +100. Post-transplant maintenance therapy with azacitidine 36 mg/m 2 was administered by four 5-day cycles (de Lima Cancer 2010). Patient achieved completed donor myeloid CD33 chimerism at Day +30, but donor lymphoid CD3 chimerism was not complete until Day +239. Tacrolimus was discontinued at Day +180. Patient initially had red cell aplasia but achieved transfusion independence by 6 months post-transplant.Circa achieving complete donor CD3 chimerism, patient developed extensive skin and gastrointestinal-overlap GVHD requiring admission for high-dose steroid therapy and resumption of tacrolimus. Onset of GVHD precluded stopping CNI. Patient became steroid refractory and ruxolitinib was added for immunosuppression with resolution of symptoms.Four weeks later, patient developed CMV reactivation and started induction therapy with valganciclovir, during which time she became red cell-transfusion dependent. Patient required 3 weeks induction and 10 days maintenance to clear CMV viremia.Subsequently, she reported dark red urine with evidence for hemoglobinuria without viruria, bilateral leg edema unresponsive to diuretic therapy, and rising serum lactate dehydrogenase (LDH). Evaluation revealed negative direct antiglobulin test, schistocytes on peripheral blood smear (~5/hpf), elevated sC5b-9 levels of 334 ng/mL (72-244 ng/mL), and elevated random urine protein of 124 mg/dL indicative of end organ damage. LDH was modestly elevated 302 IU/L (84-246 IU/L) and haptoglobin was elevated. Based on clinical symptoms and lab results, she was diagnosed with late-onset HSCT-TMA on Day +282 (9 months) using published diagnostic criteria proposed by Cho (2010) and Jodele (2014).The patient's clinical symptoms worsened with severe leg edema - which impeded her ability to walk - and red cell and platelet transfusion dependency. With no approved therapies, compassionate use of narsoplimab was requested for this clinical course of HSCT-TMA. Treatment commenced on Day +309.Patient received a total of 21 doses of narsoplimab 370 mg administered twice weekly on an outpatient basis. All infusions were well tolerated. No adverse events were noted with narsoplimab. Peripheral counts, LDH, anemia, thrombocytopenia and sC5b-9 normalized with reduction in proteinuria, reflecting resolution of HSCT-TMA by dose 19 (10 weeks of treatment); two additional doses were administered (Figure 1). Narsoplimab was given concomitantly with tacrolimus. Patient became transfusion independent and leg edema resolved.Conclusions: This report presents a real-world case study of HSCT-TMA treated with narsoplimab via compassionate use. HSCT-TMA resolved after 10 weeks of treatment, as evidenced by peripheral counts, normalization of LDH and sC5b-9, reduction in urinary protein reflecting improvement in renal function, and improvement in clinical symptoms. Narsoplimab was effective in this complicated case despite several risk factors for poor outcomes. [Display omitted] DisclosuresPantin: Omeros Corporation: Honoraria. Billy: Omeros Corporation: Current Employment. OffLabel Disclosure:Off-label use of azacitidine for post-transplant maintenance therapy

Complex Clonal Evolution Can Occur Following Transplantation for Transfusion Dependent Thalassaemia in the Context of Mixed Myeloid Chimerism and Reduced Conditioning Regimens

Haemopoietic stem cell transplantation (HSCT) is a well-established treatment modality for the cure of transfusion dependent thalassaemia (TDT) and sickle cell disease (SCD). Clonal evolution has recently been identified as a concerning event in the setting of mixed chimerism and/or ineffective haemopoiesis following conventional bone marrow transplantation and gene therapy for haemoglobinopathies. This has so far been restricted to SCD only, with the presumption that despite both conditions sharing an ineffective erythropoietic marrow compartment, there may be inflammatory and hypoxic differences enabling clonal evolution, in addition to the different exposure to hydroxycarbamide as a therapeutic agent. However, there is a need to investigate whether this may also be an occurrence in TDT.From 2011 to 2021, over a ten-year period, sixty-five consecutive paediatric patients received a sibling HSCT (n=55) or a haploidentical HSCT (n=10) for TDT in our institution. Conditioning intensity was minimised at the start of this cohort in order to limit toxicity and late effects, abandoning the use of Bu/Cy, which resulted in approximately 50% of the patients having stable mixed chimerism long-term. Sibling HSCT was conditioned with fludarabine 160 mg/m 2, treosulfan 42 g/m 2, thiotepa 10 mg/kg and ATG (Thymoglobulin) or alemtuzumab, and received GvHD prophylaxis with ciclosporin and MMF. Haploidentical HSCT was conditioned with fludarabine 150 mg/m 2, cyclophosphamide 30 mg/kg, TBI 2 or 4 Gy, and ATG 4.5 mg/kg (thiotepa 10 mg/kg added if TBI 2 Gy only) with GvHD prophylaxis provided by two doses of post-transplantation cyclophosphamide 50 mg/kg, sirolimus and MMF. All patients had pre-transplantation endogenous haemopoiesis was suppressed pre-transplantation with hypertransfusions for a minimum of 8 weeks, and/or the use of hydroxycarbamide and azathioprine. GvHD prophylaxis was provided with ciclosporin and MMF. All patients were Pesaro class I or II at the time of transplantation. The median age was 5 years (2 - 19). The median survival was 26.8 months (2.6-101.8). The OS was 93.8% and DFS was 89.2%.Three patients in this cohort developed clonal evolution in the context of myeloid mixed chimerism identified due to the development of cytopenias and transfusion dependence. All patients had a complex karyotype and it involved deletion of chromosome 7: •Patient 1 had a sibling BMT at 3 years and 2 months. Day +28 chimerism was >95% in whole blood and 95% in T cells. The myeloid fraction had a progressive reduction from day +60 onwards. At 15 months post-transplantation clonal evolution was identified [18% ring sideroblasts, 46;XY, del (7) (q22 q34) [5]/46;XY [5], chimerism 13% donor in whole marrow and 41% marrow T cells. Two months later he became red cell transfusion dependence. A second BMT with busulfan based conditioning resulted in long-term cure.•Patient 2 had a sibling BMT at 3 years and 8 months of age. Day +28 chimerism was 99% donor in whole blood and 99% donor in T cells. Day +161 post-transplantation he started requiring erythropoietin support to maintain him transfusion independent and on day +217 we first identified in the bone marrow the appearance of myeloid mixed chimerism (75% donor in whole marrow and 91% marrow T cells) and complex clonal evolution involving -7 and FISH identified deletion of one copy of KMT2E (7q22) and MET (7q31) detected [16/200]. The patient is under monitoring at present with a progressive reduction of the size of the abnormal clones.•Patient 3 had a haplo BMT at 5 years and 8 months. Day +28 chimerism was 97% donor in whole blood and 99% donor in T cells. She developed mixed myeloid chimerism following cessation of immunosuppression on day +206: 86% donor whole blood and 99% donor in T cells. At 22 months post-BMT she started to require transfusion and a complex clonal evolution involving deletion 7 in her bone marrow when the chimerism was 42% donor whole blood and 81% donor marrow T cells. FISH identified deletion of one copy of KMT2E(7q22) and MET(7q31) detected[22/100]. She is being prepared for a second bone marrow transplant.In conclusion, complex clonal evolution also occurs post HSCT in TDT, at least in the context of reduction of conditioning intensity and development of mixed myeloid chimerism. This finding warrants further investigation and may have significant implications for the design of both conventional HSCT and gene therapy strategies. DisclosuresNo relevant conflicts of interest to declare.

Predictors of Mortality and Outcomes of Liver Transplant in Spur Cell Hemolytic Anemia

BACKGROUND :Spur cell hemolytic anemia (SCHA) is a rare, acquired, non-immune hemolytic anemia of decompensated cirrhosis resulting from abnormal lipid composition of the red cell membrane. Treatment is limited to red cell transfusion. Data describing prognostic impact, outcomes of liver transplant, and clinical hematologic characteristics of SCHA are absent or limited; published data on SCHA are limited to single-patient case reports and small single-center case series. The independent prognostic impact of SCHA on patients with cirrhosis remains unclear, and it is not known if hemolytic anemia severity has a significant impact on survival of these patients. As a result, SCHA is not formally considered during liver transplant evaluation, and patients do not receive MELD exception points for this diagnosis.METHODS :We performed a multicenter, 24-year observational cohort study of patients with SCHA, retrospectively analyzing hepatic and hematologic parameters, independent predictors of mortality, and long-term outcomes of liver transplant. Strict diagnostic criteria for SCHA were applied, requiring all of the following: (1) decompensated cirrhosis; (2) anemia; (3) objective laboratory evidence of hemolysis; (4) no alternate contributing cause of hemolysis or acanthocytosis; and (5) chart documentation of a confirmed diagnosis of SCHA incorporating peripheral blood film examination. The primary outcome was mortality at 3 months after date of SCHA diagnosis. The impact of hemolytic parameters on 3-month mortality was evaluated utilizing multivariable logistic models. Observed mortality vs. expected mortality (per MELD-Na score and Child-Turcotte-Pugh class) was compared using standardized mortality ratios. Given the limited survival of this population, red cell transfusion dependence was defined as 4 or more units of red cells transfused during the 60-day peri-diagnostic period.RESULTS :Patients: 69 patients with SCHA were included (FIGURE 1). The median (interquartile range) age was 53 (42-59) years; 46.4% were female, and 11 (15.9%) received liver transplant. Alcohol contributed to the etiology of cirrhosis in 53 patients (76.8%). The median (IQR) survival from SCHA diagnosis of patients not receiving liver transplant was 58 (23-113) days. 39 patients (56.5%) were red cell transfusion-dependent. Hematologic parameters are described in TABLE 1.Outcomes of Liver Transplant: All 11 patients undergoing transplant had rapid and complete resolution of SCHA, with an improvement in median hematocrit from 22.1% to 34.6% post-transplant (P=0.001) (TABLE 2) and excellent post-transplant outcomes, with 9 patients still alive after 6.1 years median follow-up.Independent Predictors of Mortality in SCHA: In multivariable logistic models adjusting for age, sex, etiology of cirrhosis, active/recent variceal bleeding, and Child-Turcotte-Pugh score, transfusion dependence had an OR for 90-day mortality of 9.14 (95% CI, 2.46-34.00) and reduced pre-transfusion hematocrit had an OR of 4.73 (95% CI, 1.42-15.82) per 6% decrease; increased red cell transfusion requirement, reduced hemoglobin, increased lactate dehydrogenase, and increased indirect bilirubin were also independently predictive of higher 90-day mortality (FIGURE 2).Performance of MELD-Na and Child-Turcotte-Pugh Scores in Estimating 90-Day Mortality: MELD-Na and Child-Turcotte-Pugh scores consistently significantly underestimated 90-day mortality, with standardized mortality ratios (SMRs) >1 across all scores/classes [MELD-Na 20-29, SMR 2.42 (1.18-4.44); Child-Turcotte-Pugh class B, SMR 4.46 (1.64-9.90)], FIGURE 3.CONCLUSIONS :In this largest study of SCHA to date, SCHA was associated with substantial excess mortality than was predicted by MELD-Na or Child-Turcotte-Pugh scores. Several clinical and laboratory parameters of hemolytic anemia severity, including transfusion burden, hemoglobin, and markers of hemolysis were each independent predictors of 90-day mortality in SCHA. Despite its unique morbidity as a complication of decompensated cirrhosis, outcomes of liver transplant were excellent in all 11 patients undergoing this intervention, with total resolution of SCHA and no evidence of recurrence. These findings should promote greater awareness of SCHA as a clinical entity and broader consideration of MELD exception points for afflicted patients when transplant-eligible. [Display omitted] DisclosuresAl-Samkari: Novartis: Consultancy; Amgen: Research Funding; Argenx: Consultancy; Rigel: Consultancy; Dova/Sobi: Consultancy, Research Funding; Agios: Consultancy, Research Funding; Moderna: Consultancy.

Blast Phase Myeloproliferative Neoplasm: A Mayo Agimm Study of 419 Consecutive Cases

Background:JAK2 mutation-enriched myeloproliferative neoplasms (MPN) might progress into blast phase disease (MPN-BP), operationally defined by the presence of ≥20% blasts in the peripheral blood (PB) or bone marrow (BM) (Blood 2016;127:2391). In the current study, we reviewed consecutive cases of MPN-BP from the institutional databases of the Mayo Clinic, Rochester, MN, USA and the AIRC-Gruppo Italiano Malattie Mieloproliferative (AGIMM), with the intent to examine i) survival trends, ii) treatment response rates and outcome and iii) risk factors for survival, including the impact of chemotherapy and allogeneic stem cell transplant (ASCT).Methods:Diagnoses of MPN, including primary myelofibrosis (PMF), polycythemia vera (PV), essential thrombocythemia (ET) and MPN-BP were according to WHO criteria (Blood 2016;127:2391). Treatment response to MPN-BP was assessed according to conventional criteria (JCO 2003;21:4642). Statistical analyses considered clinical and laboratory data collected at the time of documented disease transformation into MPN-BP. Survival was calculated from the date of leukemic transformation to the date of death or last contact. In order to examine survival trends, comparative analysis was performed based on year of leukemic transformation.Results:Mayo Cohort (n=248):1.Patient characteristics at time of leukemic transformation: The Mayo Clinic cohort consisted of 248 consecutive patients (median age 67 years; 65% males) with MPN-BP, including 118 (48%) post-PMF and 130 (52%) post-PV/ET MPN-BP; among the latter, 60 patients had post-PV (32 without documented MF phase) and 70 post-ET (39 without documented MF phase) MPN-BP. Among all evaluable cases, at the time of leukemic transformation, 34% displayed red cell transfusion dependency, 58% platelet count <100 x 10(9)/L, 37% leukocyte count >25 x 10(9)/L, 71% PB blasts ≥20%, 87% BM blasts ≥20%, 81% abnormal karyotype, 57% unfavorable karyotype and 68% JAK2 V617F mutation. Compared to post-PMF, post-PV/ET MPN-BP cases displayed female preponderance (p=0.04), lower transfusion need (p=0.0004), higher platelet count (p=0.004) and lower circulating blast count (p=0.005), but similar karyotype profile (p=0.3).2.Survival trends over time: After a median follow-up of 3 months (range 0-122), 226 (91%) deaths were recorded. Median overall survival (OS) was 3.6 months with 1- and 3-year survival rates of 17% and 6%, respectively; survival trends appeared significantly better (p=0.002) for patients diagnosed in the year 2000 and beyond, but with no additional improvement in more recent years (1-year survival rates for diagnosis before 2000 vs 2001-2009 vs 2010 and beyond were 5% vs 17% vs 20%, respectively).3.Treatment outcome and predictors of survival: Treatment response was assessable in 122 patients including 66 treated with acute myeloid leukemia (AML)-like induction chemotherapy, 26 with hypomethylating agents (HMA) and 30 with other agents; the respective complete remission (CR) rates were 35%, 4% and 3%; an additional 24% of patients who received AML-like induction chemotherapy achieved CR with incomplete blood count recovery (CRi) and their survival was similar to those with CR (p=NS); CRi was not seen with HMA. ASCT was reported in 24 patients and included 17 patients who received AML-like induction chemotherapy and 18 patients who were in CR or CRi, at time of transplant. In multivariable analysis, platelets <100 x 10(9)/L (HR 1.7; 95% CI 1.0-2.7) and unfavorable karyotype (HR 2.3; 95% CI 1.3-4.3) predicted inferior and achievement of CR/CRi (HR 0.4; 95% CI 0.2-0.7) superior survival; additional significance was not evident for ASCT (p=0.09). A composite assessment revealed that short-term survival was similarly and positively affected by either achieving CR/CRi or receiving ASCT, but the benefit did not endure (Figure).AGIMM cohort (n=171):An external cohort of 171 patients from AGIMM was used to validate most of the aforementioned observations from the Mayo Cohort (details to follow at time of presentation).Conclusions: CR or CRi is achievable in MPN-BP, but only with AML-like induction chemotherapy and not with HMA; achievement of CR/CRi was associated with improved short-term survival, regardless of consolidation with ASCT. Outcome after ASCT was not affected by pre-transplant chemotherapy and neither ASCT nor achievement of CR/CRi resulted in durable survival benefit. [Display omitted] DisclosuresPassamonti:Novartis Pharmaceuticals Corporation: Consultancy, Honoraria, Speakers Bureau. Rambaldi:Novartis, Roche/Genentech, Amgen, Italfarmaco: Consultancy; Novartis, Amgen, Celgene, Sanofi: Other: Travel, Accomodations, Expenses. Vannucchi:Novartis: Honoraria, Speakers Bureau; Shire: Speakers Bureau.

Pure red blood cell aplasia: patient management pitfalls in major ABO-incompatible haematopoietic cell transplantation.

In this issue of British Journal of Haematology, Longval and colleagues report on the successes and pitfalls of prediction, diagnosis and management of pure red blood cell aplasia (PRCA) after major ABO-incompatible allogeneic stem cell transplantation.1 Their data confirm prior reports indicating a paucity of cases of PRCA after umbilical cord blood transplantation.2 Among the remaining 587 patients receiving major ABO-incompatible donor grafts, 66 cases of PRCA were identified. In this series, high pre-transplant isohaemagglutinin titre was the only pre-transplant variable associated with subsequent development of PRCA. Despite the various methodologies for performing isohaemagglutinin titre assays,4, 5 this observation highlights the need for pre-transplant quantitation of isohaemagglutinin titre in instances of major ABO mismatch in order to identify patients at highest risk. Furthermore, at some centres pre-conditioning therapeutic plasma exchange is considered for patients with high titres.6 In some patients, residual recipient plasma cells may secrete sufficient quantities of antibody to prevent nascent erythroblast precursors from achieving timely maturation,3 forming a rationale for consideration of plasma cell-directed therapy in patients with persistently high isohaemagglutinin titres. Interestingly, several low titre isohaemagglutinin recipient–donor pairs resulting in post-transplant PRCA were identified, pointing to the need to identify additional predictors of PRCA. This work also exposes a gap in knowledge within the transplant field, namely when can we be sure that red blood cell engraftment has transpired? To date, no universal standard for red blood cell engraftment exists, and across institutions several working definitions exist including red cell transfusion independence, ABO blood type conversion, and absence of reticulocytopenia. Advantages and disadvantages of various case definitions are outlined in Table I. Standard diagnostic assessments for profound anaemia, reticulocytopenia, and absence of red blood cell precursors in the bone marrow are certainly essential when patients display prolonged red cell transfusion dependence,7 but in the absence of alternative causes, the presumptive diagnosis in this setting is PRCA due to ABO incompatibility, and persistence of some level of the corresponding isohaemagglutinin is typical. In this series, over 10% of patients receiving transplants from donors with a major ABO incompatibility developed PRCA, but this immunologic insult did not significantly affect overall survival, which is in line with results of previous studies.8, 9 As such, any therapeutic intervention must be considered in the context of the inherent risk of the intervention itself. Introduction of rituximab,10 donor lymphocyte infusions,11 tapering of immunosuppressive medications, or use of a proteasome inhibitor12 all carry risk–benefit calculations, and to date have demonstrated mixed results in treating post-transplant PRCA. Anecdotal reports of the successful use of the anti-CD38 monoclonal antibody daratumumab for management of post-transplant PRCA13, 14 deserve mention, particularly given that the physiology of prolonged PRCA after transplant is presumably a reflection of residual host plasma cell clones producing the isohaemagglutinin. In the current study, no particular intervention was associated with more rapid resolution of PRCA, although no patients in this series received daratumumab and only a handful received a proteasome inhibitor. Management of patients undergoing major ABO-incompatible allogeneic stem cell transplantation requires close collaboration with the blood bank to identify patients at greatest risk prior to transplantation, and to optimize transfusion strategies during the post-transplant period. This may include pre-transplant minor red blood cell antigen typing to reduce the likelihood of alloimmunization,15 and consideration of pre-transplant plasma exchange for patients with very high isohaemagglutinin titres. It is fair to say that there is no ‘gold standard’ for treatment of active post-transplant PRCA, and this study does not inform us regarding how best to manage these patients. Fortunately, the situation typically resolves over time, but further studies to establish effective treatment strategies are sorely needed given the significant morbidity and symptom burden associated with this not so rare complication. As a final thought, we might speculate two distinct (but not mutually exclusive) mechanisms for what we call ‘PRCA’ in this setting: residual host isohaemagglutinin levels that simply take time to dissipate because of high pre-transplant titres versus persistence of host isohaemagglutinin-producing plasma cells. We have the molecular and blood banking tools to systematically study these post-transplant events, which could better elucidate management approaches most appropriate for individual patients. Variability in RBC products Complicated by suspected transfusion reactions Provider/institutional variability for transfusion thresholds Time to independence is not a universal definition (e.g,, 30 days without transfusion versus 60 days) Inter-observer variability in scoring of agglutination Interference between residual transfused isohaemagglutinins from platelets/plasma No established grading system for mixed field observations Interference from intravenous immune-globulin treatment Results often not reported in patient’s medical record Difficulty in interpretation for non-transfusion medicine personnel Monoclonal antibodies for minor RBC antigens are licensed Low cost and quick turn-around time Only viable if minor antigen discrepancy exists between donor/recipient. If patient has positive Direct Coombs’ test, results could be invalid based on reagent used

Molecular Analysis in the Pacritinib Dose-Finding PAC203 Study in Patients with Myelofibrosis Refractory or Intolerant to Ruxolitinib

PAC203 is a global multicenter dose-finding study of pacritinib (PAC), an oral JAK2/IRAK1 inhibitor in patients with primary or secondary myelofibrosis refractory or intolerant to ruxolitinib, including patients with severe thrombocytopenia. Patients were randomized 1:1:1 (PAC 100mg QD, 100mg BID or 200mg BID) and stratified by baseline platelet count. The mutational landscape of this patient group is not well characterised, and the impact of mutation status on disease response and hematologic parameters is unknown. We carried out baseline mutational analysis on 105 (of total 164 recruited; 161 treated) patients using an ISO accredited Illumina TruSeq Custom Amplicon Panel, including 32 gene mutation hotspots and exons (~36,000 bp, 287 amplicons). CALR mutation screening was carried out independently. Accepted coverage was achievement of a depth of ≥100 reads per base in ≥95% of targeted bases. Median follow-up time for this cohort was 163 (28-476) days. 57% of patients had a diagnosis of primary myelofibrosis (PMF), whereas 27% and 15% had post-polycythemia vera MF (PPV-MF) and post-essential thrombocythemia MF (PET-MF), respectively. The median baseline platelet count was 64.5 x109/L, with &lt;50 x109/L in 38.3% of patients and baseline Hb &lt;10g/dL in 67.8% of patients. The median age was 67.5 (37-87) years. The majority of patients were JAK2 V617F-mutated (77%), followed by MPL-mutated (8.6%), with a notably low incidence of CALR-mutated (8.6%; type 1 CALR n=6, type 2 CALR n=3) and "triple-negative" (4.8%) cases. Non-myeloproliferative neoplasm driver mutations (NDM) were present in 77.1% (n=81) with ≥3 NDMs in 18.1% of patients. Similar to previous reports, the most prevalent NDMs were TET2 and ASXL1 (n=27 and n=25 respectively). Splicing factor (SF) mutations were mutually exclusive and detected in 32.3% of patients: SF3B1 [13], U2AF1 [14], SRSF2 [6], ZRSR2 [1]. RAS pathway mutations (KRAS/NRAS) were found at a higher frequency than previously in MF cohorts; 16.2% (n=17). SF mutations were present in more PMF (45.6%) than PPV-MF (3.7%, n=1/27) or PET-MF patients (33.3%, n=5/15), P=.002. SF3B1-mutated patients had higher trial entry platelet counts (66.7% platelets ≥100x109/L, P=.014). Baseline red cell transfusion dependency was more often associated with U2AF1 mutations 24.1% (n=7/29) as compared with red cell transfusion independence, 4.5% (n=2/44), P=.047 and U2AF1-mutated patients had lower baseline hemoglobin &lt;10g/dL (n=11/12), P=.015. Overall, 41 (39%) of patients had a high molecular risk mutation (HMR; IDH1/2, SRSF2, ASXL1, SRSF2, U2AF1Q157), and 8 patients had TP53 mutations. In those with molecular analysis available, the highest rates of ≥35% SVR were observed in the 200mg BID arm: 11.1% (n=4/36) followed by 3.2% (n=1/32) in 100mg BID arm and 0% (n=0/30) in 100mg QD arm). Rates of TSS reduction ≥50% were similar across arms. There were no significant correlations between mutations and SVR or TSS response. More grade 3/4 anemia occurred in TET2-mutated patients (OR 5.7, 95% CI 1.6-20.4, P=.007). RAS pathway mutations were associated with grade 3/4 thrombocytopenia (OR 4.4, 95% CI 1.3-14.8, P=0.016). Treatment discontinuation was not influenced by mutation status. In summary, the PAC203 cohort is molecularly high risk, with a high incidence of HMR and low incidence of CALR mutations. We identified novel associations between mutation profiles and hematologic events in this population with advanced MF. Disclosures Taylor: Baxalta: Research Funding; CTI BioPharma: Employment, Equity Ownership. Gerds:Roche: Research Funding; Incyte: Consultancy, Research Funding; Pfizer: Consultancy; CTI Biopharma: Consultancy, Research Funding; Imago Biosciences: Research Funding; Sierra Oncology: Research Funding; Celgene Corporation: Consultancy, Research Funding. Buckley:CTI BioPharma: Employment, Equity Ownership. Harrison:Incyte: Speakers Bureau; Novartis: Honoraria, Research Funding, Speakers Bureau; Promedior: Honoraria; Celgene: Honoraria, Speakers Bureau; AOP: Honoraria; Sierra Oncology: Honoraria; Janssen: Speakers Bureau; Gilead: Speakers Bureau; Roche: Honoraria; CTI: Speakers Bureau; Shire: Speakers Bureau. Oh:Novartis: Consultancy; Incyte: Membership on an entity's Board of Directors or advisory committees; Blueprint Medicines: Membership on an entity's Board of Directors or advisory committees. Mead:CTI: Honoraria, Research Funding; Bristol Myers-Squibb: Consultancy; Novartis: Consultancy, Honoraria, Other: Travel/accommodation expenses, Research Funding, Speakers Bureau; Celgene: Consultancy, Research Funding; Pfizer: Consultancy.

MF management.

MF management.

Survival after Hematopoietic Stem Cell Transplantation in an Older, Fit Cohort of Patients with Advanced Myelodysplastic Syndromes: The MDS-TAO Study

Background: The utility of reduced-intensity conditioning hematopoietic stem cell transplantation (RIC HSCT) for fit elderly patients with advanced myelodysplastic syndromes (MDS) is unclear.Methods: The MDS Transplant-Associated Outcomes Study, or “MDS-TAO,” was a prospective longitudinal observational study at the Dana-Farber/Harvard Cancer Center designed to examine survival, quality of life, and other outcomes for RIC HSCT versus non-HSCT approaches for HSCT-eligible patients with advanced MDS ages 60 to 75. All patients who met eligibility criteria were approached in the leukemia or HSCT clinics; 96% agreed to enroll. Inclusion criteria included histologically-confirmed diagnosis of MDS or CMML, and (1) therapy-related disease or (2) Int-2/high IPSS (Greenberg, Blood, 1997), or (3) non-IPSS poor-risk cytogenetics (Haase, Blood, 2007), or (4) severe cytopenia/platelet or red cell transfusion-dependence. Exclusions were (1) comorbidities that in the judgment of the treating physician precluded HSCT eligibility (2) prior donor search and (3) patient unwillingness to consider HSCT. Considering time to transplant as a time-dependent variable, hazard ratio for ultimate HSCT was estimated using Cox regression analysis controlling for age, gender, ECOG performance status, IPSS, IPSS cytogenetic risk group, and year of consent. Landmark analyses at 5 months were conducted to present estimates of overall survival for patients who were alive for at least 5 months and received HSCT versus patients who did not (landmark cohort). Subgroup analyses (e.g., molecular characteristics) are also ongoing.Results: 290 patients were enrolled between May 2011 and May 2018; 24 had less than 1.5 months of follow up after consent and were excluded from this analysis. Of the remaining 266 patients, 143 were deceased at last follow up. Baseline characteristics are presented in the table. The median follow-up time among survivors was 31 months (range 1.9, 84). 102 patients received HSCT, of whom 45 subsequently died; of the 164 patients who have not undergone HSCT, 98 have died. The median time to HSCT among those transplanted (n=102) was 4.6 months. The median follow-up for patients alive and not yet transplanted (n=66) was 24 months (range 1.9, 82). Considering time to HSCT as a time-dependent variable (n=266), the hazard ratio for death in multivariable analysis was 0.63 (95% CI 0.42-0.96, p=0.03). Poor risk IPSS cytogenetic group was the only other factor associated with mortality, HR=1.86 (95% CI 1.15-3.00, p=0.006); age, gender, ECOG performance status, IPSS, and consent year were not. Five months was chosen for the landmark analysis given it was closest to the median time to HSCT. In the landmark cohort (N=229), HSCT patients were more likely to have Int-2/high IPSS at baseline (65% vs 35% for none, p=0.0003). No other baseline characteristics were different. Figure A shows Kaplan-Meier plots for the landmark cohort, comparing 54 who received HSCT ≤ 5 months versus 175 patients who did not receive a transplant within 5 months (log rank p=0.04). Figure B shows Kaplan-Meier plots for HSCT comparing 99 patients who received HSCT at any time during follow-up versus 130 patients who did not (log rank p=0.005).Conclusion: In this large cohort of fit elderly patients with advanced MDS, a treatment strategy that included HSCT was associated with better overall survival. DisclosuresHo:Jazz Pharmaceuticals: Consultancy. DeAngelo:Incyte: Consultancy, Honoraria; Glycomimetics: Research Funding; Amgen: Consultancy; ARIAD: Consultancy, Research Funding; Blueprint Medicines: Honoraria, Research Funding; Amgen: Consultancy; Shire: Honoraria; Takeda: Honoraria; BMS: Consultancy; Blueprint Medicines: Honoraria, Research Funding; Incyte: Consultancy, Honoraria; Glycomimetics: Research Funding; ARIAD: Consultancy, Research Funding; Pfizer Inc: Consultancy, Honoraria; Novartis Pharmaceuticals Corporation: Consultancy, Honoraria; BMS: Consultancy. Antin:Jazz Pharmaceuticals: Membership on an entity's Board of Directors or advisory committees. Soiffer:Jazz Pharmaceuticals: Membership on an entity's Board of Directors or advisory committees.

Marked Elevation of Serum Lactate Dehydrogenase (LDH) in Primary Myelofibrosis: Clinical and Prognostic Correlates

BackgroundIncreased serum levels of lactate dehydrogenase (LDH) typically accompany primary myelofibrosis (PMF) and might be linked to increased cell turnover from clonal myeloproliferation, including leukocytosis, low grade hemolysis and extra-medullary hematopoiesis in the liver. Despite the fact that serum LDH has been extensively utilized as a prognostic marker in both lymphoid neoplasms and solid tumors, there are limited studies in PMF that have systematically examined the clinical significance of the degree of serum LDH elevation in PMF.MethodsStudy patients fulfilled the 2016 WHO criteria for the diagnosis of PMF, including both pre-PMF and overt PMF (Blood. 2016;127:2391). Additional selection criteria included the availability of serum LDH at time of referral. Marked elevation of serum LDH was defined as a value of ≥1000 U/L (i.e. over 4-fold increase from the upper limit of the normal range for our institution, which was 122-222 U/L), based on preliminary analysis of the threshold for prognostic effect. Targeted next generation sequencing was used to screen for prognostically-relevant mutations (Blood 2015126:354). Statistical analyses considered clinical and laboratory parameters obtained at time of initial referral to the Mayo Clinic.ResultsLDH values in overt PMF versus pre-PMF:The entire study population consisted of 357 patients, including 311 with overt PMF and 46 with pre-PMF. The median serum LDH level was 514 U/L (range 136-2263): overt PMF 532 U/L (range 136-2263); pre-PMF 401 U/L (range 180-1237) (p=0.0003). Accordingly, in order to avoid the confounding effect of the difference in serum LDH level between overt PMF and pre-PMF, and considering the small number of patients with pre-PMF, further analysis was limited to the 311 patients with overt PMF.Patient characteristics:The 311 patients (median age 64 years; 66% males) with overt PMF included 205 (66%) JAK2, 49 (16%) type 1/like CALR, 13 (4%) type 2/like CALR, 16 (5%) MPL mutated cases and 28 (9%) were "triple-negative". DIPSS-plus risk distribution was 31% high, 43% intermediate-2, 15% intermediate-1 and 12% low; 30% displayed red cell transfusion-dependency and 37% abnormal karyotype, including 14% with unfavorable karyotype. 184 patients were screened for ASXL1 mutations with 42% mutated and 205 for SRSF2 mutations with 16% mutated.Clinical correlates of markedly elevated LDH (≥1000 U/L):Among all 311 study patients with overt PMF, 37 (12%) displayed marked elevation of LDH (≥1000/L). Patients with marked elevation of LDH displayed significantly higher leukocyte count (p=0.005; R-squared = 0.05), circulating blast percentage (p=0.03; R-squared = 0.07) and SRSF2 mutational frequency (44% vs 12%; p<0.0001).Survival analysis:After a median follow up of 3 years, 199 (64%) deaths and 31 (10%) leukemic transformations were documented. In univariate analysis, increased serum LDH level was associated with inferior survival, both as a continuous variable (p=0.002) and as a categorical variable with the cutoff level of 1000 U/L (HR 2.02, 95% CI 1.3-3.1; p=0.001); the survival effect LDH ≥1000/L was independent of DIPSS-plus (HR 1.6, 95% CI 1.1-2.5). Other variables that were significantly associated with shortened survival, on univariate analysis, included all 8 DIPSS-plus variables (p≤0.01 in all instances), absence of CALR type 1/type 1-like (p<0.0001) and presence of ASXL1 (p<0.0001) or SRSF2 (p=0.0006) mutations. In multivariable analysis that included only genetic risk factors, serum LDH retained its significance (HR 2.2, 95% CI 1.3-3.6), along with absence of CALR type 1/type 1-like, or presence of ASXL1 or SRSF2 mutations or unfavorable karyotype. In multivariable analysis that included only clinical variables, serum LDH ≥1000/L was again independently predictive of poor survival (HR 1.7, 95% CI 1.1-2.6), along with age >65 years, hemoglobin <10 g/dL, platelets <100 x 10(9)/L, leukocyte count >25 x 10(9)/L and constitutional symptoms. Patients with marked LDH elevation were also more likely to undergo leukemic transformation (HR 3.1, 95% CI 1.2-7.6).ConclusionThe current study suggests that marked elevation of serum LDH in PMF indicates aggressive tumor biology that is currently not accounted for by established clinical or genetic risk factors; the low R-squared values seen in relation to leukocyte count and circulating blasts are consistent with this assumption. DisclosuresNo relevant conflicts of interest to declare.

Monocytosis Is a Powerful and Independent Predictor of Shortened Overall and Leukemia-Free Survival in Primary Myelofibrosis

BackgroundThe Dynamic International Prognostic Scoring System (DIPSS)-plus currently provides the most comprehensive prognostic model for primary myelofibrosis (PMF) (JCO 2011;29:392). DIPSS-pluse uses eight independent predictors of inferior survival: age >65 years, hemoglobin <10 g/dL, leukocyte count >25 x 109/L, circulating blasts ³1%, constitutional symptoms, unfavorable karyotype, red cell transfusion need and platelet count <100 x 109/L. More recently, type 1/type 1-like CALR driver mutational status and ASXL1 andSRSF2 mutations were identified as additional DIPSS-plus-independent risk factors for survival in PMF (JAMA Oncol. 2015;1:97). Based on our earlier preliminary observation (Leuk Res. 2007;31:1503), we conducted the current study to fully examine the additional prognostic relevance of monocytosis (absolute monocyte count ≥1 x 10(9)/L) in PMF.MethodsStudy patients fulfilled the 2016 WHO criteria for the diagnosis of PMF, including both pre-PMF and overt PMF (Blood. 2016;127:2391). Additional selection criteria included the availability of absolute monocyte count (AMC) and percentage at time of referral. Targeted next generation sequencing was used to screen for prognostically-relevant mutations (Blood 2015 126:354). Statistical analyses considered clinical and laboratory parameters obtained at time of initial referral to the Mayo Clinic.ResultsPatient characteristics:The study population included 454 patients (median age 64 years; 62% males); 293 (64%) patients harbored JAK2 mutations, 74 (16%) type 1/like CALR, 16 (3%) type 2/like CALR, 24 (5%) MPL and 47 (10%) were "triple-negative". DIPSS-plus risk distribution was 29% high, 38% intermediate-2, 17% intermediate-1 and 15% low; 27% displayed red cell transfusion-dependency, 29% constitutional symptoms, 70% palpable splenomegaly and 36% abnormal karyotype, including 13% with unfavorable karyotype. 301 patients were screened for ASXL1 mutations with 39% mutated, 297 for SRSF2 mutations with 15% mutated, 286 for U2AF1 with 18% mutated, 253 for SF3B1 with 6% mutated, 229 for EZH2 with 5% mutated and 110 for IDH1/2 with 7% mutated.Clinical, cytogenetic and molecular comparisons between PMF patients with and without monocytosis:Among all study patients, 376 (83%) displayed AMC <1 x 10(9)/L; the remaining had either moderate (AMC between 1 and 3 x 10(9)/L; n=65) or marked (AMC >3 x 10(9)/L; n=13) monocytosis. Comparison of these three groups revealed that monocytosis was significantly associated with older age (p=0.0001), higher leukocyte count (p<0.0001), lower platelet count (p=0.01), higher circulating blast percentage (p=0.0002) and higher DIPSS-plus risk distribution (p=0.01). There were no significant differences in the distribution of driver mutations, ASXL1, SRSF2, U2AF, SF3B1, EZH2 or IDH1/2 mutations or incidence of unfavorable karyotype.Survival analysis:After a median follow up of 3.2 years, 265 (58%) deaths and 38 (8%) leukemic transformations were documented. In univariate analysis, all 8 variables included in DIPSS-plus were significantly associated with shortened survival (p<0.001 in all instances). Significant risk factors in univariate analysis also included AMC >3 x 10(9)/L (p<0.0001; HR 5.6, 95% CI 3.1-10.0), AMC 1 to 3 x 10(9)/L (p<0.0001; HR 2.1, 95% CI 1.5-2.9), absence of CALR type 1/type 1-like (p<0.0001) and presence of ASXL1 (p<0.0001) or SRSF2 (p<0.0001) mutations. The significant difference in survival between the three AMC categories (i.e. <1, 1-3 and >3 x 10(9)L) was independent of each one of the eight DIPSS-plus variables, DIPSS-plus, driver mutational status, ASXL1 and SRSF2 mutations (p<0.0001 in all instances). The survival difference between patients with and without monocytosis was evident in both high/intermediate-2 and low/intermediate-1 DIPSS-plus risk groups (Figure). Patients with monocytosis were also more likely to undergo leukemic transformation (HR 3.0, 95% CI 1.4-6.5) and this effect was also independent of karyotype, driver mutational status, ASXL1 or SRSF2 mutations.ConclusionThe current study identifies monocytosis as a powerful risk factor for both overall and leukemia-free survival in PMF and the effect was independent of currently established prognostic models and genetic risk factors. It was particularly noteworthy to document similar distribution of driver mutations among the three monocyte categories. [Display omitted] DisclosuresNo relevant conflicts of interest to declare.

Prefibrotic Versus Overtly Fibrotic Primary Myelofibrosis: Clinical, Cytogenetic, Molecular and Prognostic Comparisons

BackgroundThe 2016 revised World Health Organization (WHO) classification system distinguishes prefibrotic (pre-PMF) from overtly fibrotic (overt PMF) primary myelofibrosis, based on the respective absence or presence of grade ≥2 bone marrow (BM) reticulin fibrosis (Blood. 2016;127:2391). The main objective of the current study was to determine the prognostic relevance of this distinction and compare clinical and genetic features between the two entities.MethodsStudy patients fulfilled the 2016 WHO criteria for the diagnosis of pre-PMF or overt PMF (Blood. 2016;127:2391). The degree of BM reticulin fibrosis was based on "real life" BM reports from Mayo Clinic hematopathologists and often in accordance with the European consensus scoring system (Haematologica 2005;90:1128). Targeted next generation sequencing was used to screen for prognostically-relevant mutations (Blood 2015 126:354). Statistical analyses considered clinical and laboratory parameters obtained at time of BM examination that was graded for reticulin fibrosis.ResultsPatient characteristics:Analysis was conducted on 467 patients (median age 64 years; 62% males), including 63 with pre-PMF and 404 with overt PMF. 302 (65%) patients harbored JAK2 mutations, 90 (19%) CALR, 24 (5%) MPL and 51 (11%) were "triple-negative"; among the 90 CALR-mutated cases, 74 (82%) were classified as "type 1/type 1-like". Dynamic international prognostic scoring system (DIPSS)-plus risk distribution (JCO 2011;29:392) was 30% high, 38% intermediate-2, 16% intermediate-1 and 15% low; 29% displayed red cell transfusion-dependency, 29% constitutional symptoms, 70% palpable splenomegaly and 37% abnormal karyotype, including 13% with unfavorable karyotype. 308 patients were screened for ASXL1 mutations with 39% mutated, 305 for SRSF2 mutations with 16% mutated, 291 for U2AF1 with 18% mutated, 264 for SF3B1 with 6% mutated, 240 for EZH2 with 5% mutated and 118 for IDH1/2 with 7% mutated. BM reticulin fibrosis was reported as grade '0' in 5 (1%) patients, grade '1' in 58 (12%), grade '2' in 169 (36%) and grade '3' in 235 (50%). After a median follow up of 3 years, 273 (59%) deaths and 42 (9%) leukemic transformations were documented.Clinical, cytogenetic and molecular comparisons between pre-PMF vs overt PMF:Significant differences included higher hemoglobin level (p<0.0001), higher platelet count (p<0.0001), higher incidence of thrombocytosis (p<0.0001), lower circulating blast percentage (p=0.0002), lower incidence of constitutional symptoms (p=0.003), lower incidence of palpable splenomegaly and lower DIPSS-plus risk distribution (p=0.0004), in pre-PMF, compared to overt PMF. There were significantly more triple-negative patients with pre-PMF (22% vs 9% for overt PMF; p=0.02) but otherwise no significant difference in the distribution of ASXL1, SRSF2, U2AF1, SF3B1, EZH2 or IDH1/2 mutations or incidence of unfavorable karyotype.Survival analysis:In univariate analysis, all 8 variables included in DIPSS-plus were significantly associated with shortened survival (p<0.001 in all instances). Significant risk factors in univariate analysis also included overt PMF vs pre-PMF (p=0.002; HR 2.0, 95% CI 1.3-3.1), absence of CALR type 1/type 1-like (p<0.0001) and presence of ASXL1 (p<0.0001) or SRSF2 (p<0.0001) mutations. The significant difference in survival between pre-PMF and overt PMF was independent of DIPSS-plus (p=0.03), driver mutational status (p=0.001), ASXL1 (p=0.008) and SRSF2 (p=0.02) mutations; no significant difference in leukemia-free survival was noted (p=0.25). The survival difference between pre-PMF and overt PMF was most evident in high/intermediate-2 DIPSS-plus risk groups (Figure). Of note, we found no difference in survival when patients with grade ’0’ were compared to those with grade ’1’ reticulin fibrosis (p=0.96) and when those with grade ’2’ were compared with grade ’3’ (p=0.08).ConclusionThe current study demonstrates the risk-adjusted prognostic relevance of the WHO distinction between pre-PMF and overt PMF. The two clinic-pathologic entities were otherwise similar in their spectrum of prognostically-relevant mutations or cytogenetic abnormalities, although pre-PMF clustered with thrombocythemic and triple-negative phenotype and overt PMF with adverse clinical features. [Display omitted] DisclosuresNo relevant conflicts of interest to declare.

Momelotinib Therapy in Myelofibrosis: 6-Years Follow-up Data on Safety, Efficacy and the Impact of Mutations on Overall and Relapse-Free Survival

Background:Momelotinib is a JAK 1/2 inhibitor that is active in the treatment of myelofibrosis (MF); a previous phase 1/2 study included 100 consecutive patients from the Mayo Clinic (Leukemia. 2015;29:741). In the current long-term study of these 100 patients, we provide a cumulative account of short and long term efficacy and toxicity data, as well as survival analysis.Methods:The current study represents sponsor-independent analysis. The study patients are part of a larger (n=166) phase-1/2 momelotinib study (NCT00935987), which was conducted in two dose-escalation (100 mg-400 mg daily doses) and dose-confirmation (300 mg daily dose) phases. Adverse events (AEs) were monitored by Common Terminology Criteria for Adverse Events (Version 4.03) and responses by the International Working Group criteria (Blood. 2013;122:1395). All statistical analyses considered clinical and laboratory parameters obtained at the time of entry to study.Results:Baseline data: 100 patients with MF (median age 66 years; 58% males) were treated between 11/20/09 and 11/10/10; 64 patients had primary MF, 22 post-polycythemia vera MF and 14 post-essential thrombocythemia MF. 73 (73%) patients harbored JAK2 mutations, 16 (16%) CALR, 7 MPL and 4 were "triple-negative"; among the 16 CALR-mutated cases, 13 were classified as "type 1/type 1-like". DIPSS-plus risk distribution (JCO 2011;29:392) was 63% high, 36% intermediate-2 and 1% intermediate-1; 49% displayed red cell transfusion-dependency, 58% constitutional symptoms, 87% palpable splenomegaly >5 cm and 50% abnormal karyotype. 94 patients were screened for ASXL1 mutations with 41 (44%) mutated and 78 for SRSF2 mutations with 14 (18%) mutated. 21 (21%) patients were previously treated with another JAK inhibitor.Current disposition: All information was updated in July 2016. To-date, after a median follow-up of 3.2 years, 88 drug discontinuations, 70 deaths and 14 leukemic transformations have been documented; median follow-up for living patients was 5.7 years (range 5.1-6.4). Among the 30 patients who are currently alive, 12 remain on study and another 5 have received stem cell transplant.Toxicity data: After a median treatment duration of 1.7 years, "momelotinib related" grade 3 or 4 AEs included thrombocytopenia (34%), neutropenia (9%), anemia (5%), increased lipase (7%), increased ALT (4%), increased AST (2%), increased ALP (2%) and headaches (2%). In addition, noteworthy grade 1 or 2 AEs included peripheral neuropathy (PN) 47%, increased lipase (14%), increased amylase (17%), increased bilirubin (13%), increased AST (21%), increased ALT (19%), increased APTT (17%), headaches (13%), dizziness (22%), nausea (23%) and diarrhea (20%). Most of the AEs, except PN, were reversible.Efficacy data and predictors of response and relapse-free survival: Clinical improvement (CI) was documented in 57% of patients, anemia response in 44%, and spleen response in 43%. 51% of transfusion-dependent patients became transfusion independent. The majority of patients also had marked improvement in their symptoms. 46 (81%) of the 57 responding patients discontinued treatment after a median treatment duration of 2.3 years. ASXL1 mutations predicted inferior CI (p=0.03) whereas relapse-free survival was adversely affected by absence of type 1/type 1-like CALR (p=0.03) or presence of unfavorable karyotype (p=0.002); among the 11 responding patients currently still receiving the drug, all had favorable karyotype and 5 had type 1/type 1-like CALR mutations.Survival analysis and risk factors: Median survival, calculated from the time of study entry, was 3.2 years with 5-year survival rate of 32%. In multivariable analysis of genetic markers, absence of type 1/type 1-like CALR (HR 2.9, 95% CI 1.1-7.2) or presence of SRSF2 (2.9, 1.5-5.4) or ASXL1 (1.8, 1.1-3.2) mutations were independently predictive of shortened survival (Figure).Conclusions:Momelotinib therapy in MF provides effective palliation in terms of anemia, splenomegaly and constitutional symptoms. However, less than 20% of treated patients enjoy durable long-term benefit and almost half experience drug-related and mostly irreversible peripheral neuropathy. Long-term survival and durability of response were superior in patients with type 1/type 1-like CALR mutations and inferior in those with ASXL1/SRSF2 mutations or unfavorable karyotype. [Display omitted] DisclosuresAl-Kali:Onconova Therapeutics, Inc.: Research Funding; Celgene: Research Funding.

Primary myelofibrosis: 2017 update on diagnosis, risk-stratification, and management.

Diagnosis is based on bone marrow morphology. The presence of JAK2, CALR or MPL mutation is supportive but not essential for diagnosis; approximately 90% of patients carry one of these mutations and 10% are "triple-negative." None of these mutations are specific to PMF and are also seen in essential thrombocythemia (ET). According to the revised 2016 World Health Organization (WHO) classification and diagnostic criteria, "prefibrotic" PMF (pre-PMF) is distinguished from "overtly fibrotic" PMF; the former might mimic ET in its presentation and it is prognostically relevant to distinguish the two. Risk stratification: The Dynamic International Prognostic Scoring System-plus (DIPSS-plus) uses eight predictors of inferior survival: age >65 years, hemoglobin <10 g/dL, leukocytes >25 × 109 /L, circulating blasts ≥1%, constitutional symptoms, red cell transfusion dependency, platelet count <100 × 109 /L and unfavorable karyotype (i.e., complex karyotype or sole or two abnormalities that include +8, -7/7q-, i(17q), inv(3), 5/5q-, 12p-, or 11q23 rearrangement). The presence of 0, 1, "2 or 3" and ≥4 adverse factors defines low, intermediate-1, intermediate-2 and high-risk disease with median survivals of approximately 15.4, 6.5, 2.9 and 1.3 years, respectively. Most recently, DIPSS-plus-independent adverse prognostic relevance has been demonstrated for certain mutations including ASXL1 and SRSF2 whereas patients with type 1/like CALR mutations, compared to their counterparts with other driver mutations, displayed significantly better survival. Risk-adapted therapy: Observation alone is a reasonable treatment strategy for asymptomatic low or intermediate-1 DIPSS-plus risk disease, especially in the absence of high-risk mutations. All other patients with high or intermediate-2 risk disease, or those harboring high-risk mutations such as ASXL1 or SRSF2, should be considered for stem cell transplant, which is currently the only treatment modality with the potential to favorably modify the natural history of the disease. Non-transplant candidates should be encouraged to participate in clinical trials, since the value of conventional drug therapy, including the use of JAK2 inhibitors, is limited to symptoms palliation and reduction in spleen size. Specifically, JAK2 inhibitors have not been shown to induce complete clinical or cytogenetic remissions or significantly affect JAK2/CALR/MPL mutant allele burden. Splenectomy is considered for drug-refractory splenomegaly. Involved field radiotherapy is most useful for post-splenectomy hepatomegaly, non-hepatosplenic EMH, PMF-associated pulmonary hypertension and extremity bone pain. Am. J. Hematol. 91:1262-1271, 2016. © 2016 Wiley Periodicals, Inc.

Telomere Gene Complex Mutations Are Frequently Found with Shortened Telomeres in Bone Marrow Failure Syndromes and Idiopathic Pulmonary Fibrosis; Correlation with Haematological and Clinical Features

Shortened telomeres are seen in approximately a quarter of patients with idiopathic pulmonary fibrosis (IPF) and aplastic anemia (AA) and may have a role in disease pathogenesis. Mutations in the telomere gene complex (TGC) are less frequently seen in IPF (1%) and 5-10% in AA. Novel mutations affecting telomere function are increasingly being reported and involve the telomerase genes, the shelterin and helicase complexes, but their prognostic significance remains undefined. We report results on telomere length (TL) using multiplex quantitative real-time PCR (qPCR) and mutation analysis on a customised panel of 10 TGC genes (TERT, TERC, DKC1, TINF2, NHP2, NOP10, RTEL1, CTC1, USB1 and WRAP) using deeply parallel sequencing in a cohort of 69 patients with AA and IPF and their effects on clinical variables and response rates.69 patients (49 with AA, 14 with IPF and 6 with a bone marrow failure syndrome (BMFS) and pulmonary fibrosis; M/F =43/26) with a median age of 49.7 years (range 9-81) had TL (T/S ratio) tested using qPCR on peripheral blood mononuclear cells at diagnosis or pre-treatment. Massively parallel targeted sequencing of the TGC was performed in all cases and constitutional mutations identified using the exome variant server. Clinical variables studied included hemoglobin (Hb) level, neutrophil count (ANC), platelet count (PC), LDH and albumin levels, and response rates to immunosuppressive treatment (IST). In patients with AA and other BMFS, red cell and platelet transfusion dependency, bone marrow cellularity (<30), cytogenetics and p53 (Modified Quick score >1) on bone marrow (BM) staining were correlated with TL and presence of any TGC mutations. In patients with IPF, corrected transfer factor (Kco) was correlated with TL and mutation analysis.44/69 (64%) had TL below the 1st centile and 20 (29%) of them had TL very significantly below the 1st centile compared to a normal cohort (n=180) of age-matched individuals. Median Hb was (11g/dl), ANC was 1.69 and PC was 96x109/l. There was no statistical difference between patients whose TL was below or above the 1st centile for Hb levels, reticulocyte count or PC. 24 patients (34.7%) were red cell transfusion dependent and 15(21.7%) needed platelet transfusions. 42/55 (76.3%) had BM cellularity < 30% and was not statistically significant between patients with TL above or below the 1st centile. Similarly there was no statistical difference in LDH and albumin levels between the two groups. Equal number of patients were treated with IST between the two groups and response rates were similar. Median levels of Kco (0.95) were identical in IPF patients. 62 (89.8%) of patients were alive at a median follow up of 2.15 years (range 0.3-26.8).TGC mutations were seen 16 patients (23%) in the entire cohort with 13/44 (30%) were seen where TL was below the 1st centile as compared to 3/25 (12%) where TL was above the 1st centile (p<0.14). 11 patients had TERT (all missense), 4 TERC (non-coding transcript) and 1 RTEL mutations were identified. TERT A279T was the commonest mutation seen, in 4 patients.In our cohort, about two-thirds of patients had TL below the 1st centile. TL, however, does not affect blood counts, BM cellularity and p53 staining, red cell or platelet transfusion dependency or Kco in patients with IPF. A higher proportion of patients with TL below the 1st centile were found to have TGC mutations, although statistical significance was not achieved. Missense mutations in TERT were the most frequent followed by mutations in TERC. Patients with TL <1st centile were diagnosed at a younger age, and where TGC mutations were present, were also likely to show other features of telomereopathy.TableVariableTL < 1st centileTL > 1st centileMale/Female (Total)29/15 (44)14/11 (25)Age < 40 years at diagnosis23 (52.2%)7 (28%)TGC mutations %3012Hb (g/dl)1111.2Reticulocyte count ( x 10*9/L)5257ANC ( x 10*9/L)1.692.79PC ( x 10*9/L)90139Albumin g/dl4242LDH (IU)211210AA/BMFS3718Red cell transfusion dependency %3644.4Platelet transfusion dependency %18.138.8%Cytogenetic abnormality %15.60BM cellularity < 30% %77.772.2P53 (Modified quick score >1) %34.740Treatment with IST Response %23 (62.1%) 69.5%11 (64.7%) 72.7%IPF77Kco0.95 (0.6-1.9)0.95 (0.8-1.2) DisclosuresKulasekararaj:Alexion Pharmaceuticals: Speakers Bureau.

Comparison of the Impact of Two Different Definitions of Red-Cell Transfusion Dependence on the Natural History of Myeloproliferative Neoplasm (MPN)-Associated Myelofibrosis (MF)

The current definitions of red-cell transfusion dependence (TD) for MPN-associated MF are based on expert opinion. The optimal definition of TD, and its impact on the natural history of MF is not well studied. We evaluated the impact of two definitions of red-cell TD on the natural history of 306 patients (pts.) with WHO/IWG-MRT-defined primary MF (PMF, n=202, 66%), post-polycythemia vera MF (PPV-MF, n=45, 15%) or post-essential thrombocythemia MF (PET-MF, n=59, 19%).Red-cell TD was defined according to IWG-MRT 2006 criteria (Tefferi et al, Blood, 2006), and on the results of the expert consensus RAND-Delphi panel (Gale et al, Leukemia Research, 2011). The IWG-MRT criteria require patients to have received ≥2 Units (U) packed red blood cells (PRBC) in the preceding 28 days for hemoglobin (Hb) <85 g/l. On the other hand, the more stringent Gale definition requires patients to receive ≥2 U of PRBC per month over 3 months without any specification for the Hb level. Patients were evaluated for disease risk stratification according to dynamic international prognostic scoring system (DIPSS), co-morbidities according to ACE-27, and red-cell TD at their first presentation to Princess Margaret Cancer Center or diagnosis.The study cohort was divided in 4 groups (gp.): Non-transfusion dependent (NTD) pts. with Hb ≥100 g/dl (gp1, n=156, 51%); patients with Hb <100 g/dl, but no transfusion in preceding 12 weeks (gp2, n=65, 21%); pts. qualifying IWG-MRT 2006 criteria of TD, but not qualifying Gale definition (gp3, n=41, 13%); and pts. qualifying the Gale definition of TD (gp4, n=44, 14%). There was no significant difference among the 4 groups with relation to age, disease distribution (primary vs. secondary), cytogenetics, blasts%, and ACE-27 co-morbidity scores. There was significant difference in the gp1, gp2, gp 3, and gp4 in relation to constitutional symptoms (35% vs. 45% vs. 46% vs.64%, p=0.006), median WBC count (x109/L) (11.5 vs. 8.3 vs. 6.8 vs. 6.5, p<0.0001), platelets (x109/l) (317 vs. 154 vs. 124 vs. 127, p<0.0001), and Int-2/high DIPSS (24% vs. 82% vs. 90% vs. 82%, p<0.0001).In a univariate analysis, probability of survival among the 4 groups at 3-years was 80%, 55%, 68%, 30%, respectively (Fig 1, p=0.0016). No difference in leukemic transformation was observed among the 4 groups (p=0.68). In a multivariate analysis, after adjusting for DIPSS and co-morbidity scores, hazard ratios among the gp2, gp3, and gp 4 were 1.58 (95% CI 0.78-3.19, p=0.21), 2.17 (95% CI 0.88-5.34, p=0.09), 2.82 (95% CI 1.29-6.16, p=0.009) in comparison to gp 1 (ref. group). There was no significant difference between NTD patients with Hb <100 vs. TD patients according to IWG-MRT 2006 criteria, but not meeting Gale Criteria (p=0.47). DIPSS was the only other independent prognostic factor for survival.Our study shows the independent prognostic impact of TD on survival defined according to Gale criteria, but not according to previous IWG-MRT 2006 definition, which does not meet Gale criteria. No impact of anemia or TD was observed on leukemic transformation. [Display omitted] DisclosuresSchuh:Celgene: Membership on an entity’s Board of Directors or advisory committees.

Genetic Determinants of Response and Survival in Momelotinib Treated Myelofibrosis Patients

Background: Momelotinib is a JAK1 and JAK2 inhibitor that is currently being evaluated in phase-3 clinical trials for the treatment of myelofibrosis (MF) (NCT01969838, NCT02101268). In a phase-1/2 clinical trial of patients with MF, the drug was shown to improve anemia, reduce spleen size and alleviate symptoms (Leukemia 2013;27:1322). In the current study, we considered 100 consecutive patients from the Mayo Clinic who received momelotinib therapy, in order to identify molecular and cytogenetic predictors of treatment response and survival from the time of study entry.Methods: The study patients constituted part of a phase-1/2 clinical trial (NCT00935987) using momelotinib in MF. Details of the protocol, including inclusion and exclusion criteria were previously published (Leukemia 2013;27:1322). Response was determined by the 2006 response criteria published by the IWG-MRT. Data analysis and interpretation was carried out independent of any influence from the sponsor.Results: 100 patients with MF (median age 66 years; 58% males) were treated at the Mayo Clinic between 11/20/09 and 11/10/10. MF type was primary in 64% of the patients and post-polycythemia vera/essential thrombocythemia in 36%. DIPSS-plus risk distribution was 63% high, 36% intermediate-2 and 1% intermediate-1. Red cell transfusion dependency was documented in 49% and palpable spleen size of >5 cm (median 19 cm) in 92%. All patients were annotated for JAK2/CALR/MPL mutations with respective frequencies of 73%, 16% and 7%. Frequencies for other mutations included 42% for ASXL1 (84 evaluable) and 18% for SRSF2(78 evaluable). All patients were evaluable for karyotype, which was unfavorable in 17%.Previous treatment included other JAK inhibitors in 21 patients, thalidomide/lenalidomide/pomalidomide in 31 and hydroxyurea or other cytoreductive agents in 55. Momelotinib was initiated at 100 mg/day in 3 patients, 150 mg/day in 21, 150 mg twice-daily in 20, 200 mg/day in 3, 300 mg/day in 47 and 400 mg/day in 6. The maximum momelotinib dose was 150 mg/day in 6 patients, 150 mg twice-daily in 20, 300 mg/day in 68 and 400 mg/day in 6. Treatment duration was <6 months in 12 patients, 6-12 months in 22, 12-24 months in 19 and >24 months in 47.Genetic correlates of response to momelotinib: Overall response rate was 57% and included no complete remissions (0%), one (1%) partial remission and 57 (57%) clinical improvements (CI). Response rates for spleen/liver and anemia were 43% (91 evaluable) and 44% (68 evaluable), respectively. Transfusion independency was achieved in 25 (51%) of 49 evaluable cases. Spleen/liver response rate was significantly affected by JAK2/CALR/MPL mutational status (34% vs 73% vs 60%, respectively, and 50% in triple-negative; p=0.04), CALR mutated vs unmutated status (73% vs 37%; p=0.009), and unmutated vs mutated ASXL1 (53% vs 29%; p=0.035). Furthermore, all 8 (100%) patients who were CALR+/ASXL1- responded vs 6 (25%) of 24 CALR-/ASXL1+ vs 3 (50%) of 6 CALR+/ASXL1+ vs 16 (43%) of 37 CALR-/ASXL1- patients (p=0.003). Spleen/liver response rates were not affected by SRSF2 mutations (p=0.93) or karyotype (p=0.41). Anemia response rate was not affected by JAK2/CALR/MPL (p=0.81), ASXL1 (p=0.16), SRSF2 (p=0.12) or CALR/ASXL1 (p=0.42) mutational status or karyotype (p=0.65). The number of informative cases for EZH2, IDH, SF3B1 and U2AF1mutations were not adequate enough to warrant similar analysis.Genetic correlates of survival from time of protocol entry: Median follow-up after the institution of protocol drug therapy was 35 months (range 1-49). During this period, 57 (57%) deaths and 12 (12%) leukemic transformations were documented. On multivariable analysis, shortened survival was predicted by the presence of ASXL1 (p=0.01; HR 2.1, 95% CI 1.2-3.8) or SRSF2 (0.01; HR 2.4, 95% CI 1.2-4.8) mutations and the absence of CALR mutations (p=0.03; HR 3.2, 95% CI 1.1-8.9). Karyotype was significant on univariate (p=0.01) but not in multivariable (p=0.6) analysis that included the aforementioned mutations. The prognostic relevance of each specific mutation was DIPSS-plus independent.Conclusions: We demonstrate significant associations between CALR and ASXL1 mutational status and spleen response to momelotinib therapy in MF. We also show that momelotinib therapy did not overcome the inferior survival associated with the presence of ASXL1 or SRSF2 mutations or the absence of CALR mutations. DisclosuresNo relevant conflicts of interest to declare.

Primary myelofibrosis: 2014 update on diagnosis, risk-stratification, and management.

Primary myelofibrosis (PMF) is a myeloproliferative neoplasm characterized by stem cell-derived clonal myeloproliferation, abnormal cytokine expression, bone marrow fibrosis, anemia, splenomegaly, extramedullary hematopoiesis (EMH), constitutional symptoms, cachexia, leukemic progression, and shortened survival. DIAGNOSIS is based on bone marrow morphology. The presence of JAK2, CALR, or MPL mutation is supportive but not essential for diagnosis; approximately 90% of patients carry one of these mutations and 10% are "triple-negative." None of these mutations are specific to PMF and are also seen in essential thrombocythemia (ET). Prefibrotic PMF mimics ET in its presentation and the distinction, enabled by careful bone marrow morphological examination, is prognostically relevant. Differential diagnosis also includes chronic myeloid leukemia, myelodysplastic syndromes, chronic myelomonocytic leukemia, and acute myeloid leukemia. The Dynamic International Prognostic Scoring System-plus (DIPSS-plus) uses eight predictors of inferior survival: age >65 years, hemoglobin <10 g/dL, leukocytes >25 × 10(9) /L, circulating blasts ≥1%, constitutional symptoms, red cell transfusion dependency, platelet count <100 × 10(9) /L, and unfavorable karyotype (i.e., complex karyotype or sole or two abnormalities that include +8, -7/7q-, i(17q), inv(3), -5/5q-, 12p-, or 11q23 rearrangement). The presence of 0, 1, "2 or 3," and ≥4 adverse factors defines low, intermediate-1, intermediate-2, and high-risk disease with median survivals of approximately 15.4, 6.5, 2.9, and 1.3 years, respectively. High risk disease is also defined by CALR(-) /ASXL1(+) mutational status. Observation alone is adequate for asymptomatic low/intermediate-1 risk disease, especially with CALR(+) /ASXL1(-) mutational status. Stem cell transplant is considered for DIPSS-plus high risk disease or any risk disease with CALR(-) /ASXL1(+) mutational status. Investigational drug therapy is reasonable for symptomatic intermediate-1 or intermediate-2 risk disease. Splenectomy is considered for drug-refractory splenomegaly. Involved field radiotherapy is most useful for post-splenectomy hepatomegaly, non-hepatosplenic EMH, PMF-associated pulmonary hypertension, and extremity bone pain.

Pure Red Cell Aplasia In Major ABO Mismatched Allogeneic Hematopoietic Cell Transplantation Is Associated With Severe Pancytopenia

IntroductionThe persistence of anti-donor isohemagglutinins in Major ABO mismatched allogeneic stem cell transplantation (HCT) leads to pure red cell aplasia (PRCA). In our previous report of 12 patients with PRCA, severe pancytopenia was observed in one patient who eventually had a second transplant (Aung et al. B J Haematol 2013 Mar; 160(6):798-805). Furthermore, ABO antigens are expressed on or adsorbed from plasma on granulocyte and platelets and these may be affected by isohemagglutinins. To further investigate this observation we analyzed a larger cohort of patients with PRCA to determine the frequency of pancytopenia and natural history of pancytopenia in patients with PRCA after Major ABO incompatible HCT. Patients and MethodsWe reviewed 758 patients who received a Major ABO-mismatched HCT between January 2003 and December 2012 at our institution. Pure red call aplasia was determined to be present when the bone marrow biopsy on post-transplant day 30 demonstrated absent or nearly absent erythroid precursors with absence of donor red cells on forward red cell typing of the recipient and the recipient being red cell transfusion dependent. Pancytopenia was defined as ANC < 1.5 x 109/L or requiring G-CSF, Platelets < 50 x 109/L or transfusion dependent, and PRCA with red cell transfusion dependence as above at 90 days after allogeneic SCT. Results83 patients had PRCA. Of these 16 (19%) had pancytopenia at day 90 after transplant. None of these patients had any other reason for persistent pancytopenia like CMV or other viral infection or use of drugs like ganciclovir or disease recurrence. On post-transplant day 90, median absolute neutrophil counts (ANC) was 1.01 K/UL with 15 (94%) patients having intermittent G-CSF and median platelet count was 14 KL/UL (range 6-49) with 13(81%) patients platelet transfusion dependent. All patients were red cell transfusion dependent. Of the 16 PRCA patients with pancytopenia, 2 (12%) received a second transplant due to persistent pancytopenia/graft failure and 2 (12%) relapsed. 2 (12%) patients have still not recovered their platelet counts despite red cell and ANC recovery.In the remaining 10 (63%) patients, neutropenia and thrombocytopenia resolved after resolution of PRCA. Red cell recovery occurred at a median of 226 (95-549) days post transplant, ANC recovered at median of 325 (105-1080) days post-transplant, and Platelets recovered at median of 296 (94-2738) days post-transplant. ConclusionSevere pancytopenia is frequently (19%) associated with PRCA in Major ABO incompatible HCT. Neutropenia and thrombocytopenia resolve after resolution of red cell aplasia in the majority of patients. Disclosures:Andersson:Otsuka Pharmaceuticals: Research Funding. Qazilbash:Celgene: Membership on an entity's Board of Directors or advisory committees; Millennium: Membership on an entity's Board of Directors or advisory committees. Shah:Celgene: Membership on an entity's Board of Directors or advisory committees, Research Funding.

Patient Characteristics Associated With Receiving Hematopoietic Stem Cell Transplantation In An Older, Transplant-Appropriate MDS Cohort: The MDS-TAO Study

BackgroundThe factors that influence utilization of reduced-intensity conditioning hematopoietic stem cell transplantation (RIC HSCT) for “fit” elderly patients with advanced myelodysplastic syndromes (MDS) remain unclear. MethodsThe “MDS Transplant-Associated Outcomes Study,” or “MDS-TAO,” is a prospective longitudinal observational study which began at the Dana-Farber/Harvard Cancer Center in May of 2011. It is designed to examine survival, quality of life (QoL), and other outcomes for RIC HSCT versus non-HSCT approaches for HSCT-appropriate MDS patients ages 60 to 75. Inclusion criteria include: histologically-confirmed diagnosis of MDS or CMML, and at least one of the following: (1) therapy-related disease, or (2) intermediate-2/high risk IPSS (Greenberg, 1997), or (3) intermediate/poor-prognosis risk cytogenetics (Haase, 2007), or (4) severe and sustained anemia or thrombocytopenia, or (5) platelet or red cell transfusion dependence. Exclusions include: (1) comorbidities that in the judgment of the enrolling clinician preclude HSCT eligibility (2) prior donor search, and (3) patient unwillingness to consider HSCT. For this analysis, time to HSCT was estimated using Kaplan-Meier methods, and log rank tests were used to assess time to HSCT by age, gender, ECOG performance status, IPSS, IPSS cytogenetic risk group, and baseline EORTC QLQ-C30 global QoL and fatigue scores. ResultsAs of April 30, 2013, 87 patients had been enrolled. The median age was 69 years, 66% were male, and 88% had an ECOG performance status of 0 or 1. As of July 15, 2013, 22 had received HSCT within a median of 4.0 months (range 2-10 months) from study enrollment, and 17 had died without receiving HSCT. The 9-month probability of having had a transplant was 31% (95% CI [21% to 44%]). The median global QoL score was 66.7 and the median fatigue score was 33.3 (published medians are 66.7 and 33.3 for other cancers; higher global QoL scores indicate superior QoL whereas higher fatigue scores indicate worse fatigue). MDS-TAO patients with poorer cytogenetics (p<.001) and worse IPSS at enrollment (p<.001) were more likely to undergo HSCT. Age showed a complex relationship (p=.03), with those aged 65-70 most likely to undergo HSCT (34%), followed by those aged 60-65 (33%), and those aged >70 (11%). Female gender (p=.10), performance status (p=.14), global QoL (p=.56; see figure), and fatigue score (p=.58; see figure) all showed no significant association with the likelihood of undergoing HSCT. [Display omitted] [Display omitted] ConclusionOur data suggest that while older transplant-appropriate MDS patients suffer from similar QoL impairment as compared to other cancer patients, cytogenetics and IPSS likely have more influence than patient-reported QoL in influencing which patients ultimately receive HSCT. Disclosures:No relevant conflicts of interest to declare.