Single Autologous Transplantation Research Articles

Comparison of autologous and allogeneic hematopoietic cell transplantation strategies in patients with primary plasma cell leukemia, with dynamic prediction modeling.

Primary plasma cell leukemia (pPCL) is a rare and challenging malignancy. There are limited data regarding optimum transplant approaches. We therefore undertook a retrospective analysis from 1998-2014 of 751 patients with pPCL undergoing one of four transplant strategies; single autologous transplant (single auto), single allogeneic transplant (allo-first) or a combined tandem approach with an allogeneic transplant following an autologous transplant (auto-allo) or a tandem autologous transplant (auto-auto). To avoid time bias, multiple analytic approaches were employed including Cox models with time-dependent covariates and dynamic prediction by landmarking. Initial comparisons were made between patients undergoing allo-first (n=70) versus auto-first (n=681), regardless of a subsequent second transplant. The allo-first group had a lower relapse rate (45.9%, 95% confidence interval [95% CI]: 33.2-58.6 vs. 68.4%, 64.4-72.4) but higher non-relapse mortality (27%, 95% CI: 15.9-38.1 vs. 7.3%, 5.2-9.4) at 36 months. Patients who underwent allo-first had a remarkably higher risk in the first 100 days for both overall survival and progression-free survival. Patients undergoing auto-allo (n=122) had no increased risk in the short term and a significant benefit in progression-free survival after 100 days compared to those undergoing single auto (hazard ratio [HR]=0.69, 95% CI: 0.52- 0.92; P=0.012). Auto-auto (n=117) was an effective option for patients achieving complete remission prior to their first transplant, whereas in patients who did not achieve complete remission prior to transplantation our modeling predicted that auto-allo was superior. This is the largest retrospective study reporting on transplantation in pPCL to date. We confirm a significant mortality risk within the first 100 days for allo-first and suggest that tandem transplant strategies are superior. Disease status at time of transplant influences outcome. This knowledge may help to guide clinical decisions on transplant strategy.

Engraftment Syndrome in the Setting of Autologous Stem Cell Transplantation for Multiple Myeloma-a Single Institution Review of over 600 Patients

Engraftment Syndrome in the Setting of Autologous Stem Cell Transplantation for Multiple Myeloma-a Single Institution Review of over 600 Patients

TEM-MM-101: A Phase I/IIa Dose Escalation Study Evaluating the Safety and Activity of Autologous CD34+ Enriched Hematopoietic Progenitor Cells Genetically Modified for Human Interferon-α2 in Multiple Myeloma Patients with Early Relapse after Intensive Front Line Therapy

BACKGROUND Multiple Myeloma (MM) is an incurable malignancy heralded by an immunosuppressive tumor microenvironment (TME). Therapeutic efforts to reprogram the TME and release innate and adaptive immunity may synergize with current anti-MM drugs, deepen responses and ultimately prolong long-term survival. We have developed an ex vivo gene therapy approach that locally delivers interferon-alpha (IFNa) into the TME through the Tie2+ myeloid progeny of transplanted gene-modified hematopoietic stem and progenitor cells (HSPCs). Preclinical studies in the immunocompetent Vk*Myc murine model as well as in the hematochimeric xenotransplantation setting demonstrate that IFNa gene therapy has anti-MM effect and may subvert the immunosuppressive MM TME, acting both on myeloma cells as well as on the immune infiltrate. Additional toxicology data, demonstrates that a mixture of genetically modified and unmodified CD34+ cells can be transplanted safely. We have therefore progressed into the clinic at Ospedale San Raffaele in Milan, Italy, with our gene therapy approach (Temferon). METHODS The TEM-MM-101 study recruits patients with MM in early relapse (within 18 months) after intensive front line therapy defined as triplet induction (at least 3 cycles including a proteasome inhibitor and/or immunomodulatory drug [IMID]) followed by single or double autologous stem cell transplantation, or, triplet or quadruplet induction including at least a proteasome inhibitor and an IMID, followed by consolidation/maintenance treatment. Three cohorts of 3 patients will be included in the study. Patients will be dosed sequentially in each cohort with data review by an independent data monitoring committee before dose escalation to the next cohort. Key eligibility criteria include achieving at least a VGPR after second line salvage therapy, age 18-70 years, ECOG <2 and Karnofsky >70%, adequate cardiac, renal, hepatic and pulmonary function, and willingness to use appropriate contraception if relevant. Important exclusion criteria include the presence of active autoimmune disease or ineligibility for autologous bone marrow transplant. After confirmation of eligibility, patients undergo autologous peripheral blood HSPC mobilization with lenograstim and plerixafor, before undergoing apheresis. After purification, CD34+ cells undergo transduction with a third-generation, vesicular stomatitis virus-G pseudo-typed lentiviral vector driving myeloid-specific IFNa2 expression. Patients will be offered maintenance treatment from successful HSPC collection until Temferon release. A reduced intensity conditioning regimen is administered at Day -2 followed by ASCT and administration of Temferon at Day 0. Following hematological recovery, patients will be discharged from the Transplant Unit with regular outpatient follow up. After Day +100 from Temferon infusion, patients will resume anti-myeloma consolidation/maintenance treatment according to best clinical practice, unless there is Temferon engraftment and absence of disease on Day +100 evaluations, documented by stringent complete response (sCR) according to the IMWG response criteria, imaging (PET, MRI) negativity, and bone marrow minimal residual disease < 10-4 by multi-parameter flow cytometry, to be confirmed by next generation sequencing. If these response criteria are met on Day +100, patients may stay off maintenance treatment, as long as MRD≤10-5 documented on bone marrow aspirates performed every 3 months, starting from the Day +180 visit. The primary endpoints for this study are: Engraftment of Temferon between Day +30 and Day +100The proportion of patients achieving hematologic recovery by Day +30 from ASCTSafety of Temferon (short-term tolerability of Temferon; stable blood counts and absence of cytopenias > grade 2, unless related to myeloma progression or concomitant medications; absence of systemic IFNa toxicity; absence of Replication Competent Lentivirus; absence of hematologic malignancy that is distinct from progression of the primary neoplasm) The study is actively recruiting patients in Italy. In parallel, a study using Temferon in patients with glioblastoma multiforme with a similar study design and approach (TEM-GBM-001) is also in progress with the first cohort fully recruited. Disclosures Gentner: Genenta Science: Consultancy, Equity Ownership, Research Funding. Mazzoleni:Genenta Science: Employment, Equity Ownership. Russo:Genenta Science: Consultancy, Equity Ownership. Naldini:Genenta Science: Consultancy, Equity Ownership; Magenta Therapeutics: Equity Ownership; San Raffaele Telethon Institute for Gene Therapy (SR-TIGET), a joint venture between Fondazione Telethon and Ospedale San Raffaele (OSR): Other: Wiskott-Aldrich Syndrome (WAS) gene therapy was licensed to GlaxoSmithKline (GSK) in 2014. It was then licensed to Orchard Therapeutics (OTL) in April 2018. OTL is the current sponsor of the clinical trial..

Impact of Upfront Stem Cell Transplantation in Newly Diagnosed Multiple Myeloma with Del(17) and t(4;14): A Report from the EBMT Chronic Malignancies Working Party

Introduction Current consensus identifies translocations t(4;14), t(14;16), t(14;20), and del(17/17p) as high-risk cytogenetics in newly diagnosed multiple myeloma (NDMM). However, evidence on outcome of specific abnormalities according to types of transplant as first-line treatment is limited. We analyzed NDMM patients with del(17) and/or t(4;14) reported to the European Society for Blood and Marrow Transplantation (EBMT) registry undergoing either upfront single autologous (auto), tandem autologous (auto-auto) or tandem autologous/reduced-intensity allogeneic (auto-allo) stem cell transplantation. Methods Upfront transplantation was defined as first autologous transplant within 12 months from MM diagnosis and tandem transplant was defined as a second transplant (autologous or allogeneic) within 6 months from first transplant. Survival and cumulative incidence were calculated from date of first transplant (95% confidence interval) and analyses were performed using a landmark approach of patients who were alive and relapse-free by month 6. End points were progression-free survival (PFS), overall survival (OS), relapse and non-relapse mortality (NRM). Results Patients. Within the EBMT registry, 498 NDMM patients with del(17) (n=224), t(4;14) (n=229) or both (n=45) could be analyzed between 2000-2015. First-line auto was received by 337, auto-auto by 99 and auto-allo by 62 patients. Frequencies of del(17)/t(4;14)/or both were 39/51/10% in auto, 58/36/6% in auto-auto, and 55/35/10% in auto-allo (p=0.01). Median age was 60 years in auto and auto-auto, and 52 years in auto-allo (p Posttransplant outcome and cytogenetics.The median follow-up of all patients was 57 months (55 months for auto, 57 months for auto-auto, and 64 months for auto-allo). 5-year PFS according to transplant was 18% (12-23) for auto, 32% (22-43) for auto-auto, and 32% (19-45) for auto-allo (p=0.11) and 5-year OS was 47% (41-54) for auto, 51% (40-63) for auto-auto, and 65% (51-78) for auto-allo (p=0.28). Relapse incidence was 82% (77-87) for auto, 63% (53-74) for auto-auto, and 58% (44-72) for auto-allo (p=0.002) while NRM was 1%, 4%, and 10%. PFS and OS according to cytogenetics was 24% and 58% for del(17), 22% and 42% for t(4;14), and 19% and 55% for presence of both. When stratified according to cytogenetics and transplant, PFS in del(17) was 21% (12-29) for auto, 26% (13-39) for auto-auto, and 30% (13-47) for auto-allo (p=0.78) while OS was 56% (45-67) for auto, 56% (41-70) for auto-auto, and 67% (50-84) for auto-allo (p=0.74). Relapse incidence and NRM were 79% and 1% for auto, 70% and 4% for auto-auto, and 64% and 6% for auto-allo. Single autologous transplant showed significantly worse PFS in t(4;14) resulting in 15% (8-22) compared with 45% (26-63) for auto-auto, and 39% (16-61) for auto-allo (p=0.05). OS was 39% (30-48) for auto, 37% (13-60) for auto-auto, and 63% (38-88) for auto-allo. Relapse incidence was also significantly higher in auto showing 84% (77-91) in comparison with 49% (30-67) for auto-auto and 52% (29-75) for auto-allo (p=0.004). Multivariable analysis. A Cox regression was fitted to compare types of transplant after adjusting for cytogenetics, sex, age, ISS, and remission status. Subsequently, auto-auto (hazard ratio, 0.66) and auto-allo (hazard ratio, 0.58) were associated with better PFS while auto-allo appeared to result in better OS (hazard ratio, 0.71) in comparison with single autologous transplant. Both auto-auto and auto-allo were significantly associated with lower incidence of relapse after fitting a Fine and Gray model (p Conclusion In NDMM patients undergoing upfront transplantation, PFS and relapse incidence were improved in patients specifically with del(17) and t(4;14) receiving tandem autologous or autologous/reduced-intensity allogeneic transplant. Disclosures Leleu:Janssen: Consultancy, Honoraria, Membership on an entity9s Board of Directors or advisory committees; Takeda: Consultancy, Honoraria, Membership on an entity9s Board of Directors or advisory committees; Novartis: Consultancy, Honoraria, Membership on an entity9s Board of Directors or advisory committees; Amgen: Consultancy, Honoraria, Membership on an entity9s Board of Directors or advisory committees; Roche: Consultancy, Honoraria, Membership on an entity9s Board of Directors or advisory committees; Karyopharm: Consultancy, Honoraria, Membership on an entity9s Board of Directors or advisory committees; Incyte: Consultancy, Honoraria, Membership on an entity9s Board of Directors or advisory committees; Gilead: Consultancy, Honoraria, Membership on an entity9s Board of Directors or advisory committees; Abbvie: Consultancy, Honoraria, Membership on an entity9s Board of Directors or advisory committees; BMS: Consultancy, Honoraria, Membership on an entity9s Board of Directors or advisory committees; Merck: Consultancy, Honoraria, Membership on an entity9s Board of Directors or advisory committees; Mundipharma: Consultancy, Honoraria, Membership on an entity9s Board of Directors or advisory committees; Celgene: Consultancy, Honoraria, Membership on an entity9s Board of Directors or advisory committees. Kobbe:Amgen: Honoraria, Research Funding; Roche: Honoraria, Research Funding; Celgene: Honoraria, Other: Travel Support, Research Funding. Rambaldi:Novartis: Consultancy; Italfarmaco: Consultancy; Celgene: Consultancy; Roche: Consultancy; Pfizer: Consultancy; Omeros: Consultancy; Amgen Inc.: Consultancy. Garderet:Amgen: Consultancy; Takeda: Consultancy; Celgene: Consultancy. Kroeger:Novartis: Honoraria, Research Funding; Sanofi: Honoraria; Riemser: Honoraria, Research Funding; Celgene: Honoraria, Research Funding; Neovii: Honoraria, Research Funding; JAZZ: Honoraria.

Tandom Autologous Transplantation and Combined Infusion of CD19 and Bcma-Specific Chimeric Antigen Receptor T Cells for High Risk MM: Initial Safety and Efficacy Report from a Clinical Pilot Study

Background: Multiple myeloma (MM) is an incurable plasma cell malignancies despite the advent of numerously new drugs. Survival was poor particularly for high risk patients such as R-ISS stage III. The preliminary data from our center showed that the median PFS after auto-HSCT was 24 months for patients with R-ISS III stage, while 17 months for patients that achieved PR or less after induction. Chimeric antigen receptor (CAR)-transduced T cells is a promising strategy for cancer immunotherapy. Our previous study showed good response for RRMM patients after CD19 and BCMA-specific CART therapy without severe CRS and other deadly side effects. To improve the survival of high risk patients, this study was designed to observe the safety and efficacy of combined infusion of CD19 and BCMA-specific CART cells after autologous transplantation (SZ-MM-CART02 study, NCT 03455972).Methods:18-65y NDMM in R-ISS stage III, or who only achieved PR or less after 4 cycles of PAD triplet induction were enrolled with serum creatinine (Cr) <2.0 mg/dL, and adequate hepatic, cardiac and pulmonary function. BCMA and CD19 expression on MM cells were analyzed by flow cytometry. Lymphocytes were collected from PBSCs and cultured with an anti-CD3 monoclonal antibody to activate T-cell proliferation. The cells were transduced with recombinant lentiviral verctors which respectively contained the anti-BCMA or anti-CD19 single chain variable fragment (scFv), the cytoplasmic portion of the OX40 and CD28 costimulatory moiety, and the CD3z T-cell activation domain. This is the new third generation CAR technique applied in clinic. BUCY were used as conditioning, followed by infusion of autologous stem cells. Median time to engraftment were 10 days for nutrophils. CART-19 (1×107/kg on d0) and CART-BCMA cells as split-dose (40% on d1 and 60% on d2) were infused derectly on d14 to d20 after autologous transplantation. Levels of CAR-transduced cells are measured by qPCR. The cytokine release syndrome (CRS) was graded according to the UPen cytokine release syndrome grading system. Neurotoxic side effects and other toxicities were assessed according to the CTCAE v 4.03. Plasma levels of IL-2, IL-4, IL-6, IL-10, TNF-alpha, IFN-gamma, and IL-17A proteins were determined with a cytokine kit. Imids alone were given as maintenance therapy. Responses were assessed by IMWG criteria. 10-color flow cytometry was used to monitor MRD regularly after CART treatment. The median of follow-up was 3 (2∼11) months.Results: To date, 9 patients have completed the CART cells infusion (cohort 1). All cases expressed BCMA >50% without CD19 expression on MM cells. CRS occurred in 9 patients (100%) grade1 or 2 associated with fever(n=9), fatigue (n=9), elevated IL-6 and CRP (n=9), elevated ALT (n=1, grade 1). Two patients needed to use low-dose vascular active drugs (pts 04 and 07). Other toxicities to date included coagulopathy (n=6, grade 1 for 4 pts and grade 2 for 2 pts), elevated troponin T (n=4, grade 1), and atrial flutter (n=1). There was no serious CRS or neurologic complications occurred in this group of patients.The ORR was 100% with all patients were monitored for a period of more than 2 months, which may be eventually further improved. There were 2 CR, 1 VGPR, 4 PR, 2 SD after induction; 3 CR, 2 VGPR, 4 PR after APBSCT; 3 CR, 6 VGPR after CART therapy. MRD negativity in BM increased from 37.5% after transplantation to 66.7% after CART therapy latest. Four patients (pts 02, 03, 06 and 07) obtained partial PR after transplantation, and got VGPR after CART cells infusion. We found dramatic in vivo CART expansion that median of peak value of CART copies was 1059.54 folds (ranged from 536.90 to 10997.93 folds) which was 100 folds to that with RRMM patients in our previous study.Conclusions: Tandom autologous transplantation and combined infusion of CART-19 and CART-BCMA cells could be another choice of consolidation treatment for high risk MM patients. Toxicities to date including CRS and organ function impairment seemed to be mild and reversable. It is worthy of further study to compare DFS, OS between single autologous transplantation and tandom transplantation with CART therapy. Immune environment in high risk patients with multiple myelomaI remodelled by auto-HSCT may contribute to more rapid expansion of CART cells than that in RRMM patients, suggesting that the extent of CART expansion depends more than tumor burden. [Display omitted] DisclosuresNo relevant conflicts of interest to declare.

Updated analysis of CALGB (Alliance) 100104 assessing lenalidomide versus placebo maintenance after single autologous stem-cell transplantation for multiple myeloma: a randomised, double-blind, phase 3 trial

BackgroundCALGB 100104 (Alliance) studied lenalidomide vs. placebo following autologous stem cell transplant (ASCT) for newly diagnosed myeloma patients, demonstrating improved time to progression (TTP) and overall survival (OS), and an increase in second primary malignancies (SPM) for lenalidomide at 34-months median follow-up. Here we report an updated intent-to-treat analysis at 91-months median follow-up.MethodsPatients were eligible if they had active myeloma, had received at most two induction regimens and had achieved stable disease or better in the first 100 days after ASCT. In this phase 3 study, 460 patients were randomised in a double-blind manner to either lenalidomide (n=231) or placebo (n=229) utilizing a permutated-block randomisation with fixed block size. Randomisation was stratified by three factors: normal or elevated β2-microglobulin level at registration (≤2·5 mg/L vs > 2·5 mg/L), prior use or nonuse of thalidomide during induction therapy, and prior use or nonuse of lenalidomide during induction therapy. The starting dose was 10 mg daily, escalated to 15 mg daily after three months. The primary endpoint was TTP (time of progressive disease or death from any cause) using intent-to-treat analysis. After three interim analyses, the study was unblinded at median follow-up of 18 months and 86/128 placebo patients without progressive disease chose to cross over to lenalidomide. This study is registered with ClinicalTrials.gov identifier NCT00114101; new patients are no longer being recruited, but some patients remain on treatment and in follow-up.FindingsThe median TTP for lenalidomide is 57·3 months (95% CI 44·2–73·3) and 28·9 months (95% CI 23·0–36·3) for placebo (hazard ratio (HR): 0·57, 95% CI 0·46–0·71, p<0·0001). The TTP benefit with lenalidomide was observed regardless of whether patients were in a complete response at time of randomisation or whether they had received thalidomide or lenalidomide induction therapy. The most common grade 3–4 adverse events were neutropenia (116 (50%) of 231 patients in the lenalidomide arm and 37 (16%) of 229 patients in the placebo arm) and thrombocytopenia (34 patients (15%) in the lenalidomide arm and 11 patients (4·8%) in the placebo arm. Eighteen haematological (7·8%) and 14 solid tumour (6·1%) SPMs have been diagnosed following randomisation and prior to disease progression in the lenalidomide arm vs. three haematological (1·3%) and nine solid tumour (3·9%) SPMs in the placebo arm. Of the placebo SPMs, three haematological and five of nine solid tumour SPMs were in the crossover subgroup.InterpretationDespite an increase in haematological adverse events and SPMs, lenalidomide maintenance therapy following ASCT significantly improves TTP and can be considered a standard of care.

Outcome of Multiple Myeloma Patients Treated with Carrd-PACE Chemomobilization: A Single-Center Experience

Background:Bortezomib was originally incorporated into DT-PACE (thalidomide, dexamethasone, cisplatin, doxorubicin, cyclophosphamide, and etoposide) as an intensive induction regimen (VTD-PACE) prior to high-dose melphalan and autologous transplant for multiple myeloma (MM). This regimen is effective in the induction setting, and also for patients with relapsed disease (Barlogie British Journal of Haematology 2007, Singh ASCO 2013). At our center, we examined the outcomes of MM patients undergoing chemomobilization with a regimen that substituted carfilzomib and lenalidomide for bortezomib and thalidomide (CarRD-PACE).Methods:Twenty MM patients with measureable disease received CarRD-PACE for chemomobilization. We excluded in this report patients with plasma cell leukemia, renal insufficiency, heart failure, or those patients who were refractory to carfilzomib.Results:The median age was 61.5 years (range, 35- 69). Nine of these patients were women (45%). The median left ventricular ejection fraction pre-treatment was 62% (range, 50 - 77%). Of patients with initial staging information, 8 were ISS stage I (47%), 5 patients ISS II (29%), and 4 were ISS III (24%). High risk cytogenetics, defined as presence of deletion 17p, t(4;14), t(14;16), were present in 5 patients at time of chemomobilization (25%). Fourteen patients (82%) had bulky disease (defined as having > 3 lesions, or having a single lesion > 3 cm on PET-CT or MRI) prior to treatment, assessed by MRI (n=12) or PET-CT (n= 2). The median time from diagnosis to mobilization was 9.5 months (range, 4- 44). Patients had previously received a median of 2 regimens of therapy (range, 1- 5). Fifteen patients received 1 cycle of CarRD-PACE, and 5 patients received 2 cycles. Eighteen patients response evaluable; in these patients, the overall CR/PR response rate after completion of treatment was 25% (4 PR, 1 CR), with fifteen patients (75%) having SD. A total of 18 patients (90%) collected stem cells after mobilization, requiring a median of 1 day of collection (range, 1-2), and collected a median of 18.3 x 10^6 CD34+ cells/kg (range, 4.8 - 69.88). Grade 3-4 toxicities occurred in 6 patients (30%), most common was neutropenic fever (n=4) (20%). No patients experienced a cardiac toxicity. Hospital readmission following treatment occurred in 4 patients (20%) for a median of 6.5 days (range, 3 - 15). Eighteen patients (90%) underwent a single autologous transplant, and 2 (10%) received tandem autologous-allogeneic transplant. Following autologous transplant, the median time to neutrophil engraftment was 18 days (range, 14 - 29 days), and the median time to platelet engraftment was 13 days (range, 7 - 19 days). The PFS at 6 months was 63% (95% CI, 0.382 - 1), and the OS at 6 months was 91% (95% CI, 0.754 - 1) (Figure).Discussion:CarRD-PACE is a well-tolerated and effective therapy in heavily treated multiple myeloma patients with substantial disease burden at the time of autologous transplant, and can successfully mobilize autologous PBSC. Despite the theoretical concern regarding the combination of 2 agents with cardiac toxicity (carfilzomib and doxorubicin), we did not observe any cardiac toxicities of any grade during treatment. This approach may be particularly useful in individuals with bortezomib associated neuropathy and or those with bortezomib refractory disease. [Display omitted] DisclosuresBecker:GlycoMimetics: Research Funding. Shadman:Pharmacyclics: Honoraria, Research Funding; Acerta: Research Funding; Gilead: Honoraria, Research Funding; Emergent: Research Funding. Gopal:Seattle Genetics: Research Funding.

Autologous Stem Cell Transplantation for Multiple Myeloma in the Era of Novel Agents

Autologous Stem Cell Transplantation for Multiple Myeloma in the Era of Novel Agents

Allogeneic Stem-Sell Transplantation In Multiple Myeloma In Real Practice: Long-Term Results From a Single Institution

BackgroundAllogeneic stem-cell transplantation with myeloablative conditioning (MAC) in multiple myeloma (MM) is associated with a high transplant-related mortality (TRM) with a 15% of long-term survivors. Allogeneic transplantation with reduced-intensity conditioning (alloRIC) results in a lower TRM with a higher relapse rate. When used in first line in a tandem transplant approach (auto/alloRIC), the incidence of acute graft-versus host disease (aGvHD) grade II-IV reported ranges between 20-43%, chronic GvHD between 50-75% and the TRM between 10-15%. The reported PFS was 25% beyond 7 years. Because of this high morbimortality and the higher rate of relapse, the role of allogeneic transplantation in MM remains controversial, especially as part of the front-lline therapy. Aimto analyze the results of allogeneic transplantation in patients with MM outside clinical trials at our institution over a period of 27 years. Patients and MethodsBetween Feb 1986 and April 2009, 23 patients (17 M, 6 F, median age 41 –range 21-52 -) received a MAC from an HLA identical sibling donor. Disease status at the time of transplant was first response in 12 patients (53%) (3 CR, 9 PR), sensitive relapse in 3 (13%) (all PR) and refractory disease in 8 (35%). Conditioning regimen was heterogeneous (6 Cyclo/TBI, 2 Bu/Cyclo, 3 BCNU/Mel/Cyclo/TBI, 4 Cyclo/Mel/TBI, 5 Mel/TBI, 2 Bu/Mel). GvHD prophylaxis consisted on cyclosporine/MTX (10), cyclosporine/PDN (8), cyclosporine (2) or other (3).Between April 2001 and Aug 2012, 31 patients (18 M, 13F, median age 48 –range 25-64) received an alloRIC: 25 of them (80%) from an identical sibling donor and 6 (20%) from an unrelated donor. Seven patients (13%) who did not achieve a CR after front-line autologous transplant received an alloRIC in a tandem strategy. 17 (31%) were in sensitive relapse (first relapse 14, second relapse 3). Seven patients (13%) had refractory disease at the time of alloRIC. Conditioning regimen consisted on Fluda/Mel (26 patients), Flu/TBI (3) and Fluda/Mel/bortezomib (2). GVHD prophylaxis consisted on cyclosporine/MTX (6) or cyclosporine/MMF (25). All patients in the alloRIC group had received a prior single autologous transplant. ResultsOn an intention-to-treat analysis, the CR rate after MAC was 35%. The incidence of aGvHD grade II-IV and III-IV were 48% and 39%, respectively. The TRM at any time was 56%. The causes of death were GvHD in 7 patients, infection not related to GvHD in 5 patients and VOD in 1 patient. The relapse rate was 30%.There are 3 patients who remain in continued CR at 13, 23 and 27 years beyond transplantation.With alloRIC the CR rate was 45%. The incidence of aGvHD grade II-IV and III-IV were 55% and 22%, respectively. Nine patients develop chronic GvHD. The TRM at any time was 29% and the causes of death were GVHD in 7 patients and pulmonary hemorrhage and postransplant lymphoma one patient each. Nine patients remain alive in continued CR from 5 months to 9 years of follow-up.After a median follow-up of 36.4 months, the median PFS was not significantly different between MAC and alloRIC and there was a trend towards a longer overall survival in the alloRIC group (4.6 vs 35 months, p=0.05). ConclusionsAlthough a small fraction of patients with MM can be cured with MAC allogeneic transplantation, this procedure is associated with an extremely high TRM. Unfortunately, alloRIC was also associated with a high incidence of severe aGVHD resulting in a high TRM leading to a short PFS. New approaches aimed at decreasing the incidence of aGVHD are crucial. Disclosures:Jiménez:Janssen: Honoraria. Rosiñol:Janssen: Honoraria; Celgene: Honoraria. Blade:Janssen: Honoraria; Celgene: Honoraria.

Outcomes of 252 Patients with High Risk Multiple Myeloma Treated with Hematopoietic Stem Cell Transplantation: Identification of Risk Factors Associated with Early Relapse, Shortened Progression Free and Overall Survival

AbstractAbstract 3957Currently used clinical prognostic markers for patients with multiple myeloma (MM) such as the international staging system (ISS) and cytogenetics are inadequate predictors of response and survivorship after hematopoietic stem cell transplant (HSCT). Recently published large studies of HSCT as consolidation after primary therapy have demonstrated 3-year progression free survival (PFS) and overall survival (OS) rates of 45% and 78% respectively after tandem HSCT (BMT CTN 0102; Krishnan, Lancet Onc, 2011) and median time to progression of 46 and 27 after single autologous transplant, with and without lenalidomidemaintenance (CALGB 10104; McCarthy, NEJM, 2012). These studies (which include patients in the current cohort) have established expected PFS and OS benchmarks that allow identification of higher risk subsets.The aim of this study is to describe and further sub- stratify patients with high-risk myeloma (HRMM), with the goal to identify ‘higher' risk groups that may benefit from alternative treatment strategies. Methods:A retrospective cohort study of HRMM patients who received an HSCT at OHSU between 01/01/2001 and 12/31/2011 was performed. We defined HRMM by the following: FISH and cytogenetic findings of del17p, t(4:14), t(14;16), t(14;20), chromosome (ch) 1 abnormalities, del 13q by cytogenetics; the presence of multiple extra-medullary plasmacytomas; plasmablastic morphology; higher ISS categories (II and III); Salmon- Durie(S-D) stages 2 and 3; recurrence or less than a partial remission (PR) to 2 consecutive lines of therapy prior to HSCT.Outcome measures included PFS and OS. Descriptive statistical analysis was conducted for all primary and secondary endpoints, patients' individual and clinical characteristics, and gene profiles. Kaplan-Meier method was used to estimate the OS and PFS function. Log-rank test was used to assess whether the survival function differs across the groups. Factors that are significantly associated with the primary and secondary endpoints were identified using univariateanalysis. Multivariate analysis is ongoing. Results:Patient and HSCT characteristics are found in table 1.Table 1n = 252CharacteristicNo%Age at transplant, yearsMedian59Range30–79Male Sex16264ISS stageII8945III4724Salmon-Duriestage25723314558Genetic abnormalitiesdel (13q) cytogenetics3011t(4;14)218del(17p)187t(14;16)41t(14;20)10.3ch 1 abnormality*219Plasmablastic morphology62Multiple extramedullary plasmacytomas187Prior therapiesMedian2Range1–9<PR to 2 conventional lines of therapy prior to HSCT249HSCT total273Single Autologous242Tandem7Allogeneic24Sibling14MUD9Syngeneic1Indication for HSCTInduction20776Salvage6624Post HSCT maintenance5119Lenalidomide19Bortezomib2Steroids12Thalidomide18*Ch 1 abnormalities were heterogenous and included 8 deletions (1q x1, 1p x7); 4 additions (1p x2, 1q x2); 5 translocations (t1;4, t1;8, t1;19, t1;10 x2) and 4 with multiple abnormalities.With a median follow up of 40 months, relapse occurred in 127 patients, of which 77 (60%) occurred within 18 months post HSCT. Median PFS and OS are 22.3 (95% CI: 19.7 – 29.3) and 56.67 (95% CI: 40.1–69.9) months respectively. The 2-year PFS and OS rates were 47%, and 72% respectively.Univariate data analysis revealed the following factors that are highly associated with reduced PFS: del 17p (2- year PFS 26.2%; p= 0.09); ch 1 abnormalities (27.4%; p=0.0026); recurrence or < PR after 2 consecutive lines of chemotherapy prior to HSCT (27.5%; p= 0.07). For patients with chromosome 1 abnormalities, the presence of del 13q by cytogenetics further decreased the PFS (22%; p= 0.04;)(Figure 1). Factors associated with highly with a reduced OS are: ch 1 abnormalities (2-year OS 52.5%; p=0.0042); both chromosome 1 and del13q (46.2%; p=0.0016) and having multiple extra-medullary plasmacytomas (55.2%; p= 0.026 (Figure 2). Conclusion:Within the broad group of HRMM, certain groups have significantly inferior outcomes post HSCT, the worst being those with recurrence or < PR to 2 consecutive lines of chemotherapy prior to HSCT, those with any ch 1 abnormality and particularly those with additional del 13q by cytogenetics. Investigation of novel therapeutic and more aggressive strategies is warranted in these groups. [Display omitted] [Display omitted] Disclosures:Scott:Genzyme: Research Funding; Millenium: Speakers Bureau.

Economics of hematopoietic cell transplantation

AbstractGiven the rapidly rising healthcare costs, it is important to understand the economic costs of hematopoietic cell transplantation (HCT), a procedure that is being used more frequently in the treatment of various hematologic disorders. Studies have reported a wide range of costs for HCT, from $36 000 to $88 000 (USD) for a single autologous transplantation for the initial hospitalization, to $200 000 (USD) or more for a myeloablative allogeneic procedure involving an unrelated donor. Common posttransplantation complications, such as infections and GVHD, have been shown to be significant cost drivers. Comparisons across studies are limited by differences in patient populations, cost ascertainment methods, and length of follow-up. This article summarizes the current state of knowledge about costs and cost-effectiveness of HCT, highlighting the challenges in conducting these studies and identifying important areas for future research. We discuss the need for more value-based assessments of HCT using high-quality approaches to measuring costs and outcomes so that potential future efforts to contain costs are well informed and appropriate.

Clinical experience with a simple algorithm for plerixafor utilization in autologous stem cell mobilization

Plerixafor augments PBSC collection, but the optimal approach for incorporating it into mobilization is uncertain. Forty-nine consecutive patients mobilized with G-CSF alone were analyzed, and a day 4 peripheral blood CD34(+) cell count of 0.015/ml was found to predict for a day 5 apheresis yield of 2 × 10(6) CD34(+) progenitors/kg, our institutional minimum necessary for a single autologous transplant. On the basis of this relationship, a clinical guideline was developed which recommended pre-emptive use of plerixafor if the day 4 peripheral blood CD34(+) cell count was between 0.005 and 0.015/ml. A total of 166 consecutive subjects with lymphoma or plasma cell dyscrasias underwent G-CSF mobilization after adoption of this care pathway, and the mobilization failure rate was only 7% in patients managed per guideline. The median PBSC yield was 6.3 × 10(6) CD34(+) progenitors/kg with G-CSF (day 4 peripheral blood CD34(+) cell > 0.015/ml) and 4.9 × 10(6) CD34(+) progenitors/kg with G-CSF+plerixafor (day 4 peripheral blood CD34(+) cell 0.005-0.015/ml). The median number of days of apheresis was 2 in both groups. This clinical guideline is an effective mobilization algorithm that minimizes mobilization failures, reduces poor apheresis yields, does not require risk factor identification and is simple to implement.

Benefit from autologous stem cell transplantation in primary refractory myeloma? Different outcomes in progressive versus stable disease

Several studies of autologous stem cell transplantation in primary refractory myeloma have produced encouraging results. However, the outcome of primary refractory patients with stable disease has not been analyzed separately from the outcome of patients with progressive disease. In the Spanish Myeloma Group 2000 trial, 80 patients with primary refractory myeloma (49 with stable disease and 31 with progressive disease), i.e. who were refractory to initial chemotherapy, were scheduled for tandem transplants (double autologous transplant or a single autologous transplant followed by an allogeneic transplant). Patients with primary refractory disease included those who never achieved a minimal response (≥ 25% M-protein decrease) or better. Responses were assessed using the European Bone Marrow Transplant criteria. There were no significant differences in the rates of partial response or better between patients with stable or progressive disease. However, 38% of the patients with stable disease at the time of transplantation remained in a stable condition or achieved a minimal response after transplantation versus 7% in the group with progressive disease (P=0.0017) and the rate of early progression after transplantation was significantly higher among the group with progressive disease at the time of transplantation (22% versus 2%; P=0.0043). After a median follow-up of 6.6 years, the median survival after first transplant of the whole series was 2.3 years. Progression-free and overall survival from the first transplant were shorter in patients with progressive disease (0.6 versus 2.3 years, P=0.00004 and 1.1 versus 6 years, P=0.00002, respectively). Our results show that patients with progressive refractory myeloma do not benefit from autologous transplantation, while patients with stable disease have an outcome comparable to those with chemosensitive disease.

Impact of the Conditioning Regimen in Patients With Multiple Myeloma Who Undergo Autologous Transplantation

TO THEEDITOR:Recently,Regelinketal 1 reportedthelong-term results of a series of 90 patients with multiple myeloma (MM) who underwent either single or tandem autologous stem-cell transplantation. Conditioning regimens that were administered for the first and second transplantation were high-dose melphalan (MEL) and the combination of busulfan (BU) and cyclophosphamide, respectively. The authors reported a significantly higher 10-year overall survival and event-free survival for patients in the tandem transplantation group. According to their hypothesis, the better outcomes that were observed in patients who underwent tandem transplantation were only a result of the greater amount of chemotherapy administered in this group of patients; this suggests that these results would have been achieved regardless of the conditioning regimen that was administered in the second transplantation. However, and in contrast to the opinion of Regelink et al, we believe that the use of a preparative regimenthatcombinedtwoalkylatingagentsinthesecondtransplantation could have played a key role in the encouraging long-term results that were reported by the authors. In this regard, when two conditioning regimens (MEL v BU MEL, or BUMEL) were pro

Tandem Autologous Stem Cell Transplants (auto-auto) with or without Maintenance Therapy Versus Single Autologous Transplant Followed by HLA-Matched Sibling Non- Myeloablative Allogeneic Stem Cell Transplant (auto-allo) for Patients (pts) with High Risk (HR) Multiple Myeloma (MM): Results From the Blood and Marrow Transplant Clinical Trials Network (BMT-CTN) 0102 Trial

AbstractAbstract 526The prognosis of patients with high-risk myeloma (HR MM) continues to be dismal, despite the early incorporation of novel agents. Early phase trials of allogeneic hematopoietic stem cell transplant (alloHCT) suggest the possibility of an immunologic graft-versus-myeloma effect that might favorably affect survival. Less toxic reduced-intensity HCT preparative regimens now allow more widespread use of alloHCT in the MM population. BMT CTN 0102 is a phase III multicenter clinical trial that biologically assigned patients to either melphalan 200mg/m2 (MEL 200) auto-auto without (obs) or with 1 year of thalidomide and dexamethosone (ThalDex), or an auto-allo approach using MEL 200 followed by alloHCT using 2 Gy total body irradiation. Graft-versus-host disease (GVHD) prophylaxis was cyclosporine and mycophenolate mofetil. Patients were stratified by biological prognostic factors that were considered to be high risk at the time of the trial design: chromosome 13 deletions by metaphase karyotype and beta-2 microglobulin ≥4 mg/dl. The primary endpoint was 3-year progression free survival (PFS). Between December 2003 and March 2007, 710 patients from 43 US centers were enrolled, and 85 fulfilled the criteria of HR MM. Among them, 48 were assigned to auto-auto (24 Thal-Dex and 24 obs) and 37 to auto-allo. Groups differed in age (median 57 y and 51y, p=0.02) but were otherwise balanced. Compliance with second transplant was 65% for auto-auto and 78% for auto-allo. Compliance with ThalDex was poor, so the two auto-auto arms were pooled for the primary analysis. Three-year PFS was 33% (95% Confidence Interval (CI), 22–50%) and 40% (95% CI, 27–60%, p=0.74) and 3-year OS was 67% (95% CI, 54–82%) and 59% (95% CI, 49–78%, p=0.46) for auto-auto and auto-allo, respectively. Corresponding probabilities for 3-year progression/relapse was 53% and 33% (p=0.09), and 3 year treatment-related mortality was 8% and 20% (p=0.3). Among auto-allo patients, probabilities of grade 3–4 acute and chronic GVHD were 9% and 48%, respectively. Among the 59 (31 auto-auto, 28 auto-allo) patients who received second transplant, 3 year PFS was 35% and 46% (p=0.6). Disease response at day 56 after second transplant was 57% for very good partial response (VGPR) or better and 37% for complete response (CR) and near CR (nCR) in the auto-auto group; and 48% (VGPR or better) and 41% (CR+nCR) in the auto-allo group. In conclusion, this planned secondary analysis of a cohort of HR MM patients demonstrated equivalent 3-year PFS and OS for auto-auto and auto-allo in both intention-to-treat and as-treated analyses. However, trends in late PFS and time to progression/relapse suggest further follow-up is needed before final conclusions regarding the utility of auto-allo in this HR cohort can be made. Finally, this study shows the feasibility of an alloHCT approach for HR MM patients and may serve as a platform for future studies seeking to enhance graft-versus-myeloma effects. [Display omitted] [Display omitted] Disclosures:Stadtmauer:Celgene: Speakers Bureau. Krishnan:Celgene: Speakers Bureau. Qazilbash:Celgene: Speakers Bureau. Vesole:Celgene: Membership on an entity's Board of Directors or advisory committees, Speakers Bureau. Giralt:Celgene: Honoraria, Speakers Bureau; Millenium: Honoraria, Speakers Bureau.

Thalidomide-Dexamethasone as Induction Therapy before Autologous Stem Cell Transplantation in Patients with Newly Diagnosed Multiple Myeloma and Renal Insufficiency

The aim of this study was to evaluate the efficacy and the toxicity of thalidomide-dexamethasone (Thal-Dex) as induction therapy before autologous peripheral blood stem cell (PBSC) transplantation in patients with newly diagnosed multiple myeloma (MM) with renal insufficiency. The study included 31 patients with a baseline creatinine clearance value <or=50 mL/min, 7 of whom required chronic hemodialysis. Patients received 4 months of Thal-Dex, followed by PBSC collection and subsequent transplantation. After induction, a partial response (PR) or greater was obtained in 23 patients (74%), including 8 (26%) who achieved a very good PR. Renal function improved more frequently in patients achieving a PR or greater (82%, vs 37% in patients achieving less than a PR; P = .04). Twenty-six patients underwent PBSC mobilization; in 17 of these patients (65%), >4 x 10(6) CD34(+) cells/kg were collected. Double autologous transplantation was performed in 15 patients, and a single autologous transplantation was performed in 7 patients. After a median of 32 months of follow-up, median event-free survival was 30 months, and median survival was not determined. According to our data, Thal-Dex is effective and safe in patients with newly diagnosed MM and renal insufficiency. Given the relationship between recovery of renal function and response to induction treatment, more intensive Thal + bortezomib regimens could be explored to rescue higher numbers of patients.

Bortezomib plus dexamethasone can improve stem cell collection and overcome the need for additional chemotherapy before autologous transplant in patients with myeloma

The aim of this phase II trial was to investigate the efficacy of bortezomib plus dexamethasone (Vel-Dex) as induction therapy in patients with multiple myeloma (MM) and to define the role of intensification before transplantation. Fifty-seven patients were treated with four courses of Vel-Dex, two cycles of dexamethasone, cyclophosphamide, etoposide and cisplatin (DCEP), and a single autologous transplant. Fourteen patients (25%) went off-study: seven after Vel-Dex, seven after DCEP. All patients yielded high numbers of stem cells (median CD34+ cells 7.5 × 106/kg); 54 of the 57 patients (94%) collected ≥4 × 106/kg CD34+ cells, 60% with a single leukapheresis. The overall response rate (ORR) after Vel-Dex was 86% (70% had a very good partial response [VGPR] or better) regardless of cytogenetic abnormalities and International Staging System stage (ISS). The response at the end of the two DCEP cycles remained unchanged in 35 patients (70%), worsened in 15 (20%), and improved in 5 (10%). Because of the consistent drop-out, the ORR in intention-to-treat analysis decreased significantly from 86% after Vel-Dex to 76% after DCEP, and 73% after transplantation. However, when considering the subset of 43 patients who completed the program, the ORR was 96% (complete response 39%, VGPR 41%, partial response 16%). In conclusion, Vel-Dex produces high response rates, improves stem cell collection, and overcomes the need for intensification before autologous transplantation.

Standard Consolidation/Maintenance Chemotherapy Is Consistently Superior to a Single Autologous Transplant for Adult Patients with Acute Lymphoblastic Leukemia: Results of the International ALL Trial (MRC UKALL XII/ECOG E2993)

The International ALL trial, conducted jointly by the MRC in the UK and ECOG in the US (UKALL XII/E2993), recruited 1929 patients between 1993 and 2006. All patients aged 16 to 64 years with newly diagnosed ALL, received the identical two phases of induction therapy. Patients with an HLA-identical sibling were assigned to a sibling allogeneic transplant and those who were Ph-positive could also get an unrelated-donor transplant. Patients who did not have a donor were to be randomized between a single autologous transplant, after conditioning with etoposide/total body irradiation, versus consolidation/maintenance therapy for 2.5 years. Following randomization, but prior to receiving the assigned or randomized therapy, all patients received intensification with 3 cycles of high-dose methotrexate. After excluding patients assigned to an allogeneic transplant, 1028 patients were eligible for randomization but, as in other major transplant studies, only 457 were randomized. The rationale underlying the randomization was based on the fact that protracted consolidation/maintenance therapy in adults, extrapolated from the pediatric experience, had never been prospectively evaluated in the era of intensive chemotherapy. Given that the mortality from autotransplant is not higher than chemotherapy (Goldstone et al. Blood. 2008), it was postulated that if a single autologous transplant is at least as good as standard protracted chemotherapy that may make it the preferable option, except possibly in females in whom fertility may be an issue. The overall survival and the event-free survival were significantly superior among the chemotherapy patients (p = .05) as previously reported (Goldstone et al. Blood. 2008). Because the literature contains reports suggesting a trend in favor of autologous transplantation in some patients with ALL (Dhédiu et al. Leukemia, 2006), an analysis was performed to see if any subgroup of patients could be identified in whom: 1. chemotherapy may not be superior to autologous transplant and 2. autologous transplant may be superior. The table lists a detailed analysis of overall survival looking at various age groups, B- versus T-lineage, the rapidity with which a complete remission was achieved –after phase I or only after phase II of induction. Detailed analysis was also performed by cytogenetics looking at those with standard risk versus those with high risk abnormalities [ t(9;22), t(4;11), t(8;14)] and low hypodiploidy/near triploidy or a complex karyotype (Moorman et al. Blood. 2007)]. In all groups, the chemotherapy group was at least as efficacious as the autograft group, and in some was even significantly superior to autologous transplantation. There is no evidence that other risk factors, such as relapse rate or treatment-related mortality, influenced these overall survival data. In addition, the tests for heterogeneity were not significant across any group. In conclusion, the overall survival was longer in patients randomized to chemotherapy, although the superiority was not statistically significant in most of the groups. There is no clinical indication for autologous transplantation at any age and particularly this should not be considered for patients over age 50, those with high-risk cytogenetics or T-lineage, and late remitters, for whom it might appear most attractive.Overall Survival (OS) at 5 years in 457 Randomized PatientsChemoAutoSubgroupsnOSnOSP (log rank)Age (years)< 205058%4346%> 0.120–296152%7043%> 0.130–394639%4632%> 0.140–493831%3531%> 0.150 +3338%3531%> 0.1B-lineage16946%15835%0.03T-lineage4554%5449%> 0.1Time to CRphase I19348%19041%0.1phase II2636%2919%0.08Cytogeneticsstandard-risk10951%12244%> 0.1high-risk2923%277%0.02

Single autologous stem-cell transplantation followed by maintenance therapy with thalidomide is superior to double autologous transplantation in multiple myeloma: results of a multicenter randomized clinical trial

From April 2003 to December 2006, 195 patients with de novo symptomatic myeloma and younger than 60 years of age were randomly assigned to receive either tandem transplantation up front (arm A, n = 97) or one autologous stem-cell transplantation followed by a maintenance therapy with thalidomide (day + 90, 100 mg per day during 6 months) (arm B, n = 98). Patients included in arm B received a second transplant at disease progression. In both arms, autologous stem-cell transplantation was preceded by first-line therapy with thalidomide-dexamethasone and subsequent collection of peripheral blood stem cells with high-dose cyclophosphamide (4 g/m(2)) and granulocyte colony stimulating factor. Data were analyzed on an intent-to-treat basis. With a median follow-up of 33 months (range, 6-46 months), the 3-year overall survival was 65% in arm A and 85% in arm B (P = .04). The 3-year progression-free survival was 57% in arm A and 85% in arm B (P = .02). Up-front single autologous transplantation followed by 6 months of maintenance therapy with thalidomide (with second transplant in reserve for relapse or progression) is an effective therapeutic strategy to treat multiple myeloma patients and appears superior to tandem transplant in this setting. This study was registered at www.ClinicalTrials.gov as (NCT 00207805).

In adults with standard-risk acute lymphoblastic leukemia, the greatest benefit is achieved from a matched sibling allogeneic transplantation in first complete remission, and an autologous transplantation is less effective than conventional consolidation/maintenance chemotherapy in all patients: final results of the International ALL Trial (MRC UKALL XII/ECOG E2993)

An international collaboration was set up to prospectively evaluate the role of allogeneic transplantation for adults with acute lymphoblastic leukemia (ALL) and compare autologous transplantation with standard chemotherapy. Patients received 2 phases of induction and, if in remission, were assigned to allogeneic transplantation if they had a compatible sibling donor. Other patients were randomized to chemotherapy for 2.5 years versus an autologous transplantation. A donor versus no-donor analysis showed that Philadelphia chromosome-negative patients with a donor had a 5-year improved overall survival (OS), 53% versus 45% (P = .01), and the relapse rate was significantly lower (P < or = .001). The survival difference was significant in standard-risk patients, but not in high-risk patients with a high nonrelapse mortality rate in the high-risk donor group. Patients randomized to chemotherapy had a higher 5-year OS (46%) than those randomized to autologous transplantation (37%; P = .03). Matched related allogeneic transplantations for ALL in first complete remission provide the most potent antileukemic therapy and considerable survival benefit for standard-risk patients. However, the transplantation-related mortality for high-risk older patients was unacceptably high and abrogated the reduction in relapse risk. There is no evidence that a single autologous transplantation can replace consolidation/maintenance in any risk group. This study is registered at http://clinicaltrials.gov as NCT00002514.